 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Ten Principles of Crisis Intervention. We're going to start by defining crisis, of course. Identifying the six basic threats and how they relate to crisis. We'll discuss some of the characteristics of crisis. Examine cultural influences and behavior. Explore the safer model and identify ten principles of crisis intervention. So what is a crisis? Crisis happens when people are facing an untenable obstacle to goals and people's life cycles are significantly disrupted. Now that doesn't necessarily mean just having those two things doesn't necessarily mean somebody's going to have a crisis. You have to have that third ingredient. The person has no appropriate response to deal with the situation. So their coping skills are completely overwhelmed for whatever reason. And this depends on the person. I mean, some people get completely overwhelmed when my grandmother, bless her heart, used to get completely overwhelmed when something would break at the house. And it would just throw her for a loop and she'd have panic attacks. It was unpleasant for her and it was really stressful for somebody else. Something goes bad at the house. They just call up a repairman and by the being it's done. So we don't want to assume that everybody's crisis or crises are the same. Oh, lovely. So one of the things we need to consider when we're looking at crisis is when we're getting ready to intervene with someone. What is it that we need to know about them in order to effectively, what's the word I'm looking for, effectively intervene with them? So an extrovert is going to want to be around other people. So if they experienced something that may lead them to feel isolated, that may precipitate more of a crisis. Likewise, if they're an introvert and they're in a situation where they feel like everybody's looking at them, that could escalate the situation. So we want to be aware of what situations are going to exacerbate the crisis and what things can we do to help mitigate anything that's going on and reduce the stress in the immediate moment. The next thing we want to think about is how do they conceptualize the problem? And you can get a lot of this. Obviously, you're not going to give them a Myers-Briggs or something while they're in crisis, but you can get a lot of this by listening to what they're saying. If they're talking about fairness and justice and looking at things more logically, point A to point B sort of thing, they're probably more sensing and they probably are more detail oriented. So that's one of the things you want to focus on is hear the details, but try to get them to pick their head up, so to speak, and look at the bigger picture. We're focused on this one aspect right now, which may really suck. Don't get me wrong. But let's look at the bigger picture about what's going on and eventually you'll get there. If you're working with somebody who's intuitive, they may be seeing the bigger picture but missing the details. One event happened and this is how it's going to affect my life and yadda yadda yadda, missing the details that there are things they might be able to do. There are details and parts of this that they do have control over. They're just seeing it as a global thing that they are out of control. Thinking and feeling is where they get meaning from. So again, by listening to the words they use, are they more logic oriented? What's the logical resolution? What's the fairest resolution? If they are more feeling oriented and collectivistic, then you might want to focus towards having them identify things that are going to help everybody feel better and the impact of what they're doing, you know, potentially on their significant others. So thinking about, and the timing of these is obviously going to be very critical. You're not going to walk up to somebody and go, what are you doing? How do you think your kids are going to react if you do this? That's not appropriate. But you might start talking about, you know, they start talking about their family and their kids and how they've let them down and everything. And you can say, okay, you know, tell me a little bit more about your kids. So let's start talking about that. That broadens the situation, you know, gets them to look at things more than just this one little thing, broadens the situation and also helps them start focusing on their impact on others. And then judging and perceiving, you know, some people like structure and like to know how things are going to play out. Some things, some people are a little bit more spontaneous and that's okay. When you're creating an action plan for them, what are you going to do in an hour? What are you going to do in three hours or tomorrow? Some people will want more structure. Other people will want a list of things, you know, let's try to get this done tomorrow and these five things done this week. So ask them what feels comfortable to them. And obviously that's in the later versions or later parts of crisis intervention when you're talking about implementing the plan. So their temperament does have a lot to do with it. When you're looking at interventions that are helpful, you know, the extrovert is going to need to be around other people. Extroverts typically draw their energy from others and they talk and think at the same time. They're thinking everything out while they're talking. So if an extrovert doesn't have somebody to bounce ideas off of, they may feel very stuck. Whereas an introvert needs some downtime. They need some quiet time where they can think and get their thoughts together. Then they're more than happy to share. But we want to look at these sorts of things when figuring out how to mobilize resources for the person. So crisis represents the presence of opportunity and danger. You know, it's an opportunity for change because as they say, change causes crisis and crisis causes change. When we change, you know, New Year's, it is New Year's right now. And a lot of people made New Year's resolutions and they're trying to change something. And it's going to get a little uncomfortable. Now crisis doesn't have to be something where somebody's suicidal. Crisis means life is going to get uncomfortable. There is an element of discomfort or crisis or shaking things up a little bit. Change causes that. You know, when you alter the equilibrium of something, when you alter the patterns of something, it's going to require some time to adjust to. And then crisis causes change. When things are kind of