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. Personal and societal costs related to mental health and substance abuse problems exceed $400 billion per year including health care and lost productivity. Although the number of alcohol-related traffic fatalities is declining, 40% of crash-related deaths involve alcohol; for drivers age 21 to 24 the rate is over 50%. Substance abuse is heavily related to crime. For example, of those individuals convicted of burglary, 40% were under the influence of drugs at the time of the crime. Alcohol and other drug use is a factor in over 500,000 emergency room episodes per year and s for 11% of the preventable deaths annually. Suicide rates are highest for White and American Indian/Alaskan Native males, while males in the general population who have a psychotic disorder are at almost twice the risk of committing suicide as those having nonpsychotic disorders. Mental disorders are listed as a contributing factor to the cause of death on 7.6% of death certificates (Rouse, 1998).

EXPANSION OF COMMUNITY CRISIS SERVICES Reding and Raphelson (1995) note that as early as the 1920s psychiatrists in Amsterdam provided home-based psychiatric services with the belief that the care was more effective than that received in an inpatient hospital ward. During that same period, emergency psychiatric services began to appear in the emergency wards of general hospitals as “essentially an on-the-spot adjustment to situational exigencies” (Wellin, Slesinger, & Hollister, 1987, p. 476). Emergency services in urban psychiatric hospitals were begun in the 1930s, followed by community-based services in the 1950s. As documented by Roberts in the overview chapter, crisis services became available in the community following age of the Community Mental Health Center (CMHC) Act of 1963, which required that all centers receiving federal funds offer 24-hour crisis and emergency services as one of five mandated categories of services. The CHMC Act focused on moving mental health services from institutional settings to the community, and early intervention was an important

Mobile Crisis Units 605 component of these programs. With ongoing federal , these services continued to expand in the 1970s, and the total number of community mental health centers offering emergency services expanded 69% from 1976 to 1981 (Wellin et al., 1987). Between 1969 and 1992, the number of mental health episodes per year doubled, the number of issions to outpatient and partial care facilities tripled, and the rate of inpatient issions remained constant. The number of issions to state and county mental hospitals declined 45% from 1975 to 1992, and the number of issions to substance abuse treatment facilities receiving public funds remained constant from 1993 to 1996. Over 50% of the funding for substance abuse treatment is from public sources, and 90% of treatment is outpatient (Rouse, 1998). As an increasing number of clients become covered by various forms of managed care, it is likely that the trend to utilize outpatient and communitybased services will expand even further. Community-based crisis intervention presents a unique challenge to both practitioners and s of behavioral health services. The need for crisis services continues to grow, while inpatient and institutional s continue to decline. Therefore, it is essential that community programs develop and implement services that are congruent to community needs. While describing the disappointments and setbacks of federal mental health policy implementation, Kia Bentley (1994) also reports that “cumulative gains have been made, largely because of the family and consumer movements and legislation they helped to create” (p. 288). Georgia is one example of a state in which mental health services have been reformed based on legislation that was primarily driven by consumers of services and their families.

MENTAL HEALTH REFORM IN GEORGIA In 1993 the Georgia General Assembly ed House Bill 100 (HB100) to reorganize mental health, mental retardation, and substance abuse services in the state into 28 community service boards. The community boards were originally overseen by 19 regional boards; however, the number of regional boards has now been reduced to 13. The law requires that a minimum of 50% of all board must be consumers of services or their families. The 13 regional boards receive funding, determine needs, contract for the provision of services, and monitor the outcomes of services provided. Additional details about the Georgia reform are available elsewhere (Elliott, 1996). Since the 1993 reform in Georgia, services for residents of DeKalb County, located in metropolitan Atlanta, are now provided by the DeKalb Community Service Board (DCSB), based in Decatur, Georgia. DCSB provides a wide range of services to over 10,000 of the county’s 600,000 residents. The county has a long history of committment and advocacy for ad-

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dressing mental health, mental retardation, and substance abuse issues. Services had previously been provided through outpatient programs, and inpatient treatment was provided through one of the state’s eight psychiatric hospitals.

CRISIS SERVICES Following the age of HB100, DeKalb County began to offer inpatient services for crisis stabilization in the community. This was consistent with the wishes of consumers and their families that services be provided in the community so that the need for hospitalization could be reduced. The facility’s interdisciplinary team of physicians, psychiatrists, nurses, social workers, paraprofessional health workers, dietary workers, and volunteers provide around-the-clock access to assessments, physical examinations, medication, treatment, and case management services. Treatment approaches include individual therapy, 12-step groups, and education groups. In addition, many clients are transported to specialized community programs such as dual diagnosis and day treatment programs or are sent to halfway house and residential programs in the community. The crisis facility also serves as the base of operation for the county’s crisis telephone service. In addition, since 1994 a MCU has been in continuous service and provides essential intervention and services that were not available prior to its inception.

DEVELOPMENT OF MOBILE CRISIS UNITS Mobile crisis units (MCUs) can be broadly defined as a community-based program, staffed by trained professionals who may be summoned to any location to deliver services. A number of programs have been previously documented in the literature, and early efforts focused on in-home psychiatric services (Chiu & Primeau, 1991). Other programs were specifically intended to avoid hospital issions (Bengelsdorf & Alden, 1987; Henderson, 1976) and for providing training to psychiatric residents (Zealberg et al., 1990). More recent efforts have included programs that target the homeless mentally ill (Slagg, Lyons, Cook, Wasmer, & Ruth, 1994), with the ability to offer “medications that would otherwise be istered by court order in a hospital” (Reding & Raphelson, 1995, p. 181). Although the specific features of MCUs vary, Zealberg, Santos, and Fisher (1993) identify a number of advantages offered by mobile crisis units, including increased accessibility of services, the benefit of assessing in the “patient’s native environment” (p. 16), and the ability to intervene without delay, to avoid unnecessary arrests or hospitalizations, and to offer crisis

Mobile Crisis Units 607 training opportunities to mental health professionals. Because police officers are often the first source of and response to community crises, the authors also note that MCUs offer the opportunity to collaborate with the law enforcement system.

ROLE OF LAW ENFORCEMENT Police activities related to mental health and substance abuse are particularly problematic for law enforcement because these calls can be very timeconsuming and frequently are not perceived as “real police work” (Olivero & Hansen, 1994, p. 217) compared with activity associated with criminal behavior. Zealberg et al. (1993) note that police officers have little training in mental health issues and “techniques that were developed for use with criminals are often not applicable to nor successful with psychotic patients” (p. 17). This is a significant concern to law enforcement, with Hails and Borum (2003) noting that 7% to 10% of all police calls are related to mental health issues. Law enforcement agencies and behavioral health care services are systems that may be prone to clash (Kneebone, Roberts, & Hainer, 1995). For example, in the past law enforcement was integrally involved in providing assistance for the involuntary issions of mental health and substance abuse patients to psychiatric hospitals. However, the current system has become more restrictive concerning involuntary commitments (Olivero & Hansen, 1994) while favoring community-based interventions. Efforts to community treatment and avoid psychiatric hospitalizations are congruent with the intent of deinstitutionalization However, there has been a corresponding increase in the number of persons with a history of mental problems who are jailed rather than hospitalized, a systemic shift that has been referred to as “transinstitutionalization” (Olivero & Hansen, 1994, p. 217). As noted by Zealberg et al. (1993), “Mobile crisis teams can alleviate the anxiety of law enforcement personnel and can prevent police overreaction” (p. 17). Such was the case in Memphis, when the development of a crisis intervention team came about after the shooting of a mentally ill person by a police officer (Cochran, Deane, & Borum, 2000). The authors note that partnerships between law enforcement and mental health services can be of great benefit in “managing crisis calls in an effective, expedient, and sensitive manner” (p. 1315).

DIFFERENCES IN MCU STAFFING AND SERVICE DELIVERY MCUs have varied greatly in staffing and service delivery approaches. Gaynor and Hargreaves (1980) note that some mobile units were more likely

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to use mental health professionals, with psychiatrists available on a consultant basis, whereas Chiu and Primeau (1991) describe a team approach that includes a psychiatrist, a ed nurse, and a social worker. Some MCUs have been positioned as and consultant services, which are called for assistance by the law enforcement or mental health systems (Bengelsdorf & Alden, 1987; Henderson, 1976; Zealberg, Christie, Puckett, McAlhany, & Durban, 1992). Other programs have been based in vans or other vehicles and offer outreach services to targeted populations (Chiu & Primeau, 1991; Slagg et al., 1994). Community MCUs differ with respect to staffing and objectives, and the role of law enforcement in these programs also varies. Programs have been described that are designed to increase the knowledge and effectiveness of police officers when working with mental health issues (Dodson-Chaneske, 1988; Tesse & Van Wormer, 1975), as a collaboration with police and psychiatric services (Zealberg et al., 1992), or as a team consisting of police officers and mental health professionals (Lamb, Shaner, Elliott, DeCuir, & Foltz, 1995). On the other hand, many programs have focused on the delivery of services without law enforcement collaboration (Bengelsdorf & Alden, 1987; Chiu & Primeau, 1991; Slagg et al., 1994). Deane, Stean, Borum, Veysey, and Morrissey (1999) surveyed urban police departments concerning their method of response to situations involving mental health issues and found no significant differences in four approaches to the calls.

MOBILE CRISIS SERVICES IN DEKALB COUNTY, GEORGIA Prior to 1994, many crises involving mental health and substance abuse problems in DeKalb County were addressed by police department officers who responded to these calls. If necessary, individuals could be arrested, or they could be transported involuntarily by the sheriff’s department to the state psychiatric hospital. Community residents, family , and mental health advocates were very vocal about their displeasure with this arrangment for several reasons. First, the opportunity to resolve the situation at the location of the incident was limited by the expertise of the officer who responded. Second, many arrests and incarcerations were for behavior that was directly related to a mental health issue and were potentially avoidable. Finally, when clients were assessed at the psychiatric hospital, it was not uncommon for the facility to make decisions that conflicted with the judgment and opinions of community providers and family . With the consumer and family focus of the reform in Georgia, it was now possible for county residents to secure services that were desired, including the MCU. The MCU operates from 3:00 to 10:30 P.M., 7 days per week, and pairs a uniformed police officer with a mental health professional who operate

Mobile Crisis Units 609 from a regular marked police car. Each team works 4 days per week, with the operations based at the county’s mental health and substance abuse crisis center, which includes the 24-hour crisis telephone service, walk-in services, and inpatient crisis stabilization and detoxification unit. About half of the referrals to the MCU are made by police dispatchers or other officers through the police radio communications system. The other half of the referrals come from the crisis unit or other mental health workers via cellular telephone and pager. Police officers have continuous access to field supervisors, and the mental health worker has direct access to consultation, including istration and staff psychiatrists. In addition, client histories are available through both the law enforcement and the mental health information system. The MCU responds to a wide range of calls that occur in homes, public places, and schools. About half the calls involve a psychotic episode, 25% are related to suicidal individuals, and about one fourth include a substance abuse problem as well. About six calls are completed per shift, which includes a combination of crisis calls and prearranged client and family follow-up calls.

APPLICATIONS OF ROBERTS’S SEVEN-STAGE MODEL Roberts (1991) provides a highly practical approach to crisis intervention that is consistent with the needs of of mobile crisis teams. It is important to address each of the seven stages in the model, beginning with stage 1, assessing lethality and safety needs, followed by stage 2, establishing rapport and communication. Stage 3 involves identifying the major problems, followed by stage 4, dealing with feelings and providing . Possible alternatives are explored in stage 5, followed by the formulation of a plan in stage 6, and follow-up during stage 7. Roberts (1991) aptly stresses the importance of using sound judgment in sequencing the model’s stages. For example, an MCU call involving a frightened mental health client could begin with stage 2 to establish rapport, whereas a call concerning an actively suicidal client would begin with assessing lethality, stage 1.

Case Application: Gloria In the case of Gloria, assessing the lethality of her threats is consistent with stage 1 and began with s to the outpatient case manager and the telephone crisis worker. These were both excellent resources to determine from their experience and case records if any history of violence toward self or others was evident. In stage 2 the telephone crisis worker had already spoken with Gloria at her apartment as well as to her neighbor, who was with her and considered a ive person. In stage 3 it was determined that Gloria’s threats were consistent with her not being properly medicated.

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In the past this usually resulted in being transported to the psychiatric hospital and involuntarily itted. On this call, the team consisted of a uniformed officer and a licensed master’s-level social worker, who proceeded to the apartment. In stage 4 the crisis telephone worker had begun the process of offering to Gloria and her neighbor and provided an opportunity to express feelings. However, given Gloria’s level of hostility, this dialogue was of limited benefit, and her neighbor was very relieved to know that the MCU was en route. As the MCU team entered her apartment, Gloria became very fearful about the presence of a uniformed officer. It was now important to go back to stage 1 in order to specifically make sure there were no weapons in the apartment and to assess Gloria’s intent to harm herself or someone else. Although a full discussion of assessing suicidal and homicidal intent is beyond the scope of this chapter, a more thorough review of risk factors and assessment techniques is available elsewhere (Sommers-Flanagan & Sommers-Flanagan, 1995). Continuing to stages 2, 3, and 4, Gloria was calmed by the team and encouraged to relate to it the details of her missing her usual appointment, the status of her medications, her recent appetite and sleep patterns, and any recent events or circumstances that may have impacted her mental status. In stages 5 and 6 it was important to consider the input of both Gloria and her neighbor as well as the previous from the case manager and telephone worker. The team was able to acquire her trust, and she provided helpful input in developing a plan. Gloria had not stopped taking her medications, but she was running low on her supply and attempting to stretch what she had, which led to her decompensation. Although one option was to transport her to the crisis center for further evaluation, her neighbor was willing to stay with her for the night. If there were any difficulties she could the telephone crisis line. In stage 7 the neighbor was willing to bring Gloria to the outpatient mental health center for a walk-in meeting with her case worker and the psychiatrist and to replenish her medications at the center pharmacy. This case illustrates several benefits of the mobile crisis unit. First, the combination of a law enforcement officer and a mental health worker is of tremendous benefit in assessing safety and providing the option of involuntary transportation, if needed. Second, the appearance of a uniformed officer and a plainclothes worker has the effect of balancing the need for authority and empathic in crisis work. This is not always possible if an officer is working solo and may have to move swiftly to an arrest that could have been avoided. By the same token, it may not be safe for a mental health professional to attempt such a call alone. Finally, there was significant benefit in addressing the crisis from a contextual perspective in Gloria’s home. This includes her physical environment and also makes it possible to more accurately assess the viability of her neighbor as an action plan alternative.

Mobile Crisis Units 611 There was no further until the next morning, when Gloria arrived with her neighbor at the mental health center.

Case Application: Cindy In the case of Cindy, the assessment of lethality in stage 1 had been addressed by law enforcement officers prior to the arrival and in many cases MCUs. The MCU is not the first responder to police calls but is summoned by officers when appropriate. The MCU was ed by officers on the scene via police radio. On this shift, the mental health worker was a licensed clinical social worker who had the authority to sign, if necessary, an involuntary order to transport the woman to the psychiatric emergency receiving facility. Although the objective is not to arrest or hospitalize individuals, it is beneficial for the authority to initiate an involuntary intervention to be present. In stage 2, since her father had arrived, team met separately with Cindy and her father, and in stages 3 and 4 both felt comfortable with sharing their feelings and relating their views of the problems. Options in stage 5 included arrest, involuntary transportation to the psychiatric hospital, or transportation to the crisis center, which is a voluntary status facility. It was agreed that the client would come to the crisis center for further evaluation. Given her age and the lack of any client history, she was itted for overnight observation, was reevaluated the next morning, and was referred to the outpatient mental health division for both individual and family therapy. For stage 7 a telephone call was placed to the father; it was determined that Cindy had returned home, and she and her father did follow-up with outpatient services. This case description illustrates several benefits of MCUs reported by Zealberg, Santos, and Fisher (1993). First, the ability to observe and interview on-site “allows for the most complete assessment with the least trauma to the patient” (p. 16). In this case it was also possible to interview Cindy and her father individually and to then converge the information obtained to determine similarities and differences reported. Second, mobile units can respond quickly, prevent situations from escalating, and avoid unnecessary arrests or hospitalizations. Third, a well-executed mobile crisis call “allows for better public education about mental health issues and resources” (p. 17). Fourth, potential cost savings to the county include not only the avoidance of unnecessary arrests or hospitalizations but also the opportunity for “officers to return to duty more quickly” (p. 17).

Case Application: Michael This evening had been a quiet one for the MCU when a radio communication came in from the county police SWAT team. It had received a call from Amanda, who advised that her husband, Michael, was in the house with her, armed and threatening to kill himself. Upon arrival, the SWAT team

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learned that the man had a painful and debilitating physical condition that had become worse. He was very despondent and wanted to die. Amanda stated, “I’ve talked him down from these states before, but this time things are much worse. He wants to die, but he doesn’t want me to be left alone. Our parents are deceased, and we have no children. We’re really all each other has.” Although the SWAT team was requesting a backup consultation from the MCU, the scene quickly became one that required negotiation not only with the client but also with the intervening teams. The case of Michael points out the importance of stage 1 in assessing both lethality and past experiences with coping behaviors. Although his wife was not being held hostage, this case presented an element of extreme risk and danger to Michael and Amanda and required the use of negotiation skills (Strentz, 1995). On this evening, the team consisted of the uniformed police officer and a ed nurse, and computer records found no criminal or mental health information on Michael. After consultation with the SWAT team, it was agreed that the nurse would, consistent with stage 2, attempt to first establish rapport with Amanda and use her alliance to connect with Michael. The problems (stage 3) were clear, so the predominant effort on this call was to connote empathy and provide (stage 4). Given the severity of Michael’s physical and mental conditions, the only alternative in stages 5 and 6 would be to arrange for his hospitalization. The dialogue between the MCU nurse and the couple went extremely well, and Michael voluntarily surrendered the gun and agreed to go with the MCU to the hospital. A follow-up call to the hospital for stage 7 confirmed that Michael was safe and stabilizing in the hospital. Although the outcome of this case was positive, it was important to note the difference between this call and others handled by the MCU and SWAT teams. A follow-up meeting was held with the SWAT team and a mobile crisis worker to review the call. The SWAT team expressed the need for additional training around mental health and substance abuse issues, which was subsequently provided. As noted by Strentz (1995), “The element of danger coexists with the opportunity for successful resolution and personal growth” (p. 147). Therefore, it is also essential to provide cross-training about SWAT team interventions to team of mobile crisis units.

OUTCOMES OF MCUs Outcome information about MCUs is limited, and Geller, Fisher, and McDermeit (1995) note that “beliefs about mobile crisis services far outnumber facts” (p. 896). Although Reding and Raphelson (1995) reported a 40% reduction in hospital issions during a 6-month period, a study by Fisher, Geller, and Wirth-Cauchon (1990) did not “ the numerous claims

Mobile Crisis Units 613 regarding the ability of mobile crisis intervention to reduce the use of hospitalization” (p. 249). However, Fisher et al. (1990) go on to report that “some mobile crisis teams may be very effective in reducing hospitalizations because they function as part of a system which has other key services available for treatment and diversion” (p. 250). In addition, Fisher et al. (1990) note that these units often reach people in need of hospitalization, so “that the unnecessary hospitalizations prevented by mobile crisis units are offset by the ission of individuals needing inpatient care who are discovered” (p. 251). Another problem is that “large numbers of persons who have committed minor crimes are taken to jails instead of to hospitals or other psychiatric treatment facilities” (Lamb et al., 1995, p. 1267). Lamb et al. (1995) conducted a follow-up study in Los Angeles of clients having a history of criminal and mental problems who had received outreach services from a police-mental team and found that “remarkably, only two percent of the group were taken to jail” (p. 1269). A study of mental health response models in three law enforcement jurisdictions provides further that collaborations between police and mental health services can reduce arrests and unnecessary incarcerations of people who have mental health problems (Stean, Deane, Borum, & Morrissey, 2000). Dyches, Biegel, Johnsen, Guo, and Min (2002) conducted a matched samples study of those who received mobile crisis services with those receiving services from a hospital. The authors found that consumers were 17% “more likely to receive community-based mental health services after the crisis event than a consumer from the hospital-based intervention cohort” (p. 743). With respect to those who did not have a previous history of mental health services, the authors found that “the hospital-based cohort’s likelihood of receiving postcrisis mental health services was 48% less than that of the mobile crisis cohort” (p. 744). Ligon and Thyer (2000) assessed client satisfaction with mobile crisis services in Georgia and found that both mental health clients and their family reported levels of satisfaction comparable to those for other outpatient services.

INITIATING AND SUSTAINING MCUs The future of MCUs is dependent on the ability of multiple systems to perceive their value and to then collaborate in a manner that will assure quality services that can be sustained in the community. While it is impossible to document how many MCUs have opened and closed over the years, a number of factors can influence these programs. First, crisis work can be dangerous when interventions occur in neighborhoods and homes with persons who may exhibit or have histories of violent behavior (Zealberg et al., 1993). Second, the behavioral health and law enforcement systems are rife

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with conflicts between the two systems (Dodson-Chaneske, 1988; Teese & Van Wormer, 1975), so “constant attention must be given to such collaboration” (Zealberg et al., 1992, p. 614). Finally, the larger political and turf factors that exist in any community can, unfortunately, lead to premature cuts despite a program’s efficacy (Diamond, 1995; Reding & Raphelson, 1995). Indeed, Hails and Borum (2003) found that only 8% of 84 medium and large law enforcement agencies had access to a mobile crisis unit in their jurisdictions. The political and organizational environments in which these units operate will no doubt present both obstacles and opportunities. It is also essential to work closely with law enforcement and to include ongoing supervision and training opportunities for police officers and mental health workers. In addition, consumers of services and their families must be involved in the development and refinement of MCUs. As stated by DCSB director, R. Derrill Gay, “Families see Mobile Crisis Units as essential services in community mental health and these are the people who need it, use it, and value it” (personal communication, May 19, 1999). The of mental health advocacy groups at the national, state, and local levels is also beneficial in the further development of mobile crisis units.

FUTURE OPPORTUNITIES Although the application and outcomes of mobile crisis units are encouraging, there are a number of opportunities to improve these services and to expand their availability. Zealberg, Hardesty, Meisler, and Santos (1997) identify several key areas of concern that include medical issues and the need for technology to these units. The authors note that “one of the more frustrating aspects of mobile crisis work involves patients whose presenting symptoms include medical as well as psychiatric diagnoses” (p. 272). Ambulance and EMS services can assist with medical problems, but collaboration with these operations may be problematic due to multiple providers of these services in communities or poor communication capability with MCUs. Because MCUs often address issues related to physical health and medications, the DeKalb unit has found that coupling psychiatrically trained ed nurses with the police officer can be very beneficial. In addition, the DeKalb MCU has added a limited number of antipsychotic and side effects medications, which are carried onboard, ordered by the unit psychiatrist, and istered by the onboard nurse. Technology offers immense opportunities to improve mobile crisis services. First, equipment is increasingly portable and more affordable, and it is feasible to equip MCUs with computers, cellular telephones, and other emerging products. Second, the ability to merge sources of information is improving, and it is possible for MCUs to determine any criminal and mental

Mobile Crisis Units 615 health history on clients quickly and efficiently. Finally, technology enables team of MCUs to enter data and update records without burdensome paperwork and forms. This can include outcome data, new client information, and instructions for other services concerning follow-ups. Virtually all the MCUs that have been documented are based in urban areas, which is understandable given the concentration of population and availability of resources. However, rural areas are extremely underserved; 21% of all rural counties have no mental health services, compared with only 4% in urban counties. The situation is much worse if overnight care is required; 78% of rural counties have no overnight services, compared with 27% in urban counties (Rouse, 1998). Coupled with the lack of public transportation in rural areas, MCUs offer the potential not only to provide services where needed but also to initiate any follow-up services that may be required. Although the costs of operating MCUs are a significant concern to communities, Zealberg et al. (1997) note that indirect cost savings must be considered, including the reduced loss of time for police officers, court costs that are avoided when situations are resolved without arrests, and avoidance of high-cost inpatient care in many cases. In addition, behavioral health care is increasingly provided under managed care models. Therefore, managed care organizations are also in a position to gain from such cost savings as avoiding hospitalizations and need to partner with the public sector in developing and ing MCUs. MCUs operate across a wide range of geography and sites and encounter very diverse populations. Based on the experience of an MCU based in New York City, Chiu (1994) provides case examples and suggestions on working with Asian, Hispanic, African American, and other diverse groups. In addition, Lyons, Cook, Ruth, Karver, and Slagg (1996) note that the inclusion of consumers of mental health services on MCU teams may be beneficial when responding to calls across a variety of settings, including homes and public places. For example, the authors found that “consumer staff were more likely to do street outreach than were non-consumer staff” (p. 38) and go on to note that consumer experience “can be an advantage for mobile crisis assessment with persons with problems of mental illness and housing instability” (p. 40). MCUs can be of tremendous benefit to communities when they are carefully staffed and ed by all stakeholders, including consumers of services and their families, law enforcement, and both public and private providers of behavioral health services. However, more research needs to be conducted to determine what combinations of staffing, services, technology, and intervention techniques are most effective and in what settings. It is also important to learn more about working with diverse populations and to investigate the benefits to rural residents through the implementation and evaluation of programs in these underserved areas.

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ACKNOWLEDGMENTS The author appreciates the input and provided by Dr. R. Derrill Gay, Director of the DeKalb Community Service Board, Decatur, Georgia, and to the staff of the Mobile Crisis Unit in the development of this chapter.

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sourcebook. Washington, DC: U.S. Government Printing Office. Slagg, N. B., Lyons, J. S., Cook, J. A., Wasmer, D. J., & Ruth, A. (1994). A profile of clients served by a mobile outreach program for homeless mentally ill persons. Hospital and Community Psychiatry, 45, 1139–1141. Sommers-Flanagan, J., & SommersFlanagan, R. (1995). Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 26, 41–47. Stean, H. J., Deane, M. W., Borum, R., & Morrissey, J. P. (2000). Comparing outcomes of major models of police responses to mental health emergencies. Psychiatric Services, 51, 645–649. Strentz, T. (1995). Crisis intervention and survival strategies for victims of hostage situations. In A. R. Roberts (Ed.), Crisis intervention and time-limited cognitive treatment (pp. 127–147). Thousand Oaks, CA: Sage. Teese, C. P., & Van Wormer, J. (1975). Mental health training and consultation with suburban police. Community Mental Health Journal, 11, 115–121. Wellin, E., Slesinger, D. P., & Hollister, C. D. (1987). Psychiatric emergency services: Evolution, adaptation, and proliferation. Social Science and Medicine, 24, 475– 482. Zealberg, J. J., Christie, S. D., Puckett, J. A., McAlhany, D., & Durban, M. (1992). A mobile crisis program: Collaboration between emergency psychiatric services and police. Hospital and Community Psychiatry, 43, 612–615. Zealberg, J. J., Hardesty, S. J., Meisler, N., & Santos, A. B.

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(1997). Mobile psychiatric emergency medical services. In S. W. Henggeler & A. B. Santos (Eds.), Innovative approaches for difficultto-treat populations (pp. 263– 274). Washington, DC: American Psychiatric Press. Zealberg, J. J., Santos, A. B., & Fisher, R. K. (1993). Benefits of mobile crisis programs. Hospital

and Community Psychiatry, 44, 16–17. Zealberg, J. J., Santos, A. B., Hiers, T. G., Ballenger, J. C., Puckett, J. A., & Christie, S. D. (1990). From the benches to the trenches: Training residents to provide emergency outreach services: A public/academic project. Academic Psychiatry, 14, 211–217.

26 The Comprehensive Crisis Intervention Model of Safe Harbor Behavioral Health Crisis Services YVONNE M. EATON, LCSW

Safe Harbor Behavioral Health (www.safeharborbh.org) Crisis Services is recognized as a model program by the Pennsylvania State Office of Mental Health. Four types of crisis intervention are available 24 hours per day, 7 days per week, to anyone experiencing a crisis within Erie County, Pennsylvania. A crisis is defined very broadly and includes anyone who is experiencing a disturbance of mood, thought, emotion, behavior, or social functioning. Some examples include suicide (ideation, attempts, and completed), psychiatric decompensation, situational stressors, family discord, substance abuse, domestic violence, and bereavement. The structure and functioning of the crisis team results in effective, successful intervention to those in crisis. The four basic services are telephone crisis services, walk-in crisis services, mobile crisis services, and access to crisis residential unit. These services will be discussed using case scenarios to illustrate techniques of crisis intervention.

ORGANIZATIONAL STRUCTURE AND FUNCTIONS There are 21 crisis services staff scheduled around the clock who have a variety of educational and experiential backgrounds. All staff complete a month of orientation with subsequent required weekly in-services/ training. Ongoing education is essential in ensuring staff are kept current on 619

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clinical intervention strategies and community resources. Training is videotaped for those not on shift at the time it is given. All staff are also certified in Nonviolent Crisis Intervention through the Crisis Prevention Institute, Inc. Staff attend individual clinical supervision sessions twice monthly to review cases and interventions. Field evaluations, in which the clinical supervisor accompanies workers on cases, are conducted frequently to assess clinical and intervention skills, and 24-hour accessibility to a psychiatrist and are provided to all staff. Staff includes 1 intervention specialist, 13 crisis workers, 6 shift supervisors, and 1 director. The intervention specialist provides much of the phone crisis counseling, information, referrals, and telephone triage. They also provide phone to suicidal callers until the mobile crisis worker arrives on the scene. The intervention specialist is based at the office for the duration of their shift. Crisis workers provide full crisis assessments and face-to-face intervention to individuals and significant others either at the scene of the crisis or on a walk-in basis. These workers utilize techniques of crisis intervention to assist consumers in accessing and utilizing resources to resolve the crisis situation. These workers report to the office but are quickly dispatched to respond to crisis calls by the shift supervisor. Shift supervisors, who also remain in the office, provide clinical and istrative direction to the crisis staff on their shift. They assure all requests for services are responded to in a timely manner as dictated by policy. They conduct documentation reviews and juggle the various demands on their shifts. The director is responsible for the hiring, training, clinical supervision, istrative direction, and discipline of all crisis staff. They are also responsible for the istrative duties of the agency (policies, budget, etc.).

TELEPHONE CRISIS SERVICES Crisis Services receives more than 2,000 phone calls per month. Crisis calls result in crisis counseling and , information and referrals, and crisis screening and triage. Crisis staff engage all callers with empathic responses and ive listening skills. Roberts (1996) offers a comprehensive text for crisis intervention strategies, which includes hotline work. Many callers choose to remain anonymous or, with phone only, effectively resolve their crises. A screening/triage form is completed for all callers who request further services or face-to-face . This essential form addresses both clinical information (such as suicide or homicide risk) and safety issues (such as weapons on the scene and legal history). All calls are assigned an intervention priority code, which allows the shift supervisor to prioritize these multiple requests on a clinical basis. Priority I calls require immediate intervention because of an individual’s significant risk of harm to self or others. Some examples of Priority I calls include suicide attempts in progress, police on

Comprehensive Crisis Intervention Model 621 scene or en route, and suicidal or homicidal ideation with intent and means readily available. Priority II calls require timely intervention because of an inability to cope with current stressors. Risk of harm to self or others is not pressing at the time of due to the presence of reliable s or lack of feasible plan, intent, or method. Some examples include hallucinations, delusions, and suicidal or homicidal ideation with lack of plan or intent. Priority III calls require intervention because of a moderate level of dysfunction. There is no identified risk of harm to self or others. Some examples include impaired ability to meet basic needs (shelter, hygiene), impairment in ability to meet family, educational, or occupational roles, and mood disturbance or other significant vegetative disturbances. Priority IV calls require intervention because of subjective distress and/or mild level of dysfunction or difficulty coping with current stressors. Some examples include minor mood disturbance and relational conflict. Regardless of the intervention priority assigned, all requests for services are addressed as quickly as possible, and every request for service is addressed within 24 hours.

Case Scenario A phone call was received from an anonymous male caller. This individual was very reluctant to provide information to crisis services. However, it was determined that the consumer had overdosed on 20 Prozac and 20 Ambien. The caller would not provide any demographic or identifying information, and the call had to be traced. While the trace was being completed, the caller became nonresponsive, and the phone was heard dropping to the floor.

Roberts’s (1996) seven-stage crisis intervention model was initiated. Stage 1: Assess Lethality. It was quickly determined via the suicide risk assessment (on the Crisis Services triage form) that the caller had already overdosed on a significant amount of medications, making this a highly lethal/urgent situation. Stage 2: Establish Rapport. Through the use of rephrasing, paraphrasing, questioning, empathy, and ive listening, the crisis worker was able to keep the client engaged while the trace was being completed. Establishing rapport with the client was essential because if the client terminated the call, he would likely have died. The triage form utilized by Crisis Services provides workers with structure for questioning, which is particularly helpful in these stressful situations. Some excerpts from the triage appear in Table 26.1. Stage 3: Identify Major Problem(s). The number one identified problem was a known overdose, which was complicated by the secondary problem of the client’s refusal to provide identifying information.

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Health- and Mental Health–Related Crises Table 26.1 Sample Triage Questions

Suicidality

Homicidality

Are you/client having thoughts of self harm? Have you/client done anything to hurt self already? If yes, describe: How long have you/client had thoughts to hurt self? How might you/client hurt self? Have you/client made any preparations to hurt self? What keeps you/client from hurting self? Are you/client having thoughts to hurt others? Who do you think about hurting? Have you/client hurt anyone already? If yes, describe:

( ) yes ( ) no ( )unknown ( ) yes ( ) no ( )unknown

( ) yes ( ) no ( )unknown ( ) yes ( ) no ( )unknown ( ) yes ( ) no ( )unknown

How long have you/client had thoughts to hurt others? What keeps you/client from hurting others?

Stage 4: Deal With Feelings. The worker first allowed the client to tell his story about why he felt so bad at this point in his life. The worker began to address those feelings but was unable to do much work in this area because the client became nonresponsive. Stage 5: Explore Alternatives. Because of the critical nature of the case and the client’s unconsciousness, there was no opportunity to explore alternatives or develop an action plan with him in collaboration with Crisis Services. Stage 6: Develop Action Plan. The crisis worker had to take control of this situation. The following steps were completed: 1. 2. 3. 4. 5.

The trace was completed and the address was obtained. A crisis worker and the police were dispatched to the scene. The client was observed through the window lying still on the floor. The police gained entry. The ambulance was called, and the client was transported to the hospital. 6. Because of the client’s earlier refusal of crisis assistance and mental health treatment, Crisis Services petitioned for an involuntary commitment, and this was approved. 7. The client was given medical treatment. Stage 7: Follow-Up. The next morning, a follow-up phone call was made to the hospital, which indicated that the client had been itted to the mental health unit following his medical stabilization.

Comprehensive Crisis Intervention Model 623

WALK-IN CRISIS SERVICES Any individual may appear at the office for services. Crisis staff will complete a crisis assessment encoming the evaluation of the individual in crisis, as well as the social context in which the crisis is occurring. The psychosocial format of the evaluation enables the worker to determine the extent and acuity of all reported problem areas, the appropriate therapeutic response for crisis de-escalation, and any referrals indicated for ongoing treatment.

Case Scenario A 19-year-old male was brought into the office by his parents because he was becoming “bizarre.” The consumer was collecting urine in a bottle, collecting used female sanitary products, and making drawings of elaborate machinery. He also began talking about death and harmful effects of heavy metal music and was found burying heavy metal CDs in the backyard. This individual had no previous mental health history.

Roberts’s (1996) seven-stage crisis intervention model was initiated. Stage 1: Assess Lethality. The client’s father phoned Crisis Services, expressing concern over bizarre behaviors exhibited by his son. There was no evidence of risk of harm to self or others but obvious evidence of a thought disorder. The father opted to bring his son into the office for a walk-in assessment. Stage 2: Establish Rapport. Upon the client’s arrival, it quickly became apparent that he had not been informed of the purpose of his visit. It was essential that the worker gather the client’s perceptions of any difficulties he was having and seek his point of view on the issues mentioned by his father. The use of the worker’s empathic communication skills allowed the client to express his thoughts, feelings, and experiences. Stage 3: Identify Major Problem(s). The assessment of the client included information regarding his mental status. The identified problem was the emergence of a serious thought disorder. It was discovered through the parents’ contributions that a diagnosis of mental illness, specifically schizophrenia, existed within the family history. Stage 4: Deal With Feelings. The crisis worker focused on the thought processes of the client. The client was somewhat insightful at the time of assessment, indicating a realization that others viewed his behaviors as illogical. He, however, explained his delusional beliefs and behavior to the worker. The worker was able to communicate concerns in a nonjudgmental and nonconfrontive way to the client, who was agreeable to

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Health- and Mental Health–Related Crises seeking inpatient mental health treatment. The client was, however, very fearful. The crisis worker dealt with the client’s immediate feelings of fear by explaining the ission process and treatment in detail, as well as offering to accompany the client and family to advocate for their needs. This alliance between the worker and the client was an essential component in getting the client to accept further services.

Stage 5: Explore Alternatives. Various alternative treatment options were discussed with both the client and the family, including two inpatient treatment facilities. The crisis residential unit was also explained as another option if hospitalization was denied. Stage 6: Develop Action Plan. The crisis worker, client and his parents decided on the following action plan: 1. Hospitalization at one of the inpatient facilities would be pursued. 2. The client was itted to the inpatient mental health unit. 3. group information through AMIECO (Alliance for the Mentally Ill) was provided to the family. 4. Outpatient referrals were given to the client. Stage 7: Follow-Up. Upon phone follow-up with the client’s parents, it was learned that the client had started medications and was responding well. The parents were working actively with the hospital staff to assist in discharge planning.

MOBILE CRISIS SERVICES Mobile crisis services may be provided by an individual crisis worker or by a team of two crisis staff at the scene of the crisis. This service shows most clearly the social context in which the crisis is occurring, giving the worker extremely beneficial information and insights. A crisis assessment is completed at the scene, with the goal of quickly determining the most appropriate disposition to meet the individual’s needs and obtain relief from distress. Recommendations will include a disposition in the least restrictive setting appropriate for the individual and the presenting crisis.

Case Scenario Crisis Services received a call from a 30-year-old female who claimed to be calling for someone else. Her speech was slurred, and the information given was inconsistent. The caller did provide an address of the apparent individual in crisis. Because of possible safety issues and unknowns, Crisis Services responded with the police. The consumer was not answering her apartment door, but the landlord assisted us in gaining entry. The consumer was discovered unconscious with a suicide note, an empty bottle of lithium, and 12 serious self-inflicted stab wounds.

Comprehensive Crisis Intervention Model 625 Roberts’s (1996) seven-stage crisis intervention model was initiated. Stage 1: Assess Lethality. During the initial phone , the client was providing misinformation to Crisis Services, claiming to be calling for a relative in distress. The crisis worker heard various inconsistencies in her story and also noticed the phone number from where the call was originating was also the phone number the caller was claiming to be her “relative’s.” The caller’s slurred speech was another warning sign. The crisis worker did attempt to ask direct questions to assess suicidality, but the caller refused to respond to these questions. The only information gathered about this alleged relative was that she was going to kill herself by overdosing. Stage 2: Establish Rapport. Through the worker’s attentiveness, accurate listening skills, reassurance, and , the caller was kept engaged and eventually provided an address. While the initial worker was attempting to elicit more information, another worker was able to identify with police assistance that the address provided was in fact the residence that was connected with the incoming phone number; therefore, it was determined that the caller was in fact the one in distress. Stage 3: Identify Major Problems. Because of various inconsistencies and misinformation provided by the client on the initial phone , the major problems were unknown at the time of dispatch. It was not until the crisis worker and the police officer arrived on the scene that the critical nature of the problem was identified. The client would not answer her apartment door, but heavy, labored breathing was heard on the other side. The police forcefully gained entry to find the client naked and unresponsive on the bed with 12 serious self-inflicted stab wounds to her chest area. A suicide note and an empty bottle of lithium were found on the dresser. Stages 4 and 5: Deal With Feelings and Explore Alternatives. Because of the client’s unconscious state and critical condition, the crisis worker was unable to deal with the client’s feelings or mutually explore treatment options. Stage 6: Develop Action Plan. The police officer and crisis worker took control of the situation by doing the following: 1. The police immediately called for an ambulance. 2. The police and crisis worker attempted to stop the bleeding from the client’s wounds. 3. The ambulance arrived and transported the client to the hospital. 4. Crisis Services petitioned for an involuntary commitment on an anonymous female (because her true identity was unknown), and this was approved. 5. The client was treated and medically itted. Stage 7: Follow-Up. A follow-up phone call was made to the hospital the next day, but the client was still in the intensive care unit (ICU). On

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Health- and Mental Health–Related Crises day 2 the hospital revealed the client’s identity to Crisis Services and reported that the client had eloped from a mental health unit earlier that week. The client was eventually transferred to the original hospital from which she had eloped because her family wanted to assist with her treatment and discharge planning.

Face-to-face with individuals in crisis may be provided either by a walk-in or by a mobile service. Crisis Services currently sees more than 350 individuals per month.

ACCESS TO CRISIS RESIDENTIAL UNIT The crisis residential unit (CRU) provides residential accommodations and continuous, 24-hour supervision for individuals in crisis. This essential resource is another option in providing effective crisis intervention options. CRU is a truly collaborative program between Community Integration Inc, Crisis Services and Stairways (a separate community mental health provider). Crisis Services its individuals to this unit after a thorough crisis assessment has been conducted and a physician’s order from the on-call crisis physician has been obtained. In order to be considered for ission, the individuals must be medically stable, voluntary, and at least 18 years of age, and must present no overt threat to him- or herself or others. The CRU program is an eight-bed facility staffed and run by Stairways, Inc. CRU provides brief treatment (up to 5 days) as an alternative to hospitalization which focuses on problem solving and crisis management.

Services The following services are provided at CRU (Stairways, 1999): Assessment: A thorough assessment is conducted to identify and address an individual’s emotional needs. In addition, a nursing health assessment is conducted to determine one’s physical health needs. Psychiatric assessment: Each client sees the psychiatric consultant on a daily basis in order to plan and monitor the best course of treatment. Crisis counseling: Each client receives individual counseling to assist him or her in better understanding the crisis process and ways to effectively cope with the crisis situation. This involves initial problem identification and the development of a rehabilitation plan with a staff member. Stabilization: The CRU program offers a safe, therapeutic environment in which clients in crisis may feel secure and better able to address their problems with as little stress as possible. Medication monitoring: CRU offers medication monitoring and education to all clients so that the most appropriate medication regime can be developed.

Comprehensive Crisis Intervention Model 627 Programming/psychoeducational groups: The following groups are provided: 1. Stress reduction: Reviews the effects of stress on the body and teaches clients to practice one of four techniques to alleviate the symptoms of stress. In addition, assertiveness and goal planning are taught so the clients might feel better able to take control over stressful life events and implement healthy coping strategies during times of stress. 2. Conflict resolution: Assists clients in learning how to objectively recognize, evaluate, and execute a healthy course of decision making for daily living. It also helps the client to examine the primary conflict or crisis that resulted in his or her CRU ission so that a prevention plan can be developed. 3. Symptom management: Offers suggestions to assist clients in coping with symptoms associated with mental illness. Symptoms covered during this group are modified to meet individual needs. 4. Recreation: Aims planned, structured, regular group activities at promoting social interaction and introducing new time-structuring ideas.

Program Steps ission CRU’s short-term program utilizes a problem-solving model to resolve crisis situations in the shortest time possible. The maximum stay in most cases will be 5 days; however, the treatment team has the authority to authorize an additional 5 days with clinical rationale. Crisis Services, with a signed release, provides CRU with a copy of the crisis assessment, the safety contract indicating the client’s ability to maintain safety, and a verbal report. Crisis Services brings the client, clothes, and medication to the unit. Upon ission, CRU staff count and secure medications, search belongings for weapons or pills, review paperwork, determine the comfort needs of the client (need for food, bath, etc.), and orient the client to the unit and his or her assigned room (Bryan Hickman, personal communication, May 5, 1999).

Treatment Team The treatment team is run by the director of Crisis Services and includes the supervisor of CRU and an istrative case manager from Case Management Services (who authorizes issions and extensions). A homeless case manager is always in attendance to address the placement needs of the homeless. Additional providers are always welcome to attend to provide their input and recommendations.

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The treatment team meets three times per week to review the client’s progress, make recommendations for treatment needs, and make plans for discharge. Under certain situations, when there is a clinical need for additional stabilization, an extension of an additional 5 days may be granted by the majority vote of the three main . Hospitalization and/or Termination If it is determined that a client is not making adequate progress at CRU, other accommodations may be necessary. If a client presents an immediate danger to him- or herself or others, Crisis Services will be ed immediately to pursue hospitalization. Clients who are consistently unable or unwilling to follow the rules at CRU may be discharged after treatment team review and approval (Stairways, 1999). Discharge Discharges generally occur when the following conditions exist: 1. Short-term treatment goals are sufficiently met. 2. A client’s psychiatric condition or level of functioning has been raised to allow him or her to move to a less restrictive setting. 3. Discharge planning and follow-up are arranged. (Stairways, 1999)

Individuals who choose to leave the unit against clinical advice (ACA) are asked to sign an ACA form. Crisis Services is ed with every discharge and sent a discharge summary. Crisis Services attempts to follow up on all clients who left ACA.

EMERGENCY PSYCHIATRIC CRISIS STABILIZATION: CASE APPLICATION Case Scenario A 35-year-old male with a history of schizophrenia was referred to Crisis Services by another provider after being denied hospitalization. He was very paranoid and delusional, believing that people were attempting to break into his apartment at night. His speech was rapid and tangential, with loose associations. He talked about killing Jeffrey Dahmer and Hannibal Lecter and believed that he was a disciple of Satan. At times he was responding to internal stimuli, whispering to himself and making unusual gestures.

Comprehensive Crisis Intervention Model 629 Roberts’s (1996) seven-stage crisis intervention model was initiated. Stage 1: Assess Lethality. By conducting a thorough crisis assessment, it was determined that the client was experiencing nihilistic delusions but was able to contract for safety, indicating he would seek help before acting on any thoughts to hurt himself or others. He had no previous assaultive history nor any current drug or alcohol use. Although psychotic, the client was cooperative and did not appear in danger of impulsively acting out; he did, however, present in a heightened state of anxiety. It seemed that he could benefit from a structured, supervised setting. Stage 2: Establish Rapport. Understanding and were two of the most essential skills utilized by the crisis worker in establishing rapport with the client. When intervening with a psychotic client, it is essential to not challenge his or her delusional system or “play along” with it. Challenging this fixed belief system will only create a sense of distrust by the client. Playing along with delusions or hallucinations could incite violence or mistrust when the worker is not aware of or fails to respond to those perceptions that the client is experiencing. The use of attending behavior (Kanel, 1999), such as active listening and ive posture, were extremely helpful in letting the client know the worker was interested and was there to help. Stage 3: Identify Major Problem(s). Several problems were identified during the crisis assessment. The client was psychiatrically decompensating. He was not on any medications and was not receiving any outpatient treatment at the time. Stage 4: Deal With Feelings. The crisis worker, rather than focusing on the delusional beliefs, focused on the client’s feelings of anxiety and fear of being alone in his apartment. The worker was able to address these feelings and suggest that together they explore options to make the client feel more comfortable. Stage 5: Explore Alternatives. Because hospitalization was already denied, other alternative treatment options had to be explored. The CRU was described to the client, who was agreeable to being itted to this unit. The client also signed a safety contract, indicating his ability to maintain control. The crisis worker received an ission order through the crisis psychiatrist on call, and the client was transported to CRU. Stage 6: Develop Action Plan. Once the client itted to CRU, the staff formulated an action plan with him. The following goals were discussed: 1. The client would start medications as prescribed by the CRU consulting psychiatrist. 2. The client would be given an intake appointment for ongoing outpatient services.

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Health- and Mental Health–Related Crises 3. The client would participate in individual ive counseling at CRU.

Stage 7: Follow-Up. At the CRU treatment team meeting (2 days after ission), it was determined that the client had started antipsychotic medication, and an intake appointment was scheduled for that day. On the fifth day, the usual day for discharge, the client’s progress was discussed, and an extension was granted for an additional 5 days so that the client could get linked up with other mental health services and stabilize further. At the end of the 10-day stay, the client was transferred to a Stairways Group Home (Community Rehabilitation Residence), was on a waiting list for a case manager, was taking psychotropic medication, and had an outpatient follow-up appointment.

CRITICAL INCIDENT STRESS MANAGEMENT FOR CRISIS WORKERS A “critical incident” is any event that can exert such a stressful impact so as to overwhelm one’s usual coping mechanisms (Everly & Mitchell, 1999). Critical Incident Stress Management (CISM) includes a wide variety of techniques and interventions for individuals exposed to life-threatening or traumatic events (Mitchell & Everly, 1993). According to Everly (1995), CISM aims to prevent traumatic stress, mitigate the effects of the critical incident, and maximize recovery. The seven core components of CISM (see chapter 4, pp. 86–90) include the following: 1. Precrisis preparation: Educational programs are available on topics of stress, stress reactions, coping strategies, disaster response, and so on, to assist in mental preparedness. 2. Individual crisis intervention: services and individual crisis intervention. 3. Large groups: Large group crisis intervention and demobilization. 4. Critical Incident Stress Debriefing (CISD): A group meeting/discussion about a critical incident provided to those directly involved in the incident. 5. Defusing: A shortened version of a CISD that takes place about 12 hours after the event. 6. Family CISM/organizational consultation: A variety of services and education can be tailored for significant others whose loved one has experienced a critical incident. 7. Follow-up/referral: Telephone outreach, station visits, and various referrals can be made.

It is essential that crisis workers exposed to traumatic events be provided with CISM services when appropriate. CISM allows workers the opportunity to discuss the traumatic event, promotes group cohesion, educates them

Comprehensive Crisis Intervention Model 631 on stress reactions and coping techniques, and shows that the Crisis Services employer cares about the welfare of its employees. As Maggio and Terenzi (1993) state, s must review potential critical incidents and pinpoint particular vulnerabilities of their agency. The following critical incidents have warranted the use of CISM techniques with the crisis workers of Crisis Services: Nature of Incident

CISM Service

Suicide by gunshot (three times) Suicide by hanging (two times) Suicide attempt—severe stabbing Dead body—several days old Threat and assault on crisis worker Shooting at crisis worker

CISD CISD CISD CISD CISD Individual consult

Policies indicating response to these critical incidents, as well as aftercare and stress management for the crisis workers, should be in place in all crisis intervention agencies.

REFERENCES

Everly, G. (1995). Innovations in disaster and trauma psychology: Applications in emergency services and disaster response. Ellicott City, MD: Chevron. Everly, G., & Mitchell, J. (1999). Critical Incident Stress Management—a new era and standard of care in crisis intervention (2nd ed.). Ellicott City, MD: Chevron. Gilliland, B., & James, R. (1997). Crisis intervention strategies (3rd ed.). Pacific Grove, CA: Brooks/Cole. Kanel, K. (1999). A guide to crisis intervention. Pacific Grove, CA: Brooks/Cole. Maggio, M., & Terenzi, E. (1993, December). The impact of critical inci-

dent stress: Is your office prepared to respond? Federal Probation, 57, 10–16. Mitchell, J., & Everly, G. (1993). Critical Incident Stress Debriefing: An operations manual for the prevention of traumatic stress among emergency services and disaster workers. Ellicott City, MD: Chevron. Roberts, A. (1996). Crisis management and brief treatment: Theory, technique and applications. Belmont, CA: Wadsworth. Stairways. (1999). Crisis residential unit: A program handbook for clients, their family and friends. Erie, PA: Author.

27 A Model of Crisis Intervention in Critical and Intensive Care Units of General Hospitals NORMAN M. SHULMAN AMY L. SHEWBERT

Historically, when a patient in a medical-surgical hospital is recognized as having a need for psychological as a result of a medical crisis, the attending physician requests a consultation from a psychiatrist, psychologist, or other mental health professional. Although this professional can provide important diagnostic information on the immediate mental status of the patient, usually little, if any, consideration is given to the patient’s ongoing emotional needs. Typically, directives for medication and possibly a referral to another mental health or social service professional are given. Generally, only if a patient becomes a behavior management problem will daily psychological intervention be ordered. When such services are not available, behavior management is frequently left up to nursing, case management, or clerical staff, who often do not have the time or training to attend to these problems, which can be very disruptive. It is thus our assertion that this lack of proper attention to a patient’s psychological needs results in an unnecessary burden for the immediate staff and frequently leads to an exacerbation of the patient’s crisis. A standing psychological consult available to critical care and other areas of a general hospital would provide the means for giving proper attention to the patients’ mind-body experience, while alleviating stressors which the staff is neither trained nor compensated to address. As a result, potential crisis situations can be minimized and in some cases prevented. 632

Critical and Intensive Care Units 633

DEFINITION AND SCOPE OF MEDICAL CRISIS Medical crises are an inevitable part of the human experience. Although the definition of a medical crisis is subjective, the drastic change in lifestyle resulting from the crisis is a common theme. Pollin and Kanaan (1995) defined a medical crisis as “a time of unusual emotional distress or disorientation caused by the onset of, or a major change in, the medical condition” (p. 15). Another definition of a medical crisis is the reaction of a person resulting from a substantial variation in experiences differing from the person’s usual view of the world (Shulman, 1999). These emergencies create such instability and chaos in the person’s life that normality, as the patient previously experienced it, ceases to exist. People in a crisis state demonstrate the following identifiable characteristics (Roberts, 1990): 1. 2. 3. 4. 5.

Perception of a meaningful and threatening event Inability to cope with the impact of the event Increased fear, tension, or confusion Subjective discomfort Rapid progression to a state of crisis or disequilibrium

The stress involved with medical crises is typically temporary, yet it can have lifelong effects. The individual’s coping skills, cognitive processes, typical affective processes, and history of psychopathology not only determine the degree to which life is affected but also define the medical crisis itself (Roberts, 1996). The medical crisis generates stress that is universal to all persons in crisis regardless of age, gender, race, and so on. Situational factors, including medical emergencies, life-threatening and chronic illnesses, family health problems, crime, and natural disasters, often incite a medical crisis (Roberts, 1996). Roberts (1996) cites valuable statistics provided by the U.S. Department of Justice establishing the prevalence of medical crises as initiated by medical emergencies. For example, as a result of acute psychiatric or medical emergencies, 254,820 people visit emergency rooms daily; these medical crises also include between 685 and 1,645 suicide attempts per day in a year (Roberts). Regarding life-threatening disease, medical professionals diagnose 3,205 new cancer cases per day, and 140 AIDS patients die each day. Chronic illnesses also for a great deal of the medical problems experienced by persons in crisis. For instance, a 1991 national health interview survey concludes that some 36 million Americans limit daily activities because of long-term sickness (Pollin & Kanaan, 1995). In addition, 56.5 million individuals suffer problems caused by cardiovascular disease; other chronic illnesses that contribute to the high incidence of medical crises include arthritis, cystic fibrosis, multiple sclerosis, and diabetes mellitus (Pollin

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& Kanaan, 1995). Family health problems, consisting of child abuse, drug abuse, domestic violence, and so on, relate directly to the origin of medical crises (as cited in Roberts, 1996). Finally, violent crime estimates also illustrate the high incidence of crises in society today. Data based on the Bureau of Justice statistics indicate that 357 persons are victims of forcible rape every day of the year (Roberts, 1996). Medical crises arbitrarily affect all humans, thus creating a scope of immense proportions.

DIAGNOSTIC DESCRIPTORS OF PATIENTS AND FAMILY Persons in a crisis state frequently experience similar emotions, reactions, and periods of vulnerability. The medical crisis produces stress for the patient and family. Furthermore, examination of patients in specialized hospital units indicates the same characteristics identifying persons in medical crisis. Certain characteristics and vulnerabilities identify the patient in crisis. High-risk patients often have suppressed or agitated affect, or “frozen fright,” which describes the inability to react entirely (Pollin & Kanaan, 1995). Suicidal ideation combined with depressive symptoms clearly indicates a person with high-risk qualities. Depression is among the most prevalent psychological responses among patients in medical crisis. Goldman and Kimball (1987) report that 25% of patients itted to critical care units experience symptoms of depression. Four common types of depressed states among special risk patients are: (a) major depressive illness, (b) adjustment disorder, (c) dysthymic disorder, and (d) organic affective disorder (Goldman & Kimball, 1987). A contributory factor to the depression is low selfesteem. Patients report feeling dehumanized by the lack of privacy during treatment times (Rice & Williams, 1997). Additional common concerns of the patient include quality of life, death, and dying. Other traits of crisis patients consist of inadequate communication with caregivers and inadequate cognitive assimilation of the crisis (Pollin & Kanaan, 1995). Control, self-image, dependency, abandonment, anger, and so on are issues that must be dealt with by the patient in crisis. These descriptors contribute to a patient’s vulnerability during the traumatic event. At a time of extreme stress as produced by a medical crisis, patients are susceptible to emotional changes. The degree of vulnerability depends on the “newness, intensity, and duration of the stressful event” (Roberts, 1996 p. 26). Physical and emotional exhaustion, previous crisis experience, and available material resources (Roberts, 1996) are important considerations when determining the risk of the patient in medical crisis. The family of a person in medical crisis cannot be disregarded when considering the effect on lifestyle change. Family frequently deny the severity of the situation (Pollin & Kanaan, 1995). A new role as the primary

Critical and Intensive Care Units 635 caregiver during hospitalization and after discharge can be an overwhelming responsibility for a family member not properly prepared emotionally. Daily care for people with chronic illness occurs in informal, noninstitutional settings in 70 to 95% of the situations necessitating such activities (as cited in Pollin & Kanaan, 1995). Difficulty with living arrangements and financial commitments create a new burden for all persons involved. Changes in the family dynamic resulting from differing coping styles in response to the crisis provide an additional stress. Tension between family can escalate, introducing another problem for the family and patient in crisis that must be resolved. The unpredictability and obscurity of the medical problem are perhaps most difficult for the family. Rice and Williams (1997) describe the exacerbation of family ’ fears and anxieties caused by the presence of intimidating equipment and the proximity of critically ill patients. Furthermore, emergency and intensive medical treatment is typically swift and may appear impersonal to a concerned family member. Dealing with life-sustaining issues, life-or-death decisions, and the possibility of death elicit familial emotional complications (Rice & Williams, 1997). The psychological distress of families may also include guilt as a result of the medical crisis.

Specific Intensive Care Unit Symptoms Patients of specialized intensive care units experience similar symptoms; for example, rehabilitation hospitals provide services for patients with injuries that embody great potential for psychological distress (Bleiberg & Katz, 1991). As a result of medical problems with varying degrees of impairment, disability, and handicap, patients must cope with issues of autonomy, loss, self-concept, and cognitive capacity. Medical intensive care unit (MICU) patients exhibit symptoms of the high-risk patient. Patients diagnosed with cancer experience psychological distress involving matters regarding quality of life, possibilities of disfigurement or disability, pain, and changes in personal relationships (Rozensky, Sweet, & Tovian, 1991). Matus (as cited in Creer, Kotses, & Reynolds, 1991) attests that psychological precipitants (emotional arousal), psychological symptoms (panic), and psychological factors (secondary gain, low self-esteem, etc.) are operants with asthma patients. End-stage renal disease (ESRD) patients, whose treatment often requires up to 12 to 21 hours of dialysis per week, are disturbed by the constant threat of death and increasing dependency. MICUs are treating increasing numbers of patients with human immunodeficiency virus (HIV) who require psychosocial services for themselves as well as their families and loved ones. Cardiac intensive care units (CICUs) also provide an arena for crisis patients in need of psychological treatment. Thompson (1990) indicates a reduction of anxiety and depression in crisis patients being treated for coronary disease who receive psychological ser-

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vices. Finally, the pediatric intensive care units (PICUs) are the domain of children in crisis coping with a traumatic event. A sense of desperation involved with treating a sick child elicits heartfelt stressors for the staff and families (DeMaso, Koocher, & Meyer, 1996).

