“Decisions come in existential crises only.”
• Karl Jaspers Philosophy Vol. 3:100
As a staff member at the Neuropsychiatric Unit of Long Beach Memorial Medical Center, I had the opportunity to implement the theories and techniques discussed in the previous chapters. While organizing and conducting a series of workshops for other Psychiatric Unit and Emergency Room staff, I was able to explore and observe the effectiveness of small Group techniques, particularly role-playing and modified Psychodrama. These approaches were presented with a Group process and personal development orientation to teach perspectives and skills that are basic ingredients to effective Crisis Intervention.
I will describe some fundamental reorganization and extension of methods and theories previously discussed along with description of basic format and goals for these workshops. I begin with the theme of the workshops and the approach using role-playing, then a description of the workshops themselves, and, finally, discussion of the Group process that takes place during the workshops.
When patients are seen during a psychological crisis, they are involved in an event that may be compared to the First Round of Psychodrama. (Possibly an apt description of a Psychodrama is the attempt to precipitate or re-enact a crisis and carry it to its healthy resolution.) In our view of crisis we fundamentally disagree with psychologies that see adjustment as an ideal. Crisis is a goal, a necessary part of personal change, if it is resolved correctly. Carkhuff and Berenson write:
only real psychotherapy takes place at the crisis point,
most often with the focus initially on external crises for the client, but
eventually crises involving both client and therapist,
in and out of therapy. At the crisis point both client and therapist
are stripped of all façade, which is indicated
by what they do or do not do. This communication is the most intimate
person-to-person communication that there can be.
There are no rules for responding, no techniques, no rituals.
The therapist simply has to “be”
to experience the moment and stand the tests. The effective therapist
responds most honestly from the deepest wells within him.
His response reflects his recognition of the life or death
urgency of the situation. He responds the way he
lives his life and he chooses life in response. In
his “being” and acting he
discloses the meaning and efficacy of his approach to life.
Beyond Counseling and Therapy (30:147)
Patients seen in the Emergency Room in emotional or psychiatric crisis are at the point of change. They have, or their life situation has, effectively, brought to a head the same experiences that are developed to climax in the First Round of Psychodrama.
Psychodrama offers further insight into the crisis situation. If we turn the process of Psychodrama in on itself, we are given a solution: Round 2 is the effective intervention for the First Round. This is the basic premise and approach on which the Crisis Intervention Workshop is developed.
EVOLUTION OF THE CRISIS INTERVENTION WORKSHOP
The inspiration for the Crisis Intervention Workshop comes from two sources beyond my membership experience in the McAfees’ Group and my clinical supervision with Wallace McAfee. I established a Crisis Intervention Service as a liaison from the Neuropsychiatric Unit to the Emergency Room at Long Beach Memorial Medical Center. At this time, this was a newly developing mental health treatment specialty. I had seen a number of patients in this capacity, and from my previous experience in Psychodrama, I found that following a Round 2 method of responding was very effective for establishing communication with extremely emotionally upset or confused people.
When patients arrive at the Emergency Room and are in a high level of emotional turmoil, their main issues are often communicational, interpersonal, or related psychiatric problems. They are referred to Crisis Intervention after medical clearance. When confronted with the complexity of the hospital environment and red tape, they may be in a very difficult situation. Overwhelmed and frightened, it is not unusual for them to become defensive and angry.
After introducing myself and calmly explaining some basic procedural issues I listen and respond back, communicating my understanding of the facts and particularly the feelings that the patient seems to be experiencing in words and behavior. While establishing this communication, I attempt to maintain a non-alarmed tone of conversation, conveying an assumption: “We can work these issues out.” Often, repeatedly recognizing the confusion and/or upset that patients experience, verbalizing this understanding (empathizing), (“This is confusing and scary.” I take a dramatically deep breath then exhale slowly; nod my head and shrug my shoulders slightly; possibly hold their hand.), creating a calm accepting climate, they become more comfortable and organize their thoughts. A cathartic effect is achieved in this conversation, and patients begin to evaluate their situation and options with more clarity. Sometimes this catharsis comes with a temporary increase in agitation and a period of ‘draining off’ of this emotional energy. Radical therapists describe this procedure as “talking a person down”. Ruitenbeek [Going Crazy: the Radical Therapy of R. D. Laing and Others (197)] presents a number of clinical approaches to establishing therapeutic alliances with people in extremely disorganized, highly stressful mental states. At this time we also have an opportunity to evaluate how emotionally labile the crisis patient may be.
While this description is of an individual patient in crisis, it should be recognized that clients often present as couples or whole families. Often one person is identified as the presenting patient, but all parties: friends, family, and other referring persons, may be agitated and confused. For the sake of clarity and workshop practice, a single person will initially be presented as an example. In later sessions the complexities of family crises, as well as issues that sometimes develop with other interested parties, often persons who accompany or accommodate the patient’s arrival at the E. R. Jay Haley Problem Solving Therapy develops an initial treatment approach for families (90:Chapter One), an excellent introduction to a slightly different Crisis Intervention. These accompanying parties may include social support or legal services (police, sheriff deputies, rangers, EMTs, social service and case workers—even taxi cab drivers). Often discussion and problem solving will facilitate a return to the patient’s normal living situation with referral and possibly new level of support.
As the patient calms and begins problem solving procedures, I become a ‘resource person’—pointing out the different routes that can be taken, often reflecting the patient’s own ideas toward ‘next steps’. I supply additional information, as much as seems needed or is available.
The second source of inspiration leading to the development of the workshop is my day-to-day experience working on the staff of a milieu oriented psychiatric hospital unit. This is a very intense work environment in which staff members are involved at close interpersonal level with the patients. This psychiatric unit could be described as crisis oriented. The average stay for patients is two weeks and the goal for all but a few long-term patients is resolution and return to home and the community.
Often blocks in communication develop between patients and staff. When staff members or patients experience and communicate a perception of a deteriorating sense of interpersonal interaction, staff experiments with organizing a role-play or Psychodrama. These role-plays are often in staff Groups, with no patients present, but they also can be developed directly with patients in the daily Patients’ Group sessions. When a patient complains or in some way reacts to a communication problem, one approach by which we explore these issues in Group, is to develop and practice a clearer interaction by enacting a role-play. Disorganization of behavior or decompensation of thought processes is often an indication of unaddressed issues. Sometimes these issues are with staff or doctors, sometimes with other patients or family members. In a Group in which the focus is on improved relationships, other patients are also sources of help. Often fellow patients become aware of problems before the staff from their day-to-day interactions on the psychiatric unit. They are very perceptive during discussions formulating solutions. Role playing and Group communication can encourage this problem solving process.
When a staff member expresses a sense of bewilderment about approaches to what seems to be confused behavior, or when we staff feel that we are unable to interact therapeutically, we discuss and reproduce the issues in our conference sessions—playing the parts of patients and staff intervenor—following a format described in the previous chapter of Catharsis and Resolution. By role-playing these interactions and practicing new communications approaches, more congruent interactions are developed. (Sometimes the disorganization is ours.) With a clearer view, less encumbered with anger or frustration, and newly practiced interpersonal approaches, staff members are able to communicate with greater effectiveness and creativity.
With the realization that any staff member can be called on at any time to intervene in a crisis, I set about developing the workshop that I describe below. I have conducted the workshop about a dozen times (at the time of the initial writing of this study), usually six, two hour sessions in each series. During each of these rounds of workshops, I have tried different variations and approaches, with the result that, in my experience and opinion, as well as feedback that I have received from participants, the most effective format is presented below. I have also used similar themes teaching Master of Business or Public Administration students, combining social and political justice issues to the basic Crisis Intervention theme.
DESCRIPTION OF THE CRISIS INTERVENTION WORKSHOP
The workshop takes place on a weekly basis for six weeks. Many of the participants already know each other quite well, being work partners. Usually the workshop draws from two or more hospital departments such as Psychiatry and Emergency Room, so members of each department have worked with one another while they meet people from other departments anew. This allows cross-fertilization of ideas and approaches. Factors such as Group Cohesiveness are already developed. These workshops can also be the basis of institutional communications development. When participants do not know each other, I instruct them to introduce themselves to one another, sharing information about professional experience and orientation. If the number in the Group is fairly manageable, less than 10-12, a size to form a Group, I take time for members to introduce themselves, possibly having them form pairs, introduce each other, then have each of the pairs introduce the other member of the pair to the whole Group.
The first meeting is mostly didactic, with discussion about theories of Crisis Intervention. Before I present these, a description of the basic orientation of the theories is necessary.
Standard medical-psychiatric approaches to crisis have been largely of an objective nature. The patient and the crisis are viewed at a distance by the intervenor. An evaluation is made and certain ‘interventions’ are attempted after which results are evaluated. On the other hand theories and techniques of counseling and psychotherapy have developed toward an interpersonal approach. Sullivan (216, 217), Truax and Carkhuff (222), Carkhuff and Berenson (30), Erikson (60, 61, 62), and Rogers (190-195) are clinicians who exemplify this interpersonal outlook; interaction between the person in crisis and the counselor is the center. The quote by Carkhuff and Berenson, above, is an illustration of one particular approach to this orientation. Two poles, objective and interpersonal, represent a dilemma existing in the field of psychiatry today. In developing Group process the movement from the former objective approaches to the interpersonal is beneficial. This may later be followed by a return to the objective. This balance in perspective helps give the crisis counselor understanding and a ‘handle’ on the crisis situation. Even as the intervenor empathizes with the patient’s directionlessness and confusion, while establishing communication, he or she retains a sense of grounding in the Crisis Intervention process developed and presented in this workshop.
The first theories that I will present are classic crisis intervention theories. The greatest amount of work done in the field centers around them. Gerald Caplan, who could be considered a patriarch 1 of crisis intervention has given a definition of ‘crisis’ that is quoted many places in the literature:
A crisis is provoked when a person faces an obstacle to important life goals that is, for the time being, insurmountable through the utilization of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many abortive attempts at solution are made. Eventually some type of adaptation is achieved which may or may not be in the best interest of that person or his fellows.
Principles of Preventive Psychiatry (27:40)
Aguilera and Messick summarize this definition in their classic text:
A person in crisis is at a turning point. He faces a problem that he cannot readily solve by using coping mechanisms that have worked for him before. As a result, his tension and anxiety increases, and he is less able to find a solution. A person in this situation feels helpless—he is caught in a state of great emotional upset and feels unable to take action on his own to solve the problem.