up in the air or in that flux sort of state, people want to get back to a state of equilibrium. So they can either go back to the way it used to be and just, you know, that was more comfortable. Or they can say, I don't want to go back there. That was uncomfortable. I want to continue this change, but let's figure out how I can do it and make it work for me. One thing we need to recognize though is while there is this presence of opportunity. So whatever's happened, you know, how can we make lemonade out of it? Whatever you, however you want to look at it. But if somebody is feeling overwhelmed, then as the anxiety increases, they may do more things that are more impulsive and violent. So we want to make sure that we don't start throwing opportunities at them and getting them to feel overwhelmed. They want things to go back to the way they were or they want things to go back to a certain way. So we don't want to push too much. We need to recognize though that this is an opportunity for growth. Crisis is complicated. It generally does not have one simple cause. It's kind of like an onion. You know, there are things or maybe Jenga, if you want to think about it, Jenga block. Each block is built and balancing on one another and there's, you know, a certain dynamic holding everything together. When crisis happens, you know, generally it's not somebody woke up in the morning and everything is perfect. And then, you know, something happens and things are not perfect anymore and they're in crisis. Generally, there have been things leading up to it, isolation, loss of friends, changes in job. Maybe sometimes it's having, you know, getting married or having a new baby in the house. Now, I will say that they find that being married is a protective factor against suicide. But the change that happens when you go from being, especially if you didn't live together beforehand or whatever and you suddenly got married and are living together, there's going to be an adjustment period. Same thing when you bring in a new baby, you know, and that new baby may be great. But think about the crisis that happens the first time that baby is running a fever of 104. It's not just that the baby has a fever. It's that the parents may feel, oh my gosh, I don't know what to do. I feel so inept. It's that parents may not have been sleeping for two or three months because baby's not sleeping through the night yet. So there's a lot of things that build up on each other. And, you know, parents may not have had any respite from junior. I know God love him. My oldest, he had gastric reflux when he was an infant and he did not sleep. He would sleep for 15, 20 minutes at a time and then he would wake up and the poor little thing was in such pain. He would just scream and I felt so helpless. So there was a lot of things going into it. You know, when he got, when he got sick and, you know, the first time and I was just like, oh my gosh, how much more can I take? So we want to look at all the causes, you know, what caused the person to lose their job? You know, generally, maybe they started coming to work late because they separated from their spouse and now they had to get the kids to school by themselves. And, you know, you see there's other things going on here. So let's see what led up to this crisis. Beliefs may be operating when an emotion or reaction seems at a proportion. So we want to look for those cognitive distortions and, you know, everybody's against me. Nobody understands and gently challenge those, challenge those thoughts as they, as they come up and as appropriate. But we definitely want to validate how people are feeling. If they feel like everybody's against them right now, I'm not going to tell them, no, there's got to be somebody for you. You know, I'm going to validate that, wow, you know, you must feel like you're pretty isolated if everybody's against you and it's exhausting. And precipitating events may impact many different areas of life. So things that happen, like, like I said, bringing home a new baby. A precipitating event that can end up causing a crisis if junior gets sick because it impacts physical. People aren't getting enough sleep. It may impact nutritional probably not eating as well as they could because, you know, they're taking care of baby may impact social. I don't know about you when my when my children were infants, there were periods when they were really young that getting a shower was, you know, a luxury, especially getting a shower by myself without having a little baby in a in a carrier right outside. So there were a lot of different ways that having a new baby in the house while it was one of the greatest joys in the world changed things. So looking at how things changed and how things change with this person that you're you're working with that ended up resulting in or leading up to this place where the person feels completely hopeless and helpless. Generally, there's no panaceas or quick fixes for crises. They are complicated. So you can't just wave a magic wand and make it fixed or you can't say, oh, well, you just need to do this, you know, go down here and talk to this person. It'll be good. That's likely not going to happen. If somebody loses their job, for example, a lot of times there's poor work performance that led up to it. There's a lot of other things that may have happened or if the person got laid off, you know, maybe there's a downturn in the end. There's a downturn in the economic stuff or the economic climate in that community. So it may be harder to get a job. So we don't want to say, you know, you lost your job. That's tough. Go down here. I'm sure you'll get one next week. That may not be true. We want to help them figure out things they can do to ensure that they don't make the problem worse though. So you're here right now. Where do you want to go and what are your options? Now let's look at those options if you do this. You know, and I'm thinking the television hostage situations or whatever. Obviously that makes a situation worse with somebody who has lost their job. If they don't start applying for new jobs, if they feel defeated and they don't want to go out and do that again. I get that. I totally get that. However, gaps in employment can make it harder to get another job. A bad attitude about having to apply and interview again can make the problem worse. So you want to look at what do you need to do? What are some things that, steps that you can take? And what do you need to make sure you do so the problem