Crisis Case Handling

Introduction to Crisis Case Handling

Crisis case handling is considered quite a bit different from long-term counselling or therapy. While the steps might seem to be very similar e.g. (assessment, intervention, and evaluation) the short-term nature of crisis intervention and the goals are quite different. Crisis intervention aims to restore pre-crisis functioning while therapy’s goal is to work towards an even better way of coping.

Principles of Therapy

  • Diagnosis: Goal of determining DSM-V diagnostic categories
  • Treatment: Exploring the underlying causes of discomfort and behaviour to make long-term changes
  • Plan: A comprehensive, personalized approach to accomplish long-term goals
  • Methods: Therapy techniques focusing on a mix of short-term, medium-term and long-term goals
  • Evaluation: Observation of client’s functioning over several months or even years

Principles of Crisis Intervention

  • Diagnosis: Triage to determine immediate risk level
  • Treatment: Restoring pre-crisis functioning
  • Plan: Focused on restoring immediate short-term issues
  • Methods: Time-limited brief crisis and trauma interventions
  • Evaluation: Observation of how client’s current function compares to pre-crisis in hours or days

Assessment

Assessment in Therapy

Many modalities of therapy begin with an assessment stage, where data is collected to give the clinician a deep understanding of the client. This helps in the long-term when the therapist can see a change on specific assessment tools (like the Beck Depression Inventory), or can see the client’s life “come together” and the desired changes occurring.

Assessment in Crisis Intervention

Contrary to therapy, in crisis intervention, the purpose of assessment is focused more on understanding the client’s concerns so that immediate steps can be taken to recover. Extensive paperwork or assessment tools are unlikely to be filled out, with most of the data collected verbally and visually.

Intervention

Intervention in Therapy

Interventions in therapy include long-term therapies like Cognitive Behavioural Therapy that look at a person’s history of actions, beliefs and cognitions and explores them over a period weeks or months to identify maladaptive thoughts and systematically work to change these.

Intervention in Crisis Intervention

In crisis intervention, the intervention is focused on immediate short-term crisis resolution by providing stabilization, venting, referrals, and in inpatient environments medication. The whole focus of the encounter may be limited to a one hour phone call or a maximum of 72 hour psychiatric stay, so everything proceeds at a much more rapid pace.

Evaluation

Evaluation in Therapy

In therapy, evaluation is the process of determining whether there is a change in the client and whether therapy has “worked.” This is closely associated with the concept of termination, deciding when to end therapy. With psychodynamic therapies, some clients would be in therapy for years. Nowadays, 16-24 sessions (often once a week) is considered a long treatment time.

By observing changes in the client’s behaviours and beliefs over time the therapist will begin to see improvements in their behaviour.

Evaluation in Crisis Intervention

In crisis intervention, evaluation occurs over minutes, hours, or potentially days as you observe whether the client is returning to pre-crisis equilibrium. The goal is not for the client to “get better” but simply to retain enough control over their life that they’re able to function independently.

Crisis case handling is an important skill for crisis workers and therapists alike to learn, because all may experience clients in crises throughout their careers.

Cite this article as: MacDonald, D.K., (2016), "Crisis Case Handling," retrieved on July 16, 2018 from http://dustinkmacdonald.com/crisis-case-handling/.
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Crisis Triage Rating Scale (CTRS)

IntroductionCrisis Triage Rating Scale (CTRS)

The Crisis Triage Rating Scale (CTRS; Bengelsdorf, et. al. 1984) is a telephone triage tool that can be used for determining whether an individual in crisis requires psychiatric assessment. Turner & Turner (1991) determined that a cut-off score of 9 or lower necessitated admission. This was confirmed in a follow up study by Adeosun et. al. (2013)

The CTRS has three subscales:

  • Dangerousness
  • Support System
  • Ability to Cooperate

Scoring

Each category is rated from 1-3, so the entire scale is scored from 3-15 (with a lower score representing less functioning.) This copy of the CTRS from the Human Services and Justice Coordinating Committee lists the response guidelines:

Score Urgency of Response CTRS Rating
Extreme/Severe 3-9 Immediate response recommended A. Dangerousness _____
High 10 See within 2 hours B. Support System _____
Medium 11 See within 12 hours C. Ability to Cooperate _____
Low 12-13 See within 48 hours Total Score: _______
Non-Urgent 14-15 See within 2 weeks

Community Use and Validation of the CTRS

The CTRS has been used in community organizations that have mobile crisis teams, for the purpose of assessing whether callers require inpatient admission to a hospital. This can help guide the often murky process of crisis assessment.