A MODEL OF COMPREHENSIVE CARE This section focuses on how an already established program in a general hospital increases the resilience and reduces the impact of risk factors on patients suffering from a medical crisis. The section will examine how the traditional consult system has proven to be ineffective in helping a patient recover from a crisis. The rationale for a more effective and accessible system will be proposed, followed by a detailed description of the model, including how it interfaces with the rest of the hospital and the social network.

The Failure of the Traditional Consult System The traditional consult system continues to fail within most hospitals, and therefore many medical crises that could be prevented are not. For example, in teaching hospitals, where psychiatric residents depend on mental health consults to gain experience, all too frequently several unprepared students respond to a consult and overwhelm an already vulnerable patient. A balance of the patient’s emotional needs and the residents’ educational needs can be affected with a modicum of sensitivity and forethought, but, unfortunately, this scenario is more the exception than the norm. The stigma attached to the public’s perception of mental illness continues to pervade the general society, and hospitals are no exception. This prejudice creates an indirect negative impact on patient care because hospital staffs often feel that suggesting psychological consultation may be interpreted as an insult by the patient. In fact, this perspective affects staff to the degree that the patient’s emotional needs may never by considered. The social stigma attached to mental illness, coupled with the reality of an intense medical perspective of doctors and nurses, facilitates the psychological neglect of patients with psychological needs, especially those in critical care. This phenomenon occurs even when medical conditions are affected by a patient’s mental and emotional status. Depression of the chronic type (e.g., dysthymic disorder) can contribute to hostility and behavioral management problems in critical patients. Finally, physicians’ inclinations to divert immediate attention from psychological treatment adversely affect the consult system in a variety of ways. Because physicians in critical care areas are trained specifically to identify and treat medical conditions, a patient’s total care tends to remain unaddressed. A physician’s professional agenda may also be threatened by a men-

Critical and Intensive Care Units 637 tal health clinician’s involvement in the case, especially if it is not asked for, thus resulting in rejections of a psychological consultation. The end result is that all too many patients spend their hospital days without proper psychological help even in intensive care units. This neglect often complicates and exacerbates a patient’s existing medical problems to crisis proportions.

Rationale for the Standing Consult Increasing volumes of evidence demonstrate the efficacy of mental health interventions during a patient’s hospital stay for medical or surgical crises. For example, MICUs employ mental health consultants in cancer treatment centers. Rozensky, Sweet and Tovian (1991) describe the therapeutic efficacy of psychological consultation for cancer patients. Assessment of the patient’s physical and social environments, psychological strengths and weaknesses, and response to the diagnosis and treatment of cancer, as well as assessment of the patient’s personality and coping styles, provide a unique perspective that is integrated into individualized treatment strategies. It is essential that medical professionals realize the value of a holistic approach to treatment as essential within critical care areas, including psychological consultation and ongoing treatment. Such intervention during the patient’s hospital stay defies the standard of the “one time only” consult and includes the provision of ongoing ive and adjustment psychotherapy. This trend to consider a patient’s continuing needs includes family therapy, particularly when treatment is compromised by unhealthy family interactions. Additional services include arranging for psychological testing and referrals to related specialists (e.g., neuropsychologists and outpatient aftercare community medical professionals). Given the traumatic nature of a serious or critical illness or injury and the treatment necessary for patients in these conditions, it seems appropriate to adhere to a comprehensive approach to recovery. The vision of a standing psychological consult embodies the perspective of the mind-body interaction—specifically, that a patient’s mental health directly correlates to length of stay and potential for recovery. The model proposed here includes ongoing attention to fluctuations in mental stability as a result of traumatic injury or severe medical conditions. The following model (see Fig. 27.1) has been established at the Texas Tech University Medical Center in Lubbock, Texas. It includes the burn intensive care unit, transitional care center, rehabilitation, and neonatal and pediatric intensive care units. (The Southwest Cancer Center and the bone marrow transplant unit are covered in a similar fashion by an independent clinician.) The standing consult was approved on these units with the authorization of the acting chief of surgery, John T. Griswold, M.D., of the Texas Tech University Medical School after the model was proposed to him in 1992.

Dept. of Neuropsychiatry (Medication Consults) Psychiatry Residents

BICU - TCC - Rehab Licensed Psychologist (Director/Supervisor)

SICU MSW - A

PEDS PICU - NICU LMFT

Outpatient Aftercare


CICU - MICU LPC (proposed)

SWCC - BMT LPC

Pain Clinic Licensed Psychologist


CHART LEGEND BICU: TCC: SICU: MSW/A: PEDS: PICU: NICU:

Burn Intensive Care Unit Transitional Care Unit Surgical Intensive Care Unit Masters in Social Work, Advanced Clinical Practitioner Pediatrics Pediatric Intensive Care Unit Neonatal Intensive Care Unit

Figure 27.1

LMFT: CICU: MICU: LPC: SWCC: BMT:

Licensed Marriage and Family Therapist Cardiac Intensive Care Unit Medical Intensive Care Unit Licensed Professional Counselor Southwest Cancer Center Bone Marrow Transplant

Organizational chart of model of comprehensive health care at Texas Tech University Medical Center

Critical and Intensive Care Units 639 Dr. Griswold had been thinking at the time the proposal was made that only half of a patient’s needs were attended to at discharge from critical care areas. The Department of Psychiatry, the likely option to turn to regarding the provision of psychological on these units, did not consider this to be part of its curriculum agenda. Its consultation role had been narrowly defined to include assessment and pharmacotherapy only. On rare occasions, a patient would be followed a few times until discharge, but usually the extent of the consultation ended after one interaction, if a consultation was requested at all. There was also a problem of responsiveness in that frequently a patient would be discharged before a psychiatric resident saw the patient. Unfortunately, when this problem was added to the understandable lack of attention to psychological issues by hospital staff, an inordinate number of patients never had an essential aspect of their treatment attended to. Traditionally, automatic consults in general hospitals have been limited. Once the resistance to the standing psychological consult was overcome by Dr. Griswold’s insistence to the staff of the importance of the program, it was instituted as a component of overall health care. The mental health professional, in this case a licensed psychologist, was able to systematically evaluate every patient itted to the six-bed burn intensive care unit, the first unit on which it was tried. The initial assessment included the patient’s mental status, internal and external coping resources, degree of family , and premorbid mental health history. The evaluation included a determination not only of the patient’s need for services but also whether the patient and family would accept those services. Psychological interventions were never imposed on a patient (or family), and it was the patient’s (or family’s) prerogative to terminate the relationship at any time. The attending physician always retained power over the course of treatment, including the option to cancel the intervention. Rounds were made daily on the burn unit and on weekends when indicated. In addition, the attending physician or staff would call in the clinician at any other time if the situation warranted it. Deference to medical personnel was always given if a procedure was in process or needed to be done at the time of the session. The patient’s condition was also taken into consideration in the sense that the patient was never pushed to tolerate more than he or she could handle. As it turned out, the length of the sessions increased as the patient’s condition improved. Once a patient stabilized, less time was then required until discharge. Patient needs were also informally determined by any physician, resident, intern, nurse, therapist, or aide who detected and then ed on important information to the psychologist. Formally, his attendance at weekly staffings provided input regarding the degree and type of interventions. Frequently, the psychologist, with and without his colleagues, would consult with other professionals who might shed more light on a patient’s status. The psychologist was in a unique position to subsequently consult a psychiatrist for medi-

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cation issues, a neuropsychologist, a substance abuse expert, or any other professional who could contribute to the comprehensive care of a patient. Since a systems approach is utilized, family was also given on a regular basis, particularly when a patient could not be communicated with directly. The psychologist made it a priority to either convey information himself or encourage physicians working on the case to keep a patient’s family updated with concrete and realistic information, even if it was less than positive. Anecdotally, it is safe to say that the overwhelming majority of critical care patients and their families appreciated the consistent presence of a caring mental health professional on an intensive care unit—even in cases where death is imminent. This professional can serve to help a patient maintain dignity with a sense of purpose while facing death. Patients and families were also satisfied with the continuity of psychotherapeutic care made available. They realized that there were times when a patient needed to talk to a neutral party about issues that may not be easily shared with significant others, even clergy. The unit psychologist was clearly in a unique position to prevent problems from occurring and to be available to respond to occasional conflicts among patients, family , and professional caregivers, including physicians. Physicians open to the psychologist’s role with the treatment team benefited from input not normally made available, as well as from not having to commit valuable time and energy to nonmedical issues. In general, the entire scope of a patient’s needs was treated more effectively and efficiently. While a hospital nond psychiatrist was used as a consultant on medication issues, this model suggests the ideal arrangement of pairing a psychiatrist with a psychologist to work in tandem on critical care units. Questions regarding psychiatric medications and follow-up maintenance need not be the concern of the attending and resident physicians alone. As opposed to the limited consultation offered by existing models, a psychiatric counterpart to the psychologist can also follow a medicated patient daily. Such a professional liaison proves to be efficient for all of the treatment team. For example, many times issues of drug interactions and the psychologial effects of medication routinely istered to critical care patients can be handled by the specialist most uniquely qualified to address these issues. A psychiatrist experienced in the area of critical care is an invaluable member of the team, allowing other physicians to be free to concentrate on their specific areas of expertise. At the Texas Tech University Medical Center intensive care and rehabilitation units, the psychological needs of patients are no longer neglected by the absence of integrated treatment. Treatment is now more comprehensive, with issues of compliance, treatment interference, and patient-family-staff conflicts being dealt with quickly and as a function of overall care, since the psychologist is already involved. In this manner, demands on the staff to perform duties outside of their job description are minimized. After dis-

Critical and Intensive Care Units 641 charge, another advantage to the patient is the increased tendency to follow through with outpatient aftercare either with the unit psychologist or with another professional in the community. The psychologist is also available to staff whose equilibrium may be disturbed by the extraordinary demands of critical care. Individual and group interventions are useful either for ongoing or in response to a traumatic event on the unit. As a result, the staff gains a measure of solidarity and security with the knowledge that a trusted professional is readily available to respond to their professional and personal needs.

CASE ILLUSTRATIONS Case 1 T. is a 35-year-old Hispanic female seen to evaluate her emotional response to traumatic double leg amputations. The patient was injured in an automobile accident, which also involved her 16-year-old son, who was driving and had fallen asleep at the wheel. The patient’s son had informed her prior to the accident that he was very tired and that he wanted her to drive. Shortly thereafter, the accident occurred, and the patient’s legs were crushed beyond repair. The boy suffered only minor injuries.

The first intervention was agreed to by the patient’s husband, who wanted his son seen. This was to allow the boy to see his mother and determine that she was going to live, and to give her an early opportunity to absolve him of any guilt. Once this was accomplished, the patient was talked to daily and encouraged not to give up because her prognosis was good, given current rehabilitation capabilities. These interventions constituted the initial cognitive reframing efforts. The importance of employing a systems approach is exemplified in this case. As the inpatient psychotherapy progressed (eventually over a course of 65 sessions covering two issions, over a 5-month period), it came to the therapist’s attention that the patient’s husband and other son (age 17) were in the midst of their own crises. This information necessitated that family and individual therapy be done with various combinations of family collaterally with the treatment of the identified patient. Adjustments and readjustments of coping styles have had to be made over the past several months as minor crises have erupted. For example, the father and one of the sons began drinking more to numb their pain over their loved one’s condition. Second, the patient became recurrently depressed during the difficult physical rehabilitation she had to endure. In addition, she was forced to face the hard reality that an above-the-knee amputation posed extremely difficult prosthetic complications. Third, the other son considered

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dropping out of college, against his mother’s wishes, because of his inability to concentrate. At the time of this writing, the family are still struggling to balance their respective means of coping. Overall, the situation has been partially reframed successfully in that some positive adaptations have been made. For example, T. returned to graduate school to get a master’s degree in counseling so that she can help others. Her husband has stopped drinking, and the boys are being seen individually to facilitate their resolving any residual guilt, resentment, and substance abuse issues. In the best of all possible circumstances, the family would have accepted the assistance of antidepressant medication, but the patient and her family wanted to work without its potential benefits. They remain committed to working together to complete their collective resolutions and should continue their treatment as outpatients until it is no longer indicated. It is important to note that much of the success of therapy was attributed to the early and consistent interventions provided by the standing consult in place at the time in the surgical intensive care unit where the patient was initially treated. She was then able to be seen subsequently on the regular floor and later as an outpatient, thus ensuring an essential continuity of care.

Case 2 N. is a 43-year-old White male referred for a mental status exam pursuant to several days of unconsciousness caused by a propane explosion. When he was initially seen, the patient had only a sketchy memory of the incident and could no details. He was oriented to person but not to place or time. Since one suspected cause of the explosion was a suicide attempt by purposely igniting the propane tank, an assessment of suicidal risk had to be done. However, because of the nature of his mental status, a risk assessment had to be done frequently during the first 2 weeks of his stay in the burn intensive care unit. The patient vehemently denied that he was trying to kill himself, and he never changed his response.

It became imperative that the patient be seen frequently (a total of 32 sessions over a 4-month period) because of his mental health history. Shortly after ission, it became clear from the medications he was taking that he had a premorbid condition of bipolar disorder (depressed). Upon intubation, the patient was unable to receive his psychotropic medications, which included Serzone and Restoril. Therefore, it was feared that when he regained consciousness, he may present behavioral management problems and possible attempt suicide, which he did have a history of. During the course of his hospitalization, rapport was developed and maintained as a hedge against any disruptive behavior on the floor or sui-

Critical and Intensive Care Units 643 cidal ideation. At times the patient did become agitated and difficult to manage, but with the assistance of psychiatry, a proper istration of his psychotropics restored him to stability. Prior to discharge, was made with a physician in his hometown, where treatment (pharmacotherapy and psychotherapy) could continue without interruption. The standing consult again proved to be invaluable in preventing a crisis from evolving as the patient was seen shortly after ission and regularly after that until discharge. Rather than be treated with heavy sedation alone after becoming a behavior management problem, the patient did not fall between the cracks and his psychological needs were consistently attended to. His mental illness was quickly and properly addressed, and he ed through the hospital with only minimal disturbance to the patient and staff.

APPLICATION OF ROBERTS’S SEVEN-STAGE CRISIS INTERVENTION MODEL IN CRITICAL CARE AREAS Roberts’s (1996) seven-stage crisis intervention model can be applied in hospital settings where initial intervention with health emergencies and other traumatic events naturally occur. However, performing crisis intervention in critical care areas of general hospitals poses unique problems that must be considered. For example, in Case 2, a thorough assessment, including an assessment of lethality, could not be done until well after ission. Since a suicide attempt was suspected, close with the medical staff had to be maintained so that this critical assessment could be made as soon after extubation as possible. At this point, if suicidal ideation persisted, the proper suicide prevention protocol could be implemented on the unit, in this case, burn intensive care. Regarding Case 1, in spite of the fact that a suicide attempt was not the cause of the accident, the patient’s despondence in the aftermath of the double amputation had to be considered and a lethality assessment done until it was determined beyond any doubt that T. posed no threat to herself. The “captive audience” reality of the inpatient setting allows for lethality assessments to be made at least daily or, if necessary, multiple times daily by different staff . Any change in the degree of the lethality is reported to the unit mental health clinician, who would alter the treatment plan as indicated. Another distinguishing feature of the inpatient crisis intervention is the necessity of establishing rapport (Roberts’s, stage 2) with a patient over a sometimes inordinate extended period. Mind-altering pain medications, pain itself, disorientation caused by ICU isolation (resulting in a phenomenon known as ICU psychosis), and the difficulty of determining staff identity due to masks and gowns all contribute to a difficult period of rapport building. In addition, frequent interruptions from medical staff for the application of

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intensive care procedures necessarily shorten time with the patient and interrupt the therapeutic flow. Both N. and T. were unable to communicate until well after ission. Once the interventions began, rapport was established with both patients piecemeal and over several days. At times, information had to be repeated because of the patients’ relatively incoherent mental status early in their medical care. In time (longer with N. than with T. because of mental illness), rapport was successfully established. In both case examples, identification of the crisis precipitant (stage 3) was readily apparent (i.e., the accidents). Although premorbid issues with both N. and T. certainly affected their individual responses to crisis, it is clear that the interventions were necessitated by the patients’ misfortunes. In the cases of most ICU patients, the crisis begins and continues to resolve as their physical condition improves. However, in the case of T., who would suffer numerous physical and family-related emotional setbacks, each new precipitant had to be dealt with aggressively and in a timely manner. The already established rapport with her made subsequent interventions that much easier for her to take advantage of. The majority of time with both patients was spent dealing with their various feelings about what had happened to them (stage 4). Active listening techniques, as well as conveyance of validation, empathy, warmth, and reassurance, were used to help the patients understand that they were being heard by a caring professional. Basic counseling skills were employed in the course of the ive psychotherapy to foster their exploration of their emotions about what had happened to them and the potential consequences that awaited them during and after their recoveries. T. required more and longer sessions because of her many concerns about her husband and two children, who complicated her recovery. Their difficulties coping with T.’s amputations and its meaning to them initially created secondary crisis precipitants for her, such as reactive drinking and depression. N.’s adaptations were relatively straightforward and uncomplicated. In the course of helping T. and N. explore their feelings, various alternatives were generated and explored (stage 5). T. benefited greatly from being aware of the resources available to amputees that would allow her to resume a relatively normal life. The physical rehabilitation protocol for amputees was reviewed with her shortly after she was able to communicate her feelings about the loss of her legs. She received much reassurance from knowing what to expect regarding her physical recovery (which would be done in her hometown), the fitting of prostheses, learning how to walk again, and gradually being able to resume her teaching career. She was also greatly relieved that her family would be worked with individually and collectively to focus on their various problems. This allowed her to focus on her rehabilitation and to spend less time and energy on issues she had no control over. N. received comfort from learning that the unit was aware of his history

Critical and Intensive Care Units 645 of mental illness, was in with his treating doctors and family, and therefore would be able to maintain his medication schedule and his stable mental status. In addition, with his ex-wife, who remained a valuable source of in his life, was encouraged and facilitated. This person was especially important because she was N’s only nonprofessional , whereas T. had a multitude of ive family, friends, and wel-wishers. As a result of the extended stays of both patients, ample time was available for the development and formulation of their respective action plans (stage 6). Prior to discharge, the hospital assisted in setting up the medical and psychiatric resources that would ensure cognitive and affective stability. With N. several conversations were held with his treating professionals and his ex-wife, who had an investment in assuring that N. would be referred back to his mental health providers upon his return home. The patient participated in developing the discharge plan and knew exactly what was expected of him (i.e., compliance), and what resources were available to him. T. also had a clear idea of the postdischarge phase of her recovery. The mental health phase was offered to her in the form of aftercare psychotherapy for her and her family in various combinations. She was pleased with the predictability and availability of the discharge plan and knew she could inquire about it with several different professionals and receive a straight answer. Both patients agreed to follow-up plans (stage 7). Since T. and her family would return to the hospital where the initial crisis was treated for medical and psychological care, follow-up was easily confirmed. At these times the progress of her medical and emotional rehabilitation was discussed, as well as what she could next expect and have to cope with. N.’s follow-up care, on the other hand, was arranged where he was currently being treated. Phone calls to his providers near his home were made shortly after discharge to ensure follow-through. Roberts’s seven-stage model is well adapted to serving the psychological needs of patients in critical care areas. One can safely assume that crisis intervention with most of these patients is indicated by virtue of their need for intensive care. Although the model’s application has to be tempered by the specific demands on units of this kind, the essential elements of the seven stages have universal utility. As a result, patients’ crises are alleviated by timely intervention (i.e., as close to the time of the precipitating event as possible). In addition, future crises can be prevented because of the adaptive learning that takes place during the daily, intensive interventions.

CLINICAL CONSIDERATIONS AND IMPLICATIONS Several special direct service intervention considerations must be taken into when working with patients in crisis in critical care areas. First,

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deference to medical staff has to be a priority. Because of the nature of intensive care medical services, there may never be a convenient time for a proper assessment or intervention. It is commonplace for several interruptions to occur during the course of as little as 10 to15 minutes, making the atmosphere less than conducive for crisis management. At times the therapist has to do his or her best to prioritize the treatment issues and address them in the time available. This becomes especially important when assessing suicidal risk or any other self-destructive behavior that may complicate treatment. In practical , this may mean that several brief interventions have to be done before a clear picture of the patient’s functioning can be ascertained. The patient’s tenuous condition, which can limit the effectiveness of a session, is frequently more of a reason for brief intervention than procedural interruptions. A second consideration is the indicated emphasis on performing the initial crisis intervention as close to the time of the crisis as possible. As with any crisis, a medical crisis, especially a traumatic event, needs to be processed as early as possible before defenses have the opportunity of reconstituting. This issue becomes most relevant with posttraumatic stress disorder, which if not treated early can fester and manifest its myriad symptoms months or even years later. Therefore, if possible, it is recommended that the patient be seen as soon after ission as possible—for example, shortly after extubation or regaining consciousness. Another advantage of early intervention is the forging of relationships even when a patient may be initially asymptomatic. Once a bond has been established, the patient will be far more inclined to talk about an emergence of symptoms when they do occur, sometimes well after discharge. It is not unusual for a patient to a therapist for issues of PTSD or depression months after the first and request outpatient therapy. This, of course, is not as likely to occur without the initial formation of the therapeutic relationship. Creation of this early tie is particularly essential when the impact of heavy sedation, which has the capacity of masking psychopathological symptoms, is considered. A third consideration is the importance of integrating a family systems model into one’s crisis intervention techniques. A critical illness or accident affects an entire family or extended family because these relatives become victims as well. Effective crisis intervention considers the needs of the overall family, which can be used to further the emotional healing of a patient if correctly directed. When doing critical care crisis intervention, much of the work takes place in the waiting areas or in the corridors of the hospital talking to family forced to cope with the consequences of a serious illness or accident. Frequently, they become as much or even more in need of crisis services as the patient. Therefore, time and attention should be focused on them in

Critical and Intensive Care Units 647 order to maintain family equilibrium for its own sake, as well as for the ultimate recovery of the patient. A fourth consideration is the potential for burnout of the crisis intervenor performing daily crisis intervention services in repeated life-and-death situations, not to mention with patients who are severely maimed or disfigured. It is imperative that the demands placed on the crisis professional are not excessive and that the intervenor has adequate supervision and emotional . A high tolerance for stress and multiple available coping resources are prime factors for the crisis professional to have access to while working in a critical care area. The two case studies presented earlier are informative for crisis intervenors because they are reflective of the ICU patients who are seen as a matter of course. They represent more the rule than the exception. All four of the clinical considerations (i.e., treatment priority given to medical issues, early intervention, a family focus, and staff burnout potential) had to be taken into consideration when working with both patients. In fact, it is unusual to have a patient in critical care when less than all of these intervention themes are present. Occasionally, lack of family involvement becomes a problem. However, the absence of this coping resource usually exacerbates the potential for burnout because the intervenor’s role becomes more demanding as involvement with the patient necessarily increases.

Managed Care Managed care poses unique problems regarding insurance reimbursement for the work performed on the ICUs described earlier. The brunt of inpatient care must be precertified before an insurance carrier is willing to pay for psychotherapeutic services. Unfortunately, the precertification process is often cumbersome, and several days may before permission is given. One would think that any patient suffering from severe illness or injury would be automatically certifiable for at least an initial assessment, but this is not the case. All too often, billing for time spent doing crisis intervention is nonreimbursable because the sessions were not precertified. However, waiting for precertification would be anathema to the maximum efficacy of crisis intervention. Although there is no pat resolution to this issue, professional ethics dictate that the patient must be seen as soon as medically feasible. Hopefully, efforts to retrocertify will be successful on the basis of the logic of the argument. Perhaps someday a limited number of diagnostic evaluation sessions will be automatically precertified for patients victimized by accidents or some other trauma, but until that time comes, struggles with managed care will continue. Two potential means of reimbursement may be explored to compensate for the denied sessions. One is for the hospital to provide a supplementary

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stipend to a clinician working in critical care areas. The amount could be based on the average number of nonreimbursable sessions combined with the average number of sessions spent with nonfunded patients. The second alternative is for the facility to apply for grants to foundations specializing in funding innovative medical programs. In fact, both of these options are being explored at University Medical Center in Lubbock, Texas, where the comprehensive, integrated psychological program mentioned earlier is in the process of being developed in all of its critical care units.

CONCLUSION It only makes sense for the psychological needs of patients in general hospitals to be attended to along with their physical problems. The general trend in medicine is to recognize this logical, inseparable connection in patients. Although individual physicians and, on a larger scale, certain critical care units integrate treatment successfully, the premise of this chapter is that the successful integration of treatment can be effected in an entire hospital. If such treatment is properly implemented, patients, families, staff, and the facility should benefit in a variety of ways, not the least important of which is the predicted reduced length of stay (and reduced associated costs). Research soon to be published (Shulman, 1999) should validate this hypothesis, among others, such as the predicted use of less medication, fewer psychological problems, and reduced stress on staff. Common sense dictates that an essential aspect of health care is the prevention and minimization of potential psychological crises, which complicate and exacerbate ongoing and later treatment. A comprehensive model of crisis intervention in critical and intensive care units is a sensible means of bringing about this necessary improvement in overall health care.

REFERENCES

Bleiberg, R. C., & Katz, B. L. (1991). Psychological components of rehabilitation programs for brain-injured and spinal-cord-injured patients. In R. H. Rozensky, J. J. Sweet, & S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 375–400). New York: Plenum. Creer, T. L., Kotses, H., & Reynolds, R. V. (1991). In R. H. Rozensky, J. J. Sweet, & S. M. Tovian (Eds.),

Handbook of clinical psychology in medical settings (pp. 497–516). New York: Plenum. DeMaso, D. R., Koocher, G. P., & Meyer, E. C. (1996). Mental health consultation in the pediatric intensive care unit. Professional Psychology: Research and Practice, 27(2), 130–136. Goldman, L. S., & Kimball, C. P. (1987). Depression in intensive care units. International Journal of

Critical and Intensive Care Units 649 Psychiatry in Medicine, 17(3), 201–212. Pollin, I., & Kanaan, S. B. (1995). Medical crisis counseling. New York: Norton. Rice, D. G., & Williams, C. C. (1997). The intensive care unit: Social work intervention with the families of critically ill patients. Social Work in Health Care, 2(4), 391–398. Roberts, A. R. (1990). Assessment and treatment research. Crisis intervention handbook. Belmont, CA: Wadsworth. Roberts, A. R. (1996). Epidemiology and definitions of acute crisis in American society. In A. R. Roberts (Ed.), Crisis management and brief

treatment: Theory, technique and application (pp. 16–31). Belmont, CA: Brooks Cole. Rozensky, R. H., Sweet, J. J., & Tovian, S. M. (1991). Handbook of clinical psychology in medical settings. New York: Plenum. Shulman, N. M. (1999). The relative impact of an open consult system of psychological intervention on burn intensive care patients and staff. Unpublished research data. Thompson, D. R. (1990). Efficacy of counseling for coronary patients and partners (Doctoral dissertation, Loughborough University of Technology, 1990). Dissertation Abstracts International, 50. (50– 10B) 4450.

28 The Crisis of Divorce: CognitiveBehavioral and Constructivist Assessment and Treatment DONALD K. GRANVOLD

The following are brief examples of separation/divorce-related crises. • Janet initiated a separation from Terry and has filed for divorce. She and their three children came by the house to pick up some picnic supplies and found Terry lying dead in the backyard next to his shot gun and a bottle of Jack Daniels. A suicide note inside the house detailed that Terry could not stand the thought of another man parenting his children or having sex with the “only woman I have ever loved.” • Lois separated from her husband, Alex, on learning that she has genital herpes, contracted from Alex. The discovery led to Alex’s disclosure that he has been having sex with their neighbor. • Bob returned home early from a business trip to find his wife having sex with two men in the den. Shattered by the violation of trust, Bob filed for divorce. • Sam has been in and out of several substance abuse treatment programs during the 15 years of his marriage to Toni. Immediately after release from each program he has resumed drinking, stating that he is different from “those alcoholics” because he can control his drinking. After yet another episode when Sam (in a state of inebriation) became physically violent with their 10-year-old son, Toni painfully decided that she could no longer tolerate Sam’s alcohol abuse and filed for divorce. • Norma’s 7-year marriage to David has been punctuated by a series of episodes of physical abuse, each one followed by David’s expressions of re650

The Crisis of Divorce 651 morse, commitment to get help with his jealousy and anger, and assurance that he will never hurt Norma again. Last weekend, in an unprovoked jealous rage, David physically attacked Norma and broke two of her ribs, blackened her eyes, and bruised her arms. After her release from the hospital emergency room, Norma moved out and filed for divorce. • Carrie understood that Todd, her husband from whom she had separated 6 months earlier, agreed that after the divorce she would maintain managing conservatorship (custody) of their two preschool children. Carrie’s attorney called to report that Todd has counterfiled, seeking custody of the children. Carrie suspects that it is related to the fact that she has begun dating. Whatever the motivation, she feels extremely threatened by the action. • Sue received a letter from the IRS indicating that her ex-husband had failed to file t income tax returns for the past 3 years. This was information about which she had no prior awareness, as she had signed income tax returns each year with the understanding that her husband forwarded them to the IRS. The IRS letter went on to state that her share of the liability for past taxes, interest, and penalties is $14,000. Her annual income in $19,000. • Joe has worked hard to overcome the pain of his divorce from Cathy, a woman with whom he wanted to remain married despite his concerns about her stability at times. He has a strong relationship with his 5-yearold daughter and enjoys being a father. He has seen his daughter at every opportunity both during regular visitation and whenever Cathy has allowed it. He received a telephone call from Child Protective Services informing him that he has been charged by Cathy with child sexual abuse of their daughter and an investigation is underway. • Tommy thought that he had successfully completed the “letting go” process regarding his ex-wife, Mary, who had initiated their divorce a year ago. Tommy has seen Mary infrequently during the past year. Last Saturday night, at a local fund-raiser, he observed Mary romantically engaged with another man. Tommy went into an “emotional tailspin” and reinitiated therapy. The dissolution of a marital relationship or a similarly committed couple relationship is among the most stressful life circumstances (Bloom, Asher, & White, 1978; Olson & DeFrain, 2000). Divorce is a process characterized by peak periods of stress, extreme loss, pervasive change demands, and markedly altered relationships with significant of one’s personal domain. The challenges to activate robust coping capacities are great. The pain of marital dissolution is extreme for most, regardless of the individual’s role in the dissolution decision making. Both those who make the decision to divorce and those who have the decision imposed upon them suffer painful consequences.

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Divorce is not a singular event; rather, it is a process characterized both by discrete stressful events and by a cumulative set of losses and adaptation demands. The self system and family system are thrust into an extreme state of disequilibrium as pervasive change demands are realized. Individuals engaged in the divorce process are at risk of crisis in a multitude of ways. Typically, the emotional trauma is highly intense, episodes are repetitive, and crisis opportunities occur not only during the divorce process but long after the divorce is legally final. For some, the intensity of the crisis reaches life-and-death proportions. As evidence of divorce crisis intensity and lethality risk, recently a physician from the East Coast followed his physician exwife to Texas, where she traveled to visit his sister. He accosted her on a jogging path, murdered her, and moments later killed himself. His crisis was related to an imminent loss of easy access to his children for visitation. His ex-wife of two years and managing conservator of their two children planned to relocate her practice to Michigan. His recent petition to gain managing conservatorship of his children had been denied by the court. To effectively treat divorcing/divorced clients, therapists must be skilled in crisis assessment and intervention. This chapter addresses the application of cognitive-behavorial and constructivist crisis intervention procedures to divorce crises. Particular attention is given to the definition of crisis, the types and nature of divorce crises, the psychosocial needs of divorcing individuals, risk assessment, resiliency and strengths assessment, and the application of the Roberts (1990, 1996) intervention model to divorce crisis resolution.

PREVALENCE OF DIVORCE AND MENTAL HEALTH CONSEQUENCES Divorce is a commonplace phenomenon in the United States and in many countries throughout the world. In the United States, the breakup of the family is a familiar theme resounding across a range of divergent arenas, from political conventions to mental health conferences. The preoccupation with divorce is a reflection, in part, of the pervasive consequences of divorce specifically to the couple and their children, and also to many others in their personal domain. Family must somehow survive the crisis of the breakup. The paths of their survival often lead to mental health professionals.

Divorce Rates The U.S. divorce rate spiraled upward during the 1960s and 1970s, reaching a record high in 1981, when 1.21 million people divorced (5.3 per 1,000 population), affecting some 3 million men, women, and children (National Center for Health Statistics, 1986). There were 1,182,000 divorces in the

The Crisis of Divorce 653 Table 28.1 International Comparison of Divorce Rates Country

Year

Divorce Rate per 1,000

Japan* United States** ** ** Italy** United Kingdom** Sweden**

1997 1995 1995 1996 1994 1994 1996

1.78 4.44 2.07 1.90 0.48 2.97 2.40

Sources: *Ministry of Health and Welfare, Statistics and Information Department, Minister’s Secretariat. (1999, Feb. 5). Vital statistics of Japan. Tokyo. **United Nations Secretariat, Department for Economic and Social Information and Policy Analysis, Statistical Division (1998). Demographic yearbook (1996 ed.). New York: United Nations.

United States in 1990, 4.7 per 1,000 population, and 20.9 per 100 married women ages 15 and over (Monthly Vital Statistics Report, 1990). According to 1997 provisional data, there were 1,163,000 divorces annually, or 4.3 per 1,000 population. Data released by the U.S. Census Bureau in early 1999 show the U.S. divorce rate at around 50%, up from 43% in 1988. Despite the moderate decline since the 1981 high, divorces continue to occur at a remarkable rate in the United States. An international comparison of divorce rates shows the United States to have a significantly higher rate than other nations, although the United Kingdom retains a strong second-place standing (4.44 per 1,000 U.S. population, compared with 2.97 per 1,000 population in the United Kingdom; see Table 28.1). These comparative data provide evidence that divorce is occurring at significant rates in many other countries as well, although Italy has a relatively low rate of divorce. Along with a high divorce rate has come a high remarriage rate. A majority of the divorced population remarry (Glick, 1989). Many of these individuals successfully remarry, presumably benefiting from greater maturity as a product of age and learning from “bad” experiences. The divorce rate of remarriages, however, is even higher than that of first marriages (Goldstein, 1999). A notable challenge confronting subsequent marriages is the blending of families. The stresses associated with stepparental and stepsibling relationships compound the already challenging aspects of functioning in a marital relationship (Booth & Edwards, 1992; Halford, 2001).

Factors Influencing the Rise in the Divorce Rate As I have stated elsewhere (Granvold, 1989), a variety of factors have been identified as influential in the burgeoning failure rate of marriage in the

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United States from the 1950s to the present, including the liberalization of divorce laws (no-fault divorce; Katz, 1994; Parkman, 1995); the desacralization of marriage (Weiss, 1975); the shifting roles of women, including their greater economic independence; the greater social acceptance of divorce concomitant with the increasing frequency rate (divorce begets divorce); a shift away from the intrinsic permanence-of-marriage ethic toward a more “pragmatic” view based on internal and external reward-cost factors (Sanchez & Gager, 2000; Scanzoni, 1972); and, perhaps most important, the trend toward greater satisfaction of personal goals, interests, and desires along with higher expectations for marital happiness (Pam & Pearson, 1998; Sanchez & Gager, 2000; Weitzman, 1985). People are no longer willing to remain “long-suffering” in an unrewarding or abusive relationship. For many, the opportunities for success and comfort after divorce are considered to be too great in American society to choose to remain unhappily married.

Divorce and Mental Health It is well documented that couple relationship problems are among the life stresses most highly associated with psychological disorders (Beach, Sandeen, & O’Leary, 1990; Epstein & Schlesinger, 1994; Halford, 2001; Johnson, 2003; Michelson, 1987; Olson & DeFrain, 2000; Papp, 2003). Divorce is one of the most highly rated risk factors associated with major depression (Anthony & Petronis, 1991; Cozzarelli, Karafa, Collins, & Tagler, 2003; Gallo, Royall, & Anthony, 1993; Kessing, Agerbo, & Mortensen, 2003; McKenry & McKelvey, 2003; Weissman, Bruce, Leaf, Florio, & Holzer, 1991). Furthermore, the presence of a satisfying, committed couple relationship has been found to be associated with low rates of depression (Costello, 1982). The suicide rate of those separated and divorced is significantly higher than that of their married counterparts (Cantor & Slater, 1995; Kessing et al., 2003; Trovato, 1986). A recent study by the National Institute for Healthcare Research in Rockville, Maryland, found that divorced people in the United States are three times as likely to commit suicide as married people. Divorce currently ranks as the number one factor linked with suicide rates in major U.S. cities. In a recent Australian study, separated males were found to commit suicide at 6.2 times the rate of married males, and separated females were found to commit suicide at 1.7 times the rate of married females (Cantor & Slater, 1995). It can be concluded that marital separation and divorce pose significant mental health risks. The consequences are meaningful not only to the divorcing couple, but to their children, extended family, friends, and to society at large.

DEFINITION OF CRISIS A number of definitions of the term “crisis” have been posited (Bard & Ellison, 1974; Burgess & Holstrom, 1974; Freeman & Dattilio, 1994; Gold-

The Crisis of Divorce 655 enberg, 1983; McCubbin & Patterson, 1983; Olson, 1997; Roberts, 1990; Slaiku, 1990). A crisis can be thought of as consisting of three elements: (1) the presence of a precipitating stressful, life-changing or life-threatening event or circumstance; (2) the individual’s perception of the event or circumstance as a significant threat; and (3) the individual’s current inability to cope with the threat or to mobilize the psychological or physical resources to facilitate resolution. To consider an event to be crisis-precipitating, the individual must cognitively appraise the event as a significant threat to the self system. Consistent with Lazarus (1989), the degree of threat is the consequence of primary and secondary appraisals. Primary appraisals establish the relevance of an event to one’s well-being or steady state (dynamic homeostasis), and secondary appraisals reflect the individual’s coping capacities and available resources to meet the demand. Hence, an individual in crisis has experienced a precipitating circumstance that is perceived by the individual as posing a psychosocial accommodation significantly beyond the individual’s belief in his or her capacity to cope, adjust, or integrate. The personal consequences of a crisis may take the form of emotional and psychological unrest, as well as physical trauma and detrimental somatic outcomes. And beyond these outcomes, many times personal crises have a detrimental impact on social relationships. It is noteworthy that a crisis may evolve from an event that many would judge to be positive. Winning the lottery, receiving a promotion, and making a desired move to a new community are events with obvious positive meaning. Curiously, each event may become a crisis for the individual (and family) should the changes associated with it be greater than the individual’s (or family’s) current capacity to accommodate change. Also, positive life events may occasion opportunities for or stimulate associated challenges that reach crisis proportions. For example, a long-sought promotion may require travel, posing unique changes in family dynamics, division of labor task performance, and child care. It is also important to acknowledge that a crisis arising from a problematic circumstance has the potential to stimulate extremely positive outcomes (Boss, 1988; Slaiku, 1990). An individual may discover coping abilities and resiliency far beyond precrisis self-views. Meaningful relationships may develop or become strengthened or expanded through crisis resolution. Unforeseen skills and talents may be cultivated and new behaviors learned as the individual lives through the crisis.

Summary Based on the tripartite definition of crisis delineated here, a stressor becomes a psychological crisis only when the individual experiences a threat to self so intense that his or her characteristic capacities to cope and resolve distress are sured, or alternatively, the individual’s characteristic capacities to cope and resolve distress are so markedly compromised that an otherwise

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manageable challenge becomes a crisis. In either circumstance, the individual’s cognitive functioning and the availability of social and instrumental resources play critical roles in distinguishing a manageable stressor from a crisis. Conceptualizing crises in this way lends great viability to the use of cognitive-behavioral and constructivist treatment as a preventive approach for clients in a sea of crisis opportunities and as a means to facilitate a coping repertoire, sense of empowerment, and the proactive mobilization of personal and social resources for those in crisis.

DIVORCE AS CRISIS The process of divorce may reach crisis status in two ways. The individual may experience a discrete event in the couple relationship that results in an extreme perturbation to the self system, or the cumulative effects of loss and adaptation demands may limit and impair coping abilities, rendering the individual more likely to experience a stressor as a crisis.

Discrete Event Crises Discrete stressful events may occur (1) as precipitants of the decision to divorce, (2) during the transition phase of divorce, or (3) well past the finalization of the divorce. Examples of specific life events that precipitate the decision to divorce include the discovery of infidelity, an acute escalation of conflict or physical violence, death of a family member (particularly a child) or close friend, evidence of physical or sexual child abuse, disclosure or discovery of gross financial irresponsibility, excessive use of alcohol or prescription drugs, use of illicit drugs, and episodic violation of trust (e.g., dishonesty, deceit, lying). For many, the crisis of divorce is realized during the transition phase, when resolution of property settlement and child custody or visitation are being sought. This period, after the decision to divorce has been made and before the divorce is legally final, is punctuated by extreme levels of emotion, including acute feelings of loss across many categories (e.g., personal, intimate, moral/ethical, status, lifestyle, financial, physical), rejection and abandonment, hurt, anger, guilt, anxiety, worry, fear, and disappointment. Emotional consequences such as these, coupled with decision making, planning, and the mobilization of environmental and lifestyle change, seriously compromise the coping capacities of divorcing individuals. These individuals are strongly predisposed to psychological crisis. Subsequent to the decision to divorce and many times well after the divorce is legally final, divorced individuals experience a crisis in relation to the ex-mate. Examples of life events in this category include seeing for the first time the ex-mate with a new mate, learning of predivorce relationshipviolating behavior (infidelity; failure to file t income tax return), acute

The Crisis of Divorce 657 conflict over parallel parenting (e.g., ex-mate’s failure to pick up or return child on time; child not available for scheduled visitation; telephone access to child blocked), failure to receive child , episodic family and kin side-taking against the individual, and episodic discrimination socially and in the workplace. Although the marital relationship may be over, the exmates often remain interconnected in some fashion, particularly when children are involved. The ongoing relationship between ex-mates is typically replete with opportunities for conflict, hurt, and protracted loss.

Cumulative Effect Crises The second way the divorce process can reach crisis status is as a consequence of the cumulative effects of divorce. Divorce thrusts the individual into a state of distress, disorganization, and greater uncertainty about life and the future. Divorcing individuals experience highly meaningful and pervasive losses. Dealing with loss effectively reduces coping ability (Freeman & Dattilio, 1994). Although the experience of loss is a constant in one’s ongoing evolution, the loss associated with marital dissolution and the revisioning, restructuring, and reordering of oneself as a single person pose immediate and long-term challenges. Neimeyer (1998) notes that the ing of another from one’s life poses an identity challenge in the form of “reinventing” oneself. Inasmuch as one’s sense of self is socially embedded, the loss of the mate through divorce results both in a void within and a modification in the nature of one’s relationships with all others. One is no longer part of a dyad and therefore sees oneself differently and is seen differently by others. Beyond dealing with loss and identity re-formation, there are other responsibilities of a more practical nature that are physically and emotionally taxing. A change in marital status, for most, poses changes in practical needs (e.g., bank , charge cards, will) and physical needs (e.g., relocate, replace furnishings). For those who had not been previously employed outside the home, it may require job hunting or academic preparation or training for enhanced entry into the workforce. The very activity of seeking a job may become a crisis given the challenges of job interviewing, mounting economic need during unemployment, and potential rejection inherent in the process, coupled with the individual’s depleted coping capacities associated with postdivorce adjustment. The ultimate consequence of the cumulative effects of the divorce process is that events and circumstances that heretofore would have been effectively met and accommodated may become elevated to crisis status. Many clinical anecdotes could be identified in which relatively minor events or life experiences become crises. An auto accident of fender bender, noninjury proportions, an argument with a family member or friend, a child’s failure to call home from camp in a timely manner are all circumstances that require coping and resource mobilization. Events such as these, however, become insur-

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mountable, extraordinary challenges when the divorce process is consuming the individual’s emotional and psychological resources.

PSYCHOSOCIAL NEEDS OF DIVORCING/ DIVORCED CLIENTS A number of stage theorists have collapsed generally common divorce-related experiences into categories (Bohannon, 1971; Brown, 1976; DeFazio & Klenbort, 1975; Everett & Everett, 1994; Fisher, 1973; Froiland & Hozman, 1977; Kaslow, 1984; Kessler, 1975; Kressel, 1980; Rich, 2002; Storm & Sprenkle, 1982; Weiss, 1975). The conceptualization of the divorce process in stages has been criticized as failing to “highlight the complexity of the processes involved in marital dissolution” (Ponzetti & Cate, 1988, p. 3). As I have noted elsewhere (Granvold, 1994), although therapists must be sensitive to the divorcing/divorced client’s unique experience, there is facility in broadly subdividing the divorce process to better specify common objectives and tasks associated with a given period in the process. Consistent with Kaslow (1984) and Storm and Sprenkle (1982), divorce is conceptualized as being composed of three overlapping stages, decision making, transition, and postdivorce recovery. Each stage has its unique stressors and challenges.

Decision Making The decision to divorce is not easy for most people. Typically, one or both partners continue their marriage in a state of high dissatisfaction and protracted indecision before ultimately arriving at a decision to divorce. The state of indecision is stressful in itself, characterized by high levels of frustration, anxiety, uncertainty, fear, worry, insecurity, distrust (particularly for the mate who is more greatly committed), hurt, resentment, depression, hopelessness and impending doom, and feelings of disempowerment. There is often an erosion in feelings of love, intimacy, sexual desire, and sexual satisfaction. Individuals who are emotionally fragile, highly dependent on the mate, or lack self-esteem often experience situation-specific crises as the couple move closer to a final decision. This individual, typically more committed and less likely to decide to leave the relationship, is far more vulnerable to crisis responses. The decision to divorce may be the crisis event or, as noted above, a relationship-related crisis may stimulate the actual decision to divorce. In either situation, heightened emotion surrounds divorce decision making for most. Whether the decision is unilateral or shared, whether one is the initiator or the one being left, there is pain and disruption associated with the imminent coming apart (Everett & Everett, 1994; Granvold, 1989, 2002; Olson & DeFrain, 2000; Pam & Pearson, 1998; Sprenkle, 1989).

The Crisis of Divorce 659

Transition from Married to Single When the decision is made to divorce, the spouses are thrust into a major life transition. The psychological and emotional responses of the divorcing couple and their children and the behavioral manifestations of these responses during the transition phase may be extreme. A multitude of very significant decisions flow from the decision to divorce (Granvold, 1994, 2002; Olson & DeFrain, 2000; Propst & Fries, 1989; Sprenkle, 1989). During this period, children and family may be informed of the plan to divorce; often. friends and associates are informed as well. Physical separation must be achieved, which requires the determination of who is going to move, and the location and setting to which the departing mate is to go. The legal system must be accessed either through attorneys or through no-fault unilateral legal actions. The process of filing for a divorce or the experience of being served a divorce petition is commonly unpleasant. These events all too often mark the beginning of an adversarial process punctuated by great acrimony between the divorcing couple. Property settlement and child custody–child visitation determinations are often highly emotionally charged deliberations. Opportunities for interpersonal crises abound at this time.

Postdivorce Recovery Separation and divorce force the individual to accommodate pervasive change: “Against a backdrop of ambivalence and oscillating emotions, the individual is challenged to integrate: (1) the stress of wholesale change; (2) redefinition of self and object loss trauma; (3) role loss, disorientation, and restructuring; and (4) life-style adjustment” (Granvold, 1989, p. 198). Clients typically struggle with the pain of emotional separation from the mate. Even for those who have experienced an erosion of love, there tends to be a persistence of attachment to the ex-mate which exacerbates the letting-go process (Weiss, 1975). Self-esteem and feelings of self-worth diminish during the entire process of divorce, particularly for the mate who has been rejected. In response to low self-appraisals and feelings such as depression, hurt, loss, and hopelessness, those in recovery often withdraw and become isolated. Loneliness and preoccupation with loss prevail. Common maladaptive coping strategies involve the excessive use of alcohol and drugs (prescribed and illicit), oversleep, overexercise, and overinvestment of time and energy in work. Although grieving is a necessary, adaptive process, and unique from person to person, it may become debilitating to those who allow it to become allconsuming. One of the greatest challenges during postdivorce recovery is reestablishing one’s identity as a single person (Granvold, 2002; Rice, 2003). Compounded by the process of overcoming the loss of the mate, one must formulate a sense of self independent of the ex-spouse. For some, this is appealing.

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However, for those who have enjoyed the dyadic identity and connection with the ex-mate, identity re-formation may be a crisis in itself. New roles such as single parent, sole financial provider, and social single contribute to the evolving sense of self as a single person. These new roles facilitate change but are typically stress-provoking. Divorce does not terminate people’s human desires for closeness, intimacy, close relationships with others, and sexual gratification (Schneller, 2003). The world of dating and courtship is one in which skills from the past are once again called into play. Many approach dating with a sense of trepidation, distrust, anxiety, fear, and uncertainty; others find it exciting, rejuvenating, fun, and provocative. Unresolved issues from the dissolved marriage can be stimulated in dating relationships and thrust the individual into crisis. Also, the depletion of coping resources during divorce recovery may render the individual more vulnerable to stressful and crisis responses in newly forming relationships. Dating naturally leads to opportunities for sexual activity. The loss of one’s mate (love object) leaves the individual without partner sexual gratification. The availability of multiple, new sex partners coupled with normal sexual desire is highly likely to lead to sexual activity in dating relationships. Frequently, recently divorced individuals enjoy their sexual freedom by having a series of sexual partners. For some individuals, having sexual relations with several partners across time functions to prevent getting deeply involved with any one person. This pattern is perceived to be a form of self-protection. The obvious risk of having sex with many partners is the possibility of contracting a sexually transmitted disease (STD). Neff and Mantz (1998) suggest that those recently separated or divorced individuals who are dealing with postdivorce recovery issues (loneliness, isolation, depression, or low self-esteem) may fail to adopt rational “safe sex” practices, increasing their risk for disease. They maintain that, in an era in which HIV/AIDS has increasingly become a heterosexual phenomenon (Centers for Disease Control, 1990), the separated and divorced are a possible risk group for HIV infection. I would add to the combination of postdivorce recovery, available multiple sex partners, and the epidemic status of HIV/AIDS and other STDs the disinhibitory effects of alcohol consumption and “recreational” drug use on sexual behavior. While the Neff and Mantz study found inadequate evidence to the disinhibitory contributions of alcohol use on sexual behavior during marital disruption, they suggest that the lack of evidence is counterintuitive and may be partly explained methodologically. In my clinical experience, alcohol and drug use have often been reported as factors in s of indiscriminate and “unprotected” sexual encounters. Despite rational commitments to safe sex practices, substance abuse in combination with the emotional and coping challenges of postdivorce recovery and desires for sexual gratification result in people putting themselves at risk. It can be con-

The Crisis of Divorce 661 cluded that, on occasion, attitudes and beliefs are poor predictors of human behavior. Many who profess the wisdom of safe sex practices do not practice it.

RISK ASSESSMENT As noted, the vulnerabilities of individuals experiencing marital disruption and divorce include low self-esteem, depression, hopelessness, anxiety and fear of the unknown, substance abuse, loneliness, isolation, and sexually transmitted disease. This combination of vulnerabilities coupled with a depletion in coping abilities make this population particularly at risk of suicide. In rare instances, there is risk of homicidal action. The divorced/divorcing individuals in crisis are at high risk of depression, suicide, and substance abuse. Reinecke (1994) notes that risk assessment should include the identification of risk factors associated with a particular outcome, such as suicide. Risk factors are defined as experiences, events, or propensities that make a particular outcome more likely. Assessment of risk, then, requires exploration of those factors that are known to be associated with a particular outcome.

Depression Most individuals in the process of divorce or in postdivorce recovery experience some degree of depression; vulnerability to severe clinical depression may be determined by making an assessment of risk factors. Among the relevant risk factors to be assessed are self-esteem level, social involvement/ withdrawal, social from family and friends, history of depression, depression in family of origin, financial problems, parenting problems, substance abuse, and feelings of hopelessness. Both clinical interview and standardized measurement instruments should be used to assess for risk and to determine current status of depression. Recommended self-report instruments for depression include the Beck Depression Inventory–Second Edition (BDI-II; Beck, Steer, & Brown, 1996), the Zung Self-Rated Depression Inventory (Zung, 1965), and the Generalized Contentment Scale (Hudson, 1992). Additionally, the Beck Hopelessness Scale (Beck & Steer, 1988) is highly useful in gaining access to the client’s cognitive schemas related to negative expectancy about short- and long-term future. This psychological construct has been found to underlie various mental health disorders (Beck & Steer, 1988). Specifically, hopelessness is a core construct in depression and has been found to be an important mediator of suicide (Beck, 1987; Beck, Rush, Shaw, & Emery, 1979; D. A. Clark, Beck, & Alford, 1999; Reinecke, 1994, 2000).

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Lethality The most critical risk assessment is the determination of lethality. As noted earlier, the likelihood of suicide among separated and divorced men and women is significantly greater than among married individuals. The pain of coping with the loss of love is excruciating for many. Compounding this loss are many change demands that can propel the individual into crisis. Suicide over love loss is a familiar theme. An infrequent but extremely tragic occurrence is murder-suicide among separated and recently divorced couples and couples in extreme marital distress. The separated and divorcing individual is also vulnerable to physical violence, the consequences of which may be extreme physical harm and possibly death (Hardesty, 2002; Logan, Walker, Horvath, & Leukefeld, 2003; Toews, McKenry, & Catlett, 2003). With regard to physical violence and homicidal intention, statements of desire for the estranged or ex-spouse to experience pain or death should be explored regardless of the emotional state of the client at the time. That is to say, expressions made during extreme anger and rage should not be dismissed lightly as anger-driven, misrepresentative, unrealistic, or unintentional statements. Furthermore, when a client expresses fear for his or her safety, the therapist should guide the client in mobilizing protective systems and resources. Specialized skills are required to recognize a client as suicidal and to assess suicidal risk (Beck et al., 1979; D. C. Clark, 1995; Rudd, er, & Rajab, 2001). Beck and his colleagues recommend that the assessment cover four components: intent, planning, resource availability, and motive. They note that even the mildly depressed individual may commit suicide; thus, our appraisals of intention must be finely discriminating. The therapist must be sensitive to the indicators of suicide in of behaviors, emotional states, and verbalizations. The client who suddenly puts his or her affairs in order may actually be preparing for death (e.g., completes a will, organizes and clears desk at work, s friends and family with whom he or she has had no recent ). Other potential indicators of suicidal intent are depression; a sense of overwhelming grief; loss of love, parenting opportunities, and meaning in life (emptiness); hopelessness that life will improve (Beck, 1987); and coldness, hostility, and anger. Clinicians should listen for and explore verbal statements such as the following: “I can’t live without her/him”; “I’ll never be happy again”; “I can’t stand the thought of her/him making love with anyone else”; and “I have to stop this hurt.” Should the client it to suicidal planning or you surmise it from indicators of intention, make an inquiry into the way the client has considered committing suicide. Following this exploration, determine the resources available to the client to fulfill the plan (e.g., knowledge of lethal levels of drugs, access to firearms). Exploration of motive may expose objectives such as the desire to escape from life or to seek surcease, to retaliate through

The Crisis of Divorce 663 creating pain in the life of the rejecting ex-mate, and manipulation of significant others through suicidal attempts (Beck et al., 1979). Reinecke (1994) aptly notes that “if there is a truism in psychology, it is that the best predictor of future behavior is past behavior. So it is with predicting suicidal risk” (p. 75). Accordingly, determine the strength of past suicidal thinking, degree of past planning and mobilization of resources, and actual suicide attempts. Determine whether other family or close friends have committed or attempted suicide. Finally, it is important to consider the interactive effects of variables that may contribute to suicide. Substance abuse, depleted coping capacity and intensity of the love loss, social isolation, lack of system, poverty or financial problems, and history of psychological instability collectively may produce a lethal effect. The use of self-report instruments may further facilitate suicidal risk assessment, for example, Beck’s Scale for Suicide Ideation (Beck et al., 1979). Other relevant instruments may be located in Fischer and Corcoran (1994).

Substance Abuse Substance abuse is a coping strategy frequently employed by separated and divorced individuals. Alcohol and drugs are effective in reducing stress, assuaging guilt and remorse, and numbing one’s emotional pain. Although perhaps effective to these ends, the undesirable consequences of substance abuse are extreme. Depression and suicide, highly associated with substance abuse, are among the major vulnerabilities (Beck, Wright, Newman, & Liese, 1993). On the basis of the above information, it is important to assess the risks of substance abuse among separated and divorced clients. In addition to interview assessment, several viable substance use/abuse assessment instruments are available (Beck et al., 1993; Fischer & Corcoran, 1994).

CLIENT STRENGTHS, RESILIENCE, AND PROTECTIVE STRATEGIES Before addressing specific strategies that can be implemented in divorce crisis recovery, a statement about philosophy is in order. The intervention model promoted in this chapter is a constructivist approach to human functioning and human change in which individual strengths and assets are emphasized, stimulated, and expanded (Franklin & Nurius, 1998; Granvold, 1996, 2001; Mahoney, 1991, 1995, 2003; Neimeyer & Mahoney, 1995; Saleebey, 1992). Saleebey has identified three essential assumptions that undergird the strengths perspective: First, it is assumed every person has an inherent power that may be characterized as life force, transformational capacity, life energy, spirituality, re-

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generative potential, and healing power. . . . Second, a strengths perspective assumes that the power just described is a potent form of knowledge that can guide personal and social transformation. . . . Third, there is a crucial pragmatic presumption about the nature of change . . . that when people’s positive capacities are ed, they are more likely to act on their strengths. (p. 24)

Constructivist psychotherapy is optimistically focused on possibilities. Individual strengths (both active and potential), resources, and competencies are collaboratively identified with the client, emphasized, and prompted toward greater activation. Life is viewed as “an ongoing recursion of perturbation and adaptation, disorganization and distress, and emerging complexity and differentiation—a process of evolutionary self-organization” (Granvold, 1996, p. 346). Consistent with this conceptualization of life span development, human disturbance and distress are considered “normal.” Problems are construed as opportunities for constructive change. The resiliency and creative potential of all people are emphasized. Pragmatically, this means that crisis assessment and intervention are focused on the personal, social, and community resources available to the client. An essential personal resource is the client’s belief in his or her right and ability to be empowered (Freeman & Dattilio, 1994). Client self-efficacy plays a crucial role in empowerment; low self-efficacy impedes empowerment but high self-efficacy effects it. Hence, if lacking, an early goal of therapy is the development of efficacy expectations. Efficacy expectations are not only meaningful in crisis resolution, but they have been found to be associated with postdivorce adjustment (Bould, 1977; Pais, 1978; J. J. White, 1985; Womack, 1987). Basco and Rush (1996, p. 214) have generated a list of internal resources useful in coping with stress that are worthy of consideration in developing a crisis intervention treatment plan: Intelligence Practicality Analytical-mindedness Common sense Fortitude Assertiveness Sensitivity A sense of humor Time Personableness Organizational ability

Resourcefulness Energy Stamina Creativity Self-esteem Money Confidence Self-perceived competency Ability to seek out and accept help from others Perserverence

Turning now to external coping resources, it has been found that those with active systems are better adjusted to divorce than those without

The Crisis of Divorce 665 (Burrell, 2002; Granvold, Pedler, & Schellie, 1979; Hetherington, 2003; Spanier & Casto, 1979; Wallerstein & Kelly, 1980). It is recommended that individuals in divorce crisis remain active socially through involvement with family and friends, or through participation in interest groups (e.g., Sierra Club) and singles groups. Also, many communities offer psychoeducational seminars focused on postdivorce recovery or grief recovery (Blanton, 1994; Granvold & Welch, 1977; Salts, 1989). Alienation and isolation, feeling disconnected from caring others and social withdrawal, are major contributors to human disturbance and dysfunction. Every effort should be made to promote client involvement in the community. The client’s past history in resolving crises and life dilemmas should be explored as a means of activating coping and adaptive skills and instilling resiliency and to mobilize protective strategies. The risk factors identified above, along with other maladaptive responses to the crisis, should be addressed through the identification of the cognitive, behavioral, and emotional responses that have effectively reduced risk in the past. This may involve the exploration of compensatory actions, the activation of a system, or the development of novel interests and life goals. Finally, resilience is represented not only by overt behaviors, but by attitude. The therapist should access the client’s self-views regarding his or her capacity to bounce back and return stronger than before. Explorations should be made into self-esteem and self-reliance conceptualizations that or undermine views of self as resilient. Interventions should be initiated consistent with these findings.

