Roberts’s Seven-Stage Model for Crisis Intervention

This goes out to all my CISes (those are crisis intervention specialists, if you didn't know).  Most folks think of Roberts as THE crisis guy, and his seven stage model is included in pretty much every crisis intervention manual ever.

• Assess safety & lethality – Begin with a fast yet thorough biopsychosocial assessment.  You want to find out what the supports & stressors are, any medical issues, medications, any current substance use, and coping strategies & resources.  If there is concern about suicidality, you want to find out what the thoughts are, if there is intent & the strength of the intent, whether there is a plan & if the plan is potentially lethal, any history of past attempts, and other specific risk factors (substance abuse, social isolation, losses such as divorce or employment).
• Rapport building – In a crisis, you must do this quickly & it will ideally happen as part of your assessment.  Here, we harken to Rogers’s warmth, genuineness and empathy.  These three skills will go a long way in developing rapport with your client in crisis.
• Problem identification – Find out from the client why things have come to a head.  There is usually a so-called last straw, but you also want to find out what other problems the client is concerned about.  It can also be useful to prioritize the problems in terms of which problems the client wants to work on first.
• Address feelings – Validate, validate, validate!  You want to let the client vent about his or her feelings about the crisis.  This is achieved using active listening skills, like paraphrasing, reflective listening and probing questions.  With caution, you can also challenge maladaptive beliefs.
• Generating alternatives – This is where you come up with a plan.  The clinician and the client (ideally) begin to come up with options that will help improve the current situation.  You can brainstorm about possibilities or ask about what has been helpful in the past as ways to get the client’s input.
• Develop action plan – This is where you shift from a crisis to a resolution.  The client & worker will begin to take the steps negotiated in the previous stage.  This is also where the client will begin to make meaning of the crisis event.
• Follow up – The follow up can take on many forms.  A postcrisis evaluation may look at the client’s current functioning and assess the client’s progress and satisfaction with treatment.  It can also involve phone or in person visits at specific intervals.

Bandura & Social Learning Theory

Bandura’s social learning theory is sometimes seen as a bridge between cognitive and behavioral theories because he believed that people learn by observing others, which involves cognition (memory, attitude, beliefs) and behavior (actions taken, rewards).  He posited that children learn by observing the actions of others, such as parents, siblings & other peers.  This observation leads to the acquisition of new skills & information.  Intrinsic reinforcements such as a sense of pride, accomplishment & satisfaction also lead to learning.

Bandura developed this theory in part by conducting what was called the Bobo doll experiment.  Here, a video is work a thousand words: http://video.google.com/videoplay?docid=-4586465813762682933.  Basically, Bandura found that kids who watched a video of an adult aggressing upon an inflatable doll would in turn aggress upon a similar doll.  Bandura’s research primarily concentrated on the impact of TV violence on children’s behaviors.

Bandura thought that four processes were necessary for the child or other observer to learn a behavior via social modeling.

• Attention: Obviously you have to be paying attention to what the other people are doing to learn anything from it.  If I’m ignoring the people on the dance floor, I’m not going to learn to dance just by standing close by.
• Retention: You have to remember the stimuli to imitate later.
• Reproduction: This is when you reproduce the image of what you observed.  You have to have the physical capability to do so.
• Motivation: There has to be some reason that you want to recreate what you observed.  Some reasons might be positive reinforcement (a reward, a promise of a reward) or a negative reinforcement (punishment of some kind).

The main critique of Bandura’s theory is that it does not reliably predict behavior.  In his experiments, the relationship between observing & recreating violence was strong.  In later longitudinal studies, the relationship was much weaker.

Crisis Intervention

Just to keep things interesting, I'm going to start mixing in some posts based on a study guide I created for my clinical practice course final exam.  See, kiddies, it pays to hang on to old study materials!  Today, we'll start with some overview information on crisis intervention.

