Constructing Crises and Crisis Intervention Theory

CONSTRUCTING CRISES AND CRISIS INTERVENTION THEORY by Lisa A. Fontes· ABSTRACT This article discusses ways in which clinicians label. create. exacerbate and defuse situations called "crises. n Several models of crisis work are described and illustrated with examples from cases. The author develops and advocates a social constructivist view of crises -- to increase clinicians' flexibility and self-awareness. and reduce unintentional harm to clients. social interaction in which professionals and clients construct an emerging reality together. Potential seeds of crises are -- of course -- "out there". IIIness, job loss, poverty, violence, and death influence people no matter how they are defined. However, part of the trauma of an event comes from the meaning ascribed to that event. (Being left by a Just as therapists are part of the problemdetermined systems they believe they are treating. (Anderson. Goolishian & Winderman. 1986) so clinicians intervening in crises are part of those crisis systems. Whether they choose to call situations crises or non-crises, and how they make that decision, influences the course of events. This article aims to help crisis clinicians, family therapists and others see and understand "their own spouse, for instance, can mean many tbings depending on the individuals involved, their relationship, their support systems, economic circumstances, and how the separation is discussed). As soon as they join the conversation, clinicians help construct not only the intervention, but the meaning of the event il~f. Crisis Literature reflections and their own intellectual fingerprints". (pearce & Cronen, 1980, p. 2) in situations which A review of recent literature on crisis reveals numerous definitions and models for they may call "crises". intervention. There are varying degrees of consensus In an ideal world with services available to as to the effectiveness of specific interventions -- and all immediately on request, it might be useful to little research to support any position (Hobbs, 1984; eliminate the concept of "crisis" altogether. But Smitb, 1978; Bloom, 1963). witb drastic funding cuts in social services seemingly disparate approaches can be grouped nationwide and waiting lists growing ever-longer, according to their implicit definitions of crises and clinicians need tbe concept of "crisis" to belp how to re-solve them. The following categories prioritize Here I'll were devised and will be discussed in this article: examine ways clinicians and theorists write about dichotomizing, fuzzy, step, and social constructivist crises, and bow their different models increase or views of crisis. cases and avert violence. Several of the limit clinical flexibility. The DichotOmizing View My own position is close to tbat of the social constructivists. I see crisis intervention as a Most descriptions of crisis intervention assume that crises exist, and tbat they are qualitatively different from other situations. In this • School, Consulting and Counseling Psychology, University of Massachusetts, Amherst, MA 01003 Vol 10 #2. Summer. 1991 dichotomizing view, two discrete, non-overlapping ·59· Journal of Strategic and Systemic Therapies categories of client experience are implied -- crises crisis reaction, the therapist can usually proceed on and non-crises. It's as If there's a digital, crisis/non- the assumption that the patient is in a state of crisis switch, and the first step for clinicians is to crisis" (p.401). decide which way to pull the lever. Radically different interventions are then implemented based Everstine and Everstine (1983) give the decision-making power to the client, but still on the initial determination. maintain the dichotomy. They write, "It is wise to In this model, crisis is like a disease that look upon the caller as a person who is experiencing resides within clients or their social systems. a true emergency -- simply by virtue of the fact that Clinicians -- as diagnosticians -- evaluate the the person has spoken of the situation as such" (p. presenting symptoms and then decide whether or not 31). The title of their book, "People in Crisis" they detect a crisis, and implement different buttresses the dichotomized notion that either people interventions accordingly. are in crisis or they're not. They ignore the issue of potential problems when the clinician and the client In a typical statement by authors who seem hold different definitions of "crisis" or "emergency". to bold the dichotomizing position, Meyerson and Glick (1976) write, "Once a patient or family has Implications of the Dichotomizing View been identified as an 'emergency' or 'in crisis', a second order of what might be termed 'internal triage' or an assessment and decision tree must be performed as a basis for the interviewer's approach to , , this patient" (p. 5). Golan (1978) also implicitly advocates a dichotomizing view. In describing how to understand "what is often a higbly volatile and emotionally charged picture and to take advantage of the client's high motivation for relief of discomfort" sbe suggest the fllSt step for social workers must be to answer the question, "Does a crisis situation exist?" (p. 63). If crisis