Strategic Interventions for People in Crisis, Trauma, and Disaster

Revised Edition

Diane Sullivan Everstine, Louis Everstine

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136749391
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Strategic Interventions for People in Crisis, Trauma, and Disaster enables therapists to walk into difficult situations with a thorough understanding of interactional dynamics and a plan of action.

With the stressful turbulence of our present culture, more and more clinicians are called upon to intervene in crisis situations. Violent interactions, once considered rare or beyond the province of the therapist, have become familiar events to many practitioners. This volume provides them with both the theoretical background and practical techniques to help people learn from crisis experiences and move toward change and growth.

Of special interest are practical guidelines and specific intervention strategies for conducting psychotherapy with different types of violent persons and of victims. Treatment principles for each crisis situation are then illustrated in detailed case studies. As the authors demonstrate, with these troubled people a therapist must be ready to make quick decisions, draw upon all available resources from the family and community, and offer continuing support as traumas are worked through and new behavior patterns are learned. In addition, the authors discuss the legal and ethical responsibilities of the therapist.

PART ONE

CRISIS

CHAPTER 1

Introduction to Crisis

Introduction

Background

Role of the Police

A Perspective

Emergencies or Crises: Terms and Definitions

Introduction

When the ancient Greeks made myths, their gods were drawn to such human scale that they experienced problems just as ordinary mortals do. Moreover, their problems seemed inevitably to escalate into crises. Crisis was a way of life for these figments of the imagination, and how they would cope was an ever-renewable source of entertainment. Down here in the real world, there are many moments of crisis in the course of any ordinary life, nonetheless humbling for being godlike.

A person in crisis encounters a situation or series of situations that cause the person to alter his or her patterns of living. The circumstances that lead to each person’s crisis moment are unique to the person, but the experience of being-in-crisis is universal—from the cabinet minister to the cabinet-maker. The key element in everyone’s crisis is disruption in the normal conduct of one’s affairs, of change being required of the person by forces beyond control, by the feeling that “things might never be the same.”

The Chinese character for the word “crisis” is a combination of the characters for “danger” and “opportunity.” The danger part of the equation is well known, but the sense of opportunity is difficult to convey. This book intends to describe the experience of crisis in considerable detail, in both its positive and negative aspects. The book’s prime objective is to aid those who work in the helping professions to guide people through the stages from crisis onset to resolution, to the epiphany that they are stronger for having had the experience.

When a person has become so ill that he or she should be in a mental hospital, the people who care for him or her face a crisis. When potential dangerousness is feared, or when child abuse or domestic violence must be stopped, a crisis moment has been reached. Similarly, crisis occurs when a family discovers that incest has occurred, or when a threat of suicide has been made. These are the subjects of chapters comprising Part One.

Crises are, in the acute stage, emergencies and must be given immediate attention. This book contains a lot of information about how to intervene in psychological emergency situations. An experience that differs both qualitatively and quantitatively from the larger category of crisis is that of trauma. The traumatic experience will be analyzed thoroughly here, and therapy for trauma will be fully described in Part Two.

Background

Part One is the revised edition of a book that drew on and celebrated the establishment and subsequent work of a mental health program called the Emergency Treatment Center (ETC). ETC, a nonprofit corporation, was neither an agency nor a clinic in the true sense. It was a group of psychologists and a psychiatric nurse who received a local government grant to provide twenty-four-hour intervention to persons or families in emergency situations. Calls came into our crisis line (292-HELP) or from local police agencies that had been called by citizens for assistance. A team of two therapists were dispatched to the scene of the crisis, whether to a home, a motel, or a street corner. In many instances, the police arrived first and assessed the situation before calling us. After the emergency intervention, some of the people involved were seen in our offices for follow-up treatment. The rapport established at a time of dire need meant that many of these new clients could derive rapid and lasting benefits from the therapeutic experience.

Role of the Police

Many of the case studies used to illustrate emergency work in this book make reference to collaboration between clinicians and police officers. This variation in the procedures of most private practices may seem awkward, but there are practical considerations worth noting. When a call is received by a 911 operator, it will most likely be forwarded to a police agency; even if, as in cases of injury or severe illness, paramedics are dispatched or the fire department is dispatched to a fire, the police will probably arrive at the scene of an emergency. And, as will be obvious from some of the cases that you will read about here, they can be valuable allies at various stages of an intervention.

For the police, going to the home where an incident is in progress is often a source of both concern and annoyance, for two reasons: (1) family disturbances can be dangerous, as when family members turn against them as a common enemy; (2) officers see the family disturbance as a distraction from their primary mission, namely (in their words), “catching bad guys.” Yet, even with those deterrents, the police will nearly always be available to help a clinician defuse a crisis. This is a resource that cannot be overestimated.

