This material is generally excerpted from Salikeu’s book – Crisis Intervention -1990 with additional commentary from Haldane’s book – Emotional First Aid – 1988.
Crisis Intervention – What to do until professional help arrives.
This technique is based on the concept of crisis and the premise that this concept is an essential building block in any structured understanding of growth and development. Far too often people think of crises as the unusual, mostly negative events that bring disruption to ‘normal’ life. The implication is that an ideal world would be one without crises. Crisis theory, however, takes a very different perspective. Major life transitions – similar in their components, varying only in degree and intensity – are the stuff of which life is made. Very few people avoid crisis altogether. Adult life, whether neurotic or normal, healthy or ill, optimistic or pessimistic in outlook, is a function of how we have weathered earlier crises, whether changing schools, surviving the divorce of parents, dealing with a life-threatening illness, or surviving the loss of a first love.
Crisis is a time when ‘everything is on the line’. Previous means of coping and managing problems break down in the face of new threats and challenges. However, the English language is not always able to distinguish between the nuances of events. This crisis intervention process is not the same and does not have the same intention as the Nonviolent Crisis Intervention process implemented by the Crisis Prevention Institute. The Nonviolent Crisis Intervention intends to reduce the potential for violence of the situation, while this process intends to increase the coping capacity. The differences of the situations are somewhat hard to describe but some explanatory phrases may help. We are concerned here:
with what occurs after the incident, not before
with vulnerable [susceptible, weak, defenseless, exposed] people, not threatening, dangerous, people
not with a situation which causes trauma, but with a trauma which has caused a situation
We do recognize that the differences in crisis descriptions could be considered the other side of the same coin, and it is true that a person suffering from a sense of helplessness can suddenly become violent and dangerous, but this is the exception, not the rule. We are also aware that the issues of nonverbal behavior is a key element in the intervention. However, one of the major differences in the PFA process is that in the NVCI the helper is advised to keep a distance to allow the other person his/her own space. Here, we are advising a closeness and touching to indicate that we are here with you, involved and concerned. We are focused here with the child whose parent has died suddenly, and who is finding it difficult to cope. The adolescent whose girlfriend suddenly decides she doesn’t want to be together any more. The tragic accident that makes the student’s best friend a cripple and suddenly s/he feels afraid for his/her own vulnerability. Those children and adolescents who suddenly or gradually find that the trauma has taken away all of their coping skills and who suddenly don’t know what to do. They may threaten to take their own life, but even this is not the point. They are ready to ‘give up’, they are afraid and they need help.
If John’s girlfriend suddenly died in a car accident, who, within twenty-four hours, would know about it and who would have the opportunity to talk to John about it. With a few moments reflection, we might list:
John’s family
The girl’s family
John’s best friends
other students in John’s class
teachers in John’s school
the family doctor
the family pastor/rabbi
Each of these people might have the opportunity to offer solace and consolation to John and to enter into a first order helping process to reduce his pain.
“A helping process should be aimed at assisting a person to move past an unsettling event so that the probability of debilitating effects [e.g., emotional scars, physical harm] is minimized, and the probability of growth [e.g., new skills, new outlook on life, more options] is maximized.”
It is quite unfortunate, therefore, that “[a]n examination of the history of psychiatric patients shows that, during certain of these crisis periods, the individual seems to have dealt with his problems in a maladjusted manner and to have emerged less healthy than he had been before the crisis” [Caplan, 1964].
This difficulty occurs either because of the method of intervention by those immediately available, the method of intervention of the professionals, or both. Reorganization after crisis may be toward growth or psychological impairment, depending upon a host of variables in each case – not the least of which is the kind of help available during the critical time. The question of whether teachers, aides, friends and other natural support people, including other students, will be able to mobilize themselves to provide effective help in time of crisis is a critical one.
The issue is whether those available will be able to help protect these children against dangerous outcomes and mobilize resources to take advantage of the opportunities for constructive change. The stakes are very high.
