Learning From The Past and Planning For The Future
MENTAL HEALTH MOMENT July 6, 2001"Knowing is not enough; we must apply. Willing is not enough; we must do." Johann Wolfgang von Goethe LINKS AND SHORT TOPICS
LINKS AND SHORT TOPICS
The Journal of Pain, published by the American Pain Society, is now accepting original articles, research, critiques and case studies concerning all aspects of pain and pain management. Contact: The Journal of Pain, Department of Pharmacology, Bowen Science Building, University of Iowa, Iowa City, IA 52246; (319) 335-7941; WEB SITE: http://www.ampainsoc.org
National Evaluation Data Review Services (NEDS): NEDS, an independent data analysis service contracted by SAMHSA, offers three reports on how sexual and physical abuse impact substance abuse treatment.
* The Effectiveness of Substance Abuse Treatment in Reducing Violent Behavior.
* The Impact of Prior Physical and Sexual Victimization on Substance Abuse Treatment Outcomes.
* Sexually Abused Women in Substance Abuse Treatment: Treatment Services and Outcomes.
WEB SITE: http://www.samhsa.gov/csat/csat.htm
SUMMER COURSE on DISASTER SERVICES AND CRISIS INTERVENTION IN DISASTERS A one credit course offered through the Counselor Education Department at the University of Wyoming for upper level and graduate credit. The course will be offered on July 27-28, 2001. See the online flier for more details at: http://www.angelfire.com/biz3/news/flier.html Also, the information about the course and registration can be accessed at: http://www.uwyo.edu/summer The course is listed under Counselor Education.
The ACISA 2001 “Trauma Across Cultures” Conference Program is now available on http://www.acisa.org.au/conference2001 The Conference will be held at the Carlton Crest Hotel in Brisbane 2 - 5 August. Post-Conference workshops will be at Warilda Conference Centre, Brisbane, on 6 August. For further information please contact:
Sally Brown Conference Connections
PO Box 108 Kenmore QLD 4069
Telephone (61 7) 3201 2808
Facsimile (61 7) 3201 2809
The Red Cross Disaster Mental Health Services-I (DMHS-I) course will be offered in Casper, WY on Friday-Saturday, September 14-15, 2001. If you want to take this course as a Disaster Mental Health Professional, please send an email for further details on how to register to: firstname.lastname@example.org The enrollment is limited to 20 participants. APA has approved this course for 12 CEUs. Other mental health professions have also approved it for continuing education.
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Although the terms "crisis" and "emergency" may be used interchangeably in the context of counseling, it is useful to distinguish between the two (Chrzanowski, 1977). In psychodynamic theory, "crisis" refers to a turning point or a period when new demands on the ego can't be met successfully by the usual coping mechanisms. At these time, powerful emotions, such as anxiety and guilt, are intense, and cannot continue for long. The possible outcomes of a crisis can be formulated in general terms as: * Return to the previous state * Growth process, with an increase in ego strength * Destructive process (i.e. suicide, homicide, assault) or the emergence of new psychopathology To complicat matters, crises may resolve into some combination of the above. Erikson (1959) referred to the universal developmental phases of life as "developmental crises", and to individual traumatic events as "accidental crises". Caplan (1964) provided examples of the latter, such as "the death of a loved person; loss or change of a job; a threat to bodily integrity by illness, accident, or surgical operation; or change of role due to developmental or sociocultural transitions, such as going to college, getting married, and becoming a parent." In psychotherapy, acting out and transference and countertransference distortions are additional common sources of crises.