Crisis Intervention: Theory and Methodology (3:1)
It can be seen that there is a spiraling effect in a crisis that I summarize with the following diagram:
A problem exists. Solutions are attempted. These fail resulting in a sense of confusion and anxiety. As these distressing emotions increase, often a person’s self-esteem is eroded adding to an already insurmountable problem. Commonly, manifest behavior associated with this spiral is agitation, a spiral upward and outward, or depression, a spiral downward and inward. Caplan, as well as Aguilera and Messick, emphasize that a crisis is not, in and of itself, undesirable. It rather reflects a change in a person’s life that may have beneficial aspects if handled correctly. The beneficial effects are what Crisis Intervention is meant to enhance.
The place or the role of the interventionist is to strike into or intervene in the spiral. A commonly used objective approach by medical doctors is the administration of a drug. A doctor may inject the patient with a minor tranquilizer such as Valium, blocking the experience of anxiety and allowing the patient to view the initial problem with a more detached perspective. This is an effective, relatively rapid way of calming a patient overwhelmed with emotion. In most crisis situations, however, and even after calming with a medical intervention, it is vitally important to identify the source and dynamics of a patient’s reaction and also help them calm themselves. Interaction between therapist and patient, even during emotional upheaval, is important. This is an evaluative, diagnostic issue, measuring the intensity of the crisis. These issues are topics to be discussed in the latter sessions of the workshop. We have gotten a bit ahead of ourselves as sometimes happens in a crisis.
In extreme cases, when the state of crisis has existed for years, the spiral may have become such an integral part of a person’s life and usual behavior that the crisis becomes a chronic condition and is generally diagnosed as a type of such severe mental disorder that more complex treatments may be indicated. This may temporarily be treated by hospitalization and procedures such as shattering the ingrained circular thinking with a more extreme method such as major tranquilizers or even electroshock treatment which is still used for a few people who suffer from depression untreatable by other methods. For the crisis at its inception this would be like cracking a walnut with a thermonuclear device.
As one of the main goals of the Workshop, we want to develop ourselves as intervention. We want to enter into the crisis and use our own personalities, experience, and training, in interactions with the patient, to participate with and lead out of this spiral.
One technique that includes both physiological treatment and interpersonal orientation is physical movement. Walking a person in crisis has been used for untold ages to decrease anxiety. Just as the increase in metabolic rate may be used to sober up an intoxicated person, it may also be effective at decreasing agitation or animating a depressed person. While walking, the intervenor is also establishing contact with the patient at a time when verbalization may not be possible. Gardener 2 describes how he was able to dissolve an anxiety block for a thirteen-year-old boy that had interfered with his ability to read. Instead of having him sit at a constricting school desk, Dr. Gardener had the boy walk as he read. Initially the therapist put his arm around the boy’s shoulder in a supportive manner while walking. At times I have paced patients up and down the hospital halls for as long as an hour before they have been able to speak. Walking also may be a method of draining off agitation, hyperactivity, or, on the other hand, as described above, encouraging organization and talking. Counting out steps, one-by-one, sometimes in a deep, quiet but authoritative voice, can focus a patient’s attention on thought process and physical experience, both of which may initially be fairly chaotic or, in depression, hazy and vague—weighty.
In the next stage of the Workshop, I review several concepts and communicational processes developed by Harry Stack Sullivan. Sullivan’s Interpersonal Psychiatry does not speak directly to Crisis Intervention but offers a view that encompasses three areas of understanding that are important for our Crisis Interventionist perspective. He describes a developmental view of communication. He provides an understanding of anxiety states. Finally, his perspective is interpersonal. Through Sullivan we come to understand how the patient in crisis is interacting with us, as well as what a crisis is in light of that interaction. 3 Sullivan places the genesis of anxiety states in the interaction between the infant and the protective person:
Thus anxiety is called out by emotional disturbances of certain types in the significant person—that is, the person with whom the infant is doing something. A classical instance is disturbance of feeding; but all the performances of the infant are equally vulnerable to being arrested or impeded, in direct chronological and otherwise specific relationship to the emotional disturbance of the significant other person. I cannot tell you what anxiety feels like to the infant, but I can make an inference which I believe has a very high probability of accuracy—that there is no difference between anxiety and fear so far as the vague mental state of the infant is concerned.
I have reason to suppose, then, that a fear-like state can be induced in an infant under two circumstances: one is by the rather violent disturbance of his zones of contact with circumambient reality; the other by certain types of emotional disturbance in the mothering one. From the latter grows the whole exceedingly important structure of anxiety, and performance that can be understood only by reference to the concept of anxiety.
The Interpersonal Theory of Psychiatry (217:9)
Here we see that anxiety, which in later life fuels the crises of the people we meet in the emergency room or on the psychiatric floor, is an experience we have all had to deal with to some degree, at some time in our lives, although probably in not so overwhelming an amount. In its extreme form Sullivan describes this feeling as the uncanny. The uncanny is best likened to a feeling of being overwhelmed, victimized by tremendous malevolence. The “Self-System” of a person is undermined by the uncanny, a sense of of identity as Not-Me, to be discussed below, is this experience.
The uncanny may also appear in traces, e. g. as we walk on a dark, deserted street at night and feel a presence following us, but turn to find no one there. In crisis the feeling may be continually of such dread possibly magnified.
A mirror experience imbued with a positive emotional valance is that of awe. We may feel this in an enormous architectural structure such as a cathedral or listening to a symphony or highly amplified concert; possibly we experience awe in nature as on the edge of the sea or the Grand Canyon. The overwhelming sense of awe, if felt to be benevolent, may be the basis of mystical or religious experience. (217:10) 4
As the infant matures, this anxiety is woven into his or her personality and relationships with others, even while the very sense of others and perception of oneself, as an individual, develops. Sullivan describes three developmental complexities of experience relating to the infant’s symbolization of self and communication with the outside world, particularly other people: the prototaxic mode of experience, the parataxic mode of experience, and the syntaxic mode of experience. The infant grows through these three process levels towards adulthood. Sullivan calls the earliest level the prototaxic mode of experience:
The prototaxic mode, which seems to be the rough basis of memory, is the crudest—shall I say—the simplest, the earliest, and possibly the most abundant mode of experience. Sentience, in the experimental sense, presumably related to much of what I mean by the prototaxic mode. The prototaxic, at least in the very early months of life, may be regarded as the discrete series of momentary states of the sensitive organism, with special reference to the zones of interaction with the environment. By the term sensitive, I attempt to bring into your conception all those channels for being aware of significant events—from the tactile organs in, say, my buttocks, which are apprising me that this is a chair and I have sat on it about long enough, to all sorts of internunciatory sensitivities which have been developed in meeting my needs in the process of living. It is as if everything that is sensitive and centrally represented were an indefinite, but very greatly abundant, luminous switchboard; and the pattern of light which would show on the switchboard in any discrete experience of the basic prototaxic experience itself, if you follow me. The hint may suggest to you that I presume from the beginning until the end of life we undergo a succession of discrete patterns of the momentary state of the organism, which implies not that other organisms are impinging on it, but certainly that the events of other organisms are moving toward or actually effecting a change in this momentary state.
The Interpersonal Theory of Psychiatry (217:29) 5
Mullahy, a student and commentator of Sullivan summarizes:
According to Sullivan’s hypothesis all that an infant “knows” are momentary states, the distinction of before and after being a later acquirement. The infant vaguely “prehends” earlier and later states without realizing any serial connection between them. He has no ego in any distinctive sense because the self has not yet developed. For such reasons, he has no awareness of himself as an entity seperate from the rest of the world. In other words, his felt experience is all of a piece, undifferentiated, without definite limits. It is as if experience is “cosmic.” This mode of experience is often marked in certain schizophrenic states.
Oedipus, Myth and Complex (160:86-87)
Mullahy describes Sullivan’s concepts of the other two modes of experience. In addition to the prototaxic mode there follows the parataxic mode and the syntaxic mode. The parataxic mode includes the first rough efforts to understand the relationship of self to others leading to ego development. The parataxic is followed by the syntaxic mode which relates to language acquisition. Mullahy describes the parataxic mode:
Gradually the infant learns to make discrimination between himself and the rest of the world. As Sullivan puts it, he no longer reaches out to touch the moon. In other words he gradually learns to make elementary differentiations in his experience.
The parataxic mode of organizing experience occurs mainly through visual and auditory channels. Dreams are often examples of this mode of experiencing. But it occurs a good deal of the time in waking life. In other words we do not—and cannot—always organize our experience into a logically connected, related totality, in which the various elements are compared, contrasted, and ordered in a precise fashion. Ordinarily we do not indulge in careful ratiocination as we dress in the morning, proceed to work, and so on. It is not necessary and in any case there is not enough time...
...the child gradually learns the “consensually validated” meaning of language—in the widest sense of language. The meanings have been acquired from group activities, interpersonal activities, social experience. Consensually validated symbol activity involves an appeal to principles which are accepted as true by the hearer. And when this happens, the youngster has acquired or learned the syntaxic mode of experience.
Oedipus, Myth and Complex (160:286-291)
As the young child develops in the parataxic mode of experience, he or she begins to incorporate information received from others with his or her personal experience of feeling with what becomes known as identity. A reflective view is constructed called by Sullivan “The Self-System.” The Self-System functions, in part, to promote the type of relations with others that increases states of euphoria and decreases anxiety (217:164-168). Robert Jay Lifton writes: “In Sullivan’s case, with a concept of a ‘self-system,’ which, whatever early conflict it may contain, enables the organism to move in a ‘basic direction (that) is forward.’” [The Protean Self (138:26)].