doesn't get worse? And when there is a crisis, there's a necessity of choice. You have to do something. Now you can sit there and be in crisis, but eventually something's got to give. So you're required to do something. Either go back to the way things were, if possible, or change. If a relationship ends, sometimes going back into that relationship isn't an option. So what do you do? You have to take an action to move out of that crisis or you're going to stay in that crisis state. Choosing to act is still a choice. If somebody breaks up from a long-term relationship or gets divorced or whatever it is, and going back is not an option, but they're not ready to date yet. They don't want to go out and see anybody else. They really want that old thing back. They can choose to sit there and be unhappy and think about what they lost and do all that sort of stuff. Or they can choose to start working on those issues and dealing with the grief. I want to look at what choices do you have. Types of crises. Like I said, not every crisis for one person is going to be a crisis for another person. Developmentally, for example, identity formation is a crisis. When people are in high school trying to figure out where they belong, what they want to be, with a lot of people now who end up having three, four careers, there's a repeating pattern of identity formulation and formation. What do I want to be after this? So that may precipitate some sort of a crisis. The empty nest. You know, if you're a parent and all of a sudden you don't have any kids at home anymore, it's like, oh, golly. Now, how do I redefine myself? If I'm not responsible for this, what am I doing? If I'm not doing this every day, Toten kids to martial arts and this and that, what am I? What do I do? And then midlife. You know, we're all familiar with that stereotypical midlife crisis that not everybody goes through. But developmentally, even if you look at Erickson's stages, it's pretty natural to look back over your life about this point and go, oh, either I've done a lot or I thought I would have been further than this by now. So people may try to recapture some of the things that they missed out on or accomplish some of the things on their bucket list they haven't gotten to yet. Other crises, chronic illness or pain such as HIV, fibromyalgia, if somebody is diagnosed with some sort of paralysis, that will precipitate a crisis. Their life is going to change. I had my hand in a cast for six weeks. And, you know, that's not really that big of a deal. But it was amazing to me, it was my right hand, of course. And it's amazing to me how much stuff I do with my right hand and how much my life had to be altered a little bit when my hand was in that cast and I couldn't get it wet. So washing my hair even became kind of a ordeal. Yes, you can get around it and there are adaptations you can make. But something as simple as that can cause a lot of changes. So think about if you are in an accident and you wake up and you're paralyzed from the waist down or you have a stroke and one side of your body is paralyzed. That is a huge thing. It'll take a toll or it'll have an impact on your self-esteem, your self-concept, your self-efficacy, your potentially other aspects of your physical health. You know, there's a lot of ways that these kinds of diagnoses may impact a person. So we want to look at, you know, what are all the ways that your pain from that accident you had last year is affecting your life? And what are your options? The same is true if a spouse has a chronic illness and then you throw in there caregiver exhaustion and the need for respite. So if a spouse has a chronic illness, it will affect your socialization patterns. It will likely affect some of your physical stuff. You know, you may worry, so you have more stress-related illnesses. You may not sleep as well, whatever it is. So we want to look at all those things. And then situational crises. These are things that just happen. Death, you know, somebody dies. It can be expected. It can be unexpected. But that's a situational crisis that may throw somebody for a loop. And it doesn't have to be just a human. Some people, you know, and I'll say, I'm an example, when our animals pass and even our chickens, but that doesn't hurt me as much as when, you know, one of our dogs or cats passes away. But death is one of those things that precipitates a little crisis. When relationships end, when you lose a job, for people who are homeless, you know, they had a home and then all of a sudden they're living out of their car and it's not by choice. Or, you know, think of the shining and cabin fever, you know, not being able to get out, not being able to do the things that you used to do sometimes can precipitate a mental health crisis. So we want to look at exacerbating and mitigating factors and vulnerabilities. When we're trying to get a pulse on what's going on with this person, are there pre-existing mood issues? Was the person already depressed, anxious? If so, about what? Mentally and cognitively, if they're in this situation, what is that critical inner voice telling them? Is that critical inner voice saying, I knew you were going to screw this up? Or is it quiet? Most likely when somebody's in crisis, that critical inner voice is just screaming at the top of its lungs. So we want to hear what those thoughts are and we want to talk about what the person about whether they believe them. Negative perceptions, when they're looking and if everything they see looks like doom and gloom, encourage them to kind of look at the silver lining of certain things and look at some of the positive things that are going on. But if they already have a negative way of viewing the world, then you can kind of get in their head space and see how they're seeing this current situation. And once you start to understand how they're seeing it and what they're hearing in their own head, it starts to make a lot of sense why they're reacting the way they are. And we also want to listen for cognitive distortions, those unhelpful thoughts. And if somebody says everybody's always doing this, file that away and then when appropriate, you may ask for, if everybody always leaves me or nobody can be countered on, okay, file that away, then later when you're talking about mobilizing resources, you might say, I'm wondering who is it in your past that you have relied on or who do you think you could rely on now to be there for you? And if they don't have anybody, that's okay. We can start