Bonynge & Thurber (2008) determined that the CTRS was accurate in determining the difference between inpatient and outpatient treatment but that with all the tools tested (the Crisis Triage Rating Scale, the Triage Assessment Form and the Suicide Assessment Checklist), the determination of exactly what inpatient treatment (Hospitalization in a psychiatric or substance abuse settings, partial hospitalization or crisis beds) is most effective.

Limitations of the Crisis Triage Rating Scale

Molina-Lopz et. al. (2016) note that the CTRS “requires knowledge of each patient’s social and family support system at the time of assessment, which can be especially difficult to gauge in aggressive, agitated, suspicious, isolated or non-cooperative patients” which is a reasonable criticism of the Support System subscale of the tool.

The criteria used for the Dangerousness subscale is also interesting, for each rating there are 3-4 criteria given. Because of the difficulty in evaluating these (e.g. “Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control”) the reliability of the CTRS may be suspect.

Download CTRS

The CTRS can be downloaded from the Human Services and Justice Coordinating Committee here.

Bibliography

Adeosun, I., Adegbohun, A., Jeje, O., & Omoniyi, O. (2013). 1364 – Predictive validity of the crisis triage rating scale in the disposition of patients attending a nigerian psychiatric emergency unit. European Psychiatry, 281. doi:10.1016/S0924-9338(13)76409-5

Bengelsdorf, H., Levy, L., Emerson, R., & Barile, F. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal Of Nervous And Mental Disease, 172(7), 424-430.

Bonynge & Thurber (2008). Development of Clinical Ratings for Crisis Assessment In Community Mental Health. Brief Treatment and Crisis Intervention. 8(4):304-312; doi:10.1093/brief-treatment/mhn017

Molina-López, A., Cruz-Islas, J. B., Palma-Cortés, M., Guizar-Sánchez, D. P., Garfias-Rau, C. Y., Ontiveros-Uribe, M. P., & Fresán-Orellana, A. (2016). Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department.BMC Psychiatry, 161-11. doi:10.1186/s12888-016-0727-7

Turner, P.M., Turner, T.J. (1991). Validation of the crisis triage rating scale for psychiatric emergencies. Canadian Journal of Psychiatry. 36(9):651-4

Cite this article as: MacDonald, D.K., (2016), "Crisis Triage Rating Scale (CTRS)," retrieved on July 16, 2018 from http://dustinkmacdonald.com/crisis-triage-rating-scale/.

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Coping Strategies in Crisis Intervention

Introduction

Coping strategies are the things, internally and externally that we do to help ourselves work through crises. Internal coping strategies are the things that we do for ourselves, that don’t require anyone and else and may involve activities, attitudes, and beliefs that help us be resilient. External coping strategies involve others, and can include people in our immediate environment and professionals that we may bring into our circle of coping (such as a therapist.)

Caplan’s Coping Strategies

Caplan (1964) lists seven strategies for helping individuals to cope:

  1. Actively exploring reality issues and searching for information
  2. Freely expressing both positive and negative feelings and tolerating frustration
  3. Actively invoking help from others
  4. Breaking problems down into manageable bits and working them through one at a time
  5. Being aware of fatigue and tendencies toward disorganization; while pacing efforts and maintaining control in as many areas of functioning as possible
  6. Mastering feelings where possible (accepting them when necessary), being flexible and willing to change
  7. Trusting in oneself and others and having a basic optimism about the outcome

These are explored in more detail below.