• What is a crisis?
• Event is perceived as a threat, danger or loss
• Coping strategies are overwhelmed and insufficient
• Person is in a state of disequilibrium
• There is a window of opportunity to intervene
• Opportunity for growth
• What are the types of crises?
• Situational – specific incidents (dumped by boyfriend, fail a test, busted for possession)
• Developmental – developmental tasks produce a crisis. If prior developmental tasks have not been completed successfully, future tasks can produce crises
• Environmental – different from situational crises because they affect groups of people (human disasters, political disasters, economic, natural disasters)
• Existential – escalating inner conflicts related to issues of purpose in life, responsibility, independence, freedom and commitment (teen angst, midlife crisis, spiritual crisis)
• Compound or Transcrisis – crisis reaction due to multiple partially unresolved prior crises
• Dilation-Constriction Continuum Model
• The dilation-constriction continuum assesses a person's affect, behavior & cognitions related to the crisis.
• It can be used to assess where the person is on the continuum of dilation & constriction & try to bring the person back to center if they’re at extremes

	Dilation	Constriction
Affect	Overemotional Worker response: focus on specific feelings, work w/ cognitive material	Holding in feelings Worker response: facilitate emotional expression
Behavior	Excessive behavior, acting out Worker response: reality oriented & problem solving	Paralyzed, immobile, withdrawn Worker response: stimulate movement, help ct do for themselves
Cognition	Disorganized, chaotic, confused Worker response: clarification, specifics, problem identification	Preoccupied w/ solutions, ruminative, obsessive Worker response: id alternatives & workable solutions

Edited to add:  Upon listening to the social work podcast on crisis intervention, I realized that this post is essentially a summary of that podcast.  You can listen to that podcast here: http://socialworkpodcast.blogspot.com/2007/01/crisis-intervention-and-suicide.html Since Jonathan, the host of the social work podcast, is so kind as to include on his blog a properly formatted APA reference, here that is as well. Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 1 - history and assessment [Episode 3]. Social Work Podcast. Podcast retrieved October 1, 2011, from http://socialworkpodcast.com/2007/01/crisis-intervention-and-suicide.html

Major Depressive Disorder (MDD)

MDD is characterized by one or more major depressive episodes & no history of manic, hypomanic or mixed episodes.  MDD can begin at any age but most often onsets in the mid-20s.  The course can be quite variable.  Some people may have isolated episodes of depression with remissions of many years; others may have clusters of episodes with brief remissions.  You can use specifiers to indicate the course of the disorder, such as the specifier “With Full Interepisode Recovery” or “Without Full Interepisode Recovery.”

The criteria:

• Presence of a single major depressive episode (see previous post)
• Episode is not better accounted for by schizoaffective disorder & is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
• There has never been a manic, mixed or hypomanic episode unless that episode is substance or treatment induced or due to a general medical condition.

• If the full criteria are met at the current time for a major depressive episode, specify its current clinical status and/or features:
• Mild (with 5 – 6 symptoms of a major depressive episode), moderate (between mild & severe), severe with psychotic features (with most symptoms of a depressive episode and psychosis) or severe without psychotic features (with most of the symptoms & no psychosis)
• Chronic – full criteria have been met for a major depressive episode for at least the previous 2 years
• With catatonic features – with 2 of the following
• Motor immobility as evidenced by muscular rigidity or stupor
• Excessive motor activity that serves no evident purpose & is not influenced by external stimuli
• Extreme negativism (resistance to instructions with no evident motive or maintenance of a rigid posture against attempts to be moved) or mutism
• Peculiarities of voluntary movement such as posturing (assuming bizarre or inappropriate postures), stereotyped movements, prominent mannerisms or prominent grimacing
• Echolalia (repeating what you say) or echopraxia (imitating your physical movements)
• With melancholic features – defined by
• Either loss of pleasure in nearly all activities or lack of reactivity to usually pleasurable stimuli at the most severe point of the episode.
• Three or more of the following symptoms:
• Distinct quality of depressed mood
• Depression regularly worse in the morning
• Early morning awakening (at least 2 hours before usual time of awakening)
• Marked psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt
• With atypical features
• Mood reactivity – mood improves in response to positive events
• Two or more of the following:
• Significant weight gain/increased appetite
• Hypersomnia
• Leaden paralysis – a heavy, leaden feeling in extremities
• Long standing pattern of sensitivity to interpersonal rejection that results in significant social/occupational impairment
• Criteria are not met for melancholic or catatonic features during the same episode
• With postpartum onset – episode onsets within 4 weeks postpartum

