Crisis Intervention- Analysis and Application

Introduction

The Community Mental Health Act of 1963 was signed into law by President John F. Kennedy in response to the questionable practices of mental health institutions.   The new law helped people suffering from mental illlness who were institutinalized in hospitals move back into their communities during treatment. It allowed for more effective psychotropic medications and treatments to be utilized and made community based care easily available for individuals suffering with mental illness.  (National Council for Behavioral Health, 2013) According to the National Alliance of Mental Heath or NAMI (2013) approximately 61.5 million Americans experience a mental illness each year.  NAMI continues to report nearly 18.1 percent of American adults live with anxiety disorders, such as PTSD, OCD, or generalized anxiety and phobias.  Post traumatic stress disorder is very common and is the root of most crisis situations, such as substance abuse and suicide.  (James & Gilliland, 2013)  This paper will focus on a case in which crisis intervention is utlized and the client displays signs of PTSD.  The paper will provide a plan of action, interpret the crisis and identify the appropriate theory that identifies the crisis.  Futhermore, the paper will use a model of assessment, intervention, and treatment and will discuss the substance abuse of the client’s family and how it affects her directly.  Lastly, the paper will consider ethical issues that may arise during the course of the crisis intervention with the client and other parties involved.

PTSD

The MayoClinic (2015) has defined Post Traumatic Stress Disorder (PTSD) as a “mental health condition that’s triggered by a terrifying event; either experiencing it or witnessing it.”  Individuals who experience a traumatic event and suffer from PTSD may have difficulty coping for months or even years and the trauma will interfere with basic functioning.  Post-traumatic stress disorder is very disruptive causing the client to relieve the trauma over and over again.  Without proper coping techniques the client will attempt to avoid situations that remind them of the event and force them into nonresponsive or psychotic state when triggered.  The client may also become easily agitated, quick to anger, display extreme states of arousal, or suffer from hallucinations or reoccurring nightmares.  The Diagnostic and Statistical Manual of Mental Disorders provides specific standard criteria that should be used when classifying and diagnosing mental disorders.  (The National Center of PTSD, 2015)  When diagnosing a client the clinician should be aware of specific symptoms and behaviors such as reckless or destructive behavior which is identified in Criteria E.  Clinicians conclude that children are more at risk of suffering PTSD after being exposed to a traumatic experience, such as abuse, or witnessing interpersonal violence.  Our client, Cassandra displays behaviors that are thought to be symptoms of PTSD.  As the clinician discovers more about Cassandra’s past, it is learned that she witnessed her mother be victimized both physically and sexually by her father and grandfather and she may have been a victim of such abuse as well.  Dues to these experiences as a child, Cassandra is highly at risk for Post-Traumatic Stress Disorder.   The clinician must also identify intrusive recollections the client may be experiencing from the traumatic event.  The individual must show signs of experiencing recurrent thoughts, dreams, and flashbacks that are causing the stress.  Cassandra is a high rated candidate for Post-Traumatic Stress Disorder and has been experiencing reoccurring nightmares about her father that are causing adverse reactions such as night sweats and curling up into a ball.  Criterion C involved avoidance of associated trauma, people, and activities.  Cassandra is displaying acts of avoidance as she smiles when talking about her negative experience.  She is disassociated and displays flattened emotional response to the negative experience she shares.  PTSD symptoms must be present for an extended length of time and in this case, Cassandra has received a series of psychiatric treatments that date back to when she was a young girl. She also received psychiatric care when she attempted suicide.  The chronic stress that she suffers stems from the experiences she witnessed as a child and has caused significant duress in her personal life.  Cassandra has lost the ability to cope and continues on an emotional rollercoaster, repeating a series of emotional responses that lead back to its origin.  James & Gilliland (2013) allude that the client must effectively work through the crisis in order to avoid the rollercoaster of emotions that is prevalent in victims.