brainstorming where we might find those people. Pain and illness can also exacerbate a crisis. If somebody's already in pain and then all of a sudden they lose their job, I've seen people that have worked as cashiers or whatever who obviously have significant back pain and they have to sit, they can't stand for very long or maybe it's their knees, I don't know. But if they've already got pain and illness going on, they may have high medical bills and then if they lose their job on top of that, everything could exacerbate. And I know I tend to react a little more strongly to things when I don't feel well. Sleep deprivation, same thing. Low blood sugar or dehydration, we don't think real clearly when we're dehydrated and when blood sugar is low, people tend to be in that fight or flight a little bit more. So they can be a little bit more snippy or react a little less logically. Now this isn't, you're not going to give somebody an apple and a drink of water and their crisis is going to go away. But this is one of those things that can mitigate. If you've been talking to this person for two hours, you know their blood sugar is probably getting low and they're probably starting to get dehydrated. So offer them something to eat, offer them something to drink. Help them feel how much you care. Help them also mitigate some of their physical vulnerabilities. If they have new meds or there's been a med change, especially psychotropic meds or pain meds, that might also precipitate a crisis or make it worse. And this can be blood pressure meds. This can be pain meds, psychotropics. You know, and we want to look not only at is it doing what it's supposed to be doing to the degree we need it to do it, but we also want to look at what are the side effects of this medication. For some medications, you know, the first couple of days of a med change of increasing dosages or decreasing dosages or starting a new medication can be really ugly. You know, it can have a fair amount of side effects. So talking with them about what things may or may not go away and how they can advocate for themselves with their doctor. Social exacerbating factors, lack of a healthy supportive social environment. So we want to try to figure out if they've got people they can rely on. And if not, we want to start looking for where might you be able to connect. Spiritually, exacerbating factors and mitigating factors, their sense of interconnectedness and connection to something bigger than themselves. If they think that there's a higher power of some sort or spirits or karma, you know, let's talk about that. What gives them hope, faith, meaning and courage? What helps them want to go on? And what are their values? And, you know, any of these questions we can start talking to them about, you know, maybe they're a really honest person and they feel like people should be honest. Okay, so that's one of your values. And maybe this particular incident, maybe they were in business with somebody and the person embezzled $100,000. Well, that's dishonest and that's a lack of trust and all those things. So whatever happened may fly in the face of their values. So this incident has kind of shaken up the way they view the world and safety and how other people are and all that kind of stuff. So yeah, it's going to cause a significant crisis. But we also want to look at, are there things spiritually that can help give this person comfort in their religion, in their spiritual beliefs? Are there things that can help them see the proverbial light at the end of the tunnel that can help them feel like the world is not spinning out of control? What can we look at? What values do they have that they can embody to get through this challenge? Environmentally, you know, look around. And when we're talking about crisis intervention, a lot of times we're talking about the immediate situation. Look around what visual auditory triggers or auditory triggers might be there. If there are people cheering them on, if there are, you know, cheering them on or saying ugly things or whatever the case may be, if there are things that they're seeing that are making them stressed out, they may not have anything to do with the particular crisis, but if they're seeing things around them or hearing things that are stressing them out, that's going to keep them on edge. We want them to be as comfortable and relaxed as possible because the more they're that way, the less that fight-or-flight reaction has to keep going. If there's an audience, try to get rid of the audience, even for extroverts. You're right there so the person can bounce ideas off you. People don't need an audience because a lot of times they will hold on to those beliefs that they had for fear of losing face. They may act out more if there's an audience. So try to remove that audience, try to make it as a calm of an environment as possible. Remember, the fear and anger represent responses to some kind of a threat. So when we're listening to what's going on and what led up to this and how it's impacting them, listen to fears of the unknown. I don't know how I'm going to feed my kids. Okay, well, let's talk about that. Fears or the threat of loss of control or power. I don't know if I'll ever be able to get another job or, you know, this just came from out of the blue and I wasn't able to defend myself. Okay, rejection. So we want to listen for them saying, you know, people will hate me or, you know, I can't look my family in the face now. Isolation, nobody's there for me. Failure, obviously, you know what that's going to sound like. And threats of death. And when I'm talking about that, the threats I'm really talking about is, did they feel like their life was in danger? Or do they feel like there is imminent danger to them? Obviously, we're going to consider suicidal and homicidal ideation as part of this assessment. But when we're doing crisis intervention, we want to figure out what things triggered this person to be in crisis. Models of crisis intervention basically have the following goals. Equilibrium and stabilization. We want to remove reinforcers for any aggressive behavior and identify reasons for the person to calm down. And please don't tell people to calm down. Most of the time, and occasionally that'll work, probably. But most of the time, if you tell somebody to calm down, what's going to happen? I know what happens if I'm upset and somebody tells me to calm down. I'm like, don't you tell me how to feel? So calm down is probably not the right thing. But we can