Naomi Golan is the creator of the Golan Model of Crisis Intervention, and a pioneer of crisis theory and crisis intervention. She is Professor Emeritus at the University of Haifa in Israel, where she retired in 1984. (Dorfman, 2013)
Golan’s 1978 book Treatment in Crisis Situations provided a review of her three phase model of crisis intervention. While this work has been integrated into the work of modern day crisis intervention and even regular social work practice it was quite innovative in its day.
Golan Model of Crisis
The model that Golan proposes involves three stages or phases, and is designed to be completed in 5-6 sessions. The three phases are Assessment, Implementation and Termination. These are reviewed in more detail below.
The assessment stage happens in the first session. The goals of the assessment stage are very similar to Boiling Down the Problem in the ABC Model and the Step 1 (Defining the Problem) in the Six Step Model of Crisis Intervention.
First, you must identify what the traumatic event or precipitating event that caused the crisis. Second, you must understand the client’s reaction or response to crisis. Third, what context did the crisis event happen in – what else is going on in the client’s life? The term “hazardous event” is sometimes used to describe the nature of the stressor. Fourth, you must identify how the client has been affected by the crisis, and finally what is the client’s primary concern as a result of the crisis?
Golan (1969) identifies four elements that can be used to determine if a client is in crisis:
a hazardous event
a vulnerable state
a precipitating factor
a state of active crisis or disequilibrium
A comprehensive assessment will be the road-map you rely on to ensure you have accurately understood the nature of the client’s crisis.
Once you have identified the goals for treatment (collaboratively with the client), you will proceed to the Implementation phase. During implementation, you will collect information on the client’s pre-crisis functioning, coping strategies, strengths and weaknesses, and support systems available to them.
Once you have this information, you can begin to set some concrete goals with the client. For example, a recently divorced client who is completely overwhelmed with what to do next might set a goal to make an appointment with a career counsellor or resume writing service – or even something as simple as a checklist to ensure they shower and brush their teeth each morning.
The Implementation stage will run from the first session to approximately the fourth session.
Termination is the final sessions, which might be the 5th or 6th session. Now that the client has made some steps towards regaining pre-crisis functioning, the client and therapist make a plan to wrap up services and make plans for the future.
Similarities and Differences with Other Crisis Intervention Models
The ABC Model includes three stages:
Boiling Down the Problem
Contracting for Action
Boiling Down the Problem most of the elements in the Implementation Phase, including understanding the elements that are leading the client to their crisis, and getting a detailed understanding of their coping strategies. The focus in the Termination model is very similar to the Contracting for Action part of the ABC Model.
The ABC Model includes achieving rapport as an explicit element, while the Golan Model does not, this is just expected. Additionally, the Termination phase in the Golan Model covers next steps after the client wraps up therapy, while the ABC Model may lead into regular counselling or therapy, without necessarily stopping therapy.
Six Step Model of Crisis Intervention
The Six Step Model of Crisis Intervention includes six steps:
Defining the Problem
Ensuring Client Safety
Both the Six Step Model and the Golan Model of Crisis Intervention include defining the nature of the problem, understanding their supports and existing resources, making goals or plans, and a termination or wrap up phase.
The Six Step Model includes more specific phases than the Golan Model. For example, Ensuring Client Safety (meeting their basic needs like shelter and food) and Providing Support (accepting the client as a person of value and worth) are absent from the Golan Model. On the other hand, the Golan Model includes assessing pre-crisis functioning in a way that the Six Step Model does not.
Finally, the Golan Model includes a more thorough Termination phase, while the Six Step Model’s Termination phase (“Obtaining Commitment”) is more about obtaining verbal agreement about next steps.
The LAPC Model includes four steps:
The LAPC Model’s Assess Phase is very similar to the Assessment Phase in the Golan Model, while the Plan Phase is very similar to the Implementation Phase. Finally, the Commit phase includes elements similar to those in the Termination phase of the Golan Model.
The main difference is that the LAPC Model includes a step involving Listening, while the Golan Model does not. Additionally, the LAPC Model includes safety planning and taking care of basic needs, things that were less of a concern to Golan – who was frequently taking care of clients in a hospital setting where this was already assumed.
As you can see, many crisis intervention models are overlapping and interrelated. The Golan Model of Crisis Intervention is a useful model of crisis intervention, and has several important similarities and differences when compared with other models like the Six Step Model, the ABC Model, and the LAPC Model.
Golan, N. (1969) When is a client in crisis?. Social Case Work. 50(7). pp. 389-394.
Golan, N. (1978) Treatment in Crisis Situations. New York, NY: Free Press.
Dorfman, R.A. (2013) Clinical Social Work: Definition, Practice And Vision. London, England: Routledge.
There are a variety of situations where a client or helpline caller may experience negative emotions and need to use coping strategies to help themselves cope. These can include flashbacks to abuse or trauma (such as in child sexual abuse or Post Traumatic Stress Disorder), dissociation, or simply intrusive thoughts or memories of a variety of painful experiences.