CRISIS MANAGEMENT IN COUNSELING DEALING WITH CRISESFormulating The Problem An effective response to a crisis depends in part on the characteristics of the crisis and in part on the therapist's comprehensive understanding of the client. Perry, Cooper and Michels (1987) describe the elements that make up a workable formulation:` "1) A summary...that describes the patient's current problems and places them in the context of the patient's current life situation and developmental history; 2) a description of nondynamic factors that may have contributed to the psychiatric disorder; 3) a psychodynamic explanation of the central conflicts, describing their role in the current situation and their genetic origins in the developmental history; and 4) a prediction of how these conflicts are likely to affect treatment and the therapeutic relationship." Among non-dynamic factors they include such issues as genetic predisposition, mental retardation, overwhelming trauma, and drugs or any physical illness affecting the brain. In assessing current life problems it is important to be on the lookout for changes in biological (including physical illness), psychological and social circumstances of the client's life. Chrzanowski (1977) defined several common categories of crisis: * The emergence of an acute psychosis, which may or may not require hospitalization. * Self-destructive acting out often associated with alcohol or drug abuse, promiscuity, or delinquency. * Major illnesses or serious accidents involving the patient or people close to him or her. * Family disturbances, including separation and divorce. * Economic crisis. * Severe transference distortions (i.e. psychotic transference). * Serious countertransference distortions. * The paradoxical upsurge of disturbed and disturbing emotion and behavior when the patient is threatened by success in the therapy, including the prospect of termination, as cause of crisis. * The response of a significant other who perceives the patient's improvement as a threat. Whether these types of circumstances lead to an emergency depends on the interactions among the severity of the stress, the strengthof the client's ego and support network, and the therapist's skill. Some clients (schizophrenics, chronically depressed, narcissistic, and borderline personalities, substance abusers, and some adolescents) are especially prone to developing crises that become emergencies. In treating vulnerable people, therapists need to be vigilant for personality and behavioral changes that indicate increasing tension or problems in adjusting to routines of daily living. When problems are anticipated, especially early in the course of treatment, the therapist is well advised to meet with the family and lay the groundwork for working together if the need arises. Crisis Adaptation The client's adaptive mechanisms function so as to maintain overall physical and psychological equilibrium. However, in a crisis situation, the capacity of the client's (and clinician's!) coping mechanisms may be exceeded, resulting in erratic and impulsive behavior. Although there are no pathognomic signs of impending violence, precipitous assault is quite rare, if indeed it exists at all (of course, warning signs may be subtle). Typically, the crisis process entails: (1) a prodrome, (2) an identified "incident", and (3) a reintegration/restabilization period. The clinician can optimize crisis outcome through early identification and intervention (depending in clinician sensitivity and judgment), and by adopting the therapeutic stance of collaborating with the client in working through the various stages of crisis adaptation. The clinician must participate in rather than attempt to short-circuit this process. Aggressive behavior results from the client's experience of fear or anger. Both affects are meaningful and potentially understandable reactions (defensive and offensive, respectively) to the client's (perhaps accurate, perhaps inaccurate) perception of threat. While most clinicians seem to assume that aggressive client behavior is indicative of anger, most aggressive behavior in the clinical setting may instead be a reflection of fear. A fearful client must be approached differently than an angry client. However, this crucial distinction is frequently overlooked. All people direct their behavior according to the channels or alternatives that they perceive. Even a gentle person may fight when feeling cornered without alternatives. in working through the crisis process with any client, the clinician must take great care not to inadvertently structure a situation so that the client's only perceived option to meet essential needs is through dysfunctional means. An acceptable alternative must be allowed to any inappropriate behavior. Assessment and Intervention In response to the fearful aggressive client, the clinician may attempt to reduce the degree of threat that the client perceives, verbally (e.g., "It's safe here now") or nonverbally (e.g., allowing plenty of interpersonal distance). Alternatively, the clinician may attempt to help the client feel able to cope with the perceived threat (e.g., "I am on your side, and I will help"). Just as one fearful client may respond better to yielding threat reduction, another may respond better to firm support and enhancement of perceived coping capacity. Similarly, in response to the angry client, the clinician may employ a yielding strategy in order to appease the client and so defuse aggressive potential (e.g., "I