INTERVENTION In this section, the Roberts (1990, 1996) seven-stage model of crisis intervention is discussed and applied to clients in the process of divorce. Although a client may move in and out of crisis while in counseling during the process of postdivorce adjustment, the intervention highlighted here is crisis-focused.

Velia, a Hispanic woman age 46, presented for therapy shortly after filing for a divorce from her husband of 28 years. The mother of five children ranging in age from 10 to 27, Velia reported extreme unhappiness with the relationship over the past 10 years. She had experienced repeated periods of separation, the last of which began 18 months earlier. During this last separation period, Velia become involved in a sexual relationship with a family friend. The love relationship, now terminated, lasted eight months and ended with an ultimatum from her lover to end the marriage or end the love relationship. Velia, ill-prepared to made a final decision about her marriage at the time, broke off the love relationship. About two months later, immediately prior to presenting for treatment, a family member informed Velia’s husband and

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children of Velia’s affair. Velia felt extremely violated by the disclosure. Two of her adult offspring verbally attacked her and subsequently withdrew from her. All four adult children began distancing themselves from her and blamed her for the problems in the marriage. Despite Velia’s explanation that her marital unhappiness had lasted over 10 years, the children held their mother solely responsible for the marital distress due to the extramarital relationship. Velia’s husband, Jorge, remained willing to “work things out” and actively enlisted the children in trying to convince their mother to remain in the marriage. Velia felt no romantic feelings for Jorge, although she did feel love for him as the father of their children. While currently committed to the divorce, Velia was concerned with her children’s coldness toward her and their strong views that it was their mother’s wrongdoing that was able for the marital unhappiness. Although not suicidal, Velia experienced extreme depression primarily related to her children’s negative judgments of her and her own self-recrimination for allowing herself to love another. She felt a sense of hopelessness and saw her future as empty of possible joy or personal well-being. She felt that she could not go back into the marriage, nor could she gain happiness outside it. Velia’s crisis was the disclosure by her sister and the subsequent loss of respect from her children and their physical and emotional withdrawal from her.

Engagement and Relationship Formation Clients who present for therapy in crisis must feel free to express the specific details of the stressful event and their range of emotional responses with a therapist who is open, an active and careful listener, nonjudgmental, talented in Socratic questioning, and an expert in the crisis area. During extreme crises, regardless of the stage of therapy (initial session or much later), clients may evidence an array of thoughts, emotions, and behaviors that are highly uncharacteristic of them when they are not in crisis. For others, the crisis event may serve to activate or amplify characteristic maladaptive responses. Therapists can expect to hear highly irrational thinking (“I’ll never recover”); emotionally driven statements (“I’d like to smash his face in”); expressions of extreme and uncontrollable emotion (crying, anger, anxiety, panic); emotionally charged content with flat affect; perseveration—words, phrases, gestures, images (“I’m so bad”); incoherent, disted, and spotty s of events; and dissociation (“I felt numb; it was as if I was observing someone else”; “I felt nothing, nothing at all as he hit me again and again”). The therapist must be prepared to rapidly assess the client’s verbal and nonverbal behavior and to respond with clinical wisdom. Each type of expression enumerated above obligates the therapist to activate strategic responses that complement the client’s expression. For example, when a client expresses irrational thoughts during the engagement phase of crisis intervention, it would be inappropriate to attempt cognitive restructuring or cognitive elab-

The Crisis of Divorce 667 oration at that time. It is far more desirable to listen carefully and seek an understanding of the client’s thoughts and images, to gain a more global awareness of the crisis situation through Socratic questioning, to elicit feeling states, to reflect content and feelings, to offer strategic empathic expressions, and to display human emotion consistent with the nature of the client’s crisis. For the client who expresses incoherent, disted, and spotty s of a stressful circumstance, the therapist may find it effective to use combinations of Socratic questioning, guided imagery, deep muscle relaxation, and repetitive iterations of increasingly complete s. In each of these examples, therapist responses complement the client’s expressions and function to promote the therapeutic alliance and to further the treatment endeavor. Although it is highly important to maintain focus on the crisis, the engagement process requires that the therapist ultimately ascertain the client’s treatment goals and expectations of the therapist, as well as explicate therapist-held expectations (Garfield, 1998; Granvold, 2001, 2002; Kanfer & Schefft, 1988). Early on, the therapist should act in ways that establish that treatment is a collaborative effort between client and therapist. As Freeman and Dattilio (1994) point out, however, “The collaboration is not always 50:50 but may, with the crisis patient, be 30:70 or 90:10, with the therapist providing most of the energy or work within the session or in the therapy more generally” (pp. 6–7). The client should come away from the first session with the understanding that the therapist expects the client to be active in the treatment process and with the awareness that the therapist will actively participate as well. Genuine expressions of empathy, complementary responses to idiosyncratic expressions, structuring the roles of client and therapist, assuming a collaborative stance, and the expression of content about the crisis event and characteristic human responses (therapist knowledge-based expertise) are all meaningful ingredients in establishing a therapeutic alliance and building rapport. Initial Risk Assessment When a client presents for treatment in crisis, it is imperative that a risk assessment be completed before ending the session. The therapist should gain an understanding of the crisis situation and establish the severity of the crisis. The next step is to assess the client’s strengths, coping capacities, resources (personal, social, financial), and vulnerability to lethal or healththreatening responses. Attention should be given to both suicidal and homicidal ideation, including intent, planning, resource availability, and motive. As noted in the section on risk assessment, a cursory exploration of the client’s thoughts about suicide and homicide is inadequate. It is advised that the potential be explored more than once in the session to limit the perfunctory or deceptive denial and to allow greater opportunity to expose indicators of lethality.

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Problem Definition The therapist should seek an understanding of the client’s meaning constructions regarding the crisis situation. Recall that a crisis may develop in such challenges as the process of dissolving a marital union; identity re-formation as a single person; assumption of altered role relationships; and return to dating, mate selection, and potential reconstitution of the family with a new mate. These life transitions have unique meanings to each individual. Understanding these meanings may provide the therapist with clinically relevant contextual information useful in crisis intervention. For example, the individual who holds the view that he or she must stay married at all costs (intrinsic permanence view of marriage) is more likely to experience the day when the divorce is final as a greater crisis partly because of this view. In a sense, the therapist seeks a determination of why a crisis is a crisis. In recognition of the idiosyncratic nature of meaning constructions, the therapist and client collaborate in generating the meaning of the crisis. The client may have difficulty articulating his or her thoughts about the circumstance. Exploration of the crisis circumstance through Socratic questioning may allow articulation of what took place and expose the client’s views of and responses to the event or circumstance. After understanding the client’s current thinking, it may be appropriate to guide the elaboration of meanings as a means of extending possibilities. This process is a necessary prerequisite to proceeding to the generation of alternative paths of action. Constuctivist intervention focuses on the viability of meaning constructions. Viability is a function of the consequences of the construct to the individual and society, as well as its coherence with prevailing personal and social beliefs (Neimeyer, 1993). To clarify, consider the client who states that the divorce is the worst that could happen to him and that he has no reasons to go on living. These meanings, while perhaps consistent with his current thoughts, lack viability for they promote (or at least imply) actions with dire negative consequences to the individual and to society. The clinical objective in this situation is to expand and elaborate possible meanings of the divorce to arrive at meanings that may promote more viable consequences. Merely modifying the view from “It’s the worst” to “It’s one of the worst” achieves greater viability. Other meanings that might be generated with this client include “It hurts so bad”; “I never thought she’d ever leave me”; “I believe in ‘love is forever’”; and “Divorce is wrong.” All of these views may have unappealing consequences to a degree, but they may be less destructive than the client’s initial construct. Gaining access to specific beliefs and determining other relevant constructions regarding divorce and the transition to single life may contribute greatly to the formulation of an intervention strategy to meet the crisis. In the initial interview with Velia, information gathering was focused on formulating the problem specifically through (1) discovering the crisis cir-

The Crisis of Divorce 669 cumstances and her beliefs that strongly contributed to the crisis, (2) conducting a risk assessment, and (3) gaining a preliminary understanding of her current coping abilities.

On the weekend prior to Velia’s coming in for treatment she had seen a family happily interacting at a local park. She longed for the laughter, sharing, and warm interaction visible in that family. She returned home deeply depressed and realized that she must seek help. In defining the problem, I learned that warm family relationships and mutual respect and iration between children and parents were paramount in Velia’s value system. The core meanings of being a mother were to protect her children from pain and discomfort and to always “be there” for them. Her estrangement from her adult children prevented her from fulfilling these roles and threatened her purpose in life. She viewed herself as despicable for her infidelity. I learned that Velia was a survivor of incest, having been abused by her biological father. She loved her mother dearly, but felt deep hurt over her mother’s failure to protect her from her father. She was now confronting her own “failure to protect her children” from the pain of her infidelity and the impending divorce. Velia had demonstrated remarkable coping abilities in the past, but she questioned her current strength. Assessment of additional stressors in her life revealed underemployment and resulting financial hardship. This condition further depleted her coping resources. Velia reported no suicidal ideation now or at any time in her past, and there were no indicators of suicidal intention. She denied any substance abuse or use of prescription drugs. This information, along with the content reported in the introductory vignette, helped define Velia’s crisis and gave direction to the intervention.

Explore Emotions and Promote Ongoing Development Traditional therapeutic approaches have tended to consider emotions such as anger, anxiety, depression, worry, sadness, and the like to be negative, and goals of treatment correspondingly have been to control, alter, or terminate such emotions (Granvold, 1996). Constructivists, social constructionists, and other postmodernists conceptualize emotions as agents of change, adaptation, and self-development (Greenberg & Safran, 1989; Guidano, 1991a, 1991b; Mahoney, 1991,2003; Safran & Greenberg, 1991). I believe that exploring emotions with clients in crisis should be done with the view, consistent with constructivism, that emotions and their expression are crucial to the process of change. In some circumstances, it is highly appropriate to assist clients in curbing or controlling intense emotion. For example, consider the deeply depressed client whose depression is jeopardizing her job or parenting performance, or

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there is evidence of strong suicidal ideation or planning. Intervention should focus on protective strategies, behavioral activation, and cognitive changes designed to ensure safety and to prevent incapacitation and dysfunction in fulfilling key responsibilities. Many contemporary views of emotion emphasize the personal meaning constructions associated with emotionality: “The ways individuals think, feel, speak, and act are integrally tied to the concepts they use to categorize their emotions and make them meaningful” (Nunley & Averill, 1996, p. 226). It is important not only to determine clients’ views of the crisis circumstance to which they are emotionally responding, but to gain an understanding of their beliefs about their feelings and emotional expressions. For example, some clients believe themselves to be “seized” by emotion and hold the view that they have little control over their feelings (Nunley & Averill, 1996). Others believe they are “going crazy” or are weak or see themselves as worthless because they are experiencing and expressing extreme emotion. Clients may greatly benefit from the view that there is honor in being emotional—that it is “normal” and not necessarily to be considered negative (although extreme and enduring feelings and emotional expressions carry some level of discomfort for most people). Restructuring client views of emotion from negative and undesirable to positive and viable in the process of human change and adaptation will shape client tolerance and appreciation for their emotionality. As a further means of gleaning what is positive about emotionality, I have found it useful to guide clients in the externalization of their feelings and emotional expressions (M. White & Epston, 1990). This may be accomplished by asking questions such as “What do you think your depression is trying to tell you?” and “If your tears had a voice, what would they be saying?” Questions such as these give rich access to client cognitions and client awareness of behavioral and lifestyle changes that are, truly, in their best interests. Furthermore, the process of externalization reinforces the belief that feelings are useful. For clients who express flat affect or report little emotional responsivity to crisis events that typically prompt emotional reactions, it is important to employ methods to access feelings and stimulate emotional expressiveness. Experiential techniques have been found to be highly effective with these clients. The purpose of these techniques varies, including the stimulation of feelings related to a life event, a preparatory rehearsal of a behavior (e.g., assertive expression), to gain a better understanding of another’s thoughts or feelings (e.g., role reversal), and to process negative or ambivalent thoughts or feelings regarding past or more contemporary experiences. (Granvold, 1996, p. 354)

The Crisis of Divorce 671 Methods to access affective states and to stimulate emotional arousal include role-playing, psychodrama, behavior rehearsals, imagery and guided discovery, imaginary dialogues (empty-chair technique), and therapeutic rituals. The timely use of techniques such as these may facilitate the arousal and expression of emotions in the divorcing client who, although in crisis, is unemotional. As established earlier, divorce is about loss—not one loss, but a variety of losses. The accommodation of loss in divorce recovery, as with other traumatic events, requires meaningful expressions of emotion for successful adaptation. Treating the crisis of divorce, therefore, must focus on human emotion as a change process. Velia:

I have been upset since I spoke with Jorge on the phone last weekend.

Don: You say that you’ve been upset. What feelings make up being upset? Velia:

I feel so guilty . . . and I feel resentment toward him because he’s using the children to get me to come home.

Don: So, you’re feeling guilty and resentful. Are you feeling any other feelings? Velia:

I guess I am. I’m really angry with Jorge, and overall I just feel depressed. I wish that things were different.

Don: Are there any other feelings here, or do these pretty much cover it? Velia:

I think that’s all . . . there’s too much here.

Don: It can get a bit overwhelming at times. There’s a lot to your situation. . . . Suppose we explore each one of these feelings. Perhaps if we take each one we can arrive at some conclusions that may bring a bit of relief. Velia:

Okay.

Don: You first said that you felt guilty. What was it about the phone call that resulted in your feeling guilty? Velia:

Jorge always tries to make me feel guilty. He tells me how much he loves me and how he can forgive me for what I’ve done. Then he brings the children into it. He says that we can all be back together as a family. It hurts so much.

Don: So, first there’s guilt, followed closely by hurt. Velia:

Yes, that’s what usually happens, anyway.

Don: Velia, sometimes people have a tendency to allow guilt to immobilize them. As we’ve discussed before, if you were to consider guilt as a motivator, what actions might you consider taking?

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Health- and Mental Health–Related Crises Velia:

Well, I could first think that I’m not going to buy into his attempts to make me feel guilty.

Don: That sounds good. So when he makes statements as he did on Saturday night, you will begin telling yourself, “I’m not going to allow him to make me feel guilty.” Velia:

Yes, that’s what I plan to do. Also, I am going to use the guilt as a reminder that I must stay committed to seeing this divorce through, even though Jorge and the children don’t want me to do it.

Don: So you are not going to allow feelings of guilt or hurt to deter you from following through with the divorce, an action that you truly believe is best for you.

Explore and Assess Past Coping Attempts As noted earlier, the divorce-related crisis may be the result of a distinct event or the consequence of the cumulative effects of loss and adaptation demands. In either condition, it is important to assess the coping and adaptation capabilities of the client. Gathering information about loss, coping, and adaptation requires the exploration of the client’s developmental history. Goals of this exploration should focus on uncovering client strengths as well as limitations. Often, clients in crisis (and many not in crisis) do not recognize legitimate strengths among their personal resources. They have a tendency to ignore or minimize abilities and to attribute past successes to chance, others’ efforts, or the circumstances. Also, clients are inclined to maintain that their talents and their demonstrated coping capacities are uncharacteristic responses; therefore, they are viewed as invalid. Insight into these views will be most helpful to the therapist in promoting greater client self-efficacy. The therapist may gain an understanding of client coping capacities through interviewing or by means of journaling. Through either means, past successes in problem solving, coping, and adaptation, along with current selfappraisals of coping capacities and resource availability, should be identified and elucidated. During crisis, it can be expected that clients’ efficacy expectations become reduced. In response, the therapist should guide explorations into the client’s demonstrated and potential coping capacity and resource management. Various means that the client has used to cope in similar crisis situations should be specified and the client queried regarding the possibility of incorporating the same coping measures in the current crisis. Cognitive restructuring, cognitive elaboration, problem solving, and therapist are all viable approaches in the enhancement of client self-efficacy and in crisis management. Don: Velia, you have said that coping with your children’s reactions to you has been tremendously difficult for you, that

The Crisis of Divorce 673 you’ve felt extremely depressed. I understand that you are a survivor, that you have suffered terrible abuse but handled it. Do you see yourself as a survivor? Velia:

Yes, I do.

Don: What does that mean to you, that you’re a survivor? Velia:

I guess that it means that I haven’t let what Dad did to me stop me from being happy, to fall in love, . . . and to pretty much trust people.

Don: That says a lot about you, Velia. I’m really pleased for you. Can you see that you must have used tremendous coping skills to get through the abuse and survive as you have? Velia:

I’ve never really thought about it, but I guess that I have. I’m pretty good, aren’t I?!

Don: Yes you are, Velia. I’m impressed, really. Now what do you think would allow you to access those same coping abilities to deal with your current crisis? Velia:

Mmm, good question. I’ll have to think about it. But I see where you are headed with this. If I did it before, I can do it again!

Don: Exactly! You have demonstrated that you can cope, and cope well. We will continue to explore your past and uncover the specific strategies you used.

Generate and Explore Alternatives and Solution Seeking The therapist should promote the view that there is no one way or “right” way to work through a crisis. The task at hand is to generate alternative approaches to the current crisis, with the objective to tailor the solutions specifically to this client at this time. Obviously, the more alternatives generated, the greater the likelihood of creating change strategies that are more appealing to the client and of greater promise in producing effective outcomes. Once alternative strategies are determined, the perceived consequences (viability) of each should be explored. Once again, consider Velia as an illustration of this process.

Velia felt stuck with regard to her relationship with her children. She continued to write to them but received no letters in return. She felt an extreme sense of loss and her deep depression continued. We explored in session many alternative actions that she could take to improve her relationship with her children. Possible consequences of each option were discussed. The alternatives she considered included having a family reunion at her home; appealing to Jorge to talk with the children on her behalf; meeting with each child

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individually; talking with her daughter Maria, who is least upset with her mother, and enlisting her to accompany Velia in meeting with the other children individually; taking no action and allowing time to heal the hurt; and involving her brother, highly respected by Velia’s children, in talking with each of them individually with Velia. The perceived consequences of each action were considered. Velia chose to approach her daughter Maria first. She had in mind asking Maria to go with her when she went to meet individually with her other children. Once this decision was made, the focus of the intervention turned to what Velia hoped to accomplish in face-to-face interactions with her children, the determination of the specific content to be shared and discussed, and the establishment of realistic expectations.

Restore Cognitive Functioning Through Implementation of an Action Plan Divorce-related crises, like other crises, have the potential of promoting healthy change, empowerment, and creative and novel life experiences. As clients put their change efforts into effect they realize outcomes well beyond the resolution of the current crisis. Successful crisis resolution has the potential of “proving” to the client that relatively rapid and pervasive changes can be accomplished. Additionally, a multitude of cognitive benefits are possible. Several outcomes are likely in the category of self-views. The potential exists that divorced individuals learn to view the process of divorce as having meaningful positive as well as negative consequences. Divorce isn’t all negative. This contradicts the tendency to all-or-nothing thinking, or dichotomous thinking (Granvold, 1994). The client may develop a sense of greater inner strength and self-reliance. A new or renewed sense of self-confidence and self-efficacy is possible as the individual takes on new responsibilities, fulfills novel roles, and makes independent decisions. Client coping capacities get severely tested during the crisis of divorce. The result is an expansion of coping strategies and an overall increase in coping ability. Many who did not seek the divorce ultimately report a sense of rejuvenation, excitement about life, and joy in experiencing greater novelty both in relationships and in activities. Another highly significant cognitive outcome is that clients learn the benefits of expanding their meanings about crisis events. They learn that many meanings exist for any event or circumstance in life. Furthermore, they develop skills in cognitive elaboration through therapist-guided practice in sessions and self-generated cognitive elaboration in vivo. Journaling, thought records, and verbal s in therapy are useful methods in developing these skills. Another important outcome is that clients learn to view their emotions as instrumental and necessary in the process of change. Rather than viewing feelings of loss, depression, fear, and anxiety as negative, these emotional

The Crisis of Divorce 675 states and their expressions are to be viewed as positive and meaningful in their effects. Emotions are viable agents of change; they serve us well in achieving truly painful transitions. They can be useful guides in activating steps toward healing, renewal, and an evolving self.

Follow-up Follow-up is one element of relapse prevention, an aspect of intervention that is important in all forms of treatment, including crisis intervention (Granvold & Wodarski, 1994; Greenwald, 1987; Marlatt & Gordon, 1985). Follow-up telephone calls or follow-up cards or letters are appropriate methods to gain information about the client’s status following treatment. Useful information may also be gleaned from client with regard to the meaningful aspects of the treatment experience (and aspects of the counseling effort that the client did not find useful). Therapist-initiated three- and six-month follow-up is appropriate. At termination, the therapist should make it clear that he or she is always available for future s, should the client so desire. It is also important to stress that a booster session may be appropriate and that a follow-up session is not necessarily a sign of dependency or major relapse in recovery. As I have identified throughout this chapter, in the divorce process there are many opportunities for the individual to experience a crisis. Successful crisis recovery does not protect the individual from encountering future stressful events that may reach crisis proportions. A crisis may actually develop in another aspect of the recovery process well past treatment termination for the original crisis. Recently, a divorcing father who had successfully resolved the crisis of separation and impending divorce was charged by his estranged wife with the sexual abuse of their daughter. The client returned to therapy in crisis regarding the consequences of these allegations. Crisis intervention was implemented as the client was evaluated by social and legal system representatives. Although all parties concluded that the allegations were false, the client was in crisis throughout the entire process.

CONCLUSION The crisis of divorce has been noticeably absent from the crisis intervention literature. Taking only the suicide rate as an indicator of the intensity of the crisis of separation/divorce, and the high divorce rate as representative of the magnitude of the problem, one can conclude that mental health professionals should consider this population to be significantly at risk. The crisis intervention strategies and techniques discussed in this chapter, and those detailed elsewhere, should be given strong consideration in meeting the therapeutic needs of the multitudes in our society who are in the throes of coming apart as a couple or a family and attempting to re-vision their lives.

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The Crisis of Divorce 679 the mind in mental health and psychotherapy. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy (pp. 99– 121). New York: Plenum. Logan, T. K., Walker, R., Horvath, L. S., & Leukefeld, C. (2003). Divorce, custody, and spousal violence: A random sample of circuit court docket records. Journal of Family Violence, 18(5), 269–279. Mahoney, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York: Basic Books. Mahoney, M. J. (Ed.). (1995). Cognitive and constructive psychotherapies: Theory, research, and practice. New York: Springer. Mahoney, M. J. ( 2003). Constructive psychotherapy: A practical guide. New York: Guilford. Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention. New York: Guilford. McCubbin, H. I., & Patterson, J. M. (1983). The family stress process: The double ABCX model of adjustment and adaptation. In H. I. McCubbin, M. B. Sussman, & J. M. Patterson (Eds.), Social stress and the family: Advances and developments in family stress theory and research (pp. 7–37). New York: Haworth Press. McKenry, P. C., & McKelvey, M. W. (2003). The psychosocial wellbeing of Black and White mothers following marital dissolution: A follow-up study. Psychology of Women Quarterly, 27(1), 31–36. Michelson, L. (1987). Cognitivebehavioral assessment and treatment of agoraphobia. In L. Michelson & L. M. Ascher (Eds.), Anxiety and stress disorders: Cognitive-behavioral assessment and

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29 Crisis Intervention With HIV Positive Women SARAH J. LEWIS DIANNE M. HARRISON

This chapter is intended to provide an overview of crisis intervention with women who test positive for the human immunodeficiency virus (HIV) and the many factors that must be considered when working with this population. In order to provide stabilization during a time of crisis, it is necessary for clinicians to have an understanding of not only the emotional and social consequences of being HIV positive, but the physical consequences as well. Because HIV disproportionately affects minority women, it is imperative that clinicians also understand the cultural ramifications of living with HIV as well as cultural coping strategies. There are several phases of the HIV trajectory in which women typically incur disequilibrium that may require intervention: at the time of HIV positive diagnosis; disclosure of HIV status; deterioration of the immune system; commencement of antiretroviral therapy; application for disability and/or termination of employment; and at the time of a diagnosis of acquired immunodeficiency syndrome (AIDS) (Poindexter, 1997; Brashers, Neidig, Reynolds, & Haas, 1998). The continual uncertainty that results from these events can precipitate situational, developmental, social, or compound crisis states individually or simultaneously (Hoff, 1989; Poindexter, 1997). As of December 2002 there were 82,764 women with AIDS in the United States. There are disproportionately high rates of infection among African American women (48.6 per 100,000), Latina women (11.3 per 100,000), and American Indian/Alaskan Native women (5.8 per 100,000), compared 682

Crisis Intervention With HIV Positive Women 683

Figure 29.1 Estimated persons living with AIDS by region and year of diagnosis, 1992–2001, United States (CDC, 2002)

Figure 29.2 Estimated persons living with AIDS by race/ethnicity and year of diagnosis, 1992–2002, United States (CDC, 2002)

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Figure 29.3 Estimated persons living with AIDS by gender and year, 1992–2002, United States (CDC, 2002)

with Caucasian women (2.1 per 100,000). It is important to recognize that that African American and Latina women represent 25% of all women in the United States, yet comprise greater than 82% of all the AIDS cases in women living in the United States (CDC, 2002). Women living within inner cities who are disproportionately affected by poverty and crime are hardest hit by the AIDS crisis (Dodd, Nuehring, Blaney, Blakley, Lizzotte, Potter, & O’Sullivan, 2004). Because of the heterogeneity of the female HIV positive population, it is important to consider the cultural health beliefs as well as historical racism and sexism with which these women have been plagued (Gaskins, 2001). Many of the crises associated with HIV are related not to illness but to contextual factors in which HIV flourishes as well as the social and developmental consequences of HIV, a stigmatized disease. Clients with HIV often are affected by twin epidemics that are compounded by biopsychosocial factors: substance abuse and HIV (Kalichman, 1998). Substance abuse may inhibit access to medical care, producing a negative impact on quality of life (Israelski, Eversley, Janjus, & Smith, 1998). Social workers must be willing to address substance abuse issues with HIV positive clients so that the client may rise to a higher level of functioning.

CASE VIGNETTES The following cases are typical of those that face social workers working within a community based AIDS organization that provides case management.


Figure 29.4 Reported cases of HIV/AIDS in infants born to HIV-infected mothers, by year of child’s birth and race (CDC, 2002)

Case 1 Mary J., a 22-year-old African American daycare center worker, was referred to a social worker for case management by her OB-GYN after her husband called the doctor and reported that Mary had not gotten out of bed since her last appointment the prior week. At Mary’s last appointment with the OBGYN she had found out that she was HIV positive after routine testing during the first trimester of her pregnancy. When Mary’s physician presented Mary with the consent form for HIV testing, explaining that all pregnant females should be tested, she chuckled and stated, “The HIV test is one test I have worked hard to fail.” Mary had participated in no high-risk behavior except for having unprotected sex with her husband. Mary’s husband, however, had had several sex partners prior to marriage and had never been tested for HIV. Mary was not prepared for, and was totally devastated by, the news of her infection and felt as though her world as she knew it had come to an end. She had always believed that if she worked hard and had love in her heart and a strong faith in God, her life would be protected from atrocity. She felt betrayed by her husband and too dirty and infectious to be around the children she worked with, and she didn’t know whether to continue carrying the baby that she desperately wanted. When she sat down in the social worker’s office she was in shock, unable to comprehend that everything could change in an instant.

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Case 2 Linda B. was a 26-year-old White crack cocaine addict. She was arrested while prostituting herself in order to her drug habit, and the judge presiding over her case ordered that she be tested for HIV. Although Linda had been a sex worker since she left home at age16 because of physical abuse by her parents, she was shocked that she tested HIV positive. Linda told no one of her HIV status for fear of being rejected by her friends who were also sex workers. Linda attempted to stop smoking cocaine but was unsuccessful. Her health began to deteriorate, and a year after her initial diagnosis she collapsed in an alley and was taken to the local hospital with pneumonia and diagnosed with AIDS. The drug combination that could drastically reduce HIV viral load and strengthen her immune system required strict adherence and monitoring. Linda’s doctor believed that Linda would continue using cocaine when she was released and was therefore unwilling to start her on the drug combination. The doctor attempted to explain to Linda that if she could stop using drugs, keep clinic appointments, and regularly take the medication, she could look and feel healthy for several years, but without medication she would probably not live more than 2 years. When the doctor left the hospital room, Linda called for the nurse to come in. She was afraid of her doctor, but she trusted her nurse. Linda asked the nurse if she would die without the medication, and the nurse confirmed, in a much gentler manner, what the doctor had stated. Linda panicked. She did not want to die, but she did not have the coping skills necessary to live. She was at a turning point. The nurse gave Linda the phone number of a local AIDS case management organization and told her that they might be able to help but that she would have to make the call.

DEFINITION OF CRISIS Crisis is defined as a “subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope” (Roberts, 1990, p. 328). A defining characteristic of a crisis is that it is time limited, lasting from 4 to 6 weeks; however, HIV positive clients may experience serial crises. Although a stressful or hazardous event precipitates the crisis, it is the perception of the event and the individual’s inability to cope with the perceived consequences of the event using previous coping strategies that designate a crisis (Lewis, 2004). Poindexter (1997) explains that because HIV is a chronic illness that has physical, emotional, social, spiritual, and developmental consequences, an HIV positive person may experience multiple and cumulative crises over time. Crisis states can be the result of developmental, situational, or social conflict (Kanel, 1999; Poindexter, 1997). Each major event throughout the

Crisis Intervention With HIV Positive Women 687 HIV trajectory may precipitate a crisis in the life of an HIV positive woman. The following are examples of these events: • • • • • • • • •

Original HIV diagnosis Issues related to external and internal stigma Issues related to partner infidelity, or other trust issues Issues related to role definition (being a woman, partner, mother, etc.) The decision to divulge, or not divulge, HIV status to family and peers First clinical signs of a compromised immune system Issues related to antiretrovirals or other treatment Issues related to pregnancy AIDS diagnosis

The concept of developmental crisis stems from ego psychology, specifically from Erik Erikson (Pillari, 1998). Erikson proposed eight stages through which a person es in his or her lifetime. Each stage presents a conflict or crisis that must be mastered in order to successfully develop or move on to the next stage. When an individual faces a chronic or terminal illness in young adulthood, the length of time to master each stage is shortened or otherwise disrupted (Kanel, 1999). The dramatic shift in role perception can also have an impact on developmental tasks. A situational crisis is not a normal stage of development but an event that is extraordinary. A situational crisis can be precipitated by events such as a violent crime, a sudden death, a natural disaster, or the diagnosis of a chronic or terminal illness. The event can challenge the fundamental assumptions that underlie the individual’s worldview (Roberts, 1996). According to Roberts, “A person’s vulnerability to a stressful life event is dependent to a certain extent on the newness, intensity, and duration of the stressful event” (1996, p. 22). Opportunities for situational crises abound throughout the HIV trajectory, resulting in what can be considered a “chain of life stressors” (Roberts, 1996, p. 23). A diagnosis of being HIV positive often changes the way a person imagines his or her world is in the present and will be in the future. Dreams can vanish in an instant, and life plans can suddenly turn into uncertainty. Because HIV positive individuals can have a long asymptomatic period, the first signs of immune system depletion or the diagnosis of an AIDS defining illness can also trigger a crisis. The interpretation of these events by the HIV positive individual is often that death is imminent. Social crisis is brought about by societal or cultural events or responses (Poindexter, 1997). These events or responses can be racism, sexism, homophobia, or other discriminatory beliefs and their accompanying behaviors. Crisis arises in a cultural sense when cultural identity is challenged. Unfortunately, HIV triggers most of society’s negative “isms.” Individuals with HIV face a level of discrimination that is far worse than that experienced by

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individuals with other chronic or terminal diseases (Poindexter, 1999). Even when one does not disclose one’s HIV status, one can still be impacted by internalized stigma. Internalized stigma does not require overt mistreatment, but it can occur simply by accepting perceived societal judgment and threat of rejection.

SCOPE OF THE PROBLEM AND PSYCHOSOCIAL VARIABLES HIV is transmitted through body fluids such as blood, semen, vaginal secretions, and breast milk and leads to suppression of the immune system. Until 1993, a diagnosis of AIDS was given only if an individual was HIV positive and had 1 of 26 opportunistic infections. In January 1993, case definitions were changed to include other clinical markers such as a CD4+ T-lymphocyte count of less than 200 per milliliter of blood or a CD4+ percentage of less than 14, and diagnosis of pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer. Opportunistic infections are mostly ubiquitous infections that are generally thought to be benign in individuals with healthy immune systems. However, when depletion of the immune system occurs, these infections take the “opportunity” to propagate and than can be deadly. Case reporting of surveillance data related to HIV and AIDS has recently gone through several changes. Before 1993, only AIDS cases as defined by the preceding criteria were reported to the Centers for Disease Control (CDC). Immune system depletion to the point of susceptibility to opportunistic infection can take10 years or longer, and because of this the epidemiological picture was quite distorted. Only approximations of HIV infection rates have been available because HIV per se was not reportable; only the outcome of HIV (i.e., AIDS) was reportable. Since 1994, the CDC has ed uniform HIV surveillance for all 50 states and territories, however, by 1998 only 29 states had implemented HIV reporting making it difficult to analyze trends in HIV infection (CDC, 2002). Because of these unstandardized surveillance requirements, HIV infection surveillance data must be interpreted with caution (CDC, 1998). In 1997, the death rate for AIDS in the United States was the lowest in a decade—almost two-thirds below rates from just 2 years previous. The decrease is attributed to a new class of drugs known as protease inhibitors. New complex, multi-drug regimes, called highly active antiretroviral therapy, which include a protease inhibitor in combination with one or two other classes of antiretroviral drugs, are capable of lowering viral loads to the point of nondetection, allowing t-cells to resume healthy levels. Another new class of drugs, fusion inhibitors, has just been released. This class of drugs blocks HIV from infecting healthy t-cells. Unfortunately, there are several limitations to aggressive HAART, such as large pill burden, food and


Figure 29.5 AIDS cases and annual rates per 100,000 pop, by race/ ethnicity and gender reported in the continental US, 2002 (CDC, 2002) storage restrictions, severe side effects, and even reduction in quality of life measures. Because of the psychosocial life stressors that many individuals who are HIV face, strict adherence to drug regimens can be quite challenging (Lewis & Abell, 2001). As of December 2002, there are 82,765 women with living with AIDS, and an additional 199,759 had been reported HIV positive from areas with confidential name-based HIV infection reporting. From 1998 through 2002, the number of AIDS diagnoses increased 7% among women and decreased 5% among men. Women who seek treatment early tend to have the same survival rates as men; however, women have historically been less likely to receive an early diagnosis. Often the impetus for women to get tested is pregnancy.

Pregnancy and HIV Federal guidelines now require doctors to counsel pregnant women about HIV and encourage them to test voluntarily for HIV. The rationale behind these guidelines is that if women know their HIV status, they can participate in antiretroviral therapy (drugs that fight the virus) during pregnancy and lower HIV transmission risk to the fetus. Vertical transmission rates (from mother to fetus) have dropped dramatically.

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Figure 29.6 Estimated female adult/adolescent AIDS incidence, by exposure category and year of diagnosis, 2001–2002, US

It is estimated that over 6,000 HIV positive women give birth each year. Although each of the babies is born HIV antibody positive, by 18 months, most of them seroconvert to HIV antibody negative after they develop their own immune systems (Siberry, Parson, & Hutton, 2003). Vertical transmission rates have drop at least 80% from 1992 to 2001 and it is now possible to achieve transmission rates as low as 1–2%, compared to 25–30% a decade ago (Anderson, 2001). It is important to recognize philosophical and cultural perspectives about women and childbirth when considering the topic of women and HIV. The cultural identity associated with motherhood and women’s place in society is threatened by the possibility of vertical transmission of the virus. In cultures that place a high value on childbirth, HIV mothers are put in double jeopardy: Have a child and possibly expose it to the virus—making the woman a bad mother; or don’t have a child—and have diminished value as a woman. Recent research has demonstrated that HIV positive pregnant women have higher levels of depression than HIV negative pregnant women (Levine, Aaron, Laquinte, 2003). It is important to note, however, that HIV positive pregnant women had higher levels of depression prior to pregnancy than their HIV-negative counterparts. These findings may be the result of multiple

Crisis Intervention With HIV Positive Women 691 stressors related to HIV, or the contextual stressors that many women with HIV deal with on a daily basis.

Sex Work Because of the various definitions of prostitution and the often-illegal nature of the trade, it is difficult to estimate the number of persons who are currently involved in sex work. According to Shedlin (1990), there is a social hierarchy of female prostitutes. Escort services or call girl establishments recruit the younger, most attractive women, whereas women who work the street are considered to be the lowest level in the hierarchy. Studies suggest that HIV transmission is up to four times higher among sex workers who are intravenous drug s (IDUs) as opposed to those who are not IDUs, suggesting that occupational exposure via heterosexual transmission is not the highest reported risk category for sex workers (Cohen, 1994). Sex workers who use crack cocaine tend to have more paying as well as nonpaying sex partners with whom they will have unprotected sex in order to obtain drugs or charge additional money.

Drug Abuse and HIV Drug abuse and HIV have gone hand and hand since the beginning of the AIDS epidemic in the United States. Surveillance data do not accurately describe the impact of drug abuse on HIV exposure because drug use is a contributing factor in exposure via method of delivery, not a risk factor in and of itself. Intravenous drug use, therefore, is the only reported indicator of the drug abuse/HIV correlation. Although it is impossible to determine exact numbers, studies suggest up to 80% of HIV positive women were infected directly or indirectly through drug use (Ferrando, 1997). Up to 90 % of HIV positive drug abs have a comorbid psychiatric illness. Drug abuse and/or psychiatric illness exacerbates psychosocial stresses associated with the HIV disease trajectory and must be considered throughout any intervention. Even though it may seem impossible, it is imperative that treatment of substance abuse and or mental illness be provided concomitantly with medical treatment. If substance abuse and/or psychiatric illness are not addressed initially, sabotage of medical intervention as well as clientworker relationships is likely. Although there are several reasons for addressing these concurrent problems, possibly the most important are the severe individual and societal consequences associated with nonadherence to multidrug regimens.

Consequences of Nonadherence Nonadherence to protease inhibitors is directly related to the development of antiretroviral drug resistance (Lewis & Abell, 2002). Poor adherence can

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be a problem with any chronic illness; however, as early as 1996, the issue of nonadherence was recognized as a potential disaster with protease inhibitors (Vanhove et al., 1996). HIV replicates hundreds of millions of times a day, creating approximately 10 billion viral particles. Every replication is a potential for mutation (Mirken, 1998). When no antiretroviral is being used, these mutations are mostly random natural accidents and make no meaningful difference. When an antiretroviral is stopped and started, as is the case with nonadherence, Darwinian selection pressure is exerted, giving the mutated virus an advantage to survive. The mutations become systematic because the particles that are most drug-susceptible are killed, leaving only drug-resistant particles to replicate. The strength of the highly active antiretroviral therapy (HAART) is what makes it so susceptible to resistance through viral mutation. A weak regimen like Zidovudine (AZT) monotherapy does not completely halt viral replication, so mutation is not necessary for the virus to survive. When regimens are stronger and completely halt the replication process, only particles that have mutated around the medication survive and replicate. Even though resistance to AZT does happen, it usually takes 18 months to 3 years; resistance to HAART happens much more quickly (Mirken, 1997). There is a serious gap in the literature regarding how much nonadherence is too much nonadherence; however, some believe that less than 95 % adherence is unacceptable. It is interesting to note that new research findings show that viral mutation due to nonadherence follows a bell shaped curve. Individuals who have little adherence (they almost never take their medication) have low levels of viral mutation, individuals with good adherence, but not excellent have high levels of mutation (more than some of the time, but less than 95% of the time), and those with excellent adherence (95% or more) have little viral mutation (Sethi, 2004). Viral mutation has both personal and societal consequences. The first level is that of increased viral burden in the patient with the mutated virus. The Food and Drug istration (FDA) have approved only eight protease inhibitors and one fusion inhibitor, and the virus may form resistance to several of the protease inhibitors at one time. This leaves few options for effective regimes. The societal consequence is a result of an individual who has developed resistance to all available treatments infecting others. The newly infected individuals will acquire the mutated virus, which is resistant to all treatment, leaving them with no treatment options (Mirken, 1997). This new resistant strain of the virus known as a “super virus” is a new phase of the AIDS epidemic.

RESILIENCE AND PROTECTIVE FACTORS At most AIDS service organizations that provide case management, clinicians attempt to prepare clients for possible future events in order to prevent

Crisis Intervention With HIV Positive Women 693 Table 29.1 Internet Sites • http://www.aegis.com This site provides information for clients and clinicians. It has an excellent library that is an incredible resource. Site map is easy to navigate and should be a top choice when looking for something quickly. • http://thebody.com This multimedia site, like aegis, can be considered a megasite. The body is updated at least once a day, so outdated information is rare. This site is another excellent site to bookmark. • http://www.cdc.gov This is the site for the Centers for Disease Control. One has to navigate around a bit in order to find information on HIV, but if you are interested in healthcare, it is worth the visit. • http://www.medscape.com This site is a more clinical in nature, but it has the most up-to-date information on new important findings in the medical community.

crisis situations. During the intake, myths are dispelled by educating the client about the disease spectrum, constitutional symptoms, what to do and not to do to stay healthy, and strategies for safer sex. Suggestions for keeping the immune system healthy usually include nutritional facts, information on groups, hotlines, counselors for stress management and other mental health issues, medication adherence issues, and spiritual . There are remarkable Internet megasites to help clients and clinicians keep up with new clinical trials, news briefs, as well as the history of the AIDS crisis. (See Table 29.1.)

SEVEN STAGES OF ROBERTS’S CRISIS INTERVENTION MODEL Roberts’s seven-stage model of crisis intervention provides an excellent framework for working with HIV positive individuals who are experiencing a crisis state. The seven stages of intervention are as follows: • • • • • • •

Assessing lethality and safety needs Establishing rapport and communication Identifying the major problems Dealing with feelings and providing Exploring possible alternatives Formulating an action plan Providing follow-up

It is important for the clinician to that what separates a crisis from a difficult situation is the lack of tools and the perception of danger. For example, when a person gets a flat tire in his or her car, if one has the tools, a spare tire, and a safe place to change the tire, the flat is a mere inconvenience. However, if that person is alone on a dark, deserted highway

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and there is no lug wrench, a feeling of crisis begins to stir. The event, the flat tire, is not the crisis. The perception of danger generated by the lack of tools to ameliorate the situation and the feelings aroused by that perception are the crux of the crisis. The clinician’s acknowledgment and assessment of the perceived danger are the starting point for crisis intervention. Roberts’s seven-stage model is meant to be a flexible framework for practice, providing guidelines for crisis intervention without rigidity.

Lethality Assessment and Building Rapport An assessment of suicidal or homicidal ideation should be a part of every crisis intervention even if it is informal and brief. In someone who is newly diagnosed with HIV, the crisis does not usually involve homicidal or suicidal ideation, but instead a strong desire to live. Therefore, the assessment of lethality is usually informal and done within the context of rapport building. If, however, it is suspected that a client could possibly be in immediate danger, a more in-depth lethality assessment is necessary. When danger is suspected, the clinician must ask the client directly whether she has intention to hurt herself or someone else. The directness of this approach may be uncomfortable for the practitioner; however, it gives the client permission to talk about her intentions. The following questions must be answered: 1. 2. 3. 4. 5.

Do you want to harm yourself or someone else? Have you ever attempted to harm yourself in the past? Has anyone close to you ever committed suicide or homicide? Do you have a plan? (Clinician must determine if the plan is realistic.) Do you have the (pills, gun, etc.) to carry out the plan?

All agencies and private practitioners should have protocols on safety procedures in place before ever being faced with a homicidal or suicidal client. If the answer to question 1 and any additional question is yes, the clinician must follow through with the aforementioned protocols. Each affirmative answer indicates an increase in the risk of physical harm. For the most part, crisis intervention with HIV positive women generally begins with the stage of rapport building, or relationship building. The tools or assets that the clinician needs in this stage are a nonjudgmental attitude, the ability to understand verbal and nonverbal communication, sincerity, objectivity, and a sense of humor. When attempting to build rapport, it is important for the clinician to the stigma that is often attached to an HIV positive status. The clinician will be asking the client to reveal very personal actions that are not customarily talked about with anyone, let alone strangers. After working with the HIV positive population for a while, it is easy to forget the discomfort associated with topics such as sex and drug use. These topics become a part of the everyday experience of the practitioner; however, the discomfort

Crisis Intervention With HIV Positive Women 695 may remain for the client. The practitioner must provide a safe and respectful atmosphere for such disclosures; this can be done through modeling a level of comfort with sensitive material often considered taboo. It is during this stage of assessment that most information gathering will be done. Most agencies have a routine intake form consisting of several pages of questions. These questions are generally used to collect demographic information (place of residence, family size, income, etc.), possible HIV exposure routes, method of payment for medical services, some medical information, and information about the client’s family system or other avenues of . A succession of rapid-fire questions can severely hinder the attempt to build a mutually respectful relationship because there is no giveand-take between parties: The client is doing all the giving. Such one-way communication sets up a dynamic where the clinician is the one with all the power, diminishing the client. When clinicians are familiar with the intake and assessment process, it is much easier to guide the client to tell his or her story as opposed to giving one-sentence answers to a series of questions. This storytelling provides both a more relaxed atmosphere for the client, as well as an opportunity for the clinician to assess cognitive functioning. A moderately scheduled guide is used to assure the collection of all needed information. The guide does not have to be an actual object (although that may be helpful in the beginning) but instead a way of thinking or arranging the interview. The format of the guide is funnel shaped, meaning the interview starts with very open questions that lead to more direct questions. For example: • So, Mary, what brings you in to see me today? • Is this your first pregnancy? • What are your fears about keeping this baby?

Each question in the preceding sequence gets more focused. There may or may not be several questions between these questions, depending on the depth and breadth of Mary’s responses. The guide is moderately scheduled because it gives an outline, not the exact questions or timing of the questions. All the information needed by the agency must be gathered, but it can be gathered in a time frame agreed upon by both the client and the clinician.

Assessment of the Problem The primary challenge for clinicians working with HIV positive individuals is resisting the urge to become enthralled by the crisis. Because death is so embedded in societal consciousness as the ultimate negative consequence of danger, it is hard to recognize that death is not a crisis. A sign on the wall of the employee lounge in one AIDS service organization reads: “There is no such thing as a crisis.” This is to remind clinicians that no matter what the

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circumstance, when individuals have the tools they need, there is no crisis. The questions and issues that the practitioner needs to identify and assess are shown in Table 29.2 for each of the 2 case illustrations. When working with HIV positive clients, it is important to always consider possible cognitive impairment of a physiological nature. This is not to imply that the social service clinician should attempt to medically diagnose a client with HIV brain involvement; however, the clinician should be able to recognize telltale signs in order to make immediate medical referrals. These signs may include, but not be limited to, memory impairment, illogical or disorganized thinking, severe headaches, blurred vision, a change in speech, or a change in gait. Because of the heterogeneity of the HIV positive population, practitioners should take every opportunity to learn about the cultures and customs of the people they serve. For example, many African American of some fundamentalist religious groups believe that fate and God have a great impact on health (Bekhuis, Cook, Holt, & Scott-Lennox, 1995). African American students have been found to have group-specific thoughts about providers of health services and their own mental health (Millet, Sullivan, Schwebel, & Meyers, 1996). Not all cultures follow or place the same importance on stages of development or life events, and it is important to consider the presenting crisis within the context of the client’s cultural identity. The clinician must assist the client to rank order or prioritize the major problems, as well as the perceived danger that these problems evoke. Although this may seem obvious, it is mentioned as a reminder to the reader of the ease with which projection can occur. The clinician may prioritize the presenting problems differently from the client; however, it is the client who is feeling the distress. If the practitioner believes that groundwork must be laid before

Table 29.2 Type of Danger and Coping Strategies Aspect of Current Crisis

Positive and Negative Coping Strategies

• What is the perceived danger? 䉬 Mary: Not being able to have children. 䉬 Linda: Eminent death. • Is the danger physical or emotional? 䉬 Mary: Emotional. 䉬 Linda: Emotional. • How will the client’s life be affected? 䉬 Mary: Change in perceived life story. 䉬 Linda: Must make a conscious decision to live.

• What strategies (both negative and positive) have been attempted to resolve similar dilemmas in the past? 䉬 Mary: Reliance on faith and family. 䉬 Linda: Drugs and self-reliance. • What tools are presently necessary to resolve the dilemma? 䉬 Mary: Knowledge of vertical transmission risks, faith, and family. 䉬 Linda: Knowledge of disease spectrum and adherence issues, trust in someone other than herself, a system, and drug treatment.

Crisis Intervention With HIV Positive Women 697 tackling the prioritized problem, he or she is obligated to work through these issues with the client. For example, Mary identified her main problem as the moral dilemma of keeping her baby and possibly infecting it with HIV, or having an abortion, which was against her religious beliefs. Her cultural identity as a woman was challenged by the belief that she was not fit to bear children, and she was experiencing a tremendous amount of internalized stigma. Although Mary was experiencing several other issues, this was the order of priority that she felt was most important. In the case of Linda, she needed both medical treatment and drug treatment. Linda recognized that she did not want to die, knew there was some medicine that could give her a chance, but also knew the doctor wouldn’t give it to her if she continued using crack. Linda could not imagine life without crack and identified the major problem as the physician who would not prescribe the medicine for her. The clinician’s role was to help Linda to understand the true nature of the problem and to assist her in finding a workable solution.

Exploration of Feelings Women who are newly diagnosed could be experiencing one or more of many feelings: • • • • • •

Shame: “I caught this disease through drug use or sex.” Betrayal: “I can’t believe that he was cheating on me.” Anger: “That no good so-and-so gave this to me.” Loss: “I won’t be able to have sex—or a baby—ever again.” Fear: “I am afraid I am going to die soon.” Guilt: “I may have given HIV to someone else.”

Throughout this chapter perceptions and thoughts have been discussed as the driving force behind crisis. Emotions, according to cognitive theorists, are also driven by cognitions. A primary objective in crisis intervention, therefore, is to provide information to correct distorted ideas and provide better understanding of the precipitating event. This is not to be done in an emotionless vacuum, but instead in a ive environment that emphasizes the client’s strengths. The clinician must actively listen during this cathartic phase and gently keep the client on track by asking open-ended questions. The clinician’s job at this point is to not only actively listen to the client, but to see the client within the client’s system. This will provide tools for the next stage where solutions are explored. In order to see the larger client system the practitioner must constantly keep in mind five things: (1) the stage of development of the client (e.g., Ericson or some other developmental theorist);

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(2) stage of disease; (3) place in family or system; (4) cultural norms; and (5) strategies that have worked in the past in similar situations. In the first case illustration, Mary had several issues to contend with: pregnancy while being HIV positive, internalized stigma, inability to fill a cultural role, and dashed dreams. Mary also had very little knowledge about HIV, and some of her perceptions were formed by misconceptions about the disease. Mary had an amazing system consisting of both an extended family and the church of which she was an active member. Her feelings were exacerbated by her limited knowledge about the disease spectrum and misinformation that she had about vertical transmission. Linda had a tremendous amount of fear. She had not trusted anyone since she was 16 years old and left an abusive home to live on the street. She did not have a legal means to herself, and she did not know how to stop smoking crack cocaine. Linda’s fear presented as anger. Anger at the doctor for not giving her the medicine, anger at whoever gave her the virus, anger at cocaine for having a grip on her, and anger at the case manager for not being willing to talk the doctor into prescribing her the medicine.

Exploration of Solutions and Action Plan Throughout the assessment process, information is gathered in order to explore solutions. By this point in the intervention the clinician has determined whether the client is suicidal or homicidal, has established rapport, investigated the major problem(s), and has explored feelings and thoughts the client is experiencing as a result of the problem(s). Finding a workable solution and developing an action plan are the next two steps. The solution(s) must be tailor made for the client and must take into the tools with which she has to work. It is also important that the solution provide some immediate relief for the client. When finding a workable solution, the clinician often has to take an active role. The client, due to the crisis, is experiencing disequilibrium, and is unable to identify tactics or skills to alleviate the situation. The client may not recognize that she has overcome similar or more difficult hurdles in the past, and it is the role of the practitioner to point out these strengths and accomplishments. The action plan must contain identifiable steps. It is a good idea to take out a piece of paper and write down each step with the client. Draw a line vertically down the paper and on one side of the paper write down the objective or task, and on the other side write down who is to accomplish the task and the timeframe in which it is to be accomplished. The client may only be able to make one phone call a day. This may not seem like much of an accomplishment, but it starts a momentum toward the goal. In the case of Mary, education about vertical transmission and the HIV disease trajectory was the first step. Although the needed education could

Crisis Intervention With HIV Positive Women 699 begin in the office with the clinician, it was important for Mary to see a physician that specialized in prenatal HIV care. Just the knowledge of available treatments that can greatly reduce the probability of vertical transmission helped to ameliorate much of the crisis state that Mary was experiencing. An appointment was made from the clinician’s office for the first prenatal visit with the HIV specialist, and the clinician offered to sit with Mary and her husband when Mary told him about her HIV positive status. The clinician also suggested that Mary make an appointment with her pastor, who had provided her with spiritual counseling since she was a child. The counselor recognized the pastor’s name as a member of the local HIV Pastoral Network, and knew that he would provide a great deal of comfort to Mary. Linda had a completely different set of needs and skills with which to work. She had survived on the streets for many years and had a strong desire to live. She needed a safe and structured environment in order to change her drug abusing lifestyle, but before that she needed someone to explain to her in layperson why the doctor could not prescribe medication to her if she could not maintain adherence. Another major issue was that Linda had no legal means of ing herself and without such, was likely to feel the need to continue her work in the sex trade. Linda’s list of things to do was comprised of: (1) application for disability (which would provide income and health insurance); (2) education about disease spectrum and adherence issues; and (3) referral for inpatient drug treatment.

Follow Up The last step of every action plan should be some form of follow up with the crisis intervention counselor. A set appointment or follow up with the clinician gives the client both incentive to accomplish each task on the objective list, and also provides assurance that she does not have to do it all on her own. During the follow up the problem and steps taken to overcome the problem are reviewed. If the problem still exists additional possible solutions are investigated. If the problem has been resolved, it is important for the clinician to affirm the client’s accomplishment. This affirmation will help to anchor these new found coping strategies for future use.

CONCLUSION Even though the number of deaths from AIDS-related illnesses have decreased in the recent past, the number of new HIV infections has not slowed. Minority women who are often already marginalized, make up the fastest growing group of new HIV infections. Due to the nature of the virus and the stigma that is associated with it these women may face serial crises.

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When working with HIV positive women, crisis intervention clinicians must consider not only psychosocial variables but also physiological complications. It is often the crisis counselor who is the first person to provide factual information to the client in layperson . This education helps to form the foundation from which the client can begin to restore cognitive functioning and make informed decisions. Clinicians must be sensitive to cultural norms including the roles that women tend to play within each culture. The crisis intervention assessment should be within a cultural context that considers the client’s system of . It is important to recognize the strengths of the client and successful coping strategies utilized in the past. The final word on Mary is a positive one. Mary had her baby and it was HIV antibody positive, but seroconverted to HIV antibody negative at 18 months. Mary discovered that her husband had acquired the virus before he had even met her and the couple decided to stay together. Mary is employed by a women’s peer education program through her church where she tells her story to young African American women to help prevent the further spread of HIV. Mary’s life is different now than it was before, but according to Mary, it is better. Linda’s story has a positive, yet poignant ending. Linda discontinued her drug use in a treatment center and finally began to trust someone other than herself. She found meaning in life and others who cared a great deal about her. Linda’s immune system, however, was unable to recover from the damage done by HIV and years of abuse. Before Linda died, she recognized that healing had taken place and that she had the tools and inner strength to deal with anything.

