Crisis intervention as a mental health process can be conceptually summarized in terms of crisis focus, crisis definition, development of intervention hypothesis, evaluation of intervention effectiveness, reconsideration of the crisis definition and the intervention hypothesis, formulation of new or modified intervention hypotheses, further evaluation, crisis reduction.  As we can see, the crisis intervention process is reducible to a formula or a series of steps.  Following that formula in actual crises with real people however, requires careful thinking, study, and practice.

Once you have a good feel for and understanding of the crisis intervention process and are oriented to the social interaction model presented here, you are ready to consider the specialized communication skills essential to effective crisis intervention.

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As we evaluate the effectiveness of our intervention, we should ask ourselves, Are the critical symptoms going away?  Are things getting better?  If our answer is Yes, then we need only follow our hypothesis; our understanding of what is happening, what happened, and what might happen; and our understanding of the individual and his total situation.  If our intervention is not working, then either our definition of the crisis or our intervention hypothesis is wrong.  We need to develop either a better definition of the crisis or consider alternative intervention hypotheses.  The result of this rethinking should be the development of a new or modified intervention hypothesis.  That new hypothesis is then reevaluated in terms of its effectiveness.

Mr. H contacts us with what seems to be a fairly concrete problem.  He and his wife live on Social Security, and their check is a few days late.  He is very worried about how they are going to pay their bills and is concerned because they will not have any money to buy food.  You ask him if he has called the Social Security office to ask about his check.  Your initial hypothesis is that Mr. H needs some specific suggestions.  He says that he has called the Social Security office and in the next breath asks if you will take him to keep an appointment at his doctor’s the next afternoon.  You tell him that you will not be able to take him; you suggest that he call someone in his church.  Maybe they will give him a ride.  Your hypothesis suggests that you should try to help him think of a way to get to his doctor’s office to keep the appointment.  Instead of responding to your suggestion, he tells you that his wife is sick and may have to go to the hospital.  At that point, you reevaluate your initial hypothesis, which said that Mr. H wanted information and suggestions, and try a new hypothesis that Mr. H wants to talk with someone about his wife.  As you continue talking with Mr. H, developing and testing out various intervention hypotheses, you finally come to the conclusion that Mr. H is lonely and simply wants someone to talk with.  You say to him, You seem rather lonely and sound as if it is good to have someone to talk with.  He responds to this in a positive way, confirming your new intervention hypothesis. …

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Our actual intervention is, surprisingly enough, the least complicated part of the intervention process, but it requires the most skill.  Once we develop our intervention hypothesis, our actual intervention only involves following through with that hypothesis.

Some further comments related to intervention hypotheses may be helpful.  Fundamentally, our intervention hypothesis in any given crisis can focus in only a few areas.  As we discussed, we can focus on the individual and attempt to get him to calm down, slow down, and plan ahead.  As varied as crisis situations are, this focus on the individual is by far the most common need in crisis intervention.  Later we will discuss crisis communication as a way of responding to this kind of individual need.  In addition to individual focus, our intervention hypothesis could relate to environmental modification or an attempt to change something or someone in the individual’s total situation.  In some crises, we may want to focus our intervention hypothesis on the interaction between the individual and his total situation.  At other times, we may want to direct our intervention hypothesis specifically toward reducing the now potential of the crisis.  If a man tells you that he is going to kill himself, one of your first questions should relate to how he proposes to accomplish that.  If he tells you that he is going to shoot himself with a gun that is lying on the table between the two of you, the now potential will be substantially reduced if you take the gun or at least make it inoperative.  If a mother tells you she is afraid that she is going to injure one of her children severely, it would be wise to get someone else to watch the children for a while.  What can you do or what can you get the individual to do, either to lower the now potential or to increase the self-resolution factor?  Your answer to that question in any specific situation is your intervention hypothesis.

Throughout our discussion of crisis intervention, we have considered numerous examples of crisis situations and of people in crisis.  Generally, intervention has been in terms of talking, thinking, responding to feeling, and helping the individual evaluate alternative plans of action.  Intervention has been primarily a verbal, feeling process.  There are however, many crisis situations in which we should try to either get the individual to do something specific or do it ourselves.  The example about the man who is going to shoot himself can serve to stimulate our thinking.  If someone tells us that he is thinking about killing himself, we should always try to find out how he proposes to do that.  If we are talking with someone on the hot line and he tells us that he is going to overdose with a bottle of tranquilizers he has in his bathroom, we will talk with him to try to get him to externalize and focus his anger.  At some point in our conversation, we will hopefully get him to agree not to kill himself.  If it is at all possible, we should get him to flush the tranquilizers down the toilet.  If possible, we want him to lay the telephone receiver down, go flush the medication, and come back to the telephone to tell us that he has done it.  Someone who is considering suicide in a serious way usually has a good idea about how he will do it.  If the person no longer has the bottle of tranquilizers, he will at least have to think up a new way of killing himself if he again becomes acutely depressed after talking with us on the telephone. …

