Preparation

Think of a time when you have felt unable to cope. What was it about the situation that you found so challenging?

How would you define the word ‘crisis’?

Introduction

The reality is that if people are managing with life, if their normal coping mechanisms are functioning well, then they don’t see a social worker. It is only when things go wrong, when a person stops coping, that a social worker is likely to be called in. Because “crisis” is a normal experience for those using social work services Crisis Intervention, along with Task-Centred Practice, are two key models that social work can say are ‘home grown’.

Idea in Summary

It is normal for all people to find themselves confronting circumstances in life that they cannot deal with by using their existing coping strategies. When these things are experienced as being intolerable then this may be described as a crisis.

When someone is in crisis they experience strong emotional and cognitive distress and disorganisation. Although at the time this may be experienced as catastrophic, in reality, the crisis generally pass and a more comfortable level returns. Crisis intervention is a process that supports people in crisis and assists them to restore their functioning and potentially to develop more robust skills and coping strategies leaving them is a more secure after the crisis than before.

The Idea in More Depth

Before the introduction of Crisis Intervention, there was a tendency to see Crisis as an abnormal experience caused by an underlying psychological problem; for example if someone had an insecure attachment style or an unresolved conflict from childhood. Crisis intervention changed this view by taking a view of crisis as a normal part of human life. For example, James and Gilliland define a crisis as “a perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms.” (2005, p3) The important feature of this definition is that the exact details of the event or situation are irrelevant, it is the experience or perception that determines whether or not it is a crisis. Two individuals may go through the same experience. One of them may experience this as a profound and overwhelming crisis whilst the other sees it as no more than a bump on the journey of life. It is a crisis if the person experiences it as a crisis, otherwise, it is just part of life.

Caplan, the main originator of Crisis Intervention, noted that there were three main phases that a person would go through when experiencing a crisis. (Caplan, 1965) The first phase is the impact phase. In the impact phase the person may be overwhelmed and unable to process what is happening. Feelings may range from powerful and out of control to completely numb. Thoughts may be racing or it may be that the individual is unable to think at all.

The second phase is called the recoil phase. At this point, the implications of the crisis are becoming obvious. The person is more able to think through what has happened. This will not normally be experienced as a good thing. The person may experience profound changes in how they think about themselves, their life, the world or the future. Old assumptions have been shaken, but a new way of making sense of the world may not yet have emerged. Victor Frankl famously defined despair as suffering without meaning. This is a useful definition of the recoil phase. The suffering of the crisis is fully experienced but the meaning has not yet emerged.

The third phase is the Adjustment and Adaptation phase. Old assumptions have been either adjusted to take on what was learned in the crisis or they may even have been replaced by completely new assumptions.

Crisis intervention recognises two distinct types of crises. The first type of crises are usually called Developmental Crises. These may be seen as the normal stages in life where old ways of behaving have to change to make way for new ways. Typical examples might be puberty, finishing school, having children, and retirement. The second type of crises are called situational crises. This includes all unexpected life events (even predictable unpredictable life events such as the death of someone close). Example of this might include bereavements, illnesses, accidents, the breakdown of a relationship, redundancy or a sudden change in life circumstances

Regardless of the exact nature of the crisis, Crisis Intervention endeavours to support people emotionally during the impact phase; to enable them to develop new ways of thinking and behaving during the recoil phase, and to move into the Adjustment and Adaptation phase as quickly and with as little harm as possible.

Theory in Social Work Practice

It is important to remember when applying Crisis Intervention in social work practice that the model is a flexible framework and not a rigid checklist. How a social worker approaches the task will depend upon the nature of the crisis and their role. So a social worker in a mental health team might complete the whole Crisis Intervention process with a service user with a mental health crisis, but only parts of it if the crisis related to the protection of children. Equally a child protection social worker might use the whole Crisis Intervention process when the crisis involves the safety of a child, but use the early parts and refer on if the crisis related to mental health.