For the clinician who would like to connect with this resource, a useful first step is to call the local police headquarters and ask if the department has a “ride-along” policy. As part of their community outreach services, many departments arrange for citizens to ride in a patrol car during a shift, usually in an evening. This is a perfect way to learn something about police procedures, the concerns of officers, the terms that they use, and so on. Rarely does an experience such as this fail to produce a greater appreciation of an officer’s role and the work that they do.

When a clinician has begun a relationship with a local department, he or she may wish to establish contact with officers who have special assignments, for example, one who works with juvenile cases, one who works with domestic violence, and one who specializes in sexual assault cases; some departments combine these functions in a single assignment, and others subsume them within a Detective Bureau. With the passage of time, it is probable that a clinician will make use of some part of this network as an aid to client care.

A Perspective

The reader will find, in this book, reference to human tragedies of every kind and severity. Rape, incest, battering, threats of murder, and suicide are routine topics here. For all their poignancy, events such as these are relatively rare, and a mental health professional could abide for an entire career without being called on to intervene in one of them. The fact remains that clinicians are much needed to help people in crisis moments such as these. Here is a responsibility that, at least intellectually, any therapist can accept. It behooves them to have an understanding of crisis dynamics, should they encounter people in crisis in the course of clinical work.

Why do most people think of calling 911 when they can’t cope? One reason is that many who are experiencing an emergency do not define it as being “mental” or psychological in nature. When a referral to a mental health clinic is suggested, it is ignored more often than it is accepted. The fact is that many people are still fearful of mental health systems. They are afraid of the stigma of being labeled as “crazy” or “mentally ill” or as having a “disorder,” and they fear the social or occupational repercussions that may follow should someone find out about it.

To our discredit, mental health professionals still do much to mystify themselves and their methods to the public. Most people feel that they at least understand the motives and methods of the police, and so are more inclined to turn to them when they are in crisis, especially when they are afraid. But, when the help they need to solve their problems is not forth-coming from this, the only source they know and trust, a cycle of dysfunction or violence may be set in motion or prolonged.

Emergencies or Crises: Terms and Definitions

We conceptualize an acute emergency as an extremely unstable situation that has escalated out of control. There is the potential risk that someone may die, as in the case in which a person has become suicidal or homicidal. As well, there could be imminent physical danger such as occurs:

• When a person is psychotic or agitated or manic

• In domestic violence

• In stalking situations

• In child abuse

• In child molestation

• With out-of-control behavior such as in anorexia

• With high-risk behavior of any sort

• In natural disasters

• In states of war or terrorist attacks

The primary goal for an intervention in an acute emergency is to ensure people’s safety and to stop the escalation process. Most interventions in an acute emergency involve the creation of some sort of external structure or restraints to contain the escalation. Typical interventions in acute emergencies are:

• Immediate medical care

• Separation of participants

• Medication

• Temporary shelter

• Disaster relief

• Vigiling or supervision by a trusted person

• Hospitalization

We view a crisis (as do James and Gilliland, 2001, and Myer, 2001) as an unstable situation, but one that has not yet escalated out of control. Without immediate intervention, the crisis will have the potential of developing into an acute emergency.¹

CHAPTER 2

Communication Principles for High-Stress or Dangerous Situations

Connecting with the Person in Crisis

Complementary and Symmetrical

First Steps

Points of Caution

This chapter discusses aspects of communication that pertain when dealing with extremely agitated or angry people, as well as communicating with people under highly stressful conditions. Even though many of these methods are drawn from our experience in hostage negotiation, the communication principles discussed here are applicable to a wide range of problem situations, for example, working with a violent family or with a person who is threatening to commit suicide. Some of these principles may seem simplistic because it is the clinician’s own language that is being discussed, but it is easy not to notice how language is used. It is easy to relax and become sloppy, and to fall into language patterns that would probably go unnoticed in everyday life but might cause problems should a therapist become involved in a high-stress situation.

To begin with, some basic rules of communication will be reviewed, the first of which is the famous observation of Paul Watzlawick, that a person “cannot NOT communicate” (1964, p. 2). When one person says “Hello” and the other person says nothing and turns away, the second person has communicated something quite clearly.