The Self-System is composed of three parts: The Good-Me; the Bad-Me; and the Not-Me. The Good-Me is the term describing the sense of ourselves that we feel during interactions with others that bring comfort. The Bad-Me, conversely, is associated with the experience of discomfort. The Not-Me is a nebulous part of ourselves that we do not recognize to be ourselves. The Not-Me may include a sense of disorientation, dissociation, or vertigo—very uncomfortable—a state-of-consciousness to avoid! The Not-Me—or the world and ourselves from the perspective of Not-Me—may be entered in dreams, trance, what Sullivan describes as “brown-studies”, or in unusual instances such as crises. 6 As the name implies, we do not recognize this state of mind to be us. A person experiencing themselves as Not-Me may actually be more unsettled and more uncomfortable than when identifying with the Bad-Me. A sense of the uncanny, discussed above, may be a great part of this experience (217:161-164). [There is even evidence that The Bad-Me may be a preference to the The Not-Me, sometimes suppressed by substituting delinquent, criminal, and pathologically compulsive behavior (80, 92), which of course, includes alcohol and substance abuse]. An extreme, almost panic feeling, a variation of this type of discomforting primal emotion portrayed so intensely by many existentialist writers including Kierkegaard, Dostoevsky, Kafka, Sartre, Camus, and Colin Wison’s subjects of his Outsider series is often described as Dread, . Both William James and his father, Henry James, Sr., chronicle the sudden onset of a deep sense of despair and meaninglessness that is characteristic of this dread or uncanny [The Writings of William James (105)]. William also discusses an approach that he developed helping himself overcome this experience, presenting a multitude of extreme altered states of consciousness of many varied people. He details these in The Varieties of Religious Experience his Gifford Lectures (106), comparing what he considers “healthy minded” religious mental states with the “sick soul”. Possibly his entire career as the fountainhead of American psychology and major developer of the philosophy of Pragmatism may have been in response to these experiences. This is similar to Freud’s self cure psychoanalysis grew from with The Interpretation of Dreams and Psychopathology of Everyday Life. Jean-Paul Sartre has described “anguish” as a related experience—less intense or debilitating than dread or more extreme anxiety states. Anguish may be a prelude or an announcement to action, sometimes creative action—denial the source of bad faith (205:35-45).
It may be inferred that in a crisis situation we attempt to cope with the highest, most mature level of functioning that we have available. When our normal methods of coping are inadequate, the healthy person can usually reorganize his or her outlook and develop newer, creative methods for problem solving. With repeated failure, however, or shock too sudden or too great, we all may find ourselves in a regressive crisis experience. As our higher levels of resources are expended, the earlier successful lines of defense are attempted If these fail, we may continually be thrown into regression through the syntaxic mode of experience, and further back to experiencing others in a parataxic mode. (A corollary of this process is that crisis patients are often literally unable to speak or when they do, express a sense of alienation toward their environment and those around them.) At this point the foundations of the Self-System are laid bare. We are thrown into the experiences of the Not-Me and overwhelmed by anxiety in the form of the uncanny that seems to be a part of this stage of development. Different people have incorperated the uncanny, to a greater or lesser degree, as part of their Self-System or personality. All of us have some—and in milder variations it is important to our well being. As Erikson implies, cited in the following sections of this paper, in the correct instances, we need some sense of distrust and other developmental experiences that we usually find unsettling, in order to develop our abilities to do reality testing. It is when we are overwhelmed that we are in crisis. 7
With this in mind, crisis counselors may see that it is the strength of their own Self-System and the constancy that they give to interaction that works for both themselves and their patients. In the Workshop we will develop communication of this sense of stability to upset people. It is important to reiterate that the crisis counselors are able to relate to the patient to the extent that they, themselves, have resolved their own life crises or are actively working to solve them. Crisis counselors lend their experience of resolution to the patient.
We have now studied several different theories and descriptions of what a crisis consists. We have seen how crisis is an event in life that every person may face at sometime. We have postulated that it may be a chance for growth, not necessarily a detrimental experience. Now, I would offer an even more radical view of crisis. Not only is crisis a universal experience. It is a necessary experience for human development.
Erik Erikson identifies a series of eight stages of human development that he names “The Eight Ages of Man”. Each of these eight stages is marked by a definite developmental crisis. Each of us, growing up, must resolve the crisis of each stage at the age that is appropriate to continue our growth. Lifton, who studied with Erikson for many years, describes how “...in his hands, the concept of identity provided a newly liberating flexibility in self-definition... and an equivalent responsiveness to social currents. All the while he was managing the difficult psychological task of placing the ordinary person (and for that matter, the researcher) into the flow of the larger historical process” (138:26). I strongly recommend that the workshop members read especially, Chapter 7 of Erikson’s Childhood and Society (60) in which he describes his development of these “Ages” and especially examples of the manifest expression of each Age. Each of these stages is characterized by a pair of polarities which the individual must balance in their personality and develop a “favorable ratio” between these poles. Each stage has a “basic virtue” which has the potential to emerge with the properly arrived ratio. In the following table I have listed the names of the stages under the column named “AGE”. The second column named “RATIOS” is the name of the polarities, which may be a description of behavior, attitude, or experience of the developing person. This column describes the developmental crisis that is the focus of this study. The third column is the name of the “VIRTUES” describing personal qualities that are developed with the proper ratios.
THE EIGHT AGES OF MAN
AGE RATIOS   VIRTUES
Oral Sensory.............Basic Trust vs. Mistrust.................Drive and Hope
Muscular Anal..........Autonomy vs. Shame and Doubt...Self Control and Will Power
Locomotor Genital....Initiative vs. Guilt..........................Direction and Purpose
Latency......................Industry vs. Inferiority..................Method and Competence
Adolescence...............Identity vs. Role Confusion..........Devotion and Fidelity
Young Adulthood......Intimacy vs. Isolation....................Affiliation and Love
Adulthood..................Generativity vs. Stagnation...........Production and Care
Maturity.....................Ego Integrity vs. Despair...............Renunciation and
Erikson describes these Ages as
epigenic stages meaning that they are built on the preceding stages.
Like the concept of regression used with Sullivan’s work to understand and empathize
with a person in a crisis situation, Erikson’s stages show that he or she experiences the crisis
along lines of previously lived crises. If a previous stage has been resolved in an unfavorable ratio,
a developmental crisis will re-emerge, re-enacting this conflict. Exploring the topic identified as the “Hazard”
or precipitating event in the upcoming section presenting Aguilara & Mesick’s Crisis Intervention approach, along these developmental lines, develops a focus for our intervention.
Although initially this unfavorable ratio is a vulnerability of the personality, if resolved correctly, resolution at each stage will include
resolution of unfinished issues from previous stages. 8
During a crisis a person
re-experiences previous crises and, thus, may have the opportunity to resolve
earlier as well as present crises.
Finally, it is important to note the concept of ‘ratio.’ In an interview Erikson commented:
And, if you don’t mind me registering a gripe, when these stages are quoted, people often take away mistrust and doubt and shame and all of these not so nice, “negative” things and try to make an Eriksonian achievement scale out of it all, according to which in the first stage trust is “achieved.” Actually, a certain ratio of trust and mistrust in our basic social attitude is the critical factor. When we enter a situation we must be able to differentiate how much we can trust and how much we must mistrust, and I use mistrust in the sense of a readiness for danger and an anticipation of discomfort. This, too, is certainly a part of the animal’s instinctive equipment. We must learn it in terms of our cultural universe.
Dialogue with Erik Erikson (62:15)
We now have several definitions of ‘crisis’ and several theoretical notions of the experience of crisis. The topic of possible interventions has been presented and will be developed during the course of the workshop. We will discuss and practice some specific methods of intervention. I conclude the first workshop session by giving an assignment for Group members to develop (create) a crisis in which they can role-play. This may be an original idea but it may also be patterned on an actual incident or patient with whom they have worked.
In the second session we launch into Group interaction with an exercise that is challenging, controversial, and designed to involve everyone. It is also a good method to encourage the participants to introduce themselves to one another and start conversation.
I direct Group members to form sub-groups of three.
Each sub-group is to practice an interview technique.
One person plays the role of patient; one person is the counselor; one person acts as an objective observer.
After about twenty minutes triad members change roles.
After changing roles one more time, each person has played all roles.
As an added challenge, I instruct Group members playing the role of counselor to
attempt to encourage communication by making direct statements instead of asking questions.
Role-counselors may instruct role-patients about what they should talk about,
or they may listen and reflect facts or feelings that the role-patient is communicating.
Role-counselors may also empathize with role-patients.
This introduces the topic of communication for beneficial change that I present later in the workshop as a synopsis of research cited in Chapter 2
regarding types and qualities of therapeutic interaction. 9
The counselors are also instructed to refrain from giving advice to the patient. The observer should comment when the counselor asks questions or gives advice. The observer may also be a resource for the counselor if they get stuck. Because this often happens with such restricted rules of communication, the observer may suggest approaches to try.
These rules challenge and bring out several features of intervention. This exercise opens the players to the development of empathy between patients and counselors. The observer is also in a position to develop a more objective viewpoint of the interaction in a counseling session. In the usual crisis situation, the patient is typically at a disadvantage, or may at least feel at a disadvantage. This exercise subtly changes the balance in what Bateson describes as complementary and symmetrical communication. Either of these communicational types, in pure form, rigidifies interaction. Interchanging the two styles through feedback and reciprocity leads to communicational progress where both parties benefit. 10
The counselor experiences a sense of being at somewhat of a disadvantage. This may help promote empathy with the patient. To explain: hospital staff can be characterized as ‘professional helpers’. The most common method of helping by helpers, both professional and amateur, is to ask questions about the problem and, then, suggest solutions. We are all subject to the danger of asking similar questions to all patients and suggesting solutions that we would use if we were in a similar situation. In addition, both patients and counselors experience anxiety and discomfort during a crisis situation. As the crisis intervention relationship is established there is a natural tendency to come to resolution as rapidly as possible to allay this anxiety. In this haste we often take care of the most obvious issues but may miss or ignore more cogent problems that underlie and even generate the present crisis. Like valium, we may calm the emotions but do nothing about deeper causes of the crisis. Valium or similar anti-anxiety medication, may help the patient feel more comfortable. Suddenly there seem to be no issues. On the other hand, some discomfort or anxiety, if the focus of the interview, can help identify and clarify the issues to work on. Sullivan discusses the sudden emotional shifts that take place between interviewer and interviewee in The Psychiatric Interview (186:Ch. 6). He also recommends the perspective of the “participant observer”. In Psychodrama terminology the observer becomes a reflective alter-ego. The triad approach creates a reflective tension for the participants. They watch themselves talk with the role-play patient as they are being watched by the observer. 11
This exercise is also an excellent method to reproduce and introduce the Group process. The triads are small enough and personal enough to enable people who may be shy in the whole Group to comfortably begin talking. In another type of class I broke training groups up into triads and assigned a different type of group work. As an example, I asked each triad member to find out what the other members think about specific topics such as job related issues of communication or how to deal with unfairness of a supervisor. At another time I introduced problem solving, much as I will discuss in the next few pages, then posed several problems, a different one to each group, and asked Group members to interview one another to discover each of their ideas for solutions. In both instances I assigned triad members to report back comprehensively to the Group as a whole.