In these situations, there are a variety of techniques that can be taught to clients to help them stay grounded and cope. They are summarized below.
Physical Techniques for Coping with Flashbacks
Physical techniques focus on using your physical body or space to reduce your flashbacks or dissociation.
Plant your feet on the ground or grasp the arms of a chair
Repeat one’s name, age or location
Go to a safe space (e.g. home), a place where you feel calm and safe
Behavioural Techniques for Coping with Flashbacks
Behavioural techniques are actions that you can take when you feel stressed or overwhelmed. Ways of expressing yourself can give you a sense of control that will make it easier to cope.
Journal or writing
Calling a crisis line or mobile crisis team
Going to the hospital
Taking a walk
Cognitive Techniques for Coping with Flashbacks
Cognitive techniques are those things that involve your thoughts. These may be more challenging than the other techniques but with practice will become easier to use when you are feeling overwhelmed. Because these are hard to summarize they’ve been listed with more detail than the above techniques.
Identify Internal Cues
Internal cues are those things that prompt you to think that you are going to dissociate or experience flashbacks. Sometimes they come on randomly, but for other individuals there is a period of feeling flushed, having a racing heart, feeling anxious or restless, or other symptoms that precede the flashbacks or dissociation. When you recognize these occurring, using the other techniques on this list can help you cope.
Identify Associational Cues
Associational cues are those things that you associate with safety and security. These can be objects, sources of support like pets or other things that remind you that things will be okay. The association between the item and the positive thoughts it brings can help ground you.
Safe Space (Mind)
Going to a “safe space” mentally and remembering that what you are experiencing is temporary can be helpful. Guided imagery (described below) can help you find this safe space, which can also be a place in your own memory where you felt safe and protected.
Meditation and Guided Imagery
Meditation is a very common strategy for coping with flashbacks and dissociation. Meditation takes practice, but by using slow and steady breathing and trying to clear your thoughts when you are not in a state of dissociation or flashbacks, you will build this skill up to where you can implement it when you sense you are going to dissociate.
Guided imagery is similar, but rather than meditating or focusing on your own breathing, you focus on a guided story that will help keep you grounded.
Labeling your emotions can be a very effective way of reducing immediate stress. This can be both to yourself (merely talking out loud), or to a support like a friend, a pet or a crisis line. Many people who experience trauma have difficulty labeling their emotions and this exercise (especially when practiced as part of comprehensive therapy) can help keep you grounded.
Cognitive restructuring refers to techniques of identifying and challenging automatic or maladaptive thoughts. The simplest way to do this is with an ABC (Action, Behaviour, Cognition) worksheet. An ABC worksheet lists actions that made you feel bad, behaviours or results from that, and the cognitions that went along with that.
Action: A girl didn’t smile at me when I smiled at her
Behaviour: I felt bad
Cognition: I’m not attractive
This is an example of a common ABC scenario. The goal is to identify other possible cognitions so that you can “rewrite the script.” An example of a different script:
Action: A girl didn’t smile at me when I smiled at her
Behaviour: I realized she probably didn’t see me
Cognition: Nobody has judged my attractiveness yet
This process is best accomplished with a therapist, but can be done in a self-help format. The book Mind Over Mood utilizes many of these techniques.
General Self Care for Coping with Flashbacks
HALT – Hungry, Angry, Lonely, Tired. These are the 4 states that make it harder to regulate your emotions and increase your impulsiveness.
5-4-3-2-1 Coping with Flashbacks
This technique is a very popular technique for coping that focuses on what you identify as real and also serves as a form of meditation.
In 5-4-3-2-1 coping, you begin by thinking about five things that you can see around you. Listing them off out loud can help you with this exercise. Study them and describe them to yourself. Performing deep breathing (a slow inhale over 5 seconds, holding for 5 seconds, and exhaling over 5 seconds) can help with this as well.
Next, describe 4 things that you can feel, such as your heart beating, your feet on the floor or your back in your chair.
Next, 3 things that you can hear, like a television in another room, traffic outside or birds singing.
After that, 2 things that you can smell – or two smells that make you happy, like fresh baked cookies.
Finally, end with one thing you can taste. Your saliva, gum, or food you ate recently? Some people also substitute “One thing you like about yourself” for this exercise as well.
As a supporter of evidence-based treatment (EBT), and someone who endeavours to cite my sources and back up my claims wherever possible, I find the lack of science in some circles really frustrating. I recently stumbled upon an organization called International Suicide Prevention run by Matthew D. Dovel that makes very fantastic claims about the effectiveness of a treatment or set of treatments called “Nu-Rekall” on mental health and suicide, unmatched by any other treatment and without any peer reviewed studies to support their efficacy.
Naturally, my curiosity was piqued, but the Nu-Rekall treatment is vague and the proprietor, as I explain below, appears not to have the background necessary to treat mental health disorders. My hope with this article is to stimulate discussion on EBT, and to publicly challenge Mr. Dovel to bring his work in-line with established best practices.