It is extremely unprofessional to take on work that is beyond your competence to deal with. As a result when using Crisis Intervention consider first if you have the role, competence and support to do the work safely.

It is helpful to think of Crisis Intervention as proceeding through a number of over-lapping processes. These are rapport building, safety assessment, mutual exploration, psycho-education, goal setting, resource mobilisation and evaluation. As stated earlier these are not rigid. There is no single, fixed and absolute rule as to what must be included or how these processes must be carried out. Different writers and different practitioners will use slightly different names for these stages or do them in slightly different ways. However the key goals are always the same, to create realistic perceptions of the crisis, to mobilise effective coping strategies and to connect the person with an appropriate support network. (Aguilera and Messick, 1994)

It is important to understand each of these processes and see how they fit together.

Rapport building

Rapport building involves developing an empathic understanding of the person’s experience. This requires the worker to use the Person-Centred theory and active listening to support the person in telling their story. The key aim here is to allow the person to express their feelings and have them validated in an atmosphere of non-judgemental acceptance. A key feature of being in crisis is that one feels in chaos. Simply having someone listen to you can allow the feelings to be expressed and processed. The worker effectively ‘contains’ the person’s emotions by hearing them, taking them on board, but not being overwhelmed by them. This effectively detoxifies powerful distressing emotions and makes them more manageable.

Safety assessment

While many crises are unlikely to have immediate or long-term risks some do. If the crisis contains the possibility of serious negative consequences, such as suicide, self-harm, a danger to self or others, or a long-term negative effect on the person’s well-being the worker will need to carry out a safety assessment.

This will mean that the worker must follow up any indications of risk. Although new workers find this uncomfortable and may even believe it to be inappropriate, it is a good idea to ask about specific risks such as self-harm or suicide. This can be done using words similar to this.

“A lot of people find that when they are faced with the things you have been faced with they think of harming or killing themselves. This is more common than most people think. Have you had thoughts like that?”

This allows the person to share thoughts and feelings that they have felt very scared to share. If they have not had these thoughts then asking about them will not trigger such thoughts. However many people who have had these feelings will not share them unless specifically asked.

It is also helpful to ask the question, “what is it in this situation that most scares you? What is the worst that could happen?” Again this gets unnamed fears out in the open. At times this may be enough to reassure the person that their fears are unrealistic. If however their fears are realistic it is important to build safety into the system.

Safety assessments mean balancing risks with strategies to manage those risks in the most effective way. Life is inherently risky. To completely eliminate risks is to cut ourselves off from many of the positive things in life. For example SCIE have noted that in work with lesbian, gay and bisexual adults with learning difficulties, workers often focus on the risks and dangers of the person being sexually exploited but fail to explore how those dangers may be managed whilst still allowing the person to express their sexuality in ways that most enhances their well-being. (SCIE, 2011)

In general, it will be possible to balance the risks a person in crisis faces with the strategies to manage those risks safely. Where it is not possible, the work might need to be suspended whilst the person is assessed or further enquiries are made into the situation.

If the situation has enough safety it is important to explore with the person how they see the situation and what they think needs to happen in order to get their life back on track.

Mutual exploration

The mutual exploration stage of the work is identical to that in the Problem Modelling phase of Task-Centred Practice (TCP). The worker may draw on a range of theories to do this stage well. For example, Person-Centred theory will set the overall tone for the exploration. Understanding of communication theory, for example using the Meta-Model for NLP will help develop precise understandings of the person’s works. Cognitive theory might help see the links between what the person says and how their feeling and why they act the way they do.

Psycho-education

One of the main differences between Crisis Intervention and TCP comes from the use of Psycho-education. Whilst mutual modelling of the problem will help establish and maintain rapport it does not necessarily give the person new ways of seeing things; psycho-education does. Psycho-education is a process whereby a person is provided with information from psychological research to make sense of their situation, thoughts, feelings or behaviour. The main benefit of psycho-education is that it normalise things that otherwise might seem bizarre or frightening.

