The Curvilinear Model of Anxiety, which is described in Kanel’s 2011 book “A Guide to Crisis Intervention” suggests that anxiety has both positive and negative attributes depending on the situation and the individual. You may be familiar with the concept of eustress, which is a form of positive stress (American Institute of Stress, n.d.) based on our interpretation of that event. Examples include writing a test that we are confident we will perform well on, or kissing a partner for the first time.
This relates to the Curvilinear Model of Anxiety in that an appropriate amount of anxiety can be very helpful for one’s ability to change, which is especially important in the field of crisis intervention.
If we have an extremely high stress or anxiety level we will feel overwhelmed, and unable to accomplish anything. On the other hand, if our stress level is extremely low, we will experience no motivation or desire to change, which is equally problematic.
Example of the Curvilinear Model of Anxiety
Someone who is abusing substances for instance, may find themselves $100,000 in debt and facing a physical assault by someone who owes them money. In the middle of this crisis, they are likely unable to make good (or any) long-term decisions about their life until this crisis has been dealt with.
On the other hand, if that same person has $100,000 and is in the middle of their drug use, they are also unlikely to change either. The idea that someone has to hit ‘rock bottom’ is common in 12 Step Programs such as AA and NA (Narcotics Anonymous), because without this they are not motivated to change themselves.
Role of Medication
In cases where an individual has an overwhelming level of anxiety or even experiences panic attacks or other physical symptoms, medication might be necessary in order to restore an immediate level of functioning. Drugs that end in -pam such as lorazepam, diazepam or clonazepam fall into the hypnotic-sedative/benzodiazepine category and may be used as a PRN (“take as needed”) or as a once-daily medication.
Kanel, K. (2011) A Guide to Crisis Intervention, 4th ed. Cengage Learning: Boston, MA.
“What is stress?” n.d., American Institute of Stress. Accessed electronically on Jun 2 2016 from http://www.stress.org/what-is-stress/
Critical incident stress (CIS) management is the process of managing the response after a critical incident at work that causes employee stress. (Caine, & Ter-Bagdasarian, 2003) In a 911 communications environment this could be hearing a call where you’re not able to respond before someone dies of a medical injury, listening to a suicide or homicide in progress, or other events that have the potential to overwhelm an individual’s coping skills.
After an initial traumatic event or critical incident, an acute stress disorder may develop. If these symptoms (numbing, reduced awareness, derealization) continue for more than 4 weeks a client may meet the definition for PTSD. (Gibson, 2016) Approximately 20% of individuals who experience a trauma will go on to develop PTSD. (Norris, et. al., 2002)
The goal of CIS Maangement (CISM) is to short-circuit this process in people exposed to secondary trauma in order to ensure the best outcome for the individual. For primary victims of trauma CISM is ineffective. (Jacobs, Horne-Moyer & Jones, 2004)
CISM is generally broken into three categories (Guenthner, 2012):
- Primary Interventions, which focus on promoting health and resilience in employees in the absence of any critical incident
- Secondary Interventions, which focus on the immediate steps after the crisis
- Tertiary Interventions, for individuals who are experiencing symptoms of PTSD
Critical Incident Stress Management (CISM) Process
Blacklock (2012) identified the steps of the CISM process. The first step of the CISM process is diffusing. Diffusing is limited to individuals who were directly involved in the trauma (e.g. the first responders at an accident scene) so that they can begin the process of ventilating emotion. Individuals are provided with a telephone line to call or other resource they can reach out to and make sure they will be okay for the remainder of their shift.
The second step in the CISM process is debriefing. This should be done within 72 hours with all staff directly or indirectly involved being allowed to attend. Mitchell (1983) identified seven steps to the CISM Debrief which are listed in the next section.
Critical Incident Stress Debriefing (CISD)
The following table comes from Blacklock (2012) who cited it from Mitchell (1983):
Other CISM Interventions
Pulley (2005) identifies additional activities including:
- Crisis management briefing, where large groups of individuals affected by a trauma are brief on the crisis
- Family support – Providing the family of an emergency worker with practical supports to assist in the CISM process
- Assessment/consultation – On an organizational level, additional support is provided by larger organizations (such as the Tema Conter Memorial Trust) to help identify appropriate referrals
- Follow-up and referral – The organization follows up with affected individuals to identify any unmet needs and performs case management to help them access new supports.
- Mutual aid – Finally, other individuals who have previously experienced trauma provide peer support to help everyone work through their symptoms.