Paradoxically, while the small groups of three are more comfortable, the role playing is difficult enough to generate a certain tension that motivates a lively, often confrontive, discussion, when the whole Group reforms. When we reassemble, everyone is ready to talk. The assignment with the triads has been difficult from two aspects. The members are somewhat self-conscious about their performances as both patients and counselors. The rule not to ask questions has made the mini-role-play doubly hard for the person playing the counselor. The counselors are somewhat disarmed of their habitual methods of helping patients. Often they express irritation toward the leader for this unusual approach. We have created a model crisis in which the Group can be moved to intervene. While similar exercises are commonly practiced in sensitivity training and group, individual, and family counselor training, people in allied professions often find them new and interesting. As well as anger, participant often find new interview approaches stimulating and interesting. I have been told by counselors that the triad counseling role-play helps them develop new perspectives on interviewing and patient interaction.
In the next section I reproduce the whole Group discussion that followed this exercise in one workshop. Important issues are discussed that will be emphasized afterward:
Max (Irritated.): “Well, that was hard! I don’t see what the point of not asking questions is about.”
Ted: “That was hard. I’d tried it before in role-play and thought it added an interesting dimension to the interview, an added challenge. I noticed most of the Group struggling not to ask questions. Tell me what you experience.”
Jerry: “I rely on questions. Yeah, at least every other sentence I wanted to ask a question. I never noticed how often I use questions.”
Max: “Well, I found it very frustrating. There wasn’t much that I could say.”
Ted: “So when you couldn’t ask questions, you didn’t know what to do next. Talk a little about that.”
Max: “Yeah! How are we supposed to help patients if we can’t find out what’s causing their problems?”
Pam: “I thought that there was quite a bit that I could find out without even talking to the patient. Norrie (who role-played the patient for Pam) was looking at the ground. She wouldn’t talk, or just mumbled. I knew that she was depressed and probably frightened. I just told her how she appeared to me and told her to tell me about herself—then waited.”
Ted: “Give us an example of what you said to her, Pam.”
Pam: “I told her: ‘You look frightened.’ And when she responded: ‘Uh-Huh.’ I told her she could take her time. I would like to hear about why she was brought to the Emergency Room by her husband. I was just describing the reality of the situation to her and what I knew about it. I had read the admitting notes.”
Norrie: “When I started playing depressed, I was going to try to make as little sense as I could. Just grunt or something.” (Group laughter.) But, when you (to Pam) said that, I got angry. But I tried not to show it.”
Pam: “Then you said something like, ‘I don’t want to be here.’ I could really empathize. I mean, if I was here against my will, whether I was depressed or not, I'd be pissed off.”
Ted: “You were trying to get right to the core of the crisis; part of it was that she was here against her will.”
Max: “ But I still think you have to question the patient to find out what’s causing the crisis in order to solve it.”
Ted: “I think that sometimes that’s true. But first I think that it’s important to establish a relationship with the patient and evaluate their situation as accurately as possible before we offer solutions. Sometimes slowdown. Let the relationship develop.”
Jean: “That reminds me of what Dr. D___ said at the Suicide Prevention Workshop I went to last month. People often attempt suicide because they have gone to everyone they can think of and asked them what to do. Everyone tells them how to solve their problems without really finding out what they’ve tried or how they feel which might be horrible. Telling them what to do just loads up the issues. It just makes them feel worse and beyond hope. They’ve tried all they can think of and they don’t know what to do. If they knew what to do, they would do it! It’s a vicious circle. Or at least that’s how they feel. Often they feel so hopeless that talking to someone else just makes it worse.
“Dr. D____ talked about making the problem clear. He gave us the idea that if the problem is completely understood, the solution is obvious and the patient sees it. It’s not just something we give them. They might not always like it, but it’s right there. Dr. D_____ worked on ways that we could use to clarify what the patient says to us. Even write it out. Make lists or pictures or diagrams or something. Show them to the patient and have them revise them until they feel that all their issues are out there on the table. We can help them work them out later, once we all know what’s happening.
“Sometimes you have to sit with them a few minutes. I just say: ‘I understand that it doesn’t look like there’s anything you can do. We’ll work on that but let’s just be quiet for a minute and start fresh.’ Sometimes they get angry or start to cry, but if you sit quietly with them a few minutes or tell them you understand, let their emotions clear, they calm down and can think clearer. If they still are suicidal you still may have to admit them.
“I tried this with patients on the unit. When they are first admitted and I do the admission I do a whole problem-solving interview. When I first started working in psych, I felt no one would listen to my great advice. Now I have a sort of a script I can use. It organizes me and helps organize the new patient. They’re often pretty disorganized or, at best, they’re distracted, when they first arrive. I let them tell me about themselves and I tell them what they told me.”
Ted: “That’s a good example of what I’m trying to show. When you’re talking to the patient and asking for this information, you’re establishing communication with them. Even if their answers aren’t clear, by talking to them you’re greasing the wheels of the interview, so to speak. Can I use your report in future workshops?”
Jean: “Sure.” (Laughing.) “As long as you credit me as a proper reference.” (I probably could have summarized Jean’s comments and used them for an entire lesson!)
Ted: “The suicide issue is very important. It’s a topic that I want to focus on in future sessions, but right now I want to stay with your interviews and what happened.”
Max: “I see what you’re saying about finding out what’s wrong before telling patients what to do. Questions are more natural to me, though.”
Ted: “Yeah. I didn’t mean that this is the only method of interviewing. We get so used to asking questions and looking for specific answers, that doing other things allows the emotional issues to surface rather than just the logical. I think that we are trying to lend our own sense of comfort to the patient and we have to be comfortable. If we’re frustrated or angry or rushed, like Jean said, the patient’s going to pick that up and the interview is more difficult. Next week I want to present and try some other methods of intervention.
“Fred, Linda, Sarah, you had a lively group there. Tell us what happened.” (The discussion then moves to others who had mostly been listening.)
This discussion, which followed the triad-mini-group exercise, brings to the front several points about both crisis intervention and Group process. Due to time factors and the number of patients that the staff works with, there is a tendency to rush interviews. Instead of lending comfort to the patient, we can, inadvertently, lend our own feelings of being rushed to find out what is wrong and solve it. This does not necessarily help the process go faster, but it can result in more superficial solutions than are required. The Group discussion often centers on feelings of frustration, especially in working conditions, which interfere with the staff members doing an optimal job.
This particular Group discussion moved toward understanding more rapidly than usual as several members had had previous experiences with similar modes of interview. For this reason, I prefer that the Group composition be eclectic and balanced, made up of members with a variety of, as well as levels of experience. Members who are newer to the field are often more challenging, with more questions. They bring up issues and express feelings that more experienced Group members have gotten used to and are somewhat desensitized to. At the same time, the more experienced members speak from their expertise.
In other Workshop groups, several of the topics touched on here become themes of entire group discussion. Examples of these themes include staff frustration, empathy, more specific ways of communicating with patients, and, particularly, extremely disturbed patients including suicidal and potentially assaultive dangerous patients. Although Jean presented one perspective toward patients who are suicidal, there are other empathetic responses to patients that are dangerous to themselves or others. Not only do they feel alienated toward those with whom they communicate, but also experience an overwhelming amount of emotional pain and existential dread—the uncanny that was described earlier. They may also experience rage and tendency to violence. These issues will be discussed in the upcoming topic of Crisis Intervention: assessment and problem solving.
As leader, I take the role somewhat analogous to how I would work with a crisis patient. In other words, I have certain knowledge about the field that I may impart when the time comes, but participants must develop their own style and approach. With this in mind, I try to encourage Group members to talk about their own preferences in technique and help solve one another’s difficulties as a Group. I hold back with discussion of method and facilitate members sharing of their counseling approaches. I sometimes only comment empathetically and allow Group discussion to develop on its own. Then, in the next session, Group process becomes a demonstration of problem-solving.
Often, we end this session with more questions raised than solved.
The example of Group discussion presented above appears to have more resolution than usual with a
fairly long exposition by Jean of a procedure that she had recently
learned in another workshop. I present this Group discussion to
show an example of solutions coming from the Group members.
While this seems to answer or resolve the Group problem raised,
this may be somewhat of an illusion.
Frustration that Max was communicating may not have been answered but rather suppressed by the
rest of us expressing a Group consensus, a ‘more knowing’ attitude.
As such we may have stopped inquiry too soon.
A very fruitful discussion could have developed around Max’s
While establishing communication is the corpus of the Crisis Intervention process, Problem Solving is the spine. During the past 5 centuries, individuals and groups of individuals have developed organized methods of problem solving, becoming the basic structural techniques of our scientific–technological culture. We can summarize these methods of understanding and coping with the uncertainties, change, and confusion of our own society and lives.
The roots of problem solving are in the Scientific Method delineated by Galileo and Bacon at the beginning of the 17th century. 14 The Scientific Method provides approaches for the counselor, once communication has been established with the person in crisis. In the next workshop description of the Scientific Method is presented and developed for Crisis Intervention procedures, followed by Aguilera and Messick’s more elaborate and specific Crisis Intervention problem solving approach.
The five steps of the scientific method and problem solving are presented in the next Workshop session:
1• Presentation of the Problem : The crisis is defined as clearly as possible. Sometimes, when understanding of the crisis is truly clear, the solution obviously follows.
2• Collection of Data : There may be two steps to collecting data. First, all information regarding the sources of the problem(s) should be determined. Then, information leading to possible solutions is collected and/or developed. In a Group this may be handled in a brainstorming session. With individuals, any possible solutions or partial solutions are collected. These should be considered even if they seem improbable or farfetched. Ideas are collected without judgment or evaluation. Relatives or friends who accompany crisis patients are sources of information and ideas about both etiology of the crisis and potential solutions. Records of previous crisis experience or relevant treatment records are reviewed. New ideas often develop that have not previously been taken account of. Trends develop that have not been recognized. It is not unusual that in this step new information comes to light and, consequently, The Problem is redefined—sometimes even new directions are indicated including involvement of new people and authorities. (A common example may be that what initially appears as a psychiatric issue has neurological or other medical symptoms the source of which must be addressed first, for example drug or alcohol intoxication or detox, as well as brain damage, tumor, or stroke. )
3• Hypothesis: The data is evaluated as a whole and a scheme of action is planned. This step sometimes includes statements about what we may expect and how to recognize if intervention is successful. [Philosophers of a pragmatic (James, Dewey, Mead) or positivistic-analytic (Russell) tendency would insist on this type of ‘normative’ [Piaget, (144)] prediction.