am sorry that I hurt your feelings"), or alternatively may respond firmly and inhibit aggressive expression through limit setting. Good judgment is required for the clinician to choose between the yielding and the firm approach to the angry client. The practical test of the chosen approach lies in the resulting behavior of the client. One angry client may only attempt further to "push around" the yielding clinician. Another angry client may be "pushed over the edge" into violence by the firm clinician. Although appeasement is not synonymous with inappropriately pacifying a bully (it is indeed possible to defuse anger through appeasement without sacrificing the essential interests of both client and clinician), many clinicians seem loath to react gently in the face of anger. It seems likely that the most common precipitant of unnecessary client violence is clinician counterhostility. Setting Limits The ultimate goal in external limit setting is for the client to develop internal controls. However limit setting may be instrumental in the course of the client's development of autonomous self-regulation. Limit setting can be a positive technique inasmuch as it allows the client understand which behaviors are prescribed and which are proscribed. It also gives the client realistic expectations about the behavior of others, thus allowing the client to gain approval rather than disapproval. Furthermore, limit setting may prevent the client from doing something humiliating or harmful, and it can convey clinician concern and competence. Some degree of client resistance to limit setting is a positive sign. Generalized, docile acceptance of the clinician's will is dysfunctional. Whenever any of the client's intention is blocked, an acceptable alternative must be allowed. Limit setting should be presented to the client as a statement of fact, never as a request, as a bribe, as advice, as punishment, or as a challenge or threat. Reality-based, natural consequences of behavior are a more productive focus than are consequences contrived and maintained by the clinician. Fairness and consistency in limit setting are absolutely essential. Expected and prohibited behaviors must be described concretely in terms of actions that can be performed immediately. The clinician must know the actual enforceable limit, and must never describe either positive or negative consequences that he or she is unable or unwilling to deliver. Generally, limit setting is often utilized too late rather than too early by well-meaning but inexperienced clinicians. Timely implementation can prevent undue deterioration of the client and the therapeutic milieu. Once the need for a behavioral limit has been established, the clinician may briefly explain the limit and its rationale but must avoid being drawn into superfluous discussion or argument. There are two major methods of limit setting: direct and indirect. The former involves presenting the client with one specific directive. The latter involves presenting the client with choices among acceptable alternatives. Direct Technique Essentially, the direct technique of limit setting consists of stating clearly and specifically the required or prohibited behavior. Though the clinician may describe additional consequences of violating the limit, such a statement is not a defining aspect of this method. Whenever possible, a directive should be expressed in a positive format ("do this", which describes acceptable behavior), rather than in the negative ("do not do that", which does not describe acceptable behavior). The direct method is often preferable for the confused or emotionally overwhelmed client. Indirect Technique The indirect method of limit setting consists of keeping the client in a state of choosing among acceptable behaviors, thus dividing the client's will to resist. Though it may be easy for the client to oppose a single directive, attention cannot be focused simultaneously on two or more alternatives and so resistance to any one is diminished. The clinician subtly maintains control by limiting the choices while giving the client the opportunity to choose among them ("you can sit down and we can talk about how you are feeling, or you can leave"). Should the client refuse to make any choice, the clinician can then make a time-bound conditional choice on behalf of the client ("if you do not choose to sit down in 10 seconds, I will take that to mean that you choose to leave and I will have the security guards escort you out"). Even when the situation develops in this way, any resistance demonstrated is typically far less than had the client not been given a choice. The clinician must exercise sound judgment in deciding which limit-setting technique to employ. Some clients will be angered by anf vigorously resist directives. Others will be ]confused or disorganized by choices. At an appropriate time after such an intervention, the meaning of the limit setting within the context of the therapeutic relationship must be addressed with the client. Ultimately, clinician actions with the client's best interests at heart are likely to be understood and appreciated. Physical Intervention Not every episode of potential or actual aggressive behavior can be resolved without physical intervention (e.g., an individual who is so afraid or angry that sustained, meaningful interaction is not possible and with whom an attempt at nonphysical intervention might be dangerous to client and clinician alike). Even in those episodes in which