Counseling Today, Online Exclusives

Behind the Book: Crisis Intervention Ethics Casebook

Compiled by Bethany Bray July 13, 2022

Crisis situations often require rapid decision-making from a counselor, and those decisions have ethical and legal implications, write Rick A. Myer, Julia L. Whisenhunt and Richard K. James, the co-authors of the Crisis Intervention Ethics Casebook.

Their book, published in late 2021 by the American Counseling Association, explores the nuances of ethics during in-the-moment crisis counseling, which often occurs outside the traditional office setting and involves numerous outside and uncontrollable factors, such as spectators.

“The nature of ethical dilemmas is that what is right and wrong depends, in large part, on the unique situation. … What you learned in your legal and ethical issues class may not cleanly or clearly apply in a crisis situation,” write Myer, Whisenhunt and James in the book’s preface. “In this casebook, we go far beyond the everyday grind of therapy and explore what happens when all hell breaks loose and even the most seasoned crisis workers can become frozen and transfixed with indecision.”

“At that point,” the authors continue, “chaos theory overrides every counseling theory and technique you thought you knew. You may resemble a deer frozen in the headlights, paralyzed with indecision regarding your therapeutic approach, the ethical problems that go with it, institutional policies that countermand it, and political realities that negate it.”

 

Q&A: Crisis Intervention Ethics Casebook

Responses are co-written by co-authors Myer, Whisenhunt and James. Myer is a licensed psychologist, full professor and chair of the Department of Educational Psychology and Special Services of the University of Texas at El Paso; Whisenhunt is a licensed professional counselor (LPC), associate professor and program director in the University of West Georgia’s Department of Counseling, Higher Education and Speech-Language Pathology; and James is an LPC who recently retired as a full professor after teaching for 40 years at the University of Memphis.

 

How a person deals with crisis is interconnected with their level of social support and cultural/demographic factors. What should counselors know about this?

There is limited discussion of multicultural counseling as it pertains to crisis intervention. For that reason, we apply the SAFETY (stability, affect, friction, environment, temperament and yearning; Kristi ) framework to our crisis intervention ethical decision-making protocol. We hope this will be a catalyst for considering the ways in which we can better serve clients who are in crisis from a multiculturally aware perspective.

An important line of inquiry surrounds the application of Judith Jordan’s relational-cultural therapy (RCT) to crisis intervention (outlined in her book Relational–Cultural Therapy). Thelma Duffey and Shane Haberstroh also emphasized this in their book Introduction to Crisis and Trauma Counseling in 2020.

RCT provides a way for the counselor to intervene in a humanistic manner that prioritizes the client’s inherent need for connection while recognizing the acute disconnections and accompanying “survival strategies of disconnection” that can happen when people experience trauma. As a person who operates from a humanistic framework, I (Whisenhunt) value the application of RCT to crisis intervention because RCT provides a lens through which to conceptualize the crisis experience, which then allows me to intervene with intentionality and thoughtfulness.

Both the SAFETY framework and RCT will likely play a more prominent role as the field of crisis intervention continues to mature.

However, crisis counselors may also consider nontraditional methods for helping individuals to feel connected during times of crisis. Technology may provide the means through which to connect through video to loved ones, find coping skills through smartphone applications, and locate community resources through web searches. Access to connection and resources are now in the palm of our hands, and there are ways to effectively use those resources to facilitate crisis intervention. Naturally, the converse may also be true, wherein the digital world can be part of the crisis stimulus. As such, crisis counselors are wise to talk with individuals about their effective use of digital connections.

 

What would you want counselors to know about the differences between crisis counseling, disaster response and trauma counseling?

Crisis counseling, disaster counseling and trauma counseling share a common theme of supporting people through what might be their most challenging life experience. Although disaster counseling and trauma counseling are distinct from crisis counseling in their primary focus, crisis tends to emerge in both disasters and trauma, which necessitates the use of crisis intervention strategies.

Although we will be providing explanations and examples using the singular individual (i.e., person), it is important to remember that systems, particularly families, can be in crisis as well. Accordingly, as we talk about crisis intervention, we encourage readers to consider both individuals and families experiencing crisis.