4• Testing: The hypothesis is tried out. If it is effective it should move the process along. If not successful, step three is repeated, developing a new hypothesis. Step four is then repeated.
5• Theory: In the evolution and development of knowledge, the theory is the final outcome. This represents the best organization of the subject that we have at this point in time-space. In crisis intervention, the theory is the method of resolution for the crisis patient so that he or she may continue life with the highest possible personal organization. If the best theory, after several returns to step three, remains completely unworkable or inadequate, we are probably not working on the actual or correct problem. We return to the first and second steps for a redefinition of the initial problem; the crisis is not clear to us.
John Dewey bases his “inquiry” approach to Problem Solving on the steps of the Scientific Method. He sees them as products of human evolution, procedures that we all must follow to survive and thrive; our ability to approach problems in this manner is even considered a measure of our mental health (49, 50, 51). Bertrand Russell summarizes the process:
I think Dr. Dewey’s theory may be stated as follows. The relations of an organism to its environment are sometimes satisfactory to the organism, sometimes unsatisfactory. When they are unsatisfactory, the situation may be improved by mutual adjustment. When the alterations by means of which the situation is improved are mainly on the side of the organism—they are never wholly on either side—the process is called “inquiry.” For example: during a battle you are mainly concerned to alter the environment, i.e., the enemy; but during the preceding period of reconnaissance you are mainly concerned to adapt your own forces to his dispositions. This earlier period is called “inquiry.”
History of Western Philosophy (201:824)
Aguilera and Messick (3), whose Crisis Intervention approach is summarized next, cite Dewey as a source of Problem Solving methodology. His book, How We Think, is devoted largely to the development of thought and what he calls: “…the Relation of Reflective Thinking to the Educative Process” (40:Title page). A significant portion, the central section of the book, is devoted to an elaboration of Problem Solving. Under the section titled “Logical Considerations”, Dewey describes and details processes which include: psychological reflection; inference and testing; analysis; judgment; control of data; and forming conceptions, ideas, and meaning. These procedures are detailed discussions of specific approaches that are practical applications of the five steps outlined above.
In his later lectures Dewey presents an attitudinal approach to Problem Solving that is important for the Crisis Counselor. While Russell emphasizes Dewey’s pragmatic approach or frame of action of the inquirer, in The Quest for Certainty Dewey writes: “Here is where ordinary thinking and thinking that is scrupulous diverge... The natural man is impatient with doubt and suspense... A disciplined mind takes delight in the problematic, and cherishes it until a way out is found that approves itself upon examination... The questionable becomes an active questioning, a search; the desire for emotion of certitude gives place to quest for the objects by which the obscure and unsettled may be developed into the stable and clear. The scientific attitude may almost be defined as that which is capable of enjoying the doubtful.” (51:182).
The Crisis Intervention Counselor may engage the patient in this process of inquiry,
explaining the steps—that this is a process of Problem Solving—eliciting information and seeking a solution according to the steps.
In my experience, the very act of involvement in such a process stimulates thinking and lends a feeling of hope to the patient.
This is a very powerful source of motivation toward resolution of the difficulty. Answers do not need to emerge at once.
The counselor may also use this method privately to organize an approach to the patient and his or her impasse. Aguilera and Messick (3) have developed a more elaborate method specifically designed for Crisis Intervention Therapy. The following is an outline of their system:
CRISIS INTERVENTION PROBLEM SOLVING OUTLINE
Adapted from Aguilera and Messick Crisis Intervention: Theory and Methodology, 2nd Ed. (3:57-60).
• Homicidality and Danger to Others in general.
• Grave Disability.
B. Determination of “Hazard” or Precipitating Event: “ Why today?”
II. Evaluation of sources of support.
A. Problem solving methods.
B. Coping mechanisms.
C. Situational supports.
III. Plan Intervention: The Crisis Counselor plans strategy he or she will take in light of information gathered and their relationship to the patient.
IV. Carry Out Intervention:
ACTION > in response to Patient’s DISEQUALIBRIUM >> NEW EQUALIBRIUM
V. Evaluation of Outcome with possible return to Assessment if New Equilibrium inadequate to patient’s
emotional-mental organization or situation.
Once the crisis is resolved, review of how the situation developed and the action that was taken to resolve it both strengthens the present equalibrium and looks to possible future crises. Anticipatory Planning also helps patient develop consciousness about evaluating the strength and maintenance of present resolution.
Aguilera and Messick write that the entire first interview may be devoted to assessing the patient. This approach reflects a luxury of time that the Crisis Interventionist, often, does not have. Most people seen in crisis in the emergency room must be interviewed and some type of resolution or referral achieved. The following explanations and descriptions are made in light of this situation.
While the Crisis Counselor is establishing communication, he or she is also assessing the patient. Suicidal, dangerous, and very psychotic patients need much more specialized attention than crisis intervention. Often this topic generates a good deal of discussion in the Group. Much of one session can be devoted to these issues. In California persons may be held for seventy-two hours in a designated facility for evaluation and observation if their behavior can be considered gravely disabled, suicidal, homicidal or dangerous to themselves or others due to a mental disorder. A police officer or person designated by county mental health departments can sign a seventy-two hour hold. An interesting aside is the fact that the law is designated in California as PC 5150. Slang usage of this term has developed on the street so an officer or worker in the field can be heard to use a phase like: “He (or she) is ‘fifty-one, fifty’!” This means that the behavior of the person being observed is erratic, unpredictable, or eccentric in some way, though often not necessarily qualifying for a hold.
At this point the Group becomes involved in discussion of the definition of these terms, how a hold is processed, what to do with a person who must be held, admission, and transfer procedures, referral sources if able to leave, etc. These topics will vary from county to county or hospital to hospital. As leader, I gather and impart technical information from and to Group members. Group members are encouraged to share their experience and knowledge; they are an excellent source of resources and procedural information. I have developed lists of recommendations from members. This can be an illustration of problem-solving in practice.
Emerging on the group process level, Group members are experiencing strong feelings about these procedures and methods of dealing with potentially violent and unpredictable individuals. Carl Rogers and his research associates (194) found that establishing rapport with psychotic people is stressful and often disturbing to the clinician. Recognizing and sharing these underlying feelings in Group discussion, can initially be uncomfortable but leads to development of Group process. While talking about the discomfort and sometimes disorientation that Crisis Intervetionists experience establishing communications with a disturbed patient, a type of catharsis can be achieved. It is not unusual for staff members to feel confused or at least slightly out of balance during or after an interaction with a person in crisis. Empathy among Group members establishes a therapeutic environment and lends feelings and experience of support. A skillfully supervised hospital unit would provide support for staff; however, talking about feelings of confusion is not the norm in our society and may not be tolerated in some work environments. Discussion and reflection takes place. We can use role-playing and Psychodrama, with Group support, to both explore crisis and practice intervention. These procedures will be elaborated on later.
At this stage in the Workshop, Role-play and Psychodrama is re-introduced. Workshop members play extremely disorganized patients and especially threatening individuals designated “Danger to Others”. Group members play Counselor and Alter-Egos, assisting the Counselor. The action can be stopped for Group discussion of approaches. Maintenance of a safe environment is a priority. During my clinical experience, I have had to insist that officers return, who have “dropped off“ a patient on a 5150 hold, designated “Danger to Others” or who is extremely agitated, before interviewing them in person. Similar situations have been reported by other Workshop participants. Trained hospitilal staff are also good to have as co-interviewers even in less critical counseling sessions. There have also been discussions in the Workshops about dealing with administrators that do not understand the need for structured, safe interviewing space in mental health clinic, psychiatric units, and county jails. (This is not common but it does happen.) I have pretty straight forward advice at this point: If the situation is not safe, stay out of it! Get help from someone in authority who can make it safe. Often, external control is calming to the patient; they may feel out-of-control and experience even, only, the presence of authority as organizing. The Crisis Counselor should have authority in these matters. Consider: they are the persons evaluating the safety of the situation. Pardon another “war story“: when I first began working on the psychiatric unit in the early ’70s, there were poorly organized procedurses dealing with extremely agitated patients. I suggested role-playing and rehearsal. I was told by a psychoanalytically oriented psychiatrist that I was afraid of my own repressed violence. Be-that-as-it-may, (I probably was concerned about my self protective reaction to being physically threatened, not a bad ethologically based survival response!) by the late ’80s there were role-playing workshop for and presented by staff in this area.
The majority of patients seen do not require admission. Frank Pittman (178), in an excellent tape on “Crisis Intervention and Family Therapy”, has had much success with strictly limiting hospital admissions for even psychotic individuals. When family members are supported and given organization and direction, an application of previously discussed problem solving, and the patient is calmed, home, with family or friends, can be the most organizing environment available. I play this a selection from this tape at this point in the workshop.
Another audio-visual resource that I use is a Veteran’s Administration film showing intake interviewing [USVA, Psychotherapeutic Interviewing II, (224)]. This is a good modeling resource for Workshop participants some of whom have not had courses or practice in therapeutic interviewing. 15
Identifying the “Hazard” or “precipitating event” offers a valuable method of structuring the interview. The determination of the Hazard is not always so clear as might be expected. The patient may be confused as to the events that led up to the crisis. By asking the question: “Why now?” the counselor gains an effective handle on the etiology of the particular crisis. The interviewer returns to this question until all the factors are explored and placed in their proper perspective. As in Dewey’s inquiry and with the Scientific Method, once the Hazard is identified, solutions often follow as a matter of course. The correct question leads to the answer or information is developed or collected leading to a new, more fruitful ‘problem’.
It is not unusual for the patient, or person(s) bringing the patient to the hospital, to tell us that the patient has been feeling badly for several weeks, months, or even years. If we continue to focus on determining and understanding a specific Hazard: “Why now?”, we find that events in the patient’s life have constellated in such a manner that he or she is brought to the hospital at this particular time. Sometimes we find that there has been little change in the patient’s behavior, but the precipitating event has occurred in the patient’s living group and/or environment. For example, the staff members of the psychiatric unit noticed that many women are admitted with the diagnosis of depression toward the end of their children’s summer vacation. They often recover in time to return home and prepare the children for the opening of school. Sometimes a hospital admission is the only form of something approximating a paid vacation that these women have. Often they require a time when others recognize and respond to their emotional needs for awhile. Occasionally crises develop as a means of emotional release or wedge to releave pressures of life where the usual routes have been blocked.