 

Assessment/Theory/Intervention

Prior to working with Cassandra the crisis worker or clinician will need to collect as much information as possible about the client.  When using the biopsychosocial method of assessment the crisis worker will gather any information that identifies the client, current psychiatric symptoms, treatment history, list of medications, and medical concerns.  It would be beneficial to determine family history including physical, sexual, and substance abuse, personal relationships, and legal or criminal history. The psychoanalytic theory gives us a better sense of Cassandra’s crisis.  This theory suggests the early childhood fixation that Cassandra has on the abuse her mother endured is causing her inert reaction to possible triggers.  A better understanding of the crisis can be achieved by reaching her unconscious troughts and the emotional experiences.  As the clinician work’s through the trauma with Cassandra it is important to maintain client safety and the safety of those around her.  The clinician will intially want to connect with Cassandra and identify any threats to safety for all parties involved.  Although, Cassandra has attempted suicide in the past and has voiced her curiosity with killing someone, there is no immediate threats as she is in the custody of law enforcement.  Once safety has been considered it will be imperative for the clinican to define the problem and establish intial support.  These are the first three steps to Gilliland’s Six Step Method of Crisis Intervention. In the final steps the clinician will work to form coping mechanisms, implement an action plan, and plan a followup session with the client.  The clinician may also utilize the Cognitive method.  This method of crisis intervention focuses on the root problem and the negative thinking that surrounds it. (James & Gilliland, 2013) The clinician will focus on changing the emotions and thoughts that Cassandra houses in response to men and physical touch.  This method is used to rewire Cassandra’s way of thinking and will help return her to a pre-crisis psychological state.  In the current state Cassandra appears to be disconnected and uncertain of the events that have occurred as she continually requests to see her boyfriend and asks if she is going to jail.  She is unaware that she has been in a brutal fight with her boyfriend and that law enforcement believes she murdered him.  She houses a lot of negative emotions due to the overwhelming number of brutal attacks physically and sexually she was forced to witness her mother endure, and expresses her desire to kill someone in her family as payback.  When her boyfriend touched her in a physical manner she correlated the touch with the abuse and responded in a way she had hoped her mother would have when her father and grandfather abused her.  Through the cognitive method the clinician will work through the trauma and rewire Cassandra’s thoughts to understand good and bad touch.  During the assessment it is determined that Cassandra is suffering from Chronic Post Traumatic Stress Disorder with the initial trauma occurring when she was a young girl.  She has links to substance abuse, violence, and factors that can be correlated with problems in personal relationships.

Plan of Action

Together Cassandra and the clinician develop short term goals that are designed to help her cope through the triggered trauma.  Cassandra will remain in the hospital for a 72 hour observation period that will allow her to be observed for any indicated suicidal thoughts and to undergo medical evaluation.  This medical evaluation will help determine any underlying mental illness.  Once discharged she will be released into police custody to face any charges that are due her for the murder of her boyfriend.  Cassandra will be monitored for any repeat suicide ideations.  Cassandra will continue treatments and individual counseling while she is in jail.

 

Alcohol and Chemical Dependency

Cassandra informed the crisis worker that her father was an alcoholic and her brother was addicted to heroin.  James & Gilliland (2013) suggest a correlation between chemical dependency and shared genetic traits.  These genetic traits increase the risk of antisocial personality, ADHD, and forms of conduct disorder.  Studies conducted in mice and rats determine a direct correlation of the genetic influence on substance abuse.  (Browman, Crabbe, & Li, 2000)  In this case, the inherited risk affected Cassandra and her brother differently.  Cassandra developed antisocial personality traits, where as her brother inherited the risk of being addicted to an illegal substance.  The exposure of violence and substance addiction caused the onset of Cassandra’s Post Traumatic Stress Disorder as an adult.  Cassandra is currently experiencing nightmares and is having trouble sleeping at night.   The lack of sleep is a symptom of PTSD in adults and can cause the individual to hallucinate, become irritable, and violent.  As discussed in an earlier portion of this paper, the cognitive method would be effective in processing the trauma she has experienced and help develop coping methods that will enable her to work through any future triggered events.  Assisting Cassandra in anxiety management and Eye Movement Desensitization would be effective treatments for the Post Traumatic Stress Disorder she currently suffers from.