Mood Disorders & Mood Episodes

Mood disorders are characterized by having mood episodes.  I will here define the types of mood episodes: major depressive episode, manic episode, mixed episode and hypomanic episode.  The presence of these mood episodes will define mood disorders, which will be covered in subsequent posts.

Major Depressive Episode

• 5 or more of the following symptoms during the same 2 week period; must have either depressed mood or loss of interest/pleasure.
• Depressed mood for most of the day, nearly every day, as indicated by either self report or observation made by others. (In children/adolescents, mood by be irritable, rather than classically depressed.)
• Diminished pleasure in all or nearly all activities for most of the day nearly every day.  Again, this may be indicated by self report or observation made by others.
• Weight loss or gain (more than 5% in a month), or increase or decrease in appetite nearly every day.  (In children/adolescents, look for the child not to gain weight as expected.
• Insomnia/hypersomnia nearly every day.
• Psychomotor agitation/retardation nearly every day (must be observable by others; not just feelings of restlessness or being slowed down).
• Fatigue/loss of energy nearly every day.
• Feelings of worthlessness/excessive or inappropriate guilt nearly every day.  Guilt may be delusional & must be more than just self-reproach about being sick.
• Diminished ability to think, concentrate or make decisions nearly every day, indicated by either self report or observations of others.
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or suicide plan.
• Symptoms do not meet the criteria for a mixed episode.
• Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.
• Symptoms are not due to the direct physiological effects of a substance or a general medical condition.
• Symptoms are not better accounted for by bereavement.  Diagnosis may be made if the symptoms persist for longer than two months, or are characterized by marked functional impairment.

Manic Episode

• Period of abnormally & persistently elevated, expansive or irritable mood, lasting at least one week (or less if hospitalization is required).
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feeling rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees, gambling, risky investments).
• The symptoms do not meet the criteria for a mixed episode.
• The mood disturbance causes marked impairment in social or occupational functioning.  If there is psychosis, this criterion is considered to have been met.
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Mixed Episode

Mixed episodes may evolve out of a manic or major depressive episode, or can arise on their own.  A mixed episode can turn into a major depressive episode, or may remit to an asymptomatic period.  It is unusual for a mixed episode to turn into a manic episode.  Mixed episodes, by definition, must last longer than one week.

• The criteria are met both for a manic & a major depressive episode (except for duration) for at least one week.
• The symptoms must cause impairment in social or occupational functioning, require hospitalization, or have psychotic features.
• The symptoms are not caused by the direct physiological effects of a substance or a general medical condition.

Hypomanic Episode

Hypomanic episodes are essentially manic episodes that do not cause impairment in functioning.  The criteria are below, and you will find that the criteria are identical to the criteria for a manic episode except for the difference noted above & shorter duration.

• Period of persistently elevated, expansive or irritable mood, lasting at least 4 days & is clearly different from the normal nondepressed mood.
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feels rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees).
• The episode is associated with an unequivocal change in functioning that is not typical of the person when they are not having symptoms.
• The disturbance is observable by others.
• The mood disturbance does not cause marked impairment in social or occupational functioning. 
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Schizoaffective Disorder (295.70)

Schizoaffective disorder is characterized by mood disturbance along with psychosis.  The criteria are:

• An uninterrupted period of illness during which there is either a major depressive, manic or mixed episode and symptoms that meet the characteristic symptoms of schizophrenia. 
• Two or more of the following characteristic symptoms, present for a significant portion of the time over a one-month period
• Delusions
• Hallucinations
• Disorganized speech (such as frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (flatness of affect, avolition)
• Symptoms of the mood episode are present for a substantial portion of the total duration of the illness.
• This disturbance is not caused by the effects of a substance or a medical condition.