REFERENCES

Anderson, J. R. (July, 2001). Perinatal transmission and HIV: An unfinished success story. The Hopkins Report. Bekhuis, T., Cook, H., Holt, K., & Scott-Lennox, J. (1995). Ethnicity, church affiliation, and beliefs about the causal agents of health: A comparative study employing a multivariate analysis of covariance. Health Education Research (10): 78–82. CDC (1998). HIV/AIDS surveillance report, 10(1). Chesney, M. A. (1997). New antiretroviral therapies: Adherence chal-

lenges and strategies. HIV Newsline 3(3): 65–66. Cocores, J. A., & Gold, M. S. (1990). Recognition and crisis intervention treatment with cocaine abs: The Fair Oaks Hospital model. In A. R. Roberts (Ed) Crisis intervention handbook: Assessment, treatment, and research. Belmont, CA: Wadsworth Publishing Company. Ferrando, S. J. (1997). Substance use disorders and HIV illness. The AIDS Reader, 7(2): 57–64. Israelski, R., Eversley,R., Janjua, S., & Smith, S. (1998). Race, HIV symptoms, recovery from drug

Crisis Intervention With HIV Positive Women 701 abuse, and appointment adherence are associated with quality of life (QOL) among HIV infected women. [On-line]. AIDSLINE . Abstract from International Conference for AIDS, 12:1075. Kanel, K. (1999). A guide to crisis intervention. Pacific Grove, CA: Brooks/Cole Publishing Company. Katz, A. (1996). Gaining a new perspective on life as a consequence of uncertainty in HIV infection. Journal of the Association of Nurses in AIDS Care, 7(4): 51–61. Levine, A. B., Aaron, E., & Laquinte, J. (2003). Prevalence of depression in HIV-infected pregnant women. American Journal of Obstetrics and Gynecology, 189(6), Supplement 1. Lewis, S. J., & Abell, N. (2002). Development and evaluation of the adherence attitude inventory. Research on Social Work Practice, 12(1): 107–123 Linn, G. L., Anema, M. G., Hodess, S., Sharpe, C., & Cain, V. A. (1996). Perceived health, HIV illness, and mental distress in African-American clients of AIDS counseling centers. Journal of Association of Nurses in AIDS Care, 7(2): 43–52. Linsk, N. L., & Keigher, S. M. (1997). Of magic bullets and social justice: Emerging challenges of recent advances in AIDS treatment. Health and Social Work, 22(1): 70–75. Millet, P. E., Sullivan, B. F., Schwebel, A. I., & Meyers, L. J. (1996). Black Americans’ and white Americans’ views of etiology and treatment of mental health problems. Community Mental Health Journal, 32: 235–242. Mirken, B. (1997). How much does it really matter if you take your pills

on time? Bulletin of Experimental Treatments for AIDS. [on-line] DOCN: BE970902. Available at http://www.sfaf.org Parad, H. J., & Parad, L. G. (1990). Crisis intervention: An introductory overview. In H. J. Pard & L. G. Parad (Eds.), Crisis intervention, book 2: The practitioner’s sourcebook for brief therapy. Milwaukee, WI: Family Service America. Pillari, V. (1998). Human behavior in the social environment: The developing person in a holistic context. Pacific Grove, CA: Brooks/Cole Publishing. Poindexter, C. C. (1997). In the aftermath: Serial crisis intervention for people with HIV. Health and Social Work, 22(2): 125–132. Poindexter, C. C. (1999). HIV-related stigma in a sample of HIV-affected older female African American caregivers. Social Work, 44(1): 46–55. Roberts, A. R., & Burman, S. (1998). Crisis intervention and cognitive problem-solving therapy with battered women: A national survey and practice model. In A. R. Roberts, Battered women and their families: Intervention strategies and treatment programs (2nd ed.). New York: Springer Publishing Company, Inc. Roberts, A. R. (1996). Epidemiology and definitions of acute crisis in American society. In A. R. Roberts (Ed.), Crisis management and brief treatment: Theory, technique, and applications (pp. 16–33). Chicago: Nelson-Hall Publishers. Roberts, A. R. (1990). An overview of crisis theory and crisis intervention. In A. R. Roberts (Ed.), Crisis intervention handbook: Assess-

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ment, treatment and research. Belmont, CA: Wadsworth Publishing Company. Sethi, A. K. (January, 2004). Adherence and HIV drug resistance. The Hopkins HIV Report. Siberry, G. K., Parson, G., & Hutton, N. (November, 2003). Management of infants born to HIV infected mothers. The Hopkins HIV Report. Siegel, L., & Korcok, M. (1989). AIDS: The drug and alcohol connection: What health care professionals need to know. Center City, MN: Hazelden.

Ungvarski, P. J. (1997). HIV/AIDS: New knowledge, new treatments, and the challenges for nursing. Journal of the Association of Nurses in AIDS Care, 8(4): 5–6. Vanhove, G. F., Schapiro, J. M., Winters, M. A., Merigan, T. C., & Blaschke, T. F. (1996). Patient compliance and drug failure in protease inhibitor monotherapy. Journal of American Medical Association, 276: 1955–1956. Winiarski, M. G. (1991). AIDSrelated psychotherapy. Boston: Allyn and Bacon.

30 Crisis Intervention With Caregivers ALLEN J. OTTENS DONNA KIRKPATRICK PINSON

There is no consensus on a definition of caregiving. A caregiver has been defined simply as “an individual who provides care for another person who, ordinarily, would not require care” (Ilardo & Rothman, 1999, p. 7). Caregivers can be defined more globally as “people who provide tangible, financial, emotional, or informational and coordination to an impaired family member” (Arguëlles, Klausner, Arguëlles, & Coon, 2003, p. 101). However defined, family caregiving in the past two decades has become a prominent issue for researchers and clinicians in the field of geropsychology. With the graying of America—approximately 12% of the U.S. population is over the age of 65 (U.S. Bureau of the Census, 2002)—there is a concomitant increase in the segment of this population requiring care. The majority of disabled older persons are cared for at home (Stone, Cafferata, & Sangl, 1987). Ri to address this health care challenge is a vast informal (i.e., unpaid) system of friends and family, and especially among the latter, spouses or daughters or daughters-in-law. These caregivers assist their care recipients in the necessary but demanding activities of daily living (e.g., bathing, dressing, toileting) and often assume responsibility for delivering care previously provided by ed nurses (Hoffman & Mitchell, 1998). According to a recent survey, 16% of the U.S. population provides unpaid care to a recipient 50 or older, and the typical caregiver is a 46-year-old female who spends over 20 hours per week providing care (National Alliance for Caregiving, 2004). In that survey, older caregivers reported provid703

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ing care for 10 or more years. Findings such as these led Cavanaugh (1998) to refer to caregiving as a normative “life event challenge.” It is predicted that as the 21st century proceeds, the caregiving challenge will grow more complex due to the following factors: Long-distance caregiving. Blended families. Fewer children to provide care. Continued increases in the number of working women. Demands on older adults themselves in caring for their own children (e.g., for grown children with mental illness, developmental disabilities, and long-term illnesses) and possibly grandchildren. (Weiner & Goldberg, 2003, p. 11)

For today’s caregivers, tending to disabled older persons may take steep physical, emotional, social, and financial tolls. This is called “caregiver burden.” The stresses, for example, of caring for someone with Alzheimer’s disease have been vividly chronicled in the popular book The 36-Hour Day (Mace & Rabins, 1999). As the burden saps the caregiver’s capacity to cope, she or he teeters on the brink of crisis. What we hope to accomplish in this chapter is to provide a context for understanding and a method for intervening with the crises encountered by caregivers of disabled older persons. Specifically, we begin with a description, in broad brushstrokes, of the caregiving experience. Next, we present a structure for pinpointing caregiver burden and for targeting possible interventions. The third section consists of a case description of a caregiver in crisis. We conclude with a section on the application of Roberts’s (1991) seven-stage model to address this crisis.

THE CAREGIVING EXPERIENCE Providing care for a disabled older person is not necessarily an onerous or debilitating duty. For example, Thompson, Gallagher-Thompson, and Haley (2003) pointed out that longitudinal studies of caregivers of persons with dementing disorders appear to contradict the conventional wisdom that caregiver stress increases as the care recipient’s dementing disorder worsens and years of caregiving increase. The notion of caregivers as a uniformly depressed lot can be challenged as well. Schulz, Williamson, Morycz, and Biegel (1993) found that about 45% of their sample of dementia caregivers were consistently “below the threshold” (p. 136) for being at risk of clinical depression at each of four measurement points across their 2-year study. As far as physical health is concerned, 83% of caregivers surveyed recently

Crisis Intervention With Caregivers 705 rated themselves as being in good to excellent health (National Alliance for Caregiving, 2004). A caregiver may be burdened but still experience an adequate or high level of well-being due to the presence of perceived social (Chappell & Reid, 2002). Social serves as a potent protective factor against distress among caregivers. It qualifies as the most effective of caregiver stress (Logsdon & Robinson, 2000). In their review of culturally diverse caregivers, Gallagher-Thompson et al. (2000) suggested that compared to Anglo caregivers, African American caregivers may exhibit less depression, stress, and burden as a result of the strengths of the African American community being brought to bear in of caregivers and their care receivers. Besides social , caregivers’ well-being has also been found to be associated with a “benign appraisal” of stressors (e.g., perceiving that one has the capacity to manage a problem situation) and problem-focused coping as opposed to avoidance (Goode, Haley, Roth, & Ford, 1998). A caregiver’s subjectively experienced burden may vary based on the type of relationship he or she has with the care recipient. Cicirelli (1993) found that caregivers who felt stronger attachments to their care recipients experienced less subjective burden, whereas stronger obligation to assume the caregiver role was related to greater burden. This attachment versus obligation distinction has been borne out among recently surveyed caregivers who reported that their emotional distress is greater when they feel they had no choice in taking on caregiving responsibilities (National Alliance for Caregiving, 2004). The quality of the caregiving relationship can undergo improvement. King (1993), in a Canadian qualitative study of daughters caring for aging mothers, found that what began as an overinvolved, conflicted caregiving relationship evolved over time into one in which the daughters learned to balance their mother’s needs with their own. The caregiving relationship thus became healthier as the daughters were able to (a) make contextual caregiving decisions; (b) set realistic limits on their caregiving activities; (c) accept responsibility for the outcomes of their care decisions; (d) be sensitive to situations that might pose threats to their own needs; and (e) deal rationally with the guilt that necessarily accompanies contextual decisions. (p. 424)

Negative Impacts on Caregivers’ Health When caring for an older disabled person, especially one with progressive dementia, expectations can go awry and challenges can quickly turn into crises. Two types of stressors impinge on caregivers. One type arises from performing direct patient care, such as assisting with the activities of daily living. The second type arises from the patient’s behavioral manifestations

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(e.g., wandering, agitation, lack of cooperation). These behaviors, quite common in dementia caregiving, tend to be more stressful than direct patient care because they occur unpredictably (Goode et al., 1998). When laboring under these challenging and stressful conditions, caregivers may experience a variety of deleterious social, mental, and physical impacts. Often, these impacts are greatest on those with the heaviest responsibilities, such as the caregivers of persons with dementia. With regard to social impacts of caregiving, dementia caregivers report less time for leisure, more employment complications, and more family conflict than nondementia caregivers (Ory, Hoffman, Yee, Tennstedt, & Schulz, 1999). However, social impacts appear to be more typical than exceptional in the careers of most caregivers regardless of the care recipient’s disabling condition. For example, 48% of Hispanic caregivers reported giving up vacations, hobbies, or social activities; 62% of the caregivers who work or once worked had to make adjustments such as arriving late to work or giving up employment entirely; and 22% of African American caregivers say caregiving brought about financial hardship (National Alliance for Caregiving, 2004). In their exhaustive review of research on the effects of caregiving on health, Bookwala, Yee, and Schulz (2000) noted that over a decade ago, the stresses of caregiving had become solidly linked to detrimental mental health outcomes. In one study, for example, Yee and Schulz (2000) found that compared to men caregivers, women caregivers reported more psychiatric symptomatology (e.g., higher levels of depression and anxiety and lower life satisfaction). Yee and Schulz described a variety of factors that presumably place women at greater risk for psychiatric morbidity. Two such factors are that women are less likely to obtain either formal or informal assistance, and they tend to assume more hands-on roles in personal care tasks. In another representative study, Haug, Ford, Stange, Noelker, and Gaines (1999) followed a random sample of caregivers over a two-year period. This study is notable in that it utilized a longitudinal design and was not focused on only dementia caregivers. Haug et al. found that at the outset of their study, 40.5% of the caregivers assessed their mental/emotional states as “excellent.” At the study’s third and final assessment point, only 24.8% made that same claim. Haug et al. noted that a possible factor in this decline was substantial increases in the mean number of instrumental activities of daily living (IADLs) and activities of daily living (ADLs) performed by the caregivers over the course of the study. The connection between caregiving and poorer physical health is weaker than the link between caregiving and poorer mental health (Bookwala et al., 2000). This may result from the different ways that physical health can be operationalized. Nevertheless, researchers consistently find that caregivers perceive their health to be negatively impacted (Bookwala et al., 2000). In the Haug et al. (1999) study, for example, the caregivers’ self-assessed physi-

Crisis Intervention With Caregivers 707 cal health scores declined from 48.7% claiming “very good” or “excellent” health to 32.3% two years later. There are intriguing studies linking caregiving and more “objective” measures of compromised physical health. Researchers have noted poorer immune system functioning in some caregivers (Vitaliano, Schulz, KielcotGlaser, & Grant, 1997) and slow wound healing (Kielcot-Glaser, Marucha, Malarkey, Mercado, & Glaser, 1995). Perhaps most disconcerting is evidence that caregiving is a risk factor for mortality (Schulz & Beach, 1999). Schulz and Beach conducted a prospective population-based cohort study with an average of 4.5 years of follow-up. After adjusting for sociodemographic and certain health factors, they found that those who were providing care and experiencing strain (i.e., mental or emotional strain associated with helping or getting help for each caregiving activity) had mortality risks 63% higher than a control group of noncaregivers.

Summary Although the social, emotional, and physical impacts of caregiving are not necessarily negative, problems encountered and responsibilities assumed in caregiving can adversely stress the caregiver. The results of that stress are succinctly stated by Bookwala et al. (2000): In summary, based on the studies that we have reviewed here, we can conclude that caregivers of both dementia and nondementia patient groups evidence significant psychiatric morbidity compared to noncaregivers or community norms. Caregivers also consistently rate their physical health to be poorer than do noncaregivers and, in some cases, exhibit poorer health-related behaviors, physical disability, and immune and physiological functioning. (p. 127)

Where does caregiver distress come from? What is it about the caregiving experience that can strain the caregivers’ capacities to cope? These questions lead us to consider the issue of caregiver burden.

CAREGIVER BURDEN Montgomery (1989) selected several from the literature that target what is meant by burden: stress effects, caregiving consequences, and caregiving impact. For Gottlieb, Thompson, and Bourgeois (2003), burden refers to “the extent to which problems commonly seen in caregiving situations are rated as distressing or troublesome to the caregiver” (p. 42). A number of instruments have been developed to assess caregiver burden. One commonly used instrument, with reportedly good psychometric proper-

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ties, is the 24-item Caregiver Burden Inventory (CBI; Novak & Guest, 1989). The CBI has been factor analyzed recently on a U.S. sample by Schwiebert, Giordano, Zhang, and Sealander (1998). The resulting six factors provide some com points for where to locate burden and for where to target crisis interventions. Each factor is discussed below, and examples are provided from our counseling experience with caregivers that illustrate specific sources of burden.

Factor 1: Time-dependence Burden Time-dependence burden results from the caregiver’s perceived restriction on time. It is commonly experienced by dementia caregivers who are involved in almost continuous and vigilant care. Caregivers’ crises may be precipitated by a variety of time-dependence issues. For example, crises can emanate from a feeling of “role captivity” (Pearlin, Mullan, Semple, & Skaff, 1990). This term aptly captures the demoralizing sense of being tethered to the caregiving site as well as the constant monitoring performed by the caregiver. In our work, we have seen how a sense of role captivity will feed on itself. We recently heard one spouse caregiver’s dilemma arising from attending the out-of-town first communion of a granddaughter: “I want to go so bad, but I won’t. If I do step out, I’ll enjoy the freedom too much, and coming back to this house and him will be more pain than I can bear.” Similarly, we have heard a caregiver lament that even a few minutes’ trip to the supermarket aroused great agitation in her care receiver: “He panics if I even go to the mailbox!” Moreover, timedependence burden, not surprisingly, is associated in our experience with an extreme reluctance on the part of the caregiver to request in-home care assistance. As caregivers’ time and space shrink, social isolation increases. Because social isolation is a risk factor for elder abuse (Cooney & Mortimer, 1995), we recommend that crisis workers be alert to or assess for that possibility.

Factor 2: Developmental Burden This burden arises due to caregivers’ feelings of being “off-time” developmentally in comparison to peers. There is a strong sense of being left behind, of missing out on life, and of wishing that current circumstances were different. For caregivers, developmental burden can be linked with the sacrifices made (e.g., placing career, hobby, or friendships on hold) on behalf of the care recipient. It can be experienced by the daughter who expected that demands on her attention and affection would be coming from adolescent children and husband rather than from a cognitively impaired uncle. Developmental burden may be experienced in many ways. For one woman of financial means, it came in the form of an existential crisis. As she cared

Crisis Intervention With Caregivers 709 for a husband who was left permanently paralyzed by a stroke, she realized that her image of aging gracefully would never materialize. How often she had pictured herself and her husband bathed in the glow of a southwestern sunset, toasting their love and good fortune as they sat poolside in the company of their old country club friends! Her friends might not yet be in that picture, but never would she.

Factor 3: Physical Burden Schwiebert et al. (1998) found that three CBI items pertaining to fatigue and care receiver dependence constitute the physical burden factor. With this factor, stress arises due to a feeling that one is on a grueling treill: one is exhausted, but the pace never slackens. “I’m exhausted, but the person is dependent on me” is a caregiver’s stance that has crisis potential because it neither allows for easy negotiation nor for a way out. We recommend assessing the caregiver for other rule-bound thinking that closes off his or her options. For example, it is common to hear caregivers argue, “I’m exhausted, but no one can take care of her like I can” or “I’m exhausted, but we must stick to our routine.”

Factor 4: Social Burden Feelings of social burden derive from perceived role conflict. Crises are often precipitated by conflicted relationships with other family . Caregivers may lash out angrily against the family member who needs to be reminded constantly for the money she or he grudgingly promised to chip in to cover caregiving expenses. We recall the caregiver who endured frequent, intrusive long-distance phone calls from a brother who was highly critical of financial decisions being made in his absence. However, much more common are caregivers’ remarks about how little appreciation they receive from family for the work they do. The conflict is compounded by its emotional aftereffects. Caregivers may consequently worry that their anger drove away potentially valuable . Or, they may feel shame for saying things in anger that cannot be taken back.

Factor 5: Emotional Burden The burden caregivers perceive to be due to negative feelings toward their care receivers is defined as emotional burden. This type of burden can lead to a crisis when the caregiver’s resentment threatens the caregiving relationship. An overly strained and fatigued caregiver may express her or his resentment as “If it weren’t for you, my life would not be a living hell.” Resentment can also run high if there has been a history of abuse in the family. For example, a wife who had endured chronic verbal abuse from her

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husband might feel especially strained by the demands of caring for him; and we should be alert to any signs of abuse being perpetrated or threatened against the husband. Likewise, caregiving daughters may be emotionally strained in circumstances where their care receiver is a mother who, years earlier, failed to provide protection against a father’s abusive advances. In her recent review of risk factors for elder mistreatment in non–African Americans, Benton (1999) concluded that the research is still inconclusive as to whether those who mistreat older adults may have been victims of abuse at a younger age. When faced with a crisis situation as just described, we recommend assessing for the risk of care receiver abuse. Emotional burden arises also out of feeling embarrassed by the behavior of the care receiver. Should the care recipient become incontinent, the caregiver is often doubly strained due to a reluctance to invite others into the home and by the great difficulty posed by coping with incontinence, an event that often leads to the wrenching decision of nursing home placement (Mittelman, Zeiss, Davies, & Guy, 2003). With regard to emotional burden, we need also mention the exasperation that many caregivers feel when assisting an “uncooperative” care receiver with his or her ADLs. Bathing, toileting, and physician visits can become tests of whose will shall prevail. Despite the fact that their emotional burdens fairly cry out for assistance, caregivers increase their risks of experiencing crisis because they are among the most resistant or cautious about seeking from the social service system. Toseland (1995) commented on the difficulty of recruiting a critical mass of caregivers for a group: “Making initial with a sufficient number of caregivers to begin a group can be difficult. Caregivers tend to be reluctant to ask for help. Seeking help is sometimes perceived as abandoning their responsibility and the person for whom they are caring” (p. 232).

Factor 6: Health Burden Schwiebert et al. (1998) identified a sixth factor from the CBI that did not appear in Novak and Guest’s (1989) original analysis. Consisting of three items, Schwiebert et al. termed it “health burden.” These items appear to be reflective of caregivers’ perceptions of their own diminishing health. In our counseling work with caregivers, we have found that they tend to neglect their physical needs. One caregiver living with her 100-year-old mother reported to us that she had relied on gardening for her exercise and that now she and her garden were both “going to pot.” Studies such as those by Burton, Newsom, Schulz, Hirsch, and German (1997) bear out that caregivers report getting less physical activity and rest. Self-care, exercise, good nutrition, and stress management are all components of a wellness-oriented intervention focus for caregivers (Myers, 2003). Yet, as Ilardo and Rothman (1999) point out, caregivers operate out of im-

Crisis Intervention With Caregivers 711 peratives that militate against their performing essential self-care. One of these (and the one we most often hear) is “I shouldn’t need to take a break. I’m strong” (p. 78). Caregivers continue to put themselves at risk of strain and crisis until such an imperative becomes tempered with a competing awareness: “Good caregiving starts with myself. If I don’t look out for me, my care receiver suffers.” Case Study: “Meet Millie” Millie F. was an 83-year-old living at home with Frank, 82, her spouse of 57 years. They married on November 17, 1945, only a few weeks after he had been discharged from the service. A childless couple, they often talked about how they had “adopted” all the kids on their block and how theirs was the house where all the youngsters liked to hang out. Both maintained lengthy careers, he as a mail fraud investigator with the postal service and she as an interior designer with a large department store chain. With her eye for decoration and color, she always favored splashy, coordinated clothing with jewelry and accessories to match. Frank loved to introduce his vivacious wife at any opportunity. “Here she is. Meet Millie!” he would say, beaming. Over the years, fewer and fewer people would catch Frank’s little play on words— how he was also referring to Meet Millie, a popular TV show of half a century ago that starred Elena Verdugo. About a year and a half before Millie found herself on the brink of crisis, she noticed some subtle changes in Frank. For example, he seemed to be repeating the same question he had asked just minutes earlier. Then, there was the problem with his temper. He had always been an “ornery cuss,” as she described him, but now his orneriness was becoming more intense and personal. Millie wasn’t too sure what to make of her observations. After all, Frank seemed his usual self most of the time. However, after the incident with the newspaper delivery boy, she decided to mention the situation to their primary care physician. “Why, he just cursed the boy out because the paper was a little ways down the driveway. I mean, he used language that would have made a sailor blush!” After a few trips back to the physician with Frank in tow, they received some complicated information, a diagnosis of sorts of Frank’s condition, and a prescription for medication that he refused to take. “I thought he told us that Frank had ‘old timers’ disease,” was how she summarized these visits. As months went by, Millie was becoming increasingly exasperated, angry, and even fearful of Frank. She suspected something was wrong, but she wasn’t quite sure to what she should attribute Frank’s unpredictable, touchy, and hurtful behavior. Slowly, surely, and almost imperceptibly the situation deteriorated. Millie was beginning to feel like a prisoner in her own home as Frank alienated old friends. Fellowship visits from their church fell off. Frank’s anger took the forms of personal criticism bordering on abuse and demands for obedience to his dictates. With the former came a growing depression that began to gnaw at Millie. With the latter came a growing resentment against Frank. His demands failed to take into consideration the fact

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that Millie was struggling with painful osteoarthritis in her knees and back. He lacked empathy for the efforts she was making to care for him. The depression and resentment were ed by anxiety. About a week and a half before her referral to a community mental health center, Millie witnessed two events in one day that brought home to her the precarious nature of the situation with Frank. Late that morning Frank had gone out to the mailbox at the end of the driveway. Some minutes later, Millie noticed that Frank had not yet returned inside. After a quick search, she found him in the backyard with a confused look on his face. He made up some excuse to explain why he was standing in the tulip bed. A few hours later, Frank forgot that he had turned on the faucet in a basement washtub. The overflow took two hours to mop up. Perhaps it was more than coincidence that just two days later Millie made an appointment to speak with a services specialist at the Area Agency on Aging (AAA) in her community. She wanted information about a prescription drug program that she might qualify for. Besides giving Millie the prescription plan information, the services specialist noticed her fatigue and depression. The specialist inquired and learned that Millie was the sole caregiver for an older spouse with suspected Alzheimer’s disease and that she had only a tenuous ive network: a few diehard friends and some nieces and nephews who made irregular phone calls from the East Coast. Considering Millie’s strained self-presentation, the specialist tactfully broached the topic of a referral to the local community mental health center (CMHC). Fortunately, the AAA and the CMHC had established a good collaborative arrangement (Lebowitz, Light, & Bailey, 1987) so that the referral could be made swiftly given the risk inherent in this caregiving situation. Although the offer of a counseling referral took Millie by surprise (“He’s the one with the screw loose, and you want me to get my head examined?”), she agreed to it, and the next day she had a walk-in appointment with the CMHC’s on-call crisis counselor. With the referral secured, the AAA’s services specialist had done well to apprehend Millie’s signs of emotional difficulty and to inquire about her caregiving strain. Furthermore, the specialist was wise to initiate discussion of a referral, as caregivers are notoriously loath to refer themselves to programs that would alleviate their depression. (Gottlieb et al., 2003)

CRISIS INTERVENTION: THE SEVEN-STAGE MODEL Millie’s situation is not yet one in imminent crisis, but there is potential for crisis. One risk is possible mistreatment of the care recipient at the hands of a burdened caregiver, as discussed earlier. A second risk is to the caregiver’s health and emotional well-being. Without self-care, caregivers may jeopardize their health, which leads to an earlier and perhaps less appropriate longterm care placement for the care recipient. Roberts’s (1991, 2000) model has applicability to caregiving situations that are crises in the offing.

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Stage 1: Conduct a Crisis Assessment (Including Lethality) The crisis counselor noted that Millie had very limited social . She had not accessed any resources in the community for day care or respite services. Informal in the form of friends and family came sporadically. Low social fed into Millie’s isolation. She felt, she said, like the Lone Ranger. Millie’s emotional profile was that of someone experiencing depression and anxiety. Certainly her depression was exacerbated by the personal nature of the criticism she received from Frank, by her chronic fatigue and arthritis pain, and by a growing pessimism about how this caregiving situation would resolve. Worries about her health (arthritis and hypertension) featured prominently in her anxiety, and lack of sound information about the disease and what it was doing to Frank added to her uncertainty. There was no indication that Millie had been mistreating Frank, although she was worried that one day he might physically strike out at her. istration of the CBI found Millie highest on developmental and emotional burdens. The developmental burden resulted from a combination of a wish to escape her caregiving situation, the emotional drain attached to caregiving, and the role captivity and social isolation into which she felt she was sinking deeper. The emotional burden resulted from the embarrassment she felt when Frank attacked visitors, anger at his verbal criticism of her, and smoldering resentment for performing a difficult yet unappreciated caregiving role. After the initial walk-in session, the crisis counselor began to conceptualize this caregiving situation. Besides the evident anxiety and depression, the crisis counselor singled out other issues for further exploration: • Millie failed to request more information and explanations about Frank’s dementing condition from their physician. • Her attempts to reason, argue, or rationalize with Frank over his demands might actually stoke his anger and agitation. • She eventually bowed to these demands, even when there was no evidence of their reasonableness. • She neglected her own health needs. • She lacked knowledge about her community’s formal and assistance programs.

Stage 2: Establish Rapport After providing a few of the elements of good listening (eye , undivided attention, reflecting feelings), the counselor found that Millie was hungry for social . Somewhat to her surprise, Millie was really taking to this counselor who had the capacity to understand her point of view.

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Initially, the crisis counselor suggested that she and Millie address her obvious stress and exhaustion. Because Millie is from a generation that might be suspicious of counseling, stress and exhaustion, which seem to have a physical basis, appeared to be “safer” topics than anxiety and depression. Millie agreed to this, and that served as the second step toward building a relationship. The counselor established rapport in several other ways. For example, she was sensitive to some of the jargon and colloquialisms older persons might use. Thus, when Millie got off the elevator for her appointment and promptly got lost trying to find the counselor’s office, both could chuckle at Millie’s description of herself as a “Wrong-Way Corrigan.” If the counselor did not understand Millie’s slang, she asked for clarification, as when Millie described feeling the “heebie-jeebies” the day Frank was lost in the tulips. Many older clients have a capacity for humor, and this can be used in the service of relationship building. It can even be used as a springboard to address counseling topics of substance, as this snippet of dialogue illustrates: Millie: (laughing) Frank always liked to brag about his service record. And over the years, I must say, he’s really embellished that record quite a bit. Now, to hear him tell it, he practically single-handedly chased Mussolini and his henchmen right out of Rome! Counselor:

(laughing along, but then becoming serious) Like that fish that got away that just keeps getting bigger and bigger! But let me ask you this: Is there anything else that he claims that you know isn’t quite the case?

Millie: Well, come to think of it, a couple of weeks ago my friend Helen came to visit. He told her flat out, and used a few choice words in the process, that he didn’t want her coming over anymore, because he said we make too much noise that disturbs him. But he plays the TV so darn loud, he couldn’t have heard us over it! Counselor:

So, his reason for forbidding Helen to come over to visit really doesn’t hold together. But you abide by it—mainly to keep the peace—and the result is that you feel more isolated. Is that right?

From the very first, it is essential for the counselor to foster a climate of collaboration with the client. By encouraging working together, the counselor strongly suggests that something good can be accomplished, and that builds a sense of hope in the client. Finally, self-disclosure, at the right time, in the right amount, and of an appropriate content, can also help to establish rapport. In a second counseling visit, the counselor disclosed that she had had some deeply personal experience with caregiving herself. The counselor briefly talked about how

Crisis Intervention With Caregivers 715 she had been part of an extended family effort several years earlier on behalf of a physically disabled grandmother.

Stage 3: Identify Major Problems or Crisis Precipitants Roberts (2000) has pointed out the usefulness of identifying the “last straw” (p. 18), or precipitating event, as well as the client’s previous coping methods. In Millie’s case, two events—finding Frank in the backyard and the overflowing washtub—seemed to be the turning points in how she viewed her situation. These events could not be easily explained away, and they came to represent the hard truth that something was definitely wrong. They clashed with Millie’s wish that all was well and that Frank’s old self would prevail. These two events fit into the counselor’s evolving conceptualization of Millie’s modal coping style. When faced with threat, especially threat that could overwhelm, Millie’s tendency is to cope by using avoidance or hoping that things get better. This is how she had reacted to evidence of Frank’s cognitive slippage. When confronted with threat that is less easily byed, such as Frank’s barrage of verbal criticism or demands for care, Millie adopted an argue-acquiesce-blame self coping pattern. That is, she would make a noisy but feeble attempt to argue or reason with him, give in to his demand so as to keep the peace, and then come around to blaming herself for having set him off. Millie’s ive, avoidant, and reactive (as opposed to proactive) coping styles explained her surprising lack of knowledge about Alzheimer’s disease and lack of awareness of services in the community. One question that the counselor posed piqued Millie’s curiosity in such a way that she was motivated to learn more about the effect of Alzheimer’s disease. At one point, the counselor asked offhandedly, “Frank’s anger and cursing at you—do you wonder if this is Frank or the disease doing the talking?”

Stage 4: Encourage Exploration of Feelings There are two important objectives at Stage 4, as we have found from our work with older clients. One objective is for the client’s “story” to be heard. As Mittelman et al. (2003) put it, “We have found that most AD [Alzheimer’s disease] caregivers want to tell their stories and they more readily identify problems and solutions when they have been active participants in that process” (p. 79). When clients tell their stories and give us their slant or take on what the problem is, we listen for an overarching theme or title that could be given to that story. In Millie’s case, the title that came to the counselor’s mind was “I’m a Prisoner in My Own Home.” When the counselor shared that title with Millie, her nonverbal reaction was such that the

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counselor knew it struck home. With regard to identifying problems and solutions from the story, the counselor suggested, “If that’s what the title of the story is, could we put our heads together to come up with a workable ‘escape plan’?” Put that way, Millie was intrigued to hear more. A second objective is to validate the client’s feelings. Millie’s exhaustion, which Frank minimized, was validated: she is exhausted, she really is tired. That she felt anger and resentment was understandable. Her perception of the situation was validated. “Maybe,” the counselor allowed, “the rules that Frank lays down and his angry outbursts, that you take exception to but then cave into, are not as sound as your perception of the situation.” From the extraction of the story title and the validation of feelings and perceptions come possibilities and alternatives.

Stage 5: Generate and Explore Alternatives The counselor is advised to collaborate, go slowly, and work with a manageable few, but relevant, behavioral alternatives. After putting their heads together and brainstorming, the counselor and Millie came up with these alternatives: The need for more information: Information needs to be obtained from Frank’s physician. What information the physician cannot supply, given his limited time, can be obtained from other sources, such as the local chapter of the Alzheimer’s Association. The need for : Certainly, it is important for Millie to reconnect with old friends. The counselor also planted the seed for another source of by saying in a neutral way, “I don’t know if you’ve ever considered becoming a part of a group that consists of other caregivers who are going through many of the same things you are. It often helps to be with others in the same boat because they can supply an understanding perspective that our well-meaning regular friends just don’t have.” Not only would a group, such as are provided through the Alzheimer’s Association, provide much needed , but the group is also a source of useful information about the disease and its insidious progression. The need for respite: Both Millie and the counselor agreed that both she and Frank could benefit from some time away from each other, although Millie was very skeptical of how Frank would tolerate that. Part of respite also involved some necessary self-care on Millie’s own behalf, which could include some recreation and even long-neglected physical therapy for her ailing knee. The need to resolutely confront the issues: This is a behavioral alternative that was suggested by the counselor. She understood Millie’s tendencies to avoid facing issues and to fail to persevere and see a solution through. As this alternative was discussed, Millie saw the importance

Crisis Intervention With Caregivers 717 of “taking the bull by the horns” and not backing off even when the bull began to charge.

Stage Six: Develop and Formulate an Action Plan The counselor and Millie took each of the above alternatives and worked them into an action plan. To obtain more information, Millie and the counselor role-played how to assertively request information from the physician. Millie learned to write down questions for the physician so she would not forget them in the rush and crush to get Frank to the clinic. Millie was encouraged to make another appointment with the services specialist at AAA to learn about community services and how to a group. At the AAA, Millie learned about a respite program funded by the federal Older Americans Act to pay for a number of respite care hours each year. She learned how to apply and qualify for this service. Perhaps more important, she found out about places offering adult day care in her community where individuals with Alzheimer’s disease could socialize and even have lunch. The counselor suggested that Frank attend day care at least twice a week for Millie to derive beneficial respite from it (Zarit, Stephens, Townsend, & Greene, 1998). While Frank was at day care or while the respite worker was in her home, Millie could use this time to visit friends or get therapy for her arthritic knee. Resolutely confronting the issue was perhaps Millie’s toughest challenge. “He’s not going to like going to a day care center. It’ll be like moving heaven and earth to get him there.” In the past, Frank’s protestations would be too much for her to bear, and she would back down. This time she promised she would stick to her guns and give the day care and respite care “experiments” a chance to work. To her surprise, Frank began to look forward to day care. He liked the staff, flirted innocently with a couple of the women who attended, and found another veteran of World War II with whom he could share stories.

Stage 7: Follow-up The counselor and Millie agreed that follow-up (or booster) appointments be scheduled for about three weeks and then stretched to every 6 weeks. These check-in visits would be to take a measure of Millie’s current stress level, and the counselor planned to reister the CBI at each follow-up session. The counselor also looked at these follow-up sessions as an opportunity to assess how well Millie was maintaining her active coping style, as opposed to avoidance. This would come into play over the developmental course of Millie and Frank’s caregiving experience, as when, for example, the time came for Millie to consider and research long-term care placement for Frank.

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CONCLUSION The typical challenges of caregiving for an older disabled adult often become burdens that strain the caregiver’s capacities to cope. Caregiving can be a rewarding, even a spiritually deep experience, certainly insofar as there is adequate for the caregiver and a positive attachment to the care recipient. When burden takes a toll, however, there can be numerous untoward emotional and physical effects on the caregivers, and care recipients can experience the rebound effect of these, as in the case of elder abuse. The caregiver in crisis resorts to maladaptive coping behaviors that often exacerbate an already difficult situation. Also, caregivers feel out of balance socially, emotionally, and physically. This is true for both dementia and nondementia caregivers. It is important to restore a sense of balance in the lives of caregivers because their focus can be solely on the care recipient to the exclusion of themselves. In this chapter, we illustrated how the stages of a widely adopted crisis intervention model can be utilized to address the burdens of a caregiver and help her find relief from their strain.

REFERENCES

Arguëlles, S., Klausner, E. J., Arguëlles, T., & Coon, D. W. (2003). Family interventions to address the needs of the caregiving system. In D. W. Coon, D. Gallagher-Thompson, & L. W. Thompson (Eds.), Innovative interventions to reduce dementia caregiver distress (pp. 99–118). New York: Springer. Benton, D. M. (1999). African Americans and elder mistreatment: Targeting information for a high-risk population. In T. Tatara (Ed.), Understanding elder abuse in minority populations (pp. 49–64). Philadelphia: Brunner/Mazel. Bookwala, J., Yee, J. L., & Schulz, R. (2000). Caregiving and detrimental mental and physical health outcomes. In G. M. Williamson, D. R. Shaffer, & P. A. Parmlee (Eds.), Physical illness and depression in older adults: A handbook of theory, research, and practice (pp. 93–131). New York: Kluwer Academic/Plenum.

Burton, L. C., Newsom, J. T., Schulz, R., Hirsch, C. H., & German, P. S. (1997). Preventive health behaviors among spousal caregivers. Preventive Medicine, 26, 162–169. Cavanaugh, J. C. (1998). Caregiving to adults: A life event challenge. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 131–136). Washington, DC: American Psychological Association. Chappell, N. L., & Reid, R. C. (2002). Burden and well-being among caregivers: Examining the distinction. The Gerontologist, 42, 772–780. Cicirelli, V. G. (1993). Attachment and obligation as daughters’ motives for caregiving behavior and subsequent effect on subjective burden. Psychology and Aging, 8, 144–155. Cooney, C., & Mortimer, A. (1995). Elder abuse and dementia: A pilot

Crisis Intervention With Caregivers 719 study. International Journal of Social Psychiatry, 41, 276–283. Gallagher-Thompson, D., Arean, P., Coon, D., Menendez, A., Takaji, K., Haley, W. E., et al. (2000). Development and implementation of intervention strategies for culturally diverse caregiving populations. In R. Schulz (Ed.), Handbook on dementia caregiving: Evidencebased interventions for family caregivers (pp. 151–185). New York: Springer. Goode, K. T., Haley, W. E., Roth, D. L., & Ford, G. R. (1998). Predicting longitudinal changes in caregiver physical and mental health: A stress process model. Health Psychology, 17, 190–198. Gottlieb, B. H., Thompson, L. W., & Bourgeois, M. (2003). Monitoring and evaluating interventions. In D. W. Coon, D. Gallagher-Thompson, & L. W. Thompson (Eds.), Innovative interventions to reduce dementia caregivers distress (pp. 28–49). New York: Springer. Haug, M. R., Ford, A. B., Stange, K. C., Noelker, L. S., & Gaines, A. D. (1999). Effects of giving care on caregivers’ health. Research on Aging, 21, 515–538. Hoffman, R. L., & Mitchell, A. M. (1998). Caregiver burden: Historical development. Nursing Forum, 33, 5–111. Ilardo, J. A., & Rothman, C. R. (1999). I’ll take care of you: A practical guide for family caregivers. Oakland, CA: New Harbinger. Kielcot-Glaser, J. K., Marucha, P. T., Malarkey, W. B., Mercado, A. M., & Glaser, R. (1995). Slowing of wound healing by psychological stress. Lancet, 346, 1194–1196. King, T. (1993). The experiences of midlife daughters who are caregiv-

ers for their mothers. Health Care for Women International, 14, 419–426. Lebowitz, B. D., Light, E., & Bailey, F. (1987). Mental health center services for the elderly: The impact of coordination with area agencies on aging. The Gerontologist, 27, 699– 702. Logsdon, M. C., & Robinson, K. (2000). Helping women caregivers obtain : Barriers and recommendations. Archives of Psychiatric Nursing, 14, 244–248. Mace, N. L., & Rabins, P. V. (1999). The 36-hour day (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Mittelman, M., Zeiss, A., Davies, H., & Guy, D. (2003). Specific stressors of spousal caregivers: Difficult behaviors, loss of sexual intimacy, and incontinence. In D. W. Coon, D. Gallagher-Thompson, & L. W. Thompson (Eds.), Innovative interventions to reduce caregiver distress (pp. 77–98). New York: Springer. Montgomery, R. J. V. (1989). Investigating caregiver burden. In K. S. Markides & C. L. Cooper (Eds.), Aging, stress, and health (pp. 201– 218). New York: Wiley. Myers, J. E. (2003). Coping with caregiving stress: A wellness-oriented, strengths-based approach for family counselors. Family Journal: Counseling and Therapy for Couples and Families, 11, 153–161. National Alliance for Caregiving. (2004). Caregiving in the U.S. Washington, DC: National Alliance for Caregiving and the American Association of Retired Persons. Novak, M., & Guest, C. (1989). Application of a multidimensional caregiver burden inventory. The Gerontologist, 29, 798–802.

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Ory, M. G., Hoffman, R. R., Yee, J. L., Tennstedt, & Schulz, R. (1999). Prevalence and impact of caregiving: A detailed comparison between dementia and nondementia caregivers. The Gerontologist, 39, 177–185. Pearlin, L. I., Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583–594. Roberts, A. R. (1991). Contemporary perspectives on crisis intervention and prevention. Englewood Cliffs, NJ: Prentice Hall. Roberts, A. R. (2000). An overview of crisis theory and crisis intervention. In A. R. Roberts (Ed.), Crisis intervention handbook (2nd ed., pp. 2–30). New York: Oxford University Press. Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality: The caregiver effects study. Journal of the American Medical Association, 282, 2215–2219. Schulz, R., Williamson, G. M., Morycz, R., & Biegel, D. E. (1993). Changes in depression among men and women caring for an Alzheimer’s patient. In S. H. Zarit, L. I. Pearlin, & K. W. Schaie (Eds.), Caregiving systems: Formal and informal helpers (pp. 119–140). Hillsdale, NJ: Lawrence Erlbaum. Schwiebert, V. L., Giordano, F. G., Zhang, G., & Sealander, K. A. (1998). Multidimensional measures of caregiver burden: A replication and extension of the Caregiver Burden Inventory. Journal of Mental Health and Aging, 4, 47–57. Stone, R., Cafferata, G. L., & Sangl, L. (1987). Caregivers of the el-

derly: A national profile. The Gerontologist, 27, 616–631. Thompson, L. W., Gallagher-Thompson, D., & Haley, W. E. (2003). Future directions in dementia caregiving intervention research and practice. In D. W. Coon, D. Gallagher-Thompson, & L. W. Thompson (Eds.), Innovative interventions to reduce dementia caregiver distress (pp. 299–311). New York: Springer. Toseland, R. W. (1995). Group work with the elderly and family caregivers. New York: Springer. U.S. Bureau of the Census, National Center of Health Statistics, and the Bureau of Labor Statistics (2002). Washington, DC: Author. Vitaliano, P. P., Schulz, R., KielcotGlaser, J., & Grant, I. (1997). Research on physiological and physical concomitants of caregiving: Where do we go from here? Annals of Behavioral Medicine, 19, 117–123. Weiner, A., & Goldberg, S. L. (2003). Aging in the new millenium: What the future holds for us. In J. L. Ronch & J. A. Goldfried (Eds.), Mental wellness in aging: Strengths-based approaches (pp. 3– 14). Baltimore, MD: Health Professions Press. Yee, J. L., & Schulz, R. (2000). Gender differences in psychiatric morbidity among family caregivers: A review and analysis. The Gerontologist, 40, 147–164. Zarit, S. H., Stephens, M. A. P., Townsend, A., & Greene, R. (1998). Stress reduction for family caregivers: Effects of adult day care use. Journal of Gerontology: Social Sciences, 53B, S267–S277.

VI EVIDENCE-BASED PRACTICE AND RESEARCH

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31 The Crisis State Assessment Scale: Development and Psychometrics SARAH J. LEWIS

Men are disturbed, not by things, but by the principles and notions which they form concerning things. —Epictetus (c. 55–c. 135), The Enchiridion

STATEMENT OF THE PROBLEM Crisis intervention, based on crisis theory, is one of the most widely used types of brief treatment employed by counselors, social workers, and other mental health professionals working in community settings (Ell, 1995; Roberts, 2000). There is a large body of literature on crisis intervention models and techniques, and a recurring theme in this literature is the importance placed on assessment (Aguilera, 1998; Kanel, 1999; Roberts, 2000; Roberts & Greene, 2002). What is remarkable, however, is the notable lack of standardized instruments with strong psychometric properties available to practitioners. Furthermore, few studies have tested intervention models based on crisis theory (Aguilera, 1998; Janosik, 1994; Roberts, 1996, 2000; Slaikeu, 1984). This may be due to the fact that measurement instruments designed to objectively assess the degree of an individual’s crisis state are not available (J. Corcoran & Roberts, 2000). To date, there are few crisis assessment scales with strong psychometric qualities. Of the scales that have been developed, none is capable of measuring the magnitude of a crisis state from the subjective vantage point of the client. 723

724

Evidence-Based Practice and Research

The purpose of this study was to design and test a rapid assessment instrument that measures two constructs: perceived psychological trauma and perceived problems in coping efficacy. These two constructs predict or indicate the magnitude of a crisis state.

Rationale for Measurement How does a clinician justify treatment for one client and not another? The clinician most likely uses a formula to calculate risk and benefit, though this is typically an informal or even unconscious assessment. By contrast, instrumentation can help a clinician to focus, stay on task, and be conscious of the constructs that he or she is attempting to assess. Measurement tools are not meant to replace the practice wisdom and professional judgment of the clinician, but to enhance them. Measurement can be defined as the “systematic process of asg a number to something” (Nunnally, 1978, p. 126). These variables are the client’s thoughts or cognitions, behaviors, affect, feelings, or perceptions. The assignment of a number, or the quantification of the variable, allows clinicians to monitor change using a mathematical model (K. J. Corcoran & Fischer, 2000). Standardized measurement is important to the field of crisis intervention because it allows clinicians to understand the comprehensive nature of the client’s crisis state with greater accuracy (Nurius & Hudson, 1993). Accurate measurement is also necessary for gauging the magnitude of the crisis state and for monitoring progress from an objective standpoint. Accurately measuring the severity of different aspects of a crisis state permits the clinician to intervene in the area that is most germane to the current crisis and to use the appropriate degree of intervention. In this way, standardized measures can be used to triangulate: to provide additional information in which to look for congruence of assessment (Nurius & Hudson, 1993).

Focus of This Research The purpose of this research was the development and validation of a multidimensional rapid assessment instrument (RAI) to assess two constructs associated with a crisis state. The primary goals of the instrument are: (1) standardized measurement of two factors, psychological trauma and problems in perceived coping efficacy, and (2) rapid clinical assessment. The underlying assumptions on which the scale is based are derived from interactional stress theory and crisis theory (James & Gilliland, 2001; Lazarus & Folkman, 1984; Roberts, 2000). These assumptions are as follows: • A crisis state is a response to a new and intense event that is perceived through primary appraisal to pose a serious threat to either emotional or physical safety (considered to be perceived psychological trauma).

The Crisis State Assessment Scale: Development and Psychometrics 725 • An individual’s crisis response is characterized by the perception through secondary appraisal that he or she is unable to resolve the event due to a dearth of prior experience, lack of resources, and physical and/ or emotional turmoil (considered to be perceived problems in coping efficacy).

LITERATURE REVIEW Primary Assumptions of Crisis Theory One confusing aspect of crisis theory is the lexicon used to describe its features. It is often challenging to discern the difference in the literature between discussions of theory and method and between crisis intervention and other approaches. There is not one crisis theory that encomes what defines a crisis event (the phenomenon), a crisis response (human response to the phenomenon), or a crisis intervention (the helping process; Gilliland & James, 1993). Instead, there exists a body of literature grounded in the seminal work of Lindemann (1944), Caplan (1964), and Roberts and Grau (1970). A synthesis of ego and cognitive psychology and individual stress theories is also incorporated into crisis theory. A compilation of all of these theories contains the following primary assumptions (Ell, 1995; Parad & Parad, 1990; Roberts, 2000): • Everyone, at some point in his or her life, will experience acute stress which is not necessarily pathological. Whether or not the stressor is a crisis event is determined by its position in the overall context of the person’s life. • Homeostasis, or balance, is a natural state that all people seek, and when an individual is in a state of emotional disequilibrium, he or she strives to regain emotional balance. • A period of disequilibrium in which the individual (or family) is vulnerable to further deterioration is present when a stressful event becomes a crisis. • This disequilibrium makes the individual more amenable to intervention. • New coping mechanisms are needed to deal with the crisis event. • The dearth of prior experience with the crisis event creates increased anxiety and struggle, during which the individual often discovers hidden resources. • The duration of the crisis is somewhat limited, depending on the precipitating event, response patterns, and available resources. • Certain affective, cognitive, and behavioral tasks must be mastered throughout the crisis phase in order to move to resolution, regardless of the stressor.

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The underlying theme here is that a noncrisis state is a state of inner balance, and when that balance is thrown off, the individual strives to regain the balance. Crisis occurs when the individual perceives that he or she does not have the resources necessary to regain balance. Crisis is aptly defined by Roberts (2000) as follows: An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping methods. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable state, a precipitating factor, an active crisis state, and a resolution of the crisis. (p. 516)

Measurement in Crisis Assessment A major dilemma with the readily available, standardized instruments categorized under crisis assessment is that most focus on the potentiality of suicide or on buffers against suicide (Waters, 1997). The problem is that although lethality assessment is an absolutely critical component of crisis assessment, it is not the only part of the assessment process. That is, not all individuals who are in crisis are either suicidal or homicidal—and yet they are still in crisis. To assess aspects of a crisis state other than lethality, clinicians generally measure the severity of the event that precipitates the crisis, the stress caused by that event, or the emotional consequences of an unresolved crisis such as depression or anxiety (J. Corcoran & Roberts, 2000). However, measuring the magnitude of a crisis state or the resolution of a crisis state using these variables (precipitating event, stress caused by the event, or emotional consequences of the event) raises several dilemmas. Roberts (1996, 2000), Gilliland and James (1993), and Ell (1995) agree that it is the context in which someone experiences an event and his or her subjective response to the event that determines whether or not an event is a crisis. If this assumption is correct, any event may or may not be experienced as a crisis. More important, it is the subjective response to the event, and not necessarily the event itself, that defines a crisis. In other words, it is the individual who determines whether or not an event or situation is a crisis/tragedy/trauma in his or her subjective experience. Experts in stress theory such as Lazarus and Folkman (1984), in addition to the previously mentioned experts in crisis theory, claim that stressors are natural. They claim that it is the subjective context of an individual’s life

The Crisis State Assessment Scale: Development and Psychometrics 727 circumstances and perception of resources that determines whether or not the stressor induces a crisis state. Here again, it is the individual’s perception of his or her available resources in relation to the stressor that leads to a crisis, not the stressor itself. Finally, a crisis state does not equate with pathology, but is instead best viewed as a problem in personal functioning (Ell, 1995; Golan, 1986; Parad & Parad, 1990; Roberts, 2000; Slaikeu, 1984). “Personal functioning represents the internal events, processes, and experiences of an individual . . . [and] is problematic when an individual’s level of distress become[s] large enough to be clinically significant” (Hudson, Mathiesen, & Lewis, 2000, p. 76). To better understand the crisis state as a personal problem, the microtheory of personal and social problems can be employed (Hudson & Faul, 1997). This theory has two fundamental axioms: “Human problems do not exist until someone defines them . . . [and] all human problems are defined in of a value base” (p. 49). The first step has already been discussed here: defining a crisis state. The value base has been established in that a crisis state is defined as a problem. To date, no RAIs measuring the subjective severity of a crisis state from the client’s perspective have been developed and psychometrically tested. Clinicianrated crisis-specific scales exist, as do client self-report scales that indirectly tap aspects of the crisis situation (Lewis & Roberts, 2002). These are described in the section to follow.

Crisis/Stress Definitions Working in the 1950s, Lazarus and his colleagues discovered that the effects of stress were not generalizable or universal; rather, the effects were dependent on individual differences in how people thought about, or appraised, the stressor, and in their motivation to relieve the stress (Lazarus & Eriksen, 1952). The contributions of Lazarus and Folkman (1984) to the study of stress primarily have to do with conceptualizing stress and coping as processes with mediating individual variables. They defined what is now commonly known as the stress process in the following : the event (stressor); the cognitions of the event, both primary and secondary (appraisal); and the behaviors that are used to deal with the event (coping). Social cognitive theory posits that stress is a function of a cognitive appraisal process, or the evaluation of coping self-efficacy in a given situation (Bandura, 1986). When the demands of a situation outweigh an individual’s perceived ability to cope, stress is the result (Bandura, 1986; Hill, 1949; Lazarus & Folkman, 1984). This is where a clarification of terminology becomes imperative. Authors in many fields have defined stress in many different ways; there is no universal definition for stress. Lazarus and Folkman (1984) define psychological stress as “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and

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endangering his or her well-being” (p. 21). This definition of psychological stress closely resembles Roberts’s (2000) definition of a crisis: “The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function” (p. 516). This research relates the two concepts of stress and crisis by contending that the degree of a crisis, which is a psychological state, is mediated by thoughts about the magnitude of a stressful life experience (event or situation) and thoughts about whether or not a person can cope with the stressful life event. These thoughts are referred to in stress theory as primary and secondary appraisal.

Primary Appraisal Primary appraisal is the process of evaluating the threat or strain of an event or situation (Lazarus & Folkman, 1984). During the primary appraisal process, cognitions are concentrated on the magnitude of the threat or strain. According to Lazarus and Folkman, there are three kinds of primary appraisal: irrelevant, benign-positive, and stressful. If an event or situation is appraised as irrelevant, there is “no investment” (p. 32) in the outcome on the part of the individual. When a situation is appraised as benign-positive, it is believed to be solely positive, with no potential negative consequences. This study is concerned with the third type of primary appraisal: stressful. Stress appraisals include harm/loss, threat, and challenge. Harm/loss appraisals are when the individual believes that he or she has sustained some physical or emotional harm or loss. Examples of this are the death of a loved one, physical injury, financial loss, loss of friendship, diminished self-esteem or sense of worth, and loss of a commitment such as marriage or a business partner. In this type of appraisal, the harm or loss has already happened. Threat, a form of primary appraisal, is concerned with anticipated harm or loss. Even though an event or situation may have already happened, the individual may anticipate future harm or loss as a result of the event. For example, if a student fails a test, the event has happened (failure of the test). However, the student may still fear the loss of financial from his or her parents when they find out about the failure. Challenge appraisals may include threats. These appraisals tend to focus on positive events that contain within them the risk of future negative outcomes. The challenge has to do with mastery of an event or situation; however, there is risk inherent in challenge. For example, a new marriage may be seen as an exciting new challenge: it represents an opportunity to be successful in a relationship. However, it also represents the potential for failure.

Secondary Appraisal Secondary appraisal is the process of evaluating one’s ability to deal with threat or strain. Lazarus and Folkman (1984) claim:

The Crisis State Assessment Scale: Development and Psychometrics 729 Secondary appraisal is more than a mere intellectual exercise in spotting what must be done. It is a complex evaluative process that takes into which coping options are available, the likelihood that a given coping option will accomplish what it is supposed to, and the likelihood that one can apply a particular strategy or set of strategies effectively. (p. 35)

Bandura (1977) further refined Lazarus and Folkman’s (1984) theoretical model by adding the important variables of outcome expectancy and efficacy expectations to the concept of secondary appraisal. Outcome expectancy is an individual’s belief that certain behaviors will lead to certain outcomes. Efficacy expectation refers to an individual’s belief that he or she can effectively carry out the action or behavior necessary to produce the expected outcome. Basically, Bandura (1977) hypothesized that an individual’s belief in his or her ability to handle an event (coping efficacy) mediates his or her stress reaction to that event. Individuals’ belief that they can cause a positive outcome is based on their own personal repertoire, or menu, of past successes in similarly stressful situations, rather than on their belief in positive outcomes in general. Benight and colleagues (Benight, Ironson, Wynings, et al., 1999; Benight, Swift, Sanger, Smith & Zeppelin, 1999) discovered in the aftermath of Hurricane Andrew and Hurricane Opal that higher levels of coping self-efficacy were correlated with lower amounts of psychological distress. After controlling for income, education, gender, age, estimated damage, threat of death, and lost resources, coping self-efficacy ed for an additional 10% of the variance in the Impact of Events Scale (Benight, Ironson, Wynings, et al., 1999). Benight and colleagues (2000) also found higher levels of perceived coping efficacy to be significantly correlated with a reduction in experiences of distress in a study of the victims following a terrorist bombing in Oklahoma City. Cozzarelli (1993) showed with a general path model that the effects of self-esteem, optimism, and perceived control were mediated by perceived coping efficacy on both immediate and three-week postabortion psychological adjustment. Cozzarelli claims that feelings of self-efficacy for coping are an important determinant of both coping behavior and adjustment to negative life events.

Gaps in the Literature In the first place, there are currently no scales that measure the perceived magnitude of a stressor and very few that measure situation-specific coping efficacy. In addition, most studies use a single-item indicator to measure coping efficacy, which creates serious limitations in validity claims. Also, there are currently no RAIs that measure both the perceived magnitude of the event (primary appraisal) and perceived coping efficacy (secondary appraisal).

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Second, the scales currently available to measure a crisis do not measure the subjective state of the individual. The researchers who created those crisis scales claim that because an individual is in crisis, he or she is not capable of completing a paper-and-pencil test (Bengelsdorf, Levy, Emerson, & Barile, 1984; Myer, Williams, Ottens, & Schmidt, 1992). This may be true in extreme cases; however, it is not true in all cases. There is no way to determine that an individual is not capable of filling out a paper-and-pencil test until an assessment has been made. To remove the possibility of a standardized objective assessment of a subjective state without any attempt may in fact be a disservice to the individual seeking assistance.

CONCEPTUAL FRAMEWORK FOR THIS RESEARCH This research focused on the subjective state that a person may experience as a result of a stressor. This state, termed here a crisis state, is an imbalance of internal equilibrium that is the result of a subjective response to a stressor. Internal equilibrium is mental or emotional stability. A stressor can be any event or situation. Coping efficacy is an individual’s belief that he or she is capable of dealing with the event or situation considered to be the stressor. Coping efficacy is not equivalent to coping: coping is an action or set of actions that is employed to deal with a stressor. Lazarus and Folkman (1984) proposed that reactions to a stressor are mediated by cognitive appraisals by the individual. Appraisals, primary and secondary, are simply beliefs about the magnitude of the event or situation as well as beliefs about whether one can handle the event or situation. In primary appraisal, the individual assesses the magnitude of the event or situation considered to be a stressor. For example, he or she may think, “Oh my gosh, this car accident is really bad, the car is not drivable.” This perception of the stressor is termed herein perceived psychological trauma. Perceived psychological trauma is operationalized as an individual’s unique perception of an event or enduring condition that leads the individual to believe that his or her physical life, way of life, or sanity is in jeopardy. The example above relates to financial distress, which potentially jeopardizes way of life. Secondary appraisal happens immediately following the initial cognition, if not simultaneously, and concerns the individual’s thoughts about whether he or she can deal with the situation or event (Lazarus & Folkman, 1984). An example of secondary appraisal that corresponds with the prior example of primary appraisal is, “I can handle this because my insurance will cover the cost to fix the car and a rental car.” Or, “I can’t handle this because I have no insurance.” Coping is the actual action. In this example, coping would be the action of calling the insurance company. Coping effi-

The Crisis State Assessment Scale: Development and Psychometrics 731 cacy, by contrast, is the belief that one can cope by calling the insurance agency. These concepts constitute a crisis state. The state is internal and cannot necessarily be determined by indicators such as coping actions. In other words, an individual can be in a crisis state even while using healthy coping behaviors. There are two main reasons why behavior cannot be used as an indicator of crisis. The first reason is that what may be unhealthy coping in one situation may be healthy coping in another. For example, using denial of imminent death from a terminal disease because one has a project that one wants to continue to work on is beneficial, even though denial is more typically perceived to be a negative coping response. The second reason is that even though a person may appear, through behavioral indicators, to be coping very well, he or she may have the perception of an inability to cope and therefore still have a disruption of equilibrium. Internal equilibrium (a noncrisis state), referred to in the crisis literature as homeostasis, can be thought of as a playground seesaw that is perfectly balanced. On one side of the fulcrum is one’s perception of situations or events (perceived psychological trauma), and on the other, one’s perception of ability to cope (coping efficacy) with those situations or events. When the perception of the psychological trauma is greater than the perception of coping efficacy, the seesaw is off balance. The key to determining if an individual is in a crisis state is to measure both sides of the seesaw and compare the two scores: perception of the gravity of the situation and perception of ability to cope in relation to a specific event or situation. When perceived coping efficacy is viewed from the vantage point of perceived problems in coping efficacy, then both perceived psychological trauma and perceived problems in coping efficacy contribute to disruption in internal equilibrium. One important reason for measuring perceived problems in coping efficacy, as opposed to just perceived coping efficacy, is that clinicians generally focus on problem solving in a therapeutic interaction (Hudson, 1982). The reason for this is that it is not possible to define health except through the relation between healthy and unhealthy. Thus, what indicates health is the lack of markers of ill health. A higher score on either factor indicates a greater problem and will be targeted as the focal point of clinical therapy. The Crisis State Assessment Scale (CSAS) is the first scale to measure a crisis state defined as perceived psychological trauma and perceived problems in coping efficacy. Moreover, the scale focuses the respondent on a specific event by having him or her specify the event or situation at the top of the instrument. The purpose of this is to help the respondent to focus on that event when responding to each item. In this way, the instrument relies on Bandura’s (1997) argument for situation-specific coping efficacy. This idea carries over to perceived psychological trauma. In other words, the scale is also sensitive to an identified problem area.