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As we work with people in crisis, we develop an idea about what might reduce the critical effects of the crisis.  Based on our understanding of what is happening, what happened, and what is likely to happen, we work with the individual to develop an intervention hypothesis, or plan for modifying the causes or outcome of the crisis.  Our crisis focus then, combines with our focus on our intervention hypothesis.  What will probably help, of course, depends upon our intervention hypothesis and upon the precipitating event and possible unseen effects of the specific crisis.  Each time we intervene in a crisis, we develop an individualized intervention hypothesis with the person in crisis.  The specifics of that hypothesis are as individualized as the person and the crisis itself.  Frequently however, just getting the individual to settle down, slow down, and plan ahead is sufficient to resolve the crisis by helping the individual to a point where he can handle and work on the conflict himself.  In fact, if we do get him to settle down, slow down, and plan ahead, we have essentially reduced the now potential.  If he is then in a position to deal with the conflict himself, the self-resolution factor is substantially higher.  We defined a crisis as a conflict with a high now potential and a low self-resolution factor.  If, following our hypothesis, we have reduced the now potential and increased the self-resolution factor, we have effectively resolved the crisis.  Our intervention hypothesis is, of course, our idea about what will help.  What we can do to help in any particular situation depends, in large measure, on our experience and ingenuity.  Not to be underestimated however, is the effectiveness of developing and following our intervention hypothesis.  This, combined with our self-confidence, will come through to the individual and give him confidence also. …

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Recall our earlier example in which Dick learned of his wife’s marital infidelity.  Were we not to intervene, the outcome might be that Dick could pack his bags and leave.  As we look at that crisis, we see that the precipitating event (Dick’s learning of his wife’s infidelity) is not amenable to influence or change.  There is nothing that can be done to change that situation.  However, our intervention can lead to an alternative and less destructive outcome.  For example, through discussion and understanding, Dick may realize that leaving home immediately may be a less desirable option than staying at home until he and his wife work out other arrangements.  This does not mean that he necessarily will or should reconcile with his wife.  It only means that he stays at home until a better and less destructive plan can be worked out.  This enables Dick to avoid the possible snowball effect of leaving now.

As a further example, suppose the crisis involves a teenager who has left home and is tripped out on drugs.  As we think about his predicament with him, we learn that his leaving home was precipitated by a serious argument with his parents over curfew hours.  We became sufficiently involved with the teenager and his crisis so that we both understand that the curfew precipitated the crisis, and we have explored the possible consequences of being away from home and tripping out on drugs.  Intervention might be directed toward these undesirable consequences or effects of the crisis.  We may use the crisis communication skills (discussed in a later section of this text) to talk him down from his bad trip.  At the same time, we might encourage the teenager to consider the option of returning home and accepting the curfew and at the same time, with his permission, talking with his parents about the possibility of counseling or guidance for the family.  In crisis intervention, our goal is to modify or change the effects or outcomes of the crisis, modify or change situations or conditions precipitating the crisis, or achieve some change mix in both causes and outcomes. …

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At this point, we have combined an understanding of the crisis state with an insight into people in crisis.  We have learned how to assess a crisis, including ideas about its possible causes and effects.  We know how to involve the individual in the process of understanding what is happening, what happened, and what is likely to happen.  We are now ready to help the individual move toward crisis resolution because we have an idea about the possible causes and consequences of his specific crisis.  A superficially simple point is that crisis resolution necessarily involves either changing those factors, situations, or circumstances causing the crisis, or modifying the possible effects or outcomes of the crisis.

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To summarize the assessment set, we are clearly focused on the individual’s crisis.  We have it clearly defined.  We have assessed the individual and his total situation sufficiently to develop a picture of what is happening.  We have developed a causal explanation of the crisis that includes the precipitating event, and we have explored the cumulative and the unseen effects.  Basically, we are focused on the crisis and have a good idea about what is going on, what happened, and what might happen.  In addition, we have been sufficiently involved with the individual to enable him to develop a similar understanding of what is happening, what happened, and what is likely to happen.  Now we are ready to develop our intervention hypothesis—our possible solution.