Schizophreniform Disorder (295.40)

Schizophreniform disorder is essentially the same as schizophrenia except that the total duration of the illness is at least one month, but less than 6 months and social/occupational impairment is not required (although it is not exclusionary).  Some people who are initially diagnosed with schizophreniform disorder will go on to later be diagnosed with schizophrenia or schizoaffective disorder (about two-thirds).

Schizophrenia

Schizophrenia is characterized by positive & negative symptoms.  Positive symptoms are the presence of something that should not be there (such as psychosis) and negative symptoms are the absence of something that should be there (such as flatness of affect, avolition).  I could talk for a long time about various types of delusions & hallucinations and other symptoms of thought disorder; however, for simplicity sake, I will cover the basic criteria of schizophrenia.

·        Two or more of the following characteristic symptoms, present for a significant portion of the time over a one-month period

·        Delusions

·        Hallucinations

·        Disorganized speech (such as frequent derailment or incoherence)

·        Grossly disorganized or catatonic behavior

·        Negative symptoms (flatness of affect, avolition)

·        Social or occupational dysfunction – achievement in work or social life that is below the level of functioning previously experienced

·        Duration – symptoms must be present for a minimum of 6 months, with at least one month of characteristic symptoms.

·        Can't also have Schizoaffective or mood disorder; rule this out by ensuring no major depressive, manic or mixed episodes that have occurred concurrently with active-phase symptoms.

·        Disturbance cannot be caused by a medical condition or be the effects of a substance.

·        If there is autism or other PDD, the diagnosis of schizophrenia can only be made if prominent delusions or hallucinations are present for at least a month.

Specifiers for subtype are paranoid type (295.30), characterized by prominent delusions and hallucinations; disorganized type (295.10), characterized by disorganized speech or behavior & flat or inappropriate affect; catatonic type (295.20), characterized by marked immobility, excessive motor activity, mutism, echolalia (repeating what you say), echopraxia (imitating your physical movements), or peculiar voluntary movements; undifferentiated type (295.60), characterized by not meeting the criteria for another subtype; and lastly, residual type (295.60), characterized by having one schizophrenic episode, but the current clinical picture lacks prominent positive symptoms, but there are ongoing negative symptoms & the presence of milder forms of psychosis (odd behavior, strange beliefs, or mildly disorganized behavior).  Other specifiers describe the course and current symptomology, and you can refer to the DSM to learn more about those specifiers.

Substance Use Disorders

Substance use disorders differ from substance-induced disorders.  I find the names self-explanatory – substance use disorders are related to disordered use of substances and substance-induced disorders are disorders brought on by use of substances.  Rather than covering each individual substance related disorder, I am simply going to review the difference between abuse & dependence & you can apply these general criteria to most substances.

Criteria for Substance Dependence

Substance dependence is a maladaptive pattern of substance use that leads to either impairment or distress.  Person must have 3 or more of the following symptoms within 12 months. 

• Tolerance – either needing to use more & more to get the same effect or less of an effect using the same amount
• Withdrawal – either the person experiences withdrawal symptoms when they stop use or substitute a similar substance to avoid withdrawal
• Use of more or over a longer time period than intended (I go out for one drink & stay out all night; I'm only going to do two lines… ten lines later.)
• The person often wants to cut down or control use or makes unsuccessful attempts at the same.
• Much time is spent in obtaining, using & recovering from use of the substance.
• Other activities are reduced or given up because of use.
• Use is continued despite being aware that the use is exacerbating physical or psychological problems (like smoking cigs despite having cancer)

Criteria for Substance Abuse

Substance abuse is also a maladaptive pattern of use of a substance that causes impairment or distress.  The person must not have ever met the criteria for substance dependence for the class of substance in question.  The person must have one or more of the following symptoms within a 12-month period.