nonphysical intervention might have been possible, less than optimal clinical technique may fail to prevent (or may even precipitate) a physical attack. Just as cardiopulmonary resuscitation (CPR) training is preparation for an emergency situation that may occur only infrequently, brief training may be adequate for the relatively rare event of overt physical aggression and be of critical therapeutic benefit. An in-depth presentation of proper clinical techniques for humane, safe, and effective physical management of the aggressive client is beyond the scope of this article and is available elsewhere (Thackrey, 1987), a few comments are in order. Physical intervention principles are a conceptual subset of psychological intervention principles. Applied physical techniques are effective only insofar as they utilize psychological as well as mechanical/kinesiological principles. Aggressive behavior is a psychologically meaningful event for both the client and the clinician. Just as sound clinical judgment is required of the clinician in implementing the proper physical intervention, sound judgment is also required of the clinician in implementing the proper physical intervention. There is no single physical response for every possible situation. Instead, the clinician must apply principles to the situation at hand. Effective physical intervention is possible because the clinician is mentally prepared, anticipates the actions and reactions of the client, and optimizes mechanical/kinesiological factors (e.g., leverage, torque). Applied physical intervention techniques must facilitate therapeutic psychological intervention while protecting both clinician and client. They are treatment procedures, and must meet essential criteria. Primarily, they must be effective. Secondly, they must be safe for both the clinician and the client. Thirdly, they must be absolutely nonabusive, inflicting neither injury nor pain, and preserving the humanity and dignity of the client. Finally, they must require a minimum of clinician training for motor-skill acquisition and retention. Just as principles of psychological intervention are continuously evolving, so also are the principles and techniques of physical intervention technology. Innovations in physical techniques should be evaluated by the practitioner according to the four criteria presented above. Although some have expressed concern that the inclusion of physical management techniques in the context of training to prevent and manage client aggression might lead to overutilization of these methods, such a concern may be allayed by the substantial research evidence (Thackrey, 1987) demonstrating that appropriate training actually decreases the incidence of assaults and the utilization of restraint, seclusion, etc. High quality training that presents physical management methods within their proper clinical and legal context can serve as one means of helping to preserve the client's rights, consistent with the values traditionally associated with mental health services. Summary Both the client and the clinician have rights and responsibilities in the therapeutic setting. The client has the right to be free from harm and to be treated appropriately by the least restrictive methods. The clinician has the right to self-protection and to intervene in an emergency. Both the client and the clinician may be criminally liable for their actions. Judgment is central to the evaluation of the actions of both clients and clinicians. The clinician must know the general principles that relate to the legal aspects of professional mental health practice. Ultimately, however, the clinician's decisions about the client's treatment should be made on clinical grounds. Actions that make the most clinical sense will typically be best for both client and clinician. ************************************************************************************************ REFERENCESCaplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Chrzanowski, G. (1977). The occurrence of emergencies and crisis in psychoanalytic therapy. Contemporary Psychoanalysis, 13, 85-93. Erikson, E. (1959). Identity and the life cycle. Psychol Issues Monographs 1. Perry, S., Cooper, A. & Michels, R. (1987). The psychodynamic formulation: Its purpose, structure, and clinical application. American Journal of Psychiatry, 144, 543-550. Thackrey, M. (1987). Therapeutics for aggression: Psychological/physical crisis intervention. New York: Human Sciences Press. For further information on this topic, use the search engine at the following url to search for and purchase books. Begin by trying the following descriptors: crisis intervention, crisis and therapeutic intervention, crisis and physical intervention, defusing and crisis, crisis management, crisis and setting limits, crisis assessment, adaptation and crisis, etc. http://www.angelfire.com/biz/odochartaigh/searchbooks.html ************************************************************************************************ ************************************************************************************************ Contact your local Mental Health Center or check the yellow pages for counselors, psychologists, therapists, and other Mental health Professionals in your area for further information. ***************************************************************************************** George W. Doherty O'Dochartaigh Associates Box 786 Laramie, WY 82073-0786 MENTAL HEALTH MOMENT Online: http://www.angelfire.com/biz3/news