All the quoted content below is used within the DMCA and 17 U.S.C. § 107 on Fair Use in the United States and § 29.1 of the Copyright Act of Canada.
Matthew D. Dovel
Matthew Dovel says on his website that he is a suicide prevention expert. He also says he is a scientist. Everyone has different criteria for that word, but I would define a scientist as someone who contributes to the body of knowledge in a field through academic scholarship, like publishing in a journal.
His academic education includes:
Charter College-Anchorage (2 years), took Computer Aided Drafting (CAD)
University of Nevada-Las Vegas (3 years), majored in Civil Engineering and minored in Psychology and Business. It’s unclear if Dovel earned a degree here.
Palomar College (2 years), he indicates mostly computer-related topics but may have taken a couple Psychology courses
In addition to these formal educational pursuits Dovel also notes PSI Seminars and other self-help workshops. There is no evidence that he has participated in any training or education related to Social Work, Psychology, Medicine or an allied field relevant to mental health, nor has he indicated any evidence-based training in suicide intervention like Applied Suicide Intervention Skills Training (ASIST), QPR, or others.
Since March 2015, Dovel has sat on the Editorial Board of the prestigious-sounding International Journal of Emergency Mental Health and Human Resilience which is published by OMICS Group. That someone can sit on an editorial board with no graduate study or published literature themselves is worrisome. That journal is not indexed by PubMed or other reputable warehouses for scientific data, like most of the OMICS Group journals.
His LinkedIn proclaims that “There is no one better than I am at preventing suicides!”, I have my doubts.
Dovel has written a book called “Life After Death” chronicling two Near Death Experiences (NDE). It appears to be these NDE, not his suicide prevention work, that led him to be profiled on Good Morning America (you can see that interview here), A&E and 20/20. This is clearly stated on his LinkedIn in the publications section, but is less clear in other areas, such as the about page of his organization ISP (detailed below) where he states under a column about partnerships with ISP “As seen on:CBS, NBC, ABC, FOX, ESPN, Coast to Coast, Good Morning America, 20/20,.” This is very misleading.
International Suicide Prevention is Dovel’s charity. It is a registered 501(c)(3) non-profit (EIN#20-4671131), though its Form 990 indicates less than $25,000 in revenue.
On the contact page, there is an opportunity to buy posters promoting ISP with their 24/7 helpline number (which Dovel claims he answered himself for 10 years.) There is no attribution indicating he has permission to use the intellectual property of Fox, which owns the rights to the Fry character from the TV series Futurama. Update: Dec-20-2016: This image has been removed, though other potentially infringing images may remain.
On the page for law enforcement targeted initiatives, Dovel notes that his Suicide Prevention Guide Booklet has been “endorsed by mental health professionals, doctors, and advanced behavioral studies experts as a viable solution to drastically reduce suicide rates.” Although he does list one endorsement by a Psychologist in the back of the handbook, the other individual listed is a neurolinguistic programming practitioner. There is insufficient evidence to support the efficacy of NLP (Sturt, et. al., 2012).
On an ISP page listing endorsements Dovel lists an orthopedic surgeon (Andrea E. Salvi) as endorsing his material. This surgeon is also a Board Member of an OMICS Group Journal, and appears to have has no professional experience in psychology or suicide. I can find no evidence to support Salvi’s assertion that he has performed any work for the US military.
Nu-Rekall (trademarked) is the basis for the treatments that Dovel promotes. The website claims that “Nu-Rekall™ has self-help procedures that are completely autonomous removing suicidal ideation permanently.” Dovel does not link to any peer-reviewed studies evaluating his techniques. Dovel claims he helps over 200 individuals daily, but as this page suggests, he is likely counting every visitor to his website as a client he has delivered service to.
Dovel does actually describe his 4 phase model on one page. I’ve paraphrased it here to the best of my ability.
The client should ask themselves how long they’ve been suicidal and what occurred at the time those suicidal thoughts started?
Next, because the treatment can cause amnesia, the client fills out a questionnaire about the event that triggered the suicidal thoughts and its emotional intensity
Now the client imagines the event occurring again, but changes details about it (such as altering the weather)
No peer-reviewed studies are provided to explain why this movement technique is supposed to have any impact on one’s suicidality or emotional state, and ignores that for many people suicidal thoughts are not caused by a single distressing event but rather a constellation of risk factors, with no identifiable cause at all (see the Suicide Prevention Resource Centre’s list of suicide risk factors, the majority of which are not negative life events.)
Suicide Prevention Guide Booklet (SPGB)
This booklet (running 32 pages with wide margins and a large font) includes two ad spaces, both unused. Rather than go through the book line by line I’ve picked out some quotes for commentary.
“it takes fewer muscles to smile than to get angry according to Japanese’s” (this article confirms the origins of the concept that it takes fewer muscles to smile than to frown are uncertain; there’s no evidence suggesting they are Japanese.)
