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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.

Crisis counseling: A blend of safety and compassion

By Bethany Bray July 27, 2021

When crisis strikes, clients need a counselor who can listen and share their heartbreak without inserting themselves into the situation, says Amanda DiLorenzo-Garcia, an American Counseling Association member and mobile response coordinator for the Alachua County Crisis Center in Gainesville, Florida. She describes crisis counseling as a short-term intervention to an acute situation with a singular purpose: ensuring that the client is safe and feels seen and heard.

Clients need someone who is “willing to be there, be present and be uncomfortable,” she explains. “We can’t help to fix the situation; all we can do is help the client to withstand it, to survive it — and often that’s heartbreaking. It challenges our humanity. … We have to stretch ourselves to be able to hold space for the immense emotions of despair, grief, hopelessness and helplessness, and that can be really uncomfortable to do.”

Part of life

Crisis counseling is a specialty within the counseling profession, but it’s also a skill that all counselors need to master because crises will pop up in everyday life for clients in all settings. 

Thelma Duffey and Shane Haberstroh, in the ACA-published book Introduction to Crisis and Trauma Counseling, explain that crisis “is often an immediate, unpredictable event that occurs in people’s lives — such as receiving a threatening medical diagnosis, experiencing a miscarriage or undergoing a divorce — that can overwhelm the ways that they naturally cope.” 

Crisis can also occur when multiple stressors are present simultaneously in a client’s life and a seemingly small incident, such as losing their keys and getting locked out of the house, pushes them to “the end of their rope” and sends them into a tailspin, says Ruth Ouzts Moore, an associate professor in the Counselor Education Department at the Chicago School of Professional Psychology.

Shock, denial and disbelief are often the first emotions that clients experience in crisis situations, along with hopelessness and helplessness, says DiLorenzo-Garcia, who co-presented on “Breaking Through Barriers to Provide Effective Crisis Support” at ACA’s Virtual Conference Experience this past spring with Jessica L. Tinstman Jones and Amber Haley. A vast range of physical, mental, emotional and behavioral symptoms can indicate that a client is in crisis, she notes. (See list below.) 

Moore defines crisis as the presence of a “risk of foreseeable harm” in a client’s life, either immediately or in the short term. The client may not automatically disclose this risk factor in counseling, however. Instead, their presenting concern can often be a “Band-Aid” or something more benign, she says, and it’s up to the counselor to “peel away the layers” to assess for risk. This can especially be the case with children, who may be referred to counseling for behavioral issues or because they’re falling behind at school. Sometimes, a crisis — such as abuse at home — may be the root cause of these struggles, notes Moore, an ACA member who specializes in working with children and adolescents who have experienced crisis and trauma.

Ali Martinez is a licensed marriage and family therapist and director of the Alachua County Crisis Center (where DiLorenzo-Garcia also works). In addition to mobile crisis response and in-person counseling services, the center operates a local 24/7 crisis hotline and responds to calls from their area of Florida to the National Suicide Prevention Lifeline. Most of the more than 45,000 calls the agency answers each year are from people who are feeling utterly alone as they face something that feels threatening to them, Martinez says. This includes losses that involve the death of a loved one as well as relational, financial and other losses.

“Most [callers] are not suicidal but are in some level of pain — experiencing something big that hasn’t been fully expressed, and they’re seeking space to do that,” Martinez explains. “They either are truly alone in what they are facing or feel alone in what they’re facing. They’re desperate for some sense of connection. They often know we can’t fix what’s happening — and that’s not usually what they’re seeking. …The struggle with crisis, what creates the danger and the true pain around a crisis, is the sense of how it disconnects us from people. The chaos, lack of control and strong emotions can make us feel alone. On the hotline, so often it’s trying to manage that chaos and find validation and connection — that what they’re feeling is a normal response to an abnormal situation. People often need someone outside their own world to let them know that what they’re feeling is OK and give them permission to express it.”

Crisis is self-defined

People can express their feeling of being in crisis very differently, but one common way that it manifests is tunnel vision, according to Martinez. In counseling, practitioners may hear a client who is experiencing a crisis speak with a narrowed scope or train of thought, returning to a singular experience or feeling over and over again.

Clients in crisis may feel like they’re drowning in emotions and that the issue that sent them into crisis is all-encompassing. Counselors may get the sense that their words are not getting through to the client because the client’s anger or despair is “filling the room,” Martinez says. Attending to the pain a client experiences during a crisis forces counselors to slow down their approach.

If counselors are “trying to get [the client] to look at the long term or take a bigger perspective and they can’t seem to do that and they keep coming back to that one painful thing, then we must change our approach and realize that this is the most important thing for them right now — and we have to listen for that,” Martinez says.

Above all, counselors must remember that “a crisis is defined by the person in it,” Martinez stresses. “For them, if it’s a crisis, it’s a crisis, and we have to honor that. Be aware that in that moment, we might have a much broader perspective on the possibilities [in the client’s life] and we might have good ideas about what could happen, but they may not be ready to hear it.” One of the most powerful things a counselor can say to a client in crisis is “tell me what this means to you,” she adds.

Martinez gives an example of a 12-year-old adolescent who is devastated after their first romantic relationship ends in heartbreak. As an adult, it would be easy for a counselor to tell the preteen client that this is the first of many heartbreaks life will bring. However, the client won’t be ready to focus on larger lessons about relationships and self until the counselor has helped them attend to their initial pain and despair over the breakup.

“For them, this is everything — feeling rejection and shame, sadness and despair. It doesn’t make it any less of a crisis experience for them,” Martinez says. “We [counselors] have to go in understanding it from their thinking.”

Josh Larson, a licensed professional counselor (LPC) in private practice in Denver, agrees that crisis must be self-defined by the client. He previously worked as a crisis clinician and operations and quality assurance specialist at Rocky Mountain Crisis Partners, a nonprofit organization that answers calls around the clock for several crisis hotlines, including the National Suicide Prevention Lifeline.