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SCALE PSYCHOMETRICS Scale Construction The phenomenon that this scale attempts to capture is a crisis state, defined as an internal disequilibrium resulting from perceived psychological trauma and perceived problems in coping efficacy. These two factors are defined as follows: Perceived psychological trauma is an individual’s unique perception of an event or enduring condition that leads the individual to believe that his or her physical life, way of life, or sanity is in jeopardy. Perceived problems in coping efficacy is an individual’s belief that he or she cannot effectively master the demands of a traumatic condition, threat, or challenge because it exceeds his or her resources.

The tool developed in this study uses a 7-point Likert scale based on presence or absence of the item. The scaling is as follows: 1 = never, 2 = very rarely, 3 = rarely, 4 = sometimes, 5 = often, 6 = almost always, and 7 = always. A single-item indicator of subjective units of psychological distress is also present on the instrument and is scaled with a category partition. The category partition is broken up into equal parts ranging from 1 to 10 in of difficulty of the current situation. The partition is anchored with the easy and most difficult.

Subjects In this study, a convenience sample was used of students 18 years old and older enrolled at two universities, one in the South (University 1), and one in the Northest (University 2), for the spring semester of 2001. A total of 475 data packets were distributed. The return rate at the school in the South was 91.2% and the return rate at the school in the Northeast was 85.14 % (Table 31.1).

RESULTS Demographics of Subjects The sample from University 1 (n = 114) was predominately female (87%), and the sample from University 2 (n = 297) was 50% female. The racial/ ethnic makeup of the University 1 sample was as follows: 19% African American, 2% Asian, 67% Caucasian, 7% Hispanic, and 5% other. The racial/ethnic makeup of University 2 was 9% African American, 8% Asian, 69% Caucasian, 7% Hispanic, 1% Native American, and 6% other. Figure 31.1 illustrates the gender and racial/ethnic makeup of the combined sample.

The Crisis State Assessment Scale: Development and Psychometrics 733 Table 31.1 Data Collection Sites and Participant Rates

Location University 1 University 2 Total

Packets Distributed

Packets Returned

Percentage Returned

CSAS Completed

Percentage CSAS Completed

125 350 475

114 298 412

91 85 87

110 292 402

88 83 85

The mean age of the sample from University 1 was 26.68, with a standard deviation of 8.02. Because of the outliers in this sample, it is important to report that the inner quartile of this sample was between the ages of 21 and 28. The sample from University 2 was younger, with a mean age of 20.72 and a standard deviation of 2.34. The inner quartile for this sample was between the ages of 19 and 21.5.

Reported Crisis Event(s)/Situation(s) on the CSAS Respondents were asked to write a short description of the crisis event(s) and/or situation(s) to which they would refer while completing the CSAS (see Figure 31.2). The form provided space for three separate events or situations. Table 31.2 describes the crisis event(s) and/or situation(s) and the frequency with which they were reported. Sixteen respondents did not report a crisis event or situation, yet still completed the CSAS. Of those reporting an event, 403 reported one event, 69 reported two events, and 37 reported three events.

Content Validity for the CSAS Content validity was established via the method purported by Nunnally and Bernstein (1994), in which competent judges determined whether or not each item was a member of the population of items that composed each domain. Three experts in crisis theory judged each item and were in agreement on all items. The original CSAS consisted of 10 to 12 items per domain and had an overall Fleisch-Kincaid grade level index of grade 5.3.

Reliability for the CSAS There are two distinct scales in the CSAS: perceived psychological trauma and perceived problems in coping efficacy. The alpha and reliability for each of these scales was calculated as well as the global reliability. Listwise deletion was used to remove cases with missing data. Thus, the reliability analyses for the CSAS was 403 (n = 403). The alpha and reliability for each of these scales was found to be good to excellent at 0.85, 0.84 and 0.92, respectively.

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Figure 31.1 Changes in target behavior

The Crisis State Assessment Scale: Development and Psychometrics 735

Figure 31.2 Crisis State Assessment Scale This questionnaire is designed to measure the way you feel as a result of a recent traumatic event or situation. Answer each item in relation to the event/situation as carefully and as accurately as you can by placing a number beside each one as follows: 1 = Never 5 = Often ___ 1. ___ 2. ___ 3. ___ 4. ___ 5. ___ 6. ___ 7. ___ 8. ___ 9. ___10.

2 = Very rarely 6 = Almost always

3 = Rarely 7 = Always

4 = Sometimes

I think about the event/situation when I don’t want to. I feel like the event/situation throws my life off balance. I feel like my physical or emotional well-being is threatened by the event/situation. The event/situation is very distressing to me. The event/situation makes me feel like I am going crazy. I feel like I don’t have the resources and/or energy to deal with the event/situation. I don’t know what to do to make this event/situation manageable. I feel like I cannot handle the event/situation. I don’t deal well with events/situations like this one. I am confident that I can cope with the event/situation.

Imagine that you are facing the easiest situation that you have ever experienced; consider that feeling a 0. Now imagine that you are facing the most difficult situation that you have ever experienced in your lifetime; consider that a 10. On a scale from 1 to 10 indicate the difficulty of the event/situation described above by circling a number below: Easy :

0

1

2

3

4

5

6

7

8

9

10

:

Most difficult

Table 31.2 Crisis Event(s)/Situation(s) Event Trouble with significant other Problems with grades/school Death of a loved one Trouble with parents Parents’ or grandparents’ health problems Happy event Accident Problems with job Problems with housing/moving Problems with friends Personal health Graduation Financial problems Problems with siblings Friend’s tragedy Know or saw someone who died violently Rape Other (baby, divorce, auto trouble, coming out, happy/sad anniversary, pet, know/saw suicide)

Frequency

Percentage

86 53 48 36 30 30 28 25 26 21 21 19 19 15 10 9 7 60

21 13 12 9 7 7 7 6 4 5 5 5 5 4 2 2 2 15

Respondents could report up to three events, so percentages do not add up to 100.

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Factorial Validity Because each of the subscales in the CSAS was developed according to theoretical propositions, multiple groups confirmatory factor analysis (CFA) was used to establish factorial validity. Correlations between subscale scores and item responses were computed. These correlations were then examined to determine whether items had the highest correlations with their intended subscale. The CSAS has a strong factor structure, which suggests the presence of distinct factors. The strong correlations observed between the two factors of perceived psychological trauma and perceived problems in coping efficacy are consistent with the theory that these two factors compose another factor, a crisis state. This is also indicated by the strong global reliability coefficient.

Convergent Validity To establish convergent validity, correlations were found between factors on the CSAS and other indicators of those factors. First, the perceived psychological trauma mean scale score was compared to the mean score of the Index of Clinical Stress. With a sample size of 393, the Pearson’s r was 0.536 and was significant at the p = .001 level. Item number CSAS22 was used as the single-item indicator for perceived problems in coping efficacy. The item states: “I am confident that I can cope with the event/situation.” Reverse-scoring this item demonstrates problems in perceived coping efficacy. Because the indicator was a member of the final scale item grouping, its influence had to be removed before the correlation was found. The correlation for the four remaining items on problems with perceived coping, and the single-item indicator, was 0.296 and was significant at the p = .001 level with a sample size of 403.

Discriminant Validity Discriminant validity of the CSAS was tested using the background variables ethnicity, age, and academic standing. Table 31.3 illustrates the correlations between mean scale scores for both factors on the CSAS and the background variables.

Table 31.3 Discriminant Validity Correlation Coefficients

Perceived Psychological Trauma Perceived Problems in Coping Efficacy *Significant at the p = .01 level (2-tailed).

Ethnicity

Age

Academic Standing

.079 .031

−.013 −.093

.059 −.035

The Crisis State Assessment Scale: Development and Psychometrics 737

Criterion Validity Criterion (concurrent) validity was established for perceived psychological trauma by creating two groups, low psychological trauma and high psychological trauma, from the single-item indicator for perceived psychological trauma. Subjects scoring 0–3 (n = 87) on the single-item indicator were placed in the low psychological trauma group, and subjects scoring 4–10 (n = 304) were placed in the high psychological trauma group. Logistic regression was computed to demonstrate the ability of perceived psychological trauma to predict group hip. There were 389 cases included in the analysis, and after five iterations, the–2 log likelihood was 320.116. The Cox & Snell R square was 0.208 and the Nagelkerke R square was 0.319. Perceived psychological trauma was able to correctly predict group hip into the low psychological trauma group with 41.9% accuracy, and into the high psychological trauma group with 93.1% accuracy. The overall percentage correct was 81.7. The weighting value of B was 1.060, and the standard error was 0.137. The Wald test coefficient was 59.669 and was significant at the p = .001 level.

DISCUSSION AND CONCLUSIONS Crisis intervention has flourished as a therapeutic technique in the field of social work. However, there has been very little research to show whether or not the technique is effective. One of the reasons for this lacuna is that it has been nearly impossible to objectively determine the efficacy of the intervention. To determine effectiveness, one needs to determine the magnitude of the state when the client enters therapy and the magnitude of the state when the client terminates therapy. Never before has there been an instrument to measure the magnitude of a crisis state through the eyes of the client. Although the results of this study are preliminary, the CSAS shows great promise in this area.

Crisis Theory An interesting finding of this research is that relationships between perceived psychological trauma and specific crisis events were found (chi square = 0.006); however, perceived problems in coping efficacy and crisis events were independent of one another (chi square = 0.261). This finding is consistent with the guiding theory that coping efficacy is independent of the traumatic event and mediates the magnitude of a crisis state. It can be inferred from this finding that some individuals feel they can handle a specific difficult event, and some believe they cannot handle that same event. It is the individual’s subjective belief about his or her ability to cope with the event that determines whether or not the individual will enter into a state of crisis.

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Clinical Implications One of the purposes for which the CSAS was developed was to aid clinicians in the assessment of individuals presenting in a crisis state. The CSAS should not be used as the sole determinant of a crisis state, but as an adjunct to other clinical assessment strategies (Lewis & Roberts, 2002). No instrument until now has attempted to capture the magnitude of a crisis state. Although the CSAS has limitations, such as its correlated measurement error, it is an important first step toward the measurement of the degree to which an individual is in crisis. Crisis intervention has become an increasingly popular therapeutic modality. One of the main reasons for this popularity is that managed care organizations and other insurers will often pay for only a few sessions, which is making longer therapies a thing of the past for all but the affluent. This means that crisis intervention is often used with the most marginalized individuals, those without many health care choices. Social workers have an obligation to ensure that available services to these vulnerable individuals are as effective as possible. A unique feature of the CSAS is that it allows the client to identify the event or situation that he or she believes is the precipitant of the crisis. The client then has to focus on his or her feelings regarding the magnitude of the event, as well as feelings about whether or not he or she can cope with the event. By requiring the client to focus and complete a pencil-and-paper test, the instrument itself is a part of the intervention, because it begins the process of de-escalation. The CSAS also provides talking points to which the clinician can refer to keep the intervention focused on problem solving in relation to the crisis state (Lewis & Roberts, 2002). The CSAS can be used in college counseling centers for emergency/crisis sessions, as well as in other facilities. One strategy could be to give the client the scale along with other paperwork that must be completed before the session. Because the CSAS has only five items for each of the two factors, the client burden is not significant. The CSAS is easy to score: the clinician can calculate and interpret the instrument in less than two minutes. The ease of istration and scoring makes it possible to ister the scale at both the beginning and the end of the emergency session to quantify improvement. This suggestion is made with the caution that the score should not be the only indicator of a successful or unsuccessful therapeutic outcome and that the clinician should be cognizant of the measurement error potential of the scale. In other words, there may be something other than perceived psychological trauma and perceived problems in coping efficacy that is causing the variation in the scale score.

Scoring Instructions Both factors on the final version of the CSAS (see Figure 31.2, p. 735) consist of five items and are based on a 7-point scale. This makes summing

The Crisis State Assessment Scale: Development and Psychometrics 739 and interpreting the scores quick and easy. There are two steps in the scoring process: finding each subscale score and calculating the global score. To find subscale scores, reverse score item 10 by replacing scores as follows: 1 with 7, 2 with 6, 3 with 5, 4 with 4, 5 with 3, 6 with 2, 7 with 1. Then Find the mean of each subscale by adding all item responses in that subscale and dividing by 5. To find the CSAS global score, add each of the subscale scores (mean scores) together and divide by 2.

Interpretation The same 7-point Likert scale that is used when responding to CSAS items is used to decipher the scores. If, for example, a person received a 6 on the perceived problems in coping subscale, it can be surmised that he or she “almost always” perceives that he or she is experiencing problems in coping. This may indicate that an intervention is called for to assist the client in finding alternative coping strategies. The global score is meant to be an indicator of the magnitude of a crisis state. Higher scores mean that the individual is in a greater state of crisis.

REFERENCES

Aguilera, D. C. (1998). Crisis intervention: Theory and methodology. St. Louis: Mosby-Year Book. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215. Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman. Bengelsdorf, H., Levy, L. E., Emerson, R. L., & Barile, F. A. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal of Nervous and Mental Disorders, 172(7), 424–430. Benight, C. C., Freyaldenhoven, R. W., Hughes, J., Ruiz, J. M., Zoschke, T. A., & Lovallo, T. (2000). Coping self-efficacy and psychological distress following the

Oklahoma City bombing. Journal of Applied Social Psychology, 30(7), 1331–1344. Benight, C. C., Ironson, G., Wynings, C., Klebe, K., Burnett, K., Greenwood, D., et al. (1999). Conservation of resources and coping self-efficacy predicting distress following a natural disaster: A causal model analysis where the environment meets the mind. Anxiety, Stress, and Coping, 12, 107–126. Benight, C. C., Swift, E., Sanger, J., Smith, A., & Zeppelin, D. (1999). Coping self-efficacy as a mediator of distress following a natural disaster. Journal of Applied Social Psychology, 29(12), 2443–2464. Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Corcoran, J., & Roberts, A. R. (2000). Research on crisis intervention and recommendations for future research. In A. R. Roberts

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(Ed.), Crisis intervention handbook: Assessment, treatment, and research. New York: Oxford University Press. Corcoran, K. J., & Fischer, J. (2000). Measures for clinical practice: A sourcebook (3rd ed.). New York: Free Press. Cozzarelli, C. (1993). Personality and self-efficacy as predictors of coping with abortion. Journal of Personality and Social Psychology, 65(6), 1224–1236. Ell, K. (Ed.). (1995). Crisis intervention. In R. Edwards (Ed.), Encyclopedia of social work (19th ed., Vol. 1). Washington, DC: National Association of Social Workers. Gilliland, J., & James, J. (1993). Crisis intervention strategies. Belmont, CA: Wadsworth. Golan, N. (Ed.). (1986). Crisis theory (3rd ed.). New York: Fress Press. Hill, R. (1949). Families under stress, adjustment to the crisis of war, separation, and reunion. New York: Harper Hudson, W. W. (1982). The clinical measurement package: A field manual. Homewood, IL: Dorsey Press. Hudson, W. W., & Faul, A. J. (1997). The Index of Drug Involvement: A partial validation. Social Work, 42(6), 565–572. Hudson, W. W., Mathiesen, S. G., & Lewis, S. J. (2000). Personal and social functioning: A pilot study. Social Service Review, 74(4), 76– 102. James, R. K., & Gilliland, B. E. (2001). Crisis intervention strategies (4th ed.). Belmont, CA: Wadsworth/Thomson Learning. Kanel, K. (1999). A guide to crisis intervention. Pacific Grove, CA: Brooks/Cole.

Lazarus, R. S., & Eriksen, C. W. (1952). Effects of failure stress upon skilled performance. Journal of Experimental Psychology, 43, 100–105. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lewis, S., & Roberts, A. R. (2002). Crisis assessment tools. In A. R. Roberts & G. J. Greene (Eds.), Social workers’ desk reference (pp. 208–212). New York: Oxford University Press. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141–148. Myer, R. A., Williams, R. C., Ottens, A. J., & Schmidt, A. E. (1992). Crisis assessment: A three-dimensional model for triage. Journal of Mental Health Counseling, 14(2), 137– 148. Nunnally, J. C. (1978). Psychometric theory. New York: McGraw-Hill. Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill. Nurius, P. S., & Hudson, W. W. (1993). Human services: Practice, evaluation, and computers. Pacific Grove, CA: Brooks/Cole. Parad, H. J., & Parad, L. G. (1990). Crisis intervention, book 2: The practitioner’s sourcebook for brief therapy. Milwaukee, WI: Family Service America. Roberts, A. R. (1996). Epidemiology and definitions of acute crisis in American society. In A. R. Roberts (Ed.), Crisis management and brief treatment (pp. 3–17). Chicago: Nelson-Hall. Roberts, A. R. (2000). An overview of crisis theory and crisis intervention. In A. R. Roberts (Ed.), Crisis

The Crisis State Assessment Scale: Development and Psychometrics 741 intervention handbook: Assessment, treatment, and research (2nd ed., pp. 3–30). New York: Oxford University Press. Roberts, A. R., & Grau, J. J. (1970). Procedures used in crisis intervention by suicide prevention agencies. Public Health Reports, Vol. 85 (8): 691–698. Roberts, A. R., & Greene, G., (Eds.), (2002). Social workers’ desk refer-

ence. New York: Oxford University Press. Slaikeu, K. A. (1984). Crisis intervention: A handbook for practice and research. Boston: Allyn & Bacon. Waters, D. (1997). A study of the reliability and validity of the triage assessment scale. Unpublished doctoral dissertation, University of Memphis, Tennessee.

32 Designs and Procedures for Evaluating Crisis Intervention SOPHIA F. DZIEGIELEWSKI GERALD T. POWERS

The overall efficacy, popularity, and necessity of brief, time-limited therapeutic encounters, including crisis intervention approaches used with various types of clients, although well-documented, remains focused on clearly ascertaining the variables that can be linked directly to client change (Auerbach & Kilmann, 1977; Dziegielewski, 2004; Dziegielewski & Roberts, 2004; Dziegielewski, Shields, & Thyer, 1998; Evans, Smith, Hill, Albers, & Neufeld, 1996; Koss & Butcher, 1986;). To date, however, methodological limitations inherent in most forms of time-limited intervention remain, particularly with respect to the paucity of evidence-based practice approaches that significant differences in the overall effectiveness of and between competing intervention approaches (Monette, Sullivan, & DeJong, 2005; Neimeyer & Pfeffier, 1994; Nugent, Sieppert, & Hudson, 2001). Historically, establishing treatment effectiveness in all areas of counseling has often been met with resistance, especially because client change behavior and the resulting therapeutic gains can be seen as subjective. In fact, Bergin and Suinn (1975) originally suggested that clients are likely to change over time even without any therapeutic intervention. We recommend that all practitioners make a commitment to evidencebased practice. In other words, all crisis workers and counselors need to thoroughly prepare for intervening on behalf of a large number of different types of persons in crisis. This can be done effectively only if practitioners develop the knowledge base to find out which crisis intervention protocol is most likely to lead to positive outcomes and crisis resolution among clients 742

Designs and Procedures for Evaluating Crisis Intervention 743 in crisis (Roberts & Yeager, 2004). Evidence-based practice places necessary emphasis on the crisis clinician’s use of empirically validated lethality assessments, intervention protocols, and program evaluation procedures as well as the use of critical thinking in making decisions (Roberts & Yeager, 2004). Professional judgments should be systematically grounded in empirical research, and each client should be carefully assessed to determine the degree to which predicted outcomes have been attained. This subjectivity makes the task of establishing therapeutic effectiveness and efficiency a complicated one (Dziegielewski & Roberts, 2004). In an effort to formulate the evaluation process, it is useful to first identify two basic assumptions that underlie counseling efforts in the area of crisis management and intervention, and then discuss why they can complicate the measurement of intervention outcomes. First, in time-limited intervention of any type, most counselors agree that the main effect of therapy is not curative, but rather one that directs, facilitates, and accelerates the pace of client progress toward change. Not only is the experience considered noncurative, it must also be time-limited in regard to service delivery. This makes the importance of early and brief intervention a consistent requirement, especially because clients typically remain in treatment fewer than six sessions (Dziegielewski, 1997). Crisis intervention strategies need to and stabilize clients as well as help them develop new coping strategies that allow them to adjust to the situational experience (Hartman & Sullivan, 1996; Roberts & Dziegielewski, 1995). Second, crisis is itself a multifaceted phenomenon that does not respond readily to traditional forms of therapeutic measurement and evaluation. In addition, those who encounter them do not uniformly experience crisis situations. The nature, extent, and intensity of any given crisis are, in large measure, a product of the individual’s construction of the social reality. The intervention as well as the methods used to evaluate it, often referred to as the blueprint to guide the data collection efforts, must vary accordingly. In the absence of any compelling evidence in of long-term therapy as a more effective mode of practice, crisis intervention as a unique form of brief, time-limited intervention is often preferred (B. L. Bloom, 1992; Dziegielewski, 2004; Dziegielewski et al., 1998; Koss & Shaing, 1994). Crisis intervention as a time-limited therapy may actually accelerate treatment efficacy as time frames are clearly and openly established and agreed upon between the client and the counselor (Reynolds et al., 1996).

THE IMPORTANCE OF INTEGRATING RESEARCH AND PRACTICE Helping professionals who routinely work with victims (or survivors) of crises report that there are several factors that seem to be common to virtually all crisis situations. The first of these factors is the acknowledgment that the

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crisis situation often brings about a time-limited disequilibrium that must be addressed in order for the client to reach a homeostatic balance (Roberts & Dziegielewski, 1995). The disequilibrium associated with crisis serves as a powerful motivational force that can heighten the client’s susceptibility to intervention (Dziegielewski, 2004; Koss & Butcher, 1986). Faced with a crisis, the client is often more willing to question previous ways of coping, and thus to explore new or alternative ways of addressing situations that prior to the crisis would not have been considered acceptable. This renders the client more open to trying new courses of action for therapeutic intervention that can facilitate the planning of concrete goals and objectives. All of this is entirely consistent with the so-called strengths perspective in which clients are believed to already possess the resources necessary to address stressful situations. They simply are not using them, are underutilizing them, or are currently unaware of how to best use them on their own behalf (see Greene, Lee, Trask, & Rheinscheld in this volume for a detailed discussion of how to integrate the strengths perspective and solution-focused treatment with crisis intervention). By nature, a crisis situation and the attendant reaction is self-limiting (Dziegielewski & Resnick, 1996; Roberts, 1990; Slaikeu, 1984). Beginning with Lindemann’s (1944) initial formulation of crisis intervention in his now classic study of the Coconut Grove Nightclub disaster, crises have been characterized as time-limited phenomena that inevitably get resolved one way or another (with or without professional help) in a relatively brief period. The client’s pressing need to resolve the crisis and thus alleviate the associated pain appears to heighten motivation, so much so that nominal levels of therapeutic intervention provided during the crisis period tend to produce positive and sometimes dramatic therapeutic results (Parad et al., 1990). Given this narrow window of vulnerability to change, it is considered essential that clients who experience crisis must be provided immediate assistance to maximize the potential for constructive growth. Some authors, particularly those in the domestic violence field, believe that immediate intervention is so important that the postponement of appropriate help for more than 11 days places the client at greater risk of repeat victimization (Davis & Taylor, 1997). According to Roberts and Dziegielewski (1995), Gilliland and James (2003), and other professionals in the area, positive life changes can be achieved following a crisis. Furthermore, the way a client handles a present crisis may have a profound and lasting impact, not only on the individual’s current adjustment, but also on his or her capacity to cope with future crisis situations. From a research perspective, this suggests that practitioners should seek to understand and accurately explain the intervention approach being implemented. In addition, it is important to accurately identify the expected impact of the intervention and the anticipated adaptive responses. Unless outcome measures are clearly defined in operational , it is difficult to

Designs and Procedures for Evaluating Crisis Intervention 745 determine whether the intervention goals and objectives have been attained. The goals and objectives, in turn, must clearly be linked to positive life changes and methods of coping that enhance continued client functioning. Consequently, the central task of outcome-based research is to measure the presence and magnitude of both immediate and long-term changes that result from the counseling process (Lambert & Hill, 1994).

THE ROLE OF THE PRACTITIONER IN EMPIRICAL PRACTICE From a clinical perspective, some of the important limitations associated with many of the studies that have traditionally compared short- and longterm intervention methods remain. In establishing an empirical basis for crisis intervention, similar to other forms of practice, one primary limitation rests in the fact that the independent variable cannot be adequately addressed in a homogeneous fashion alone. For example, when evaluating crisis intervention programs in particular, Neimeyer and Pfeiffer (1994) report that many researchers operate on the assumption that there are no important individual differences among clinicians with respect to what goes on during the therapeutic encounter. Limited attention is often given to ensuring that those who provide crisis intervention services have been adequately trained. It is assumed that all practitioners have the same effect on client progress. This lack of attention to measuring the relative effectiveness of the social worker can lead to myths that some sort of global and homogeneous index of client improvement. These “uniformity myths,” as Kiesler (1966) originally coined them, deflect attention from possible important individual differences both within and between groups of clients and therapists who treat them. Several studies clearly provide ample evidence in of the relative effectiveness of time-limited crisis intervention strategies (Davis & Taylor, 1997; Hartman & Sullivan, 1996; Mezzina & Vidoni, 1995; Neimeyer & Pfeiffer, 1994; Rudd, er, & Rajab, 1995). Equally apparent, however, is the relative absence of any clear-cut preferences regarding the “impact of alternative treatments, on alternative clinical problems with clients of varying characteristics and other manifold conditions that may mediate treatment” (Kazdin, 1994, p. 20). Simply stated, the critical issues to be addressed are essentially no different now than they were when Paul first issued his now famous dictum in 1966: “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (p. 111). The purpose of this chapter is to present clinically grounded research models that are relevant for those in crisis situations and that remain sensitive to the three major variables of the therapeutic paradigm: the client, the social worker as a researcher/practitioner, and the outcome. Against a gen-

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eral background of group design, or nomothetic, research, we consider several different evaluation models, all of which emphasize what Chassan (1967) and others have referred to as “intensive” or “idiographic” designs. When used alone, none of them is foolproof. Together, however, they provide a useful set of assessment tools that can help social workers evaluate the efficacy of their practice and improve the quality of the services they provide.

MACRO AND MICRO ANALYSES IN CRISIS INTERVENTION Over the years, a variety of measurement strategies have been employed in an effort to assess various dimensions of the crisis intervention process. When viewed as a whole, they provide an intriguing array of designs ranging from macro to micro levels of analysis. For example, in an attempt to assess the process and outcome of crisis intervention in of suicide interventions, Neimeyer and Pfeiffer (1994) attempted to chronicle the relative effectiveness of various suicide intervention strategies and how such strategies actually contributed to the therapeutic relationship. When effectiveness was measured from a macro perspective, these methods focused primarily on epidemiological data collected by local, regional, and national organizations. Some studies compared suicide rates before and after the implementation of a particular intervention program. Other studies employed quasi-experimental designs in which similar populations of treated and untreated suicide attempters were compared. In still other studies, cohorts of treated clients were compared with population parameters based on data derived from the National Center for Health and Statistics in the United States. There are serious methodological problems inherent in the use of extant data, however, especially with respect to threats to internal validity as well as comparability across idiosyncratic samples. In an effort to address some of these apparent weaknesses, client or caller satisfaction methods are sometimes used to help validate client perceptions and the intrinsic worth of the study. Based on these macro types of analyses, many suicide programs and crisis intervention services have failed to gather the kinds of information necessary to adequately establish program effectiveness (Neimeyer & Pfeiffer, 1994). Without such information, it is impossible to determine whether negative findings are the result of inadequacies in the practice theory or liabilities in the research methodology. For questions like this, there are no easy answers. The fact that a crisis is itself a dynamic and multifaceted phenomenon can also complicate the measurement process, particularly when it is done on an aggregate basis, or when primarily relying on secondary sources. Studies that rely exclusively on self-report can also be problematic. For example, when looking specifically at rural adolescents at risk of suicide, Evans et al.

Designs and Procedures for Evaluating Crisis Intervention 747 (1996) clearly established a relationship between characteristics such as the respondent’s family dynamics and whether there was a history of abuse. Regardless of how data are collected (via a database, lines, or selfreport) crisis intervention strategies represent multifaceted perspectives that consistently pose challenging assessment problems for the professional practitioner. Some practitioners have argued that the most effective way to assess the efficacy of practice interventions at the micro level is to focus the evaluation lens on the idiosyncratic interactions that take place between the worker and the client (M. Bloom, Fischer, & Orme, 2003). The approach typically combines both quantitative and qualitative methods that rely heavily on the client’s personal constructions of the crisis experience. Such methods tend to minimize threats to internal validity, but they raise serious questions with respect to generalizability. In focusing on the rich detail of the client-worker transactions and subsequent outcomes, the search for scientifically objective generalizations is abandoned in favor of in-depth insights that can be attained only by exploring the individual case as it is subjectively experienced. Toward this end, the worker can employ a variety of evaluation strategies. It is generally agreed that no single measure can adequately capture all the relevant subtleties of the crisis intervention process. As a result, Denzin (1970) and others encourage the use of multiple measures. Through an evaluation strategy referred to as “triangulation,” it is believed workers can arrive at a reasonably accurate approximation of what is actually going on in the intervention process. When addressing service effectiveness on a much smaller scale or with a more individualized focus, the micro level of intervention becomes the primary locus of attention. For example, from a micro perspective, issues such as individual worker influences and the subsequent treatment effectiveness that results become paramount. To highlight this perspective, skills are sometimes measured through simulated calling experiences or formalized role-plays. In an attempt to quantify this more micro perspective, Neimeyer and Pfeiffer (1994) discuss the potential value of using specific measurement instruments designed to directly measure the skill of the worker. When dealing with suicide prevention, these authors also suggest that one such instrument that may be utilized is the Suicide Intervention Response Inventory (SIRI-2), designed to measure forced responses of the professional helper in the crisis intervention setting. In fact, a variety of useful rapid assessment instruments have been designed and tested for use in crisis situations, including indices that measure life stress, negative expectations, depression, problem-solving behaviors and attitudes, personality characteristics, and other, similar traits associated with psychiatric conditions, as well as other relevant crisis-related phenomena (see Buros, 1978, Corcoran & Fischer, 1999a, 1999b). The micro approach not only invites the use of these indices for the measurement of crisis behaviors, it virtually mandates it. However, the au-

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thors of these instruments recommend caution in their use. They recognize that the evaluation of a crisis situation is a multifaceted undertaking that cannot be adequately assessed if one relies solely on a single instrument or focuses on a single dimension such as the worker’s effectiveness. Overall, these authors warn that there is a paucity of literature from both a macro and a micro perspective. Very few studies address outcome-based measurement involving the evaluation of crisis intervention in general or suicide prevention services in particular (Neimeyer & Pfeiffer, 1994).

PREREQUISITES TO EFFECTIVE EVALUATION Each of the chapters in this handbook discusses the application of crisis intervention strategies with a different population at risk. While sharing much in common with respect to many of the technical characteristics of the crisis intervention process, it is clear that there is wide variability regarding various dimensions of the short-term therapeutic experience. Crisis experiences can vary in of the identified problem, the client’s reaction, the social worker’s handling of the situation, the surrounding circumstances, and the expected outcome. Although some researchers have utilized the classical pretest-posttest design to measure practice effectiveness (Dziegielewski, 1991), other researchers have concluded that such attempts at utilizing group designs remain problematic (Bergin, 1971). Similarly, Kazdin (1986, 1994) noted that investigations that involve groups and conclusions about average client performance can either misrepresent or under- or overrepresent the effects of intervention on the individuals being served. In discussing the need for specificity in conducting outcome research, Bergin (1971) cautioned that “it is essential that the entire therapeutic enterprise be broken down into specific sets of measures and operations, or in other words, be dimensionalized” (p. 253). This ideal is still ed and considered essential in crisis intervention, as evidenced in the more recent work of Neimeyer and Pfeiffer (1994). This concept, however, remains complicated because in the measurement of crisis intervention, techniques that evaluate crisis situations require an intimate understanding between the crisis counselor and the individual in crisis. The resulting assessment must also reflect the multifaceted assessment process that will be initiated (Dziegielewski & Roberts, 1994). In viewing crisis intervention from an empirical standpoint, the various dimensions of the intervention experience need to be treated as a complex network of functional relationships within which there occurs a series of interactions among the primary factors (i.e., the independent and dependent variables). Simply stated, in any functional relationship, the independent variables operate as presumed causes and the dependent variables operate as the presumed effects. Therefore, in crisis intervention, an impor-

Designs and Procedures for Evaluating Crisis Intervention 749 tant first step in the evaluation process is to sort out what are believed to be the causal connections operating in any given crisis situation. This involves identifying a series of interdependent problem-solving steps that logically flow from the presenting problem (Powers, Meenaghan, & Toomey, 1985). Embedded in the logic of this problem-solving process is an implied hypothesis, the calculus of which can be stated as follows: In crisis situations, if X (e.g., suicide prevention service) is employed as an intervention strategy (i.e., the independent variable), then it is expected that Y (i.e., a return to previous functioning level) will be the predicted outcome (i.e., the dependent variable).

Crisis intervention is no different from any other form of intervention. Inevitably, it involves, in one way or another, the testing of this implied hypothesis. For example, when it is believed that residential crisis services can serve as a ive measure for those in crisis, thereby limiting hospitalization and increasing stabilization, specific steps to outline a plan of action become necessary. Teague, Trabin, and Ray (2004) recently identified and discussed key concepts and common performance indicators and measures that should lead to ability in behavioral health care. The Adult Mental Health Workgroup (AMHW) is a nationally representative group tly sponsored by the Carter Center in Atlanta and SAMHSA’s Center for Mental Health Services and SAMHSA’s Center for Substance Abuse treatment. Based on the consensus of five work groups, they recently developed measures and outcomes for key aspects of quality and appropriate behavioral treatment. Examples of performance indicators are: Treatment duration—Mean length of service during the reporting period for persons receiving services in each of three levels of care: inpatient/24hour, day/night structured outpatient programs, and ambulatory; and Follow-up after hospitalization—Percent of persons discharged from 24hour mental health inpatient care who receive follow-up ambulatory or day/night mental health treatment with 7 days. (Teague, Rabin, & Ray, 2004, p. 59)

Empirical practice requires that the clinician-researcher specify clearly what it is he or she intends to do with or on behalf of the client, as well as the expected consequences of those actions. To do this, both the intervention and the outcome must be defined in operational or measurable . To say that emotional will result in enhanced client self-esteem, or that ventilation will reduce depression, although on the surface both may appear very important in practice, they simply are not adequate statements of testable hypotheses. As is true in all time-limited interventions, counseling and social work clinicians are expected to state exactly what is meant by concepts

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such as “emotional ” and “ventilation,” as well as what changes are expected to occur as a result of their use (Dziegielewski, 1996, 1997; Roberts, 1990). Based on this premise, Hartman and Sullivan (1996) clearly established specific objectives for center staff working in residential crisis services. They maintain that the key objectives include stabilizing crisis situations efficiently by reducing presenting symptoms; maintaining or reducing the frequency of hospitalizations or preission levels; helping consumers return to previous levels of satisfaction and service, such as housing and vocational status; and attaining high levels of consumer satisfaction with services. Although the task of operationally defining concepts is not an easy one, most researchers concur that it is essential to the effective evaluation of empirically based practice, regardless of one’s theoretical orientation (Bisman & Hardcastle, 1999; M. Bloom et al., 2003; Monette et al., 2005). Furthermore, the value and subsequent recognition of our clinical practice efforts will prove to be only as good as the empirical observations on which they are based.

MEASURING GOALS AND OBJECTIVES The brief and time-limited nature of crisis intervention presents some interesting challenges for the clinician who wishes to evaluate his or her practice. From the very outset, clients in crisis need to be convinced that change is possible and that they are capable of contributing to the change process. In so doing, they gain confidence and competence, attributes that should be mirrored in the behavior of the helping professional. The development of this mutual respect and confidence in one another’s abilities provides the necessary foundation for both practice and its evaluation. Basically, no matter what evaluation strategy one employs, it is likely to be meaningful only if it is initiated early and brought to closure fairly quickly. In addition, the methodology itself should not be experienced by the client as being in any way intrusive to the helping process. Ideally, the purposes of both the intervention and the evaluation should be compatible and mutually ive. This mutuality of purpose can be facilitated by the social work professional not only by helping the client to participate in the development of appropriate treatment goals, but also by enabling the client to stay taskoriented in regard to pursuing them. The social work professional can facilitate this process by helping the client establish specific and limited goals (Dziegielewski, 2004). Simply stated, a goal may be defined as the desirable objective that is to be achieved as a result of treatment. Well-stated goals permit the practitioner to determine whether he or she has the skills and desire to work with the client (Cormier & Cormier, 1991). Brower and Nurius (1993) suggest two key characteristics to be considered when deg effective intervention goals. First, goals need to be as

Designs and Procedures for Evaluating Crisis Intervention 751 clear and as behaviorally specific as possible. The more precisely they are defined in measurable , the easier it is to if and when they are achieved. Once defined, the goals may be further refined in of more specific immediate, intermediate, and long-term objectives. Second, both the helping professional and the client should mutually agree on all goals and objectives. This may seem difficult during times of crisis, particularly when the helping professional is required to assume a very active role to help the client meet his or her own needs. This role, however, should always be one of facilitation in which the client is helped to achieve what he or she has deemed essential to regain an enhanced homeostatic balance (Dziegielewski, 1997). Only the client can determine whether the goals and objectives sought are consistent with his or her own culture and values. It is up to the social worker to help the client structure and establish the intervention strategy; however, emphasis on mutuality is central to the development of goals and objectives. Social workers have long realized the value of goal setting as a means of facilitating the intervention process. With the advent of managed care, however, pressures from both within and outside the profession have heightened awareness of the importance of documenting outcomes. A new performance standard has been established, one that requires practitioners to have mastered the technical skills necessary to evaluate the efficacy of their interventive strategies. For empirically based practice to be meaningful, social workers must be capable of establishing the kind of practice climate in which programmatic goals, and the specific objectives designed to meet them, are viewed as realistic, obtainable, and measurable. Given the complexities of contemporary practice, however, no one methodological approach is likely to prove appropriate for all types of crisis situations. The research challenge for crisis workers, as it is inevitably for practice in general, is to fit the method to the problem, and not vice versa. This requires a thoughtful selection of research strategies, the various threads of which can be creatively woven throughout the broader fabric of the overall intervention plan.

Goal Attainment Scaling One evaluation model that has historically gained and continues to receive widespread attention and use is Goal Attainment Scaling (GAS; Lambert & Hill, 1994). This type of scaling was originally introduced by Kiresuk and Sherman (1968) as a way of measuring programmatic outcomes for community mental health services and appears to be adaptable to a wide range of crisis intervention situations. It is discussed here as an example of an evaluation model that combines a number of very useful idiographic as well as nomothetic methodological features. GAS employs a client-specific technique designed to provide outcome information regarding the attainment of individualized clinical and social

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goals. Several researchers the belief that in today’s practice environment, insight-oriented intervention strategy is limited (Bellak & Small, 1978; Dziegielewski, 1997, 1998; Fischer, 1976; Koss & Butcher, 1986; ). Therefore, these types of highly structured scaling methods, with their clear conceptualization and methodology, remain popular and necessary for practice survival in today’s managed care environment. The structured nature of crisis intervention, organized around the attainment of limited goals with concretely specified objectives, articulates especially well with the methodological requisites of standardized measures such as the GAS. The GAS requires that a number of individually tailored intervention goals and objectives be specified in relation to a set of graded scale points ranging from the least to the most favorable outcomes considered likely. It is suggested that at least two of the five points comprising the Likert-type scale be defined with sufficient specificity to permit reliable judgments with respect to whether the client’s behavior falls at, above, or below a given point. Numeric values are then assigned to each point, with the least favorable outcome scored −2, the most favorable outcome scored +2, and the outcome considered most likely assigned a value of 0. The net result of this scaling procedure is a transformation of each outcome into an approximate random variable, thus allowing the overall attainment of specific goals to be treated as standard scores, a feature that becomes important when GAS is used for program evaluation purposes. This process is operationalized in the form of a Goal Attainment Guide. For example, the intervention objectives for a particular suicidal client may include (1) the elimination of suicidal ideation, (2) the alleviation of depression, and (3) the enhancement of self-esteem. Table 32.1 illustrates how these goals might be defined in of expected outcomes that are relevant to a specific client. Although goals can be tailored to each client’s needs, a Dictionary of Goal Attainment Scaling is available to assist clinicians in their efforts to operationally define goals and construct Goal Attainment Guides (Garwick & Lampman, 1973). Although somewhat dated, the definitions contained in the Goal Attainment Guide continue to be relevant to today’s behaviorally based, outcomefocused practice environment, structured as it is with a specific time frame in mind. The definitions for the expected level of success (i.e., the midpoint of the 5-point scale) represent clinical predictions concerning client performance at some predetermined future date (e.g., four or six weeks following the formulations of the goals; Lambert & Hill, 1994). The amount and direction of goal attainment can then be measured by comparing baseline functioning with the level of functioning recorded on the identified target date. A checkmark is used to record the initial performance level and an asterisk (*) is used to record performance at the point of follow-up. The guide can be revised at follow-up to reflect new goals or anticipated changes in the performance levels of existing goals. While goals and objectives are some-

Designs and Procedures for Evaluating Crisis Intervention 753 Table 32.1 Sample Goal Attainment Guide Illustrating Scaling Procedure for Hypothetical Suicidal Client Goals Levels of expected attainment

Suicide Weight: 40

Least favorable outcome thought likely (−2) Less than expected success (−1)

Commits suicide or makes additional suicidal attempt(s). Preoccupied with thoughts of suicide as a possible solution to personal problems; says “life is not worth living.” Occasionally thinks about suicide, but is able to consider alternative solutions to personal problems.

Expected level of success (0)

More than expected success (+1)

Most favorable outcome thought likely (+2)

No longer considers suicide a viable solution to personal problems; talks of future plans.

Depression Weight: 20

Self-esteem Weight: 10

Complains of being very depressed all the time; eating and sleeping patterns irregular; cries daily; not working.

Considers self a “bad person”; criticizes self; feels people would be better off without him or her. Doesn’t verbally criticize self, but says he or she is not very happy.

Complains of being depressed all the time; eats at least two meals a day; sleeps at least six hours a night; cries occasionally; misses work occasionally. Only occasional feelings of depression; eating and sleeping regularly; no longer crying; working regularly.

Reports he or she likes self and way of living and/or reports being “reasonably happy.”

times used synonymously in treatment records, in the context of GAS, they function as benchmarks in relation to which the outcome variables are identified and measured. Specific weights can also be assigned to each goal or objective as a way of reflecting its relative importance or priority in the overall intervention plan. Because weighting represents a relative rather than an absolute indicator of importance, however, the sum need not equal 100 or any other fixed total. The actual numerical value of the assigned weight is of significance only when GAS is used as a basis for comparing the relative effectiveness of alternative intervention approaches within or between programs. The computing of GAS scores can be a simple or a complex matter, depending on the purposes for which the evaluation methodology is to be used. When employed as a program evaluation technique, which relies on the availability of aggregate data, it is appropriate that composite standardized

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scores be derived. This is a fairly complex process requiring some statistical sophistication. When used as a framework for the evaluation of a single case (e.g., individual, family, or group), however, the process is much less complicated. In fact, the only meaningful determination is whether or to what extent the predicted goals have been attained. For those who prefer to quantify such judgments, it is possible to derive a composite score by determining the amount and direction of change occurring in relation to each goal and then summing their respective contributions. An average attainment score can be calculated simply by dividing the composite score by the total number of goals. This makes it possible to compare attainment levels across clients while controlling for the number of goals. Any number of goals may be specified for a particular client and any subject area may be included as an appropriate goal. Even the same goal can be defined in more than one way. For example, the goal of alleviating depression may be scaled in relation to self-report or in relation to specific cutoff points on a standardized instrument such as the Beck Depression Inventory (Beck, 1967). It is essential, however, that all goals be defined in of a graded series of verifiable expectations in ways that are relevant to the idiosyncrasies of the particular case. It should be emphasized that the use of GAS as a framework for the intensive study of a single case does not warrant inferences concerning causal relationships between intervention and outcome. In fact, by stressing the importance of outcome factors, it tends to deflect attention away from concern for issues directly involving interventions. Although it cannot be concluded that the identified intervention is necessarily responsible for the attainment of goals, when expected goals are not realized it does raise serious questions concerning the efficacy of the intervention strategy. In addition, the construction of a Goal Attainment Guide can serve as a useful rallying point around which practitioners and clients can negotiate the particulars of an intervention contract, including the formulation of objectives, the establishment of priorities, and the assignment of responsibilities. In summary, the GAS is an example of how goal and objective attainment can be specified in order to monitor, organize, and aid as a means for collecting information on the assessment process to establish empirically based practice (Hart, 1978). GAS suffers from many of the same limitations as other systems of measurement that are designed to treat data that are inherently ordinal in nature as if it possessed the characteristics of an interval or ratio scale. Researchers have modified the original version of GAS to fit local conditions. Therefore, any consideration of it as a single system of measurement would be misleading (Lambert & Hill, 1994). Nevertheless, measurement vehicles such as the GAS can provide a systematic yet flexible practice evaluation model that can help bridge the methodological gap between clinical and istrative interests.

Designs and Procedures for Evaluating Crisis Intervention 755

USING MEASUREMENT INSTRUMENTS Once the goals and objectives of intervention have been established, the difficult task of evaluating the clinical intervention in standardized or operationally based can be addressed. This task is simplified greatly when problems are articulated in of realistic goals and operationally defined objectives rather than in vague and nebulous language. such as “stress,” “anxiety,” and “depression” are often used to describe important facets of a client’s social-psychological functioning. Although commonplace in our professional jargon, such tend to carry rather subjective connotations. This semantic elusiveness makes it very difficult to establish reliable measures of change. Measuring practice effectiveness, as stated earlier, typically involves a process designed to determine whether or to what extent mutually negotiated goals and objectives have been met. Change is documented through some type of concrete measurement that is indicative of client progress. Dziegielewski (2002, 2004) suggests that this process can be greatly facilitated by establishing clear-cut contracts with clients, who, in turn, provide a viable foundation for a variety of individual or group evaluation designs. Once the contract is in place, standardized instruments can be used as repeated measures to gather consistent data from baseline through termination and follow-up. It is the responsibility of the social work professional, of course, to select, implement, and evaluate the appropriateness of the measurement instruments. Most professionals agree that standardized scales (i.e., those that have been assessed for reliability and validity) are generally preferred. In recent years, social workers have begun to rely more heavily on standardized instruments in an effort to achieve greater accuracy and objectivity in their attempts to measure some of the more commonly encountered clinical problems. The most notable development in this regard has been the emergence of numerous brief pencil-and-paper assessment devices known as rapid assessment instruments (RAIs). As standardized measures, RAIs share a number of characteristics in common. They are brief, are relatively easy to ister, score, and interpret, and they require very little knowledge of testing procedures on the part of the clinician. For the most part, they are self-report measures that can be completed by the client, usually within 15 minutes. They are independent of any particular theoretical orientation, and as such can be used with a variety of interventive methods. Because they provide a systematic overview of the client’s problem, they often tend to stimulate discussion related to the information elicited by the instrument itself. The score that is generated provides an operational index of the frequency, duration, or intensity of the problem. Most RAIs can be used as repeated measures, and thus are adaptable to the methodological requirements of both research design and goal assessment purposes. In addition to providing a standardized means by which change can be monitored over

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time with a single client, RAIs can also be used to make equivalent comparisons across clients experiencing a common problem (e.g., marital conflict). One of the major advantages of standardized RAIs is the availability of information concerning reliability and validity. Reliability refers to the stability of a measure; in other words, do the questions that compose the instrument mean the same thing to the individual answering them at different times, and would different individuals interpret those same questions in a similar manner? Unless an instrument yields consistent data, it is impossible for it to be valid. But even highly reliable instruments are of little value unless their validity can also be demonstrated. Validity speaks to the general question of whether an instrument does in fact measure what it purports to measure. There are several different approaches to establishing validity (Chen, 1997; Cone, 1998; Powers et al., 1985; Schutte & Malouff, 1995), each of which is designed to provide information regarding how much confidence we can have in the instrument as an accurate indicator of the problem under consideration. Levels of reliability and validity vary greatly among available instruments, and it is very helpful to the social work professional to know in advance the extent to which these issues have been addressed. Information concerning reliability and validity, as well as other factors related to the standardization process (e.g., the procedures for istering, scoring, and interpreting the instrument), can help the professional make informed judgments concerning the appropriateness of any given instrument. The key to selecting the best instrument for the intervention is knowing where and how to access the relevant information concerning potentially useful measures. Fortunately, there are a number of excellent sources available to the clinician to help facilitate this process. One such compilation of standardized measures is Measures of Clinical Practice by Corcoran and Fischer (1999a, 1999b) and another is Sourcebook of Adult Assessment Strategies by Schutte and Malouff (1995). These reference texts can serve as valuable resources for identifying useful RAIs suited for the kinds of problems most commonly encountered in clinical social work practice. Corcoran and Fischer have done an excellent job, not only in identifying and evaluating a viable cross-section of useful clinically grounded instruments, but also in discussing a number of issues critical to their use. Schutte and Malouff provide a list of mental health–related measures for adults and guidelines for their use with different types of practice-related problems. In addition to an introduction to the basic principles of measurement, these books discuss various types of measurement tools, including the advantages and disadvantages of RAIs. Corcoran and Fischer also provide some useful guidelines for locating, selecting, evaluating, and istering prospective measures. Further, the instruments are provided in two volumes in relation to their appropriateness for use with one of three target populations: adults, children, or couples and families. They are also cross-indexed by problem area,

Designs and Procedures for Evaluating Crisis Intervention 757 which makes the selection process very easy. The availability of these as well as numerous other similar references related to special interest areas greatly enhances the social work professional’s options with respect to monitoring and evaluation practice (Buros, 1978; Mitchell, 1983a, 1983b). Overall, the RAIs can serve as valuable adjuncts for the social work professional’s evaluation efforts. In crisis intervention, however, more emphasis on their utility is needed. To date, the reviews and acceptance of this type of assessment tool have been mixed. For example, in the area of suicide risk, Jobes, Eyman, and Yufit (1995) found that most professionals familiar with such instruments tended to use them only infrequently. Many of these same professionals believed that, when specifically used to quantify behaviors and feelings in times of crisis, their utility was limited. Until these perceived shortcomings have been resolved, RAIs should probably be employed only as one aspect of a more comprehensively triangulated evaluation strategy. One of the more notable deficits cited in the evaluation literature related to crisis intervention is the paucity of studies that look directly at social work practitioner effectiveness. It should be noted that there are a variety of tools available that can help the social worker to measure his or her own perceived effectiveness (Fischer, 1976). This type of introspective practice assessment is intentionally designed to provide social workers with the kinds of timely they need to enable them to modify and refine their techniques and strategies for future use in similar cases. Several scales and other concrete measurement indices have been designed to assist the social worker to do this (Corcoran & Fischer, 1999a, 1999b). Last, to further enhance the measurement of practice effectiveness, many social workers are feeling pressured to incorporate additional forms of measurement as part of the treatment plan (Dziegielewski, 1997). The pressure to incorporate individual, family, and social rankings is becoming more common. This requires a procedure capable of monitoring a client’s functioning level that can be clearly measured and documented. To provide this additional form of measurement, an increasing number of professionals are turning to the DSM-IV and providing Axis V (Generalized Assessment of Functioning [GAF]) rating scores for each client served. In this method, ratings of a client’s functioning are assigned at the outset of therapy and again on discharge. The scales allow for the assignment of a number that represents a client’s behaviors. The scales are designed to enable the worker to differentially rank identified behaviors from 0 to 100, with higher ratings indicating higher overall functioning and coping levels. By rating the highest level of functioning a client has attained over the past year and then comparing it to his or her current level of functioning, helpful comparisons can be made. This process can help social workers to both quantify client problems and document observable changes that may be attributable to the counseling relationship. This allows the worker to track performance variations across behaviors relative to client functioning. See the DSM-IV (American Psychiat-

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ric Association, 2000) for scale rankings for the above. Also, in the DSMIV-TR “Criteria Sets and Axes Provided for Further Study,” there are two scales that are not required for diagnosis yet can provide a format for ranking function that might be particularly helpful to social work professionals. The first of these optional scales is the relational functioning scale termed the Global Assessment of Relational Functioning (GARF). This index is used to address the status of family or other ongoing relationships on a hypothetical continuum from competent to dysfunctional (American Psychiatric Association, 2000). The second index is the Social and Occupational Functioning Assessment Scale (SOFAS). With this scale the individual’s level of social and occupational functioning can be addressed (American Psychiatric Association, 2000). The complementary nature of these scales in identifying and assessing client problems is evident in the fact that all three scales, GARF, GAF, and SOFAS, use the same rating system. The rankings for each scale range from 0 to 100, with the lower numbers representing more severe problems. The use of all three of these tools has been encouraging for obvious reasons. Collectively, they provide a viable framework within which social workers can apply concrete measures to a wide variety of practice situations. They also provide a multidimensional perspective that permits workers to document variations in levels of functioning across system sizes, including the individual (GAF), family (GARF), and social (SOFAS) perspective. In summary, it is obvious that the helping relationship is a complex one that cannot be measured completely through the use of standardized scales or social worker assessment measures. To facilitate measurement of effectiveness, specific concrete goals and objectives must incorporate a number of direct behavioral observation techniques, self-anchored rating scales, client logs, projective tests, Q-sort techniques, unobtrusive measures, and personality tests as well as a variety of mechanical devices for monitoring physiological functioning. Together, these methods can provide a range of qualitative and quantitative measures for evaluating practice. Several of them are especially well suited for the assessment of practice based on the more phenomenological and existentially grounded theories. Space limitations do not permit a discussion of these methods in this chapter; however, there are a number of excellent sources available that discuss in detail the kinds of information one would need to make informed decisions regarding their selection and application to specific cases (M. Bloom et al., 2003; Powers et al., 1985; Rubin & Babbie, 1993).

CASE-RELATED OR MICRO DESIGNS IN CRISIS INTERVENTION As a specific type of micro-level design, intensive is distinguished from extensive models of research because it is primarily concerned with the study of

Designs and Procedures for Evaluating Crisis Intervention 759 single cases (i.e., N = 1). In this chapter, the single-system (M. Bloom et al., 2003), single-subject, and single-case designs (Bisman & Hardcastle, 1999) are used more or less interchangeably. Preference is noted, however, for the term single-system and single-case designs as they allow for a broader definition of the case under study rather than simply referring directly to one specific client as a subject. We have chosen to highlight the single-system or case designs in crisis intervention, even though it has been argued that they add little to the confirmatory process that leads to scientific generalizations. The reason for this focus is simple: they are of enormous value to the scientifically oriented clinician interested in evaluating the effectiveness of his or her own practice interventions (M. Bloom et al., 2003). These intensive designs provide the means by which clinicians can evaluate the idiosyncratic aspects of their practice, while at the same time allowing for the generation of practicerelevant hypotheses suitable for testing via the more traditional extensive research approaches. Further, it is important to note that the distinction between extensive and intensive models of research relate directly to the long-standing controversy regarding the relative merits of nomothetic versus idiographic research as originally differentiated by Allport (1962). Advocates of the nomothetic approaches emphasize the primacy of the confirmatory aspect of scientific activity, in which the ultimate goal is to discover the laws that apply to individuals in general. These researchers believe that the aggregate is of greater importance than are the individuals who compose it. As a result, nomothetists devote their time to the study of groups in an effort to confirm or disprove hypothetical statements and thus arrive at scientific generalizations concerning some aspect of the empirical world. In contrast, advocates of the idiographic approach tend to be more interested in the study of individuals as individuals. Rather than focusing their attention on the discovery of general propositions, they prefer to investigate the rich and intricate details of specific cases, including the deviant cases that prove to be exceptions to the rule. In crisis intervention, the acknowledgment of both approaches appears relevant and both contribute to the cushion of knowledge that informs our practice. One should not be seen as superior to the other, and with some overlap they can prove to be complementary. The intensive or idiographic models of research are emphasized here simply because they lend themselves more directly to the primary purposes of the clinician, that is, the assessment of the social worker’s own practice on a case-by-case basis. There is no intent to discount the importance of the extensive or nomothetic approaches. In fact, the probability of success in practice is likely to increase to the extent that more social workers can participate in studies that involve controlled observation and systematic verification. In this sense, the two approaches are indeed complementary, one generating scientific generalizations under controlled circumstances and the

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other applying and evaluating their utility in the idiosyncratic crucible of practice. Ideally, in measuring the effectiveness of any time-limited crisis situation, the clinician-researcher needs to be able to identify with confidence a causal relationship between the independent variable (i.e., the intervention) and the dependent variable (i.e., the target behavior). For the social worker it is problematic when extraneous variables (those not directly related to the intervention) occur and cannot be clearly identified and controlled during the therapeutic process. These extraneous variables represent competing hypotheses that could be conceived as possible causes of change in the target behavior. To the extent that this occurs, it raises serious questions with respect to the internal validity of the intervention, thus reducing the level of confidence warranted by any causal inferences that might be drawn. The classic work by Campbell and Stanley (1966) clearly describes a number of possible design weaknesses that pose threats to internal validity. For social workers engaging in empirically based practice, knowledge of these factors is essential for measuring effective and efficient services. It is important to that when a practice design can effectively control the influences and subsequent contamination from outside (extraneous) variables, it is said to be valid. Single-case designs can offer the practitioner a means for measuring practice effectiveness; however, as Barlow and Hersen (1984) and other researchers (Bisman & Hardcastle, 1999; M. Bloom et al., 2003) openly point out, single-case study designs vary widely with respect to their ability to accomplish this goal.