“Education has been shown to be the best method for reducing suicide rates.” Certainly, training gatekeepers is important. But educating clients themselves in methods of self-help has a limited contribution to the suicide rate when compared to broad community interventions that works on multiple levels, as Fountoulakis, Gonda, & Rihmer (2011) explain.
“According to scientific research humans have only two core emotions: love, and fear.” This is also incorrect. It used to be thought that there were 6 core emotions (anger, fear, surprise, disgust, happiness and sadness), although research from the University of Glasgow (Jack, Garrod & Schyns, 2014) suggests four (anger, fear, happiness, sadness.)
Russell (2003; 2009) conceptualizes “core affect” as the idea of feeling either good or bad – but there are no studies that I could find indicating two core emotions of love and fear.
“At the University of Berkley, California a study was done on a group of Manic Depressants with just the following self-therapy for one year. At the end of the year ALL were declassified as Manically Depressed.” Note the spelling errors and the use of the outdated term “manic depressive” (manic depression was replaced in the DSM-III in 1980 with “bipolar disorder”) while person-centered language would suggest calling the participants “people with bipolar disorder” instead. There’s is no citation listed and I would doubt if any such study ever existed.
“Top two reasons for a suicide attempt[:] The sudden change of status for an individual’s: romantic, and/or financial situation.” While there is support to the idea that relational changes commonly precede a suicide attempt (e.g. Yen et. al., 2005; Bagg, Glenn & Lee, 2013; Conner, et. al., 2012) that is because social support is an important buffer to suicide. (Gonçalves, et. al., 2014; Kleiman, Riskind, & Schaefer, 2014; Farrell, Bolland & Cockerham, 2014; Kleiman, et. al., 2012; Hirsch & Barton, 2011)
While Hempstead & Phillips (2015) notes that financial issues can lead to suicide, “mental illness, health problems, and other personal issues [and] access to lethal means also importantly affects suicide risk.” It appears that financial issues only commonly precede suicide in middle age.
Near the end is an “EMR” (Emotional Memory Removal) chart that requires an individual to think about a strong emotion while raising or lowering their hands (the chart indicates when to do which) and saying a number out loud, and then repeating the process but raising an arm and a leg. No sources are provided for why this would be effective.
I reached out to Dovel for some clarification on the evidence-base for his work. He responded linking me to some of the sources that you see above. He also linked me to this suggested evaluation of his techniques.
The way the study appears to be constructed was that Dovel would have each participant rate their suicidal thoughts on a scale of 1-10. Then they would perform the Nu-Rekall procedures and receive a follow up call at 1 week, 1 month and 6 months to determine if the level of their intensity increased or decreased, and whether they had demonstrated any suicidal behaviour.
There are a number of methodological issues with this study that would prevent it from being accepted for peer review. Just a few that come to mind:
He indicates he had 500 volunteers (gender-matched exactly 50/50), but he only started with 60. Each month he surveyed other callers for a total of 500 surveys. If that’s the case, there is not 6 months of continuous data (as in a longitudinal design) for 500 people, there is 6 months of data for 60 people, severely limiting the usefulness of the large sample size.
There is a failure to define intensity (how do you verify a change if you’re not defining the variables?)
There is a failure to define suicidal behaviour or how he determined there was no recurrence in suicidal behaviour
There is a failure to control for the impact that emotional support from any helper would provide (a control group where someone received supportive check-ins without doing Nu-Rekall would have showed this)
Best Practices and Recommendations
I invite Dovel to follow some recommendations for himself, his website and the Nu-Rekall program. These include:
Taking a proper suicide intervention training like ASIST so that he can incorporate the evidence-base into his literature
Change references to the ISP helpline number to the National Suicide Prevention Lifeline (1-800-273-8255) until such time as Dovel has completed helpline training through an NSPL or AAS-accredited crisis line. This will ensure he is competent to perform suicide risk assessment
Write up a proper proposal for a study of the Nu-Rekall techniques that includes repeatable methods, proper controls, and results and then having that study performed by an independent third party
Get that study peer-reviewed and published in a PubMed-indexed journal to open it to critique
Remove references to media like Good Morning America and 20/20 from the ISP websites so that visitors are not misled into thinking those appearances were related to suicide prevention work; make it clear those appearances were focused on near-death experiences
Provide citations for claims throughout existing pamphlets (like the UC Berkeley study noted above)
Bagge, C. L., Glenn, C. R., & Lee, H. (2013). Quantifying the impact of recent negative life events on suicide attempts. Journal Of Abnormal Psychology, 122(2), 359-368. doi:10.1037/a0030371