The Canadian Critical Incident Stress Foundation provides individual and group training that meets the requirements of the International Critical Incident Stress Foundation (ICISF). Online CISM Training is also offered online through the ICISF.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.
Blacklock, E. (2012) Interventions Following a Critical Incident: Developing a Critical Incident Stress Management Team. Archives of Psychiatric Nursing. 2-8.
Caine, R., & Ter-Bagdasarian, L. (2003). Advanced practice. Early identification and management of critical incident stress. Critical Care Nurse, 23(1), 59-65 7p.
Gibson, L.E. (2016) Acute Stress Disorder. U.S. Department of Veterans Affairs, National Center for PTSD. Accessed electronically on Sun May 22, 2016 from http://www.ptsd.va.gov/professional/treatment/early/acute-stress-disorder.asp
Guenthner, D. H. (2012). Emergency and crisis management: Critical incident stress management for first responders and business organisations. Journal Of Business Continuity & Emergency Planning, 5(4), 298-315.
Jacobs, J. Horne-Moyer, H.L., Jones, R. (2004) The effectiveness of critical incident stress debriefing with primary and secondary trauma victims. International Jounal of Emergency Mental Health. 6(1):5-14
Norris, F.H., Friedman, M.J., Watson, P.J., Byrne, C.M., Diaz, E. & Kaniasty, K (2002). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001. Psychiatry 65, 207–239.
Pulley, S.A. (2005) Critical Incident Stress Management. Accessed electronically on May 28, 2016 from http://web.archive.org/web/20060811232118/http://www.emedicine.com/emerg/topic826.htm
There are a variety of crisis theory and crisis intervention models used to explain how crises develop and what it means for an individual to need crisis intervention. Some explanations of crisis theory are more academic in nature, while others are considered more applied or practical.
Before reviewing the three types of crisis, it’s important to review basic crisis theory. While there are dozens of models – James (2008) lists 7 theories and 5 models of crisis intervention only a few will be covered below. These ar the most important.
James (2008, p.3) lists several definitions of crisis, which are an important precursor to understanding crisis theory. The core element in each of them is that an individual is overwhelmed. Three of the 6 definitions are listed below:
“People are in a state of crisis when they face an obstacle to important life goals–an obstacle that is, for a time, insurmountable by the use of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many abortive attempts at a solution are made.” (Caplan, 1961, p.18)
- “Crisis results from impediments to life goals that people believe they cannot overcome through customary choices and behaviors” (Caplan, 1964, p.40)
- Crisis is a crisis because the individual knows no response to deal with a situation (Carkhuff & Berenson, 1977, p.165)
- A negative event occurs which leading to a feeling of subjective distress
- This distress leads to an impairment in functioning
- Coping skills fail to improve functioning
The term “cognitive key” refers to your belief about the negative event, which influences how well you will be able to cope with the event. Changing your perspective and help improve your ability to cope.
Basic Formula for Crisis Intervention
- Alter the perception of the negative event and offer coping strategies
- Distress is lowered
- Functioning returns to pre-crisis levels
Crisis as Danger and Opportunity
Crisis can be thought of as both of a danger or an opportunity. There’s a myth that says that the Chinese word for “crisis” means both danger and opportunity. While this is not exactly accurate (any more than the word “opportunity” contains the word port), the sentiment is true
If an individual in crisis is able to muster their coping skills, supports, and resources, they will find themselves able to come through the crisis and be more prepared to work through future crises. On the other hand, if they don’t seek that support their functioning will decline further and they will find it harder to deal with things.
Historical Crisis Theory
Erich Lindemann, a German psychiatrist authored the first papers in the field of crisis intervention, relating to bereavement in the aftermath of the Cocoanut Grove nightclub fire which killed nearly 500 people. (Wright, 2014) His paper, Symptomatology and Management of Acute Grief noted that crises tended to share a similar features and progression and most did not require formal intervention. (1944)
Lindemann’s colleague Gerald Caplan extended the field of crisis intervention to look at all kinds of traumatic events. Both Lindemann and Caplan saw crisis as developing from a state of disequilibrium, with Lindemann identifying four stages of crisis (James, 2008; p.10):
- Disturbed equilibrium
- Brief therapy or grief work
- Working through the problem or grief
- Restroation of equilibrium
With Caplan extending this crisis theory to identify affective, behavioural and cognitive impacts.
Modern Applied Crisis Theory
While Caplan and Lindemann’s work has been influential and is important in understanding the development of crisis intervention it is insufficient for describing modern mental health crises that may develop without a single precipitating event or pre-existing mental health issues.