identify, you know, I really want to help you. I need you to slow down a little bit so I can understand everything that's going on. That's saying calm down without saying calm down. Cognitively, we want to help them gain control by starting to change their thinking. Like I said, start looking up instead of being stuck down in the details, see the big picture. Or if they're overgeneralizing to that big picture, help them see the details. Help them see what parts they do have control over. Psychosocially, we want to assess internal and external factors that could be making this worse. From physical to mental health to cognitive. And help them choose and identify or identify and choose workable alternatives. Now when we're doing this, you're balancing temperament and crisis and trying to figure out what's going on. Let's just add another layer, cultural competence. There is no one normal range of behaviors. If somebody is upset, you know, they get fired and they are really enraged about it. They're in crisis. They feel out of control. They may get angry and act out. They may just break down crying. They may get very quiet and stoic. Or they may do something completely different. But those are kind of the three points along the continuum. Unless you know that person really well, you probably can't predict how they're going to react to something. So being aware of that. When you're working with somebody from a different culture or maybe from your same culture, be aware that not everybody is from an individualistic society. A lot of the things, if you remember back to the past few webinars, a lot of other cultures are collectivistic. So what is in the best interest of the person is less important than what's in the best interest of the whole family. So we don't want to talk about, but what is it that you need? What is it that's in your best interest? We want to talk about, you know, your family is very important to you. How can you do what's in the best interest of the family and in the best interest of yourself? You know, try to find that dialectic. Language is not always interpreted in the same way. So don't use colloquialisms and even things like the word depression doesn't necessarily translate the same and love doesn't necessarily translate the same between cultures. So make sure that you're not having a communication impasse. We must accommodate the client's needs. So being cognizant of what their needs are if they need an interpreter, if they need, you know, time for prayer, whatever it is. Remember that past history certainly does impact current events. So if they are a oppressed minority, for example, they may be reacting from some of that learning from some of that experience. They may be reacting from something that happened, you know, 50 years ago that is currently still impacting their culture. So we want to be aware of those things. And we want to be aware of our personal assumptions about that person's culture when we're working in crisis intervention. So the safer model, stabilize, make sense, acknowledge what's going on, facilitate understanding, encourage adaptive coping, restore functioning and refer as needed because we can't do everything. So ensuring safety is the part of stabilize. Physically, remove the client from the situation if possible, get them to a place where that's kind of neutral. Inform them you want to help, but it's hard for you to focus while they are maybe being, I don't want to say being aggressive, while they are pacing around so much. So maybe proposing a solution that doesn't take away his power. One of the things when I have highly agitated clients, we go walk outside. So they're still able to move. They're not having to sit, but it's in a situation where I'm safer and I don't feel like I'm in a bad position. Psychologically, remove bystanders because an audience may add fuel and reframe the situation with the client not being bad. The client is struggling. The client feels out of control. They're not bad. Maybe they made an unfortunate decision or an unfortunate choice, but they're a good person. Stabilize through assessing the ABCs. What is their effective state? And this is different than this is not the cognitive ABCs. What is their effective state? What level of behavioral functioning do we have? Are they erratic and impulsive or are they pretty controlled? Where are they at with cognitive functioning? Reality testing? Are they able to think through things? They're emotional mind, full bore. And what is the severity of the crisis? Is this something where somebody is suicidal or homicidal? Or is this something where somebody is really uncomfortable? Acknowledge. You want to define the problem and seek help from the client in understanding what's going on. Listen to the person's orientation in order to figure out whether you want to pair it or identify their feelings or start out with solutions. So one of the things that we're looking at here is if somebody is a feeler, an F on the MBTI, they need to have their feelings acknowledged and validated. If somebody is a thinker and they're talking about solutions from the get-go, you know, sometimes it may be helpful to start with solutions. It usually never hurts to acknowledge and validate feelings first, but... And then are they visual, auditory or kinesthetic? So let's talk about what are you seeing? What are you hearing? What are you feeling? What can you do? Empathize to see the problem as the client does. Ask open-ended questions and pay attention to their verbal and non-verbal messages. You know, obviously that's pretty much counseling 101, but here we're really working on that therapeutic alliance. Acknowledge the situation and or the client's feelings. Not that they're incorrect because their client's feelings are the client's feelings and they are, as they are, radical acceptance. You may not agree, but you don't have the same life experience and perception necessarily that that person does. So we want to acknowledge where they're at and then we can help them move out from there. Own your own feelings. When you're facilitating understanding, you know, you may stop and say, I'm confused here or I'm feeling really frustrated. It feels like we've been going over the same thing for an hour and I'm wondering what I'm missing. So I'm owning the fact that I'm feeling frustrated because likely the client is feeling frustrated too. Be aware of transference and counter-transference reactions. You know, what do you represent to that person that they may be