TIME-SERIES DESIGNS The prototype for the intensive/idiographic model of practice research is the time-series design (Fischer, 1976). The process involves the measurement of change in some target behavior (usually the identified problem) at given intervals over a more or less extended period of time (M. Bloom et al., 2003). In this case, the successive observations made during the course of therapeutic intervention enable the clinician to systematically monitor the nature and extent of change in a target behavior. The actual observations and the recording of those observations may be done by the social worker, the client, or any other willing mediator with whom the client interacts on a regular basis, including, for instance, a family member, a friend, or a teacher. Once a target behavior has been identified and an appropriate observational approach selected, it is a relatively simple matter to record any changes that occur during the course of intervention. The amount and direction of changes are usually portrayed in the form of a two-dimensional graph, as illustrated in Figure 32.1.

Designs and Procedures for Evaluating Crisis Intervention 761

Figure 32.1 Changes in target behavior

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Basically, the practitioner identifies the target behavior and plots it in relation to gradations (in frequency, duration, or intensity) arranged along the vertical axis. Successive observations are similarly recorded at regular time intervals, as indicated along the horizontal axis. The points are then ed in a continuous line that reflects the pattern of behavioral change that has occurred over the intervention time period. This type of graph creates a visual presentation of information that facilitates the display of client behavior change. For example, a client reports an inability or lack of desire to handle his or her own affairs after the death of a loved one. When charting client responses, it would be expected that frustration and the actual inability to handle everyday affairs would decrease when given a subsequent intervention. Conversely, if the intent were to increase activities of daily living and eventually eliminate any dysfunctional crisis-related behaviors, we would expect the observed pattern to go in the opposite direction in response to intervention. In all single-subject designs, the preintervention observation phase is referred to as the baseline period and generally labeled A. The intent of the baseline is to determine whether the pattern of behavior observed during the baseline (i.e., Phase A) changes in the expected direction following the introduction of treatment (the treatment is referred to as Phase B). If changes occur during intervention, then the social worker has some basis on which to infer that the treatment may have had something to do with it. In working with clients in crisis, however, collecting baseline data in advance of treatment may not be practical, as the necessity of an immediate intervention may negate the luxury of advance data collection.In most crisis situations, delays in the initiation of treatment are not only likely to be viewed as theoretically questionable, but also may pose serious ethical implications (Kazdin & Wilson, 1978). In crisis, often the best one can expect with respect to the collection of baseline information may be a retrospective reconstruction of relevant data as reported by the client or some other available informant. In some instances, as in the case of a suicidal individual, reliable preintervention data concerning the target behavior (i.e., desire to commit suicide) may not be possible. In such cases, preintervention data of a historical nature may be available from family or friends or from archival records. In other instances, such as those involving work with AIDS patients and their families, the use of available data can prove to be a potentially valuable and reliable resource for the systematic reconstruction of important baseline information concerning the history of prior difficulties. For example, Christ, Moynihan, and Gallo-Silver (1995) describe the assessment process with someone who has recently been diagnosed with HIV infection. They define a specific protocol to assist in gathering an expeditious and comprehensive assessment. The purpose of such a protocol is intended, in part, to document the incidences of current sexual activities and relation-

Designs and Procedures for Evaluating Crisis Intervention 763 ships as well as to use the information gathered to address past, current, or future potential for high-risk behaviors. To the extent that such “hard data” are systematically gathered and recorded in relation to specific high-risk behaviors, it may be possible to selectively exploit such information to create useful baseline measures. With some modifications, this strategy for collecting baseline information can be adopted by virtually any service delivery system that regularly interacts with clients who may subsequently be seen in a crisis situation. It is apparent that the more rigorous the design, the more confidence one can have that threats to internal validity can be effectively ruled out. Unfortunately, the most rigorous designs require the use of baseline measures. Despite the limitations already noted, it is useful to understand some of the more sophisticated derivations of the time-series design. Although they may not always prove to be of practical value in the evaluation of particular crisis situations, they do provide useful models against which to compare the rigor of alternative approaches. Two of the most commonly encountered variants of the basic time-series design are the reversal design and the multiple baseline approach (M. Bloom et al., 2003). In the reversal design, intervention is introduced for a prescribed period of time and then abruptly withdrawn, with the resulting circumstances essentially approximating preintervention or baseline conditions. In the absence of intervention, certain types of client behaviors might be expected to move in the direction of preintervention levels. When this occurs, it is generally considered to a causal relationship, especially when treatment is subsequently reinstated (A1-B1-A2-B2) with concomitant improvements in the client’s functioning. Suppose, for example, a clinician were employing cognitive therapy as a means of reducing anxiety associated with the inability to control violent tendencies. The theory ing the use of this intervention assumes that the inability to control one’s temper is escalated by irrational thoughts, which in turn inhibit self-control and justify violence as a course of action. The clinician employs cognitive techniques and observes an improvement in the client’s self-control during the intervention phase (B1). The techniques are subsequently withdrawn and the client returns to his former state of irrational thinking during the second baseline period (A2), with a concomitant increase in anxiety and potential fear over loss of control. This return to baseline conditions and ultimately to a second intervention phase provides the rationale for naming the process a reversal design. As can be seen by this example, reversal designs can be problematic, especially when the behavior one is exhibiting is dangerous to self or others. In this case, once the client’s locus of control becomes questionable, immediate reinitiation of the treatment phase is warranted. In a second type of design, the multiple baseline approach, like its A-BA-B counterpart, is also used to minimize the possibility of behavior change

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due to chance. Unlike the reversal design, however, there is no withdrawal of intervention. Instead, baseline data are collected either on more than one target behavior, on the same target behavior but in more than one setting, or on more than one but similar clients. Intervention techniques are applied in a sequential manner so that once a change in the initial target behavior is observed, the intervention is systematically introduced with the next target behavior or in an alternative setting (Bisman & Hardcastle, 1999; M. Bloom et al., 2003; Fischer, 1976). The sequential nature of the multiple baseline approach is especially useful in client interventions where more than one problem must be addressed or there is more than one target behavior that is expected to be affected by the intervention. This is true in most crisis situations where the precipitating events typically affect various aspects of the client’s overall social-psychological functioning. It is important to keep in mind, however, that the validity of any multiple baseline approach is based on the assumption that the selected target behaviors are themselves independent of one another. If changes in one behavior were somehow functionally interdependent, use of the multiple baseline approach would be discouraged. Both the A-B-A-B design and the multiple baseline approach begin to approximate the level of confidence achieved in what Campbell and Stanley (1966) refer to as true experiments. However, they are the most difficult to implement and, with respect to the evaluation of crisis intervention, have only limited utility for the practical, ethical, and methodological reasons cited earlier. A final note is in order before we conclude our discussion of the timeseries designs. In most instances, it is possible to determine whether meaningful change has occurred by means of simple visual inspection of the twodimensional graph. Sometimes, however, it is impossible to determine from visual inspection alone whether the shift that occurs between the baseline and the intervention phases is dramatic enough to constitute a significant change. This is due to the fact that time-series data tend to be serially dependent (Gottman & Leiblum, 1974). In cases in which the observed changes may be due to serial dependence, the worker can apply some fairly simple statistical procedures (referred to as autocorrelation) to help resolve the issue (M. Bloom et al., 2003).

ALTERNATIVE MODELS Thus far, we have discussed a number of basic time-series designs as prototype examples of intensive, idiographic, or micro-based models of practice research in crisis situations. In light of the identified limitations, a number of recommendations have emerged recently involving adaptations of the singlesystem model. When viewed collectively, they provide added flexibility with

Designs and Procedures for Evaluating Crisis Intervention 765 respect to the evaluation process. When used alone, they are not as methodologically rigorous as some of the more controlled designs. However, they do represent marked improvements over the methodologically soft or vague assessment techniques that typically characterize most efforts to evaluate social work practice. Most of the research strategies discussed here can be used in conjunction with various components of the more rigorous designs, thus providing a repertoire of techniques that can be used selectively in response to the idiosyncratic demands of a particular case. In addition, it is sometimes possible to employ several of the proposed evaluation strategies simultaneously within or across client systems. When this is done intentionally, it is referred to as triangulation, a process that enables the clinician to use each strategy as a means of cross-validating the findings generated by alternative strategies (Denzin, 1970). In most crisis situations, there is a need for immediate clinical intervention. This inevitably makes the task of gathering relevant baseline data and the application of empirically based measures very difficult. Although direct observations of the client’s preintervention or baseline functioning can be very useful, caution needs to be exercised to avoid the drawing of unwarranted conclusions. As Bisman and Hardcastle (1999) remind us, it is inappropriate to infer that any observed changes, which rely solely on the sample recording of repeated measures, are necessarily attributable to the social worker’s intervention. Although positive (or negative) changes may occur concurrently with intervention, this approach does not permit us to rule out the possibility that other factors may be responsible for the observed change. To address this limitation, a number of useful suggestions appear in the literature, including careful replication as a means of increasing causal validity (Bisman & Hardcastle, 1999) to variations on the basic time-series design, including the use of baseline measures (Barlow & Hersen, 1984). In such models, the series of observations used to monitor change in the target behavior begins prior to the introduction of any formal treatment and relies on an extended baseline with continuous measurements of the target behavior (Bisman & Hardcastle, 1999). It is worth noting, however, that extended baselines should not be relied on to control for many of the threats to causal validity. Only careful replication under controlled conditions can adequately address this limitation.

INTERVENTION AND EVALUATION: INTEGRATING THE TWO The process of integrating our social work interventions with appropriate evaluation strategies requires that the two functions complement one another in a seamless and synergistic manner. For many social workers, this requirement has been both frustrating and confusing. Social work prac-

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titioners are increasingly being expected to operationalize the target behaviors they wish to change in clients as part of the assessment process (Dziegielewski, 1996). Yet the link between their actual practice behaviors and the strategies required to effectively assess them has proven to be elusive. For example, in case planning, empirically based practice dictates that the problem statement, the behaviorally based goals and objectives, and the accompanying intervention plan be clearly identified. To effectively implement such a plan in an informed and sensitive manner, the social worker should be well versed in the following procedures. Initially, it is essential that the worker create a positive and ive relationship with the client. This process is greatly facilitated by the articulation of a set of mutually negotiated, realistic, and specific time-limited goals and objectives. These goals and objectives should be clearly outlined in relation to the client’s identified needs and capacities. Further, the social worker must be well aware of the personal, cultural, and environmental dynamics that surround the crisis situation as well as how these dynamics may impact the problemsolving process. The social worker’s role is one of action and direction, particularly when individuals are in the early phases of the crisis experience. It is essential to realize that for individuals in crisis, the usual methods of coping do not always appear to be working. At times, clients may feel as though they are losing control and, as a result, seek the active direction and involvement of the social worker. Second, the social worker must also be aware of the unique set of characteristics embedded in the crisis situation and how those characteristics can personally affect the social worker. The use of standardized methods, such as RAIs, are essential in helping to quantify subjective aspects of the intervention; however, they should not be viewed as all-inclusive. They are often limited in utility by the very nature of the crisis situation itself. For example, an RAI designed to measure depression may in fact prove quite reliable in measuring the symptoms associated with chronic depression. In crisis situations, however, the development of depressive symptomology might indeed be functional for a grieving widower or widow. The most appropriate approach may be to allow the experience of losing a loved one to progress naturally. In this instance, the dynamics that surround the crisis situation are somewhat atypical. Stated simply, the person who is depressed following a crisis (e.g., the loss of a loved one) may need to be treated very differently from the individual who is experiencing depression based on a specific mental health problem. As a situational factor, a reactive depression might actually prove to be a positive step in the client’s overall adjustment to the crisis situation. Issues such as these, which are somewhat unique to crisis situations, can complicate the use of RAIs. This ambiguity has encouraged social workers to strive for other modes of formalized measurement. This has increased the usage of methods that require the client to rate stress and feelings of discontent on instruments such as self-anchored rating scales. To further

Designs and Procedures for Evaluating Crisis Intervention 767 supplement these efforts, scales such as the GAF, GARF, and SOFAS have also been used to assist in behaviorally based outcome measures. Overall, social workers are well advised to develop a range of measurement techniques that will enable them to operationally define the various dimensions of their practice. Finally, if our goal is one of establishing empirically based practice, the importance of applying practice wisdom that is informed by theory cannot be overestimated. This requires that social workers not only be aware of what is likely to work for a particular client, but also that they possess the theoretical knowledge necessary to justify the selection and application of appropriate interventive techniques. Theory informs practice by providing a plausible framework within which critical intervention and evaluation issues can be simultaneously raised and interpreted. The more we know about the theoretical underpinnings of any given problem-solving-focused counseling strategy, the better informed we will be in our efforts to predict and explain the possible consequences of the entire intervention process. As stated earlier, practice wisdom often dictates how best to proceed in helping a client, given the specific nature of the crisis situation and the surrounding circumstances. It can also help the practitioner decide when to apply or withdraw the various components of the treatment package throughout the course of the intervention process. Counseling and social work professionals are increasingly being called on to balance practice skills with empirical techniques, techniques that in the end will yield more efficient and effective modes of service. For the crisis intervention worker, the use of measurement devices, such as structured questionnaires and psychometric instruments, needs to be supplemented with practice wisdom, theory, and, in the final analysis, life experience (Corcoran & Fischer, 1999a; Rittner, Smyth, & Wodarski, 1995).

SUMMARY The efficacy of crisis intervention as a viable alternative to the more traditional long-term models of therapy has been well documented. The question is no longer whether crisis intervention or short-term therapeutic measures work, but rather, what techniques work best with what kinds of clients and problems and under what set of circumstances (Dziegielewski et al., 1998). Managed care presents a type of service delivery never before experienced. Social workers must show that the time-limited, brief services they provide are necessary and effective. This challenge has been a particularly vigorous one for crisis intervention advocates because of the fluctuating nature inherent in any crisis response. In this arena, however, effectiveness must extend beyond merely helping the client. Ultimately, the process of validating the effectiveness of our practice dictates that we be able to demonstrate that

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the greatest concrete and identifiable therapeutic gain has been achieved, in the quickest amount of time, and with the least expenditure of financial and professional resources. This means that not only should the treatment that social workers provide be therapeutically necessary and effective, but also that it should be delivered in a manner that is professionally competitive with other disciplines that claim similar treatment strategies and techniques. Professional interest in the various forms of time-limited, brief therapy has increased greatly and will most probably continue to increase in the coming years. Social work practice that operates within a framework of a planned, time-limited, brief intervention format appears to be both a viable and essential practice modality, especially in today’s managed care environment. Health maintenance organizations and employee assistance programs generally favor highly structured, brief forms of therapy, and as they continue to grow, so, too, will use of the time-limited models they (Dziegielewski, 2004). Further, insight-oriented intervention strategies and cure-focused therapeutic approaches seem to have given way to more pragmatically grounded practice strategies. Social workers, like their physician counterparts, rarely “cure” client problems; nor should they be expected to do so. What should be expected, however, is that we help clients utilize their own potential to help diminish or alleviate symptoms and states of being that cause discomfort. The prevailing emphasis on client individuality and time-limited, concrete changes is not only accepted as a reasonable professional expectation, but these elements are now generally recognized as essential to state-of-the-art practice (Dziegielewski, 2002, 2004). Throughout this chapter, it has been argued that the best way to evaluate the relative effectiveness of our crisis intervention strategies is through the creative use of various intensive research designs. In recent years, a range of quantitative and qualitative research methods has evolved (Dziegielewski & Roberts, 2004). These idiographically grounded methods are of particular value to the social work and counseling professional because they are specially designed for use in clinical practice situations where the primary unit of attention is a single-client system (i.e., an individual, a family, a couple, or a group). For the most part, they are relatively simple, straightforward evaluation strategies that can be unobtrusively incorporated into the helping professional’s daily practice routines. When used appropriately, they not only provide useful evaluative , but also enhance the overall quality of the intervention itself. The micro or intensive designs of research make no pretense with respect to their contribution to scientific generalizations (Baumgartner, Strong, & Hensley, 2002). They do, however, enable the crisis clinician to test the utility of scientific generalizations in the crucible of practice. The time-limited nature of most crises is such that both the intervention and the evaluation must be initiated quickly. In many instances, it is necessary to proceed under

Designs and Procedures for Evaluating Crisis Intervention 769 less than optimal circumstances. The clinician is inescapably faced with the issue of somehow balancing the requirements of evaluation with those of practice, and of course, in any apparent conflict between the two, the interests of the latter must always be accorded primary consideration. It is not surprising, therefore, that methodological purists may at times be critical of our evaluation efforts. But the methodological rigor of any research endeavor is inevitably a relative rather than an absolute condition. Each evaluation effort represents an imperfect attempt to arrive at a closer approximation of the truth. As such, research provides no guarantee of certitude. It simply helps us reduce the probability of error in the face of uncertainty. If we can tolerate its limitations and exploit its possibilities, we can almost certainly improve the quality of the services we provide our clients. One final observation before we conclude our discussion. The delivery of any human service, regardless of its form, never takes place in an ethical and political vacuum. Professional actions should always be guided by an unequivocal set of professional values. All professional codes of ethics speak to the paramount importance of client rights, including self-determination and confidentiality—rights that are believed to play a critical role in the helping process. However, practice also takes place in an istrative context that is driven, in part at least, by ability issues that are of central concern to the profession, to the agencies that deliver services, and to the vendors that reimburse them (Dziegielewski, 2004). These opposing forces may, at times, cause tension between ideological and istrative considerations, particularly as the worker struggles to satisfy the conflicting expectations of multiple constituencies. Issues of this type are never easily resolved. They require an uncanny ability to understand and balance multiple personal and organizational demands in ways that ultimately serve the best interests of our clients. Assuming that we are not immobilized by the magnitude of such moral and political dilemmas, we can take some solace in the words of the late John Cardinal Newman (1902): “Nothing would ever be accomplished if a person waited so long as to do it so well that no other person could find fault with it.”

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Glossary

A-B-C model of crisis management: A three-stage sequential model for intervening with persons in crisis. The “A” refers to “achieving ,” the “B” to “boiling down the problem,” and the “C” to “coping.” (See chapter 19.) Acquaintance rape: Nonconsensual sex between adults who know each other. (See chapter 18.) Adolescence: Transitional period between childhood and adulthood, typically commencing with the onset of puberty, during which youth develop the physical, social, emotional, and intellectual skills necessary for adult functioning. (See chapter 16.) Adolescent school subgroups: Naturally formed groups within school populations, commonly identified by ethnicity, activity, or year in school. Individuals may be associated with multiple groups. Examples include “jocks,” “brains,” “druggies,” “homeboys,” or “seniors.” (See chapter 22.) Adult abuse protocol: A detailed assessment and intervention guide for the abused adult, based on assessments made by multidisciplinary staff, such as a triage nurse, a physician, and a social worker. Using this protocol accomplishes two purposes: (1) It alerts the involved hospital staff to provide the appropriate clinical care, and (2) it documents the violent incident, so that if the victim decides to file a legal complaint, reliable, court-issible evidence (including photographs) is available. (See chapter 23.) 775

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GLOSSARY

Affective disorders: Affective disorders affect moods and are commonly called mood disorders. They comprise a wide spectrum of emotions, from elation to depression to mania, with depression dominating the clinical picture. Affective disorders also manifest themselves in physical symptoms, self-destructive behavior, loss of social functioning, and impaired reality testing. The frequency, intensity, and duration of the moods distinguish affective disorders from common, everyday moods. (See chapters 25 and 26.) Aggression: Acting with intent to dominate or behave destructively; physical or verbal force directed toward the environment, another person, or oneself. (See chapter 10.) AIDS service organization (ASO): A not-for-profit or for-profit community organization that may or may not provide health services. ASOs are generally funded through federal, state, and/or local dollars to provide psychosocial services to people with HIV and/or AIDS. (See chapter 29.) Anticholinergic: An agent that blocks parasympathetic nerve impulses. Associated with medications utilized to minimize the discomfort associated with opioid withdrawal. (See chapter 24.) Anticomplementary counselor responses: Counselor responses such as interpretations, reframes, and probes that are designed to “loosen” client’s maladaptive cognitions or challenge dysfunctional behavioral choices. (See chapter 7.) Antiretroviral therapy or antiviral therapy: Medication that slows, stops, or alters the production of viral particles. There are currently three classes of antiretroviral drugs: nonnucleoside reverse transcriptase inhibitors (NNRTI), nucleoside reverse transcriptase inhibitors (NRTI), and protease inhibitors. (See chapter 14.) Baseline period: The period during a pre-intervention phase when a series of observations are made to monitor subsequent changes in the client’s target behavior. It provides a basis on which to determine whether the behavior observed during baseline (i.e., phase A) changes in the expected direction following the introduction of treatment (i.e., phase B). (See chapters 20 and 21.) Battered women’s hotlines and shelters: The primary focus of these services is to ensure women’s safety through crisis telephone counseling or provision of short-term housing at a safe residential shelter. Many shelters provide not only safe lodging but also peer counseling, groups, information on women’s legal rights, and referral to social service agencies. In some communities, emergency services for battered women have expanded further to include parenting education workshops, assistance in finding transitional and permanent housing, employment counseling and job placement, and group counseling for batterers. These crisis intervention and housing

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placements for battered women and their children exist in every state and in many large metropolitan areas in the United States. (See chapters 1 and 8.) Bereavement: See “Normal bereavement” and “Uncomplicated bereavement.” Binge: A prolonged episode of continuous alcohol or drug use extending over a period greater than 24 hours. (See chapter 24.) Bioterrorism: The use of biological weapons by terrorists that produce pathogens, organic biocides, and/or disease-producing microorganisms that inflict death, disease outbreaks, and injuries. (See chapter 11). Brief therapy: A type of intervention based on the premise that a system in crisis is more open to change, and that certain and often brief intervention into the unstable system can result in lasting changes in how the system functions. (See chapters 1, 3, and 24.) Buprinex: A medication used in opioid detoxification that binds with opiate receptors in the central nervous system, altering both perception of and emotional response to pain through an unknown mechanism. (See chapter 24.) Catastrophic events: Acute, localized violent occurrences producing widespread trauma in those experiencing or exposed to the event. These incidents commonly directly victimize groups of people and frequently include multiple fatal assaults. (See chapters 5, 6–11, 14, 16, and 22.) Code: Word used to alert the medical team to start resuscitation efforts (R) to revive a victim of cardiac and pulmonary arrest. Combined with different words to designate different types of emergencies at hospitals and broadcast over the PA system. Examples: CODE Blue for victim of cardiac arrest; CODE Red for fire. (See chapter 23.) Cognitive elaboration: The generation of alternative conceptualizations of a given event, phenomenon, or stimulus condition. This process is completed in recognition that multiple meanings exist for all human experience. (See chapter 28.) Completed suicide: See Suicide. Suicide and completed suicide are interchangeable . (See chapter 2.) Constructive: A term associated with “constructivism” or “constructive metatheory” in psychology, a tradition emphasizing the active participation of each person in his or her own life organization and development. (See chapter 28.)

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Coping questions: Coping questions ask clients to talk about how they manage to survive and endure their problems. Coping questions help clients to notice their resources and strengths despite adversities. (See chapters 1–4.) Counterterrorism: This is a diplomatic, strategic, law enforcement intelligence offensive operation that uses specially trained personnel and resources to discover, disrupt, or destroy terrorist capabilities, plans, and networks. (See chapters 7 and 11.) Cravings: A term defined in various ways related to drug use. Typically it refers to an intense desire to obtain and use a drug. (See chapter 24.) Crisis: An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping methods. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable state, a precipitating factor, an active crisis state, and the resolution of the crisis. (See chapters 1–4.) Crisis call to domestic violence hotline: A telephone call to a hotline in which the caller is in imminent danger or has just been abused or battered by an intimate partner. (See chapters 1 and 19.) Crisis intervention: The first stage of crisis intervention, also known as emotional “first aid,” focuses on establishing rapport, making a rapid assessment, and stabilizing and reducing the person’s symptoms of distress and the impact of a crisis. The next stages utilize crisis intervention strategies (e.g., active listening, ventilation, reflection of feeling, storytelling, reframing, and exploring alternative solutions) while assisting the individual in crisis to return to a state of adaptive functioning, crisis resolution, and cognitive mastery. This type of timely intervention focuses on helping to mobilize the resources of those differentially affected. Crisis intervention may be given over the telephone or in person. (See chapters 1 and 2.) For in-depth case applications of Roberts’s seven-stage crisis intervention model to a range of urgent and acute crisis episodes. (See chapters 1–5 and 16–30.) Crisis intervention service: These services provide a person in crisis with the phone numbers of local hotlines, community crisis centers, crisis intervention units at the local community mental health center, rape crisis centers, battered women’s shelters, and family crisis intervention programs, which then provide follow-up and homebased crisis services. Crisis intervention services are available 24 hours a day, seven days a week, and are usually staffed by crisis clinicians, counselors, social workers,

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hospital emergency room staff, and trained volunteers. (See chapters 1, 2, and 23– 30.) Crisis-oriented treatments: Treatment approaches that apply to all practice models and techniques, which are focused on resolving immediate crisis situations and emotionally volatile conflicts with a minimum number of s (usually one to six), and are characterized as time-limited and goal-directed. (See chapter 1.) Crisis residential unit: A 24-hour supervised setting for individuals experiencing any type of crisis who are 18 years of age or older, medically stable and no overt threat to themselves or others. This brief stay (up to 5 days) focuses on problem solving and crisis management through individual ive counseling, group treatment, psychiatric and nursing services, as well as appropriate referrals. (See chapter 20.) Crisis resolution: The goal of interventions given by trained volunteers and professionals to persons in crisis. Resolution involves the restoration of equilibrium, cognitive mastery of the situation, and the development of new coping methods. An effective crisis resolution removes vulnerabilities from the individual’s past and bolsters the individual with an increased repertoire of coping skills that serve as a buffer against similar situations in the future. (See chapters 1 through 5.) Critical incident: An event that has the potential to overwhelm one’s usual coping mechanisms, resulting in psychological distress and an impairment of normal adaptive functioning. (See chapters 6, 8, and 9.) Critical Incident Stress Debriefing: A seven-stage structured group meeting or discussion in which personnel who have been affected by a traumatic event given a chance to discuss their thoughts and emotions in a controlled manner usually, 1 to 10 days after an acute crisis and 3 to 4 weeks after a mass disaster. (See chapter 9.) Critical Incident Stress Management (CISM): An integrated and comprehensive multicomponent program for providing crisis and disaster mental health services. A variety of stress management techniques/intervention provided to emergency services personnel, police, and/or firefighters who are exposed to life-threatening or traumatic incidents. This model was developed by Jeffrey Mitchell and George Everly (authors of chapter 9 and cofounders of the International Critical Incident Stress Foundation). (See chapters 8 and 9.) Date rape: Nonconsensual sex between partners who date or are on a date. (See chapter 18.) Date rape drugs: Sedative-type drugs, some of which are illegal substances, that render victims unable to defend themselves against sexual exploitation; alcohol, Rohypenol, and Ectasy are three of the most common date rape drugs. (See chapter 18.)

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Debriefing at school: A meeting held soon after a crisis event to review the activities of a school crisis intervention team during a recent crisis response with the primary goal of ing team and ultimately improving the future functioning of the team as a whole and the quality of the interventions offered. (See chapter 21.) Decompensation: Person having a chronic mental condition may periodically experience worsening symptoms such as depression or psychosis. This general decline in condition is called decompensation. (See chapters 15, 25, and 28.) Defusing: An approximately 1-hour, three-phase, structured small-group discussion provided within hours of a crisis for purposes of assessment, triaging, and acute symptom mitigation. (See chapters 8 and 9.) Deinstitutionalization: The Community Mental Health Centers Act of 1963 required that mental health services be moved from inpatient institutions to community-based services. This transition is referred to as deinstitutionalization, and one of the services mandated by the act is crisis services. (See chapters 25 and 26.) Delayed: Group that can be transferred to a “walk-in” location. These include conditions that do not require emergency room care at all and can be seen at any time, like most rashes or a previous wound that needs checking. (See chapter 23.) Dependent variables: Variables that represent the presumed effect in any functional relationship. (See chapter 32.) Disequilibrium: An emotional state that may be characterized by confusing emotions, somatic complaints, and erratic behavior. The severe emotional discomfort experienced by the person in crisis propels him or her toward action that will reduce the subjective discomfort. Crisis intervention usually alleviates the early symptoms of disequilibrium within the first 6 weeks of treatment, and hopefully soon restores equilibrium. (See chapters 1, 2, and 5.) Dismantling treatment strategy: A strategy involving the orderly removal of one or more components of the treatment package, accompanied by careful recording of the apparent effects. This systematic elimination, or isolation, enables the clinician to “determine the necessary and sufficient components for therapeutic change.” (See chapter 35.) District-level crisis intervention team: A school crisis intervention team composed of staff from the school district’s central office to provide oversight, resources, and istrative to school-based crisis intervention teams. (See chapter 21.) Ego fragmentation: Ego fragmentations, sometimes referred to as dissociative disorders, are characterized by disturbances in normally integrated functions of memory,

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identity, or consciousness. They are found in diagnoses such as posttraumatic stress disorder, acute stress disorder, and somatization disorder. Harsh psychosocial stressors such as physical threat, wartime, and disasters predispose susceptible persons to ego fragmentations. (See chapters 5 and 8.) Emergency room: A department in a hospital open 24 hours a day to victims of emergent and urgent situations. Treatment is provided by a medical team of doctors, nurses, respiratory therapists, lab technicians, and social workers. (See chapter 23.) Emergent: Group that requires immediate attention and includes cardiac arrest and trauma codes. (See chapter 23.) Exception questions: Questions that inquire about times when the problem is either absent, less intense, or dealt with in a manner that is acceptable to the client. (See chapter 3.) Excitatory toxicity: Massive release of neurotransmitters that in high enough concentrations may damage or destroy the neural substrates they serve. (See chapter 5.) Extensive designs of research: Designs that emphasize the primacy of the confirmatory aspect of scientific activity. The goal of these designs is to discover laws that apply to aggregates of individuals rather than to the individuals who constitute the aggregate. In this approach, the ultimate goal is to discover scientific generalization under controlled circumstances. (See chapter 32.) Goal Attainment Scaling (GAS): This evaluation method measures intervention outcomes in which a number of individually tailored treatment goals are specified in relation to a set of graded scale points ranging from the least favorable to the most favorable outcomes considered likely. It is suggested that at least five points comprising a Likert-type scale is assigned with the “least favorable outcome” scored −2, the “most favorable outcome” scored +2, and the “most likely outcome” assigned a value of zero. (See chapter 32.) HIV trajectory: The stages of HIV infection and the symptoms that accompany those stages. (See chapter 29.) HIV viral load: The amount of viral particles per milliliter of blood (scientifically “quantitative plasma HIV RNA”). The viral load is an indication of prognosis, with a high load indicating that the virus is progressing rapidly. (See chapter 29.) Idiographic research: This approach focuses on the study of individuals as individuals, rather than on the discovery of general propositions. Idiographic research investigates the rich and intricate detail of specific cases, including deviant cases that prove to be exceptions to the general rule. (See chapter 32.)

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Imposter phenomenon: An internal experience of intellectual phoniness that persists despite independent, objective, and tangible evidence to the contrary. (See chapter 18.) Independent variables: Variables that represent the presumed cause of any functional relationship. (See chapter 32.) Information and referral (I and R) services: The goals of I and R services are to facilitate access to community human services and to overcome the many barriers that may obstruct a person’s entry to needed community resources. (See chapter 1.) Intensive designs of research: Designs primarily concerned with the study of single cases. They provide the means by which clinicians can evaluate the idiosyncratic aspects of their practice. Intensive research models can serve to generate relevant hypotheses suitable for testing by the more traditional extensive research approaches. (See chapter 32.) Internal validity: The level of confidence warranted by any causal inference. The designs that effectively control contamination from outside variables are said to be internally valid. (See chapter 32.) Intervention period: The period of time, typically referred to as the B phase, in any time-series design during which treatment is purposefully istered. (See chapter 32.) Intervention priority code: Method of prioritizing crisis requests on a clinical basis. Priorities range from I to IV, depending on clinical symptoms and presenting problems of the individual. These priorities dictate in which order cases should be responded to and in what time frame. (See chapters 6 and 26.) IOP Intensive outpatient program: Outpatient substance dependence treatment, usually offered three evenings per week, 3 hours each evening. (See chapter 12.) Lethality: Measuring the degree to which a person is capable of causing death. Assessing for lethality entails asking about suicidal ideation, prior suicide attempts, homicidal thoughts, and feasibility of carrying out suicidal ideation or homicide. (See chapters 1, 2, 6, and 17.) LSD (Lysergic acid diethylamide): A class of drugs referred to as the serotonergic hallucinogens. (See chapter 24.) Maladaptive reaction: A codependent’s tendency to continue investing time and energy to control a substance ab’s actions and behaviors despite repetitive adverse consequences. (See chapter 24.)

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Managed care: A health care services delivery model that attempts to control the cost of services in two ways: first, by restricting services to approved providers who accept reduced payment levels; second, by restricting access to higher-cost services such as specialists or inpatient services by requiring referrals from primary care physicians and precertifications for certain services. (See chapters 5, 23, and 27.) Maslow’s hierarchy of needs: A continuum of needs continually experienced by humans, as identified by Abraham Maslow. These hierarchically ordered needs include (from lowest to highest level): physiological needs, safety needs, belongingness and love needs, esteem needs, aesthetic and cognitive needs, and self-actualization needs. Lower-level needs must be satisfied before the next level of need can be addressed. Memorialization: Activities of grieving individuals and groups to and honor those who have died. (See chapter 16.) Methamphetamine (methedrine, desoxyn): Synthetic stimulant drug. Acts to stimulate or mimic activity in the sympathetic branch of the autonomic nervous system (See chapter 24.) Miracle question: Miracle questions help clients to construct a vision of life without the presenting complaint. A widely used format is: “Suppose that after our meeting today you go home and go to bed. While you are sleeping a miracle happens and your problem is suddenly solved, like magic. The problem is gone. How will you know a miracle happened? What will be the first sign that tells you that a miracle has happened and the problem is resolved?” (See chapter 3.) Mobile crisis services: Crisis counseling, assessment, and intervention provided at the scene of the crisis (someone’s home, other agencies, community, prison, etc.). (See chapters 25 and 26.) Mobile crisis unit: A self-contained team of mental health and law enforcement professionals trained to respond to a crisis anywhere in the community, including residences, public places, and schools. (See chapters 25 and 26.) Multiple baseline approach: A crisis intervention approach designed to minimize the possibility of behavior change due to chance. Baseline data are collected either (1) on more than one target behavior, (2) on the same target behavior but in more than one setting, or (3) on more than one but similar clients. Intervention techniques are then applied sequentially so that once a change in the initial target behavior is observed, the intervention is systematically introduced with the next target behavior or in an alternate setting. (See chapter 32.) Net nanny: A brand-name computer software system for blocking access to certain Internet Web sites.

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Nonurgent: Problems that need to be treated sometime today and not necessarily in the emergency room (e.g., sore throat or simple laceration). (See chapter 27.) Nonviolent crisis intervention: Variety of prevention and intervention techniques proven effective in resolving potentially violent crises. This model is taught by the I Crisis Prevention Institute, Inc. (See chapter 22.) Normal bereavement: The reactions to loss of a significant person, which may not be immediate, but which rarely occurs after the first 2 to 3 months after the loss. Normal bereavement involves feelings of depression that the person regards as “normal,” although professional help may be sought for associated symptoms, such as insomnia or weight loss. Bereavement varies considerably among people of different ages and cultural groups. (See chapters 1 and 12.) Objectified case studies: Studies that attempt to relate the process of intervention (what the worker does) to the outcome of that intervention (whether what the worker does can be concluded to be effective). (See chapter 32.) Outcome evaluation: A process aimed at establishing whether a program or intervention is achieving its objectives and whether the results are due to the interventions provided. (See chapter 32.) Parametric treatment strategies: Strategies that attempt to determine in what quantity and/or in what sequence the components of a treatment package are likely to have their most beneficial impact. By systematically manipulating one or more of the components of a treatment package, it is possible to monitor the differential effects. (See chapter 32.) Perturbation: A state of system disequilibrium characterized by disorganization and distress, resulting in adaptation and emerging complexity and differentiation. (See chapter 31.) Postmodernism: Refers to philosophical reflection in which a conception of reality independent of the observer is replaced with notions of language actually constituting the structures of a perspectival social reality. (See chapter 3.) Posttraumatic stress disorder (PTSD): A diagnosis given to people who experience symptoms of intrusion, avoidance, or hyperarousal after experiencing or observing serious injury, threat, or death of a close associate (after experiencing any event that is extremely traumatic and terrifying, and that provokes feelings of helplessness). PTSD occurs when a person perceives an event as life-threatening and/or when the experience challenges his or her notions of fairness and justice. (See chapters 4 and 6.)

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Postvention: Activities that take place in the aftermath of a crisis event to review the crisis response to date, with the primary goal of identifying ongoing needs of students and staff, as well as steps that can be taken to prevent the occurrence of comparable events (e.g., in suicide postvention, case finding for additional students at risk of suicide). (See chapter 21.) Prevention: Efforts designed to avert inappropriate and antisocial behaviors prior to their occurrence. (See chapter 21.) Primary adolescent suicide prevention: Programs offered in schools, churches, and recreational and social organizations, designed to serve as a deterrent to a suicidal crisis. These programs focus on education, peer counseling, and other prevention methods. Teaching about the prevention and identification of possible suicide attemptors may be part of these programs. (See chapters 17 and 18.) Protocol: The step-by-step or sequential plan of a treatment. (See chapters 8 and 17.) Psychosocial crises: Crises that are characterized primarily by psychosocial problems such as homelessness, extreme social isolation, and unmet primary care needs, and that may contribute to physical and psychological trauma and illness. (See chapter 1.) Rape crisis programs: Programs that include specialized protocols for rape victims and that have been established by medical centers, community mental health centers, women’s counseling centers, crisis clinics, and victim assistance centers. The protocol in these crisis intervention services generally begins with an initial visit from a social worker, victim advocate, or nurse while the victim is being examined in the hospital emergency room. Follow-up is often handled through telephone and in-person counseling sessions for 1 to 10 weeks following the rape. (See chapters 1 and 5.) Rape-ive attitudes: Stereotypic beliefs or societal “myths” about rape that result in the following: women being portrayed as sexual objects, discounting the impact of rape as a traumatically violent act, and absolving the perpetrator of full responsibility for committing rape. (See chapter 18.) Rape victim: A person who reports having experienced a sexual assault that meets the legal criteria for rape. Forcible rape is unwanted and coerced sexual penetration of another person. (See chapters 18 and 20.) Rapid assessment instruments (RAIs): Evaluation instruments that refer to any one of numerous assessment devices that are relatively easy to ister, score, and interpret and can be used to measure one or more dimensions of a client’s target behavior. RAIs require very little knowledge of testing procedures on the part of the practitioner. The score that is generated provides an operational index of the fre-

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GLOSSARY

quency, duration, or intensity of the problem or target behavior. (See chapters, 1, 6, 8, 31, and 32.) Regional resource team: A group of professionals representing a range of allied disciplines (e.g., educational, emergency response, law enforcement, medical, mental health) that meet on an ongoing basis and provide consultation and technical assistance to district-level crisis intervention teams in the development and implementation of school crisis intervention responses. (See chapter 21.) Relapse prevention: A set of procedures designed to maintain therapeutic change and to facilitate accommodation of trauma with limited long-term negative effects. (See chapter 24.) Relationship questions: Relationship questions ask clients how their significant others are reacting to their problem situation and progress in solution-finding. The establishment of multiple indicators of change helps clients develop a clear vision of a desired future appropriate to their real-life context. (See chapter 3.) Reliability: An evaluation term that refers to the stability of a measure. One aspect of reliability is whether the questions that comprise an instrument mean the same thing to one or more individuals answering them at different times. (See chapter 32.) Reversal designs: Designs that involve a process in which an intervention is introduced for a time and then abruptly withdrawn, with the resulting circumstances essentially approximating pre-intervention or baseline conditions. In the absence of intervention, certain types of client behaviors might be expected to move in the direction of the pre-intervention levels. (See chapter 32.) Revictimization: Victims may experience this process when counselors, police officers, or prosecutors place themselves in the role of judging whether a reported rape or incest experience was “real,” or whether they think the client “provoked” the attack. (See chapters 1, 3, 4, and 20.) Safety contract: Written agreement between the crisis worker and client that acknowledges that the client has agreed not to harm himself or herself or anyone else; and are unable to resist that urge, the client will call for help first. (See chapter 19.) Scaling questions: Question that ask clients to rank their situation and/or goal on a scale of 1 to 10. Scaling questions provide a simple tool for clients to quantify and evaluate their situation and progress so that they establish clear indicators of progress for themselves. (See chapter 3.) School-based crisis intervention team: A team composed of school staff from one school to provide direct services to student and staff within that particular school. (See chapters 21 and 22.)

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School crisis intervention team: A group of individuals formed, outside the context of a particular crisis event, with the purpose of developing plans and protocols to meet the needs of students and school staff in the event of a crisis affecting the school community. (See chapters 21 and 22.) School violence: Aggression against property, or persons within a school context. Against persons, the term denotes an intentional verbal or physical act that produces pain, either physical or emotional, in the recipient of that act while the recipient is under the supervision of the school. Similarly, this operational definition is concerned primarily with violence that occurs within the school environment and not with general violent incidents involving adolescents. (See chapters 21 and 22.) Secondary adolescent suicide prevention: Process involving the identification of the at-risk adolescent and his or her family. The at-risk adolescent is often difficult to approach and may have withdrawn from friends, school, and family. (See chapter 17.) Secondary trauma responses: (Also known as secondary victimization or comion fatigue.) Psychological aftereffects of traumatic victimization experienced by those who assist victims of violence. This vicarious traumatization commonly occurs in mental health workers who assist or treat victims of traumatic events. These responses can occur as reactions to short-term interactions with specific clients or as alterations of long-held beliefs that are challenged by interactions with multiple clients over time. (See chapters 4, 6, and 8.) Self-efficacy: The conviction that one can successfully execute the behavior required to produce desired outcomes. (See chapter 32.) Single-system design: Crisis intervention approaches that focus on the study of individuals as individuals. These designs investigate the rich and intricate details of specific cases, including the deviant cases that prove to be exceptions to the general rule. (See chapter 32.) Solution-focused approach: A solution-focused therapy is a time-limited treatment model aiming to assist people to find solutions to their concerns in as few sessions as needed. Rather than focusing on the history of the problems, such an approach emphasizes an individual’s strengths and resources. (See chapter 3.) Somatization: This term is synonymous with somatic distress. Somatization involves experiencing physical symptoms that suggest a medical condition but to which physiological causes are undetermined. It is usually assumed that psychological factors are connected to the multiple, recurring medical complaints. Somatization manifests itself in tension headaches, gastrointestinal problems, back pain, tremors, choking sensations, and sexual complaints. (See chapters 4 and 5.)

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GLOSSARY

Steady state: A total condition of the system in which it is in balance both internally and with its environment, but which is in change; a moving balance or dynamic homeostasis. (See chapter 11.) Strengths perspective: A practice perspective that looks at individuals, families, and communities in light of their capacities, strengths, talents, competencies, possibilities, and resources. (See chapter 3.) Stress inoculation training (SIT): A useful treatment package for clients who have resolved many assault-related problems but continue to exhibit severe fear responses. A cognitively and behaviorally based anxiety management approach, SIT is designed to assist the client in actively coping with target-specific, assault-related anxiety. (See chapters 1, 7, and 20.) Student developmental tasks: Predictable challenges facing late adolescent college students that require some measure of successful resolution or adaptation. Typical age-related tasks include coordinating apparent contradictory aspects of self, managing emotions, achieving greater cognitive complexity, and forming mutually satisfying relationships characterized by autonomous interdependence. (See chapter 21.) Suicidal behavior: Potentially self-injurious behavior for which there is evidence that the person intended at some level to kill herself or himself or wished to use the appearance of such an intention to obtain some other end. (See chapter 2.) Suicidal ideation: Any self-reported thoughts of engaging in suicidal behavior. (See chapter 2.) Suicidal intent: One’s motive for engaging in suicidal behavior. (See chapters 4 and 5.) Suicide: Death where there is evidence that the injury was self-inflicted and that the person intended to kill herself or himself. (See chapter 2 and 16.) Suicide attempt: A potentially self-injurious behavior with a nonfatal outcome, for which there is evidence that the person intended at some level to kill herself or himself. (See chapter 2.) Suicide prevention and crisis centers: Centers that provide immediate assessment and crisis intervention to suicidal and depressed callers. The first prototype for these centers was established in London in 1906 when the Salvation Army opened an antisuicide bureau aimed at helping suicide attemptors. The first federally funded suicide prevention center was established in 1958 in Los Angeles. The Los Angeles Suicide Prevention Center, codirected by Edwin Schneidman and Norman Farberow, provided comprehensive training to medical interns, psychiatric residents, and graduate students in psychology, social work and counseling. (See chapters 1 and 6.)

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Suicidologists: Researchers who study suicidal behavior and suicide-related phenomena. The founder of the term suicidology was Edwin Schneidman. (See chapters 1, 2, and 5.) Surveillance data: Reports produced by the Centers for Disease Control (CDC) or state departments of health on the number of HIV and/or AIDS cases and the routes of transmission, age, race, and gender of those cases. (See chapter 28.) SWAT team: Special weapons and tactics teams are units based within police departments that receive focused training to deal with hostage situations. SWAT usually use state-of-the art equipment and communications technology, and team are trained in hostage negotiation skills. (See chapters 19 and 20.) Telephone crisis services: Crisis counseling, crisis stabilization, screening, information, and referrals provided to any individual calling in crisis or any significant other calling for someone else. (See chapters 1 and 25.) Time-series designs: Research designs that involve the measurement of change in some target behavior (usually the identified problem) at given intervals over a more or less extended period of time. Successive observations made during the course of therapeutic intervention enable the practitioner to systematically monitor the nature and extent of change in a target behavior. Typically, the phases of the time-series are referred to as baseline (A) and intervention (B). (See chapter 32.) Transdermal infusion system: A method of delivering medicine by placing it in a special gel-like matrix “patch” that is applied to the skin. The medicine is absorbed through the skin at a fixed rate. (See chapter 29.) Transinstitutionalization: Movement of clients back and forth between systems. For example, it is common for people to move between the mental health and criminal justice systems. (See chapter 26.) Treatment package strategy: A treatment evaluation strategy in which the impact of intervention is assessed as a total entity. In order to rule out potential threats to internal validity, such as changes attributable to motivation, spontaneous remission, intervening historical events, and the like, some sort of control or comparison condition must be incorporated into the research design. (See chapter 32.) Triangulation: A process involving the use of several evaluation strategies simultaneously within or across client systems. When done intentionally, triangulation enables the clinician to use each strategy as a means of cross-validating the findings generated by alternative strategies. (See chapter 28.) Trigger: A term used to describe environmental cues that lead the substance-dependent person to crave his or her drug of choice. (See chapter 24.)

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GLOSSARY

24-hour hotlines: Telephone services, often staffed by volunteers, that provide information, crisis assessments, crisis counseling, and referrals for callers with various problems, such as depression, suicide ideation, alcoholism, chemical dependency, impotence, domestic violence, and crime victimization. Because of their 24-hour availability, they can provide immediate, though temporary, intervention. (See chapters 1 and 2.) Two-factor model of acute crisis: A unifying model of acute crisis consisting of neurological hypersensitivity and psychological hypersensitivity. (See chapter 9.) Uncomplicated bereavement: Grief that continues to be characterized by guilt that is associated with things done or not done by the survivor at the time of death. (See chapter 12.) Urgent: Urgent conditions are those requiring immediate attention within a few hours; there is possible danger to the patient if medically unattended and the disorder is acute. Problem should be treated as soon as possible—generally within 1 to 2 hours. (See chapters 2, 5, and 6.) Validity: An evaluation term that refers to the question of whether an instrument measures what it purports to measure. (See chapter 32.) Vertical transmission: The transmission of HIV from mother to fetus. (See chapter 29.) Viability: The evaluation of a construct on the basis of its consequences to the individual and society, as well as its coherence with prevailing personal and social beliefs. (See chapter 13.) Victim: An innocent person, such as someone who suffers as a result of a violent crime or a disaster, and who encounters physical injury, trauma, fear, acute anxiety, and/or loss of belongings. (See chapter 7.) Violence risk factors: Biological, social, and familial characteristics or phenomena that have been shown to contribute to participation in adolescent aggression and delinquency. Although numerous risk factors have been identified, associating with negative peer groups; overly lax, inconsistent, or harsh parenting styles; and involvement with illegal substance use are among the most powerful factors associated with aggressive and violent behavior by adolescents. It is believed that increasing numbers of risk factors are associated with an increased likelihood of association with aggressive acts. (See chapters 6 and 16.) Viral mutation: A change in the genetic structure of the viral particle. Mutation is a naturally occurring process in all living organisms and is dangerous in HIV when the

GLOSSARY

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new or mutated viruses are the only ones to survive and thrive, rendering the antiretroviral therapy ineffective. (See chapter 29.) Walk-in crisis services: Crisis counseling, assessment, and intervention provided at the Crisis Services office. (See chapters 25 and 26.) Weapons of Mass Destruction (WMD): This term refers to the most destructive weapons, including nuclear and radioactive, chemical, or biological weapons used by terrorist or paramilitary groups with the purpose of inflicting fear, evacuation and clean-up, economic disruption, and huge numbers of casualties. (See chapters 7 and 11 and the Introduction to this book.) Weltanschauung: An individual’s worldview regarding safety, security, or sense of self. (See chapter 5.) Withdrawal: A definable illness that occurs with a cessation or decrease in use of alcohol or a drug. (See chapter 24.)


Directory of Suicide Prevention and Crisis Intervention Internet Resources and 24-Hour Hotlines PREPARED BY DAVID AURISANO JONATHON SINGER ALBERT R. ROBERTS

SUICIDE PREVENTION WEBSITES Organizations • American Association of Suicidology (AAS): The American Association of Suicidology is a national organization devoted to understanding and preventing suicide through promoting research, training professionals and volunteers, and working to raise public awareness. AAS offers a credentialing program both for crisis centers and for individual crisis workers. http://www.suicidology.org. Dr. Alan L. Berman and Dr. David A. Jobes, co-authors of Chapter 17 in this book, are Executive Director of AAS, and former president of AAS respectively. • American Foundation for Suicide Prevention: This organization is committed to advancing knowledge and prevention of suicide. It provides statistics, articles on suicide, and information and services for survivors. http://www.afsp.org/home.htm. • Befrienders International: Befrienders International provides free, nonjudgmental counseling services for people in crisis. The website contains statistics and articles on suicide, and information on depression, selfharm, homosexuality, and anti-bullying. http://www.befrienders.org. • Kristin Brooks Hope Center: The Kristin Brooks Hope Center runs the international 1–800-SUICIDE hotline system. The website provides information on crisis centers and hotlines, suicide and advocacy. http:// www.hopeline.com. 793

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INTERNET RESOURCES AND 24-HOUR HOTLINES

• LivingWorks Education— Applied Suicide Intervention Training: LivingWorks Education provides training on suicide intervention and prevention. http://www.livingworks.net/ASX.php. • National Suicide Prevention Lifeline consists of a network of 115 24hour crisis centers in 43 states throughout the United States. The network and telephone hotline routing system is operated by the Mental Health Association of New York City with funding from Substance Abuse and Mental Health Services istration (SAMHSA) of the U.S. Department of Health and Human Services. http://www.suicidepreventionlifeline. org. For callers in crisis, the 24-hour hotline number is: 1–800-273TALK (8255). • Suicide Prevention Action Network USA: SPAN USA is an organization that promotes suicide prevention through community organizing to raise awareness in local communities as well as among federal, state, and local policy makers. http://www.spanusa.org. • Suicide Prevention Resource Center: The Suicide Prevention Resource Center aims to advance the national strategy for suicide prevention by providing prevention , training, and informational materials. http://www.sprc.org • Yellow Ribbon Suicide Prevention Program: The Yellow Ribbon Suicide Prevention Program is a multidimensional program providing a forum for youth, and education for parents, teachers, and clergy. http://www. yellowribbon.org

Government Websites • Suicide Prevention— A Resource Manual for the U.S. Army: This manual covers primary, secondary, and tertiary prevention of suicide, including training on providing to the suicidal person and screening. It also covers dealing with the chain of command and the use of critical incident stress debriefing after a suicide. http://chppm-www.apgea.army. mil/dhpw/Readiness/suicide.aspx • Marine Corps Suicide Prevention Website: The Marine Corps suicide prevention website is a part of Marine Corps Community Services. It contains information on risk factors, protective factors, frequently asked questions, and resources in suicide prevention specific to the Marine Corps. http://www.usmc-mccs.org/perssvc/prevent/suicide.asp • Taking Action, Saving Lives—U.S. Navy Suicide Prevention Training Manual: This is a suicide prevention training manual for the U.S. Navy. It contains an overview of suicide and its warning signs as well as protective factors. It also identifies local resources and describes how to access them through the military chain of command. http://www-nehc. med.navy.mil/s/hp/manual.pdf • National Strategy for Suicide Prevention: This website is a collaborative effort of SAMHSA, CDC, NIH, HRSA, and IHS and presents the national strategy for reducing suicide. http://www.mentalhealth.org/ suicideprevention • Surgeon General’s Suicide Prevention Call to Action: This Surgeon Gen-


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eral’s report addresses suicide statistics, suicide among special populations, and the surgeon general’s recommendations for suicide prevention. http://www.surgeongeneral.gov/library/calltoaction/default.htm

Resources on Youth Suicide • National Youth Violence Prevention Resource Center: The National Youth Violence Prevention Resource Center provides information on prevention of youth suicide. It also provides information on preventing a host of other violent situations that youth often face. http://www. safeyouth.org • Youth Suicide Prevention Program: This website provides information on preventing suicide and self harm, as well as public awareness and training. http://www.yspp.org/resources-links/links.htm • Youth Suicide Problems: Gay, Bisexual Male Focus: This website focuses on information about and prevention of suicide among the highly neglected population of gay and bisexual adolescents. http://www. youthsuicide.com/gay-bisexual

CRISIS INTERVENTION WEBSITES Brief Treatment and Crisis Intervention: The quarterly peer-reviewed international Journal, Brief Treatment and Crisis Intervention: A Journal of Evidence-Based Practice is dedicated to advancing clinical practice, mental health policy, and knowledge building related to behavioral health, crisis assessment and crisis intervention, trauma treatment, and forensic studies. Dr. Albert R. Roberts is the Editor-in-Chief and it is published by Oxford University Press journals division. http://www.brief-treatment.oupjournals. org • Crisis Intervention Network: This website provides information about crisis intervention strategies and protocols as well as the latest books and journal articles focusing on evidence-based crisis intervention and time-limited treatment. It also includes News Alerts on recent empirically based step-by-step crisis intervention protocols, the continuum of the duration and severity of woman battering, domestic violence safety protocols, and links to other suicide prevention and social work websites. The website was developed by Dr. Albert R. Roberts, with sections added on crisis intervention with substance abs by Dr. Kenneth R. Yeager. http://www.crisisinterventionnetwork.com • Crisis Prevention Institute: The Crisis Prevention Institute trains professionals in working with potentially violent individuals through a behavior management program called Non-violent Crisis Intervention. http:// www.crisisprevention.com • The American Academy of Experts in Traumatic Stress: The American Academy of Experts in Traumatic Stress is a multi-disciplinary organiza-

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•

•

•

•


tion of professionals that aims to advance the treatment of trauma, emergency services, and forensic mental health. This organization works to identify expertise and provide standards and training for professionals who provide trauma services. They publish and disseminate to their monographs and info sheets of traumatic stress response protocols for emergency responders and violence prevention protocols. The 10-step Trauma Response Protocol developed by Dr. Mark D. Lerner (President of the Academy) and Dr. Raymond Shelton (Director of Professional Development at the Academy) and their associates is highlighted in chapter 6 in this book. http://www.aaets.org. National Organization of Victim’s Assistance: The National Organization of Victim Assistance is a professional organization devoted to the recognition of victim’s rights and the delivery of victim services. NOVA offers training in group crisis intervention throughout North America and maintains a national crisis response team. http://www.trynova.org International Critical Incident Stress Foundation (ICISF): The ICISF is a foundation dedicated to understanding and ameliorating the stress reactions that occur following a critical and emergency incident. The foundation offers training in multi-component Critical Incident Stress Management and Critical Incident Stress Debriefing every month in different parts of the United States. This foundation is well-known for training and certifying critical incident and disaster response teams throughout the world. Two of the authors of Chapter 9 in this book, Dr. George S. Everly, Jr. and Dr. Jeffrey T. Mitchell are co-founders of the ICISF, and Dr. Victor Welzant is the Director of Training at ICISF and co-author of chapter 8 in this book. Every two years, ICISF convenes a World Congress on Crisis Intervention, Emergency Preparedness, and Critical Incident Stress Debriefing with 1,200–1,500 participants in attendance. The next Congress is scheduled for March 2007 in Baltimore, Maryland. http://www.icisf.org National Clearinghouse on Child Abuse and Neglect Information: This website offers a manual on crisis intervention in child abuse and neglect. This manual is designed to assist caseworkers is responding to families in crisis. It presents information on crisis theory, a 9-step model of intervention, and examines specific approaches to crisis intervention. http:// nccanch.acf.hhs.gov/pubs/manuals/crisis/index.cfm National Domestic Violence Hotline: The National Domestic Violence Hotline is a national hotline provided for by the Violence against Women Act of 1994. In addition to information about the hotline, the website contains information on domestic violence, teens and dating violence, domestic violence in the workplace, information for victims and survivors of domestic violence, and information for abs. http://www. ndvh.org/.

CHILD ABUSE AND NEGLECT • National Clearinghouse on Child Abuse and Neglect Information (NCCANCH): A service of the U.S. Department of Health and Human Services, istration for Children and Families, Children’s Bureau.