and non-crisis are discrete categories, the attitudes and techniques clinicians use to face these situations must also be qualitatively different. After they determine that a situation is a crisis, clinicians frequently look for help from a higber power of social control -- the courts, police, departments of protective services, professionals authorized to administer mind-altering medication, and locked hospital units. Theorists frequently suggest that clinicians assume a directive attitude towards clients in crisis. There is little agreement on how to determine wbether or not a crisis is present. After In characterizing Rapoport's theory of crisis intervention, for example, Golan (1978) suggests suggesting that it is "imperative" that the .clinician that clinicians use their "authority, derived from make this determination, Smith (1978) describes the competence and expertness ... to capitalize on the procedure in a somewbat circular way. "If the precipitating event can be clearly identifIed and the patient is displaying symptoms characteristic of a Vol 10112, Summer, 1991 ·60- client's readiness to trust during this period of confusion, helplessness and anxiety" (p. 49). In their search for external controls and in their efforts Journal of Strategic and Systemic TMrapies to exercise authority, clinicians may communicate steps. In this dramatic example and in frequent less- to clients that they are out of control, enforcing a dramatic but equally-damaging ones, clinicians add self-fulfilling prophesy. wind to hurricanes when they strengthen tbe categorization of situations as crises. United States law recognizes the disinhibiting nature of crises and imposes lesser sentences on those who murder spontaneously than Acting quickly without reflection when careful thought is most essential, clinicians unwittingly perpetrate violence against clients. on those who plan murder ahead (first versus second degree murder). I believe that "little murders" are often coinmitted by clinicians who precipitously Similar principles are also at work in situations where there is no threat to clinicians: define situations as crises and take corresponding drastic action. Here is a dramatic example which came to my attention while I worked on a crisis Upon admission to a hospital oncology unit, an elderly woman in the final stages of cancer told the admitting physician that her schizophrenic team: busband was now alone in their trailer and A psychologist who was employed at a large unable to care for bimself. hospital and whose home number was listed in husband had no other family members or friends the telephone book received an anonymous call to help, and was unlikely to consent to at 4 AM from a woman who said she was going hospitalization. to kill him and kill herself. The psychologist information to tbe crisis team supervisor, who hung up and contacted the police, identifying decided that the situation was a crisis and the caller as a private client he had seen for the advocated frrst time that week, although he later said that bospitalization. Transport by ambulance and a her "tone of voice and pacing were different, like police escort were arranged. maybe she was a split personality." After clinician showed up at the client's trailer park bearing no reply to their knocking, the police accompanied by an ambulance, a half-dozen climbed up to her second-storey window and pOlice officers· and two police cruisers. forcibly entered. They found that she had been Neighbors stepped out of their trailers to watch sleeping in ber bed, naked, and was as the police knocked on the client's door with understandably terrified at the intrusion. The their hands on their weapons, and finally client was a survivor of child sexual abuse who dragged the protesting, half-naked elderly man to -- after years of feeling safer -- was severely the ambulance stretcber where he was forcibly traumatized by this incident strapped down, and transported to the emergency for She said her The pbysician relayed the immediate involuntary At 1 AM the room and then to the state bospital. If the psychologist had not panicked about what he thought was a life-threatening crisis, be A discussion with the family's physician could bave taken less drastic but equally cautious later revealed that the client had cared for bimself Vol 10 #2. Summer. 1991 - 61 - Journal of Strategic and Systemic Therapies poorly, but had survived, during his wife's earlier immediate danger). Thus labelling a situation as a stays in the oncology unit that year. If the crisis no~cris team had been more reflective and viewed the which often means no help is available. situation as less of a crisis, it is likely that the man clinicians fail to respond to a situation after they could have been spared the humiliation and added determine that it isn't a crisis, clients and families disorientation he suffered when the crisis services may escalate into apparent crises to obtain help. puts it into the "preventive" category, If descended on him in the dark. (Ironically, this The dichotomizing viewpoint can be useful would have Deen more cost-effective for the state, which ended up spending a great deal on the ambulance, the clinicians' overtime labor, police reenforcements, the