THE SEMANTIC ROOTS OF CRISIS
The semantic analysis of the word crisis reveals concepts that are rich in psychological meaning. The Chinese term for crisis [weiji] is composed of two characters which signify danger and opportunity occurring at the same time. The English word is based on the Greek krinein meaning to decide. Derivations of the Greek word indicate that crisis is a time of decision, judgment, as well as a turning point during which there will be a change for better or worse.
Crises then is a decision point, a point upon which a person within the crisis can change their lives for better or worse.
Every school probably has people trained in and prepared to respond with use of the Heimlich maneuver or Cardio-Pulmonary Resuscitation in time of crisis. Yet the intense personal cost – both physical and psychological – of tragedies is all too familiar. Kids often experience or play out their psychological crises in school. The idea that the poor resolution of life crises can lead to long-range psychic damage has been one of the cornerstones of crisis theory, and yet we don’t give the same ‘life saving’ attention to the planned response. When insurmountable problems and life stresses build to such a point that something has to give – people who care offer solace and support, but are they doing it well?
A crisis is a temporary state of upset and disorganization, characterized chiefly by an individual’s inability to cope with a particular situation using customary methods of problem solving, and by the potential for a radically positive or negative outcome. One does not enter into a ‘never ending’ process in crisis intervention. In fact, first order interventions are usually short [one session], can be provided by a wide range of community helpers, including older students, and are most effective early in the crisis. In this way, psychological first aid is comparable to CPR in that it does a specific thing in a specific way, and if more is needed, professional help is used.
The PFA intervention is both exploratory and instructional. The helper must assess the state of the person in trauma, identify the subsystems both interpersonal and intrapersonal, model calm and reasoned behavior, seek alternative solutions, take action and provide feedback.
Moos [1976] identifies four theoretical influences on crisis theory.
- Charles Darwin’s notion of the survival of the fittest examines the struggle for existence of living organisms in relationship to their environment and led to the development of human ecology whose distinctive hypothesis is that the human community is an essential adaptive mechanism.
- Carl Rogers [1961] and Abraham Maslow [1954] emphasized positive human growth and fulfillment, focusing on the tendency toward self- actualization, which is congruent with Buhler’s [1962] emphasis that human behavior is intentional, and is constantly oriented toward seeking and restructuring goals.
- Erikson’s [1963] developmental life cycle focus suggested that with each transition, subsequent development was ‘on the line’ so to speak, and that something had to be given up in the process.
- Finally, empirical data on how human beings cope with extreme life stress added to the theoretical underpinnings. In the final analysis, psychologists have concurred that “growth can only occur after previous patterns have been destroyed and the rebuilding process takes place”.
The distress of the destruction of previously used coping patterns, however, can immobilize the individual and cause the reorganization to become chaotic and therefore, maladjusted. This technique is one which has been demonstrated to have a positive impact upon the reorganization process and can help restore order, on an improved scale, by its quick and consistent use.
A crisis state is time limited, is usually touched off by some precipitating event, can be expected to follow sequential stages, and has the potential for resolution toward higher or lower levels of functioning. How a person perceives the crisis event, especially how the event fits in with the person’s existing frame of reference about life, makes the situation critical. When the person begins to view the crisis as part of their overall explanatory style, it begins to become a part of their personal world view. If the view is personal, persistent and pervasive as well as negative, the individual has failed to use the situation as a catalyst for growth and development.
Perception is a cognitive process in which one feels the sensations from the senses and interprets them based on prior experience. If one parses a ‘panic attack’ one finds that it is the interpretation of the bodily sensations in a catastrophic manner that causes the panic [See CBT#08 – Coping With Panic]. Further, if one looks at Post Traumatic Stress Disorder, it must be recognized that it is the distorted thoughts that occur during the trauma that are the disturbing factors [See CBT#28 – Traumatic Incident Reduction].
Students who have distorted beliefs about self, others and future prospects are likely to apply these distorted and distressing thoughts to any crisis they encounter. The ability to help the student cope in a present crisis in a manner that suggests that they are, in fact, competent, strong and capable is likely to reinforce a positive world view and present adaptive problems for a maladaptive mental context.
