Crisis Assessment in Critical Incident Counselling

Over time, the distinction between the three terms, stress, traumatic stress, and crisis, have become blurred, thus numerous professionals started using these terms synonymously. Some authors specifically indicate that they deal with both stress and developmental crisis, but do not make distinctions between these terms/concepts.  Others define their work as dealing with crisis, but take cases from stress (Cornell & Sheras, 1998). Only a few authors have been consistent with the more traditional definition of stress and thus use the term crisis in terms of its proposed meaning of developmental crisis (France, 1990). In order to alleviate this confusion stress and crisis have been defined below.

Stress is the tension felt internally by an organism when an external threat (stressor) disrupts the normal course of life, requiring some action of coping in order to regain homeostasis. When an individual faces a threat, he/she must go through an appraisal process in which the realistic essence of the risk involved is evaluated and at the same time, the person evaluates possible ways of coping, inner resources, and potential help and support from trusted others.

Crisis refers to an acute disruption to psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairments. It incorporates the subjective reaction to the relevant stressful life events and the related experiences that compromise the individual’s stability and ability to cope (Lewis & Roberts, 2001).

Thus, a person is in a crisis state if they have experienced an event or situation whereby they have failed to cope with it due to not being able to lessen the impact of the event by using customary coping strategies and, as a result, enter into a state of disequilibrium (Dulmus & Hilarski, 2003). While the most overt causes of crisis are intensely stressful, traumatic or hazardous events, crisis events are not limited to this.

How the individual responds to a crisis event depends on the individual‘s perception of the event and their ability to cope with it (Roberts & Ottens, 2005). If the event is perceived to be the cause of considerable upset and disruption and their ability to resolve the disruption by previously used coping methods is perceived to be unlikely, then the person will most likely move in to a state of crisis (Roberts & Ottens, 2005). Thus crisis is an acute response to a critical incident or event whereby:

• Psychological homeostasis is disrupted
• Usual coping mechanisms have failed
• There is evidence of human distress/dysfunction

Among the vast array of possible stressor events or crises (e.g., migration, unemployment, illness, etc.), there are some that are more likely to lead to traumatic stress situations, such as rape, child abuse combat trauma, natural disasters, and terminal illness. This is because they constitute a threat to the individual’s existence rather than simply create a state of disequilibrium (Kardiner & Spiegel, 1947). Thus traumatic stress is when an event or crisis is perceived as life threatening and overwhelms normal coping skills (Behrman & Reid, 2002).

When a traumatic stress is not coped with successfully, the person is flooded with intense feelings of helplessness, rage, and resentment at the apparent or actual arbitrariness of the traumatic event. In some cases after the traumatic event, these feelings may periodically return for an extended period of time, sometimes for life, in the form of images, feelings, somatic sensations, and other reactions related to recollections of its impact and memories of the traumatic event. Following a traumatic experience, the body, mind, spirit and relationships with others can be wounded.

The predominant therapeutic models for treating trauma and survivors of major disaster have tended to be individually focused and pathology based, centred on identifying and reducing symptoms of post traumatic stress disorder (PTSD) (Walsh, 2007). Studies suggest that acute stress symptoms are very commonly experienced immediately after extreme trauma situations. However, most people are resilient in coping and adaptation and therefore do not suffer long term disturbance (Walsh, 2007).

When a catastrophe occurs it appears to evoke a deep humanitarian need to want to help. Historically this help has been dominated by providing basic physical care e.g. shelter and first aid. However, since the mid 1980s, there has been increased interest in early psychological interventions following exposure to traumatic events. In particular, there has been a huge increase in the use of ‘one off’ sessions of a procedure termed ’critical incident stress debriefing’ (Mitchell, 1983). Because crisis intervention strategies have become one of the most widely used time limited modalities of treatment they have also inevitably, come under rigorous scientific scrutiny for their effectiveness.

Traumatic events are a particular form of crisis that can cause psychological morbidity. This is not only due to large scale disasters but also a consequence of the more common day to day catastrophes such as road traffic accidents or assaults.

For example, Mayou, Bryant and Duthie (1993) reported that one year after a road traffic accident a quarter of those followed up had defined psychiatric disorders, with 11% showing evidence of post traumatic stress disorder (PTSD). The current best estimate of the prevalence of PTSD suggests it has a lifetime prevalence of 5% in males and 10% in females (Kessler, 1995).