On this site it is impossible to give a complete list of areas of knowledge that can be useful for psycho-education. For someone who has experienced bereavement Kübler-Ross’s ‘five stages of grieving can be very helpful. (Kübler-Ross, 2005)  More generally the bio-psycho-social model can be a useful tool for linking people’s biological well-being (including diet, sleep hygiene, pain levels, and exercise), their social well-being (including stressful and supportive relationships, social oppression and complex social systems) and their psychological well-being (including thoughts, feelings and behaviour). Understanding of both Attribution theory and the cognitive theory of trauma can help normalise experiences that may be troubling someone in crisis despite in fact being quite normal.

In general, in psycho-education it is best to avoid describing things as ‘normal’. On a statistical level, a specific reaction to a crisis may be normal, in that more than fifty percent of people who have had that experience will have that reaction. However the one thing it does not feel like to the person concerned is ‘normal’. In such cases, it may be far safer to describe the reaction as ‘natural’ rather than normal.

One of the key effective elements of Crisis Intervention is that what seems scary or abnormal to the person makes perfect sense to the worker.

Goal setting

In general the shift from rapport building, safety assessment, mutual exploration and psycho-education to goal setting is likely to be significant in the work. These earlier stages are essential for building a solid base for the work to succeed. These processes may overlap and may be completed with someone still in the impact phase of a crisis. Goal setting is only likely to be appropriate once this has been successfully completed and when the person has moved from the impact phase to the recoil phase and is at least minimally able to see the possibility of getting to the adjustment and adaption phase.

The goal setting process acknowledges that the crisis has happened and that it is likely that the person’s sense of themselves and their life will have, in some way, changed permanently. Having acknowledged that, the key question becomes, how will things need to be different in the future for the person to feel that things are now ‘good enough’.

In terms of goal setting the start point are questions like, “what will need to be different in order for you to feel that your life is back on track?” or “how would you like to think, feel or behave differently from the way you are now?” Another key goal setting word is “instead”. If the person is locked into their current ways of seeing life; their current feelings; their current behaviour patterns; it is possible to simply ask, “What would you like instead?”

These questions are designed to help the person think in concrete terms about the things that they would like to change. It is important to state them in terms of positive, or presences, and not in terms of negative or absences. Instead of having a goal of ‘not feeling sad’ the goal could be phrased something like, ‘I will feel happy more often than I feel sad.’ Instead of ‘I won’t be crying all the time’ it could be phrases ‘when I think about X I will remember the good times we had and know that X would want me to get on with life.’ Negatives and absences are hard to assess and tend not to lead to motivation. Progress towards goals is stated as what the person will do, think or feel rather than what they won’t are better. This is because progress towards these goals is easier to recognise and so tends to be more motivating.

When it comes to goal setting in a crisis situation the CIA model of stress reduction is very helpful. (Thompson, 2006a) This has nothing to do with the American CIA. The initials stand for Control, Influence and Accept. The basic idea is that in any situation in life there are certain factors that we can control. These control factors should be the main focus on our goal setting. Other factors we cannot control, but we can influence. Finally some things we just have to accept.

This model can be shared with someone in crisis as part of the goal setting work. For example a person may be encouraged to see that they can control whether or not they take some daily exercise (something known to promote psychological and physical well-being), they may be able to influence the way a colleague at work talks to them, and they will need to accept that events in the past cannot be changed.

The key purpose of the goal-setting stage of the work is to create a plan that will enable the person to mobilise their resources to achieve their goals.

Resource mobilisation

When talking about resources Crisis Intervention does not just mean a person’s material resources, money, possessions etc. Resources are the total sum of the emotional, psychological, social, spiritual, physical and behavioural things that a person can draw upon to achieve their goals. In many ways this is very similar to the Middle Phase of Task-Centred Practice. Much the same questions will be asked in much the same order. However special attention will be paid to two specific areas of problem solving and resource mobilisation within the Crisis Intervention model.