“We would always assure the caller that what they feel is a crisis, is a crisis. For one person, it could be that their cat got outside and they haven’t seen [the cat] for two hours and they’re feeling suicidal. For someone else, it’s something much bigger or more layered,” says Larson, an ACA member. “As a practitioner, even if what the client is telling us wouldn’t be a crisis for us, if they identify it as a crisis, then we need to treat it as such.”

Freedom to speak authentically

There is no shortage of crisis counseling models and assessment tools in the professional literature for practitioners to draw from in their work with clients. The counselors interviewed for this article did not recommend any one particular model or framework over another. They instead encouraged practitioners to research and select the counseling approach that works best for their style and client population.

No matter the model — or even if no model is used at all — a competent crisis counselor should shape a session into an arc that begins with rapport building and ends with connecting the person with resources. This last step ensures that the client has a safety plan (if needed) and is aware of options for follow-up care, such as local counseling services, walk-in crisis clinics and emergency hotline numbers. In the middle of this arc, at the core and heart of the therapeutic interaction, counselors create a nonjudgmental and empathetic space for the client to talk about their situation and share their burden.

The client does most of the talking in crisis counseling sessions, with the majority of the time spent simply “letting them tell their story,” DiLorenzo-Garcia explains.

Given that some clients may experience suicidal ideation during a crisis, an important part of this work is becoming well-versed in suicide assessment. DiLorenzo-Garcia and the other counselors interviewed for this article recommend that practitioners weave questions about a client’s safety, including those focused on suicide assessment benchmarks and protective factors, throughout the conversation.

In some situations, crisis counseling can offer clients the much-needed freedom to make strong statements without feeling judged or censored, Moore notes. This includes the freedom to talk about feelings such as anger or thoughts of harming oneself that can have shame or stigma attached to them.

This was the case for a 15-year-old client Moore once counseled who had turned to drinking, taking drugs and other risky behaviors to deal with turmoil at home, including feeling powerless when his father was abusive toward his mother. In session, the teen, referring back to an invective his father had directed at him, asserted, “I want to be an asshole.” Moore didn’t flinch at the client’s use of profanity. Instead, she responded, “You’re not an asshole.” When she repeated her statement, the teen began to cry, releasing emotions that had been pent-up. 

“He had a deep, deep level of anger, resentment and betrayal that we needed to talk through. He found freedom in being able to say those things in a safe environment,” Moore recalls. “It was freeing that he could speak so strongly and hear his counselor repeat it back.”

Many of the crisis calls DiLorenzo-Garcia’s team responds to are in the public schools. Sometimes they respond because a student has called the county hotline themselves, but most often it’s because a school staff member (a school counselor, principal, school resource officer or administrator) has called to request their help.

In such cases, DiLorenzo-Garcia often begins a one-on-one session with a student by explaining the context of why the school asked her to come and speak with them. She assures the student that they are not in trouble and that she’s there because people are concerned about them. For example, she may say, “This is what I’ve heard from your school counselor, but I’m curious what your perspective is. What’s going on for you?” 

“That’s the door opener. I reassure them, ‘I don’t want to make any assumptions about you. Your experience is your own, and I want to understand,’” says DiLorenzo-Garcia, a postdoctoral scholar at the University of Central Florida whose dissertation was on the loss and growth experience of mass shooting survivors and their families.

If the client’s experience includes thoughts of suicide, allowing them to talk through how they truly feel can help both the client and counselor realize how serious those thoughts are, DiLorenzo-Garcia adds. Sometimes a client has thoughts of suicide but doesn’t want to die, which can be accompanied by feelings of shame or isolation. If a client has a concrete plan to end their life, talking that through can help determine whether or how soon the client might act on that plan — and the necessity for follow-up care.

Assessing client needs

Larson notes that a majority of the callers during his time at Rocky Mountain Crisis Partners were not suicidal. However, some callers would say at the start of the call that they were not suicidal, but as the conversation went on and they began to unpack the depth of their emotions, it would become clear they were in fact experiencing suicidal ideation, he says.

This aspect of crisis counseling is why it’s imperative for counselors to be familiar with and proficient in suicide assessment. A counselor should be able to assess for preparatory behaviors, substance use problems, a client’s internal and external coping mechanisms, and other benchmarks to determine next steps, including safety planning or follow-up counseling, DiLorenzo-Garcia says.

Moore says it is important to be knowledgeable about assessing for not only suicidal ideation but also homicidal ideation when clients are in crisis. She acknowledges that asking questions about homicidal intent can be uncomfortable for practitioners. However, counselors must keep in mind that when in crisis, clients could have thoughts about harming others as well as themselves, she says.

“Be comfortable asking those difficult questions: ‘Are you having thoughts of killing yourself or harming anyone else?’ Don’t sugarcoat it,” says Moore, who presented the session “One Size Doesn’t Fit All: Creative Strategies for Counseling Diverse Families in Crisis” at ACA’s Virtual Conference Experience.

Larson points out that, along with active listening, validation of a client’s concerns and assurance of safety, de-escalation is a large part of crisis counseling. This can include mini versions of deep breathing and other grounding skills that clinicians might use in long-term counseling sessions with clients.

It can be helpful to match the person’s affect level, Larson says. For example, a counselor shouldn’t respond to a person who is hysterical with a flat, monotone voice. Instead, mirror them with a tone that is slightly calmer to gradually de-escalate the situation, he advises. Similarly, a crisis counselor shouldn’t respond to a client who is monotone or expressionless with a bright, bubbly demeanor. Instead, mirror their tone at a slightly more expressive level to gradually lift their affect, he says.

In crisis counseling, de-escalation and being presented with the opportunity to talk through what they are feeling will be enough for some clients, Larson continues. Others will be looking for help with problem-solving, such as conflict resolution or next steps to take after receiving a crushing health diagnosis. But Larson finds that clients in crisis are usually looking for one or the other, not both. Therefore, he advises counselors to be upfront and ask those in crisis, “What do you need? Do you want someone to listen or [someone to] help you problem-solve?” 