Conner, K. R., Houston, R. J., Swogger, M. T., Conwell, Y., You, S., He, H., & … Duberstein, P. R. (2012). Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity, timing, and type. Drug & Alcohol Dependence, 120(1-3), 155-161. doi:10.1016/j.drugalcdep.2011.07.013
Sturt, J., Ali, S., Robertson, W., Metcalfe, D., Grove, A., Bourne, C., & Bridle, C. (2012). Neurolinguistic programming: a systematic review of the effects on health outcomes. The British Journal Of General Practice: The Journal Of The Royal College Of General Practitioners, 62(604), e757-e764. doi:10.3399/bjgp12X658287
Farrell, C. T., Bolland, J. M., & Cockerham, W. C. (2014). Original article: The Role of Social Support and Social Context on the Incidence of Attempted Suicide Among Adolescents Living in Extremely Impoverished Communities. Journal Of Adolescent Health, doi:10.1016/j.jadohealth.2014.08.015
Fountoulakis, K. N., Gonda, X., & Rihmer, Z. (2011). Review: Suicide prevention programs through community intervention. Journal Of Affective Disorders, 13010-16. doi:10.1016/j.jad.2010.06.009
Gonçalves, A., Sequeira, C., Duarte, J., & Freitas, P. (2014). Suicide ideation in higher education students: influence of social support. Atencion Primaria, 46(Supplement 5), 88-91. doi:10.1016/S0212-6567(14)70072-1
Hempstead, K. A., & Phillips, J. A. (2015). Research Article: Rising Suicide Among Adults Aged 40–64 Years. The Role of Job and Financial Circumstances. American Journal Of Preventive Medicine, 48491-500. doi:10.1016/j.amepre.2014.11.006
Hirsch, J. K., & Barton, A. L. (2011). Positive Social Support, Negative Social Exchanges, and Suicidal Behavior in College Students. Journal Of American College Health, 59(5), 393-398. doi:10.1080/07448481.2010.515635
Jack, R. E., Garrod, O. G., & Schyns, P. G. (2014). Dynamic Facial Expressions of Emotion Transmit an Evolving Hierarchy of Signals over Time. Current Biology, (2), 187. doi:10.1016/j.cub.2013.11.064
Kleiman, E. M., Riskind, J. H., & Schaefer, K. E. (2014). Social Support and Positive Events as Suicide Resiliency Factors: Examination of Synergistic Buffering Effects. Archives Of Suicide Research, 18(2), 144-155. doi:10.1080/13811118.2013.826155
Kleiman, E. M., Riskind, J. H., Schaefer, K. E., & Weingarden, H. (2012). The moderating role of social support on the relationship between impulsivity and suicide risk. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(5), 273-279. doi:10.1027/0227-5910/a000136
Russell, J.A. (2003) Core Affect and the Psychological Construction of Emotion. Psychological Review. 110(1). 145-172. DOI: 10.1037/0033-295X.110.1.145
Russell, J. A. (2009). Emotion, core affect, and psychological construction. Cognition & Emotion, 23(7), 1259-1283. doi:10.1080/02699930902809375
Yen, S., Pagano, M. E., Shea, M. T., Grilo, C. M., Gunderson, J. G., Skodol, A. E., & … Zanarini, M. C. (2005). Recent Life Events Preceding Suicide Attempts in a Personality Disorder Sample: Findings From the Collaborative Longitudinal Personality Disorders Study. Journal Of Consulting And Clinical Psychology, 73(1), 99-105. doi:10.1037/0022-006X.73.1.99
When we normally think of crisis intervention, we think of adults responding to events in their personal life. Of course, people young and old can require crisis intervention, and not just from events in their personal life. School violence, natural disasters and other elements can require crisis intervention.
Werner (2015) noted that the tow most important activities school counsellors can do to prepare for crisis events are to develop a comprehensive crisis plan and to practice it regularly. The goal of the PREPaRE Curriculum is to train mental health worker, school psychologists and other administrators, educators and clinicians to develop such a crisis plan, to build a crisis team to execute that plan and to understand the tasks of crisis intervention in the aftermath of a crisis.
School Crisis Intervention
Most school counsellors receive little or no crisis intervention training and therefore enter the field feeling unprepared to handle tasks that become assigned to them in the aftermath of a crisis. (Allen, et. al., 2002) Training like the PREPaRE Model and other programs can help bridge this gap.
Knox & Roberts (2005) performed a comprehensive literature review on school crisis intervention and specifically crisis intervention teams. They found that there was a need for well-thought out crisis intervention programs and plans before crises occur, and that there were similarities in the literature about how experts believed response to a crisis should be structured.
They recommended school crisis intervention be split into three phases:
Primary prevention activities are those that are provided to all students in order to promote safety and health. These could be “conflict resolution, gun safety and safe driving courses, alcohol and drug awareness programs, teenage parenting resources, and suicide prevention programs.” (Knox & Roberts, 2005; p.94)
Secondary prevention activities focus on individuals in the aftermath of a crisis in order to limit its impact. This can include physical measures like moving students, debriefing and immediate crisis intervention in the aftermath, and notifying parents and the media.
Tertiary interventions include long-term counselling and psychotherapy that extends after the crisis period ends and the school environment returns to normal.