emergency room visit, and the at times, particularly with those clients who have suffered trauma or loss (Golan, 1978; Kubler-Ross, 1969). After being raped, for instance, a victim may be subject to a barrage of strong feelings and disorder temporary stay in the state hospital). in his/her personal life which are frightening. Even clinicians who ordinarily believe that Identifying these responses as normal and time- slow steps are needed to produce lasting change may limited may help provide faith in their ability to look for a quick fIX when a situation is dichotomized heal -- reducing long-term damage. Using the label into a crisis -- ignoring the history and context of "crisis" can help them know that they are normal if the problem. These quick-fix solutions may allay they have extreme responses to an extreme situation anxiety but may not lead to helpful lasting change, - a crisis. When used appropriately, switching into as demonstrated by the families, individuals and a crisis mode can ensure that resources are mobilized treatment systems which seem to be in perpetual quickly and result in healthy lasting change. crisis, despite almost-constant "emergency" Some reframes used in family therapy take interventions. advantage of the dichotomizing view to move Holding the dichotomized position and situations into the set of non-crises. "It may look deciding that a situation is a non-crisis can also be like your daughter is hurting you deliberately, but problematic, especially for low-income clients who her actions are typical of an adolescent who is close . have few or no alternatives when public agencies to her mother and is experimenting with her own deny them services. If a screening device is used to voice." determine that a situation is not a crisis, it's likely that services will be withheld -- clients may be put on waiting lists or denied services outright (reduction in the Massachusetts Department of In the next sections I'll describe alternatives to the dichotomizing view and their implications. Applying Fuzzy Logic to Crises Social Services budget for voluntary services, for example, means that access to services is severely For tbe last twenty-five years the scientific restricted for families whose children are not in academic community bas been toying with notions Vol 10 #2, Summer, 1991 -62 - Joul7IQl of Strategic and Systemic Therapies of fuzzy logic, "that things in the real world do not determine this. (Questions might include, "Has fall into the neat, criSp categories defined by physical damage been done to anyone? Has anyone traditional set theory." (Elmer-Dewitt, 1989, p. 79). labelled the situation a crisis? Do the main people Some categories, like the set of humid summers, involved believe they are in a crisis?"). But even cannot be defined in this digital, on-or-off way. without a formal evaluation system, simply holding Membership in some sets, according to fuzzy set a notion of ~ theory, is a matter of degree. the dichotomized view. "Fuzzifying" of crisis increases flexibility over predicates like "rather", "very", and "not too", aren't scorned as in most scientific writing but rather are hnplications of the fuzzy view With fuzzy set theory, the membrane welcomed as useful ways to describe the world. True and false are not considered clear, absolute terms, but rather "vague" or "fuzzy" (Turner, 1984 around the set of crises is permeable, and interventions can be adjusted for the best fit in specific situations. (A clinician using this model p. 101-114). would be like the fuzzy heating system that doesn't Principles of fuzzy logic can enrich our merely switch on and off, but rather has several thinking about crises. Rather than dichotomizing degrees of being on -- from full-blast to slightly. crises and non-crises, we can speak of degrees of It's more responsive to conditions!). membership in the set of crises. Just as there are The writings of Thomas Rusk (1971) people who we cannot classify as either tall or short, but would feel comfortable calling "rather tall" or "not too short," I propose that there are situations where fuzzy descriptors like "somewhat of a crisis" or "very much of a crisis" are more useful than the dichotomizing labels of "crisis" and "non-crisis". Ironically, fuzzifying terms allow for an infinite number of more precise classifications than the suggest that his implicit model is that of a fuzzy logician. "The golden rule for the therapist in crisis intervention is to do unto others that which they cannot do for themselves and no more!" (p.251). He recommends that the clinician adjust interventions in increments so they correspond to of crisis present the de~ dichotomous categories of "crisis" and "non-crisis"! Here is an example of a series of A given situation could be a .66 or a .99 member of the set of crises. For our purposes, arriving at an exact decimal figure doesn't seem possible or appropriate, but the idea of partial membership remains useful. The type of intervention used would depend in part on how much of a crisis a given situation seemed to be. A checklist or a computer program might help clinicians Vol 10 #2, Summer, 1991 - 63· interventions designed in accordance with fuzzy set theory: Every year on the anniversary