“If you offer solutions to someone who is not wanting them, it can escalate them further into crisis,” Larson adds. Instead, he may tell clients, “I’m listening, and I’m willing to offer solutions if that’s what you’re looking for.” 

In cases of suicidal ideation, DiLorenzo-Garcia finds it helpful to focus on the short term with clients. For example, she may say, “It’s a lot to ask you to live forever or live until next year, but right now, let’s talk about if you can live to tomorrow. What might that look like? Can you withstand the pain you’re going through just for tonight? What would it look like to survive and come back to school tomorrow?” 

The counselors interviewed for this article emphasize that it is critical to arrange for follow-up support after crisis sessions but say that involving law enforcement to conduct welfare checks on a person in crisis should be done only as a last resort.

Always follow up with a person who is in crisis, even if your session ends well and it sounds like things are going to work out,” DiLorenzo-Garcia stresses. Her agency contacts each client within three days after the initial crisis counseling session to make sure they are supported and doing well. In school settings, she also debriefs the adults involved in the student’s care (e.g., parents, school counselor) to ensure they are aware of the student’s needs and any next steps after a crisis counseling session.

Client safety

Meredith McNiel, an LPC who co-wrote the chapter “Crisis and Trauma Counseling With Couples and Families” in Introduction to Crisis and Trauma Counseling, notes that during crisis counseling, practitioners should focus on client safety through three lenses:

  • Feeling safe to express themselves fully in the crisis counseling session
  • Feeling safe at home and in the world outside of the counseling session
  • Feeling safe within their life, including protective factors and social connections

An important part of this focus, she says, is reminding clients (multiple times if needed) that the counseling session is a safe and confidential space to speak freely about what they are experiencing.

Clients may disclose dark and powerful thoughts, such as suicidal or homicidal ideation, during crisis counseling, and McNiel acknowledges that many counselors’ first instinct may be to refer these clients for more intensive care. However, practitioners need to push through this initial reaction to keep from breaking clients’ trust.

“If a counselor is worried or nervous or scared about handling a situation, the client will feel that,” McNiel says. “We need to be comfortable asking hard questions while keeping the client comfortable.” The counselor should allow the client to say what they need to in session and “hold that space” without trying to fix their situation, she stresses.

“In a suicide crisis session, many professionals might [automatically] think, ‘Where can we send you?’ and in my experience, that is an absolute last resort. If a client hears that they’re going to be hospitalized or referred out to someone they don’t know or trust, they can instantly lose trust with a counselor,” says McNiel, an ACA member with a private counseling practice in Austin, Texas. Instead, “allow the session to happen fully in the way the client needs to share or release and process, and go from there,” she advises. “I assure [the client] that if anything further needs to happen, we will decide that together. I will not take control of what’s going to happen. I remind them that they are in control of their circumstances.” (See more about the ethical guidelines regarding protecting clients from “serious and foreseeable harm” in Standard B.2.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Crisis counseling is “less clinical and more relational” than long-term counseling, explains McNiel, who was a crisis counselor at the University of Texas at San Antonio Academy for Crisis and Trauma Counseling during her LPC internship. Practitioners need to let clients share and talk through their experience “until it feels complete” — whatever that looks like for them. 

To ensure that a client’s safety and comfort are the primary focus in crisis counseling, practitioners must be so familiar with assessment tools that they don’t need to read the questions off a piece of paper or computer screen, says McNiel, whose doctoral research was on college counseling work with students who were suicidal. “[Instead of] saying, ‘Hold on, I’m going to grab this checklist and ask you some questions’ … ask questions in a relational way and fill out the assessment afterward rather than stopping the flow of a session,” she says. Counselors should be “getting answers [from the client] through conversation rather than interrogation.” 

For example, an assessment tool might prompt a counselor to ask the client, “Are you thinking about killing yourself?” Practitioners still need to ask direct questions about suicidal ideation, but couching those questions in a more conversational way aids in maintaining trust, McNiel notes. Alternatively, the counselor could say, “I can see and hear that you are really struggling with this situation. You’ve shared with me that you have thoughts about killing yourself, and that makes sense considering what you’ve been through. I’m wondering how close you are to doing that? How close are you to going home and following through [on those feelings]?” 

“The difference [in phrasing it this way] is the compassion in the language surrounding those really heavy questions,” she notes.

At the conclusion of a crisis session, counselors should talk through next steps with the client, including addressing what the client would do if things became worse and a crisis resurfaced after the session, McNiel says. If the individual is a long-term client, she advises scheduling their next session and letting them know how and when to reach the counselor during nonbusiness hours, as well as providing crisis hotline numbers.

Martinez agrees that in crisis counseling, practitioners should resist the urge to “fix” the situation the client is facing. In addition, counselors should avoid viewing it as a linear cause and effect. This includes thinking of suicidal ideation in binary terms of yes or no.

“We have to think of suicide in a much broader continuum, a range of pain and despair,” Martinez says. “[Society’s] fear and the stigma around suicidality makes us think about it as an on-or-off switch, but it’s more complicated than that.”

By definition, crisis is chaotic and messy, and the goal of a crisis counseling session is to de-escalate and share that burden, rather than organize or reorder it. Martinez illustrates this with a metaphor of a jumbled pile of sticks on the ground. A counselor’s instinct might be to gather the sticks and assemble a neat structure for the client, she says. Instead, crisis counseling involves allowing the client to pick up the sticks, one by one, and assemble them however they need to — even if it’s just into another pile on the ground that, to an outsider, looks equally as messy. “That’s much more powerful than us trying to figure out where the sticks belong,” Martinez says.

If a counselor approaches a crisis counseling session with the goal of tracking a client’s story in context, the counselor will miss the client’s full range of emotions — and the chance to connect and help the client bear that pain, Martinez says. “We can get caught up in [feeling that] ‘I need to make sense of the story.’ But that’s our need, our desire. The client may not need that or be ready for that. … When they talk and are listened to, they often begin to make sense of it themselves.”