Prevent and Prepare for psychological trauma
Reaffirm physical health, perceptions of security and safety
Evaluate psychological trauma risk
Provide interventions and Respond to psychological needs
Examine the effectiveness of crisis prevention and intervention
The PREPare Model is structured around two workshops. The first (1-day) workshop is provided for all school staff to teach them how the crisis team and crisis intervention works, while the second (2-day) workshop is designed specifically for crisis team members.
The following information comes from Nickerson et. al. (2014):
Crisis Prevention and Preparedness (1-day workshop for all staff)
Identify four characteristics of a crisis event.
Identify the key concepts associated with the PREPaRE acronym.
Describe the four activities of the school crisis team.
Understand the importance of hierarchical crisis team structure and response.
Identify the five major functions of the Incident Command System (ICS).
Identify strategies for communicating with school boards creating or sustaining teams.
Identify three concepts related to crime prevention through environmental design.
Identify guiding principles in crisis plan development.
Identify essential components of crisis plans.
Identify key concepts from the workshop that their crisis team needs to learn or address to be adequately prepared for crisis situations
Crisis Intervention and Recovery (2-day workshop for crisis intervention staff)
Report improved attitudes toward, and readiness to provide, school crisis intervention.
Identify the variables that determine the traumatizing potential of a crisis event.
Identify the range of school crisis interventions indicated by the PREPaRE acronym.
Indicate how school crisis interventions fit into the larger school crisis response.
Specify the critical factors in evaluating psychological trauma risk after a crisis event.
Match psychological trauma risk to a range of appropriate school crisis interventions.
Elements of a Crisis Team
A crisis team should be in place before a crisis occurs so that they can immediately get to work after a crisis occurs. Knox & Roberts (2005) recommend that the team be comprised of 4-8 multidisciplinary members (e.g. Principal, counsellor, nurse, etc.)
Responding to a Crisis
Brock (2006) indicates a variety of responses for each level of the framework that are available to the mental health professional facilitating a crisis intervention. These items assume that a crisis has already occurred.
Reaffirm physical health, perceptions of security and safety
Meet physical needs like shelter and water
Provide a sense of safety by removing individuals from the site of a crisis
Remove or restrict access to dangerous objects or crisis site (remove sharps, put up barriers, etc.)
Evaluate psychological trauma risk
Evaluate exposure to crisis and note reactions (physical, behavioural, cognitive)
Examine internal and external resources (within the school and local community agencies)
Refer clients to psychotherapy where possible
Provide interventions and Respond to psychological needs
Re-establish social support systems. This can involve
Provide psycho-education: Empower survivors and their caregivers
Provide immediate crisis intervention
Provide/Refer for longer term crisis intervention
Evaluation of the PREPaRE Curriculum
Brock et. al. (2011) performed the initial evaluation of the program and found that participants significantly improved on their skills related to crisis prevention, crisis intervention and displayed high general satisfaction with the workshops. When Nickerson et. al. (2014) evaluated the PREPaRE after making changes they found that these benefits continued to be demonstrated in follow-ups, proving the efficacy of the program.
Training in the PREPaRE Model
Brock (2006) publishes the content of the PREPaRE workshop online, where they can be accessed in order to help individuals build their crisis intervention skills. Additionally, workshops can be accessed through the National Association for School Psychologists (NASP).
Allen, M., Burt, K., Bryan, E., Carter, D., Orsi, R, & Durkan, L.(2002). School counselors’ preparation for and participation in crisis intervention. Professional School Counseling, 6, 96-102
Brock, S.E. (2006) “Crisis Intervention Training”, Workshop PDF. Accessed on November 19, 2016 from www.csus.edu/indiv/b/brocks/workshops/district/smfcsd.12.06.pdf
Brock, S. E., Nickerson, A. B., Reeves, M. A., Savage, T. A., & Woitaszewski, S. A. (2011). Development, Evaluation, and Future Directions of the PREPaRE School Crisis Prevention and Intervention Training Curriculum. Journal Of School Violence, 10(1), 34-52. doi:10.1080/15388220.2010.519268
Knox, K., & Roberts, A. (2005). Crisis intervention and crisis team models in schools. Children & Schools, 27(2), 93-100.
Nickerson, A. B., Serwacki, M. L., Brock, S. E., Savage, T. A., Woitaszewski, S. A., & Louvar Reeves, M. A. (2014). PROGRAM EVALUATION OF THE PREPaRE SCHOOL CRISIS PREVENTION AND INTERVENTION TRAINING CURRICULUM. Psychology In The Schools, 51(5), 466-479. doi:10.1002/pits.21757
Violence risk assessment is an important element of counselling and crisis intervention. Although in high-risk situations it can (and should be) performed by clinicians with specific training in violence risk, there may be situations where clinicians or others (corrections officers, private practice therapists, crisis line supervisors, etc.) need to have a understanding of the principles of violence risk assessment in order to respond appropriately.