transferring onto you? Do you represent the system? Do you represent someone that's helpful? Do you represent a mother figure or whatever it is? And at the same time, what is that person triggering in you? So be aware if you have any feelings of irritation or whatever, what is that person triggering in you? Or do you have the need to rescue? Convey understanding, preferably not by saying, I understand, but by using good paraphrasing. And please don't assure the person that everything's going to be all right. You can assure them that you're going to do everything you can to help them, but you don't know how things are going to turn out. Provide positive reinforcement for positive behaviors. If they start calming down and stuff like that, you may consider, you know, offering them food or a drink or something. Avoid value judgments and set limits. Don't tolerate controlling or aggressive behavior. Encourage adaptive coping. What thoughts, reactions and behaviors help you get closer to a rich and meaningful life? That basic question from ACT. So we want to ask the person, what does this rich and meaningful life look like to you? All right, you're here and that's there. So what responses do we have to this situation that can help you resolve how you feel or improve the next moment and still work towards your goals for a rich and meaningful life? Reduce tunnel vision or increase focus to things that are meaningful to the person. So you might say something like, this is really awful situation right now, but you keep mentioning your kids. Tell me a little bit more about them than they might start thinking about all the things they have to lose if they make a rash decision. Examine with them the alternatives. What response options do you have? What supports can help you? What coping mechanisms do you have? How can you alter your thinking to not see this as destroying you or however they're seeing it? And restore functioning by promoting mobilization, preferably nearly immediately. You want them to walk out of that crisis intervention session with a plan. You want them to be mobilized so they feel like they can start implementing order and getting control back over their life because crisis represents a sense of a loss of control. And obtain commitment with assertion statements from them by saying, you know, I need you to call me tomorrow after you make your appointment with your psychiatrist, or I need you to do this. And the person will say, ideally, yes, write all this down. Don't expect them to remember Diddly Squawk right now. Write it down so they can look at it tomorrow morning when they get up. If they have a social support person that's going to drive them home or that's there if the crisis occurred in their house. Make sure with permission, obviously, that that person is looped into what the plan is so they can help the person who's in crisis follow through. When we're in crisis, our memory is not good. Refer to medical and psychiatric services is needed. You know, if chronic pain is part of the problem that's contributing to what's going on, maybe, you know, maybe they lost their job because they couldn't work as many hours because they were having too much pain so they're calling in too much. Now they lost their job and they are wondering how they're going to pay the bills. Okay, so the crisis is they lost their job, but what led up to it part of it is uncontrolled pain. So we may need to refer for medical stuff. And obviously, if they've got other, if they haven't had a physical in a while, there may be other medical things going on that need to be addressed to help them be happy and healthy. And psychiatric referrals as appropriate refer for medication. If they're on medication, make sure they're able to access it. If they can't help them learn about patient assistance programs, formularies at different stores and oh golly, what's the other one? Some of the discount pharmacy programs and most of them are online they can find. Refer them to support groups, survivors of suicide, depression, anxiety, divorce, substance abuse. There are support groups for everything. Contact your local NAMI for mental health groups. You can also contact your local United Way information and referral. They generally have a pretty exhaustive list of support groups. Refer for vocational counseling if they need a new job or a different job. Reverb for legal assistance if they've got issues with domestic violence, child welfare issues, divorce, bankruptcy, those sorts of things. A lot of times attorneys as part of their ethics or part of their continuing education can do a certain number of pro bono hours every year. In areas where there's a university that has a law school, a lot of times there's a free legal clinic at the law school. Again, information and referral should know about this. Provide specialized counseling or refer to specialized counseling if they need treatment for trauma or substance abuse or whatever. And maybe they're just, they're really struggling right now to even get up and put one foot in front of the other. And they would benefit from having some sort of assistance with child care or even just an hour or two of respite a week from taking care of the children. Just at their wit's end. We can look for ways to help find that. A lot of times churches have help boards that people volunteer to help out church members, United Way information and referral. And sometimes, depending on your community, there may be vouchers that they can get for temporary respite care, child daycare vouchers. So change causes crisis. Whenever you change, it can be, it gets uncomfortable when you're having to learn new behaviors. So we want to recognize that something changed in this person's life and we want to help them figure out how they can get back to a state of equilibrium. But in order to do that, we need to know what equilibrium looks like for them. Crisis by its very definition is a state of extreme anxiety, you know. Well, I shouldn't say by its very definition. You can have minor crises and but when we're talking about crisis intervention, the crisis we're generally dealing with is a state of extreme anxiety. The person feels helpless and hopeless and out of control and they don't know what to do next and they feel like they're kind of spinning. It's important when the client is in a state to hear them understand what's going on with them. It may not be this particular thing. It may be the fallout from this particular thing. I remember I was watching one show. Oh, I