PFA then is a preventive intervention. It is oriented toward enhancing the positive aspects of crisis as an opportunity for growth, and to minimize the potential for erosion of self-actualization and, in that process, reduce the potential for mental disorder. The process will utilize all of the cognitive intervention techniques that you have acquired.
At certain times in the crisis state, people are ready for new ways to explain the data and to understand what has happened or is happening. This vulnerability, suggestibility or reduced defensiveness is what produces the opportunity for change. It is the very weakness of the person’s personality structure that presents the opportunity to incorporate new and better thoughts about self and capability. But a person who offers help cannot enter into a crisis situation without having a pre-conceived goal structure and an implementation plan.
The goal of crisis intervention is to IMPROVE THE PERSON’S immediate COPING SKILLS.
The implementation intentions must include a means of intervening, without intruding, with specific strategies for dealing with the emotions of the person, and a process of fostering self responsibility.
The Stages of Crisis
Outcry refers to the initial reaction. Horowitz [1976] gives a model in which the first reaction to a threatening event is an almost reflexive emotional reaction such as weeping, panic, screaming, fainting or moaning. Outcry leads to either denial or intrusiveness.
Denial refers to a blocking of the impact. It can be accompanied by emotional numbing, not thinking of what happened, or structuring activity as if the event had not occurred.
Intrusiveness includes the involuntary flooding of ideas and pangs of feeling about the event. If these thoughts are not resolved, recurrent nightmares or other daily images and preoccupation with what has happened may occur – a classic Post Traumatic Stress Disorder. There is a critical balance for the person in crisis, between focusing on and talking about the event too much and/or too little. This balance is hard to describe, but generally easy to identify.
Working through is the next stage is the process in which the thoughts, feelings and images of the crisis experience are expressed, identified and aired. It is during this stage that the event has been faced and reorganization has begun.
Completion is the final phase of the crisis experience and refers to an integration of the crisis experience.
There are really only three outcomes of a crisis experience, 1) the person returns to their normal state, 2) they improve their functional abilities, or 3) their functional abilities deteriorate.
THE STRUCTURE OF PSYCHOLOGICAL FIRST AID
Time: teachers or other school personnel should expect to spend several minutes to several hours depending upon external and internal factors including how long it takes the professionals to arrive. It is important that the practitioner learn the entire process for it may be needed either because the person is quite effective in getting the student to move through the steps fairly quickly, or because of some untenable delay in professional help arriving.
Goal: Reestablishing immediate coping
- provide support: this assumes that people should not be left alone as they bear extraordinary burdens.
- reduce lethality: take measures to minimize destructive possibilities and to defuse the situation.
- link to helping resources: Rather than try to solve the whole problem immediately, pinpoint critical needs and then make appropriate referral.
Place: Anywhere – but if you can, move the person into a calm area away from stimuli.
Time is a critical issue. Some people process crisis easier than others. The willingness to spend WHATEVER TIME IS NECESSARY is an essential quality of providing appropriate support. You cannot allow your own feelings about time or anything else to enable you to ‘cut short’ the process that will unfold. This is not to say that you cannot turn the process over to someone better qualified, if sanctioned by the person in need. But often the opportunity to use PFA, like the opportunity to use CPR or the Heimlich maneuver is thrust upon the helper and not a choice that the helper made. Regardless of your willingness or desire to participate in helping others, you may find yourself, so to speak, ‘the first one on the scene’. Given that you are therefore in the most optimal position to help or harm, are you going to add to the crisis, avoid it, or use whatever skills you have to make the best of a bad situation? It is important to understand that you are in the process of ‘saving a life’. It is not likely that you would leave a person who was not breathing before they start breathing again or before professional help arrives. The same sense of emergency should hold you to the task of PFA. You will know when it is safe to walk away.