The first is that the worker is likely to give even more attention to previous coping strategies. The definition of a crisis given earlier was “a perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms.” (James and Gilliland, 2005, p3) One very common effect of experiencing a crisis is that the person also temporarily loses their connection to previous resources and coping mechanisms. Often a worker can quickly and easily reconnect the person to these by asking a question like, “When you have faced difficulties in the past what did you do then that helped you cope?” Simply reminding the person that they are a competent human being with a wide range of effective strategies to cope with the challenges of life can make a huge difference to how someone feels when they are in crisis. This needs to be done in a Person-Centred way otherwise it can come across as patronising and harm the relationship. When done with a deep respect for the person’s value and worth as a person it can be incredibly helpful.

These past coping mechanisms can be explored in depth. What the person did, how they did it, what effect it had and how they can apply it now are all fruitful lines of enquiry with the person. The key point is that any utilising existing strategies is always easier and more effective than trying to generate completely new ones.

The second area that is more likely to be given prominence in the Crisis Intervention than in the Task-Centred model is the role of the social network. Crisis Intervention draws heavily upon an Ecological-Systemic model of human experience. In understanding the way a person experiences a crisis the roles of family, friends, and neighbours are important. For many people a crisis may also raise issues of the meaning of life and values. Core beliefs about spirituality, politics and purpose are often heightened by a crisis. Drawing on people who have a key role in this area, such as members of a person’s faith community, can be extremely important.

On a more practical level bringing family, friends and neighbours in to the work can reduce the sense of loneliness and isolation that often accompany a crisis. As mentioned earlier physical exercise is linked to well-being, so also is the act of conversations with people who care about us as a person.

As with Task-Centred Practice a key to the success of this stage of the work is what the person does after they meet with the worker. It is not the conversation between the worker and the person that makes a difference, it is the actions that this leads to that counts. Gently and compassionately the worker aims to create a safe space where the person can feel emotionally supported and then to use this safe space to plan and prepare to take action.

Once this action has been taken the final part of the Crisis Intervention process is to review and evaluate.

Review and evaluation

When the worker and the person meet again it is important to ask about what has been tried and what the results have been. This needs to acknowledge thoughts, feelings, and behaviour. As with Task-Centred Practice, the key goals of this phase are to encourage the person to internalise the credit for what has gone well and to learn and apply the lessons from what has not gone well.

It will often be necessary to remind someone that progress is a case of ‘three steps forward, two steps back.’ Progress is rarely a smooth path from the way things are now to the way the person would like them to be. By normalising these setbacks, the worker prevents the person from falling into the trap of despair when things go wrong, as they inevitably will. Even in the most disastrous of set-backs, there will also be things that did not go as badly as they could have done, and things that give important information on how to do better next time. It is important that the worker calmly and supportively explores these with the person.

When things have improved key questions will be things like “How did you do that?” and “What does that say about you?” These questions are designed to help the person make internal, permanent and pervasive attributions of the causes of the improvement. The worker must not try and impose this meaning on the person, but allow the person to reach this conclusion for themselves. If the person sees the reason that things improved as stemming from the type of person they are (strong, resourceful, creative, competent, caring etc) rather than from the actions of others or mere chance, then the chance of sustained improvement is greatly enhanced.

The aim of Crisis Intervention is to keep the intervention as brief as is possible. Unlike Task-Centred Practice CI rarely has a time-limit imposed on it from the start. This is because people cannot resolve a crisis according to a timetable. However, CI does have a strong sense of ‘enough is enough’. If someone comes in crisis, meets with the worker, explores the crisis and mobilises their resources and then feels ready to carry on without the worker then the work is complete. Enough has been done and the work stops. At each subsequent meeting, the worker begins with the assumption that this meeting might be the last one. For effective and efficient CI the worker will ask in the review session a question like, “do you think you have resolved things well enough to carry on with your life?” This helps avoid the work drifting or the person starting to become dependent on the worker.