can't remember the name of it right now. But hostage negotiation situation. This guy had had his house foreclosed on and he was at the bank and he was holding people hostage and whatever. But the interesting thing was it wasn't the house going into foreclosure that tore him up and put him here. It was the fact that his wife committed suicide after the house went into foreclosure that got him to this point. So we want to hear what's going on and hear all of the nuances. Helpless, the client reestablish equilibrium. What can they do to help them feel like they're not spinning anymore? What is the first thing that could help them? And sometimes clients will know and sometimes they won't. Whatever it's the first thing that comes out of their mouth is probably what they're hoping for. And if that can be something that can be achieved right now, then great. If not, you may say, well, that's probably a long-term goal. What's, you know, maybe they want to get their house back if they had their house foreclosed on. Okay, getting a house is probably a, that's a long-term goal. I can't help you get another house tomorrow. You're looking for somewhere for you and your kids to be safe and have a roof over your head until you can get another house. That we can start working on tomorrow. So help them start breaking it down into manageable steps where they don't feel like they're just kind of fighting against a mountain. Identify environmental and social supports. And social supports are obvious, you know, what things, what people in your environment can help you. And it may be friends, it may be family, but it also may be resources such as social services, food stamps, Red Cross. You know, what other supports are out there that can help you manage this? If a person's house burned down, Red Cross is really great about helping them get a roof over their head and enough new clothes so the kids can start getting back to school and start re-establishing normalcy. Because that's what people are often looking for is to get back to that routine. Help them develop a plan and then help them take action. And help them take action. Don't say, here's your plan, go off and do that and, you know, have a great life. No. Give them the plan and then say, alright, so what's the first thing you're going to do tomorrow? Please call me tomorrow after you do that first thing and tell me how it went. Which will encourage them if they feel accountable, so to speak to you. If they've got a report in on it, it will encourage them to take action. If they're not willing to do it, you may find that they are apprehensive about calling and doing whatever it is. They may feel not okay about calling certain facilities or asking certain questions. So we can help them through that process. If they don't feel like they can go down to apply for food stamps by themselves, or maybe they don't know how, they don't have a car anymore because their car got totaled. And they have to take the bus to get to work, but they've never ridden a bus before. They have no idea how to even get a bus schedule. Well, we can help walk them through that or find somebody who can walk them through that. It's not always something that we as clinicians can do, but a lot of times we're going to do it anyway. And then the safer our model, stabilize, acknowledge the issue, facilitate understanding. So, you know, you acknowledge what's going on that they're in crisis, yada yada, and then you start developing an understanding of what led up to it and what the possible options are. Then encourage adaptive coping in order to help start restoring functioning. And, that shouldn't be or it should be and, refer. Because most of the time, since crisis is complicated, it's not just one thing, there's no panacea. When you refer, when you come to some conclusion and you're encouraging them to take action, there will be places that you need to refer to. It may be another clinician or it may be somewhere like the Red Cross or a church that can help them out to get their needs met. Crisis represents the presence of opportunity and danger and necessitates choice. It's complicated and there are no panaceas or quick fixes. These are the 10 points I told you about. Persons in crisis are initially at high risk for maladaptive coping or immobilization. They may act impulsively and do things that make poor choices or they may not do anything at all. They may just freeze. Most of the time we talk about the fight or flight response, but it's actually fight, flight or freeze. Emotional, mental, physical, social, environmental and spiritual factors can exacerbate the crisis or it can mitigate it. So, if the person has emotionally, we want to look at things that make them happy. What can help them get restored to happiness? Mentally, what factors do they have? What can we help them focus on? How can we help them change their thinking in order to mitigate the crisis? Physically, how can we help them mitigate this crisis? How can we help them get more sleep, know that they're going to be able to feed their kids or whatever the case is? Socially, what factors are out there? What people can they rely on? Who do they trust? Environmentally, how can we mitigate the crisis? What can we do to help you feel calmer in this environment right now, approximately in this crisis incident? But also when you walk out of this office or this scenario, when you go home tonight, how can we help your environment mitigate that crisis? Be more calming, be more supportive, be more restorative. And spiritual factors. You know, I'm Catholic, so I can speak more to those and Christian factors than I can to other religions. But all religions have some sort of sense of connectedness and control by a higher power. People who are not religious are also very spiritual though. So encouraging them to look at what spiritual factors can help them overcome this to help them find peace. Crisis intervention involves regaining equilibrium, gaining control of thoughts, which is kind of getting into their wise mind, and identifying and choosing workable alternatives. Remember, there's no one normal, quote unquote, range of behaviors. People are going to react however they do. And what you may expect from someone, even if you've known them since you were three years old, may not be how they react. So we just want to take it as it comes. Crisis impacts the person emotionally, cognitively, physically, socially, environmentally, and spiritually. So not only do all of these factors exacerbate or