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The final phase of the assessment comes after we have developed an understanding of the cause or causes of the individual’s crisis.  Our understanding of possible causes includes possible effects.  An example may serve to clarify the point.  Suppose your married daughter calls you one afternoon, and she is quite upset and crying.  From some of the things she says, you get that fear in the pit of your stomach that comes with recognition that someone may be suicidal.  At a minimum, she is confused and hysterical.  We have some ideas about what might have caused these intense emotions and feelings.  In addition, we know that people who become that upset are very caught up in their own feelings and emotions.  Frequently, one effect of this intense self-concern is to forget or to be unable to deal with other responsibilities, for example, the care of young children.  As you respond to your daughter and her crisis, discussion about her children may not develop spontaneously.  Our knowledge about this kind of crisis though, should prompt us to inquire about the children.  Where are they?  Who is taking care of them?  We know that one possible effect of the mother’s crisis may be her unintentional neglect of her children.  It is our responsibility to be aware of this possible effect of her crisis and to check out the situation.

As you think about the possible causes of a variety of crisis situations, you begin to develop notions of possible effects or undesirable situations that frequently accompany such crises.  Considering and thinking about this dimension of crisis intervention will stimulate your imagination and enable you to foresee possible consequences by drawing on your own experience and common sense. …

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Following from our considerations of crisis focus, crisis definition, and cumulative effects, let us now focus our attention on causes and effects.  Figure 4 indicates that our question is, What could cause a crisis like this one?  It is important to see that the question is not What did cause? but rather, What could cause?  For example, what could cause someone to want to kill himself?  What could cause someone to become extremely upset or hysterical?  What could cause a teenager to want to run away from home?  What could cause someone to want to quit his job?  What could cause someone to abuse or misuse drugs or alcohol?

The focus on could cause is, on one hand, a relatively simple notion but, on the other hand one that goes against our usual way of thinking about problems.  Typically, we look at a problem and want to know in detail, the situations, circumstances and events leading to the specific problem.  In crisis intervention however, we need to have in mind a set of likely causes of a variety of crisis situations.  When we are dealing with a person in crisis, we need to know the most likely causes of a crisis such as the one we now see.  For example, the three most likely causes for crises involving threats of suicide are: severe marital or family difficulty or disruption, having done something or having experienced a situation that causes extreme feelings of guilt or worthlessness, or some external event that threatens an individual’s social and/or economic well-being.  For each type of crisis situation with which we deal, there are one or more likely causes.  As we look at the individual and his crisis, we want to consider the kinds of things that probably have caused his crisis. …

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Once we have a clear crisis focus and a satisfactory definition of the crisis, our assessment turns to the individual and his situation.  Remember, we are not seeking full understanding in the psychiatric sense.  In crisis intervention, we concentrate on looking for immediate and potentially long-range cumulative effects.  The notion here is that crises tend to spread out or diffuse.  It is rather like the well-known snowball effect.  As a generalization, crisis tends to be contagious.  In any crisis, anticipated diffusion is included as a special part of the crisis definition.  Consider this very exaggerated example.  Suppose Dick’s crisis involves a severe marital disruption.  The precipitating event was a serious argument in which he learned of his wife’s marital infidelity.  We find him very hurt, frustrated, angry, and feeling that the only solution is for him to pack his bags and leave.  Let’s think about what the snowball effect (the potential cumulative effects) of his leaving might be.  If Dick leaves his wife, his boss might fire him.  If he loses his job, his wife may not have enough income to care for the children.  As a result of her frustration and discouragement, she may neglect them.  If she finds herself unable to care for the children, she may leave them with her mother, whom Dick and the children detest.  If the children are forced to stay with their grandmother, the oldest one (age sixteen) may run away.  If she runs away, she may get hurt or in trouble with the police.  If the police get involved, Dick’s friends and business associates may find out about it.  If they find out about it, his social position and interpersonal relationships may be jeopardized.  If that happens, he may become even more angry, hurt, frustrated, and at a loss as to what to do.

This example is, of course, quite exaggerated.  Nevertheless, we need to see that people in crisis tend to act in impulsive and sometimes self-destructive ways.  One of the main reasons for this is that they tend to be functioning less as rational, reasoning people and more as feeling, emotional, impulsive individuals.  Most crisis situations result because feeling and emotion have supplanted reasoning and planning.  Thus, it is difficult for people in crisis to think ahead, anticipate the consequences of their behavior and actions, or develop plans leading to a satisfactory solution for their problems.  This is, in large measure, what we mean when we judge a crisis to have a low self-resolution factor.  As we intervene into crises then, along with asking, What happened? we want to ask the individual, What ideas do you have for dealing with the problem? and What do you think will happen if you follow through with those ideas?  In that way, we can help him consider possible implications of his ideas and impulses and begin to help him think about alternative solutions and alternative ways of dealing with the crisis. …

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