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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Six Step Model to Crisis Intervention

Crisis intervention refers to the methods that are implemented to offer short term assistance to a victim that is suffering physical, mental, emotional, and behavioral distress.  Many trauma victims are not capable of coping with the effects of the crisis on their own accord and are in dire need of psychological assistance and support. (James & Gilliland, 2013)  Clinicians must display a series of skills that enable them to successfully support their client.   This paper will review a case study found in the Journal of Individual Psychology in which the clinician utilized Gilliland’s Six Step Model of crisis intervention and proved this method successful.

In the article titled, “Integrating Crisis Theory and Individual Psychology: An Application and Case Study”, provided by the journal we are introduced to Kate, a young adult that is currently in her second year of an undergraduate program.  Kate remains focused and strives to accomplish her educational goals and remain a prime example for her younger siblings.  Kate’s mother is very involved in her life and expects Kate to complete her degree and establish a career before focusing on building a family.  Kate feels a lot of pressure from the expectations held by her parents, specifically her mother.  These expectations have made it difficult for Kate to cope with the news of being pregnant, and shortly after the miscarriage.  In fear that she is a disappointment and shaming her family she has experienced difficulty focusing on class assignments, become withdrawn from friends and family, has trouble sleeping, and extreme anxiety.

Individuals like Kate often have difficulty in adapting to new challenges and environments.  Instead they adhere to the adaptive ways of their family upbringing; causing difficulty in coping with an uncomfortable situation.   (Parikh & Morris, 2011)  Individuals become more involved in the role they play in their family unit and the rules of the family culture, rather than themselves as an individual.  Kate’s crisis has become difficult to work through on her own based on the connection that bonds her with members of her family and her individual role.  Kate very distraught with her current situation has reached out to the counselor at the university.  Luciana, the campus counselor has been supporting Kate and helping her discover new coping mechanisms that will allow her to work through the pregnancy crisis.

Luciana has utilized the six step model in order to help Kate.  Using the six step model, Luciana focuses on listening, interpreting, and responding in a systematic manner to assist Kate in order to return her to a pre-crisis psychological state.  As we have learned from James & Gilliand (2013) we know that the six step model is split into two phases; the listening phase and the action phase.  During the listening phase, Luciana defines the problem, ensures Kate’s safety, and provides support.  In defining the problem, active listening is critical.  While defining the problem, Luciana has discovered Kate’s inner most feelings are contributing to her fear of being a bad person and helps understand what the true crisis is.  In step two, the counselor focuses on ensuring the client’s safety.  Luciana makes a professional assessment to conclude Kate is in no way harmful to herself or others.  In fact, Kate is so worried about her social role with her family and friends that she would in no way want to sadden those in her social circle.  There is also no history of suicidal thoughts or plans.  She has been cleared of any physical harm.  In step three, Luciana established herself as a support system.   This stage is critical to gain the client’s trust, as the counselor remains positive without passing judgement.  By empathizing with her client, Luciana is successful in addressing hidden fears and helps avoid social rejection.  In the action phase the counselor will actively develop a plan of action through brainstorming and commitment.  By looking at the situation and the individuals that have already stepped up to provide support for Kate during the crisis, Luciana’s able to establish an ongoing support system in Kate’s social circle. Although, the two have never spoken about the miscarriage, Kate believes her mom is aware of the situation and has been comforting Kate.   Kate is terrified of how her friends will take the news that she caused the miscarriage due to her irresponsible actions.  Luciana focuses on the same fear that Kate bestowed regarding the initial news that she was pregnant.  The friends that found out about the pregnancy were supportive.  Challenging Kate to focus on alternative responses helps prepare her for a more positive and controlled situation.  In stage five, Luciana empowers Kate, by enabling her with control of how much information she will share with her social network of close friends and family in order to work through the crisis.  Finally, Kate is able to commit to a plan of action in which she will journal each day, tell a friend about the miscarriage, thank her mother for her kind actions, and email her professors to get an extension on the assignments she has missed.

The six-step model has been an effective approach to working through Kate’s personal crisis.  Kate was able to work through her fears and evaluate alternative solutions in order to remain connected and in control of her social life.  By working through each step she was able to redefine herself and find meaningful ways to cope with the shift in her environment.

In this case study provided by the Journal of Individual Psychology we have established the success of the integrated psychological approach to crisis intervention.  The six step model by Gilliland allows clinicians to redefine problem solving and coping mechanisms empowering clients to overcome a traumatic and critical situation.

References:

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

Tedrick Parikh, S. J., & Wachter Morris, C. A. (2011). Integrating Crisis Theory and Individual Psychology: An Application and Case Study. Journal Of Individual Psychology, 67(4), 364-379.