Take Care of Yourself

The counselors interviewed for this article agree that it is imperative for practitioners who engage in crisis counseling to take steps to avoid burnout. In addition to regular self-care, this can include ongoing supervision or consultation with colleagues as well as other methods to combat feelings of isolation and empathy fatigue that can easily overwhelm practitioners whose clients share such heavy and troubling topics.

Moore suggests counselors take steps to maintain a balanced caseload and stay aware of how stress and burnout manifest for them personally. “Doing trauma and crisis work is heavy stuff. It can be super rewarding but super draining,” Moore says. “We carry [clients’] trauma with us, so it’s important to take care of ourselves. … Sadly, we need more and more counselors to do crisis work, and if you don’t take care of yourself, that’s one less counselor to help people who need it.”

It’s also important to remember that sharing the burden of crisis with clients is a gift, Larson says. A crisis counselor may be the only person the client feels they can talk to during their lowest moments. 

“It takes a lot of courage to pick up a phone and tell a stranger [a crisis counselor] that you want to die,” Larson says. “Always remember that it’s an honor and privilege to hear people’s hardest stuff — their deepest, darkest secrets.”

fran_kie/Shutterstock.com

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Contact the counselors interviewed in this article: 

 

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Crisis counseling via text message

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. Its team of volunteers across the U.S. has had nearly six million chat conversations since the nonprofit organization was established in 2013.

How can aspects of crisis counseling be translated for use via text? Counseling Today talked with Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line, to find out more about the nuances of crisis counseling via text message. Read more in an online exclusive article here.

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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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.

Crisis counseling via text

By Bethany Bray July 22, 2021

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. The organization has responded to nearly six million chat conversations since the nonprofit was established in 2013. Some people find the text line more accessible and comfortable than in-person talk therapy, notes Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line.

In crisis counseling, clients need a safe and empathic environment to disclose deeply troubling thoughts and emotions. But how can crisis responders create this same environment using text messages, which don’t allow the clinician and client to see or hear each other?

Reyes acknowledges that crisis counseling through text feels much different than in-person counseling and demands a different approach from the responder. Words sent via text must be chosen very carefully, with the intent of validating the texter’s experience and building rapport.

“During in-person [counseling] services, my face responds to someone’s sadness. In text messaging, my words have to be that mirror, have to communicate that empathy,” says Reyes, who does group and individual counseling at a private practice in Denton, Texas.

Reyes is among Crisis Text Line’s staff of licensed mental health practitioners who oversee the organization’s volunteer crisis counselors, who are located across the United States and come from a wide variety of backgrounds. These volunteers undergo more than 30 hours of training, a large portion of which is focused on ways to ensure safety and build rapport through text messaging, Reyes notes.

Responders are encouraged to frequently use “feeling words,” Reyes says, because they reflect the emotions a texter is describing and help them feel heard, understood and validated. “Perhaps a texter describes that they’re feeling frustrated,” she explains. “We would name that [in a text response]: ‘It feels like you seem frustrated because your mom didn’t respond in the way you hoped she would’ or ‘It sounds like you’re feeling stuck, and it’s normal to feel stuck when things aren’t going the way you hoped or planned.’” These types of statements not only validate what the texter is saying but also act as a gentle way to de-escalate the crisis, she points out.

Many of the aspects of Crisis Text Line’s response model mirror the work a crisis counselor would do in a traditional session with a client, either face-to-face or via telebehavioral health. Crisis Text Line responders begin by introducing themselves and sending the texter a confidentiality disclosure, Reyes says. They use a warm tone throughout the conversation and use open-ended questions to fully understand the texter’s situation and allow them to talk through the issue and emotions that prompted them to contact the organization.

The responders also assess for abuse, homicidal and suicidal ideation as well as self-harm or nonsuicidal self-injury. However, they don’t begin to weave risk assessment questions into the conversation until after report and trust is established. Letting the texter know that Crisis Text Line asks everyone these questions also keeps them from feeling singled out, Reyes adds.

“We acknowledge their braveness,” Reyes says, and continue to use warm tones and statements that communicate care and validation when determining risk. For example, a responder may text, “Thank you for telling me about the stress you’re facing. I just want to make sure you’re safe, and to make sure I’d like to ask, Do you have thoughts about ending your life?” If they answer in the affirmative, the responder would follow-up with more assessment questions, including whether the person has a plan, time frame or means to carry out their thoughts of suicide.

Crisis Text Line responders do not know the location, name or phone number of the person with whom they are texting, although some texters do choose to disclose their name, Reyes says. However, a supervisor does have access to a texter’s phone number and can arrange for external intervention if the texter is deemed a danger to themselves or others, she adds.

Supervisors monitor anywhere from three to 20 conversations happening live on their computer screen, and they can step in anytime a crisis responder needs additional support. They also triage the incoming texts to immediately assign those with the greatest need and queue other less urgent conversations to wait for the next available responder.

In addition to risk assessment and validation, Crisis Text Line responders help texters identify goals and next steps that could improve their situation in the short or long term, Reyes says. Responders then work collaboratively with the texter to explore the resources they have in their life, from self-care to community and social supports. If needed, they may also suggest resources to help texters with a limited or inadequate support system. They share links to national organizations that can direct them to support in their local area because they do not know where the texter is located, Reyes explains.

At the end of the conversation, the responder checks in with the texter one final time to assess how they’re feeling and validate the work they’ve done. They also summarize the next steps and resource options they discussed during the chat. Most importantly, the responder honors the courage it took for the texter to reach out and reminds them that the Crisis Text Line is available 24/7 if they need to chat again, Reyes says.

Many of the people who reach out to the organization in distress are younger, simply because younger generations are usually more comfortable with text messaging. Reyes, who recently completed a doctorate in the counseling program at the University of North Texas, notes that common presenting issues include anxiety, stress, depression, and feelings of isolation and uncertainty — many of which have been heightened during the COVID-19 pandemic — as well as bullying or academic or school-related pressures. There is also a subset of texters who struggle with sexual or gender identity issues, such as the decision to come out to family or friends, she says.

The organization hopes to reach more people with its upcoming launch of Spanish-language services, which Reyes is helping to plan.