Ethical Dilemmas

Clinicians and case workers must adhere to a strict rule of confidentiality.  They have a legal obligation to protect the client’s privacy and the right of confidentiality through privileged communication.  (James & Gilliland, 2013) The presence of outside parties during the crisis intervention interview can be considered an ethical dilemma in this case.  During the interview, law enforcement officers were present in the room, stood over the patient and listened to every personal detail that was shared.  These officers refused to leave because Cassandra was in their custody.  This is a direct violation of the client’s rights to confidentiality and is a breach of the HIPAA Security Rule.  The Office for Civil Rights enforces the HIPAA Privacy Rule.  The HIPAA rule is enforced to protect the privacy of an individual’s identifying heath record.  (U.S. Department of Health and Human Services, 2015)  Legally, anything that she shares with the crisis worker cannot be used in a court room, and should be considered private.  Prior to initiating the interview the clinician should have requested the officers to leave the room and stand outside the door.  There was no immediate danger to the client or the crisis worker, therefore there was no need for law enforcement officers to monitor Cassandra.

Conclusion

            Post-Traumatic Stress Disorder is prevalent in many individuals suffering from a crisis experience.  As James & Gilliland (2013) have expressed children that witness or experience a traumatic event are more likely to develop a case of PTSD as an adult.  Cassandra suffered symptoms of Chronic PTSD that stemmed from a series of abusive events that she witnessed and experienced as a young girl.  As she grew up she had trouble coping with this crisis and attempted suicide several times.  In a triggered event she attacked her boyfriend and brutally murdered him.  Through methods of intervention the clinician was able to work through the crisis and help Cassandra identify coping mechanisms that enabled her to maintain a pre-crisis psychological state.  With continued treatment and counseling Cassandra will have the ability to overcome the PTSD.  Traumatic events can change how our bodies and minds respond to triggered stressors.  The role of the crisis intervention worker is to aid the mentally ill in working through a crisis and enable them to deal with their struggles so that they can effectively live in society.

 

References:

Community Mental Health Act. (2013, February 25). Retrieved August 11, 2015, from http://www.thenationalcouncil.org/about/national-mental-health-association/overview/community-mental-health-act/

Mental Illness Facts and Numbers. (2013). Retrieved August 11, 2015, from http://www2.nami.org/factsheets/mentalillness_factsheet.pdf

James, R. & Gilliland, K. (2013). Crisis Intervention Strategies (7th ed). Cengage Learning Inc. Obtained from https://online.vitalsource.com/#/books/9781285404714/pages/56707132

http://www.ptsd.va.gov/professional/PTSD-overview/diagnostic_criteria_dsm-5.asp

Post-traumatic stress disorder (PTSD). (2015). Retrieved August 11, 2015, from http://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/basics/definition/con-20022540

DSM-5 Diagnostic Criteria for PTSD Released. (2015). Retrieved August 11, 2015, from http://www.ptsd.va.gov/professional/PTSD-overview/diagnostic_criteria_dsm-5.asp

Browman, K., Crabbe, J., & Li, T. (2000). Genetic Strategies in Preclinical Substance Abuse Research. Retrieved August 6, 2015, from http://www.acnp.org/g4/gn401000077/ch.html

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Family in Crisis

A crisis is defined by Merriam Webster (2015), as an emotionally significant event or radical change of status in a person’s life that causes trauma.  Merriam Webster continues to define crisis as a difficult or dangerous situation that needs serious attention.  The underlying characteristic of a crisis is resulting in trauma.  When something unexpected occurs it can result in traumatic reactions that affect not just the individual, but those that are in our everyday life, such as family.   James & Gilliland (2013), infer that a crisis can have “many different meanings, to different people” and the reactions can vary from people to people and event to event.   This paper will address how family can effectively deal with a family member in crisis without causing additional harm or trauma.