Another interesting trend is the correlation of emotional instability with political and economic events. A striking example was provided by the political tension associated with Watergate. There was a gradual increase in the number of patients seen in the emergency room by Crisis Intervention Services during several weeks leading up to President Nixon’s resignation. Over the course of this period incidents reached an all-time high. Following the resignation, there were virtually no crises for the next fortnight. (Even medical emergencies decreased.) Gradually the number returned to a more normal average. (In weird synchronicity Nixon ended up on the sixth floor of Memorial Medical Center immediately after leaving office, ostensibly to recover from medical problems with his legs. Crisis Services then had to help the Secret Service return young schizophrenic patients to the Psychiatric Unit when they would try to go up and share their world visions with the former President.)
There also seem to be peak crisis times associated with time-of-the-year related events. Occasionally full moons seem to precipitate an emotional instability for people who are at risk. Time change: standard to daylight savings, and Mother’s Day has overwhelmed the service, at least for the better part of the day or night. (These events have been so obvious that comments and even pictures sketched by Crisis Intervention Counselors of themselves falling over with beads of sweat flying from their heads, an overwhelmingly large, glaring moon in the sky, have been recorded in Crisis Intervention Log Books.)
SITUATIONAL AND MATURATIONAL ROOTS
The crisis can usually be traced to either situational factors or developmental issues with which the patient is dealing. In other words, the basic source of the present crisis may be due to a change in the patient’s environment or personal relations, or difficulty the patient is having in age related maturational issues. Typical of the former may be a loss of a job, recently (post 2008) home foreclosure, or the death of a relative or close friend. Erik Erikson’s “Eight Ages of Man” is an outline of sources of maturational crises. It should be emphasized that a crisis is usually not only one or the other. There are both maturational issues as well as situational issues that surface during a crisis. A patient may react to a situational crisis with a degree of regressive behavior which is a calling up of an unfinished maturational crisis. On the positive side, this may be an opportunity to resolve the crisis of the period that has, heretofore, lain dormant without proper closure.
Conversely, a maturational crisis has definite situational effects. This may be illustrated by a crisis involving a person reaching the age of puberty. An adolescent’s struggle for identity often has the effect of upending the established order of family, friends, school, church, and any other institutions involved. Family therapists have noted that often a child’s or adolescent’s crisis reflects deeper family issues which are indication of a systems crisis [Ackerman (1), Erikson (50), Haley (87, 88, 89,), Whitaker and Napier (240)].
POST TRAUMATIC STRESS DISORDER:
There are special forms of situational crisis that lead to a diagnosis of Post Traumantic Stress Disorder. Witnessing death or disaster, being in a war or large-scale disaster, being the victim of a crime or participant in an accident, all have emotional after-effects. Sometimes these are immediate, but it is not unusual for the problems to take time to incubate. The Hazard may be a resurfacing of a trauma from the past and not easy to uncover. It is not uncommon for contact with people who have been in a recent disaster to trigger memories for another person from traumas long in their past. Relief workers who are helping victims of disasters will sometimes have memories return of crises that they have previously experienced. I have participated in debriefings for crisis workers who have been assisting disaster victims, when several of us have shared our memories of traumantic events from the past, even childhood. These experiences included earthquakes, house fires, automobile wrecks, experience as refugees—having to flee suddenly, as children, in the dead of night— and internal family crises which may include loss of job for providers, abuse, instability of parents and/or relationship, issues with siblings. Disturbance of sleep, appetite, dreams, increased emotional lability or, on the other hand, a feeling of numbness and even mild dissociation or depersonalization, a sense of “burn-out“ are some of the indications. Relief worker Group members reported a cathartic effect after discussing memories; they felt less emotionally drained after discussing the sources.
Children are often affected by disasters but do not have the language development to express distress. Regressive behavior, nightmares and unusual fears, disturbance of sleep, appetite, and school functioning are some indication of children’s PTSD. Acknowledgement and explanation of events with time for venting through words, drawing, or dramatic play including dolls, puppets, and various toys at hand, for instance, can go a long way to releave children’s anxieties. Greenspan and Greenspan: Clinical Interview of the Child (68) provide excellent examples of initial interviews with children that are often sources of discussion for Crisis Intervention Workshop approaches including PTSD. Any child who has experienced a disaster should be given attention and opportunity to talk about what happened, even if they seem unconcerned about the event. Repeatedly recounting the disaster is a way of digesting the experience for both children and adults. Anna Freud and Dorothy Burlingham studied the effects of the blitz on children in World War II London, finding that the emotional expression of the mother related strongly to the child’s present reaction and subsequent PTSD. Helping mothers calm their own anxiety (no easy task in the midst of being bombed!), and providing mothers with methods to help their children process the disaster that they are in the midst of, strengthened both the mothers‘ and the child’s sense of safety (67). Discussion of these symptoms and specialized approaches to PTSD is an important workshop topic. Identification and treatment of PTSD is a field in itself which has developed a great deal since the time of the original series of workshops.
Kurt Vonnegut’s novel Slaughterhouse Five is a tragi-comic collage of flash-backs and/or memories, present day events, and future fantasies, reflecting his experience as a survivor of World War II prisoner of war camps. He was actually present in the fire storm bombing of Dresden, saved only because he and his fellows were held in an underground slaughter house. The novel (and film) skip back and forth from that experience to the present, an upper middle-class wealthy American life style, including the death of his wife in a car wreck during a manic driving episode to the hospital where Billy Pilgrim (Vonnegut’s alter-ego) is being treated after surviving an airplane crash. (I believe this part is fiction.) Never one to miss irony,Vonnegut has her crash into the back of the emergency reception area but, die of carbon monoxide poisoning due to a leaky muffler. He developments a futuristic sci-fi sexual fantasy: being held prisoner with a favorite voluptuous porn star by invisible space aliens as in a zoo, on a distant planet: Tralfamador, being ordered to mate—this an elaborate PTSD epoch. It may be worth a brief reference to Jung’s study of flying saucers as a compensatory reaction to the public’s fear of nuclear war!
John Colson [Stress, Self-Concept, and Violence (39)]. details an individual behavioral treatment approach for Vietnam veterans whose PTSD symptoms include violent behavior with severe addictions to violent environments—often with episodic compulsion to seek these situations out—resulting in a very chaotic domestic life, frequent fights, arrests, or hospitalizations. (The film The Deer Hunter is a portrayal.) Treatment includes detailed history and neurological evaluation, behavioral recognition and sensitization training to precipitating events and internal experiences, bio-feedback and progressive relaxation training, desensitization training to violent siutation responses, with journaling—recording stressful experiences and resulting behavior including violence, drug and alcohol use, highlighting successful control. As a psychiatrist Colson prescribes medication when necessary. A veteran’s group is also encouraged but not his primary focus which is research about self concept. Colson reports high success rates for control resulting in decreasing episodes for participants who continue in the treatment. The record keeping seems to be a major source of reorganization of behavior and related issues, leading to an improvement of self image and self control. Similar regimens have been developed for families with physical punishment and abuse problems. Both family members episodes of abuse and disturbed veterans episodes of violence and related destructive behavior decreased, sometimes without any clear evidence of insight or self awareness. While recognition of PTSD is important in understanding the Hazard, this parallel but related field, like short-term therapy, is a topic around which an entire series of workshops could be developed. 16
As the counselor assesses the ingredients of the crisis, he or she may also begin to determine means of support for the patient. Aguilera and Messick detail three levels of complexity from which this support comes.
• Situational Supports: The environment is the first level of support. The patient’s environment includes significant others with whom he or she has ties, as well as institutions or organizations that the patient is already or may become involved with. These organizations are a part of the patient’s community life. They may or may not be primarily designed for personal support. Examples of the former are family and friends, and to varying degrees physicians, insurance, public welfare institutions, schools, jobs, hospitals, religious organizations, clubs and a host of others. A social history or mental history should identify and evaluate these. These institutional organizations can also be a source of stress for the patient. How to recognize this stress and resolve it into support is a problem at this stage of the interview.
• Problem-Solving Methods is a reference to the second level of support. These are conscious techniques that the Crisis Intervention patient has used at different times previously, often without being completely aware that they are dealing and maintaining balance with difficult issues. With a review, a person in crisis can often describe familiar procedures that have been successful in the past. These also can usually be determined while taking a history or mental status. Patients whose mental functioning is organized and oriented are fairly cognizant of methods that they usually use to deal with difficulty. They sometimes have to be coached to become aware of personal problem-solving methods. With help, patients are able to discuss their usual means of dealing with life issues as well as their shortcomings with the present crisis. By reflecting this history of previously successful techniques, the crisis counselor often brings to light methods that the patient has used before but, at this time, inadvertently ignored. Direct questioning may bring these to light: “Has anything like this happened to you before?...What did you do about it?” or “You have faced problems before. Tell me what you did in that time.” for those of you still developing non question interviews. Sometimes the patients will even say something to the effect of: ”That worked last time. Why didn’t I think of it this time?”
• Coping Mechanisms, on the other hand, are unconscious methods that patients practice without awareness. Often these are habitual responses to stress; in this case they are not adequate to the situation. Coping mechanisms are sometimes inappropriate, poorly developed, or too extreme for the present situation. Identification and alteration of coping mechanisms, a sort of a ‘tuning up’ makes up a large portion of the domain of psychotherapy. Discussion of anxiety sources, fantasies, dreams, and resistance; discussion of inner experience and habits that serve the patient poorly help improve awareness and may lead to questions for problem solving. Erikson’s developmental descriptions may catalyze this discussion. The Crisis Intervention Counselor should take note of basic strengths of patients’ personalities while assessing their coping mechanisms. These strengths are emphasized when planning and carrying out interventions. It often becomes clear, while taking a history, that patients have functioned well in many areas of life until recently. While crises may interfere with functioning that patients have previously taken for granted, these are areas of strength that may be supported and recovered relatively quickly.