Crisis Text Line isn’t meant to be a substitution for long-term counseling, Reyes notes, but it can be a big help to people in moments of despair. The organization does see an increase in text volume in the evening hours, which is often when people are experiencing acute moments of despair, she says. It can also be a first step toward connecting with a local counselor for long-term care.

“It’s beautiful to see how our volunteers learn and blossom through training and experience. This work is meaningful, and it is heavy, but there is also this deep knowledge that you’re helping someone who hasn’t otherwise received any support that day,” Reyes says. “The need at the center of that is decreasing the stigma of mental health services and increasing access to services regardless of financial need or language.”

Tero Vesalainen/Shutterstock.com

Crisis texting in 2020

In 2020, the Crisis Text Line engaged in 1.4 million conversations with 843,982 texters.

The organization began receiving a higher-than-usual volume of texts in March 2020, as the COVID-19 pandemic began to affect Americans’ daily life. Perhaps unsurprisingly, the most common struggles these texters identified were stress and anxiety. However, the Crisis Text Line reports that the volume of conversations in which texters disclosed feelings of depression or sadness dropped by 10% between 2019 and 2020.

Additionally, conversations in which texters expressed thoughts of suicide dropped by 20% from 2019. The Crisis Text Line supported 26,629 conversations in 2020 during which the texter was deemed to be “at imminent risk of suicide because they mentioned that they had thought about ending their lives, they had a plan, the means, and wanted to make an attempt within 48 hours.”

The Crisis Text Line has made this data publicly available in a report, “Everybody hurts 2020: What 48 million messages say about the state of mental health in America.” View the report, including data breakdowns by issue, demographics and state-by-state, at crisistextline.org/everybody-hurts.

 

 

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Related reading

Look for Counseling Today’s August cover story, “Crisis counseling: A blend of safety and compassion.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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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.

Lessons learned from a community crisis

By John Rogers and Cynthia Miller October 5, 2020

Counselors in the quiet university town of Charlottesville, Virginia, had noticed that some of their clients were anxious about their safety. As winter changed to spring in 2017, demonstrations and counterprotests at local Civil War monuments had become heated and confrontational. Now, in early summer, there was word on the street that a major pro-statue demonstration was being planned, potentially involving hundreds or even thousands of members of extremist White supremacist organizations. 

Counselors did their best to help clients cope with the worrisome news flow, but none of us could have anticipated the explosion of hatred, violence and loss that occurred on Aug. 12 of that year. On that day, Charlottesville experienced a violent episode of domestic terrorism that left three people dead, scores injured and an entire community shaken to its core.

This painful episode in our nation’s recent history is also the story of one counseling community’s challenge to organize, respond and incorporate lessons learned. We offer these experiences with a sense of humility and hope that others might consider incorporating some of the lessons we learned. Our own journey as a community of counselors might help others prepare for human crises that can tear at the social fabric of a city or town. Communities, like individuals, can experience a victim-survivor-thriver cycle, but that growth includes painful introspection.

As Charlottesville residents, we were both actively involved in the counseling community’s response to the Aug. 12 violence. At the time, John was a master’s degree student at James Madison University in clinical mental health counseling and a volunteer at Charlottesville’s main homeless shelter, while Cindy was (and is) a Charlottesville-based licensed professional counselor and counselor educator. We have seen and been personally involved in the personal and collective transition from victim to survivor, and then on to the resolve and determination to thrive as a community. In the course of developing this article, we met with local and regional counselors to present our initial thoughts and to gather feedback and suggestions. While our colleagues’ input was invaluable, this article and any errors or omissions within are the responsibility of the authors.

Setting and storm clouds

Nestled in the Blue Ridge Mountains in central Virginia’s Albemarle County, Charlottesville is a university town with deep roots in the South. As home to Thomas Jefferson and the University of Virginia (UVA), our town has a complex and at times contradictory history of slavery, visionary political and philosophical leadership, support for the Confederacy during the Civil War, and upheaval during the civil rights movement. Charlottesville itself has a population of roughly 50,000 residents, whereas the surrounding county has a population of 107,000. Students attending UVA add an additional 23,000 residents to the population each year. Charlottesville’s racial diversity is broadly similar to the country as a whole, with Whites constituting 70% of its population. It is a relatively highly educated community, with more than 50% of adult residents holding a bachelor’s degree or higher (compared with the national average of 35%). 

The demand for mental health services in Charlottesville far exceeds the availability of these services. Although Charlottesville has two hospitals, only one of them has psychiatric facilities. The local community services board offers a crisis stabilization unit, limited residential services and a range of outpatient services, but it is primarily devoted to serving those with severe mental illness. UVA’s two counseling centers typically operate at capacity and refer students into the community for long-term needs. Although there is a fairly large community of mental health professionals in private practice in the immediate area, most have waitlists. It is estimated that there is one mental health provider for every 116 residents in Charlottesville and one mental health provider for every 977 residents in Albemarle County.

As is the case in many Southern towns and cities, White civic leaders placed monuments to Confederate Civil War leaders in Charlottesville’s main squares during the peak years of the Jim Crow laws from the late 19th century to the early 20th century.  These statues became symbols of the increasingly racially charged rhetoric leading up to and in the aftermath of the 2016 U.S. presidential election. The volume of local discussions on race rose in Charlottesville with the national trend, resulting in heated city council meetings and activism on both sides of the symbolism of the statues in town.

In February 2017, the Charlottesville City Council approved a measure to remove the statue of Confederate Gen. Robert E. Lee from Lee Park, in the center of town. Lawsuits seeking to block this action followed, and in May 2017, a march by pro-statue supporters, including self-proclaimed “alt-right” and White supremacist groups, took place in the park housing the statue. This was met with counterdemonstrations and an editorial in The New York Times denouncing the racist protest. Afterward, the Ku Klux Klan filed for a permit to hold a demonstration in Lee Park in July, and a separate filing was made to permit a “Unite the Right” rally in Charlottesville on Aug. 12. The stage was set for the event that would put Charlottesville on the front pages of newspapers across the country.