The time will be spent in an emotional laden and emotionally draining situation. In addition, caring person’s will often find that their empathy with the person’s distress is incompatible with helping them use the opportunity for growth.
Thus, a person who presumes to provide psychological first aid must make a commitment to see it through and to find their own growth in each traumatic situation.
PROCEDURE
The procedure used in PFA is composed of five steps:
- Tune In
- Get The Picture
- Explore Possibilities
- Assist In Taking Action
- Follow Up
PFA constructs can be used by you in your own time of crises, if you incorporate them effectively.
Step Number One
MAKE PSYCHOLOGICAL CONTACT:
TUNE IN – empathic listening is a precondition for any helping activity.
- invite the person to talk
- articulate the obvious – I can see you are very upset or angry
- communicate concern
- listen for what happened [facts]
- listen for the person’s reaction to the events [feelings]
- use reflective statements so the person knows you have really heard what they said
- physically touch or hold
- maintain a calm, controlled manner
In empathy the self is the vehicle for understanding, and it never loses its identity. Sympathy, on the other hand, is concerned with communion rather than accuracy, and self-awareness is reduced rather than enhanced. While you may feel sympathy for the individual, that is not the point of emphasis. In empathy you substitutes yourself for the other person; in sympathy you substitutes others for yourself. To know what something would be like for the other person is empathy. To know what it would be like to be that person is sympathy. In empathy one acts ‘as if’ one were the other person. The object of empathy is understanding. The object of sympathy is the other person’s well-being. In sum, empathy is a way of knowing; sympathy is a way of relating. Empathy is a cognitive process that is fundamentally analogical. through the use of analogy from our own life. the helper seeks to understand what is going on in the individual so that s/he can reframe the experience into a more positive occurrence. Sympathizing can place the helper in the same vulnerability as the student – sharing the same experience in the same way.
The first objective for making psychological contact is for the person to feel heard, accepted, understood and supported, which in turn leads to a reduction of the intensity of the emotions. Psychological contact serves to reduce the pain of being alone during a crisis. By recognizing and legitimizing feelings of anger, hurt, fear, etc., the helper reduces emotional intensity. The person’s energy may then be redirected toward doing something about the situation.
Your capacity to stay in contact with the person and the situation depends on your character structure and your habitual response to emergency. If you feel panicky or your eyes are tending to mist, move your gaze away from the person and back a few times. If you feel constriction, you may be holding your breath and need to allow your breathing to move in your abdomen, take a deep breath.
Don’t invade, interpret or condescend.
Step Number Two
EXAMINE THE DIMENSIONS OF THE PROBLEM:
Ask questions that focus on three areas:
- immediate past – what were the events leading up to the crisis? Especially the specific event that triggered the crisis.
- present – Who, what, when, where, how? Have the person tell the story.
- immediate future – What are the likely future difficulties that might be impacted?
In this step you are try to get information about the person’s BASIC [Behavioral, Affective, Somatic, Interpersonal, and Cognitive] functioning prior to the crisis. Strengths/Weaknesses. Why did problem solving break down now? Has anything like this ever happened before?
BASICs – remembering this mnemonic will help you to carry out this step
B stands for Behavior, which includes patterns of work, play, leisure, exercise, diet [eating and drinking habits], sexual behavior, sleeping habits, use of drugs and tobacco, presence of suicidal, homicidal or aggressive acts.
What is the customary methods of coping with stress? If they have gone through something similar before, how did they handle it? The fact that they came through it is a calming thought.
A stands for Affect, which includes feelings about any of the above behaviors; presence of feelings such as anxiety, anger, joy, depression, etc.; and the appropriateness of affect to the life circumstance.
We often face the emotions of others with an increasing sense of paralysis and distress in ourselves. Sometimes we have problems with our own emotions and join in the victimization of the person in crisis by sympathizing so much with their distress that we merely echo their anguish. Maintain your own calm stance and calm the person in stress, even if your are sure that the trauma will not end well. There is no value in acknowledging that the ‘sky is falling’, even if it is. Look at the situation optimistically. Somehow, someway, this is going to work out.