The second basic rule is that human communication is a multilevel phenomenon (Watzlawick, 1964, p. 3; confirmed by Birdwhistell, 1970; Hackney and Cormier, 1999; Myer, 2001). In fact, an attempt at communication may prove meaningless when it is reduced to one level. When a person speaks in a way that ignores the context of the communication, what is said can very likely be meaningless. Should a person say, “I am not the person who is speaking to you,” the paradox sounds odd because it doesn’t fit within the context in which it was uttered. Thus, communication has content, which is the information that the individual is conveying, and also communication can only occur in a specific context. For example, when someone enters a store and a salesperson walks up and says, “May I help you?,” that remark is seldom prefaced with, “I am a salesperson and my job in this store is to sell you something.” That fact is understood and the relationship of employee to prospective customer is already established. In general, disagreement about the content of communication may be resolved quite easily. That is, if someone walks up to a person and says, “You’re blue,” the person can say, “No, I’m not. My sweater is blue, my face is flesh-colored, and my hair is brown;” both can then appeal to a third party to settle the disagreement. And, if someone says that the earth revolves around the moon, the hearer can verify or disqualify the assertion. However, in respect to context, disagreements can become more complicated and much more emotionally charged, as will be shown in this chapter.

Contextual disagreements arise in respect to how one person in a conversation misperceives the other, or how one has managed to misunderstand what the other said. Although we may like to think that we live in a world of reality, the reality is that we live in a world of personal opinion (Watzlawick, 1976). Much of what each of us considers to be reality consists of the sum total of our personally arrived-at, and absolutely unique, set of opinions. This fact is vitally important when a therapist is engaged in a crisis situation. In such a situation, it is highly probable that the clinician will be attempting to communicate with a person who does not share his or her reality or perceptions of the world. The other person may inhabit a totally different value system, may come from a totally different socioeconomic background, and may represent a different ethnic group; moreover, he or she may not have grown up in this culture. The issues of relationship, and how another person thinks that he or she is perceived, may become critical in communicating with people in psychological emergencies and other high-stress situations.

One of the clinician’s primary tasks is to understand the “worldview” of the person in crisis and to communicate with him or her in a way which is consonant with that view. When this worldview is examined carefully, the clinician will probably discover a discrepancy between the conception of present reality of the person in crisis and the clinician’s own conception (For a detailed discussion of how world images may be discrepant from reality, see Watzlawick, 1978, Chapter 5.) When contradictions of this type are observed, a clinician has essentially two options: (1) change the reality conditions that pertain to the person, for example, by attempting to “make deals,” give practical advice, or persuade people whom the person in crisis has mentioned as being significant to come to the scene; or (2) work toward changing the worldview of the person in crisis. Although the latter course of action may seem an impossible task, it is often the first choice of a skilled therapist and the wiser course of action in most instances. By contrast, changing reality conditions may be very difficult indeed; in fact, any rapid change in those conditions may be disbelieved by the person in crisis, in which case it will not have the desired effect. Instead, a clinician usually tries to help the person in crisis to change his or her perceptions of reality in such a way that the person can see alternative, beneficial means of resolving current problems.

A third basic rule of communication is that message sent is not necessarily message received (Watzlawick, 1964, p. 4). Just because one person has said something does not mean that the other person has understood what was said. Often, we assume that the people to whom we are speaking share our views, our values, and our feelings, and we assume that certain words have the same connotations for others as for us. It is helpful to imagine a series of events such as the following: a therapist says something to a person in crisis. The therapist assumes that the person understood what was said, that is, understood both the denotative meaning and the connotations of the words in the message. But, actually, the person in crisis has, in some way, misunderstood what the clinician said, and the reply is based upon that misunderstanding. Next, the therapist replies to what the person in crisis replied, which was based on misunderstanding in the first place, and so it goes back and forth.

A case example to which this rule of communication applies is that of a couple who were being seen for counseling. It was not a seriously disturbed relationship, although the two had trouble in communicating because of their very different ethnic backgrounds (she was Scandinavian and he was from a second-generation Latin family). One of their main problems concerned a woman friend of the wife, about whom they had been arguing for at least six months. Although the husband hated his wife’s friend, the wife felt that she should defend her. The husband’s view was that the friend was immature, loud, and inconsiderate of her own husband.

In counseling, one of the first things each was asked to do was to give a detailed description of the woman in question, with this instruction: “I want to make sure that I hear both sides of the story. I want you to take turns in describing the person to me.” When they described her, it seemed as though they were both saying similar things about this woman, and for that reason the counselor asked for more details from each, for example, “Did you mean such-and-such?” After some time had been devoted to this form of translation from one person’s English to the other’s, they realized that some of the words that each had been using were being perceived as inflammatory by the other. Apparently, because of their different cultural backgrounds, the same words had acquired differing connotations (in effect, diffe...

Table of contents

• Cover Page
• Half-Title Page
• Strategic Interventions for People in Crisis, Trauma, and Disaster
• Copyright
• Foreword
• Table of Contents
• Acknowledgement
• Foreword by Paul Watzlawick
• Overview
• Part One: Crisis
• Part Two: Trauma
• Postscript
• Notes
• References
• Index