As the weather warmed and gatherings increased, local counselors began to hear from clients who had attended anti-racist rallies or witnessed the frequent pro-statue demonstrations. Clients brought their fears, determination and other emotions to the counseling room as they processed the buildup in tensions in the community. Some counselors who were connected to anti-racist information sources volunteered to provide on-site services at a counterprotest held the night of the July 8 Ku Klux Klan rally. Their experiences providing crisis counseling services led them to reach out to the local counseling community through informal channels in an effort to prepare on a larger scale for the impending Aug. 12 rally.

This unofficial network of information, in part spurred by information from clients, leads us to our first takeaway in terms of preparing for and responding to community crises:

Lesson #1: Counselors are connected to critical information sources that are often unavailable to local officials. While client confidentiality must always be protected, a counseling community that is connected internally and to official channels can use this information to support advance planning and coordination efforts. 

Into the storm

As the Unite the Right rally approached, several groups — unfortunately, not connected to one another — considered how to respond. Law enforcement authorities prepared contingency plans, with questionable levels of coordination across jurisdictions. The clergy was an early and visible organizing force, coming together to offer worship services for hope and calm, places of refuge, and leadership in counterdemonstrations. Students at UVA quickly came together to respond to a racist protest, organized secretly by White supremacist groups, that occurred on the university’s grounds the evening of Aug. 11. 

Anti-racist organizers operated largely below the radar to assemble demonstrators and support services in anticipation of a major rally. A small number of counselors, in cooperation with the First United Methodist Church, established an on-site presence on the edge of Lee Park. They were joined by observers from the emergency services unit attached to Charlottesville’s community services board, a major mental health care provider. In coordination with street medics and clergy, the on-site counseling team helped more than 20 demonstrators who asked for help dealing with the chaotic scene unfolding around them. 

The demonstration quickly turned violent, with sustained clashes between Unite the Right demonstrators and counterprotesters, police and bystanders. The city center became a scene of destruction, fear and mayhem. The violence continued even after police ordered the downtown area cleared, culminating in the death of Heather Heyer and multiple others being injured when a Unite the Right demonstrator plowed his vehicle into a crowd of counterdemonstrators. (The driver was convicted of first-degree murder in 2019 and sentenced to life plus 419 years in prison.) During the hours of chaos, two Virginia State Police officers died when their helicopter, which was being used to coordinate law enforcement activities, crashed.

Struggling to organize

Even before the bottles, tear gas canisters and other debris could be cleaned from the streets, an online discussion group used sporadically by local counselors began to buzz with messages and questions about what had just happened and what to do next. The town convulsed with grief and anger, but there was no disaster recovery or crisis counseling plan in place. Despite informal outreach by a few counselors to authorities prior to the demonstration, there was no offer to coordinate resources. 

In this vacuum, counselors from the online discussion group, including Cindy, organized a venue to convene an initial meeting of those interested in responding to the crisis. In trying to cast a broad net to area counselors, we discovered that the Virginia Counselors Association (VCA), a branch of the American Counseling Association, could help with a critical link: a database of members in the area that VCA used to send out a blast email announcing the organizing meeting. This proved to be a critical resource in communication, but the fact is that we landed on it somewhat randomly. The uncertainty and lack of direction we experienced as we struggled to organize leads us to our second major lesson:

Lesson #2: Prior planning is essential. A community crisis overwhelms individual and group coping mechanisms, but a well-thought-out plan, combined with rehearsals, can provide essential structure, guidelines and stress testing. A crisis strains already full counseling workloads, and resources must be identified before they are needed to create capacity for crisis counseling. Crisis counseling often takes place outside of the conventional office environment.

The initial meeting of counselors took place three days after the violence ended. More than 60 counselors, students and others in the helping professions showed up, overwhelming our expectations. We were surprised by the numbers and by the fact that many of those attending had never met, despite being members of the local counseling community. Much of the initial meeting was taken up with introductions, processing the trauma, venting, and making space for tears and anger.

Although this made for an unusual meeting, it makes sense in hindsight. Most of the counselors present had little training in responding to mass trauma and were focused more on providing pro bono services in their private offices than on conducting primary prevention and outreach. What time remained was used for breakout groups to brainstorm on immediate needs and steps the counseling community could take to provide help. At the end of the meeting, a small subgroup agreed to stay behind to attempt to organize a set of initiatives to respond to the needs raised in the breakouts. 

By the time the main meeting broke up, it was late in the evening, and participants, already on edge and dealing with a cascade of calls from clients, were physically and emotionally exhausted. The small group that remained included leaders from the Green Cross Academy of Traumatology, an organization dedicated to training and deploying crisis counseling teams, as well as local counselors, agency leaders and a handful of students. This group took the summaries from the breakouts and prioritized several initiatives, including establishing a command center to coordinate the response, a crisis counseling center and a community communications strategy. 

‘Resilient Charlottesville’ comes to life

As the small group meeting began wrapping up, the difficult question of “Who coordinates this?” still needed to be answered. Fortunately, one of our local counseling agencies had a strong communications manager who raised her hand to help. John was on summer break from graduate school and could help organize and manage the logistical aspects of a crisis counseling center. Our community services board’s emergency services leadership offered to help coordinate with other agencies and government offices. A gift from the city arrived in the form of an offer of space in the downtown Charlottesville library, with ample room for a welcome desk, consultations and rest space for counselors. 

By noon the next day, we had a plan in place that we named “Resilient Charlottesville.” We began recruiting pro bono counselors from a list we had developed at the Wednesday meeting. We created a website and were communicating with counselors via the expanded group email list and with other community leaders. The Green Cross offered to deploy teams in the community for assertive outreach, and we gratefully accepted this support. We produced and distributed flyers to post in local businesses and on community buildings, and we opened the crisis counseling center that Friday at the library. This coming together of resources leads us to offer another observation:

Lesson #3: In a crisis, be flexible and open to offers of help from unexpected quarters. You will need a wide range of skills and experience. Take advantage of retirees, students and others who are willing to lend a hand. Community trauma affects counselors, and links to outside resources are essential when local capabilities are overwhelmed.