Sometimes anxiety or fear has blocked a patient from carrying out a plan or resolution. This may seem like a minor issue to the counselor but it may be experienced as a major distress by the patient. With support and encouragement, as well as important feedback from the Crisis Specialist, the patient tries to carry out his or her plan often with enough success to continue. Expected disasters do not materialize and this can be shown to be a degree of success. Even if the crisis continues, reviewing previously attempted resolutions is a source of knowledge and can be used to re-evaluate and develop the next plan. It is important that these issues surface during the crisis sessions or immediate follow-up. The Crisis Counselor acts as an ally to reinforce re-evaluations and action.
If a patient is extremely emotionally overwhelmed, sitting quietly, breathing slowly and deeply can be calming and centering.
At this point discussion and identification of previous crisis experience is important if not identified during evaluation of situational or maturational roots or mental status history. Once again, because crises are uncomfortable and the patient may not feel that he or she has successfully resolved the present crisis plus previous experiences, it is an important opportunity to gain an experience of resolution. This may be an experience akin to Forgiveness discussed in previous chapters. As with Erikson’s developmental stages, this is time to reflect on the past and improve both this and the present.
FOLLOW-UP AND FEEDBACK:
Follow-up sessions are extremely important to the Crisis Intervention process. If a patient is seen once and achieves a resolution, it is vital that another session is planned in which the crisis is reviewed and the effectiveness of the intervention is evaluated. This is more than a check to be sure that the patient is ‘ok’. It is also a step leading to but preceding anticipatory planning. Crises, by nature, are events that people try to avoid. They are uncomfortable, even dangerous! When a person is in a crisis they are trying to find solutions and resolve the issues. After establishing a degree of control in a crisis situation, it is important to revisit the experience. Discussion of how the crisis came about, the patient’s reaction, difficulties that he or she had mobilizing resources, both personally and situationally, and how this was finally achieved can lead to a broader perspective. Sometimes some of the experience must be referred back to. There are often additional issues and sources of support that are missed in the haste of the original crisis that become clear in the Follow-up. This session helps the patient understand the crisis on a more organized level that may have been initially confusing. Planning for a Follow-up also helps to structure the initial interview. Requesting Feedback from the patient can bring out unaddressed issues that the patient may not initially volunteer.
Caplan views a crisis as a state of disequalibrium. As we plan our intervention and carry it out, our actions exert forces to bring this imbalance to a stable ground. With optimal effect, intervention will help the patient to continue on an even higher level of organization than before the crisis.
Aguilera and Messick emphasize that crisis intervention is an active, though not
necessarily directive, approach toward a person in crisis.
We must be aware of and utilize every possible, appropriate resource.
For this reason, a good portion of one workshop session is devoted to reviewing and collecting, from
participants, different options available to patients: institutionally, in the community, and personally.
Often the crisis counselor must discuss and explain what these different options involve.
We often forget how little most of the public knows about fields such as medicine, psychiatry, or community mental health.
Our constant exposure sometimes leaves us with a perception that
everyone knows how to function in the mental health or the medical system, when,
in fact, most people are not aware of certain basic options and procedures.
Even clinicians in private practice have trouble arranging for evaluation or
admission for their patients when necessary.
Much of our patients’ common knowledge about psychiatry, especially, may be sensational, even bordering on superstition.
A person in top mental health, in a calm state of mind, can easily become confused when involved in institutional medicine.
Caplan summarizes the importance of the crisis for the patient, significant others, and the interventionist:
A characteristic finding in crisis is that, as the individual’s tension rises to a climax, he begins not only to mobilize his own resources, but also to solicit help from others. The signs of his increasing tension appear to have a significant effect on others, so that they are stimulated to come to his assistance. This reciprocal pattern of seeking and offering help appears to have primitive biosocial roots; similar phenomena can be found in many social animals.
A corollary to this is that, during the disequilibrium of crisis, the individual is more susceptible to influence by others than at times of stable functioning. When his normal balance is upset, a relatively minor force will tip him to one side or another. This means that the help offered him by significant others may have a major effect in determining his choice of coping mechanisms, which in turn will influence the outcome. (Italics added, T. K. W.)
Principles of Preventive Psychiatry (27:48)
I would like to re-emphasize that a relatively small intervention can have a major effect during a crisis and even lead to resolution of past crises.
Finally, when the crisis has moved toward resolution, one more step is important. Discussion of the process of the crisis and how the resolution was achieved should be reviewed. The counselor helps the patient develop plans and strategies for any continuation of the crisis, even discussing other future crises. The Crisis Specialist’s observations of the patient’s Coping Mechanisms, Problem-Solving Methods, and identification of Supports helps the patient recognize or develop methods which may be used to deal with future crises, hopefully at their inception. This stage develops from the previous Follow-up and Feedback.
Once the basic Crisis Intervention theory and process has been presented and discussed, different applications may be developed. This process is also an extension of the evaluation of severity. There are several other topics that enter into this part of the workshop discussion. We have seen the patient for a short time, possibly two or three hours. He or she came in or was brought in in a confused or an emotionally disturbed state. Ideally, the patient is calmer and able to communicate and plan. What is available now?
Different organizations or services may structure on-going Crisis Intervention in different ways. Follow-up also is affected by insurance and payment issues. Although the safety of the patient should be foremost, financial pressure may be felt by both patient and counselor. This issue generates discussion and often anger and frustration for staff members who must work aound these limitations. When this workshop was originally developed Medi-Cal provided initial resources for everyone if needed. This ‘safety net’ has essentially been destroyed in the last 40 years. Consequently, the at-risk population is a great deal more vulnerable. Much of what is called Crisis Intervention is now done in county jails. In Santa Cruz County there is no longer a county hospital where overnight evaluation is possible. What was a $55 overnight evaluation and stabilization in 1980 now is a $1000+ admission to a private hospital. The ways that crisis services are structured respond to social and economic pressures. Often workshop time is needed for venting on the part of participants. This can sometimes be worked into Psychodramas. [2016 note: Santa Cruz County now has its own Neuro-psychiatric Unit again. Financial issues have undoubtedly gone through many transformations since 1977! including the procedures that go with California’s version of the Affordable Care Act and changes that Washington is making in this. Then! with threats to repeal the Affordable Care Act, emotionally and financially at risk people are under tremendous pressure and extremely vulnerable to this politically produced situational stressor ( 2017)].
In the original Workshop all participants were employees of the same hospital. We could discuss the process in relation to that institution. If a new service is being developed or several organizations are represented, different delivery systems of Crisis Intervention Services may be discussed and compared. Important questions can be solved by different services in different ways. For example, after a patient is seen and continues to be emotionally or behaviorally labile, and if they continue to be unpredictable, should he or she be admitted voluntarily for 24 hour observation and stabilization or held involuntarily for 72 hours? Under what conditions can patients be sent home with family supervision and follow-up? Is there a Crisis Intervention follow up group or counseling session available on the next day or in the next day or two?
The structure of services similar to those that Aguilera and Messick report about (at USC/LA County Medical Center, in the 1970s) would be two weeks of very intense Crisis Intervention sessions, daily or every other day. Even if a Crisis Service has already been established and change seems unlikely, in this part of the Workshop it is important to discuss improvements that may be made. If the workshop participants represent a variety of experiences, I ask them to share their different ideas about Crisis Services. If there is not a wide range of ideas, I present the following outline:
1. There should be an immediate way that patients may be helped to stabilize themselves and be supervised either in a half-way house type of environment with trained staff or a hospital as needed.
2. Most patients can be sent home with a follow-up appointment the next day. They must agree to this follow-up and a family member or responsible friend should be part of this procedure. A Crisis Intervention Group the next day is one possible way that a service with a high volume can be provided. Out-patient and private referrals may be arranged when appropriate.
3. Two to three weeks of Crisis Intervention appointments should be available with an evaluation appointment at the end of this time when termination, continuation, or referral to longer term therapy is possible.
4. Members of the workshop often have additional issues and suggestions at this point.
Usually, involvement in this type of program has an organizing effect for patients. If they need longer term therapy it can be determined at this time. This procedure should be active, not only evaluative. The workshop Group discusses how Aguilera and Messick’s CRISIS INTERVENTION PROBLEM SOLVING OUTLINE can be the grounds for this service. Evaluation, determination of the “Hazard”, evaluation of Situational Supports, Problem-Solving Methods, and Coping-Mechanisms, and, finally, Anticipatory Planning can all be discussed within this context.
At this point the entire theory and process of Crisis Intervention has been presented and discussed. We will refer to and practice these concepts and procedures in the remaining sessions. In recapitulation, we have seen what a crisis is and we have related the process to growth and maturation that each human being experiences, including ourselves. We have discussed and practiced how we may establish communication with a person caught up in a crisis. We have even experienced a little discomfort ourselves in the brief introduction to role-playing. We then discussed various methods of problem solving. Now that we have grounded ourselves in theory, the last half of the workshop is a practicuum of the processes through role-playing and Psychodrama.
While this process is centrally that of the Group and the Group leader, it is important that each Group member develop a style of intervention with which they are most comfortable. This is the goal of this part of the workshop. Role-playing is an extremely effective technique to practice this goal. It is also interesting and fun!
Participants are encouraged to take the roles of patient, interventionist, and helping alter-ego, each of these in different Psychodramas. The type of patient and crisis situation is developed by Group members, often from experience. The rest of the Group forms an audience and is a powerful resource for both creative ideas about problem solving and training in technique. When an intervener becomes stuck, the Group stops the play and discusses various alternatives. Group members bring situations from their work or imagination and set up role-play. They play the parts of both patients and crisis interventionist. In the First Round, the interventionist is allowed to vent, often telling the role-patient off. In Round 2 correct intervention communication is practiced. Alter-egos help the interventionist in both rounds. Chapter Four, above, presents the details of Psychodrama technique.
Several features of this particular approach became clear as I led Crisis Intervention Groups in this manner. Psychodrama and role-playing are excellent methods for Group members to share both the emotional aspects of their jobs and their individual interview styles with one another. Seeing someone else do intervention is an entirely different experience than reading about it. Playing the part of a patient in crisis and having another person intervene—or the whole Group intervene—is still another dimension: an experience that teaches a great deal about effective interventions. Empathy for patients is developed from these experiences. Playing a patient, even exaggerating chaotic or bizarre behavior, can be cathartic for staff members who always have to be the straight, responsible person in the E. R. or on the ‘Psych Unit’. Group members develop empathetic responses to other counselors in portrayals of problem patients who we all recognize when acted out. After the First Round catharsis, counselors can focus on the patient’s experience. It is often a challenge to the person playing the patient to stump the interventionist and a challenge for the Group to develop interventions for this ‘stuck’ situation. This is good sport and interesting and fun. Workshop members even develop a bit of ‘trickster’ attitude that influences the workshop and can even be effective, if used judiciously, on the psychiatric floor. Humor and play, even in a grim situation, can have a therapeutic effect, as pointed out in both the research cited in Chapter 2 on Group outcomes and Norman Cousin’s research about medical healing effects of laughter.
