W When a crisis strikes, clients need a counselor who listens and shares their heartache without meddling, says Amanda DiLorenzo-Garcia, American Counseling Association member and mobile aid coordinator for the Alachua County Crisis Center in Gainesville, Florida. She describes crisis counseling as short-term intervention in an acute situation with a single goal: to give the client security and to feel seen and heard.
Clients need someone who is "willing to be there, to be present and to feel uncomfortable," she explains. “We cannot help fix the situation; All we can do is help the customer bear it, survive it – and that is often heartbreaking. It challenges our humanity. … We have to make an effort to give space to the immense emotions of despair, sadness, hopelessness and helplessness, and that can be really uncomfortable. "
Part of life
Crisis counseling is a specialty within the counseling profession, but also a skill that all counselors must master, as crises will arise in everyday life for clients in all settings.
Thelma Duffey and Shane Haberstroh explain in the book Introduction to Crisis and Trauma Counseling published by the ACA that a crisis "is often an immediate, unpredictable event in people's lives – like a threatening medical diagnosis or a miscarriage". or get a divorce – that can overwhelm your natural coping. "
Crises can also occur when several stressors are present in the life of a client at the same time and an apparently small incident, such as losing the key and being locked out of the house, pushes him to the “end of his rope” and sends him into the house a downward spiral, says Ruth Ouzts Moore, associate professor in the counselor training department at the Chicago School of Professional Psychology.
Shock, denial and disbelief are often the first emotions clients experience in crisis situations, along with hopelessness and helplessness, says DiLorenzo-Garcia, who speaks at the ACA virtual conference on "Breaking Through Barriers to Provide Effective Crisis Support" co-lectured Experience last spring with Jessica L. Tinstman Jones and Amber Haley. A wide range of physical, mental, emotional, and behavioral symptoms can indicate a client is in crisis, she notes. (See list below.)
Moore defines crisis as the presence of a "risk of foreseeable harm" in a client's life, either immediately or in the short term. However, the client must not automatically disclose this risk factor in the consultation. Instead, her concern can often be a "plaster" or something more benign, she says, and it is up to the counselor to "peel off the layers" to assess the risk. This can be the case in particular with children who are referred to a counseling center because of behavior problems or because of the backlog in school. Sometimes crisis – like home abuse – can be the main cause of these struggles, notes Moore, an ACA member who specializes in working with children and adolescents who have experienced crisis and trauma.
Ali Martinez is a licensed marriage and family therapist and director of the Alachua County Crisis Center (where DiLorenzo-Garcia also works). In addition to mobile crisis response and personal counseling services, the center operates a local 24/7 crisis hotline and responds to calls from its Florida area to the National Suicide Prevention Lifeline. Most of the 45,000+ calls the agency answers each year are from people who feel completely alone when faced with something that feels threatening to them, Martinez says. These include losses that include the death of a loved one, as well as relationship, financial and other losses.
“Most [callers] are not suicidal, but they do have some level of pain – they are experiencing something big that has not been fully expressed and they are looking for space for it,” explains Martinez. “They are either really alone in what is facing them, or they feel alone in what is facing them. You are desperately looking for a sense of connection. They often know that we can't fix what is happening – and that's usually not what they're looking for. … The struggle with the crisis that creates the danger and real pain around a crisis is the feeling of how it separates us from people. The chaos, loss of control, and strong emotions can make us feel alone. So often on the hotline they try to manage this mess and find reassurance and connection – that what they feel is a normal response to an abnormal situation. People often need someone outside of their own world who will tell them that what they are feeling is okay and give them permission to express it. ”
Crisis is self-defined
People can express their feeling of being in a crisis very differently, but a common form that manifests it is tunnel vision, according to Martinez. In counseling, the practitioner may hear a client going through a crisis speak with a narrow train of thought or train of thought that keeps returning to a unique experience or feeling.
Customers in crisis can feel like they are drowning in emotion and that the problem that sent them into crisis is all-encompassing. Counselors may feel that their words are not reaching the client because the client's anger or desperation “fills the room,” says Martinez. Tending to the pain a client experiences during a crisis forces counselors to slow down their course of action.
When advisors "try to get [the client] to look long-term or take a bigger perspective, and they don't seem to do that and they keep coming back to this one painful thing, then we have to change our approach" . and realize that this is the most important thing for them at the moment – and we have to listen to that, "says Martinez.
Above all, consultants need to remember that “a crisis is defined by the person in it,” Martinez emphasizes. “For them it is a crisis when it is a crisis and we have to acknowledge that. Be aware that right now we may have a much broader perspective on the possibilities [in the client’s life] and we may have good ideas about what could happen, but you may not be ready to hear it. ”One of the most powerful things that what a counselor can say to a client in crisis is "tell me what this means for you," she adds.