Types of Violence Risk Assessment
There are three types of violence risk assessment, based on the way risk is estimated or “calculated.” The first is unstructured professional judgement. This is where the clinician merely listens to the client and makes their best judgement, based on their existing professional training. (Murray & Thomson, 2010) While some professionals made good predictions relative to others, some were very poor. It emerged that the reason for this disparity was that some clinicians considered factors relevant to violence while others did not. Unstructured professional judgement no longer stands up in court.
The second form of risk assessment is known as actuarial risk assessment. This is an entirely mathematical technique that examines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This is similar to the approach used in insurance to calculate the likelihood a person will die, and has the same flaw as that approach: you can determine over a large pool what percentage of individuals will be violent, but you risk ignoring salient risk or protective factors in an individual that may heighten or reduce their violence risk.
The final form of risk assessment is Structured Professional Judgement (SPJ; Falzer, 2013). SPJ attempts to merge the predictive ability of the actuarial approach with the flexibility of the unstructured approach by providing a list of evidence-based risk factors (elements that have been demonstrated to increase risk of violence) along with a coding or scoring method to generate a “Low”, “Moderate”, or “High” risk, and usually the freedom to modify the scoring for items or list additional contributing factors that entered into a clinician’s assessment.
Static vs Dynamic Risk Factors
Static risk factors are elements that are known to increase risk that are not changeable. An example of static risk factors for violence include sex and age. As a male, you will always have elevated risk of violence versus a female (Sorrentino, Friedman, & Hall, 2016), and as someone who is aged 18-24 you will always have a heightened risk of violence relative to someone older or younger. (Harris & Rice, 2007) There is nothing a clinician can do to change your age or sex.
On the other hand, other risk factors are called dynamic risk factors. These are factors that can be modified by the clinician or by the client (Public Safety Canada, 2010), such as one’s peer group, use of alcohol or stimulants, or access to a pool of victims.
Affective vs. Predatory Violence
Affective violence is also called impulsive or reactive violence. (Berg, 2014) This is violence that results from a threat, causes an individual to experience physiological arousal (heart racing, blood pressure increase, etc.) and then to strike back in a “fight or flight” response.
In contrast, predatory violence is more common among psychopaths and serial killers. This is violence that is not associated with an increase in physiological arousal or an identified threat. Instead, the predatory killer “stalks his prey” and then strikes without warning.
Biopsychosocial Model Items
This model comes from “Violence Risk and Threat Assessment” by Meloy (2000), but closely matches other models of violence risk.
Past History of Violence
Intelligence Below Average
Psychopathy / Other Attachment Difficulties
Family of Origin Violence
Adolescent Peer Group Violence
Weapons History/Skill/Interest and Approach Behaviour
History of CNS Trauma
Signs and Symptoms
Objective CNS Measures
Major Mental Disorder
Assessing Psychological Factors of Violence Risk
The elements in the psychological or individual domain cover static and dynamic items that relate to the person’s mental health and personal demographics. They include:
Men are up to 10x more likely to be involved in violence than women (Meloy, 2000; p.19); sex is a static variable. Significantly more crimes are committed before the age of 25 (Bureau of Justice Statistics, 2011), therefore age is an important static variable. Past history of behaviour is one of the most important future predictors of future violence. If the situations that led to violence in the past aren’t modified, we will find ourselves in them in the future, therefore Past History of Violence becomes an important static behaviour.
Other elements associated with increased violence risk include acute paranoia or a delusional state (Yang, 2008); this can cause them to genuinely believe they are in danger, and therefore Not Guilty by Reason of Insanity (NGRI) or Not Criminally Responsible (NCR). Someone in a paranoid state, with thought insertion or homicidal thoughts needs immediate psychiatric attention.
Below average intelligence and anger/fear problems are linked to the concept of affective violence above. Lower levels of intelligence are perhaps linked to violence in that people cannot think of responses quick enough to avoid violence (Freeman, 2012), and may find themselves unable to label or understand their emotions. Anger and fear problems cause an increase in violence by causing an individual to perceive threats where maybe none exists. It is the presence of these threats that causes affective violence (Helfgott, 2008)
Psychopathy and other attachment difficulties are associated with an increased risk of predatory violence. Psychopaths have difficulty perceiving empathy for others, and individuals who lack attachments may be able to cause those individuals pain without considering the impact their actions have on those people. (Brook & Cosson, 2013) A standardized assessment like the PCL-R (Hare Psychopathy Checklist–Revised; Hare, 2003) can be used to assess for the presence of psychopathy, with a score of 30 (out of 40) indicating psychopathy.
Assessing Social Factors of Violence Risk
Social factors of violence risk include those individuals that are around us who can model violent behaviour, and are caused by factors beyond mental health.