•  Recurrent use that results in the person being unable to fulfill role obligations (missing work, neglecting children).
• Recurrent use in hazardous situations (driving while intoxicated, etc.)
• Recurrent substance-related legal problems.
• Continued use despite social/interpersonal problems that are either caused by or exacerbated by the substance use (arguing with significant others about use, fighting due to intoxication).

Attention-Deficit/Hyperactivity Disorder (ADHD) (314.xx)

ADHD is characterized by a pattern of inattentive and/or hyperactive behavior that is more severe than what would normally be observed in a person of a similar developmental level.  Some of the symptoms have to be present before the age of 7.  Look for people who aren’t able to pay close attention to details; work may look messy and disorganized.  The person may jump from task to task without actually completing any.  They may seem like they are not paying attention in conversation & look like they aren’t listening.  You want to be certain, however, that the person is unable to complete tasks due to having difficulties with attention & not due to being oppositional.  Symptoms are more often observed in group settings than in individual settings, so even if a person doesn’t display any symptoms in your office, if you suspect ADHD, it may be worthwhile to observe in other settings. 

It is difficult to diagnose in children younger than age 4 – 5 & it would be exceedingly rare to be able to diagnose in a 2 or 3 year old, as it is normal for 2 – 3 year olds to flit from one thing to the next.  Generally, the symptoms become less noticeable as the person ages; adolescents might just look a little fidgety, or may just feel restless but be able to sit still.  Adults may look pretty normal, but may avoid desk jobs, or activities that require a lot of sitting still.  ADHD is more common in males than females.  Use caution in making an ADHD diagnosis, as it is easy to mistake the symptoms of something else for ADHD.  Some common misdiagnoses include mistaking a smart child who is bored in an under stimulating environment for being inattentive.  Oppositional behavior may look like ADHD at times.  Sometimes mood or anxiety disorders can cause children to have difficulty focusing or completing tasks.

On to the criteria!

• Symptoms have to occur for more than six months, have to cause impairment & have to be inconsistent with what is considered normal for the stage of development.
• Symptoms have to be present before the age of 7.
• Impairment has to be observed in multiple settings (such as at home as well as at school).

Six or more of the following symptoms of inattention AND/OR

Six or more of the following symptoms of hyperactivity-impulsivity

-fails to give close attention or makes careless mistakes in work -often has difficulty sustaining attention on play, work, or other activities -seems not to listen, even when spoken to directly -doesn’t follow through on instructions & doesn’t finish work (and is not due to being oppositional) -has difficulty organizing tasks -avoids/dislikes tasks that require sustained mental effort (like schoolwork or homework) -loses things that are necessary to complete tasks or activities -is easily distracted by extraneous stimuli (Hey, look, a chicken!) -is forgetful

-often fidgets or squirms in seat -leaves seat during class or elsewhere where remaining seated is expected -runs around or climbs at inappropriate times (adolescents & adults may feel restless, and are less likely to be observed climbing on their desks during math class) -has difficulty playing quietly -is usually “on the go” or described as like the infamous Energizer bunny (Okay, so the DSM doesn’t use copyrighted terminology, but that’s what they mean.) -talks too much -blurts out answers before the question is finished being asked -has difficulty waiting for his/her turn -interrupts/intrudes on others, like interrupting conversations or games

• ADHD combined type has 6 from both columns above
• ADHD predominantly inattentive type has 6 from the 1^st column & less than 6 from the 2^nd
• ADHD predominantly hyperactive-impulsive type has 6 from the 2^nd column & less than 6 from the 1^st
• You can specify “In Partial Remission” for people, particularly adults & older adolescents, who no longer meet the full criteria.