READ THIS AND LET IT REALLY SINK IN..
Michael is the kind of guy you love to hate. He is always in a good mood and always has something positive to say. When someone would ask him how he was doing, he would reply, “If I were any better, I would be twins!”.
He was a natural motivator. If an employee was having a bad day, Michael was there telling the employee how to look on the positive side of the situation. Seeing this style really made me curious, so one day I went up to Michael and asked him, “I don’t get it! You can’t be a positive person all of the time. How do you do it?”.
Michael replied, “Each morning I wake up and say to myself, Mike, you have two choices today. You can choose to be in a good mood or you can choose to be in a bad mood. I choose to be in a good mood. Each time something bad happens, I can choose to be a victim or I can choose to learn from it. I choose to learn from it.
Every time someone comes to me complaining, I can choose to accept their complaining or I can point out the positive side of life. I choose the positive side of life. “Yeah, right, it’s not that easy, “I protested. “Yes, it is,” Michael said. “Life is all about choices. When you cut away all the junk, every situation is a choice. “You choose how you react to situations. You choose how people will affect your mood. You choose to be in a good mood or bad mood. The bottom line: It’s your choice how you live life.”
I reflected on what Michael said. Soon thereafter, I left the Tower Industry to start my own business. We lost touch, but I often thought about him when I made a choice about life instead of reacting to it.
Several years later, I heard that Michael was involved in a serious accident, falling some 60 feet from a communications tower. After 18 hours of surgery and weeks of intensive care, Michael was released from the hospital with rods placed in his back. I saw Michael about six months after the accident. When I asked him how he was, he replied. “If I were any better, I’d be twins. Wanna see my scars?” I declined to see his wounds, but did ask him what had gone through his mind as the accident took place. “The first thing that went through my mind was the well-being of my soon to be born daughter,” Michael replied. “Then, as I lay on the ground, I remembered that I had two choices: I could choose to live or I could choose to die. I chose to live.”
“Weren’t you scared? Did you lose consciousness?” I asked. Michael continued, “..the paramedics were great. They kept telling me I was going to be fine. But when they wheeled me into the ER and I saw the expressions on the faces of the doctors and nurses, I got really scared.
In their eyes, I read, ‘he’s a dead man.’ I knew I needed to take action.”
“What did you do?” I asked. “Well, there was a big burly nurse shouting questions at me,” said Michael. “She asked if I was allergic to anything.
‘Yes, I replied.” The doctors and nurses stopped working as they waited for my reply.
I took a deep breath and yelled, “Gravity.”
Over their laughter, I told them, ‘I am choosing to live. Operate on me as if I am alive, not dead’.”
Michael lived, thanks to the skill of his doctors, but also because of his amazing attitude. I learned from him that every day we have the choice to live fully.
Attitude, after all, is everything. You have two choices – maintain Michael’s attitude or fall prey to your own misgivings. If you want to be helpful, you will stay with Michael.
Talking about feelings places a cognitive framework around the emotions that helps to mediate them. Psychological First Aid works mainly in the release of tension that has already built up. But certain guidelines must govern the support so that it does not become an invasion of the other person.
Use of internal attributions [See CBT#24 – Attribution Training] is a good method of dealing with catastrophic notions such as I want to kill someone or I want to kill myself – “you are not the kind of person who would do that” – is a response that not only defuses, but provides an internal attribution of control.
Since emotional distress is not a sickness, there is no need to assume a person needs further help once the distress has been relieved.
Feelings in response to trauma tend to ‘register’ mainly in the chest or abdomen and ‘contract’ in anxiety.
S stands for Somatic, which refers to general physical functioning or health. The presence or absence of tics, headaches, stomach difficulties and any other body complaints and the general state of relaxation/tension; sensitivity of vision, touch, taste, or hearing.
Again, the process of focusing on specific somatic occurrences going on in the moment, diverts from the emotional response to the trauma and deals with specific issues. A person may not recognize that they feel cold and clammy, until you ask them to detail specifically what sensations they are having.