Lawrence Brammer’s 1985 book “The Helping Relationship: Process and Skills” (as cited in Miller, 2011) identifies three types of crisis that make up his theory of applied crisis.
These domains are:
- Developmental Crisis
- Situational Crisis
- Existential Crisis
A developmental crisis is the result of a normal life event (like a pregnancy or graduation) that causes stress and strain on an individual. (James, 2008, p. 13) While developmental crises are normal they may need close monitoring to ensure that a client returns to normal functioning.
One useful way of conceptualizing a developmental crisis is to consider the concept of grief and loss. Because all changes in a person’s life result in loss and loss requires grief work to process, an individual will need to take the time to process their life changes.
A situational crisis is the most common kind of event when we consider crisis intervention. This is an event that is so overwhelming and sudden (Schottke, 2001, p.236) that it overwhelms normal coping. Examples of situational crises include sexual assault, a motor vehicle accident or sudden loss or grief.
This is the most common form of crisis that emergency responders and other crisis intervention workers (hotline workers, social workers) are likely to encounter.
Existential crises are based on larger concepts of a person’s purpose and attainment of actualization, a deep sense of personal fulfillment (Olson, 2013) Often existential crises are related to situations of regret or belief that life has passed them by (Price, 2011) or realization that one will not reach goals they had set for themselves at a certain age (James, 2008, p. 13)
Existential crises are particularly common at life transition points like 30, 40, and 50 when people “take stock” of their life. A significant existential crisis can predispose suicide and may be linked to the markedly high suicide rate among men and women between 45 and 54. (MacDonald, 2015)
Other Theories of Crisis and Crisis Intervention
There are a variety of other resources identified in James (2008) that are not covered here. They are:
- Psychoanalytic Theory
- Systems Theory
- Ecosystems Theory
- Adaptational Theory
- Interpersonal Theory
- Chaos Theory
- Developmental Theory
Other Models of Crisis Intervention
- Equilibrium Model
- Cognitive Model
- Psychosocial Transition Model
- Developmental Ecological Model
- Contextual-Ecological Model
Caplan, G. (1964) Principles of Preventive Psychiatry. Basic Books: New York, N
Brammer, L.M. (1985) The Helping Relationship: Process and Skills. Prentice Hall: Upper Saddle River, NJ
James, R.K. (2008) Crisis Intervention Strategies. Brooks/Cole: Belmont, CA.
Lindemann, E. (1944) Symptomatology and Management of Acute Grief. American Journal of Psychiatry, 101.141-148. Accessed electronically on May 28, 2016 from http://www.nyu.edu/classes/gmoran/LINDEMANN.pdf
MacDonald, D.K. (2015) Understanding and Preventing Male Suicide. Accessed electronically on May 29, 2016 from http://dustinkmacdonald.com/understanding-and-preventing-male-suicide/
Miller, G. (2011) Fundamentals of Crisis Counseling. John Wiley & Sons: Hoboken, N
Olson, A. (2013) The Theory of Self-Actualization: Mental illness, creativity and art. Psychology Today. Accessed electronically on May 29, 2016 from https://www.psychologytoday.com/blog/theory-and-psychopathology/201308/the-theory-self-actualization
Price M. (2011) Searching for meaning. Monitor on Psychology. 42(10). 58.
Schottke, D., Pollak, A.N. (Ed.) (2001) Emergency Medical Responder: Your First Response in Emergency Care. American Association of Orthopaedic Surgeons. Jones & Bartlett: Suffolk, MA
Wright, B. (2014) “The Cocoanut Grove Nightclub Fire Happened 72 Years Ago in Boston”, Boston.com. Accessed electronically on May 29, 2016 from http://www.boston.com/news/local-news/2014/11/28/the-cocoanut-grove-nightclub-fire-happened-72-years-ago-in-boston
When confronted with a crisis situation it’s important to be have the knowledge to tackle a crisis but also to have appropriate referrals for the client. In some roles, like that of 911 Operator, dispatching of police, fire and ambulance will be the sole “referral”, and while police or Victims Services may provide some referrals, the majority of the time this falls on to social services workers they come in contact with.
On services like Distress Centre Durham’s 24-hour helpline, referrals make up a small portion of our calls (between 5 and 10% each year), and more than half of these are to the local Mobile Crisis Team. On the Online Text and Chat Service (ONTX), the numbers are even smaller. Not all crisis roles will involve referrals but it good to be aware of them for times when client needs fall outside the boundaries of the service provided by your own agency.