Crisis counseling is a time-limited intervention that is used when a person’s coping skills and problem-solving strategies either are not adequate or fail to resolve the specific situation causing the crisis. Situations causing the crisis are individualistic and are generally not predictable. Crisis counseling involves real-time, in-the-moment attempts to help the person reassert some control and attain stability. Crisis counseling involves the use of specific intervention strategies that are employed over the course of a few minutes to a few hours, with the short-term goal of helping individuals to attain stability or securing containment for individuals who are a danger to self and/or others.

Disaster counseling incorporates crisis intervention but on a much larger scale. Disasters are defined by the massive impact of the event. As such, disaster counseling may involve planning to help individuals obtain housing, clothing and medical care, for instance. Disaster counseling may also involve psychoeducation and helping individuals and families understand how to navigate the disaster recovery process. However, crisis counseling may also be used in disaster counseling, as individuals experience destabilization and significant loss.

Trauma counseling may also initially incorporate crisis counseling strategies but involves a more long-term sustained intervention process. The sustained intervention is needed because trauma generally is considered to result in neuropsychological changes, altered worldview and interpersonal difficulties (the latter is particularly true for those experiencing personal transgressions and/or human-made trauma). During trauma counseling, individuals tend to experience moments of transcrisis, to which counselors may respond using crisis counseling techniques that help the person to reestablish control/equilibrium.

 

What should counselors know about the nuances of crisis and how clients’ needs might be different from these other scenarios?

Destabilization is the cornerstone of crisis. Individuals experience crisis because their coping strategies and problem-solving skills are not sufficiently able to address the crisis-causing stimulus/event. As such, the focus should be on helping the person to reestablish control or helping to promote safety for those who are a danger to themselves and/or others.

Generally, effective crisis counseling can help people achieve sufficient stabilization to leave on their own recognizance, or perhaps with loved ones who will provide adequate support. However, when crisis counselors’ best efforts to de-escalate have failed, we need to take directive action and obtain help to control out-of-control behavior. Safety (for the person in crisis, the crisis counselor, bystanders, first responders and others) is always the priority in crisis intervention. Although, despite our training, counselors may experience the temptation to “fix” things for individuals who are in crisis, the best crisis counseling may not lead to stabilization. We cannot undo the situation that led to the crisis, but we can help individuals to feel some sense of safety and support on what may be the worst day of their lives.

We do this through communicating in a manner that demonstrates sincere caring and through the use of crisis intervention strategies. But we do not attempt to process past transgressions when doing crisis intervention — the focus is on the present situation. That does not mean we invalidate the past; rather, our attention remains focused on the present moment and how we can assist the person in finding stability in the here and now. As such, the counselor’s use of traditional counseling strategies that promote reflection, insight and connection to emotion are not typically suitable in crisis intervention.

In crisis situations, emotions are raw, and the person’s affective, behavioral and/or cognitive functioning are altered. The crisis counselor’s job is to promote stabilization across these three domains, which we call the ABCs: affective, behavioral and cognitive. When counselors utilize too many reflections of feeling, reflections of meaning and other insight-provoking counseling skills, they may further destabilize the person who is in crisis.

However, by using the nine crisis intervention strategies identified by Richard James and Burl Gilliland in their book Crisis Intervention Strategies, crisis counselors can help individuals to reattain stability across the ABCs. These nine crisis intervention strategies include creating awareness, allowing catharsis, providing support, promoting expansion, emphasizing focus, providing guidance, promoting mobilization, implementing order and providing protection and are based on the triage assessment the crisis worker makes upon initial contact.

 

What types of crisis response tools do counselors need to learn and keep handy? What aren’t they learning in graduate school that they might need to fill in on their own?

The Council for Accreditation of Counseling and Related Educational Programs (CACREP) requires training in crisis intervention. However, [counselor education] programs may choose to offer a stand-alone course in crisis intervention or integrate the content into other courses. Both approaches can be effective if the training includes real-time assessment methods, strategies and [an] understanding that crisis counseling is unique from traditional counseling.