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The purpose of NCCANCH is to provide the most current information on child maltreatment to researchers, service providers, consumers, and the media. Services include telephone staff (non-hotline), publications (free for , hardcopy, or CD orders), and online databases. http://nccanch.acf.hhs.gov/ • ChildhelpUSA: Treatment and Prevention of Child Abuse: ChildhelpUSA is a private non-profit organization founded in 1959 with programs in Arizona, California, New York, and Virginia. ChildhelpUSA services include counseling, residential treatment, group homes, foster care, professional training, educational programs, community outreach, and public awareness. ChildhelpUSA sponsors the ChildhelpUSA National Child Abuse Hotline, 1–800-4-A-CHILD which provides tollfree 24 hour crisis counseling, referrals to local agencies and adult survivor groups throughout the United States and Canada. http://www. childhelpusa.org/ • National Data Archive on Child Abuse and Neglect (NDACAN): The purpose of NDACAN is to improve and expand the use of data collected by researchers. Based out of Cornell University, NDACAN acquires microdata from researchers and national data collection efforts and makes these datasets available to the research community for secondary analysis. http://www.ndacan.cornell.edu/ • The Child Abuse Prevention Network: The target audience of CAPN is professionals in the field of child abuse and neglect. CAPN serves as a clearinghouse of websites related to child abuse prevention. http://childabuse.com/

DEATH OF A LOVED ONE • HealthyPlace.com: Provides basic information about grief and loss. Three online videos discuss how to prepare for the death of a loved one, how to cope with the loss of a parent, and how to help your child through a death in the family. http://www.healthyplace.com/communities/ depression/related/loss_grief_3.asp • AARP: A clearinghouse of resources on grief and loss, including links to community resources, articles on grief and loss over the lifespan, financial preparation, and remembrance rituals. http://www.aarp.org/life/ griefandloss/ • Alive Alone, Inc: Resources for parents who have lost a child. Includes a bi-monthly newsletter and information on self-help groups. http://www.alivealone.org • Bereaved Parents of the USA: Non-profit self-help group for parents who have lost a loved one, including children, pets, parents, etc. Includes an excellent resource page with information on grief and loss, medical information and financial resources. http://www.bereavedparentsusa. org/ • Parents of Murdered Children: PMOC, originally only for parents of murdered children, has an expanded focus to include for all survivors of loved ones who have been murdered. Services include

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monthly meetings at local chapters, training for service providers, and a national crisis hotline at (888) 818-POMC.http://www.pomc.com/ • The National SIDS/Infant Death Resource Center: Provides online free publications regarding SIDS and Infant death. Useful resource page with links to related website. http://www.sidscenter.org/

PERSONS WITH LIFE-THREATENING ILLNESS • AIDS Info: This National Institute of Health website provides information on treatment guidelines, clinical trials, vaccines, and frequently asked questions. http://www.aidsinfo.nih.gov • CDC Division of HIV/AIDS Prevention: This website provides information on the National CDC STD/HIV/AIDS/TB Hotline which is open 24/7 call 1–800-342–2437. This website also provides information on testing, transmission, symptoms, and HIV/AIDS in special populations. http://www.cdc.gov/hiv/dhap.htm • National Ovarian Cancer Coalition: The National Ovarian Cancer Coalition is a clearinghouse for information on ovarian cancer, and includes information on symptoms, diagnosis, treatment and coping with the disease. http://www.ovarian.org/ • Ovarian Cancer National Alliance: The Ovarian Cancer National Alliance provides information and for people with ovarian cancer, survivors, and family . http://www.ovariancancer.org/ • Colorectal Cancer Network: The Colorectal Cancer Network provides information on colon cancer and treatment options. It also provides groups for people suffering from colorectal cancer. http://www. colorectal-cancer.net/ • The Leukemia and Lymphoma Society: The Leukemia and Lymphoma society provides information on leukemia, lymphoma, myeloma and other blood cancers. It provides free educational material and information on groups for people with blood cancer. http://www.leukemia.org/hm_lls

SELF-HELP GROUPS/ GROUPS CLEARINGHOUSE • American Self-Help Group Clearinghouse: Located at the Graduate Center of the City University of New York, it provides research reports and information on how to set up a peer group. Information is available to member agencies on over 1,100 national, international, local as well as online groups for addictions, bereavement, health, mental health, disabilities, abuse, parenting, caregiver concerns, and other possible crisis-inducing situations. http://www.selfhelpgroup.org or call (212) 817–1822.


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• New Jersey Self-Help Group Clearinghouse: This is a non-profit service of Saint Claire’s Health System and is funded by the New Jersey Division of Mental Health Services. It provides information by phone on over 4,500 local self-help groups throughout the state of New Jersey, as well as s of national groups. In New Jersey call: 1–800367–6274; outside New Jersey call: (973) 326–6789.

SERIOUSLY MENTALLY ILL ADULTS • National Alliance for the Mentally Ill (NAMI): NAMI is a self-help, , and advocacy group for consumers, friends and families living with mental illness. The website includes online information regarding mental illness, education, and training, and local groups and resources. National Information Hotline (not crisis): 1–800-950-NAMI (6264). http://www.nami.org • National Resource and Training Center on Homeless and Mental Illness: A service of SAMHSA, the website provides information on effective delivery of services to people with mental illness or substance abuse problems who are homeless. http://www.nrchmi.samhsa.gov/ • National Alliance for Research on Schizophrenia and Depression (NARSAD): This organization provides up-to-date information on research on schizophrenia, depression, bipolar disorder, and anxiety disorders. It also provides information on evidence-based treatment options and best practices. http://www.narsad.org

SUBSTANCE ABUSE AND OTHER ADDICTIONS • National Council on Alcoholism and Drug Dependence, Inc. (NCADD): The NCADD lists local resources, provides free publications, and has sponsors a national alcoholism hotline 800–622-2255. http://www. ncadd.org/ • Substance Abuse and Mental Health Services istration (SAMHSA): SAMHSA provides the most current and comprehensive information on substance abuse information for service providers, consumers, and researchers. Free publications. National Hotline for Alcohol and Drug Information: 800–729-6686. http://www.samhsa.gov/treatment/treatment_ public_i.aspx • Focus Adolescent Services: Designed for consumers, this website has links to USA-specific and international resources, describes different types of drugs and identifies slang associated with them. The substance abuse section is part of a more comprehensive website that addresses many of the issues faced by adolescents. http://www.focusas. com/SubstanceAbuse.html

800


• Al-Anon/Alateen: Information on one of the largest and oldest groups for people who live with alcoholics. National Hotline: 800–3442666. http://www.al-anon.org/ • American Council on Alcoholism: Resource for the public on the effects of alcoholism. Provides information about treatment resources. National Hotline: 800–527-5344. http://www.aca-usa.org/

RUNAWAY YOUTH • National Runaway Switchboard: A service of the Family and Youth Service Bureaus. NRS provides a 24-hour hotline for runaway youth. Statesponsored hotlines (e.g. Texas and Florida) are connected to the NRS’s national hotline. The hotline provides crisis intervention, referrals to local services, and education on ways to return home. The site also provides information for parents, educators, social service providers, and law enforcement officials. 1–800-RUNAWAY. http://www.nrscrisisline. org/kids.asp • Focus Adolescent Services: Designed for consumers, FAS provides an annotated list of internet resources about runaway youth. http://www. focusas.com/Runaways.html

ADOLESCENT AND YOUNG ADULT MENTAL ILLNESS • Substance Abuse and Mental Health Services istration (SAMHSA): SAMHSA provides information on Child and Adolescent Mental Health for consumers, service providers and researchers. The child and adolescent section provides information on national programs which address the various issues associated with children’s mental health. http://www. mentalhealth.org/child/childhealth.asp • Youth and Mental Illness: A self-help booklet produced by the Canadian Psychiatric Association. http://www.a-apc.org/MIAW/pamphlets/ Youth.asp

SEPARATION AND DIVORCE • Canadian Mental Health Association: Provides information for consumers on separation and divorce. http://www.cmha.ca/english/info_centre/ mh_pamphlets/mh_pamphlet_08.htm • Divorce Anonymous: This is a 12-step self-help group designed to help participants manage their feelings of loss, confusion, loneliness, anger, and/or grieve related to separation and divorce, and to help participants to learn new coping skills in of new relationships. http://www. divorceanonymous.org/blog/index.php

Index

AA. See Alcoholics Anonymous abandonment, 634, 656 Abbey, A., 420 A-B-C crisis management model, 466, 775 ABCX adjustment model, 279–80 abuse, 11, 132, 445 adult abuse protocol, 462–64, 775 of care receivers, 708, 710, 718 of elders, 552, 708, 710, 718 emergency room protocol, 551–53 of homeless adolescents, 348 See also battered women; child abuse or neglect; domestic violence; sexual assault Abuse Counseling and Treatment (ACT) program (Fort Myers, Fla.), 466, 467, 476 Abused Women’s Active Response Emergency Program, 473 ACA. See against clinical advice acceptance, 69 accidents, 4, 5, 547–48, 604 acetaminophen, 399 acquaintance rape, 417–26, 775 acquired immunodeficiency syndrome. See AIDS

ACT intervention model, 43, 102–16, 143–67, 331 battered women program, 466–67, 476 action plans, 5, 24–25, 67, 133 addiction treatment and, 578–79, 584 adolescent suicidality intervention and, 409–11 caregivers and, 717 child/adolescent psychiatric emergencies and, 339, 346–47, 354–55 college student counseling and, 425–26, 433 comprehensive crisis intervention model and, 622, 624, 625, 629–30 critical care areas and, 645 disaster mental health and, 157, 274, 286 divorced/separated people and, 674–75 early adolescents suffering from loss and, 376–77, 381–82, 387 emergency room crisis interventions and, 561 801

802

Index

[action plans] (continued) for HIV positive women, 698–99 mobile crisis unit interventions and, 610 school violence interventions and, 532 solution-focused therapy and, 67, 79–81, 346–47 for stalking victims, 495–96 strengths perspective and, 160 suicidal ideation crisis intervention and, 58 activators/stressors, in stress-crisis continuum, 122 active emergency response pendants, 457–58, 459, 473, 474 active listening, 12, 492, 493 expression of client’s feelings and, 23, 285, 373, 379, 432 by hotline workers, 29, 49, 54, 159 for patients in medical crisis, 644 verbal and, 159 activities of daily living (ADLs), 703, 705, 706, 710 acute crisis, two-factor model of, 223–27, 790 acute crisis episodes, 9, 94–95 aftermath outcomes, 12 battered women and, 448–50 differentiation of, 6, 90, 145 mobile crisis units and, 603 stress-crisis continuum and, 121–22 suicidality and, 395–412 acute psychological crises, 365 acute psychotic episodes, 328 acute situational crises, 365 acute stress disorder, 162, 236, 365 definition of, 95 differentiation of, 6, 90, 99–103, 109–12 posttraumatic stress disorder vs., 98 precipitating events for, 103 trauma and, 95, 96 acute stress management, 143, 164, 166 Acute Traumatic Stress Management (ATSM), 96–97, 147–48 adaptation divorce and, 672 Double ABCX model and, 287 stress and, 92

adaptive coping, 12, 24 addiction, 566–96 evidence-based practice and, 592–94 incidence and prevalence of, 569–72 risk and protective factors for, 579–80, 584–85, 591–92 seven-stage crisis intervention model and, 566, 567, 573–92 substance dependence definitions and, 573 See also alcohol abuse or dependency; substance abuse adjustment disorder, 634 ADLs. See activities of daily living adolescents basic rules for working with, 349 crises in lives of, 365–68 definition of, 775 depressive disorder prevalence in, 327 developmental tasks of, 362–63, 388, 401 distrust of adults by, 349, 401, 525, 529 emergency responder parents of, 255 grief and, 367 homelessness and, 322, 348–55 loss suffered by, 362–90 psychiatric disorder incidence in, 4 psychiatric emergency response for, 319–57 resilience of/protective factors for, 369–71 school subgroups, 775 school violence and. See school violence special considerations when working with, 387–90 stress and, 368–69 suicidality crisis intervention for, 395–412 trauma exposure prevalence for, 222 adrenaline, 93 ADT Security, 458, 473 adult abuse protocol, 462–64, 775 adult day care, 717

Index 803 Adult Mental Health Workgroup, 749 aerosolization, of biological agents, 183 affective disorders, 604, 776 African Americans adolescent suicide victims, 398 as caregivers, 705, 706 courtship violence and, 419 female rape victims, 418, 419, 423 HIV/AIDS-infected women, 682– 84, 696 spirituality’s importance to, 423 against clinical advice (ACA), 628 aggression definition of, 776 psychiatric emergencies and, 136 school violence and, 521, 522 aging agencies, 26 agitation, 406 agoraphobia, 22–23, 165 agreeableness, 452 Aguilera, D., 160 AIDS, 660, 688, 761 deaths daily from, 5, 633 persons living with, 682–84, 689 See also HIV AIDS service organization (ASO), 776 Air Force, U.S., 222 airplane disasters. See plane crashes alarm reaction, stress and, 92 alarm/security systems, 457–58, 473 alcohol abuse or dependency, 9 as adolescent suicide risk factor, 407 battered women and, 467 binge drinking and, 9, 445, 569, 571 divorced/separated people and, 660, 663 drug overdoses and, 399 incest survivors and, 147 incidence/prevalence of, 569–70, 571 motor vehicle accidents and, 604 by parents, 371–77 as school violence risk factor, 524 as sexual assault risk factor, 420 sexual behavior and, 660 by survivors, 285 alcohol assessments, 158

Alcoholics Anonymous, 591 alcoholism. See alcohol abuse or dependency Alessi, J. J., 472 Alexander, E., 19 Alexander, Franz, 94 Algeria, 177 Allen, M. H., 333 Allport, G. W., 759 Alpert, Elaine, 475 alternatives, exploration of, 23–24, 67, 133 addiction treatment and, 577–78, 589 adolescent suicidality and, 408–9 caregivers and, 716–17 child/adolescent psychiatric emergencies and, 338–39, 345–46, 353–54 college student counseling and, 425, 432–33 comprehensive crisis intervention model and, 622, 624, 625, 629 in critical care areas, 644–45 disaster mental health and, 157, 274, 285–86 divorced/separated people and, 673–74 early adolescents suffering from loss and, 374–76, 380–81, 386–87 emergency room crisis intervention and, 560–61 HIV positive women and, 698–99 mobile crisis unit interventions and, 610, 611, 612 school violence interventions and, 531 stalking victims and, 494–95 suicidal ideation crisis intervention and, 57 Alzheimer’s disease, 704 ambiguous loss, 281 ambulance services, 614 American Academy of Experts in Traumatic Stress, 96, 147, 164 American Airlines Flight 93, terrorist attack on, 3, 247 American Association of Suicidology, 11

804

Index

American Medical Association, 266 American Psychiatric Association, 60, 99, 164, 224, 327, 569, 573 American Red Cross, 26, 149, 187, 201, 209, 215, 222, 231 American Society of Addiction Medicine, 579 AMHW. See Adult Mental Health Workgroup amplifying, posttrauma intervention and, 298–99 Anders, T. F., 327 Angel Dust, 158 anger battered woman’s suppression of, 449 caregivers and, 709, 713 as crisis reaction, 12, 130, 274 divorce and, 656, 662 of emergency responders, 250, 252 handling of, 23 patients in medical crisis and, 634 rage vs., 285 stalkers and, 487 stalking victims/survivors and, 488, 494 of survivors, 285, 286 as traumatic event response, 268, 295 Ann Arbor (Mich.) Police Department, 454 ANS. See autonomic nervous system ANSER Institute for Homeland Security, 267 anthrax, 177, 179, 183, 265, 266, 267 antianxiety medication, 130 antibiotics, 266 anticholinergic, definition of, 776 anticipatory grieving, 282 anticomplementary counselor responses, 432, 776 antidepressants, tricyclic, 399 antiretroviral (antiviral) therapy, 682, 688–89, 691–92, 776 antisocial personality characteristics, 421 antisocial personality disorder, 407 antistalking laws, 484

anxiety, 9, 66 as adolescent suicide risk factor, 407, 410 battered women and, 445, 448, 450 bereaved children and, 382 caregivers and, 706, 713 as crisis reaction, 12, 130 death-related, 162, 163 divorce and, 656, 661 impostor phenomenon and, 428 somatic distress and, 123, 124 terrorist attacks and, 268 anxiety disorders, 224, 604 battered women and, 445 generalized anxiety disorder, 162, 165, 448 See also acute stress disorder APA. See American Psychiatric Association appetite changes, 9, 268 appraisal, 452, 655, 727, 730 benign, 705, 728 primary, 452, 655, 724, 727–30 secondary, 452, 655, 725, 727–31 approach, 332, 352, 354 Army, U.S. See military, U.S. arthritis, 633 art therapy, 345, 468–69, 514 Asahara, Shoko, 179 ASAP. See Assaulted Staff Action Program Ashby Wills, T., 370 ASO. See AIDS service organization aspartate, 225 aspirin, 399 assault, 136. See also sexual assault Assaulted Staff Action Program, 240 assessment in ACT intervention model, 103–4, 150–54 adult abuse protocol and, 462–64 alcohol, 158 biopsychosocial, 21–22, 41, 153– 54, 158 of crisis calls, 21–22 of crisis state, 723–39 in death aftermath, 282–83 drug, 158 in early intervention, 203, 204

Index 805 emergency room protocol, 550–55, 556 homicide/violence risk, 153, 158, 340–43, 694, 726 of imminent danger, 21–22, 41, 49, 399 of lethality. See lethality assessment medical, 41, 158 preexisting mental illness concerns and, 325 psychosocial, 21–22, 423–24, 431 rapid, 38, 43, 47, 95. See also rapid assessment instruments suicide risk, 153, 158, 332–34, 350, 396, 398–407, 646 triage, 41–46, 47, 52, 150–52 asthma, 635 Astor, R. A., 521 atropine, 181 ATSM. See Acute Traumatic Stress Management attachment, 487 attending behavior/skills, 335 attribution theory of somatization, 125 Aum Shinrikyo cult, 179–80 Austin (Texas) Police Department, 454–55 Austrian, S., 154 authority, students and, 525, 529 automobile accidents, 5, 547–48, 604 autonomic nervous system (ANS), 224, 225 avoidance, 332 battered women and, 448, 449 caregivers and, 715 stalking victims/survivors and, 494 as traumatic event response, 268 AWARE Program, 473 AZT (Zidovudine), 692 Bacillus anthracis, 266 Bacon, Francis, 229 bacteria, 182, 183, 266 Baldwin, B. A., 122, 138 Bandura, A., 729, 731 Bard, M., 13 Barlow, D. H., 760 Basco, M. R., 664

baseline information, 761–64, 765 baseline period, 761, 763, 776 BATF. See Bureau of Alcohol, Tobacco and Firearms battered women, 8, 21, 22, 27–29, 30, 441–77 art therapy for, 468–69 children of, 30, 446, 449, 450, 465, 468–72, 477 crisis episode precursors for, 449–50 emergency room treatment for, 445, 462–64, 474–75, 477, 552 high-risk crisis episodes and, 448–49 resilience of/protective factors for, 450–53 safety of/protection for, 454–61, 465–66, 473–75 scope of problem of, 444–47 services for. See battered women’s hotlines and shelters vocational training for, 461–62 zero violence tolerance and, 447–48 See also domestic violence battered women’s hotlines and shelters, 11, 32, 446, 489 definition of, 776–77 electronic monitoring devices and, 473, 474 hotlines, 27–29, 30, 441, 443, 464–65 intervention techniques of, 464–68 policies and procedures manuals for, 467 referrals and, 28–29, 475–77 telephone logs and, 467–68 treatment approaches of, 468–72 battering, 8, 132, 469. See also battered women; domestic violence Beach, S. R., 707 Beck, A. T., 45, 60–61, 406, 662 Beck, Judith, 526, 527 Beck Anxiety Scale, 109 Beck Depression Inventory, 44, 154, 162, 754 Beck Depression Inventory–Second Edition, 661

806

Index

Beck Hopelessness Scale (BHS), 44, 45, 46, 661 Beck Scale for Suicide Ideation, 44, 663 behavioral contracts, 433 behavioral sensitization, 225 behavior rehearsals, 671 Behrman, Gary, 107, 161, 291–301 Belanger, S. K., 280 Benight, C. C., 729 benign appraisal, 705 benign-positive appraisals, 728 Bentler, P., 591 Bentley, Kia, 605 Benton, D. M., 710 Benton, S. A., 416–17 Benton, S. L., 416–17 bereavement. See grief and mourning Berg, I. K., 68, 69 Berg, W., 563–64 Bergin, A. E., 742, 748 Berkowitz, A. D., 421 Berman, Alan L., 395–412 Berman, M., 294 Bernstein, I. H., 733 Berry, T. R., 416 Bertolino, B., 378 Best, K., 330 BHS. See Beck Hopelessness Scale B.I., Inc., 458, 473 Bidgood, B., 443 Biegel, David E., 613, 704 binge, definition of, 777 binge drinking, 9, 445, 569, 571 biological disposition, coping and, 369 biopsychosocial assessment, 21–22, 41, 153–54, 158 bioterrorism, 146, 177–79, 182–83, 262–76 bipolar disorder, 327, 328, 407, 445, 487 Birmaher, B., 327 Bisman, C. D., 765 Black, Linda L., 416–34 blaming, 295 blended families, 653 blister agents, 180, 181–82 Blocker, L. S., 370 body language, 493 Boes, Mary, 543–64

booby traps, 186 Bookwala, J., 706, 707 Boon, J., 485–86 borderline personality disorder (BPD), 147, 407 borders, United States, 262–63, 264, 275 Bordow, S., 223 Borum, R., 607, 608, 614 botulism, 183 Bourg, S. E., 421 Bourgeois, M., 707 Bowlby, John, 226, 280, 367, 373 Boyd, Vicky, 462, 464 BPD. See borderline personality disorder brain–stress response, 93 Brent, D. A., 404 Breslau, N., 98 Brief Symptom Inventory, 154 brief therapy, 129, 363, 364, 417, 433, 484, 742, 743, 767, 768 for addictions, 566–96 definition of, 777 Brightpoint, Inc., 457 British Psychological Society, 231 Brower, A. M., 532, 751 Brown, Gregory, 44 Brown, R., 580 bullying, 521, 523, 524, 530 Bunch, K., 253 Bunn, T., 223 Buprinex, 777 Bureau of Alcohol, Tobacco and Firearms, 187 Bureau of Justice, 634 Burgess, Ann Wolbert, 120–38 burglary, 604 Burkhart, B. R., 421 burnout, crisis intervenors and, 647 burns emergencies, 548 Burt, K., 333 Burton, L. C., 710 Calhoun, L. G., 452 Call for Action, 476 Call to Protect, 457 cameras, instant, 473, 474–75 Campbell, B. S., 330 Campbell, D. T., 760, 764

Index 807 cancer, 5, 125, 633, 635, 637 canine rescue teams, 188 Cannon, Walter, 93 Cantor, P., 401 CAPE teams, 324, 333, 343 Caplan, Gerald, 13–19, 227, 446, 725 Caprio, Raymond, 149 car accidents, 5, 547–48, 604 Carbon, J. B., 99 cardiac intensive care units (CICUs), 635 cardiovascular disease, 633 caregiver burden, 704, 705, 707–12, 718 Caregiver Burden Inventory (CBI), 708, 709, 710, 713, 717 caregivers, 635, 703–18 health and well-being of, 704–7, 710–11, 712 seven-stage crisis intervention model and, 712–17 types of stressor impingements on, 704, 705–7, 709 Carlson, B. E., 453 Carroll, K., 591 Carter Center (Atlanta, Ga.), 749 Carver, C. S., 428 case management HIV-infected people, 692–93 serious mental illness, 135 stalking victims/survivors, 489 case planning, 766 catalytic sequences, 232 catastrophic events definition of, 777 school violence and, 520, 522, 533–37 catastrophic traumatic stress crises, 120, 122, 138 cathartic ventilation, 230, 239, 494 Cavanaugh, J. C., 704 CBI. See Caregiver Burden Inventory CDC. See Centers for Disease Control and Prevention cellular phones, for battered women, 457, 459, 473–74 Cellular Telecommunications Industry Association, 457 Census Bureau, U.S., 653

Center for Mental Health Services, 749 Center for Strategic and International Studies, 267 Center for Studies of Suicide Prevention, 18 Center for Substance Abuse, 749 Centers for Disease Control and Prevention, 265, 266, 444, 688 central nervous system, 225 certificate programs, 148–49 CG. See phosgene challenge appraisals, 728 change, 67–68, 292 change talk, 64, 68 Chassan, J. B., 746 chemical-resistant protective gear, 185 chemical weapons, 177–82, 267 Cheung-Chung, M. C., 163 Chiauzzi, E., 580 child abuse or neglect batterers and, 469 crisis clinician reporting of, 467 emergency room protocol for, 552 as family crisis, 132 homelessness and, 348 hotlines and referral networks for, 29, 30 medical crises and, 634 sexual abuse intervention programs and, 11 solution-focused therapy and, 85 Child and Adolescent Psychiatric Emergency teams, 324, 333, 343 Child Bereavement Project, 382 Childhelp USA, 29 children abuse of. See child abuse and neglect of battered women, 30, 446, 449, 450, 465, 468–72, 477 bereavement and, 367–68, 378–79, 380, 382, 389, 508 depression in, 147, 327, 380, 382 developmental psychology and, 331, 362–63, 378, 388, 390, 401 domestic violence treatments for, 468–72 of emergency responders, 249, 250, 254, 255, 256–57

808

Index

[children] (continued) eye movement desensitization/reprocessing and, 165 grief and, 363, 389, 508, 531, 536 HIV/AIDS and, 685, 690 of Holocaust survivors, 252–53 informed consent and, 389 in medical crisis, 636 parental posttraumatic stress disorder and, 252 pediatric intensive care units for, 636 psychiatric disorder incidence in, 4 psychiatric emergency response for, 319–57 sudden death of, 7, 9, 16, 23 suicidal, 147, 336–37, 372–73, 378–79 trauma and, 96, 146–47 trauma contagion and, 252–53 trauma exposure prevalence for, 222 of Vietnam veterans, 253 World Trade Center attack experiences of, 305–18 See also adolescents China, 178 Chiu, T. L., 608, 615 chlorine, 182 chlorine gas, 177, 178 choking agents, 180, 182 cholera, 183 Christ, 763 Cicirelli, V. G., 705 CICUs (cardiac intensive care units), 635 cigarettes, 571 Cimbolic, P., 400, 402 CISD. See critical incident stress debriefing CISM. See critical incident stress management civilians, critical incident stress management for, 236, 238 Civil War, U.S., 98 Clance, P. R., 427, 428, 429, 430 clarification, 379 Clark, H., 585 Clarke, A., 223 classic stalking behaviors, 486

Cleary, S. D., 370 clergy, 11, 32, 233, 236, 443 client rights, 769 clinical disorders, stress-crisis continuum and, 120–38 Clinician-Assisted PTSD Scale, 426 Clinton, Bill, 461 closed-ended questions, 340 closure, 355 club drugs, 445 CMHC Act. See Community Mental Health Center Act of 1963 CMHCs. See community mental health centers CNS. See central nervous system Coast Guard, U.S., 222 cocaine, 570, 572, 574–76, 579–80 Coconut Grove fire (1942), 16, 98, 129, 744 code, definition of, 777 code situations (emergency room protocol), 550–51 codes of ethics, 769 cognitive-behavioral therapy, 125, 130, 363, 489 school violence trauma and, 521, 526–28, 530, 532, 534 cognitive elaboration, 672, 674, 777 cognitive functioning, 39, 95 cognitive mastery, 12, 15, 24–25, 39, 95 cognitive processing therapy. See cognitive-behavioral therapy cognitive psychology, 725 cognitive restructuring, 25, 449, 672 Cohen, Michel, 317 collaboration, strengths perspective and, 451 college counseling centers, 416–34, 738 coloring books, 470–72 combat. See war communication. See notification/communication; rapport and communication, establishment of Communities on Phone Patrol, 457 community-based services expansion of, 604–5 mobile crisis units and, 603, 606–15

Index 809 school crisis response programs and, 512, 515, 517 for youths in crisis, 323, 329–30 community disasters ACT intervention model for, 143–67 mental health care for, 208–10 posttrauma intervention and, 291, 292–301 psychiatric triage and, 43, 151–52 Community Integration, Inc., 44, 152, 160, 331, 343, 626 Community Mental Health Center Act of 1963, 18, 27, 604 community mental health centers (CMHCs), 18, 32, 121, 236, 604–5 crisis units, 27 information and referral services, 26 waiting lists, 37 community mental health movement, 18, 121 Community Service Society, 26 comorbidity, 124, 327 comion fatigue, 216 complementary counselor responses, 432 completed suicide. See suicide complimenting of clients, in solutionfocused therapy, 78–79, 83, 353 comprehensive crisis intervention model, 619–31 crisis residential units, 619, 626–28 critical incident stress management, 630–31 emergency psychiatric crisis stabilization, 628–30 mobile crisis services, 619, 624–26 organizational structure and functions, 619–20 telephone crisis services, 619, 620–22 walk-in crisis services, 619, 623–24 compulsive shopping, 298 concentration, difficulties with, 9, 268 confidentiality, 769 employee assistance programs and, 516 legal issues and, 389, 390

rape victim concerns about, 422, 423, 425 conflict mediation, 345 confusion, 9, 12, 13, 95, 130 Congress, Elaine, 149 connectedness in ACT intervention model, 103, 104–5 posttrauma intervention and, 291– 92, 296, 297 Conoley, J. C., 522 conscientiousness, 452 consensual normalization, 230 consent, 238, 389, 390, 422 consequences, in stress-crisis continuum, 122 Consortium on Veterans Studies, 130 construct, definition of, 777 constructive, definition of, 777 constructivist intervention model, 663–64, 668, 669 constructivist therapies, 121, 664 consult system, 636–43 failure of traditional, 636–37 rationale for standing consults, 637–43 continuum of care mobile crisis services and, 325, 326 in stress-crisis, 6, 120–38 contracts, 433, 755, 786 control, 407, 634 perceived, 729 Cook, J. A., 615 Cooley, E. L., 428, 429 Copeland, Ellis P., 362–90 Copenhaver, S., 420 coping acute crisis episodes and, 9 adaptive, 12, 24 by battered women, 451–53 by caregivers, 715, 718 coping efficacy vs., 730–31 crisis intervention and, 5–6, 23–24, 65, 66, 67, 271–72 crisis resolution and, 15 crisis states and, 13, 64, 94, 280, 655–56, 730–31 definition of, 453 divorce and, 657, 659, 661, 664– 65, 672–73, 674

810

Index

[coping] (continued) by early adolescents, 368–69, 374– 75, 380–81, 386–87 early intervention and, 203 by emergency responders, 255 by emergency room patient loved ones, 560–61 emotion-focused, 353, 453 by homeless youths, 353, 354 by incest survivors, 147 with medical crises, 641–42 by mentally ill youths, 325 problem-focused, 353, 453, 705 in seven-stage crisis intervention model, 23–24, 273, 374–75, 380–81, 386–87, 408–9, 560– 61, 577–78, 588–89, 672–73 in social cognitive theory, 727 by stalking victims/survivors, 494–95 strengths perspective and, 159–60 stress and, 727 suicide risk and, 380, 406, 663 terrorism-related stress and, 275–76 coping efficacy, 724, 729, 730–32, 733, 736–39 situation-specific, 731 coping questions, 74, 77–78, 159, 353, 777 COPP. See Communities on Phone Patrol Corcoran, K., 153, 663, 756, 757 Cormier, L., 379 Corty, E., 419 Cotrell, D., 327 counseling services for college students, 416–34, 738 for first responders, 191 pastoral, 11, 32, 233, 236 phone-based, 340–43, 356 counterterrorism, 264 couples therapy, 275 courtship violence, 419 Cousins, A. V., 486 Cozzarelli, C., 729 crack cocaine, 570, 573, 574, 691 Craddock, S., 568 cravings, 579, 778 crime. See homicide; rape; terrorism; violence

crisis acute situational, 365 conditions characterizing, 13 definition of, 11–12, 13–14, 16, 38, 64, 94–95, 323, 556, 619, 654–56, 686–88, 726, 728, 778 differentiation of, 99–103, 114–16 diverse perceptions of, 90, 91 divorce as, 656–58, 668 duration of, 14–15 early adolescents and, 365–68 importance of prompt intervention in, 99. See also crisis intervention interrelated factors causing, 17 medical, 633–34 precipitators of, 66, 103, 655 resolution of. See crisis resolution single episode vs. series of events as, 388, 389 stages of, 16, 17 trauma reactions vs., 161–65 types of, 365 crisis assessment, 152–53, 166–67 crisis calls assessment of, 21–22 from battered women, 464–65 definition of, 778 telephone crisis services and, 620–22 See also hotlines crisis centers, 10–11, 32 crisis debriefing groups, 93 crisis game plans, 410 crisis intervention ACT model and, 104–5, 155–61, 331 for adolescents suffering from loss, 362–90 for battered women, 441–77 with caregivers, 703–18 at college counseling centers, 416– 34, 738 comprehensive model of, 619–31 contemporary issues and concerns in, 3–33 crisis reactions and, 12 crisis theory and, 14–17, 129 in critical and intensive care units, 632–48 definitions of, 13, 95, 778

Index 811 early intervention and, 202–4 educational and training needs, 148–49, 356 evaluation designs and procedures, 742–69 evaluation prerequisites, 748–50 evaluation strategy integration with, 765–67 goals of, 5, 12, 26, 66, 223, 365, 750–55 historical development of, 15–19, 129 with HIV positive women, 682–700 in hospital emergency rooms, 543–64 hotlines and units, 25–32, 441, 443, 464–65 macro and micro analyses in, 746–48 models and strategies for, 19–25 phone counseling and, 340–43, 356 police-based crisis teams and, 459– 61, 465 precertification issues and, 647 preexisting mental illness and, 323– 28, 331, 332–48, 356 rapid assessment instruments for, 723–39, 747, 755–57, 766 in schools, 499–517, 519–37 September 11 attacks’ effects on, 3, 107, 201, 262, 275 seven-stage model of. See sevenstage crisis intervention model single-system research designs and, 759–60, 761, 765, 768, 787 solution-focused therapy and, 23– 24, 54, 64, 65, 66–85, 346–47, 451 for stalking victims/survivors, 484, 489–96 stress-crisis continuum and, 120– 38 for suicidal adolescents, 395–412 time-series designs and, 760–65 triage assessment model for, 321, 323, 331–32, 341–42, 351–53, 356 worker do’s and don’ts, 39–41 crisis intervention service, definition of, 778

crisis nurseries, 29, 32 crisis-oriented treatments, 19 definition of, 778–79 Crisis Prevention Institute, Inc., 149, 620 crisis-prone situations, increase in, 4 crisis reactions, 12, 13 stages of, 17, 130 crisis residential units (CRUs), 619, 626–28, 779 crisis resolution definition of, 15, 779 equilibrium restoration vs., 15 goal of, 15 seven-stage crisis intervention model and, 12, 39, 95, 133 for stalking victims/survivors, 495–96 suicidal adolescents and, 411 crisis response programs emergency responder families and, 257–58 schools and, 502–17 crisis response teams, 6, 222 critical incident stress management and, 106, 161 schools and, 505–9, 516–17 crisis state, 730–32, 737–38 assessment of, 726–27 definition of, 724 Crisis State Assessment Scale, 723– 39 psychometrics, 732 research conceptual framework, 730–31 research results, 732–37 study conclusions, 737–39 crisis theory, 14–18, 279–80, 281, 489–90, 724, 725 ABCX adjustment model and, 279–80 basic tenets of, 14, 325 Caplan and, 15, 16–17, 18, 725 crisis duration and, 14–15 Crisis State Assessment Scale findings and, 737 Lindemann and, 15–16, 17, 129, 725 primary assumptions of, 725–26 Rapoport and, 17–18

812

Index

critical and intensive care units, 632–48 comprehensive care model for, 636–41 intervention considerations/implications and, 645–48 medical crisis definition/scope and, 633–34 patient and family diagnostic descriptors and, 634–36 seven-stage crisis intervention model and, 643–45 critical incident, definition of, 779 critical incident stress debriefing (CISD), 93, 106–7, 145–46, 160–61, 206 critical incident stress management and, 232, 236, 238, 630 definition of, 779 group crisis intervention innovations and, 227–31 misconceptions about, 240 critical incident stress management (CISM), 6, 106, 145–46, 161, 222 ACT model and, 143 crisis workers and, 630–31 definition of, 779 first responders and, 106, 206, 208, 236 group crisis intervention innovations and, 231–38, 239 misconceptions about, 240 CRUs. See crisis residential units CSAS. See Crisis State Assessment Scale CTIA. See Cellular Telecommunications Industry Association cue reactivity, 579–80 cultural assessment, 153–54 cultural issues caregiving and, 705 HIV positive women and, 682–84, 690, 696, 697, 700 school violence interventions and, 533 work with adolescents and, 388– 89, 390 Cummings, E. M., 330 Cummings, G., 580

cumulative event crises, divorce and, 657–58, 672 Curran, D. K., 407 current successes, tracking of, 80–81 custodial parents, 389 Customs, U.S., 187 cutting, 350 CX. See phosgene oxime cyanide, 179 cyberstalkers, 484, 488 cynicism, 250 cystic fibrosis, 633 cytokines, 94 DaCosta, Jacob, 98 Dark Winter (security drill exercise), 267 date abuse, 445 date rape, 418, 421 definition of, 779 date rape drugs, 417, 418–19, 420, 423 definition of, 779 dating, divorced people and, 660 Dattilio, F. M., 667 Davies, G., 485–86 Davies, P. T., 330 Davis, T. L., 421 “DCC in a Box” Replication Project (NYDCC), 195 DCSB. See DeKalb Community Service Board Deane, M. W., 608 death of adolescent peers, 367 adolescents’ feelings of loss and, 362, 367–68, 371–87 caregiver high risk rate of, 707 emergency responder exposure to, 247–48, 254 of emergency room patients, 551 fear of, 163 grief therapy and, 146, 279–89 Lindemann’s crisis theory and, 16, 129 of loved ones, 7, 9, 16, 23, 371–77 mental disorders as contributing factor to, 604 from motor vehicle accidents, 5, 604 of parent, 16, 367, 378–83

Index 813 from plane crashes, 8 school memorialization and, 508–9 of siblings, 16, 367, 383–87 threats to battered women of, 450 See also grief and mourning; homicide; lethality assessment; suicide death anxiety, 162, 163 debriefing, 417 definition of, 779 by first responders, 6, 41, 43, 150 school crisis response teams and, 516 See also critical incident stress debriefing decision-making skills, battered women and, 449 Decker, J., 223 decompensation, 779 decompression, emergency responder, 256 decontamination, 180, 186 deep muscle relaxation, 667 Defense Advanced Research Projects Agency, 267 Defense Department, U.S., 176, 201, 263, 267. See also Pentagon, terrorist attack on defusing, 232, 236, 238, 630, 780 deinstitutionalization, 607, 780 DeKalb Community Service Board, 605–6 DeKalb County, Ga., 605–6, 608–9, 614 DeKeseredy, W. S., 420 delayed, definition of, 780 delayed gratification, 401 delusional disorder, 487 dementia, 704, 705–6, 707, 708, 718 denial, 12, 295, 494, 535, 536, 731 Denzin, N., 747 departments and agencies, U.S. See key word, e.g. Defense Department dependency, 132, 634 dependent variables, 760, 780 depersonalization, 95 depression, 9, 766 battered women and, 445, 448, 450 bereaved children and, 380, 382 caregivers and, 704, 706, 713

children/adolescents and, 147, 327, 380, 382 as crisis reaction, 12, 17, 130 divorce and, 654, 659, 661, 662, 663 HIV positive women and, 690–91 impostor phenomenon and, 428 patients in medical crisis and, 634, 636 posttraumatic stress disorder and, 162–63 rape and, 130 somatic distress and, 123, 124 stalking and, 487 stress and, 93, 269 substance abuse and, 580, 663 suicide and, 38, 406, 662, 663 derealization, 95 Derogatis Symptom Checklist SCL– 90, 154 de Shazer, S., 68 desoxyn. See methamphetamine despair, 9 detoxification programs, 555, 584, 588 developmental burden, caregivers and, 708–9, 713 developmental crisis, 682, 687 developmental psychology, 331, 362, 362–63, 378, 388, 390, 401 developmental stages, 378, 388, 390, 401 developmental tasks family crises and, 132 transitional stress and, 126–27 diabetes mellitus, 633 Diagnostic and Statistical Manual of Mental Disorders, 98, 99, 125, 154, 163, 327, 569, 573, 757, 758 Dictionary of Goal Attainment Scaling, 752 DiLorenzo Healthcare Clinic, 208 Dimercaprol, 182 diphosgene, 182 dirty bombs, 177, 183–84 disappointment, 23, 656 disaster mental health, 5 ACT model and, 143–67 early intervention literature on, 202–3

814

Index

disaster mental health] (continued) emergency responder families and, 246–58 grief therapy and, 146, 279–89 group crisis intervention innovations and, 221–41 Pentagon terrorist attack aftermath and, 146, 200–218 posttrauma intervention basic tasks for, 291–301 terrorism first responders and, 145, 171–97 U.S. bioterrorism response and, 146, 262–76 disasters, 4, 6, 161 mass incident victims of, 221 psychiatric triage and, 43, 151–52 response and recovery phases and, 204–5, 206, 208, 210, 214 disbelief, 12, 130 discomfort, 13, 19 discrete event crises, divorce and, 656–57, 672 disequilibrium crisis and, 11, 13, 66, 67, 84, 273, 280, 489, 495, 530, 725, 744 crisis state assessment and, 732 definition of, 780 equilibrium restoration after, 14– 15, 54, 66, 81–82, 273, 495 HIV positive women and, 682, 698 substance abuse and, 580 Disillusionment Phase, disasters and, 205, 210, 214, 215 dismantling treatment strategy, 780 disordered thoughts, 95 disorganization, as bereavement phase, 280 disorientation, 9 dissociation, definition of, 780 dissociative disorder, 147 dissociative symptoms, 95, 147, 273 distance, first responder attention to, 185, 186 distress early intervention and, 203 psychological, 162 somatic, 120, 122, 123–25, 295 stalking victims/survivors and, 488, 495

district-level crisis intervention team, 505, 780 divorce, 650–75 adolescents’ experience with, 366–67 adolescents’ feelings of loss and, 362, 371–77, 389 battered women and, 450 as crisis, 656–58, 668 crisis risk assessment and, 661–63, 665, 667 emergency responder rates of, 248–49 factors in increased rates of, 653–54 mental health risks and, 654 psychosocial needs and, 658–61 rates of, 652–54, 675 seven-stage crisis intervention model and, 665–75 strengths/resilience/protective strategies and, 663–65 Dohrenwend, B. P., 93–94 Dohrenwend, B. S., 93–94 domestic violence case example of, 30–32 emergency room protocol for, 552 as family crisis, 132 hotlines for reporting, 27–29, 30, 441, 464–65 imminent danger assessment for, 21, 22 medical crises and, 634 police-based crisis teams for, 459– 61, 465 prevalence of, 5 solution-focused therapy and, 85 specialized police units for, 454–56 stalking and, 486 technological aids in dealing with, 456–59, 473–75 trauma and, 161 zero tolerance for, 447–48 See also battered women; child abuse and neglect; elder abuse domestic violence units, police departments and, 454–56, 459–61, 465 Donate a Phone Program, 457 dopamine, 93, 225 dosing technique, 449

Index 815 Double ABCX adaptation model, 287 Dozois, D. J., 370 DP. See diphosgene dream question, 71 drinking. See alcohol abuse or dependency drug assessments, 158 drugs (therapeutic). See medication drug use (illicit) as adolescent suicide risk factor, 407 by battered women, 467 date rape and, 417, 418–19, 420, 423, 779 divorced/separated people and, 660, 663 HIV and, 691 incidence and prevalence of, 570, 571–72 medical crises and, 634 mental illness and, 571 overdoses and, 136, 398, 399 as school violence risk factor, 524 sexual assault and, 445 sexual behavior and, 660 by survivors, 285 DSM-IV-TR. See Diagnostic and Statistical Manual of Mental Disorders Dunteman, G., 568 Dyches, H., 613 dysthymic disorder, 634 Dziegielewski, Sophia F., 6, 12, 19, 146, 262–76, 484, 530, 742–69 EAPs. See employee assistance programs early intervention, 202–4 application of, 204 further research on, 217–18 literature review, 202–3 principles of, 203–4 Eaton, Yvonne, 106, 153, 160–61, 619–31 EBAM. See evidence-based addiction medicine Ecstasy (drug), 570 education course work in crisis intervention training, 148–49, 356

as crisis intervention, 125 in Pentagon attack aftermath, 211–12 posttrauma intervention and, 295–96 See also psychoeducational interventions; training programs Education Department, U.S., 267 efficacy expectation, 729 Egan, G., 379 ego fragmentation, 780 ego psychology, 17, 687, 725 elder abuse, 552, 708, 710, 718 electronic monitoring, battered women and, 457–58, 459, 473, 474 Ell, K., 726 Ellison, K., 13 embarrassment, caregivers and, 710, 713 EMDR. See eye movement desensitization and reprocessing emergency medical intervention, 399 emergency medical services, 614 emergency medical technicians critical incident stress management for, 236, 237 exposure to suffering and death of, 247, 248 families of, 250 as first responders, 175, 184, 186, 187, 191, 192, 196–97 psychiatric emergencies and, 137 emergency mental health, 222 emergency psychiatric services, 604–5 crisis stabilization and, 628–30 hospital-based, 11, 32, 604 emergency responders, 6 critical incident stress debriefing for, 228 divorce rates for, 248–49 early intervention for, 204 emotional numbing and, 255–56 exposure to suffering and death of, 247–48, 254 families of, 6, 190–91, 246–58 family crisis response programs and, 257–58 family preventive programs and, 256–57

816

Index

[emergency responders] (continued) intervention needs and, 205–6 organizational culture and, 250, 255 stressors for, 248, 249–50 See also first responders emergency rooms, 11, 32, 543–64 battered woman treatment at, 445, 462–64, 474–75, 477, 552 crisis intervention protocol of, 549–55 definition of, 781 incidence and prevalence estimates and, 547–50, 604 seven-stage crisis intervention model and, 556–62, 563 social workers and, 546, 547, 549, 550–64 visits to daily, 633 emergency services, school crisis response programs and, 506, 510 emergent, definition of, 781 emotional abreaction, 230 emotional burden, of caregivers, 709– 10, 713 emotional detachment, 95 emotional exhaustion, 250, 535, 634 emotional first aid, 222 emotional intimacy, 132 emotional numbing, 255–56 emotional well-being, school crisis response initiatives for, 505 emotion-focused coping, 353, 453 emotion labeling, 159 emotions exploration of. See feelings and emotions, exploration of positive view of, 669–70, 674–75 empathy, 12, 273, 400, 644 hotline workers and, 29, 49, 54 in solution-focused therapy, 69 for stalking victims/survivors, 492, 493, 494 employee assistance programs (EAPs), 210, 237, 768 emergency responder families and, 257 first responders and, 191–92, 197, 208, 236 school staff and, 515–16

employment skills training programs. See vocational training empowerment, 67, 70, 77 Four-S model of, 299–300 posttrauma intervention and, 299–300 strengths perspective and, 451, 664 emptiness, suicide risk and, 406 empty-chair technique, 671 EMS (emergency medical services), 614 end-stage renal disease, 635 environmental crises, 505 environmental model, 226 Epictetus, 723 Epstein, Laura, 107, 161 equilibrium internal, 730, 731 restoration of, 14–15, 54, 66, 81– 82, 273, 495 Ericsson, 457 Erikson, Erik, 127, 362, 687 erotomania, 487 Ertl, B., 106, 160–61 Etheridge, R., 568 ethical issues, 769 of consent, 389, 390, 422 of suicidal adolescent hospitalization, 403 in work with adolescents, 388, 389–90 Ethiopia, 178 Evans, M. E., 330 Evans, M. R., 324 Evans, W., 747 Everly, George S., Jr., 98, 145–46, 213, 221–41, 630 evidence-based addiction medicine, 593 evidence-based practice crisis intervention evaluation designs and procedures and, 742–69 social workers and, 564 substance dependence treatment and, 592–94 evidence-based research, 363 Crisis State Assessment Scale, 723–39 exception questions, 74, 75–76, 159, 338, 353, 588–89, 781

Index 817 excitatory toxicity, 225, 781 exercise, 273, 375–76, 449, 710 exhaustion, 9, 92, 709 emotional, 250, 535, 634 experts, clients as, 69 expressive therapies, 345 extensive designs, research, 759–60, 781 extroversion, 452 eye movement desensitization and reprocessing (EMDR), 131, 165, 489 Eyman, J., 757 failure, handling of, 23 Fairchild, T. N., 15 families blended, 653 of caregivers, 709 as catastrophic event , 535 critical incident stress management for, 630 cultural views of, 388 death in, 7, 9, 16, 23, 367, 378–87 divorce effects on, 652 of emergency responders, 6, 190– 91, 246–58 of emergency room patients, 545– 46, 550–51 as impostor phenomenon factor, 429, 432 of Pentagon attack victims, 201, 212–16 of people in medical crisis, 634–35, 640, 646–47 of September 11 attack victims, 282–83, 284, 287–89 of stalking victims/survivors, 493 unresolved grief in, 129 See also children; parents; spouses family art therapy, 345 family assistance centers, 201, 212, 213, 214–16 family-centered treatment, mobile crisis response and, 321, 328, 344– 48, 356 family crisis intervention in, 233 stress-crisis continuum and, 120, 122, 131–33

family preservation programs (FPPs), 324–25, 329, 346 family therapy, 275, 411, 637, 641 Family Violence Center, 469 fantasies, 401, 402, 484 Farberow, Norman, 18 fatigue, 295, 406. See also exhaustion Fawcett, J., 46–47 FBI. See Federal Bureau of Investigation FDA. See Food and Drug istration fear, 9, 275 as crisis reaction, 12, 13 of death, 163 divorce and, 656, 661 emergency responder families and, 253–55, 258 as family crisis response, 132 of school violence, 523 stalking victims/survivors and, 488 terrorist attacks and, 268 as traumatic event response, 268, 295 weapons of mass destruction and, 179, 183 Federal Bureau of Investigation, 4, 128, 178, 187 Federal Emergency Management Agency, 177, 187, 195 feelings and emotions, exploration of, 23, 66–67, 133 active listening to, 23, 285, 373, 379, 432 addiction treatment and, 577, 584, 588 adolescent suicidality and, 407–8 caregivers and, 715–16 child/adolescent psychiatric emergencies and, 337, 344–45, 351–53 college student counseling and, 425, 432 comprehensive crisis intervention model and, 622, 623–24, 625, 629 in critical care areas, 644 disaster mental health and, 157, 273–74, 284–85 divorced/separated people and, 669–72

818

Index

early adolescents suffering from loss and, 373–74, 379–80 emergency room crisis interventions and, 560 HIV positive women and, 697–98 mobile crisis unit interventions and, 610, 611 school violence interventions and, 531 stalking victims and, 494 suicidal ideation crisis intervention and, 53–54, 57 validation of, 285, 352–53, 494, 644, 716 feelings identification charts, 515 Feldman, S., 121 FEMA. See Federal Emergency Management Agency females. See women fight or flight response, 93, 535 Figley, Charles R., 130, 216 Finley, C., 419 Finn, E., 26–27 firearms. See gun violence firefighters exposure to suffering and death by, 247–48 as first responders, 175, 184, 186, 187, 191, 192, 193, 196–97 spouses of, 253 Firestone Assessment of Self-Destructive Thoughts, 45 first responders, 5 critical incident stress management and, 106, 206, 208, 236 debriefing by, 6, 41, 43, 150 domestic violence units as, 454 intervention needs and, 205–6 New York Disaster Counseling Coalition and, 5, 145, 193–96, 197 posttraumatic stress disorder and, 191, 248, 252 safety issues for, 184–87 terrorism and, 145, 171–97 traumatic impact on, 189–93, 197 See also emergency responders Fischer, J., 663, 756, 757 Fisher, R. K., 606, 611 Fisher, W. H., 612–13 Fisher-McCanne, L., 417

Flaherty, E. W., 464 Flannery, R. B., 240 flashbacks, 9, 449 Fleming, S. J., 280 Flomenhaft, K., 223 floods, 161 Folkman, S., 452, 453, 726–29, 730 follow-up, 25, 67, 133 addiction treatment and, 581, 585, 592 adolescent suicidality intervention and, 411 with caregivers, 717 child/psychiatric emergencies and, 339–40, 347–48, 355 in college student counseling, 426, 433–34 comprehensive crisis intervention model and, 622, 624, 625–26, 630 critical care areas and, 645 in critical incident stress management, 233, 236, 238, 630 disaster mental health and, 157, 274–75, 286–87 divorced/separated people and, 675 early adolescents suffering from loss and, 377, 382–83 emergency room crisis intervention and, 558, 561 HIV positive women and, 699 mobile crisis unit interventions and, 610, 611, 612 school crisis interventions and, 515–16 school violence interventions and, 532–33 solution-focused therapy and, 84 stalking victims and, 496 strengths perspective and, 160 suicidal ideation crisis intervention and, 54, 58 Fonagy, P., 327, 328, 347 Food and Drug istration, 692 Ford, A. B., 706 Ford, W., 568 Formal Operational Stage, 378 formula first session task, 80 Fosha, D., 363

Index 819 Foundling Hospital (N.Y.C.), 29 Four-S model, 299–300 FPPs. See family preservation programs framing, posttrauma intervention and, 295 , 177 Frankl, Viktor, 227 Fraser, J. S., 66 fraternity parties, 420 Freedy, J. R., 534 Freeman, A., 667 Frey, R., 591 Friedman, M., 94 frozen fright, 634 frustration, impostor phenomenon and, 428 Fukuyama, M. A., 417 Funk, W. W., 427 fusion inhibitors, 688, 692 future orientation, 272, 493 GA. See Tabun GAF. See Generalized Assessment of Functioning Gaines, A. D., 706 Gallagher, R. P., 416 Gallagher-Thompson, D., 704, 705 Gallo-Silver, 763 gamma-aminobutyric acid (GABA), 225 gamma hydroxybutrate (GHB), 418 Ganellen, R. J., 428 Gardner, Carol, 310 GARF. See Global Assessment of Relational Functioning Garland, David, 311 Garmezy, N., 330 GAS. See Goal Attainment Scaling gaseous poisons. See poison gases gas masks, 181, 185 Gawin, F., 591 Gay, R. Derrill, 614 Gaynor, J., 607–8 GB. See Sarin GD. See Soman Geldard, D., 380 Geldard, K., 380 Geller, J. L., 612–13 Gelles, R., 521

gender of AIDS-infected persons, 684 coping and, 369 impostor phenomenon and, 428 posttraumatic stress disorder and, 369 of rape victim counselors, 422 resilience and, 370 role socialization and, 421 school violence intervention and, 533 severe mental illness rates and, 571 stalking and, 486 suicide victims and, 397–98 See also men; women general adaptation syndrome, 92 General Health Questionnaire, 247 generalized anxiety disorder, 162, 165, 448 Generalized Assessment of Functioning, 757–58, 767 Generalized Contentment Scale, 661 genetic disorders, 524 genetics, psychiatric disorders and, 328 Georgia, 605–6, 608–9, 613, 614 Geo Satellite Positioning Equipment, 458 German, P. S., 710 , 177, 178 GHB (gamma hydroxybutrate), 418 GHQ. See General Health Questionnaire Gidycz, C. A., 419 Gill, A. M., 416 Gilliland, B. E., 726, 744 Gingerich, W., 68 Giordano, F. G., 708 Gitterman, A., 152–53 Glaser, B. G., 545 Global Assessment of Relational Functioning, 758, 767 glutamate, 225 Goal Attainment Guide, 752–53, 754 Goal Attainment Scaling, 154, 751– 55, 781 goal setting, 70–72, 346–47, 751 Golan, Naomi, 14, 18, 19 Goldman, L. S., 634

820

Index

Goldstein, A. P., 522 Goodrich, Peter, 305–13, 315, 316, 317 Goodrich, Ronnie Mills, 305–13, 315, 317, 318 Gordon, J., 443, 580 Gottlieb, B. H., 707 Granvold, Donald K., 650–75 gratification, delay of, 401 Grau, J. J., 725 Grauerholz, E., 420 Great Britain, 177, 178 Greene, Gilbert J., 32, 64–85, 323, 353, 451 Gregoire, Thomas K., 555, 566–96 grief and mourning, 7, 9, 23, 129, 274 adolescents and, 367 anticipatory, 282 bereavement phases and, 280–81 children and, 363, 367–68, 378– 79, 380, 382, 389, 508, 531, 536 as crisis reaction, 12 differentiation of, 145 grief work and, 16, 129, 287 guilt and, 790 memorialization and, 214, 216, 508–9, 783 normal, 784 over divorce, 659 phases of, 280–81 posttrauma intervention and, 296–97 related reactions to, 16, 129 school crisis response initiatives for, 505 seven-stage model of intervention for, 371–77 suicide risk and, 662 of surviving family , 212 trauma and, 280 unresolved, 129 grief theory, 279, 280–81 grief therapy, 146, 279–89 grief work, 16, 129, 287 grieving. See grief and mourning Griswold, John T., 637, 639 group crisis intervention, 6, 93 cautionary considerations for, 238–41 for community , 209–10

critical incident stress management and, 630 for emergency responders, 206 historical background of, 221–23 innovations in, 221–41 in Pentagon attack aftermath, 211, 217 for surviving family , 213–14 task-based posttrauma intervention model of, 291–301 group identity, student, 525 group therapy, 275 for children of battered women, 472 family crises and, 133 for impostor phenomenon, 433 for rape victims, 422, 426 serious mental illness and, 135 See also and self-help groups Guest, C., 710 guided imagery, 449, 667 guilt, 9, 174, 272 bereavement and, 790 divorce and, 656 rape victims and, 419 as traumatic event response, 268 gun violence, 366, 522, 523 suicide and, 397, 409–10 See also homicide Guo, S., 613 HAART. See highly active antiretroviral therapy Hadfield, Chris, 253–54 Hails, J., 607, 614 Haley, W. E., 704 Hall, D. M., 488 Hall, S., 580 hallucinogens, 570, 573 Hansel’s Law, 110 harassment statutes, 484 Harborview Medical Center (Seattle), 462, 464 Hardcastle, D. A., 765 Hardesty, S. J., 614 Hargreaves, W. A., 607–8 harm/loss appraisals, 728 Harrison, Diane M., 682–700 Hartman, D. J., 750

Index 821 hashish, 570 Haug, M. R., 706–7 Haugh, R., 356 Havassy, B., 580 Haven House (Buffalo, N.Y.), 472 Hayden, D. C., 367 healing, strengths perspective and, 451 Health and Human Services Department, U.S., 5, 28, 267, 524, 604 health and well-being, of caregiver, 704–7, 710–11, 712 health maintenance organizations, 768 Hearn, K., 472 heart disease, 93, 94 helplessness, 9, 12, 130, 268 learned, 132 suicidal behavior and, 404, 406 Henry, Vincent E., 145, 171–97 Heroic or Rescue Phase, disasters and, 205, 206, 208, 214 heroin, 570, 571, 572, 587 Hersen, M., 760 Hickey, Eric, 484 hierarchy of needs, 226–27, 238, 534–35, 783 highly active antiretroviral therapy (HAARI), 688–89, 692 hijacked airplanes, 177 Hill, Reuben, 279, 287 Hillman, J. L., 365 Hipple, J., 400, 402 hippocampus, 225 Hippocrates, 15 Hirsch, C. H., 710 Hispanics, 682–84, 706 HIV, 635, 660, 763 antiretroviral therapy and, 682, 688–89, 691–92, 776 crisis states and, 686–88 drug abuse and, 691 pregnancy and, 689–91 resilience/protective factors and, 692–93 seven-stage crisis intervention model and, 693–99 sex work and, 691 women infected with, 682–700 See also AIDS HIV trajectory, 682, 687, 691, 781 HIV viral load, 781

HN. See nitrogen mustard Hoff, L. A., 345, 399, 409 Holmes, Thomas, 93 Holocaust survivors children of, 252–53 posttraumatic stress disorder and, 162 Homeland Security First Responder study, 318 homelessness adolescents and, 322, 348–55 emergency room protocol for, 554 mobile crisis units and, 606 homeostasis, 14, 23, 94, 271, 489, 495, 725, 731, 744 crisis intervention and, 16, 54, 274, 751 homework tasks client strengths enhancement and, 64 crisis intervention and, 67 in solution-focused therapy, 79–80 homicide adolescent victims of, 366 divorce/separation and, 661, 662, 667 as psychiatric emergency, 136 rates of, 4 risk assessment of, 153, 158, 340– 43, 694, 726 school violence and, 522, 523, 534 stalkers and, 484, 487 homophobia, 687 Honeymoon Phase, disasters and, 205, 206, 208, 214 hope, 18, 19, 272 hopelessness, 9, 66 divorce and, 659, 661, 662 suicide and, 38, 403, 404, 406, 407, 408, 662 hospitals, 11 critical and intensive care units, 632–48 mobile crisis services and, 324, 612–13 suicidal adolescents’ issions to, 403, 411 See also emergency rooms hotlines, 10–11, 25–32 battered women, 30, 441, 443, 464–65