Family of origin violence (a static risk factor) and adolescent peer group violence (a dynamic risk factor) are both risk factors because of the ability of them to model answers to threats or problems that involve violence (Franklin, Menaker & Kercher, 2011), rather than non-violent alternatives. Additionally, family of origin violence can lead to a sense of detachment which can involve the attachment difficulties noted in the Psychological Factors above; finally, a family that suppresses emotional expression may prevent men from ventilating their stress until it is expressed in a maladaptive way (e.g. through violence.)
Economic instability or poverty is a static or dynamic risk factor for violence (McAra, & McVie, 2016) because of the known causal relationship between poverty and violence; additionally, for those who are at risk of or have recently lost their jobs, intense anger can cause violent acts and so should be kept in mind. (Catalano, Novaco, & McConnell, 1997)
Weapons history/skill/interest is a static variable and approach behaviour is a dynamic behaviour. The first set refers to a potentially violent individual’s history with weapons, especially firearms. Do they own any guns, have they received professional training (e.g. police, military, private instruction)? Owning guns does not make a person more violent on their own, but they do provide a violent individual with easier tools with which to carry out their violence.
“Approach behaviour” (Meloy, 2000; p.57) is the term used to describe what someone does when they cannot possess guns (for instance, because of a felony conviction or financial reasons). This could include reading about guns, owning gun accessories and being around people who own guns. Approach behaviour is a person’s ability to “approach” the off-limits items psychologically. The more approach behaviour is noted, the higher the violence risk is.
Victim pool is important in assessing violence risk because violence does not occur in a vacuum. This is especially important in predatory violence (such as sex offenders or serial killers) but may also be important for gang members or others who only become violent in specific, limited situations. Meloy (1996) discusses this in particular in violent stalkers but it applies equally to all violent crimes.
Drugs and alcohol (especially psychostimulants like cocaine) increase violence risk by reducing one’s inhibition and increasing impulsiveness. (Haggård-Grann, Hallqvist, Långström, & Möller, 2006) Additionally, stimulants like cocaine, methamphetamine and others can cause “stimulant psychosis” (Curran, Byrappa & Mcbride, 2004), a condition that can cause paranoia and homicidal thoughts.
The last element in assessing social factors of violence risk is popular culture. (De Venanzi, 2012) This is a controversial element but like suicide contagion, mass media glorifying elements of homicide can increase the risk of violence in vulnerable individuals. It’s important to pay close attention to court cases, movies or other elements that the person being assessed may identify with.
Assessing Biological Factors of Violence Risk
Biological factors are elements not related to a person’s mental health or social environment, but rather their neurological. They include a history of central nervous system (CNS) trauma (Rao et. al., 2009), signs and symptoms of CNS problems (such as headaches, dizziness, memory difficulties, and many others), objective CNS measures and the presence of a mental health diagnosis. (Rueve & Welton, 2008)
With the exception of some CNS measures which may be administered by clinicians, these items are most easily determined by a neuropsychologist or neurologist who can perform the required brain scans and administer and interpret the tests for CNS function. Major mental disorders may be diagnosed by social workers in some jurisdictions, or may be required to be diagnosed by a psychologist or psychiatrist in others.
Violence Risk Assessment Tools
Below are some tools that I’ve got articles for on my blog.
Brook, M., & Kosson, D. S. (2013). Impaired cognitive empathy in criminal psychopathy: Evidence from a laboratory measure of empathic accuracy. Journal Of Abnormal Psychology, 122(1), 156-166. doi:10.1037/a0030261
Catalano, R., Novaco, R., & McConnell, W. (1997). A model of the net effect of job loss on violence. Journal Of Personality And Social Psychology, 72(6), 1440-1447. doi:10.1037/0022-3522.214.171.1240
Curran, C., Byrappa, N. & Mcbride, A. (2004) Stimulant psychosis: systematic review. British Journal of Psychiatry. 185 (3) 196-204; DOI: 10.1192/bjp.185.3.196. http://bjp.rcpsych.org/content/185/3/196
De Venanzi, A. (2012). School shootings in the USA: Popular culture as risk, teen marginality, and violence against peers. Crime, Media, Culture, 8(3), 261-278. doi:10.1177/1741659012443233
Falzer, P. R. (2013). Valuing Structured Professional Judgment: Predictive Validity, Decision-making, and the Clinical-Actuarial Conflict. Behavioral Sciences & The Law, 31(1), 40-54. doi:10.1002/bsl.2043
Sorrentino, R., Friedman, S. H., & Hall, R. (2016). Gender Considerations in Violence. Psychiatric Clinics Of North America, doi:10.1016/j.psc.2016.07.002
Yang, S. (2008) Dangerously Paranoid? Overview and Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome. Psychiatric Times.
Rao, V., Rosenberg, P., Bertrand, M., Salehinia, S., Spiro, J., Vaishnavi, S., Rastogi, P., Noll, K., Schretlen, D.J., Brandt, J., Cornwell, E., Makley, M. & Miles, Q.S. (2009) Aggression After Traumatic Brain Injury: Prevalence and Correlates. The Journal of Neuropsychiatry and Clinical Neurosciences. 21(4):420-429