mitigate crisis, but a crisis also impacts all of these factors. So we want to look at how is the crisis impacting these areas and how can we mitigate or minimize the negative impact the crisis is going to have on these areas. Resource mobilization should be immediate in order to provide persons in crisis with the tools they need to return to some sort of order and normalcy. Facilitating understanding of the event by processing the situation or trauma helps the person gain a better understanding of what has occurred and allows him or her to express their feelings about the experience. So we want to talk about and get, have them tell us what happened and have them explain it to us. And we can ask questions to probe and help them see a little bit more of the bigger picture. Who else was there when this happened or what else contributed to this so they can start looking and broadening their view. And problem solving within the context of their situation and feelings is necessary for developing self-efficacy and self-reliance. So we don't want to write down the plan and give it to them and go, here do this. We want to work together and mutually problem solve to develop a plan that they can start to implement and then encourage and assist them to take action. Now there are some thinking traps that I'm going to go over if you want to stick around. That is the end of the quote official part of the CEU class. Are there any questions up till now? I apologize for the little hiccup at the beginning this morning. I'm not sure why my computer freaked out on me, but I think it was just reacting to being cold too. Alrighty everybody, I appreciate you being here. Like I said, if you want to stick around for the next few slides on the thinking traps, more power to you. Love to have you. Otherwise, have a great day and I'll see you tomorrow. So talking about thinking traps, these are some of the things we may be hearing from clients when we're in that facilitating understanding period. They may say, me, me, me. I'm the sole cause of every problem I encounter. So we lost or I lost my house because I did this and I did this when the person lives in a house with with a spouse and children and yada, yada. So, you know, what part of this was that person's responsibility and what parts were out of their control. Encouraging them to determine the appropriate level of personal responsibility. Examine all the contributing factors and limit self criticism. Okay, the problems happened. You can sit here and lash yourself with a wet noodle or we can figure out what to do to improve the next moment. Thinking error two is focusing on always believing that problems are always unchangeable and I have little or no control over them. So sit down and conduct a problem analysis, you know, what happened, what led up to it, what's maintaining this. Identify what you can and cannot change and then develop a plan of action for addressing those things that you can change. And then for the ones you can't, you need to learn how to accept reality, figure out how you can sort of embrace the bad. Make meaning out of it, you know. Dialectical behavior therapy is really good at helping people accomplish these things. Them, them, them as opposed to me, me, me. In this thinking error, the person has a very external locus of control and they believe that outside circumstances cause every problem. So encourage people again to look what are all the causes of the problems. What factors contributed to it. What are the facts for and against your belief that you had no part in this and this was done to you examine how you may have contributed and then develop a plan. You know, likely there are outside circumstances at work. But what part did you have. Nobody understands. So encourage the client to identify supportive others or referral sources. Help them focus on what's important to them. And then, you know, and it is very basic develop that therapeutic alliance. So if nothing else, you understand at least a little bit, you know, and, you know, you don't, you probably when they're saying this, you probably don't fully understand. But you can say, I'm not you. I don't really understand everything that's gone into this, but I want to. So help me try to help me understand what's going on and how I can help. Error five is jumping to conclusions, despite having little or no evidence to support it. This is one of those typical cognitive distortions. Encourage people to understand complex events. You know, this X happened or you did X and then why happened. Okay, well, that's fine. But what else contributed to it. A lot of times it's not a single cause and effect. Review events objectively and realistically appraise situations and encourage clients to acknowledge personal limits in preventing problems. And thinking error six, what ifs and shoulds. Well, we can what if and should until we're blue in the face. You know, there's always what ifs and shoulds, but you can you waste a lot of energy doing that. So we want to encourage clients to accept it is what it is. And remember that change takes time. Be aware of memories grudges and resentments. Encourage them to write it out or talk it out what whichever learning style they prefer to identify if they have what if I would have done this. Well, let's play that play out that scenario from beginning to end. Let's just get it out of your mind figure out what the what if might have been and encourage them to focus on what they can control. What ifs and shoulds, you know, what if this happens is generally a worry. What if, you know, I get fired and I lose my job or I get fired and I lose my house and then we're homeless. Or I should have or I should be doing something. So a lot of that represents worry or anger or other dysfunctional things where the person doesn't feel okay with the way things are. Or they're worried about things they can't control. So we want to look at those things and go, All right, what's the present? What is the actual reality of right now? We can't change the past. You can make amends for it. You can there's a lot of things you can do. You can learn from it, but you can't change it. And the future you can't predict. And the weatherman can't even predict the weather tomorrow very well. So what ifs just wind you up. So what is the present? And what is the likelihood that these what ifs are actually going to come to fruition? Alrighty, thank you for sticking in with me and I will see you guys tomorrow. 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