of the day she had given birth as a teenager to a child conceived through paternal incest, and on the anniversaries of her father's birth and death, 25 year-old Susan seemed to have a crisis, made a suicidal gesture and was hospitalized. After beginning Journal of Strategic and Systemic Therapies individual therapy she managed to live without year, and blew it out with sighs of relief. She hospitalization for the rest of the year, but these returned to work the next day. anniversary crises persisted. Her therapist worked with her to end this pattern. As an anniversary approached during her second year of therapy, they discussed different ways she could handle the crisis (discussing and planning it made it less of a crisis!). They decided that she would voluntarily sign into a ward that specialized in incest survivors with PostTraumatic Stress Disorder on the eve of the anniversary. , During the most difficult hours, when she felt terrified and her heart was racing, she believed she was in crisis. But even as the crisis occurred she could tell that it had limits and was less of a crisis than in years past In this example the therapist didn't deny that the client needed a crisis, nor did she enforce extreme external measures of control. Rather, she She described this ten-day adjusted her interventions in increments, using the hospitalization as useful and less traumatic than least-wrenching interventions possible. The notion those of previous years -- she wasn't carted away that there are degrees of being in crisis proved useful by ambulance screaming and thrashing at night in designing this series of interventions. - - but expressed her wish that on the next anniversary she would have even less of a crisis. Step Theories She didn't like missing work and she saw the crises as a way in which her father still had A number of crisis theorists view the descent (or escalation) into crisis as a series of steps. power over her. Step theories add a sense of time to fuzzy logic; As the next anniversary approached, she and situations move from non-crisis to more-like-a-crisis her therapist planned her crisis even more carefully, and perhaps fmally into an-absolute-crisis and vice- designing a ritual for the beginning of the versa over time. Many crisis teams, residential anniversary, discussing different things she could do units, agencies and clinics have explicit protocols during that day, and planning a way to mark its end. for measures to be used as situations seem to She and the therapist consulted with the local crisis progress from bad to worse. unit, asking for support if she called. Friends agreed to spend the day with her. Towards midnight she panicked and contacted the crisis unit. The clinician listened and offered supportive suggestions on how to get through the night safely (she spent hours in an arcade playing pinball with her friends). At dawn she called her therapist and friends together, they burned a candle, expressed their hopes for the next Rapoport (1962), Sachs (1968), Hill (1958) and Caplan (1964) posit different numbers of stages of progression into crisis, but the models are structurally similar. Events proceed linearly in discrete steps from non-crisis through various stages of crisis, with different interventions appropriate at each stage. Step theories go beyond a dichotomizing, ooloff crisis model to a more detailed Vol 10112. Summer. 1991 -64 - Journal of Strategic and Systemic Therapies and complex description of the moves towards and impossible to determine whether a given situation is away from crisis. . "truly" a crisis, or whether Freud or Watson or Minuchin or Satir is more correct about the nature Caplan (1962), who has written what is probably the best~know step theory of crisis, suggests that individuals are usually in a state of of human beings, or whether Mom or Dad or Junior is the family scapegoat. The truth is impossible to determine or irrelevant. The crisis clinician needs to "homeostasic balance" with the outside environment determine, rather, whether it is most useful to act as (in Smith, 1978, p. 397). if a situation is a crisis, or a given theorist is A potential crisis- provoking event occurs, familiar problem-solving behaviors are employed but prove inadequate, tension mounts, atypical coping measures are attempted, and their failure eventually leads to a full- correct, or whether given members adopt certain roles. With this view, any of the previously- described models might be usefully employed in particular situations. blown crisis. In the dichotomizing, fuzzy, and step Implications of step theories models, the "crisis" may be seen as the figure and all According to step theories, at any point in time a person's resources or the environment could else is the ground. Clinicians -- as diagnosticians, intervenors or observers -- are outside the system. change in such a way that the progression might be With the constructivist view, clinicians must reversed, with the general goal of returning the client recognize that they are part of the picture, and bring to a new homeostasis (Smith, 1978, p. 399). with them definite roles, values and interests. Step-models are easily taught to less- Implications of the social constructivist view