According to the National Institute of Mental Health (2015), tens of millions Americans suffer an emotional crisis each year.  A variety of crises can affect a family, including financial, separation, and health related crises and can test the strength and steadfastness of a family.  There is nothing that is more bothersome then seeing a loved one suffering from deep emotional pain; in fact it can be extremely stressful.  In order to intervene successfully it is imperative to remain calm and remain aware of any sensitivity.  The first step to helping someone in a crisis is to identify the signs.  One of the most common signs is a drastic change in behavior.   An individual suffering an emotional crisis may also neglect personal hygiene practices, change sleep pattern; such as excessive sleeping or not sleeping well, and they may also suffer withdrawal.  Other traumatic events such as a natural disaster or a terrorist attack can result in a crisis in a much shorter period of time.  However, most often the victim’s behavior will change gradually.  It can be found most helpful to look back over the last several months and review the changes of behavior.  Much like Merriam Webster alluded, it is ever so important not to delay and address your concerns immediately.  It is better to intervene early, before your loved one’s emotional distress becomes an emergency situation; in which they cause self-inflicted harm to themselves or others.  Once you have determined your loved one is experiencing a crisis, reaching out and providing support in a non-judgmental way is the best approach in beginning the intervention.   Addressing your concerns with a large group may be stressful and cause more trauma to the individual.  It is suggested by the American Academy of Experts in Traumatic Stress (2014) to begin a light hearted conversation one on one with the victim while leading them to open up about the distress and trauma they are experiencing.  The rule of thumb is to allow the loved one to speak while you listen without interrupting, passing judgment, or blame to the victim.

Connecting with your loved one and providing support may help your family member release negative energy and help get a handle on the emotional crisis.  In order to address the inner issues of the crisis further, you can suggest professional help with a psychologist.  Offer to be involved through each step of the process if the individual requests it.  Each person is different and how they work through the emotions with a trained therapist will also vary.  Family members can explain to a reluctant trauma victim that a psychologist has specialized training that makes them an expert in understanding and treating the underlying emotional conflict.  A therapist will teach the victim techniques that will make them skillful in dealing with the challenges as they arise in order to successfully work through uncomfortable situations and avoid trauma.

Working through an emotional crisis with a family member can be extremely stressful for everyone involved in the intervention.  The affects can be overwhelming and do not discriminate.  There may be an extreme rollercoaster of emotions that affect the family including restlessness, anger, and hopelessness.   It can be difficult when the loved one in crisis decides he/she does not need any help and may accuse you of betrayal. (Mayo Clinic, 2014)  Families may be torn apart during the crisis and may suffer extreme trauma.  It is important for families to remain focused on every day responsibilities and be prepared for a negative response to the intervention, but never give up hope.

When working through a crisis families should remain united and provide emotional support to the loved one suffering.  It can be difficult, but remaining patient and direct will help everyone manage the crisis together.  It is important to care for all personal needs including: physical, emotional, and social throughout the intervention and healing process.  Healthy families keep sound minds and are able to cope better and the road to recovery will be speedily.

References:

Define Crisis. (2015, January 11). Retrieved June 14, 2015, from http://www.merriam-webster.com/dictionary/crisis

James, R. & Gilliland, B. (2013). Crisis Intervention Theories. (7th ed.). Cengage Learning Inc. Obtained from https://online.vitalsource.com

Statistics. (2015, April 12). Retrieved June 14, 2015, from http://www.nimh.nih.gov/health/statistics/index.shtml#Intro

Dealing with Crisis and Traumatic Events. (2014). Retrieved June 14, 2015, from http://www.aaets.org/article164.htm

Who should be on the intervention team? (2014, September 26). Retrieved June 14, 2015, from http://www.mayoclinic.org/diseases-conditions/mental-illness/in-depth/intervention/ART-20047451?pg=2