In the same way, if the work continues for three or four meetings with no discernible progress then it is important to acknowledge this. It may be necessary to return to the goal setting stage or to review the CIA Model, as the person may be trying to control things that are beyond their ability to control. If so then the worker may need to negotiate a goal of acceptance rather than change.

In an ideal world it will be the person who determines when enough is enough, but in practice when the worker and the person have agreed that the person is now experiencing the situation as being manageable the work will generally stop.

Theory Checklist

Does the person perceive current events as being beyond their current coping mechanisms?

Has the worker actively listened to the person and validated their perceptions and feelings about their life?

Has the worker normalised the thoughts and feelings as being a natural response to a crisis?

Has the worker collaborated with the person to mobilise resources to enable the person to be in control of their life again?

Unless you can say ‘yes’ to all these questions you are not using Crisis Intervention, regardless of what other techniques and approaches you use.

Critique of the Theory

The most important critique of Crisis Intervention is that it is built upon an entirely individual definition of crisis. By seeing ‘crisis’ as rooted in the experience of individuals and their perceptions it is easy to ignore the role of social inequality and oppression in shaping people’s lives. Many crises are not the result of individual’s coping mechanisms or perceptions, but of the structural power imbalance in society.

As with Task-Centred practice it is essential that a worker incorporates elements of human rights and social justice into their practice. (IASSW, 2001) When using CI a worker must also be aware of the need to incorporate Anti-Discriminatory Practice into the model. (Thompson, 2006b)

As with Task-Centred Practice, CI might also be critiqued for being Euro-Centric. A model cannot be accused of being Euro-centric purely on the basis of where the model originated. The question must be asked ‘is there anything inherent in the model that would be culturally inappropriate for someone from a non-European culture. For CI there is some validity in this critique as the model rests upon an individual definition of crisis. For many African, Asian or South American cultures crisis may need to be understood in a more collective and social embedded sense than those who come from more individualistic cultures. However the assumption that the concept of crisis or Crisis Intervention as an approach would automatically be inappropriate for someone from a more collectivist culture seems hard to sustain. To sustain this view it requires that those from different cultures possess such a different experience of life that they lack a sense of life presenting challenges beyond their current coping strategies. This creates the danger of seeing others as so ‘alien’ that workers from a different culture cannot understand their way of experiencing life. An acceptance of the idea of common humanity, human rights and social justice are embedded in notions of the universal humanity, that all people have the same rights with no preference given on grounds of perceived race, class, gender, culture or nationality.

CI needs to be implemented with a clear regard for the unique cultural background of each person. The worker must show great respect for the way that both the concept of crisis and of resources are embedded in a specific cultural and social setting as well as having individual meaning.

Further Reading

Maclean, S. and Harrison, R. (2011) Theory and Practice: a straightforward guide for society work students. Lichfield: Kirwan Maclean Associates. Chapter 44 – “Crisis Intervention” pp237-240

Skinner, J. (2013) “Crisis Theory” in in Davis. M. The Blackwell Companion to Social Work: Chichester, Wiley-Blackwell. Pp428-431

Coulshed, V. and Orme, J. (2012) Social Work Practice. Basingstoke: Palgrave Macmillan. Chapter 7 – “Crisis Intervention” pp128-151

Payne, M. (2014) Modern Social Work Theory. Basingstoke: Palgrave Macmillan. Chapter 5 “Crisis and task-centred practice” pp 127-149

Trevithick, P. (2012) Social Work Skills and Knowledge: a practice handbook. Maidenhead: Open University Press. Appendix 3 – “Crisis Intervention” pp319-322

Teater, B. (2010) Applying Social Work Theories and Methods. Maidenhead: Open University Press. Chapter 12 – “Crisis Intervention” pp196-211

Last update – 18.8.16 – by M. Allenby