experienced clinicians. Agencies frequently outline With a social constructivist model, the cues they use to determine that a certain stage in clinicians must face the highly-political nature of the development of a crisis has been reached, and crisis intervention. prescribe corresponding interventions. The further a seemingly objective notions like "returning a client crisis has advanced, the more likely that extreme to homeostasis" or providing clients "with relief measures of social control will be employed. from stress and the possibility of growth" (Golan, They cannot hide behind 1978 p. 50). A crisis intervention -- like all other The Social Constructivist View Social constructivists adopt the view that crises -- like other experiences -- are sociallyconstructed events, and our experience of them is created and maintained through language. As Efran, Lukens & Lukens (1988) write, "Utility' as opposed to 'truth' is high on the good constructivist's list of social contacts, including and perhaps especially those termed "therapeutic" -- is a value-laden exercise. Rather than expecting their questions to yield "truths" about a crisis which is static and already-formed. constructivist clinicians understand priorities (p. 28)." It doesn't matter and it may be Vol 10 #2. Summer, 1991 - 65- Journal of Strategic and Systemic Therapies that their inquiries help create the emerging reality - world views. As clinicians relinquish the notion that the crisis event. they can discover the truth and the one right way to proceed, they examine series of alternatives and their Clinicians infonned by constructivism are cognizant of the power they wield in most interventions, since their "vantage pOint in the social hierarchy, their ability to manipulate symbols of authority and their greater influence in negotiating therapeutic realities" (MacKinnon & Miller, 1987, possible consequences, noting the different meaningsystems at play simultaneously. Through thought and language they are "creating a series of universes and evaluating them to determine which works to explain the phenomena" (pearce & Cronen, 1980, p. 11). p. 151) often given them unusual power over An action taken by a constructivist clients. clinician might in any given case resemble that of Cons tructi vist-influenced clinicians carefully consider how a given situation is described by all involved -- clients, professionals, and bystanders alike. In fact, the distinctions between these different groups may be blurred. Who is the another clinician, but the attitude toward the work would probably differ, and I expect a skilled constructivist clinician would perpetrate less violence on clients than a clinician limited to an absolutist view. client in a case where a man is found washing his face in the toilet of a restaurant? Is it the man who In this model, a clinician may decide to call was washing his face calmly until others intervened, a situation a crisis, a non-crisis, a potential crisis, a or the owners of the establishment, or the customers fonner crisis, a maybe-crisis, or a crisis for some who are upset by what they've seen? OR is the but not for others -- using "fuzzy" language when client the police, who want to get the "crazy" off useful. their bands? deal strictly with the metaphor of conversation and The Clinician might discuss dichotomies or meaning-systems. The clinician could outline steps Rather than assuming that a crisis can be observed from the outside and detected by a clever diagnostician, constructivist clinicians assume that the event has been and is being constructed. They are interested in exploring the construction process, including their own participation. Their questions might focus on how history, meaning, power, and moral and legal constraints have shaped events and beliefs. needed to escalate or de-escalate - or explore and take advantage of the clients' models for crises. A· constructivist clinician is not wed to the truth of any given model, and therefore has the ability draw on various models. Some of the elements for clinicians to consider when deciding whether or not to help construct a situation as a crisis include: - Where do we punctuate (Watzlawick, 1967, p. 54) Differences in belief systems due to class, the incident in time? culture, and gender, need to be considered to negotiate interventions sensitive to all participants' Vol 10112, Summer, 1991 -66 - Journal of Strategic and Systemic Therapies -- Who is involved in the problem? Who might be you left her first. What would that look like?" Or, involved in the solution? "Can you describe the same situation pretending you looked on her leaving as a good thing. Tell me why -- What are the costs and benefits in using dichotomizing, fuzzy, step, constructivist or other models? you're glad she's gone." Or, "Let's imagine you two find some way to talk tomorrow. What could you say?" Or, "I know you're in a lot of pain, but if you -- What are the costs and benefits in calling the situation a crisis, a turning point, a developmental leap, a predictable occurrence, a mistake, bad luck, were going to live, what would you most like to do tbis week?" Tben, "What would belp you get to this time next week?" Or, "Considering how sad and angry you feel, what