Crisis Assessment

The primary role of the counsellor in conducting an assessment is to gather information that can help resolve the crisis. While crisis assessment is orientated to the individual, it always must include an assessment of the person’s immediate environment and interpersonal relationships (Roberts, 2002). Crisis assessment facilitates the treatment planning and decision making.

The ultimate goal of crisis assessment is to provide a systematic method of organising client information related to personal characteristics, parameters of the crisis episode and the intensity and duration of the crisis in order to utilise the data to develop effective treatment plans.

Not all traumatised individuals move into a crisis state therefore, it is important to assess and measure whether or not the person is in fact in a crisis state to insure that appropriate crisis interventions are implemented (Roberts, 2002, Lewis & Roberts, 2001).

Some of the common crisis assessment tools include the following:

• Crisis Triage Rating Scale (CTRS)
• Triage Assessment Form (TAF)
• The Suicide Assessment Checklist
• Scale for Suicide Ideation (SDI)

Triage Assessment: In the immediate aftermath of a traumatic event, the first type of assessment by a mental health practitioner should be a psychiatric triage. Triage has been defined as the medical “process of assigning patients to appropriate treatments depending on their medical conditions and availability of medical resources” (Roberts, 2002).

Psychiatric or psychological triage assessment refers to the immediate decision making process in which a mental health practitioner determines the lethality and referral needs of the client to one of the following alternatives:

• Emergency hospitalisation
• Outpatient treatment facility or private therapist
• Support group or social service
• No referral needed

A triage or screening tool can be useful in gathering and recording information about the initial contact between a person experiencing trauma or crisis and the mental health practitioner. Demographic details such as name, address, contact number, should also be collected. Other information that must be collected at this stage include perception of the magnitude of the traumatic event, coping methods and presenting problems, safety issues, social support networks, drug and alcohol use, pre-existing psychiatric conditions, suicide risk and homicide risk (Roberts, 2002).

Biopsychosocial and Cultural Assessments: These assessments are designed to measure such things as the client’s situation, stress levels, presenting problems and acute crisis episodes. These assessments include monitoring, and observing through a client log, semi structured interviews, individualised rating scales and goal attainment scales.

Specifically, it is important for the mental health practitioner to gather information of the following:

1. Current Health Status: (e.g. past health status or injuries, current medication use, health and lifestyle behaviours such as exercise.)
2. The Psychological status of the client including mental status and appearance
3. The sociocultural experiences and background of the client including ethnicity, language, social networks and relationships (e.g. family and friends).

The 10 basis elements of biopsychosocial assessment include but are not limited to the following:

1. Demographic data
2. Current and previous agency contacts
3. Medical, psychiatric and substance abuse history
4. Brief history of client and significant others
5. Summary of client’s current situation
6. Presenting request
7. Presenting problems as defined by the client and the counsellor
8. Contact agreed on by client and counsellor
9. Intervention plan
10. Intervention goals

References:

• Behrman, G. & Reid, W. J. (2002). Post trauma intervention: Basic tasks. Brief Treatment and Crisis Intervention, 2, 39-47.
• Dulmus, C.N. (2003). When stress constitutes trauma and trauma constitutes crisis. The stress–trauma-crisis continuum. Brief Treatment and Crisis Intervention, 3, 27-35.
• France, K., (1990). Crisis Intervention: A Handbook of Immediate Person-to- Person Help. (2nd Ed.). Springfield, Ill.: Charles Thomas Pub.
• Kessler, R., Somnnega, A., Bromet, E., & Nelson. C. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.
• Lewis, S. & Roberts, A.R. (2001).Crisis assessment tools: The good, the bad and the available. Brief Treatment and Crisis Intervention, 1, 17-28.
• Mayou, R., Bryant, B., & Duthie, R. (1993). Psychiatric consequences of road traffic accidents. BMJ, 307, 647–51.
• Mitchell, J.T., Everly, G.S. (1997). The scientific evidence for critical incident stress management. Journal of Emergency Medical Service, 22, 86–93.
• Roberts, A. R. (2002). Assessment, crisis intervention and trauma treatment: The integrative ACT intervention model. Brief Treatment and Crisis Intervention, 2, 1-21
• Roberts, A.R. & Ottens, A.J. (2005). The seven stage crisis intervention model: A road map to goal attainment, problem solving and crisis resolution. Brief Treatment and Crisis
• Intervention, 5, 329-339.
• Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience, Family Process, 46, 207-227.

Source: www.mentalhealthacademy.com.au