Making Good Referrals
- Initiate referrals or option exploration only when the client requests it or agency limits and boundaries (e.g. time limits, in-person vs. telephone service) require it
- Obtain a copy of the United Way Blue Book, access to the 211.ca website/211 phone number for situations where referrals fall outside of your scope of knowledge
- Ensure that any referral list is regularly updated to ensure individuals have correct contact information
- If possible, conduct tours or bring in speakers from your most popular referrals so that you can confidently describe the intake and service delivery
- Set a date for when the client will access the referrals and then follow up (if this is allowed as part of your agency procedures) to see if they were able to. If not – explore why. Long wait list? Bureaucracy? Client not sure how?
- Review referral data regularly (at least on once a year) to determine what unmet needs exist in your community
Durham Region Referrals
The following are referrals that are regularly referred within Durham Region. These referrals should meet the Course Learning Outcome for CRIS 1342 “Describe and discuss various crises and suggest agency referrals.” All the below issues may be handled by Distress Centre Durham helpline workers or Online Text and Chat Responders, in addition to the specific external agencies listed.
These organizations are in no way comprehensive – there are many situations not covered here (e.g. motor vehicle accidents, issues involving children, pregnancy, relationships and so on) but this is a good start. 211 is your friend!
Addiction Referrals in Durham Region
- Pinewood Centre – Pinewood is a full-service addiction treatment facility. They provide detox and withdrawal management, in addition to addictions counselling on both an inpatient and outpatient basis.
Counselling and Mental Health Referrals in Durham Region
- Catholic Family Services of Durham Region – Catholic Family Services provides counselling (both on a walk-in basis and scheduled appointments) on a geared-to-income basis for a range of mental health issues. They provide service in both English and French and specialize in trauma but work with a wide variety of clients.
- Durham Region Family Services – The Region of Durham also provides counselling with a team of trained counsellors.
- Durham Mental Health Services – Durham Mental Health Services provides case management, counselling and emergency support (including Mobile Crisis and residential crisis beds) within Durham Region.
Financial and Employment Crisis Referrals in Durham Region
- Community Development Council Durham (CDCD) – CDCD has programs for some areas of financial need like winter heating costs and housing stability.
- John Howard of Durham Region – John Howard provides employment-based supports as well as counselling in the areas of anger management and intimate partner violence.
- Ontario Works – For individuals who are in need of immediate assistance, Ontario Works can provide direct cash benefits to unemployed or underemployed individuals to help them pay their bills and remain homed and fed.
Homelessness Referrals in Durham Region
- Bethesda House – Bethesda House is a shelter for women fleeing abuse located in Bowmanville.
- Cornerstone Community Association – Cornerstone is the only men’s shelter in Durham Region. They provide transitional housing, and a residential shelter. Cornerstone will take single men over 16 years of age, single men with young children and couples with children. It is located in Oshawa.
- Denise House – Denise House is a shelter for women feeling abuse located in Oshawa.
- DYHSS (Durham Youth Housing and Support Services) – Also known as Joanne’s House, this is the only youth shelter in Durham Region, for youth 16 to 24, located in Ajax. Youth below 16 are required to be housed with Children’s Aid Society.
- Herizon House – Herizon House is a shelter for women feeling abuse located in Ajax.
- Muslim Welfare Home – The Muslim Welfare Home is a shelter for homeless women, whether or not they are fleeing abuse. It is located in Whitby.
Legal Referrals in Durham Region
- Durham Community Legal Clinic – The Durham Community Legal Clinic provides general legal support to low-income individuals in the Durham Region who are in need of legal advice.
- Durham Family Court Clinic – The Durham Family Court Clinic helps youth and families who have come into contact with the criminal justice system by providing assessment, counselling and support groups.
- Luke’s Place – Luke’s Place provides women with emotional support and practical advice as they navigate the Family Court system with a trained advocate. For men as well as women who are survivors of intimate partner violence, Luke’s Place provides an adovcate that may accompany you to Court.
Physical and Sexual Health Referrals in Durham Region
- Brain Injury Association of Durham – For those individuals who have experienced a traumatic brain injury, the Brain Injury Association provides peer support and support groups.
- Durham Sexual Health Clinic – The sexual health clinic provides confidential and anonymous STI screening, contraception and referrals.
- Oshawa Community Health Centre – The Oshawa Community Health Centre provides a full spectrum of physical and mental health services including general medicine, counselling, nutrition and other supports in one location.
Sexual Assault and Domestic (Intimate Partner) Violence Referrals in Durham Region
- Durham Rape Crisis Centre – For women who have been victims/survivors of sexual assault, the Durham Rape Crisis Centre provides 24/7 emotional support and crisis intervention.