Although Group members are self-conscious at first, they usually become deeply involved with and enjoy this approach. One member of a workshop recounted the experience of playing the part of the patient. She told the Group that she became so involved in the role that she felt absolutely depressed and disoriented. It even frightened her. However, several insights emerged. First, she stated that from the point of view of the patient in crisis, she could sense the caring of the person playing the counselor and, going with the process, she could experience the crisis as it moved toward resolution. She also told, later, that the experience helped her empathize with patients who were disoriented, even hallucinating. She felt that she was becoming a more effective crisis interventionist by practicing role-playing in this manner.
One of the most impressive experiences for workshop participants was to watch an extremely skilled Emergency Room nurse demonstrate her favorite style in role-play. From many years in the E. R. she had developed truly amazing abilities to talk and communicate with the most disturbed patients (Often with medical issues as well as psychiatric. Being sick or injured often leaves patients as upset, afraid and emotionally overwhelmed as mental-emotional disturbance.) She sits down with patients after getting them a cup of coffee, smoking a cigarette with them if they smoke, and generally helping them feel comfortable, even welcome. (Remember the early ’70s when it seemed like everyone smoked, everywhere. I had a good number of clients and consultees among these nurses in the ’80s, practicing hypnosis and teaching self-hypnosis, to help them quit smoking!) She then discusses with them what seems to be the most confusing accounts of a crisis. Very gradually she focuses the conversation toward the realities involved: the ingredients of the crisis and the options for the patient. It is an understatement to say that she exudes warmth and a presence that you want to trust. She asks questions or talks in a somewhat oblique manner to determine how well the patient is oriented and whether they understand where they are and what is actually happening. During this time she identifies and notes indications of symptoms that may be associated or confused with psychiatric conditions. These may include neurological damage, chemical, or medical issues—intoxication, side effects, or withdrawl, even reactions to physical illness or injury, for example. Further medical testing would be indicated by these. She takes enough time to help the patient become comfortable. By thoroughly understanding them and their situatuon the Hazard presents itself. Often patients are able to come to solutions themselves then discuss the practicality involved. She also presents options and notes if the patient seems to understand these and responds in an appropriate, concrete solution oriented manner.
One of her favorite methods of establishing contact was the judicious use of physical touch. This may be a handshake or holding the patient’s hand while talking to them. It may be a gentle pat on the shoulder or back. Because of the medical environment, as with nursing staff in general, this could extend to a physical exam if an injury or illness was involved. Often standard procedures for all E. R. patients include blood pressure and other vital sign measures. Physical contact can be established at this time. Difficulties with touch can also be noted. While most patients find touch calming, some people may become very anxious if touched, even in such benign ways as a handshake. This, of course, depends on how the patient feels and also the feelings of counselors when they touch patients. Once again, the counselor’s sense of comfortable is communicated to the patient. Our nurse also emphasized that even emotionally withdrawn or psychotic patients that are not initially speaking, will often find questions about physical health less threatening than those regarding mental health. “I just tell them ‘You’re here in the E. R. I have to ask you these questions so answer me the best you can.” That gives them something to focus on that they can understand and respond to.” Straight forward discussion about conditions of health or illness in a calm, warm, reassuring manner, is often a means of organizing confused, frightened, and sometimes angry crisis patients.
It was gratifying for me, as leader, that many participants reported, after the workshop series, that they understood more about the crisis process and, due to new experience and orientation toward crisis, were more comfortable doing interventions. Some members reported greater comfort and interest in communicating and helping very disturbed patients on the in-patient unit, as well as crisis patients. They told of changing their style of communication. Because I continued to work with many of the participants on the in-patient unit, co-leading inpatient and family groups, discussion of the workshop techniques and approaches continued, even effecting styles of staff supervision.
At this point in the workshop I do not take a directive approach except to encourage Group members to develop roles of patients and alter-egos roles in Psychodramas about crisis situations. Most of the topics that members discuss in the Group come from their own experiences. This allows the Group to become creative and often very surprising. I have learned more about crisis and interventions during this time in the workshop than the information presented here. Possibly, the leader should learn as much as any Group member. Group members who, as psychiatric hospital staff, lead patient and family Groups for in-patients’ families, have tried out and practiced these techniques in their own Groups. They report and share experiences, including new approaches and ideas for Group communication development and role-playing. These Group members have later told me that they had learned methods of effectively directing role-playing and Psychodrama in their Groups. Often they share ideas with me that are new and interesting . I try to emphasize creation from the Group members themselves.
As the workshop Group becomes more involved, there is a deepening of common feeling between members. The various therapeutic ingredients developed in the Group have a helpful effect for all of us. Along with this process more and more personal events are shared. At times the role-play merges with real life situations in such a way that delightful and frightening experiences emerge. If the orientation toward dealing with crisis in constructive and comfortable ways is achieved, if not completely in any single individual, but, in the tone of the Group as a whole, these events may be carried out to very successful resolutions.
One member of the workshop Group, a psychiatric nurse, arrived exhausted and noticeably upset. He requested to play the patient and told the following story: He was depressed and had lost the will to live. When the role-counselor requested that he tell what had happened that brought him to this point of despair, he continued that he had had a very grueling exam that morning for a nursing specialty licensing class. When he arrived at work his immediate supervisor told him angrily to report to the senior clinical nurse who was her supervisor. The fact that this had been a joke only disconcerted him further. (The senior clinical nurse and supervisor were both excellent psychiatric nurses who often used playful humor with other staff to keep us both entertained and on our toes. She happened to touch an uncharacteristically exposed nerve. They had established trust among their staff and would have encouraged the types of issues, even with them, to be brought up in role-playing.) On top of this, his wife had called to tell him that, according to her OB/GYN, an expected child might very well be triplets. The part that rattled the role-counselor, as well as all of us watching, was that we knew that all the facts that he had described actually happened.
The role-counselor asked: (Seeming a bit unnerved.) “Wait a minute! Is this reality?!! I mean, this all happened to you today! Do you really feel that desperate?” (The role-patient had mentioned suicide.)
The nurse playing the role-patient replied that he was actually feeling confused, anxious, and somewhat depressed, but he was not about to kill himself. He did need to vent his anger and frustration though, including about the supervisory nurse who happened to catch him at an unusually vulnerable time. They normally got along very well and this was an opportunity to demonstrate creative use of Catharsis. He told the person playing her role: “Hey! You caught me at a really bad time for a joke. I was really feeling dumped on.” After continuing a First Round toward the Antagonist playing his present supervisor, he expanded this to past experiences with less sympathetic administrators. He even got a good deal of spleen off toward encounters he had as an army medic with marginally competent officers, including throwing a seat cushion at the Antagonist. Afterward, he told me that it felt good to get it off his chest, especially to an empathetic group. Their expression of concern, especially the role-counselor’s, was comforting. He also related that he could better understand the pressures that could suddenly hit anyone and drive them to the point of considering suicide, as well as the experience of relief from a warm, concerned listener. This may be extremely helpful in his job of caring for suicidal or very pressured and confused patients.
It was fun, a few months later, to present our role-play-patient with a video-tape that I had made as part of the training session in which he had played such an effective part. This was a present on the birth of his single son.
NOTES Chapter Six
Robert Paul Wolff: Kant’s Theory of Mental Activity (251:123-125) attempting to explain “Analytic Concepts of Subjective Deduction” from Kant’s Critique of Pure Reason describes a probably, young adolescent office boy given the assignment to produce a card game according to structural rules laid down by his boss, a toy store owner. He deals with multiple levels of consciousness, probably taking his mental work for granted, issues touched on in different ways by Piaget (increasingly complex developmental stages), Bateson (metalevels of consciousness), Russell (The concept ‘Logical Types’ is an example of a Logical Type. Therefore, a statement may be about itself. So: If the sentence ‘This sentence is a lie.’ is about itself, as it claims, it must be a lie which means that it is true, meaning that it is a lie, etc., etc.). You can step away and say “Stop it!” But some people may be hooked. A person who might be diagnosed with schizophrenia if he or she causes too much distress for their peers by not being able to disengage. “No matter what I do I’m a liar. These painful thoughts! They can’t be mine; I wouldn’t think such things. So you must be putting them in my head! Ah Ha! Get your thoughts—thoughts that think they are my thoughts—but think they are your thoughts out of my head!”. To return to Wolff from this mental excursion: The problem for the boy as one of “synthetic unity”: “The Paradox of a multiplicity which has unity without losing its diversity...” The boy has to deal with two or more types (actually two levels, many types) of rule directed activities: A) rules being made by his boss for the boy’s production of the new game. B) rules for how the rules that the boy is producing for the game are followed. (The boy’s job?) C) rules to play the game. (If the boy is expected to produce the game, what rules are demanded by the boss, and what is the boy supposed to produce?—a potential Double-Bind in the foundation of this whole drama!) D) and then, the rules of the game itself. [This may be similar to C , but if not, (e. g. structure vs. process), may be a source of confusion.) Then whether it will sell, something the boy is responsible for completely outside his control—the roots of the Double-Bind—and Capitalism as well. (Because you made the game, you’re responsible for this too!) My own (T. K. W.) take on this has to do with complications of rules of language and grammar (“truthiness”? See Wikipedia))—issues of semantics—while interpersonal higherarchical depersonalization structure the whole interaction, or on the other hand, the boss may be impressed and give the boy a raise and praise, i. e. the boy’s relationship with his boss. One of the other complications for the boy, that Wolff points out, is that there is no criteria for success (It sells? or the raise? or what would be interesting to the players?) To understand all of this, we have removed ourselves with a transcendental perspective. (Yeah, I’m pretty inelegant, or over analytic, with my Double-Bind examples.) Have you ever considered how complicated starting to work, keeping your job—communicating (getting along) with your boss(es) and peers, then becoming competent at your work is? WHEW!