We fundamentally believe that assessment is key to the crisis intervention process and should guide our work. If we monitor the client’s ABCs — we use the Triage Assessment Form: Crisis Intervention (Revised), or TAF: CIR (Rick Myer and Richard James, 2009) — we can get a pretty good idea of how effective our intervention efforts have been. And, if the client’s ABCs do not begin to diminish, we know it is time to try a different tactic and use other crisis interventions.

This process of adapting in the moment is a critical skill for crisis counselors. James and Gilliland outline the nine crisis intervention strategies in their book Crisis Intervention Strategies (creating awareness, allowing catharsis, providing support, promoting expansion, emphasizing focus, providing guidance, promoting mobilization, implementing order and providing protection), which are essential skills for crisis counselors.

Further, we recognize that crisis counseling tends to require a higher level of guidance or directiveness than is seen in traditional counseling. This is because individuals in crisis, whose ABCs are diminished, may not be able to make life-promoting decisions for themselves. Until individuals are able to attain stability across their ABCs, crisis counselors should provide more guidance/directiveness that helps the client to maintain safety and achieve equilibrium. This is in opposition to the training most counselors receive early in the program. A nondirective, person-centered approach certainly has its utility in traditional counseling, but not always in crisis intervention.

However, clients in crisis respond to the counselor’s disposition. So, it is critical that crisis counselors remain calm and provide some reassurance that they are able to help. Likewise, if the crisis counselor is panicked, their decision-making is certainly less than optimal. As such, crisis counselors can employ internal coping skills that clients cannot see, such as mindful breathing, counting or visualization to calm themselves. Although using these skills may distract the crisis counselor for a few seconds, grounding oneself can help us to more effectively navigate the crisis situation.

 

You mention that crisis situations often involve “politics,” which counselors have to learn to navigate. Can you elaborate on what you mean by politics? Why do politics and crisis seem to go hand in hand?

Politics refers to the setting in which crisis counseling occurs. However, politics is only one of the three “Ps” that influence the crisis counseling process in an organization. The other two are “policies” and “procedures.” All organizations have politics, policies and procedures. It is important for counselors to be aware of these and work within the three Ps, assuming doing so would not violate ethical or legal responsibilities. Politics can play an important role, wherein crisis counselors may be implicitly or explicitly pressured to make decisions that safeguard the organization to the clients’ detriment.

For this reason, use of a formalized assessment procedure, such as the TAF: CIR, is warranted and substantiates the crisis counselor’s interventions. Although the organization may, at times, oppose the crisis counselor’s interventions, those interventions and actions are grounded in assessment; the TAF: CIR guides both the intervention and decision-making processes. When clients experience higher TAF: CIR scores that cannot be diminished through use of the nine crisis intervention strategies, a response is needed to promote safety for the client and/or others.

When decision-making is guided by reliable and valid assessment, there is less room for scapegoating by unhappy administrators.

 

What prompted you to collaborate and write this book? Why do you feel it’s needed now?

A quick search through various data banks shows that very little has been written about crisis intervention and ethical dilemmas. In addition, searching through professional codes of ethics yielded only a few mentions of crisis intervention. Expanding the search to include “disaster” had similar results. Ethical codes address issues of abuse, suicide, and homicide or threat of harm, but crises involve many more issues.

Given the lack of attention in codes of ethics to the reality of providing crisis intervention, we believe that counselors need to learn ways to make ethically based decisions in crisis intervention. The rapid-paced nature of crisis intervention does not typically afford counselors the opportunity to utilize a traditional ethical decision-making model or engage in supervision or consultation. Naturally, when counselors have the opportunity to do those things, we highly recommend them. But crisis intervention is often so rapid and the stakes are so high that counselors must make decisions quickly.

For that reason, in this book, we introduce the Legal Issues, Assessment, Setting, Ethical Principles and Resolution (LASER) protocol to aid in the ethical decision-making process while prioritizing safety for the client, counselor and bystanders. We believe the gap in the literature surrounding ethical decision-making in crisis intervention presents an important opportunity for the development of evidence-based procedures, and this book is our first attempt to develop those procedures.

 

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Crisis Intervention Ethics Casebook was published by the American Counseling Association in 2021. It is available both in print and as an e-book at counseling.org/store or by calling 800-298-2276.

 

Related reading: See Counseling Today’s recent cover story, “Crisis counseling: A blend of safety and compassion.”

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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