- Lakeridge Health Domestic Violence and Sexual Assault Care Centre (DVSACC) – For men or women who have experienced recent intimate partner violence or sexual violence (ideally within the previous 72 hours) you can be examined by a nurse for signs of injury, which can be documented without getting the police involved. This can help if you later decide to pursue a case against the person who injured you.
- Support Services for Male Survivors of Sexual Abuse – Run by the Ministry of the Attorney General of Ontario, this toll-free service provides men access to information and referral. Like most lines of this nature run by the province (ConexOntario, the Mental Health and Addictions Helplines), I don’t believe they provide emotional support. This is a glaring absence
Sudden Loss or Grief Referrals in Durham Region
- Bereaved Families of Ontario – Bereaved Families of Ontario has a Durham chapter that provides peer support through telephone, support groups and one-on-one sessions. Their programs tend to be focused on parents grieving the loss of their children but they provide other groups as needed.
- Distress Centre Durham – Distress Centre provides two 8-week support groups, one for survivors of suicide (who have lost someone in their life to suicide) and a homicide survivor group, in addition to weekly “call outs” with a peer support survivor who has completed training. The Suicide Survivor group runs approximately 4 times a year while the homicide group runs once every 1-2 years based on availability.
- Pregnancy and Infant Loss (PAIL) – The Pregnancy and Infant Loss Network provides support for women and men grieving the loss of a child, either during pregnancy (through miscarriage, illness, abortion, etc.) or in infancy.
- VON Durham Hospice – Durham Hospice provides both palliative care support (resources for individuals with less than a year to live) and bereavement support (for those who have lost someone close to them.) Bereavement services are provided one-on-one in a peer support model, with groups available for teens/children, adults grieving the loss of their mothers and general grief support groups.
The LAPC model was created by Cavaiola and Colford (2006) in their textbook Crisis Intervention Case Book. The advantage of the LAPC process is that it is easy to remember and apply, whether you are a degreed professional or a layman who has received a short amount of training. One of the difficulties of other crisis intervention models is that it can be difficult to recall the processes when they are needed most.
A client who is at high risk of danger will need a very directive approach where the crisis worker directs the intervention, a client at a moderate risk of danger will work best with a collaborative approach where control is shared, and a client at a low risk of danger should have a very non-directive approach where they lead.
The four steps of the LAPC Model are listed below:
LAPC Step 1. Listen
The first step in the crisis intervention process is to listen! This seems obvious but in a crisis it can be very easy to fall into the trap of hearing what we think is happening, rather than what is actually happening. If we fail to understand what the person in crisis is actually experiencing we will respond inappropriately.
Techniques used in the listening process include open-ended questions, paraphrasing and clarifying, and summarization. These are all primary counselling skills and are an inherent part of the active listening process.
In addition to hearing what a client is actually telling you, you should work carefully to avoid facial expressions or reactions which could be seen as judgemental. This is especially important when disturbing or scary content like suicidal or homicidal thoughts, sexual abuse or others are covered.
LAPC Step 2. Assess
Assessment is the next part of the process. This may be a structured and formal process (such as if you choose to use the CPR or DCIB Suicide Risk Assessments) or may be a much more informal process of synthesizing what you have learned in order to formulate an accurate picture of where needs are unmet or risk is present.
If you have failed to listen correctly, your assessment will not target the correct areas the client will not feel heard. Additionally, if you’ve missed signs of suicide or homicide risk (or in children, neglect or abuse) you may place the client or others at risk.
LAPC Step 3. Plan
The third step in the process is planning. In cases of suicide or homicide risk, safety planning will be the first order of business. For instance, someone who wants to overdose may give the pills to someone who can safeguard them, employ coping strategies to help ground themselves (watching their favourite movie or exercising for instance), or agreeing to call a crisis line if they can’t stay safe.
Once immediate safety concerns have been taken care of, other planning can take place. This may involve referrals to organizations (an article on this will be published June 6) for longer-term support (like counselling or case management), or otherwise performing the first steps to restoring equilibrium.
Planning should be a collaborative process between you and the client. If you simply take control and do everything for the client they will feel disempowered and dependency may result.
LAPC Step 4.Commit
Finally it’s important for the client to commit to the plan. If they have been involved in the process up until now, they should have little concern with committing. In some situations (like child welfare) there will be no option for them to “opt out” and they may be upset but getting them involved is still required.
Cavaiola, A. & Colford, J.E. (2010) Crisis Intervention Case Book. Nelson: Toronto, ON