Our crisis counseling presence remained up and running for two weeks following the violent demonstrations. During that time, volunteer counselors conducted more than 70 pro bono sessions, and our outreach teams made hundreds of contacts on their “counseling by walking around” perambulations of the downtown area. Many of the people we met told us that the mere presence of a counselor (we wore orange vests with clear identification as counselors) provided a calming influence. So much trauma had occurred on the streets that many residents visited the scene of Heather Heyer’s murder to try to process what had taken place. Business owners welcomed the chance to talk with counselors about what they were dealing with. Our counseling presence served as a sign of resilience and hope.

Even as Resilient Charlottesville offered support through crisis counseling, other elements of our coming together as a community were sending down deeper roots. There was anger and sadness that more coordination had not taken place across the public and private sectors prior to the demonstrations. Some of our counselors and their sponsoring agencies committed to bridging these gaps. A communitywide “go-to” website and toll-free hotline, Here to Help, was developed as a clearinghouse for mental health needs. The Virginia Medical Reserve Corps extended its presence and recruited mental health professionals as standby volunteers for future crises. Plans for training and crisis preparation began to take shape.

From victim to survivor

As members of the counseling community came together in various settings to debrief on what we had learned, several themes emerged. One was that crisis counseling skills are a distinct form of intervention, and that without practicing them, these skills can become rusty.

Most counselors spend their days in a consulting room meeting on a predictable schedule with clients they have seen before. Crisis counseling involves outreach, walking the streets and meeting people, often in brief encounters that can help support survivors’ natural resiliency. In their book, Beyond Brief Counseling and Therapy, Jack Presbury, Lennis Echterling and J. Edson McKee remind us that brief and crisis counseling are, at heart, an attitude about change. The World Health Organization recommends psychological first aid training for mental health professionals who might be in a position to help people experiencing traumatic events. The Knowledge Center section of ACA’s website (counseling.org) offers an extensive set of links to resources, training and volunteer opportunities related to trauma and disaster mental health.

We should note that responding to a community crisis is not solely the purview of mental health professionals. We were dismayed to learn that some massage therapists were turned away from the initial organizing meeting after being told it wasn’t for them. A good response takes an “all hands on deck” approach, honoring the multiple ways in which people manage stress and welcoming the inclusion of allied professionals such as massage therapists, body workers, clergy and lay helpers. A comprehensive community response would train allied professionals and lay helpers in psychological first aid and provide multiple avenues for community members to relieve stress and receive support.

It also became obvious that while our marginalized communities were deeply affected by the presence of White supremacist demonstrators, our outreach efforts had not purposefully or effectively extended into these communities. We realize now that forming alliances with religious and community leaders in our Black and other marginalized communities is essential.

We were also chagrined to learn that our local first responders had preexisting arrangements with nonlocal providers of counseling services to support their staff members’ mental health needs. We agreed that our own “internal marketing” in the community needed to be reconsidered to raise the profile of local counselors with public agencies, including our first responders.

From surviving to thriving

The Charlottesville community experienced its own painful transition, from surviving the violence and trauma of Aug. 12, 2017, to establishing an attitude of resolve. As part of that community, the counseling profession had its own time of testing in the form of the one-year anniversary of the violence. Unlike the events of 2017, this anniversary could be anticipated. A lack of organization would be unacceptable. In retrospect, it offered us an (unwelcome) opportunity to test our determination and coordination.

The Federal Emergency Management Agency offers guidelines in what it calls the “whole community approach” to crisis planning. We took this attitude to heart. This time, there was extensive coordination between local, state and federal agencies, including the U.S. Medical Reserve Corps, the Virginia Volunteer Health System, the Virginia Department of Behavioral Health and Developmental Services, and assorted law enforcement agencies.

Our local mental health community was involved and engaged in coordinating meetings and gathering resources. We conducted training in psychological first aid and trauma-informed counseling. We also conducted community outreach to marginalized populations through the Boys & Girls Club and had school counselors briefed and standing by to offer their support and assistance. As the date approached, we deployed volunteer counselors, all trained in crisis intervention, in two locations — one in the center of downtown and another just at the edge of the downtown area. Both groups coordinated throughout the day with local officials to provide safe and secure sites for crisis counseling. The community had protocols in place to deal with large numbers of medical and mental health emergencies.

Lesson #4: Community engagement is a year-round form of preparation for crisis. The ACA Code of Ethics directs counselors to advocate, contribute pro bono resources, work effectively in interdisciplinary teams and build new skills. It turns out that these areas are also central to successful crisis planning and management as counselors.

In the end, the first anniversary of the Charlottesville violence was a relatively quiet day, with no injuries and a small number of demonstrators. Thankfully, our preparations were not put to the test. In many ways, this was an exercise in resilience and building pathways to thriving for our counseling community.

Today, we are closer together as a group of professionals than ever before. We recognize our vulnerabilities and are taking steps to prepare, practice and collaborate. We feel closer to our community, not just through one-to-one interaction with our clients, but in the sense of shared responsibility for our safety, shared participation in strengthening our city’s psychological fabric, and shared efforts to advocate for social progress. These are parts of being a counselor that perhaps we had taken for granted prior to the shattering of our illusions.

 

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Additional resources:

 

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John Rogers is a board-certified counselor and licensed resident in counseling in Virginia, where he also teaches in the graduate counseling program at Longwood University. He is a doctoral candidate in counseling and supervision at James Madison University. His practice and research interests center on homelessness and marginalization. Contact him at counseling@thehaven.org.

Cynthia Miller is a licensed professional counselor and counselor educator with a private practice in Charlottesville, Virginia. She has been a practicing counselor for almost 20 years, working with adults in university, community and correctional settings. Contact her at cynthiamillerlpc@gmail.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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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.