could you do without or a push towards change? hurting yourself that would help you deal witb your -- What happens if the concept of crisis is ignored? pain and anger? How else can make your voice What can relieve (or increase) the pressure? heard?" Tbese are not magic bullets, but rather small suggestions of ways a constructivist clinician -- How do different members of the system describe the situation? Has it happened before? How is it usually resolved? What are the participants' ideas for might recreate the story of the crisis to help shift the lenses of all the participants --, including his or her own. ways to resolve it? To understand and employ constructivist-- If the crisis seems like the figure, what are the elements of health in the background which might be amplified? informed crisis intervention, crisis clinicians may need additional training. Many crisis workers are volunteers or young professionals who are poorly paid and at the beginning of their careers. Younger Teaching constructivism to clients "in crisis" professionals may find the dichotomizing or step There are many ways clinicians can make views of crisis easier to grasp than constructivism, clients aware of the constructed nature of crisis due to the fit within their modal epistemological without denying their pain. Clinicians can tell levels (Carey, 1989). stories (a la Erickson) of different ways crises I believe that the extra training would be Clients can be asked to cost-effective, since skilled constructivist clinicians describe the incident from another's viewpoint, or would rely more on their own and the clients' describe it from the way it will look the next day or strengths, and make more judicious use of the police five years later. Clients can be asked to alter certain and emergency hospitalizations. In addition, the elements and then re-describe the situation. For constructivist clinician would be able to respond in a example, in the case of a man wbo is threatening variety of ways with chronic users of crisis services suicide because his wife has left him, "Let's imagine that might reduce their dependence on these services. develop and unravel. Vol 10 #2, Summer, 1991 - 67- Journal of Strategic and Systemic Therapies In sum, I believe that a social constructivist view of crisis leljds to: - reduced violence against clients (reduced likelihood of misuse of power) -- greater ability to deal with a variety of situations Everstine, D.S. & Everstine, L. (1983). People in Crisis: Stratel:ic Therapeutic Interventions • New York: Brunner Mazel. Golan, N. (1978). Treatment in Crisis Situations. New York: MacMillan. Hill, R (1958). Generic features of families under stress. Social Casework 39, 139-49. and consider a variety of options - greater cultural, gender and class sensitivity and Hobbs, M. (1984). Crisis intervention in theory and practice: A selective review. British Journal of Medical Psychol0I:Y 57, 23-34. -- more cost-effective crisis intervention. Most crisis theories including those I have referred to here as the dichotomizing, fuzzy and step Kubler-Ross, E. (1969). On Death and Dyina. New York: Macmillan. theories, assume that crises are objective, fixed realities which the clinician tinkers with and tries to cure. In contrast, the social constructivist position helps understand the clinician's role in making as well as unmaking crises. I hope increased attention to the construction of crises will lead to greater reflection on the part of the intervenor, and therefore MacKinnon, L.K. & Miller, D. (1987). The new epistemology and the Milan approach: Feminist and sociopolitical considerations. lournal of Marital and Family Therapy 13. 139-155. Meyerson, A.T. & Glick, R.A. (1976). Introduction. In Glick, RA., Meyerson, A.T., Robbins, E., & Talbott, J .A. (Eds.), Psychiatric Emerl:encies (pp. 3-7) more conscious and responsible actions. Pearce, W.B., & Cronen, V.E. (1980). Communication. Action. and Meaninl:. New York: Praeger. Reference Anderson, H., Goolishian, H., & Winderman, L. Problem determined systems: Towards transformation in family therapy. Journal of Stratel:ic and Systemic Therapies S: 1-14, 1986. Bloom, B.L. (1963). Definitional aspects of the crisis concept. Journal of Consultinl: Psychol0I:Y 27. 498-502. Caplan, G. (1964). Principles of Preventive Psychiatc'. New York: Basic Books. Rusk, T.N. (1971). Opportunity and technique in crisis psychiatry. Comprehensive psychiat.[y .l2. 249-263. Sachs, V.K. (1968). Crisis intervention. Welfare 26,112-117. ~ Smith, L. L. (1978). A review of cnsts , intervention theory. Social Casework 2, 396- Carey, 1. C. (1989). Private conversation. Efran, 1.5., Lukens, RJ. & Lukens, M.D. (1988, September/October) Constructivism: What's in it for you? The Family Therapy Networker, pp. 27-35 .. Elmer-Dewitt. (1989, September 25). Time for some fuzzy thinking. Time Mal:azjne, p. 79. Vol 10 #2, Summer. 1991 Rapoport, L. (1962). The state of crisis: some theoretical considerations. Social Service Review 36, 211-217. -68- 405. Turner, R. (1984). LOl:ics for Artificial Intelliience. New York: John Wiley & Sons. Watzlawick, P., Beavin, J., & lackson, D.O. (1967). Praamatics of Human Communication. New York: Norton Journal of Strategic and Systemic Therapies