Martinez gives an example of a 12-year-old teenager who is devastated after his first love affair ends with heartbreak. As an adult, it would be easy for a counselor to tell the teenage client that this is the first of many heartaches life will bring. However, the client will not be willing to focus on major lessons about relationships and themselves until the counselor has helped them deal with their initial pain and despair over the breakup.
“For them that's all – rejection and shame, sadness and despair. That doesn't make it any less of a crisis experience for them, ”says Martinez. "We [counselors] have to understand it from their thinking."
Josh Larson, a Licensed Professional Consultant (LPC) in private practice in Denver, agrees that the crisis must be defined by the client. He previously worked as a crisis clinician and operations and quality assurance specialist at Rocky Mountain Crisis Partners, a nonprofit that answers calls to multiple crisis hotlines around the clock, including the National Suicide Prevention Lifeline.
“We would always assure the caller that what he perceives as a crisis is a crisis. For a person, it could be that their cat has come outside and hasn't seen them for two hours [the cat] and they feel suicidal. For someone else, it's something much bigger or more complex, ”says Larson, an ACA member. "Even if what the client tells us would not be a crisis for us as practitioners, if he identifies it as a crisis, we must treat it as such."
Freedom to speak authentically
In the specialist literature there is no shortage of crisis counseling models and assessment instruments that practitioners can fall back on when working with clients. The consultants interviewed for this article did not recommend any particular model or framework. Instead, they encouraged practitioners to research and select the counseling approach that best suited their style and clientele.
Regardless of the model – or even if no model is used at all – a competent crisis counselor should shape a session into an arc that begins with building relationships and ends with connecting the person to resources. This last step ensures that the client has a safety plan (if necessary) and is aware of follow-up care options, such as: B. local counseling services, accessible crisis clinics and emergency numbers. In the middle of this arc, in the core and heart of the therapeutic interaction, counselors create a value-free and empathic space for the client to talk about his situation and to share his burdens.
The client speaks mainly in crisis counseling sessions, with most of the time being spent simply “letting him tell his story,” explains DiLorenzo-Garcia.
Given that some clients may have suicidal ideation during a crisis, an important part of this work becomes proficient in suicide assessment. DiLorenzo-Garcia and the other counselors interviewed for this article recommend that practitioners ask questions about a client's safety throughout the interview, including those that focus on suicide rating benchmarks and protective factors.
In some situations crisis counseling can offer clients the much-needed freedom to make strong statements without feeling judged or censored, notes Moore. This includes the freedom to talk about feelings such as anger or thoughts of harming yourself, which may be associated with shame or stigmatization.
This was the case of a 15-year-old client whom Moore had once counseled who had turned to drinking, using drugs, and other risky behaviors to help deal with the unrest at home, including feeling powerless when his father abused his father's mother. At the session, referring to a verbal abuse from his father, the teenager claimed, "I want to be an asshole." Moore did not shy away from using the client's profanity. Instead, she replied, "You're not an asshole." As she repeated her statement, the teenager began to cry and let go of pent-up emotions.
“He had a deep anger, resentment and betrayal that we had to talk about. He found freedom in being able to say these things in a safe environment, ”recalls Moore. "It was liberating that he could speak and hear so strongly as his advisor repeated it."
Many of the crisis calls to which DiLorenzo-Garcia's team reacts are in public schools. Sometimes they answer because a student called the county hotline himself, but most of the time it is because a school worker (a school counselor, headmaster, school resource officer, or administrator) called to ask for their help.
In such cases, DiLorenzo-Garcia often starts a private session with a student by explaining the context why the school asked her to speak to them. She assures the student that she is not in trouble and that she is there because people are worried about her. For example, you might say, “I heard this from your school counselor, but I'm curious to see what your perspective is. What's going on with you? "
“This is the door opener. I assure you, “I don't want to make any assumptions about you. Your experience is yours, and I want to understand it, "says DiLorenzo-Garcia, a postdoctoral fellow at the University of Central Florida whose dissertation was on the experience of loss and growth experienced by mass shooting survivors and their families.
If the client's experience includes suicidal thoughts, it can help both the client and the counselor realize how serious those thoughts are, adds DiLorenzo-Garcia. Sometimes a client has thoughts of suicide but does not want to die, which can be accompanied by feelings of shame or isolation. If a client has a specific plan to end their life, discussing it can help determine whether or how quickly the client could implement that plan – and the need for follow-up care.