822

Index

[hotlines] (continued) call volume, 11, 28–29 child abuse, 29, 30 domestic violence, 27–29, 30, 441, 464–65 parental stress services, 29 resources available to, 21 solution-focused technique used by, 85 suicide prevention, 18, 21, 26, 27, 47 telephone crisis services, 619, 620– 22, 789 types of, 26–27 verbal and, 159 hot zone, WMD events and, 185 House Armed Services Committee, U.S., 267 “How Are You Feeling Today?” chart, 337 Hubbard, R., 568 human immunodeficiency virus. See HIV humiliation, 487 humor, 349, 352, 714 Humphreys, K., 591 hurricanes, 161, 729 Hussein, Saddam, 179 hypermasculinity, 421 hypervigilance. See startle reaction ICISF. See International Critical Incident Stress Foundation ICU psychosis, 643 identity, adolescent, 362 idiographic research, 759–60, 764, 768, 781 “I don’t know” technique, 350–51 IDUs. See intravenous drug s IES. See Impact of Events Scale “if only” perspective, 285 Ilardo, J. A., 710–11 illness, mental. See mental illness illness, physical somatic distress and, 120, 122, 123–25, 295 stress and, 93, 94 imagery and guided discovery, 671 imaginary dialogues, 671 Imes, S. A., 427, 428, 429

immigration, terrorism and, 262–63, 264–65 imminent danger assessment of, 21–22, 41, 49 battered women and, 459, 465, 473 suicide and, 399, 403 immobility, 332, 342 immune system of caregivers, 707 HIV/AIDS and, 682, 687, 688, 690 stress and, 94 Impact of Events Scale, 154, 247, 729 Impact Phase, disasters and, 205, 208 impatience, of emergency responders, 250 imposter phenomenon, 426–34, 781 improvised nuclear devices (INDs). See dirty bombs impulse control, 524 impulse control disorder, 487 impulsivity, adolescents and, 401, 405, 407 incest, 147, 161, 782 incontinence, 710 independent variables, 760, 782 Index of Clinical Stress, 736 individual therapy, 127, 275, 484 INDs (improvised nuclear devices). See dirty bombs infants, HIV/AIDS, 685, 690 information and referral (I and R) services, 26, 461, 782 informative change, 292 informed consent, 238, 389 Ingala, Ann M., 362–90 injuries to battered women, 449, 474 photographic records of, 474–75 from plane crashes, 8 instant cameras, 473, 474–75 Institute of Medicine, 122 intake forms, 104, 152, 163 integrating, posttrauma intervention and, 299 intensive care units. See critical and intensive care units intensive designs of research, 759–60, 764, 768, 782 intensive outpatient program, 782 interactional stress theory, 724

Index 823 internal locus of control, 370, 452 internal validity, 760, 763, 782 International Critical Incident Stress Foundation, 106, 161, 209, 222 intervention period, definition of, 782 intervention priority code, definition of, 782 Intervention Priority Scale, 44, 152, 331, 343 intimate partner abuse. See battered women; domestic violence intravenous drug s, HIV transmission and, 691 intrusive imagery, 9, 448, 449, 450 intrusive psychological reexperiencing, 224 IOP. See intensive outpatient program IP. See imposter phenomenon Iran, 179 Iraq, 178, 179, 221 irrational beliefs, 67 irrelevant appraisals, 728 irritability, 9, 95, 252, 268, 295 isolation, 434 adolescent suicide risk and, 406, 410–11 caregivers and, 708, 713 divorce and, 659, 663, 665 impostor phenomenon and, 430 Italy, 178 “It’s not you, it’s them” concept, 338 Jackson, T., 445 James, R. K., 726, 744 Janet, Pierre, 223–24 Janoff-Bulman, R., 226 Janosik, E. H., 446 Japan, 178, 179 Jaya, A., 68 Jersey Battered Women’s Service (N.J.), 470–72 jitteriness, as traumatic event response, 268 Jobes, David, 757 Jobes, David A., 395–412 Johnsen, J., 613 Johns Hopkins Center for Civilian Biodefense Studies, 267 Johnson, Eric D., 146, 279–89 er, T., 47, 334, 335

ing, solution-focused therapy and, 69–70 Jones, W. A., 466 Jordan, K., 253 journaling, 426, 449 jumpiness, as traumatic event response, 268 Juris Monitor ankle bracelets, 458 Justice Department, U.S., 419, 633 Kahler, C., 591 Kail, B., 585 Kalafat, John, 107 Kaloupek, D. G., 369 Kanaan, S. B., 633 Kanel, K., 335 Kanin, E. J., 421 Kardiner, A., 224–25 Karver, M., 615 Kaslow, F. W., 658 Kastburg, S. M., 429 Kaul, Rachel E., 146, 165, 200–218 Kazdin, A. E., 748 Keane, T. M., 369 Kelley, Patricia, 121 Kennedy family, 563 Kidd, S. A., 353 kidnapping, 450 Kiesler, D. J., 745 Kilpatrick, D. G., 534 Kimball, C. P., 634 King, J. E., 428, 429 King, T., 705 Kiresuk, T. J., 751 Klein, D., 327 Klein, James F., 416–34 Klingbeil, Karil, 462, 464 Knox, Karen, 483–96 Korkeila, K., 346 Kormanik, M. B., 299 Koss, M. P., 419 Kowalski, K., 75 Kral, R., 75 Kroll, J., 163 Krumholz, Susan T., 456 Kurds, 178, 179 L. See Lewisite Labor Department, U.S., 267 Labouvie, E., 591

824

Index

Lamb, H. R., 613 Lambie, G. W., 349 Lane, J., 487 Langsley, D., 223 language, in -focused therapy, 69 large group interventions, 206, 210, 211 Latina AIDS cases, 682–84 Lating, Jeffrey M., 145–46, 221–41 law enforcement agencies, 187 mobile crisis services and, 324, 342, 343 mobile crisis units and, 607, 608–9, 610, 613–14 specialized domestic violence units and, 454–56 stalking victims/survivors and, 489, 490 See also police departments Law Enforcement Assistance istration, 460 lawyers. See legal issues Lazarus, Arthur, 121 Lazarus, R. S., 368, 452, 453, 655, 726–29, 730 learned helplessness, 132 learning theory, 17 Leary, M. R., 427, 429 Lee, Mo-Yee, 32, 64–85, 323, 353, 451 legal issues battered women and, 443, 450 restraining orders and, 450, 457, 458, 473, 474 stalking and, 484, 485 suicidal adolescent hospitalization and, 403 work with adolescents and, 389– 90 Lerner, Mark D., 96–97, 106, 147– 48, 164, 166 Lerner, R. M., 362–63 lethality definition of, 782 of suicide methods, 404–5 lethality assessment, 5, 21–22, 41, 66, 133, 726 adolescent suicidality and, 398–400 for caregivers, 713

child/adolescent psychiatric emergencies and, 332–34, 340–43, 348–50 comprehensive crisis intervention model and, 621, 623, 625, 629 in critical care areas, 643 disaster mental health and, 155–56, 270–72 for divorced/separated people, 662– 63, 667 early adolescents suffering from loss and, 364, 372, 378, 385 emergency psychiatric treatment and, 151 emergency room crisis intervention and, 557, 559 for HIV positive women, 694 mobile crisis units and, 609, 610, 611, 612 school violence interventions and, 528–29 in solution-focused therapy, 70 for stalking victims, 491–92 for suicidal clients, 35–61, 137, 153, 270, 271, 398–400 suicidal ideation crisis intervention and, 51–52, 56 Let’s Talk It Over (coloring book), 470, 471–72 Levenson, R., 251 Lev-wiesel, R., 162 Levy, S. M., 125 Lewinsohn, P. M., 327 Lewis, Sarah J., 153, 682–700, 723–39 Lewisite, 181–82 liability abatement, police agencies and, 191–92 Liddell, D. L., 421 Lifetime Parasuicidal Count, 45 Lifton, Robert Jay, 189–90, 226 Ligon, Jan, 602–15 limbic system, 225 Lindemann, Erich, 15–16, 17, 129, 227, 725, 744 Linehan Reasons for Living Scale, 45 Linton, M. A., 420 listening skills. See active listening Litwak, E., 585 logotherapy, 227

Index 825 loneliness, divorced people and, 659, 661 longitudinal follow-up studies, 167 Longview (Wash.) Police Department, 455 Loos, battle of (1915), 177 Los Angeles Police Department, 487 Los Angeles Suicide Prevention Center, 18 loss, feelings of adolescents and, 362–90 crisis intervention/grief therapy, and, 279–89 as crisis reaction, 12 divorce and, 656, 657, 659, 662, 671 school crisis response initiatives for, 505, 508 suicide risk and, 406, 662, 663 See also grief and mourning loss counseling, 146, 214 loss of meaning, 297 love obsessional stalking, 487–88 LSD (lysergic acid diethylamide), 782 Luthar, S. S., 330 Lyons, J. S., 615 Machotka, P., 223 MacNeil, Gordon, 519–37 Madison (Wis.) Police Department, 459 Maggio, M., 631 Mahrer, A., 563 major depressive illness, 634 maladaptive coping, 23 maladaptive reaction, 782 males. See men Malouff, J. M., 756 managed care, 356, 411, 738, 751 brief (time-limited) therapy and, 767, 768 critical care unit reimbursements by, 647–48 definition of, 783 mental health care and, 121, 122 mobile crisis unit and, 603, 605, 615 substance abuse treatment and, 568–69 manic-depressive illness. See bipolar disorder

Mantz, R. J., 660 marijuana, 570, 571, 572 Marlatt, G., 580 marriage. See families; spouses Martin, Catherine E., 395–412 Mash, E. J., 370 Maslow, Abraham, 226–27 hierarchy of needs, 226–27, 238, 534–35, 783 Mason, J. W., 91–92 Massachusetts General Hospital, 15– 16, 129 mass disaster victims, 221 mass hysteria, 239 Masten, C. A., 330 Masters of Social Work (MSW) programs, 149 matching, in solution-focused therapy, 69 Matthews, G., 429 maturing process, early adolescents and, 368 McBride, Joseph, 146, 279–89 McCauslan, P., 420 McCrady, B., 591 McCubbin, Hamilton, 287 McDermeit, M., 612 McDermott, Virginia, 543–64 McFarlane, A., 247 McGee, R. K., 110 MCUs. See mobile crisis units Measures of Clinical Practice (Corcoran and Fischer), 756 Mechanic, D., 124, 125 media domestic violence awareness campaigns by, 29 school crisis response teams and, 508 school violence portrayals by, 522, 534 medical assessments, 41, 158 medical crises, 633–35 medical intensive care units, 635, 637 medical social workers, 464, 489, 490 medical triage, 43, 151, 548 medication acute psychotic episodes and, 328 critical care patients and, 640 healing facilitation and, 271

826

Index

[medication] (continued) psychiatric emergencies and, 137 serious mental illness and, 135 suicidal adolescents and, 409, 410, 411 traumatic stress crisis and, 130 See also specific medications Meisler, N., 614 memorialization, 214, 216, 508–9 definition of, 783 memory loss, 95 men coping by, 369 hypermasculinity and, 421 impostor phenomenon and, 428 rape-ive attitudes of, 420–21 resilience and, 370 severe mental illness rates for, 571 stalking and, 486, 487, 492 suicide incidence for, 397–98, 604, 654 trauma exposure lifetime prevalence for, 221–22 mental disability, 85 mental health care, 121, 122, 124 mobile crisis units and, 27, 52, 602–15, 783 See also disaster mental health mental health workers Pentagon attack and, 206–8, 210–17 trauma contagion and, 251 World Trade Center attack and, 188–89, 193 mental illness as adolescent suicide risk factor, 406–7 battered women with, 467 child/adolescent crisis intervention and, 323–28, 331, 332–48, 356 genetics and, 328 HIV infection and, 691 increase in, 4 in parents, 328, 336, 356 prevalence of, 4, 570–72, 604 stalking and, 487 stigma attached to, 636 stress and, 93

stress-crisis continuum and, 120, 122, 133–35 suicide and, 604 See also specific disorders Messick, J., 160 methamphetamine (methedrine), 158, 783 methylphosphonothioic acid, 180, 181 microtheory of personal and social problems, 727 MICUs. See medical intensive care units Milburn, M. A., 421 military, U.S., 187 combat neurosis and, 16 crisis intervention programs of, 222 critical incident stress debriefing by, 228 posttraumatic stress and, 221 Vietnam War veterans and, 98, 252, 253 See also Department of Defense, U.S.; war Miller, D. G., 429 Miller, W., 585 Millon, Theodore, 231–32 Mills, Linda G., 146, 305–18 minimal encouragers, 432, 493 miracle question, 23, 71–72, 346–47, 589–90, 783 miracle task, solution-focused therapy and, 81, 346–47 Miranda, J., 124–25 mirroring, 69 Mishne, Judy, 313 Mitchell, Jeffrey T., 98, 145–46, 221–41 Mittelman, M., 715 mobile crisis services child/adolescent psychiatric emergencies and, 319–57 comprehensive crisis intervention and, 619, 624–26 continuum of care and, 325, 326 definition of, 783 organization and structure of, 324–25 preexisting mental illness and, 323– 28, 331, 332–48, 356 seven-stage crisis intervention model and, 320–23, 331–55

Index 827 mobile crisis units (MCUs), 27, 602–15 definition of, 606, 783 development of, 606–7 future opportunities for, 614–15 initiating and sustaining of, 613– 14 law enforcement agencies and, 607, 608–9, 610, 613–14 outcome information for, 612–13 seven-stage crisis intervention model and, 609–12 staffing and service delivery approaches, 607–8 suicide risk assessment and, 52 modeling, battered women and, 449 Modified Scale for Suicide Ideation, 45 Monitoring the Future Study, 587 Montgomery, R. J. V., 707 moodiness, as traumatic event response, 268 Moos, R., 591 Morgenstern, J., 591 Morrison, J., 327 Morrissey, J. P., 608 mortality. See death Morycz, R., 704 Mothers Against Drunk Drivers, 299 Motorola, 457 motor vehicle accidents, 5, 547–48, 604 mourning. See grief and mourning Moynihan, 763 MSW program, 149 Muehlenhard, C. L., 420 multiaxial differential diagnosis, 49–50 multiple baseline approach, 763, 764, 783 multiple sclerosis, 633 Munoz, R., 125 murder. See homicide murder-suicide, 662 Murphy, Cindy, 459 Murray, H. A., 406 mustard gas, 178, 181 Myer, R. A., 321, 323, 331–32, 341, 351–53, 356

Nader, K., 369 NAMI. See National Alliance for the Mentally Ill narrative constructivist psychotherapy, 121 narrative theory, 133 Nassau County, N.Y., 458 National Alliance for the Mentally Ill, 347 National Center for Children Exposed to Violence, 504 National Center for Health and Statistics, 746 National Center for Post Traumatic Stress Disorder, 268 National Center for Victims of Crime, 418 National Coalition Against Domestic Violence, 457 National Crime Survey, 419 National Domestic Violence Hotline, 27–29 National Guard, 187 National Hospital Ambulatory Care Survey, 547–48 National Household Survey on Drug Abuse, 569, 571 National Institute for Healthcare Research, 654 National Institute of Justice, 444 National Institute of Mental Health, 5, 27, 44 Center for Studies of Suicide Prevention, 18 Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment, 363 National Institute on Drug Abuse Survey, 571 National Mental Health Association, 45 National Organization for Victim Assistance, 149, 209, 231, 535, 536 National Save-a-Life League, 15, 27 National Violence Against Women Survey, 444, 486, 488 Native Americans, women with AIDS, 682 natural disasters, 4, 161

828

Index

natural killer cells, 125 Nazis, 179 NBC (nuclear, biological, and chemical) weapons, 177 NCADV. See National Coalition Against Domestic Violence NDVH. See National Domestic Violence Hotline needs. See hierarchy of needs Neff, J. A., 660 negative self-talk, 67 neighborhood watch patrols, 457 Neimeyer, R. A., 657, 745, 746, 747, 748 nerve agents, 177, 178, 179–81 Net nanny, 783 neuroendocrine effector mechanisms, 225, 226 neurological hypersensitivity, 224–26 neurologic arousal, 224 neurotransmitters, excitatory, 225 Newgass, Scott, 499–517 New Haven (Conn.) Police Department, 503 New Jersey Division of Youth and Family Services, 470 New Jersey State Police, 187 Newman, John, 769 Newsom, J. T., 710 Newton, F. B., 416–17 New York City Adult Protection Services, 291, 293–300 New York City Department of Education, 504 New York City Department of Mental Health, 300 New York Disaster Counseling Coalition, 5, 145, 193–96, 197 New York State Police, 187 NHSDA. See National Household Survey on Drug Abuse Nicastro, A. M., 486 Nicholson, J., 356 Nietzsche, Friedrich, 227 nightmares, 268, 295, 448, 449 NIMH. See National Institute of Mental Health nitrogen mustard, 181 NK cells, 125 Noelker, L. S., 706

nomothetic research, 759–60 nonurgent, definition of, 784 nonverbal communication, mirroring of, 69 nonviolent crisis intervention, 620, 784 norepinephrine, 93, 225 normal bereavement, definition of, 784 North, C., 253 North American Emergency Response Guide, 186 notification/communication, school crisis response teams and, 506–8 NOVA. See National Organization for Victim Assistance Novak, M., 710 nuclear material, 177, 183–84 numbing, 224, 255–56, 298 as traumatic event response, 268, 295 Nunnally, J. C., 733 Nurius, P. S., 379, 532, 751 nutrition, 449, 710 nutrition therapy, 133 NVAW Survey. See National Violence Against Women Survey NYDCC. See New York Disaster Counseling Coalition objectified case studies, 784 obsessional stalkers, 484 obsessive-compulsive disorders, 22 occupational functioning, 38, 95 Occupational Safety and Health istration, 222 occupations, stress and, 92 OCDs. See obsessive-compulsive disorders Office of Homeland Security, 4 O’Halloran, M. Sian, 362–90 Ohio State University Hospital, 572 Oklahoma City terrorist bombing, 128, 253, 729 Oklahoma National Memorial Institute for the Prevention of Terrorism, 267 Older Americans Act, 717 older persons abuse of, 552, 708, 710, 718 caregiving for, 703–18

Index 829 Olweus, D., 521 one-down position, 69 one-on-one assistance for community , 208, 210 critical incident stress management and, 232–33, 236, 238 for first responders, 206, 236 for mental health providers, 217 for suicidal adolescents, 400 for surviving family , 212 “On Irritable Heart” (DaCosta), 98 online police information, domestic violence and, 458–59 open-ended questions, 23, 159, 340, 373, 374, 697 openness, 452 Operation Perseverance, 247 optimism, 18, 346, 370, 729 Order of the Rising Sun, 178 organic affective disorder, 634 organic mental disorder, 487 organismic model, 226 Orlando, A. E., 427 OSHA. See Occupational Safety and Health istration O’Toole, M. A., 427, 429, 430 Ottens, Allen J., 416–34, 703–18 outcome evaluation, 784 outcome expectancy, 729 outcome goals, construction of, 64 outreach to affected disaster communities, 210 early intervention and, 204 mobile crisis units and, 615 in Pentagon attack aftermath, 211– 12, 216 pain healing and, 270–71 self-injurious behavior and, 350 substance abuse and, 581–85 suicidal behavior and, 404, 407–8 Pan Am Flight 103 bombing, 281 panic, 271, 562 panic alarms, 457–58, 473 panic attacks, 450 panic disorder, 147, 445 Parad, H. J., 13, 19, 280 Parad, L., 280

paralysis of initiative, 784 paramedics. See emergency medical technicians parametric treatment strategies, 784 paraphrasing, 159, 335, 373, 379, 432 parents with alcohol problems, 371–77 of battered women, 450 child’s positive relations with, 346 child treatment confidentiality and, 389, 390 death of, 16, 367, 378–83 informed consent and, 389 lethality assessment and, 334, 341–42 with mental illness, 328, 336, 356 with posttraumatic stress disorder, 252 school notifications to, 508 stress hotline services for, 29 of suicidal adolescents, 406, 410 partial miracle question, 23 pastoral counseling services, 11, 32, 233, 236 past successes, 672 questions about, 74, 76–77, 159, 353, 354 Patton, K. M., 427 Paul, G. I., 745 P, 158 Peak, K., 455 pediatric intensive care units, 636 peer pressure, 525 peers adolescent’s relationships with, 368, 401, 406, 525 death of, 367 Pennsylvania State Office of Mental Health, 619 Pentagon, terrorist attack on (2001), 3, 144, 150, 166, 172, 175, 177 disaster mental health and, 146, 200–218 emergency responders to, 247 survivors of, 5 Pentagon Employee Referral Service, 208 perceived psychological trauma, 729– 32, 733, 736–38

830

Index

perception, as crisis state determinant, 13, 66 Perez-Stable, E., 124 perfectionism, 428, 433 personal growth, 12 personality disorders, 166, 407, 487 personal safety, 9, 268, 348 Person-in-Environment system, 154 perturbation, 784 pessimism, 370 Petretic-Jackson, P., 445 Pfefferbaum, B., 253 Pfeiffer, A. M., 745, 746, 747, 748 pharmacotherapy, 411. See also medication Phillips, J., 327 phobias, 22–23 phone counseling, 340–43, 356. See also hotlines phosgene, 182 phosgene gas, 178 phosgene oxime, 181, 182 physical abuse. See abuse; domestic violence; sexual assault physical disability, 85 physicians, critical care, 636–37. See also psychiatrists physiological responses, stress, 93 physioneurosis, 224 PICUs (pediatric intensive care units), 636 Pima County (Ariz.) District Attorney’s Office, 460 Pima County (Ariz.) Victim Witness Program, 460 Pinson, Donna Kirkpatrick, 703–18 plague, 183 plane crashes, 8 death anxiety and, 163 emergency responders and, 246–47 terrorism and, 3, 247, 281 See also September 11 (2001) terrorist attacks planning and intervention models, 144 plasma beta endorphins, 125 play therapy, 334, 388 Podgen, Deborah, 313 Poindexter, C. C., 686 poison control centers, 399 poison gases, 177–78, 179, 181–82

poison ingestion, 398 Polanyi, M., 294 Polaroid cameras, 474 Polemis, B., 19 police-based crisis intervention programs, 11, 25, 459–61, 465 police departments battered women and, 443, 454–61, 465, 473, 474, 477 emergency room social workers and, 551 as first responders, 175, 184, 186, 187, 191–92, 196–97, 454 imminently dangerous situations and, 399 information and referral services, 26, 461 liability abatement concerns and, 191–92 mobile crisis units and, 607, 608–9, 610, 613–14 online information dissemination by, 458–59 psychiatric emergencies and, 137 school crisis response teams and, 506 specialized domestic violence units, 454–56, 465 stresses encountered by, 248, 249, 250–51, 252 Pollin, I., 633 polythetic nature, of CISM approach, 232 Ponto, J. M., 563–64 Porritt, D., 223 Post, Robert, 225 postmodernism, 784 posttrauma intervention, task-centered model, 291–301 posttraumatic stress disorder, 5, 97– 98, 269 acute stress disorder vs., 98 battered women and, 445, 448–49 children with trauma and, 147 definition of, 97, 784–85 depression and, 162–63 differentiation of, 6, 90, 99–103, 112–14, 145 emergency responders and, 191, 248, 252, 253

Index 831 eye movement desensitization and reprocessing and, 165 gender differences in, 369 incest survivors and, 147 intervention innovations for, 221 intervention model for preventing, 106 patients in medical crisis and, 646 precipitating events for, 103 prevention of, 106, 281 rape and, 130 September 11 attack first responders and, 191 stalking victims/survivors and, 488, 496 trauma treatment and, 162, 163–64 two-factor model of acute stress and, 223–27 postvention, 785 potential danger, suicide and, 400 potentiating pairings, 231–32 powerlessness, 9, 66, 562 Powers, Gerald T., 742–69 practice wisdom, 767 Prato, Laura, 470 precertification, 647 precipitating events, 432 for battered women, 447, 449–50 for caregivers, 715 crises and, 23, 64, 66, 373, 489, 738 for divorce, 656 five-way diagram of, 102–3 patients in medical crisis and, 644 psychiatric emergencies and, 336– 37, 344, 345–46, 350–51 school violence and, 519–21, 530, 531 for substance dependence treatment, 576–77, 580 suicide and, 38, 53, 406 for trauma, 90–91, 103 See also triggers prediction task, 81 pregnancy HIV positive women and, 689–91 partner abuse during, 445 “presses” construct, 406 prevention, definition of, 785

prevention programs for emergency responder families, 256–57 for school violence, 524–25, 537 See also suicide prevention primary adolescent suicide prevention, 785 primary appraisal, 452, 655, 724, 727–30 primary care providers, mental health care and, 124 primary loss, 282, 283 Primeau, C., 608 privacy rights, 390 private sector, terrorist WMD attacks and, 187–89 problem definition, solution-focused therapy and, 70 problem-focused coping, 353, 453, 705 problem identification, 23, 66, 133 addiction treatment and, 576–77, 588 adolescent suicidality and, 401–7 caregivers and, 715 child/adolescent psychiatric emergencies and, 336–37, 344–45, 350–51 college student counseling and, 424–25, 432 comprehensive crisis intervention model and, 621, 623, 625, 629 in critical care areas, 644 disaster mental health and, 157, 272–73, 284 divorced/separated people and, 668–69 early adolescents suffering from loss and, 373, 379 emergency room crisis intervention and, 559–60 HIV positive women and, 695–97 mobile crisis units and, 609–10 school violence interventions and, 530–31 stalking victims and, 493 suicidal ideation crisis intervention and, 53, 56–57 problem solving, 672 adolescents and, 401, 408 crises and, 14, 16–17, 23, 738

832

Index

[problem solving] (continued) crisis intervention method and, 353–54 solution-focused therapy vs., 68 problem talk, 64, 68, 70 progressive relaxation, 449 Project Liberty, 195, 318 Project RISE, 462 Project Superwomen, 462 prostitution, 691 protease inhibitors, 688, 691–92 protective factors for acquaintance rape victims, 422–23 addiction and, 585, 591–92 battered women and, 450–53 for caregivers, 705 for children and adolescents, 330– 31, 349 for divorced/separated people, 665 for early adolescents, 369–71 for HIV-infected people, 692–93 impostor phenomenon and, 430 school violence and, 523–24 protective gear, for WMD event responders, 185, 187 protocol acute traumatic stress management, 143, 164, 166 adult abuse, 462–64, 775 definition of, 785 emergency room crisis intervention, 549–56, 560, 562 suicidal ideation intervention and treatment, 47–50 psychiatric clinics, 37 psychiatric disorders. See mental illness psychiatric emergencies crisis intervention programs and, 166 emergency room protocol for, 553–54 mobile crisis response to, 319–57 stress-crisis continuum and, 120, 122, 135–37 psychiatric services, emergency hospital-based, 11, 32 psychiatric treatment, emergency, 43– 44, 151

psychiatric triage, 43–44, 151–52, 398–99 psychiatrists psychological standing consults and, 640 World Trade Center attack response and, 188–89, 193 psychic stress, specific, 94 psychodrama, 671 psychoeducational interventions family crises and, 133 for first responders, 207 for traumatic stress crisis, 130 psychological distress, 162 psychological first aid, 203–4, 207, 222, 233 psychological hypersensitivity, 224, 226–27 psychological numbing. See numbing psychological stress, 276 psychological terrorism, 488 psychological trauma perceived, 730–32, 733, 736–38 standardized measurement of, 724 psychological warfare, 221 psychologists psychological standing consults and, 640, 641 World Trade Center attack response and, 188–89, 193 psychology of survival, 189–90 psychosexual dysfunction, battered women and, 448 psychosocial assessments, 21–22, 423–24, 431 psychosocial crises, 785 psychosomatic disorders, stress and, 93, 94 psychotherapeutic drugs, 570 psychotherapy for battered women, 443 constructivist, 664 crisis intervention and, 240, 281, 365–66 patients in medical crisis and, 637, 640, 641, 644 for suicidal adolescents, 411 psychotic disorders children/adolescents with, 327–28 stalking and, 487 suicide incidence and, 604

Index 833 PTSD. See posttraumatic stress disorder Public Health Service, U.S., 5 public libraries, 26 public policy, battered woman protection as, 452–53, 460, 461, 474 public service announcements, 29 questioning, rapport establishment and, 335 race, adolescent suicide victims and, 398 racism, 684, 687 radioactive contamination, 183–84 rage anger vs., 285 battered women and, 449 divorced/separated people and, 662 stalkers and, 487 stalking victims/survivors and, 494 suicide risk and, 406, 407 as traumatic event response, 268 Rahe, Richard, 93 RAIs. See rapid assessment instruments Rajab, H. M., 334, 335 Rajneeshee cult, 178 rape, 8 acquaintance, 417–26, 775 crisis intervention, 11, 29–30, 32, 489, 785 daily incidents of, 634 date, 418, 420, 421, 779 emergency room protocol for, 553 as psychiatric emergency, 136 stalking victims and, 489 groups for, 30 See also sexual assault rape crisis programs, 11, 29–30, 32, 489 definition of, 785 rape-ive attitudes, definition of, 785 rape trauma syndrome, 129–30 rape victim, definition of, 785 Raphelson, M., 604, 612 rapid assessment, 26, 38, 43, 47, 95 rapid assessment instruments (RAIs), 104, 152, 154, 747, 755–57, 766, 785–86 Crisis State Assessment Scale, 723–39

Rapoport, Lydia, 17, 49 rapport and communication, establishment of, 12, 22, 26, 31, 47, 66, 133 addiction treatment and, 576 adolescent suicidality and, 400–401 caregivers and, 713–15 child/adolescent psychiatric emergencies and, 334–35, 343–44, 348–50 college student counseling and, 423, 430–31 comprehensive crisis intervention model and, 621, 623, 625, 629 in critical care areas, 643–44 disaster mental health and, 156, 158, 159, 272, 283–84 divorced/separated people and, 666–67 early adolescents suffering from loss and, 372, 378 emergency room crisis intervention and, 557, 559 HIV positive women and, 694–95 mobile crisis units and, 609, 611, 612 school violence interventions and, 529–30 stalking victims and, 492–93 suicidal ideation crisis intervention and, 53, 56 Ray, C., 749 reactions, in stress-crisis continuum, 122 Reasons for Living Scale, 154 reassurances, 432 Reconstruction or Recovery Phase, disasters and, 205, 206, 210 Reding, G. R., 604, 612 referrals for battered women, 28–29, 461, 463–64, 475–77 child abuse hotlines and, 29 domestic violence hotlines and, 28–29 emergency room protocol for, 552, 554, 560, 562 to mobile crisis units, 609 for patients in medical crisis, 637 from police-based crisis teams, 461

834

Index

[referrals] (continued) psychiatric triage assessment and, 43 school crisis response and, 510, 512, 515 for stalking victims/survivors, 495 reflection, 159, 294–95, 335, 373, 379, 432, 493 reformative change, 292 reframing, 273, 449, 641 Regehr, Cheryl, 93, 246–58, 280 regional resource team, 505, 786 Regional School Crisis Prevention and Response Program (Conn.), 505 rehabilitation hospitals, 635 rehabilitation programs, 555 Reid, William J., 107, 161, 291–301 Reinecke, M. A., 661, 663 relapse prevention, definition of, 786 relationship abuse, 132 relationship questions, 72–74, 786 relaxation techniques, 130, 133, 272, 426, 667 for battered women, 449 for stalking victims/survivors, 489 reliability, 756, 786 religious beliefs, 9 remarriage, 653 reoccurrence, personal impact measurement and, 97, 148 reorganization, as bereavement phase, 280 rescue squads, 137, 399 resentment, caregivers and, 709, 713 resilience, 203, 218, 318 of acquaintance rape victims, 422–23 battered women and, 450–53 of children and adolescents, 330– 31, 369–71 definition of, 65–66, 330 divorced/separated people and, 665 emergency room patients and, 562–63 HIV-infected people and, 692–93 impostor phenomenon and, 430 strengths perspective and, 23–24, 32, 85, 158, 451 substance dependence treatment and, 566, 587

Resnick, C., 530 Resnick, H. S., 534 respirators, 181, 185 respite, caregivers and, 716, 717 respite centers, child abuse prevention and, 29 responsibility, sense of, 227 restraining orders, 450, 457, 458, 473, 474 Retirement Services Division (NYDCC), 195 reversal designs, 763–64, 786 revictimization, 421, 490, 786 revisiting, posttrauma intervention and, 301 Rheinscheld, Judy, 32, 64–85, 323, 353 Rice, D. G., 635 Ringler, L. L., 367 Ripple, L., 19 robbery, 8 Roberts, Albert R., 3–33, 35–61, 64, 84, 90–117, 120–38, 143–67, 227, 269, 280, 282, 323, 331, 340, 356, 365, 373, 375, 382, 398, 441–77, 483–96, 521, 530, 555, 556, 574, 604, 609, 620, 633, 687, 715, 725, 726, 728, 744. See also seven-stage crisis intervention model Roberts, Beverly Schenkman, 441–77, 530, 555 Roberts, N., 251 Robertson, J. M., 416–17 Robinson, J., 585 Rogers, J. R., 357 Rohde, P., 327 Rohypnol, 417, 418–19, 423 role captivity, 708, 713 role-playing, 671, 717 romance breakups, 9 Rosenman, R., 94 Ross, L. T., 420 Rothery, M., 443 Rothman, C. R., 710–11 Rounsaville, B., 591 Rozensky, R. H., 637 Rubin, A., 165 Rudd, D. M., 334, 335 Rudd, M., 47

Index 835 rural areas, mobile crisis units and, 615 Rush, A. J., 664 Russia, 178 Rutgers University, 149 Ruth, A. R., 615 Sachs, Gordon M., 185 sadness, 268, 274, 295 SADS Person Scale, 45 Safe Harbor Behavioral Health Crisis Services, 619–31 SAFER-R model, 212–13 “safe sex” practices, 660–61 safety battered woman protection and, 454–61, 465–66, 473–75 emergency responder family fears about, 253–55, 258 first responders and, 184–87 personal, 9, 268, 348 school crisis response initiatives for, 505 school violence concerns about, 528–29 stalking victims/survivors and, 488, 490, 491–92 suicidal adolescents and ensuring of, 409–10 safety contract, definition of, 786 St. Martha’s Hall (St. Louis, Mo.), 470, 475, 477 Saleebey, D., 663 Salmonella bacteria, 178 Salvation Army, 27, 231 SAMHSA. See Substance Abuse and Mental Health Services istration Sandler, Herman, 314 Sandy, J. M., 370 Santos, A. B., 606, 611, 614 Sarin, 179–80, 181 Scale for Suicide Ideation at Worst Point, 45, 46 Scale for Suicide Ideation-Current, 45 scaling, 578 scaling questions, 23, 74–75, 82, 351, 353, 589 definition of, 786

SCBA. See self-contained breathing apparatus schizophrenia, 604 as adolescent suicide risk factor, 407 children/adolescents with, 327–28 education about, 347 stalking and, 487 stress’s effects on, 345 Schneidman, Edwin, 18 Schonfeld, David J., 499–517 school-based crisis intervention team, definition of, 787 school crisis intervention, 499–517 classroom interventions, 512–15 crisis response programs, 502–17 levels of intervention, 505–6 risk factors for students, 511 training and technical assistance, 516–17 school crisis intervention team, definition of, 787 School Crisis Response Initiative, 503–4 school violence, 366, 519–37 catastrophic events and, 520, 522, 533–37 definition of, 521, 787 interventions for, 524–33 precipitating events for, 519–21, 530, 531 risk and protective factors for, 523–24 scope of problem of, 522–23 special considerations about, 533–37 See also school crisis intervention Schorr, J., 253 Schulz, R., 704, 706, 707, 710 Schut, H., 280 Schutte, N. S., 756 Schwartz, M. D., 420 Schwiebert, V. L., 708, 709, 710 Sealander, K. A., 708 secondary adolescent suicide prevention, 787 secondary appraisal, 452, 655, 725, 727–31 secondary devices, 186 secondary loss, 282, 283, 284

836

Index

secondary trauma responses, 206, 209, 216 definition of, 787 emergency responder families and, 248, 251–53 school violence and, 533, 536 Secretariat of Communications and Transportation (Mexico), 186 Secret Service, U.S., 187 Seeley, J. R., 327 Sees, K., 585 self, sense of divorce and, 657, 659–60 suicide risk and, 406, 408 self-anchored rating scales, 767 self-blame, 272, 285, 425, 426, 494 self-care, 273 caregivers and, 710, 711, 712 crisis workers and, 165 disaster response workers and, 214, 216–17 self-concept, positive, 370 self-confidence, 428, 674 self-contained breathing apparatus, 185 self-destructive behavior, 448, 646 self-determination, 769 self-discipline, 132 self-disclosure, 714–15 self-efficacy, 433, 591, 664, 672, 674, 727, 729, 787 self-esteem, 729 battered women and, 449, 451 crisis reactions and, 12, 130, 272 depression and, 634 divorce’s effects on, 659, 661, 665 early adolescents and, 368, 370 impostor phenomenon and, 428 suicide risk and, 406 self-fulfilling prophecy, 68 self-harm assessment of, 332–33 psychiatric emergencies and, 136, 151 solution-focused therapy and, 85 See also self-destructive behavior; suicide self-help groups. See and selfhelp groups self-identity, 525 self-image, 272, 634

self-injurious behavior (SIB), 350 self-medication techniques, 298 Self-Monitoring Suicide Ideation Scale, 45 self-mutilation, 147 self-perception, impostor phenomenon and, 430 self-presentation, impostor phenomenon and, 429–30 self-reliance, 665, 674 self-reports, 746–47, 755 self-worth, 408, 659 Seligman, M. E. P., 368, 370 Selye, Hans, 92–93 Senate Armed Services Committee, U.S. 267 sensitivity, 12 September 11 (2001) terrorist attacks, 3, 5, 107, 200–218 aftermath vulnerabilities and, 262–63 disaster mental health and, 143, 144, 146, 150, 165–66 distinguishing aspects of, 268 emergency responders to, 172, 175–77, 187–96 families of emergency responders and, 247 families of victims of, 282–83, 284, 287–89 general population’s shared stress reaction to, 98, 268 longitudinal research on, 167, 221 mental health workers and, 188– 89, 193, 206–8, 210–17 New York Disaster Counseling Coalition and, 193–96, 197 personal narrative of, 305–18 posttrauma intervention and, 291 posttraumatic stress disorder and, 98, 191 private sector response efforts to, 187 psychiatric triage and, 44 school crisis response efforts to, 504 secondary victims of, 7 stress-crisis continuum and, 120–21 See also Pentagon, terrorist attack on; World Trade Center terrorist attack

Index 837 serotonin, 93 SES. See socioeconomic status seven-stage crisis intervention model (SSCIM), 9–10, 12, 32, 39, 66– 67, 69, 95, 99, 105 ACT model and, 107–16, 143, 155–57, 166 adolescents suffering from loss and, 362, 364, 371–87, 390 adolescent suicidality and, 398–412 caregivers and, 712–17 child/adolescent psychiatric emergencies and, 320–23, 331–55, 356 college counseling center use of, 416, 423–26 critical care areas and, 643–45 divorce and, 665–75 emergency psychiatric crisis stabilization and, 629–30 emergency rooms and, 556–62, 563 family crises and, 133 grief and, 282–87 HIV positive women and, 693–99 impostor phenomenon and, 430–34 mobile crisis services and, 625–26 mobile crisis units and, 609–12 overview of, 20–25 school violence and, 525–26, 528– 33, 534 seven-stage crisis intervention model stalking victims/survivors and, 490–96 substance dependence treatment and, 566, 567, 573–92, 595, 596 suicidal ideation and, 36, 41, 47, 50–61, 270, 271, 372–73, 378– 79, 400, 431, 694 surviving family and, 215 telephone crisis services and, 621–22 U.S. bioterrorism response and, 146, 262, 269–75 walk-in crisis services and, 623–24 sexism, 684, 687 sex role socialization, 421 sexual abuse, 11, 348 sexual assault, 445, 489, 492. See also rape sexual identity development, 132

sexuality, divorced people and, 660–61 sexually transmitted disease (STD), 660, 661. See also AIDS; HIV sexual predators, 484 sexual rituals, 298 sexual victimization, among college students, 419–21 sex work, HIV positive women and, 691 SFT. See solution-focused therapy shame, 9, 419 Shanksville, Pa., 3, 247 Shapiro, Francine, 131 shared suffering, 283, 296 Sharma, K. K., 487 Shedlin, W., 691 shell shock, 98 shelters. See battered women’s hotlines and shelters Shelton, Raymond D., 96–97, 106, 147–48, 164, 166 Sheridan, L., 485–86 Sherman, R. E., 751 Shewbert, Amy L., 632–48 shielding, first responder attention to, 185, 186–87 shift work, emergency responders and, 248, 249, 256 Shinar, O., 370 Shneidman, E. S., 400, 407 shock as bereavement phase, 280–81 catastrophic events and, 535, 536 as crisis reaction, 12, 130 stalking victims/survivors and, 494 surviving family and, 212 “shooting bullets” technique, 349 shopping malls, 26 Shulman, Norman M., 632–48 SIB. See self-injurious behavior siblings adolescent conflicts with, 368 death of, 16, 367, 383–87 simple obsessional stalking, 488 Singer, Jonathan, 319–57 single-system design, 759–60, 761, 765, 768, 787 SIRI-2. See Suicide Intervention Response Inventory

838

Index

SIT. See stress inoculation training situational crisis, 682, 687 situation-specific coping efficacy, 731 Slagg, N. B., 615 Slaikeu, K. A., 110 sleep disturbances, 9 acute stress disorder and, 95 battered women and, 448, 450 children with trauma and, 147 emergency responders and, 252 suicidal adolescents and, 410 as traumatic event response, 268 sleeping pills, 399 small group interventions, 206, 209– 10, 211, 214, 217, 239 smallpox, 177, 183, 266 Smith, R. S., 369, 370 Social and Occupational Functioning Assessment Scale, 758, 767 social casework, 17 social cognitive theory, 727 social crisis, 682, 687–88 social functioning, 38, 95, 252 socialization, of sex roles, 421 social phobia, 165 social readjustment rating scale, 93 social responsiveness, 370 Social Security istration, 201 social service agencies, 26 social stress, 276 social addicted women and, 585 for battered women, 449, 451 caregivers and, 705, 713 for divorced/separated people, 663, 664–65 for emergency responder families, 257–58 for emergency responders, 248, 257 for rape victims, 424, 426 for substance-dependent people, 580 See also and self-help groups social workers battered woman interventions and, 464 emergency room, 546, 547, 549, 550–64 empirical practice role of, 745–46 evaluation-crisis intervention integration and, 765–67

evidence-based practice and, 564 medical, 464, 489, 490 posttrauma intervention and, 292–301 practice effectiveness evaluation and, 757 stalking victims and, 489, 490 World Trade Center attack response and, 193 socioeconomic status, impostor phenomenon and, 429 sociograms, 346 Socratic questioning, 666, 667, 668 SOFAS. See Social and Occupational Functioning Assessment Scale solution-based therapy, 23–24, 54, 449, 451 solution-focused approaches, 23–24, 32 definition of, 787 mobile crisis response and, 321, 346–47, 353, 356 strengths perspective and, 64–85, 159 solution-focused therapy (SFT), 64, 65, 66–85, 130, 159, 363 for addictions, 566–96 approach structure of, 69–84 solution identification in, 74–79 solution talk, 68 Soman, 180, 181 somatic distress, 120, 122, 123–25, 295 somatization, 124–25, 787–88 Sourcebook of Adult Assessment Strategies (Schutte and Malouff), 756 Southwest Cancer Center, 637 Southworth, R., 255 Soyka, K. M., 357 spatial dimensions, personal impact measurement and, 97, 148 special education students, 515 specialized domestic violence units, 454–56 specific psychic stress, 94 Spectra instant point-and-shoot cameras, 474 Spence-Diehl, E., 484 spirituality, 385, 386, 387, 423

Index 839 spiritual , 133 Spitzberg, H. C., 486 spouses of emergency responders, 249–51, 253, 254, 256–57 sudden death of, 7, 9, 16, 23 trauma contagion and, 252 See also battered women Sprenkle, D. H., 658 Springer, D. W., 325 SSCIM. See seven-stage crisis intervention model SSI-C. See Scale for Suicide IdeationCurrent SSI-W. See Scale for Suicide Ideation at Worst Point Stairways, Inc., 626 stalking, 483–96 characteristics of, 487 definitions of, 485–86 impact on victim of, 488–89 prevalence and incidence of, 486 as psychiatric emergency, 136 types of, 487–88 standardized measurement tools crisis intervention evaluation and, 755–58 rapid assessment instruments and, 104, 152, 154, 723–39, 747, 755–57, 766, 785–86 rationale for using, 724 reference sources for, 756–57 suicide risk assessment and, 726 See also specific instruments standing psychological consults, 637–43 Stange, K. C., 706 Stanley, J. C., 760, 764 startle reaction, 95, 448, 449 State Department, U.S., 281 STD. See sexually transmitted disease Stean, H. J., 608 steady state, 16, 17, 788 Steinberg, L., 362–63 Steinmetz, S. K., 521 Stewart, Chris, 519–37 stigmatization of HIV infection, 684, 688, 699 of mental illness, 636 students and, 525

Stop Bullying Now! campaign, 524 Storm, C. L., 658 storytelling, classroom crisis interventions and, 515 Stotland, E., 19 strategic solution-focused therapy, 130 strategic therapy, 130 Straus, M., 521 Strauss, A., 545 strengths-based language, 340, 344 strengths perspective, 23–24, 32, 349, 744 battered women and, 451 definition of, 788 divorced/separated people and, 663–64, 672 seven-stage crisis intervention model and, 158–60 in solution-focused approaches, 64–85 substance dependence treatment and, 566, 567, 579, 582, 583, 585, 595 Strentz, T., 612 stress, 91–94 appraisals of, 728 battered women and, 446, 451 caregivers and, 704, 705–7, 709 coping and, 727 crisis states and, 730 definition of, 91–92, 727–28 differentiation of, 6, 90, 99–103, 107–9, 145 differing responses to, 5–6, 91, 94 diverse perceptions of, 90 divorce and, 651, 660 early adolescents and, 368–69 emergency responders and, 248, 249–51, 253 fight or flight response and, 93 general adaptation syndrome and, 92 impact of, 93–94 importance of prompt intervention to, 99 medical crises and, 633, 634, 635 precipitating events of, 103 resilience and, 370 schizophrenia and, 345

840

Index

[stress] (continued) in social cognitive theory, 727 specific psychic, 94 suicide risk and, 406 symptom reduction, 268–69 terrorism-related, 275–76 trauma distinguished from, 295 as traumatic event response, 268 See also acute stress disorder stress-crisis continuum, 6, 120–38 activators of, 122 stress/immune response research, 125 stress inoculation training (SIT), 449, 788 stress management battered women and, 449 caregivers and, 710 See also acute stress management; critical incident stress management stress reduction, 130, 133 stress theory, 725, 726–29 Stroebe, Margaret, 280, 287 Stubblebine, J., 223 student assistance teams, 505 student developmental tasks, 788 subjective crime clock, personal impact measurement and, 97, 148 substance abuse, 604 addiction treatment for, 566–96 adolescent protective factors and, 370 as adolescent suicide risk factor, 407 battered women and, 448, 467 dependence definitions, 573 divorced people and, 660, 661, 664 emergency room protocol for, 554–55 HIV infection and, 684, 691 as school risk violence factor, 524 as self-medication technique, 298 as sexual assault risk factor, 420 sexual behavior and, 660 stalking and, 487 suicide and, 38, 41, 407, 663, 664 by survivors, 285 treatment facilities for, 605 See also alcohol abuse or dependency; drug use

Substance Abuse and Mental Health Services istration, 571, 604, 749 successes, in solution-focused therapy, 74, 76–77, 80–81, 83, 159, 353, 354 sudden death, 7, 9, 16, 23 suffering emergency responder exposure to, 247–48, 254 shared, 283, 296 Suffolk County, N.Y., 458 suicidal behavior, 761 adolescents and, 395–412 definition of, 788 suicidal ideation, 332 assessment measures/tools/guidelines, 41–47 battered women and, 445 cautionary considerations, 46–47 children and, 147, 336–37, 372– 73, 378–79 coping and, 380 crisis intervention overview, 37–41 definition of, 788 intervention and treatment protocols, 47–50 lethality assessment and, 35–61, 137, 153, 270, 271, 372–73, 378–79, 400, 694 patients in medical crisis and, 634 previous history of, 405 scope of problem, 36–37 seven-stage crisis intervention model and, 36, 41, 47, 50–61, 270, 271, 372–73, 378–79, 400, 431, 694 solution-focused therapy and, 85, 379 verbal expressions of, 38, 61 suicidal intent, 332, 396, 402, 403–5 definition of, 788 See also suicide attempts; suicide plans suicide, 396 adolescent victims of, 397–98, 401, 408 definition of, 403–4, 788 direct inquiry about, 402–3, 404

Index 841 divorce/separation and, 654, 661, 662–63, 667, 675 incidence of, 5, 35, 36, 604 intervention strategy evaluation and, 746, 747 risk factors for, 38, 41, 46, 403–7 warning signs for, 45, 402 suicide assessment, 153, 158, 332–34, 350, 398–407, 646 suicide attempts, 51 adolescents and, 396, 397–98, 399, 403, 404–5 annual rate of, 36 children with trauma and, 147 daily number of, 633 definition of, 788 homeless youths and, 348 previous history of, 46, 49, 61, 405 as psychiatric emergencies, 136, 137 stress and, 93 Suicide Intervention Response Inventory, 747 suicide plans, 41, 46, 47, 49, 61, 333, 404–5, 662 Suicide Potential Lethality Scale, 45 suicide prevention, school initiatives, 505 suicide prevention and crisis centers, 11, 27, 32 definition of, 788–89 development of, 15, 18 goal of, 49 hotlines and, 18, 21, 26, 27, 47 resources available to, 21 women and, 166 suicidologists, 396, 789 Suinn, R. M., 742 sulfur mustard. See mustard gas Sullivan, W. P., 750 summarization, 335, 379, 432 Sumner, Kristy, 146, 262–76 , 69. See also social and self-help groups, 25, 127, 130, 591–92 for affected disaster communities, 210 for battered women, 443 for caregivers, 710, 716, 717

catastrophic events and, 535 for emergency responder families, 257 school crisis response programs and, 510 for sexual assault victims, 30 for stalking victims/survivors, 484 rooms, school crisis response and, 509–12 Surgeon General, U.S., 325 surveillance data, 789 survival mechanism, 93 survivors early intervention for, 204 of Holocaust, 162 “if only” perspective, 285 of incest, 147 psychological symptoms of, 16, 129 psychology of survival and, 189–90 of stalking, 484, 488–96 of terrorist attacks, 145 suspension of disbelief, 451 suspiciousness, 9 Sussman, T., 280 Swanson, W. C., 99 SWAT teams, 611–12, 789 Sweet, J. J., 637 Swissair 111 plane crash, 246–47 Sysco, H. M., 416 systemic (physiological) stress, 276 Tabun, 178, 180, 181 TAF. See Triage Assessment Form Target, M., 327 task-centered practice, 107, 161, 532 posttrauma intervention model and, 291–301 tasks, solution-focused, 79–81, 346–47 teachers classroom crisis interventions and, 512–15 violence against, 525 teaching hospitals, 636 Teague, G. B., 749 technology battered woman protection and, 456–59, 473–75 mobile crisis units and, 614–15

842

Index

Tedeschi, R. G., 452 telephone crisis services in comprehensive crisis intervention model, 619, 620–22 definition of, 789 verbal and, 159 See also hotlines telephone logs, battered women’s shelters and, 467–68 temperament, coping and, 369 tension, as crisis reaction, 13, 17 10-step acute traumatic stress management protocol, 143, 164, 166 Terenzi, E., 631 termination, 495 posttrauma intervention and, 300 in solution-focused therapy, 81–84 Terr, Lenore, 96, 146–47, 365 terror, 9 terrorism, 3, 4, 5, 247, 276, 281 ACT intervention model and, 143–67 current trends in, 263–64 definition of, 263 first responders to events involving, 145, 171–97 problems contributing to, 264–65 psychological effects of, 221, 268– 69, 488 seven-stage crisis intervention model and, 269–75 trauma and, 161 U.S. vulnerabilities to, 262–63, 264 See also bioterrorism; Oklahoma City bombing; September 11 (2001) attacks tertiary loss, 282, 283, 284 Texas Council on Family Violence, 27–28 Texas Tech University Medical Center, 637–41, 648 therapeutic rituals, 671 Thoennes, Nancy, 444, 445–46 Thompson, D. R., 635–36 Thompson, L. W., 704, 707 Thompson, T., 428 thought stopping, 449 threat appraisals, 728 threatening stalking behaviors, 486 Thurman case, 460

Thyer, B. A., 613 time, first responder attention to, 185–86 time-limited treatment. See brief therapy time-series designs, 760–65, 789 Tjaden, Patricia, 444, 445–46 T.L.P. Technologies, Inc., 458, 473 Tokyo subway attack (1995), 179–80 tornadoes, 161 Toseland, R. W., 710 Tovian, S. M., 637 toxins, 177, 183 Trabin, T., 749 tracking, in solution-focused therapy, 69 training programs for battered women, 461–62 early intervention and, 204 for school crisis response teams, 516–17 trance-like states, traumatized children and, 147 tranquilizers, 399 Transcience, 458, 473 transdermal infusion system, 789 transformative change, 292 transient stress reactions, 162 transinstitutionalization, 607, 789 transition, 339 transitional stress-crisis, 4, 120, 122, 126–27, 132 Transportation Department, U.S., 186 Transport Canada, 186 Trask, Rhonda, 32, 64–85, 323, 353 trauma, 96–97, 508 ACT intervention model and, 103, 105–6 acute stress disorder and, 95, 96 assessment and treatment of, 161–64 crisis vs., 161–65 definition of, 96 differentiation of, 6, 99–103, 145 differing responses to, 5–6, 91 emergency responder families and, 248 emergency room protocol for, 550–51 first responders and, 189–93, 197

Index 843 grief and, 280 importance of prompt intervention and, 99 posttrauma intervention model and, 291–301 precipitating events for, 90–91, 103 prevalence of exposure to, 221–22 solution-focused therapy and, 85 stalking victims/survivors and, 492–93 stress distinguished from, 295 types of, 96, 146–47 See also posttraumatic stress disorder; psychological trauma trauma centers, hospital-based, 11, 445 trauma contagion emergency responder families and, 251–53, 258 See also secondary trauma responses trauma reenactment, battered women and, 448, 449 traumatic neurosis, 98 traumatic stress-crisis, 120, 122, 127–31 traumatic stressors, increases in, 4 traumatization, vicarious, 92, 93, 533 trauma treatment, 5, 144, 148–49, 161–64 Travelers’ Aid, 31 travelers’ aid centers, 26 treatment package strategy, 789 triage definition of, 43, 151 medical, 43, 151, 548 psychiatric, 43–44, 151–52, 398–99 triage assessment ACT intervention model and, 150–52 suicidal ideation and, 41–46, 47, 52 Triage Assessment Form, 423, 431 triage assessment model, 321, 323, 331–32, 341–42, 351–53, 356 triangulation, 747, 757, 765, 789–90 tricyclic antidepressants, 399 triggers, 296 definition of, 790

for stalking victims/survivors, 496 for substance-dependent people, 578–79 See also precipitating events trust, 159, 390, 400, 449, 492, 493 Tseng, W. C., 416–17 Tucson (Ariz.) Police Department, 460 tularemia, 183 Turner, A. L., 416 Tutty, L., 443 12-step programs, 591–92 24-hour hotlines definition of, 790 See also hotlines two-factor model of acute crisis, 223– 27, 790 Tyhurst, J. S., 17, 127, 130 Type A personality, 94 Type I crises, 365 Type II crises, 365 Type I trauma, 96, 146–47 Type II trauma, 96, 147 typhoid, 178 Tyvek jumpsuits, 187 uncertainty, terrorist attacks and, 268 uncomplicated bereavement, definition of, 790 Underwood, Maureen, 107 Uniformed Services Organization, 201 uniformity myths, 745 unique weakness/vulnerability, 230 United Nations, 222 United Way, 26, 32, 476 University Hospital and Medical Center (Stony Brook, N.Y.), 547 University of Texas at Austin, 28 urgent, definition of, 790 Ursano, R. J., 534 U.S. departments and agencies. See key word, e.g. Defense Department, U.S. utility companies, 187 vaccines, 266, 267 Valentine, P. V., 448 validation of feelings, 285, 352–53, 494, 644, 716

Index 845 Weltanschauung, 224, 227, 791 Welzant, Victor, 146, 200–218 Werner, E. E., 369, 370 What Is a Shelter? (coloring book), 470 Williams, C. C., 635 Williams, M., 254 Williamson, G. M., 704 Wilmshurst, L. A., 329 Wilson, T., 253 wind, direction and velocity of, 177– 78, 186 Wireless Foundation, 457 Wirth-Cauchon, J., 612–13 Wisniewski, N., 419 withdrawal, definition of, 791 WMD. See weapons of mass destruction Wolfe, D. A., 368–69 Womanspace, 467, 468 women abuse of. See battered women; domestic violence; sexual assault adolescent suicide victims, 397–98 with AIDS, 682–84, 689, 690 as caregivers, 703, 705, 706, 709–10 coping by, 369 criminal victimization prevalence for, 222 crisis intervention program effectiveness for, 166 divorcee suicide rates, 654 HIV positive, 682–700 impostor phenomenon and, 426– 34 pregnancy and, 445, 689–91 prescription drug abuse by, 582 resilience and, 370 self-esteem and, 370 severe mental illness rates for, 571 sexual victimization of, 419–21. See also rape; sexual assault as stalking victims/survivors, 484, 486, 492 suicide prevention programs and, 166 trauma exposure prevalence for, 221–22 women’s centers, 26, 423

Worden, J. W., 367–68, 378, 380, 382, 389 workaholic behavior, 298 workplace violence, 222, 240 World Health Organization, 573 World Trade Center terrorist attack (2001), 3, 144, 146, 166, 291 first responders and, 172, 175, 176 first responder traumatization from, 189–93 neighborhood family’s experience with, 305–18 New York Disaster Counseling Coalition and, 193–96, 197 posttraumatic stress disorder and, 98, 191 private sector response efforts, 187–89 psychological implications of, 268 secondary victims of, 7 World War I, 98, 177–78 World War II, 16 wound healing, 707 written activities, classroom crisis interventions and, 513–14 x-y-z sequence, stress-crisis continuum and, 122 Yaeger, A. M., 370 Yale Child Study Center, 503–4 Yale University School of Medicine, 503 Yeager, Kenneth R., 35–61, 90–117, 555, 566–96 Yee, J. L., 706 youth crisis centers, 26 Yperite. See mustard gas Ypres, Second Battle of (1915), 177 Yufit, R. I., 757 Zarrina, K., 327 Zealberg, J. J., 606, 607, 611, 614, 615 zero tolerance, for battering, 447–48 Zhang, G., 708 Zidovudine (AZT), 692 Zona, M. A., 487 Zung Self-Rated Depression Inventory, 661

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