Doing the groundwork after a large-scale traumatic event

By Lindsey Phillips June 24, 2019

Finding and helping people suffering from survivor guilt, PTSD and complicated grief can be challenging after large-scale catastrophic events, which are becoming more common. According to Mother Jones, since 1982, there have been at least 110 public mass shootings across the United States.

John Super, one of the coordinators of the Orlando recovery effort after the 2016 Pulse nightclub shooting in Orlando, Florida, acknowledges the sad reality that it’s not if collective trauma happens but when it happens, so counselors need to be prepared and adequately trained for crisis response.

Super, coordinator of the Community Counseling and Research Center and a lecturer of counselor education at the University of Central Florida, points out that the underlying thoughts and feelings of survivor guilt are the same regardless of the type of loss. However, he adds, large-scale traumatic events carry their own additional stressors: the lack of privacy, communal trauma and the increased fear for one’s safety in public areas (such as being afraid to go to the grocery store).

Because people are in a state of pain, dysregulation, fear and distrust, they put up walls, notes Melissa Glaser, a licensed professional counselor (LPC) in private practice in Connecticut. Glaser, a consultant and public speaker on trauma and relevant clinical applications, served as director of the Newtown Recovery and Resiliency Team following the mass shooting at Sandy Hook Elementary School in 2012. “Lots of times people in helping professions, particularly clinicians, come into a situation like [a mass shooting] where there’s collective community trauma or even coming into situation where you’re working with individuals that are in the throes of their grief — complicated grief and trauma reaction — and you think that you’re going to be welcomed with open arms,” she says. “And often the opposite is true.”

Super was surprised that people weren’t showing up to the grief counseling centers after the Pulse shooting. Instead of getting angry, Super and his co-coordinators reconceptualized what their response would look like, and they literally started meeting the clients where they were. Counselors went to the blood donation lines and handed out water bottles. They attended the vigil and watched for people who were having severe emotional reactions.

The Pulse nightclub in Orlando, Florida, pictured after the shooting that killed 49 people and wounded 53 in June 2016.

They even went to local bars. A few days after the shooting, a local LGBTQ bar contacted Super asking for counselors to come to the bar because people were using alcohol to self-medicate. “Receiving that call was the lightbulb that went off,” he says. “What we found was some of our most productive counseling work happened in those environments.”

After the 2018 shooting at Marjory Stoneman Douglas High School, Luna Medina-Wolf, a licensed mental health counselor and the owner of Helping Moon Counseling in Florida, and the other therapists found themselves frustrated because they couldn’t access the survivors. The school system, with its background check and credentialing procedures, would not let them in. They decided to turn this frustration into action and figure out what they could do. Medina-Wolf, president of Professionals United 4 Parkland, reached out to Deb Del Vecchio-Scully, an LPC and trauma specialist who helped with response and recovery after Sandy Hook. Del Vecchio-Scully guided them through the process of organizing a recovery response and suggested they accumulate a list of mental health professionals who could help if the need arose.

Medina-Wolf reached out on social media to her connections and asked for trauma-trained therapists who could donate their time. Within three hours, she had 100 emails. To avoid being overwhelmed, she created a Google spreadsheet to track the names, specialties, credentials and phone numbers of the mental health professionals.

She discovered another therapist had started a similar list, so they combined their lists and eventually created the nonprofit Professionals United 4 Parkland. Through this collaboration, they have provided training sessions for therapists, parents, and educators and staff at Stoneman Douglas.

Medina-Wolf advises mental health professionals to come together, figure out existing gaps and ways that they can help, and reach out to community organizations to offer assistance. “This is a long-term healing process,” she says. “So, if [community organizations] won’t need you in the beginning, they will need you moving forward.”

That’s what is happening in Parkland now, she adds. After the initial shock, the community has had time to reflect on the long-term impact of this trauma, so they are reaching out to mental health professionals and figuring out a way to work together. For example, the first training they had for the teachers and staff at Stoneman Douglas was done independently from the school, but in January, the school reached out and requested that they host a training workshop as part of the school’s planning day. Medina-Wolf notes that they purposely called the workshop a retreat, not a training, to help reduce the stigma attached to mental health issues. The retreat included gifts, therapy dogs, breakout sessions on coping skills (such as meditation), and strategies on how to handle students and future drills.

Glaser, author of Healing a Community: Lessons for Recovery After a Large-Scale Trauma, also recommends collaborating with other professionals and organizations. “We have to get rid of the territorial aspect that the work can bring sometimes and bridge those gaps and be collaborative because one person or one organization can’t meet all the needs,” she says.

Glaser and her staff developed relationships with other professionals so they could appropriately direct those needing help. Providers would tell them when they had openings, the insurance they accepted and the therapeutic approaches they used, and new providers would provide a presentation on their services and even practice some of their techniques on Glaser and her team.

Glaser warns that clinicians can do more harm than good if they send clients to the wrong practitioner or if therapists promise things that they can’t deliver, which only undermines trust in all mental health professionals.

Glaser also stresses the importance of being hands-on and following up with clients. Because a traumatized brain can be extremely disorganized, counselors can’t simply give out phone numbers and a list of resources, she stresses. Sometimes, they have to make that call themselves and follow up with clients after they have had an appointment.

At the ACA 2019 Conference in New Orleans, Glaser spoke with school social workers from Parkland who were frustrated by their inability to help with the emotional aftermath after a lockdown drill because it wasn’t a priority to the administration. Glaser agrees that clinicians could do a better job with debriefings after a drill, and she also shared in their frustration with dealing with resistance from organizational leaders.

In fact, Glaser learned the importance of educating community leaders during her work with the Newtown community. She would invite the heads of organizations and school administration to participate when she brought in an expert or held a workshop on the importance of mental health efforts.

“We as clinicians now have the responsibility of educating from the top down,” Glaser says. “We can’t expect that the people that are following [safety] protocols and putting those measures together are necessarily well-versed in the clinical implications. So, part of our work now has to be to teach all of those involved.”

 

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Look for a companion piece to this article, “Relieving the heavy burden of survivor guilt” in the July issue of Counseling Today magazine.

Related reading, from the Counseling Today archives:

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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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.