Assessment of customer needs
Larson notes that the majority of callers were not suicidal while at Rocky Mountain Crisis Partners. However, some callers said at the beginning of the call that they were not suicidal, but as the conversation moved on and they started unpacking the depths of their emotions it became clear that they were indeed suicidal, he says.
This aspect of crisis counseling is the reason why it is essential for counselors to be familiar and competent with suicide assessment. A counselor should be able to assess preparatory behaviors, substance problems, a client's internal and external coping mechanisms, and other benchmarks to determine next steps, including safety planning or follow-up counseling, says DiLorenzo-Garcia.
Moore says it is important to be concerned with assessing thoughts of suicide as well as thoughts of killing when clients are in crisis. She admits that practitioners may find it uncomfortable to ask questions about intent to kill. However, the counselors must bear in mind that in times of crisis clients could also think of harming others and themselves, she says.
"Ask yourself these difficult questions: 'Do you have the thought of killing yourself or harming others?' Don't gloss over it," says Moore, who moderated the "One Size Doesn't Fit All: Creative Strategies" session for Counseling Diverse Familien in Crisis ”at the ACA's Virtual Conference Experience.
Larson points out that de-escalation is a large part of crisis counseling in addition to active listening, confirming a client's concerns and ensuring security. This may include mini-versions of deep breathing and other grounding skills that clinicians could use in long-term counseling sessions with clients.
It can be helpful to match the person's affect level, says Larson. For example, a counselor should not respond in a flat, monotonous voice to a person who is hysterical. Instead, mirror them in a slightly calmer tone to gradually de-escalate the situation, he advises. Likewise, a crisis counselor should not respond with a bright, bubbly demeanor to a client who is monotonous or expressionless. Instead, mirror your tone on a slightly more expressive level to gradually lift your affect, he says.
In crisis counseling, de-escalation and the opportunity to talk about their feelings are sufficient for some clients, continues Larson. Others will seek help solving problems, such as conflict resolution or the next steps to take after an overwhelming health diagnosis. But Larson notes that in times of crisis, customers typically look for one or the other, not both. Therefore, he advises counselors to be open and ask those in crisis, “What do you need? Would you like someone to listen or to help you [someone to] with problem solving? ”
"If you offer solutions to someone who doesn't want them, it can create another crisis," adds Larson. Instead, he can tell his customers: "I listen and I am ready to offer solutions if you are looking for them."
In the case of suicidal thoughts, DiLorenzo-Garcia finds it helpful to concentrate on the short-term with clients. For example, she might say, “There is a lot to ask to live forever or to live until next year, but now let's talk about whether you can live until tomorrow. What could that look like? Can you withstand the pain you're going through just for tonight? What would it look like to survive and go back to school tomorrow? "
The advisors interviewed for this article emphasize the importance of organizing follow-up after a crisis meeting, but say that involving the police in carrying out social checks on a person in crisis should only be a last resort.
“Always chase someone who is in crisis, even if your session ends well and it sounds like things are going to work out,” emphasizes DiLorenzo-Garcia. Your agency contacts each client within three days of the initial crisis consultation to make sure they are supported and are fine. In the school environment, she also carries out debriefings for the adults involved in caring for the student (e.g. parents, school counselors) to ensure that they know the needs of the student and the next steps after crisis counseling.
Customer security
Meredith McNiel, an LPC who co-wrote the “Crisis and Trauma Counseling with Couples and Families” chapter in Introduction to Crisis and Trauma Counseling, states that practitioners should focus on customer safety through three lenses during crisis counseling :
Feeling secure in expressing yourself fully in crisis counseling
Feeling safe at home and in the world outside of the counseling sessions
Feeling safe in their life, including protective factors and social connections
An important part of this focus, she says, is to remind clients (several times if necessary) that the counseling session is a safe and confidential space to freely talk about their experiences.
Clients can reveal dark and powerful thoughts such as suicidal or killing thoughts during crisis counseling, and McNiel admits that the first instinct of many counselors is to refer these clients to more intensive treatment. However, the practitioner must enforce this first reaction in order not to break the trust of the clients.
"If a counselor is concerned, nervous, or afraid to deal with a situation, the client will feel it," says McNiel. “We need to feel comfortable asking tough questions and at the same time supporting the client.” The counselor should allow the client to say what to say in the session and “hold this space” without trying to answer hers To improve the situation, she emphasizes.
“In a suicide crisis meeting, many professionals [automatically] might think, 'Where can we send you?' And in my experience this is the absolute last resort. If a client hears they're being hospitalized or referred to someone they don't know or trust, they can immediately lose confidence in a counselor, ”said McNiel, an ACA member with a private counseling practice in Austin , Texas. Instead, "leave the session entirely as the client needs to share, or approve and process, and go from there," she advises. “I assure you [the client] that if something has to happen, we will decide it together. I will not control what will happen. I remind them that they are in control of their circumstances. ”(For more information on the ethical guidelines for protecting clients from“ serious and foreseeable harm ”see Standard B.2.a. of the 2014 ACA Code of Ethics at consulting.org/ethics.)