Recognizing the somatic indicators of emotional distress also provides a source of comfort. A usual response to trauma is to contract the body in emotional expression – to hold one’s breath. This is not a conscious process. The jaw claps shut or the muscles of the chest and abdomen spontaneously tighten. Focus the person on his/her breathing, use relaxation techniques [See CBT#4 – Relaxation Technique] to both divert from the emotional source and to address the response movement. One cannot be relaxed and stressed at the same time. One alleviates the somatic feelings of tightness through the release of emotion, not its containment.
I is for Interpersonal, which refers to the nature of relationships with family, friends, neighbors, and co-workers; number of friends, frequency of contact with acquaintances; roles taken with various intimates [passive, independent, leader]; conflict resolution style [assertive, aggressive, withdrawn]; interpersonal style [congenial, suspicious, manipulative, exploitative, submissive, dependant].
When a person responds to a crisis, there are only a few basic emergency options which include:
Rigidity [tightness of muscles] or paralysis [flaccidity of muscles], both of which result in minimal movement or freezing.
Clinging, which represents a flight toward protection.
Panic or flight away from danger
Or attack, which is aggressive or fighting.
How does the perceived response fit with the general personality type formally perceived? Is there a way to connect the flight away from danger or toward protection to the usual method of withdrawal and set in motion a change in personal habit?
C represents Cognitive and refers to current day and night dream; mental pictures about past & future; self image; life goals; philosophy of life; presence of catastrophizing, overgeneralizing, delusions, hallucinations, irrational self talk, general positive & negative attitudes towards life.
It is important to remember that people interpret events, including crisis, through their own ‘inner logic’, if that logic is distorted [e.g., the student believes that s/he is worthless], the crisis may be interpreted as being just punishment. These kinds of distorted thoughts are the nexus of PTSD and other ongoing difficulties. It is important, therefore, for the helper to NORMALIZE as much as possible the most awesome crisis. Other people have experienced and survived similar crisis.
INVASION
PFA is most helpful when there is already an established relationship since it requires contact and caring. However, a contract can be as simple as an offer to help and its acceptance by word or gesture.
Invasion may occur when a helper loses sight of the distressed person’s autonomy even in great need. Common invasions can be identified as: unasked for help, programming the distressed person, manipulating them into what the helper decides, doing therapy, faking concern, relentless contact, stickiness or smothering.
You may need to give the person distance, while continuing to keep a line of calm, caring communication open. Positioning yourself in relation to the angry or fearful person is an art. You must be near enough to be a center of interest, but far enough away to not evoke further rage. Demeanor is vital. Talking quietly, calmly in the midst of explosions of anger or anguish is a must. Never underestimate the person’s vulnerability, even if it is covered by rage.
Listen for BASIC functioning. How does the person feel right now – about the events? Is the person on alcohol or drugs? What is the impact on family life and friendships? Explore possible lethality. Who is the most significant person who might be called upon to help? Part of the process is to develop with the person a ‘thinking’ problem to replace the ’emotional’ problem. Exploration of the BASICs is helpful to begin to define the crisis in thought terms. It also helps to get the person refocused away from the emotional trauma and pain onto the potential solution.
Step Number Three
EXPLORE POSSIBLE SOLUTIONS
- The helper takes a step-by-step approach, asking first about what has been tried already, then getting the person in crisis to generate alternatives, followed by the helper adding other possibilities.
- It may be important to coach some people to even consider the idea that a possible solution exists.
- Make room for untried prematurely rejected options, and guide the person in fully considering them.
- Examine obstacles to implementation. Take the responsibility to address these issues before a plan is implemented.
- If agreement on a solution between you and the person in crisis has not occurred there is need to talk further about the parameters of the problem, solutions, and/or a match between the two.
- Sometimes it is important to separate the crisis into components and to deal with one at a time.