Actively Explore Reality Issues

Exploring reality means ensuring that you actually have a reliable view of your situation. This goes back to the concept of ego strength – if you have an accurate view of the situation you’re in a better position to handle it.

Someone who has to drop out of college may believe that they will be doomed to a life of poverty as a result of doing so. While they might have more difficulty achieving their goals, there are other avenues to continuing their college education or making a good living that will help them avoid poverty. For instance, they can attend a community college on a part-time basis, online, pursue apprenticeship or vocational training, self-study, and so on.

Freely Express Positive and Negative Feelings

It’s important that a person can express both positive and negative feelings in order to cope effectively.

Being unable to express positive feelings may indicate that an individual is having trouble seeing the world accurately (as in above) which is something that counselling can help. On the other hand, someone unable to express negative feelings may be the result of someone bottling up their emotions, which can cause difficulty working through those feelings. This may be related to alexithymia, the inability to express feelings with words.

Actively Invoking Help from Others

We know that having available resources is one of the most important protective factors to prevent suicide. Help-seeking is a very important part of your library of coping strategies. This does not necessarily mean seeing a therapist or a doctor – but also reaching out to those in your immediate environment like friends and family, trusted coworkers or other support systems.

Research has shown that the high rate of male suicide is partially explained by a pattern of help-seeking that is characterized by withdrawing from others and trying to deal with things internally rather than externally.

Break Problems into Manageable Bits

This is a common element in effective problem-solving. Many problems can seem so large as to be overwhelming and therefore un-fixable. Someone who has lost their job may feel like it’s impossible to get another one, especially in a rough economy. Breaking “get a new job” down into a series of manageable steps that can be done over a week can make them easier:

  • Monday: Create budget to find minimum salary
  • Tuesday: Update resume
  • Wednesday: Reach out to job network (if exists)
  • Thursday: Begin applying to jobs
  • Friday: Create learning plan to identify missing skills for desired jobs
  • Saturday and Sunday: Begin putting learning plan into place while continuing applying to jobs

As you can see, there is a lot of tasks here – but if you spend a couple hours a day it seems much more manageable.

Be Aware of Fatigue

Fatigue can set in for both helpers and individuals who are in crisis. This is where self-care becomes important: recognizing your own limits and taking time to recharge ensures that you can continue to be be an effective crisis worker.

By pacing yourself when you realize you don’t have the energy to handle both your own emotional issues and those around you will help prevent compassionate fatigue, which can lead to burnout.

Master Feelings Where Possible

Sometimes we don’t have control over our feelings. Although counselling can help us reframe our beliefs in order to gain new perspective and defuse negative emotions, sometimes it is necessary to simply accept that we feel the way we do and then to control our reactions.

Acceptance and Commitment Therapy (ACT) focuses on the idea that we have to accept our emotions but that we can control our reactions and responses in order to have the best outcomes.

Optimism About the Outcome

By believing in your ability to deal with your situation and having faith or trust in the individuals who are supporting you, it is easier to deal with the demands of your life. This, in combination with the other internal coping strategies listed here will help you cope effective as you perform crisis work.

Bibliography

Caplan, G. (1964) Principles of Preventive Psychiatry. Basic Books: New York, NY

Cite this article as: MacDonald, D.K., (2016), "Coping Strategies in Crisis Intervention," retrieved on July 16, 2018 from http://dustinkmacdonald.com/coping-strategies-crisis-intervention/.
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Curvilinear Model of Anxiety

Introduction

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.

Bibliography

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/

Cite this article as: MacDonald, D.K., (2016), "Curvilinear Model of Anxiety," retrieved on July 16, 2018 from http://dustinkmacdonald.com/curvilinear-model-anxiety/.
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Critical Incident Stress (CIS) Management

Introduction

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):

Critical Incident Stress Debriefing

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

CISM/CISD Training

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.

Bibliography

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

Cite this article as: MacDonald, D.K., (2016), "Critical Incident Stress (CIS) Management," retrieved on July 16, 2018 from http://dustinkmacdonald.com/critical-incident-stress-cis-management/.
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