Crisis counseling is "less clinical and more relational" than long-term counseling, explains McNiel, who was a crisis counselor at the University of Texas at the San Antonio Academy for Crisis and Trauma Counseling during her LPC internship. Practitioners need to have clients share their experiences and talk through "until they feel complete" – whatever that looks like to them.
To ensure that a client's safety and comfort are central to crisis counseling, practitioners must be familiar with the assessment tools that they do not have to read the questions off a piece of paper or computer screen, says McNiel, whose PhD thesis dealt with college counseling with students at risk of suicide. "[Instead of] say, 'hold on, I'll take this checklist and I'll ask you some questions' … ask questions in a relational way and then fill in the assessment instead of breaking the flow of a session," she says. Counselors should get "answers [from the client] through discussion rather than interrogation."
For example, an assessment tool might prompt a counselor to ask the client, “Are you thinking about killing yourself?” Practitioners still need to ask direct questions about thoughts of suicide, but formulate those questions in a more dialogical way, helps maintain confidence, notes McNiel. Alternatively, the counselor could say, “I can see and hear that you are really struggling with this situation. You told me you were thinking about killing yourself and that makes sense considering what you've been through. I wonder how close you are to it? How close are you to going home and [on those feelings] through? "
"The difference [in phrasing it this way] is the compassion in the language that surrounds these really tough questions," she notes.
At the end of a crisis session, counselors should discuss next steps with the client, including what the client would do if things got worse and a crisis re-emerged after the session, says McNiel. If the client is a long-time client, she advises planning the next session and informing you how and when the advisor can be reached outside of business hours, as well as the numbers of the crisis hotline.
Martinez agrees that crisis counseling practitioners should resist the urge to "fix" the client's situation. In addition, counselors should avoid viewing it as a linear cause and effect. This includes thinking about suicidal thoughts in binary terms of yes or no.
"We have to think of suicide on a much broader continuum, a series of pain and despair," says Martinez. "[Society’s] Fear and the stigma surrounding suicidality make us think it's an on or off switch, but it's more complicated."
Crisis is, by definition, chaotic and chaotic, and the aim of crisis counseling is to de-escalate and share this burden instead of organizing or rearranging it. Martinez illustrates this with a metaphor of a cluttered pile of sticks on the floor. A consultant's instinct might be to gather the sticks and put together a neat structure for the client, she says. Instead, crisis counseling consists of allowing the client to pick up the sticks one at a time and assemble them as needed – even if it's just another pile on the floor that looks just as messy to an outsider. "It's much more powerful than trying to find out where the sticks belong," says Martinez.
When a counselor approaches a crisis counseling session with the aim of following a client's story in context, the counselor will miss the full range of the client's emotions – and the chance to connect and help the client relieve that pain to endure, says Martinez. “We can get caught up in [feeling that]: 'I have to make sense of the story.' But that's our need, our desire. The customer may not need it or may not be ready for it. … When they talk and are listened to, they often begin to make sense of it themselves. "
Take care of yourself
The consultants interviewed for this article agree that it is imperative for practitioners who provide crisis counseling to take steps to avoid burnout. In addition to regular self-care, this may include ongoing supervision or consultation with colleagues, as well as other methods to combat feelings of isolation and empathy fatigue that can easily overwhelm practitioners whose clients share such difficult and troubling issues.
Moore suggests that counselors take steps to maintain a balanced sample size and be aware of how stress and burnout manifest themselves for them personally. “Doing trauma and crisis work is a difficult thing. It can be super rewarding, but also super draining, ”says Moore. “We carry [clients’] trauma with us, so it is important to take care of ourselves. … Unfortunately we need more and more advisors for crisis work, and if you don't take care of yourself, that's one less adviser who helps people who need them. ”
It's also important to remember that sharing the burden of the crisis with customers is a gift, says Larson. A crisis counselor can be the only person the client can speak to in their deepest moments.
"It takes a lot of courage to pick up the phone and tell a stranger [a crisis counselor] that you want to die," says Larson. "Always remember that it is an honor and a privilege to hear people's toughest things – their deepest and darkest secrets."
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Bethany Bray is the senior writer and social media coordinator for Counseling Today. Contact them at [email protected].
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Opinions and statements in articles appearing on CT Online should not be construed as the opinions of the editors or guidelines of the American Counseling Association.