- Part of the solution may include implementing the person’s social network; find a significant person who can help. Who is s/he thinking about right now in the midst of crisis? Can this person be helpful?
How an individual responds to a precipitating event and later works through the crisis experience depends on his or her material, personal and social resources. PFA is a process of enhancing personal resources, and may also offer opportunities to enhance social resources, as the person may find and accept solace and support from unexpected sources.
A poorly handled crisis or transition can lead to subsequent disorganization and “mental illness”. The crisis must become a problem solving opportunity. The person needs to be helped to frame the problem and to begin to examine alternative solutions.
Step Number Four
TAKE ACTION
- The objective is very limited, no more than taking the best next step given the situation; implementing the agreed upon immediate solutions(s) aimed at dealing with the immediate need(s).
- Depending upon two major factors [lethality and capability] the helper takes either a facilitative or directive stance.
- The facilitative stance is one in which:
- the helper and person in crisis talk about the situation, but
- the person takes major responsibility for any action. Further,
- any contract regarding action is a matter involving only the helper and the person.
Facilitative approaches may range from active listening to advice.
- The directive stance is different. Though the
- talk is again between the helper and the person in crisis, the
- action part may include the helper as well as the client. Similarly, the
- contract for action might involve others.
Directive action ranges from actively mobilizing resources to controlling actions.
This is not to imply that the helper simply directs the behavior of the other person. It is a subtle process of working on the original contract to give help and the directions test the resolve of the other person to resist. Violence is not treatable. There is no pat remedy for stopping it once it occurs, and it would be irresponsible to suggest any such methods. It has to be stopped before it occurs.
Directives that become provocative, which evoke a fixed respiratory inflation where the person has the look of imminent explosion – breathing is held, shoulders pulled back and neck stiffened – require a relaxation of whatever you are doing, and attendance to the potential violence with calm assurance to the student that s/he is in control and capable of dealing with the issues.
In the case of anger, the most important gift you can offer is acceptance. When the person is sounding off verbally or making restless signs of imminent explosion, an attempt to make it go away may play into a sense of impotence that may be fueling the anger. Reason can have space only after the emotion has been discharged. You can start defusing by articulating how well the person is containing their anger, and maintaining their ability to control themselves even in time of crisis. You must make suggestions that imply they are in control, in power and are capable. [See CBT#24 – Attribution Training]
Step Number Five
FOLLOW UP
The last component involves getting information and setting up a procedure to check progress.
- the objective is first and foremost to complete the loop, to determine whether or not goals have been met;
- support provided,
- reducing lethality, and
- making linkage to resources.
If the immediate needs have been met by one of the agreed upon immediate solutions, followed by concrete action steps, and if linkage for later needs has been accomplished, then the process is complete.
- If the above issues have not been met, then the helper goes back to exploring the dimensions of the problem and reexamines the situation as it presently stands.
There is also the need to be clear as to what is the problem. The discharge of emotion may produce a cleansing feeling of accomplishment, which ignores the reason for the crisis. The helper must both congratulate the person on their regained coping skills, and then focus them on the need to address the issues which brought about the problem while now in a more relaxed state.
Two specific concerns must be addressed: first, an evaluation of the crisis in terms of its actual level of intensity. This include the decision as to whether to refer for professional help. Sometimes we use the word crisis or trauma too loosely applying to situations that feel threatening to us, but are not necessarily a psychological crisis for the other person – as when an adolescent ‘goes off’ in the classroom. On the other hand, there are clearly traumatic situations that hold life threatening possibilities and part of the goal structure outcome needs to be a transition to professional help.
Second, is post trauma. We must recognize that traumatic events can often result in lingering and/or recurring symptoms, particularly those that remain unresolved. Depression, sadness, fatigue, crying, flashbacks, fear, withdrawal are all elements that may be quite disconcerting and impair functioning. While such potentials should be anticipated and discussed, they should also be monitored. Thus. teachers and parents should become aware of what to look for and how to reconnect if necessary to professionals for further help. [See CBT#28 – Traumatic Incident Reduction]