31 Dec Please see Attachments for required reading? It is common for social workers to be presented with a crisis situation brought forth by clients, families, communities, and/or organizations. T

7 Social Work Theory and Practice for crisis, disaster, and Trauma page 117-130

Turner, F.J. (ED.) (2017). Social work treatment: Interlocking theoretical approaches (6th Ed.) New York, NY: Oxford University Press.

A crisis is “an acute emotional upset arising from situational, developmental, or socio- cultural sources and resulting in a temporary inability to cope by means of one’s usual problem-solving devices” (Hoff, Hallisey, & Hoff, 2009, p. 4). Parad and Parad (1990) expand upon this definition by describing a crisis as “an upset in a steady state, a turning point leading to better or worse, a disruption or breakdown in a person’s or family’s normal or usual pattern of functioning” (pp. 3–4).

As these definitions convey, crises take many forms, including the sudden death of a family member; a school shooting; poverty; a devastating hurricane or earthquake; homelessness; diagnosis of a chronic or life-threatening illness; job loss; sexual assault; family, domestic, and intimate partner violence; psychosis; divorce; retirement; physical and sexual abuse; rape or

sexual assault; a family’s immigration from a war-torn country; suicidality; and homocidality. While some social work practice settings specifically provide crisis intervention services such as hospital emergency rooms or mobile crisis programs, most social workers encounter crises, at various times, in all practice settings, with all client populations.

In response to a wide range of crises, traumatic events, and disasters, many people experience significant distress, do not function at their normal levels, and are in danger of ongoing dysfunction if they do not receive appropriate help in a timely way. In a similar manner, organizations and communities experience these reactions in response to crises and disaster. As is the case with the individuals within it, the organization or community’s continued health and ability to function effectively will

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depend on receiving prompt and effective crisis intervention.

Danger and opportunity (Hoff, Hallisey, & Hoff, 2009; Knox & Roberts, 2008; Parad & Parad, 1990; Slaikeu, 1990), as represented by two symbols in the Chinese language for crisis, are two words that are frequently associated with crises. “Danger” describes the states of disequilibrium and vulnerability that can result from a crisis and the possibility that individuals will experience long-term distress and impaired functioning. “Opportunity” describes the unexpected possibilities that exist for growth and development when individuals discover previously unknown or underutilized resources and strengths within themselves or their support systems as a result of a crisis. This opportunity for growth results from the markedly increased abilities individuals have for developing alter- native coping mechanisms when they experience a crisis (Parad & Parad, 1990).

Crisis theory and intervention are historically integral to the social work profession. However, over the past decades, as a result of events such as the September 11, 2001, World Trade Center and other terrorist attacks, more frequent natural disasters related to climate change, and dramatic increases in school and violent mass shootings, social workers have increasingly been called upon to help people respond to a wide range of public emergencies (Mirabito, 2012; Patterson, 2009). Consequently, disaster mental health has become an area of expertise for social workers across all fields of practice, including in hospitals, schools, agencies, and within communities (Carp, 2010; Mirabito, 2012; Pomeroy, 2009).

As direct practice providers and as members of crisis teams, social workers are frequently leaders in providing crisis intervention ser- vices to individuals, families, and groups, as well as within organizations and communities. Therefore, in addition to crisis intervention skills for direct practice, it is equally important for social workers to develop an enlarged vision of practice that focuses on the strengths and resilience of individuals, organizations, and communities that have experienced chaos (Carp, 2010). As highlighted by Patterson (2009), social workers need skills in the pro- vision of micro interventions to assist victims

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and survivors of disaster, as well as mezzo and macro skills to intervene with complex systems and entire communities. As a result of the training and education social workers receive in both clinical and organizational responses to crisis and trauma, they are often better prepared than other professionals to provide crisis intervention in the aftermath of a traumatic event.

History of Crisis Theory and Intervention in Social Work

Crisis theory and crisis intervention have a rich history in the social work profession, which developed largely during the time period from the 1950s through the 1980s, in collaboration with leaders from other disciplines including psychiatry, psychology, and community and public health. Important contributions that led to the development of crisis theory included observations of soldiers in combat, research on grief and mourning, the expansion of suicide prevention programs, and the proliferation of crisis-oriented services resulting from federal policy initiatives to develop community mental health, disaster relief, and victim services.

Eric Lindemann and Gerald Caplan, both psychiatrists, were the first professionals to conceptualize and develop crisis theory and intervention and are considered the “pioneers” or “grandfathers” of this area of practice (Knox & Roberts, 2008). In 1944, Eric Lindemann, a com- munity psychiatrist affiliated with the Harvard Medical School and Massachusetts General Hospital, observed, evaluated, and treated 101 survivors and close relatives from the devastating 1942 Coconut Grove nightclub fire, which killed 493 people (Roberts, 2008). In his seminal paper, “Symptomatology and Management of Acute Grief,” Lindemann (1944) described a predictable sequence of stages during the grief process. He further established that the duration and severity of grief reactions depended on the success with which the bereaved were able to mourn their multiple losses (Knox & Roberts, 2008; Lindemann, 1944). One of Lindemann’s key contributions was his belief that clinical interventions prevented psychopathology, leading to his development of the first community mental health center for bereaved disaster victims and their families (Roberts, 2008).

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Gerald Caplan, also a psychiatrist, built on Lindemann’s concepts about grief and mourning by extending our understanding about the significance and impact of normative and developmental life transitions and extraordinary traumatic events (James & Gilliland, 2013; Knox & Roberts, 2008; Regehr, 2011). Caplan (1981) is credited with advancing the field of preventive psychiatry and psychiatric consultation by developing community-based programs for early intervention of situational stress and also for training medical and mental health professionals to intervene in critical life transitions (Goldstein & Noonan, 1999; Roberts, 2008).

Observations of soldiers during World War II and the Korean and Vietnam wars who suffered from “combat fatigue” or “combat neurosis,” now conceptualized as post-traumatic stress disorder (PTSD), led mental health practitioners to understand that soldiers who were exposed to traumatic events could be treated effectively with immediate, brief therapy, at or close to the front lines of battle (Goldstein & Noonan, 1999; Parad & Parad, 1990; Roberts, 2000).

Pivotal developments during the 1960s and 1970s included the expansion of community mental health services and suicide prevention hotlines, funded through the Community Mental Health Centers Act of 1963, which contributed significantly to the development of crisis intervention services. In 1958, Bellak developed the first psychiatric emergency 24- hour walk-in clinic in the United States at Elmhurst Hospital in New York City (Parad & Parad, 1990). Funding through the com- munity mental health movement established 24-hour emergency and crisis intervention ser- vices, which rapidly expanded from 376 centers across the country in 1969 to 796 centers in 1980 (Roberts, 2000). Suicide hotlines were first established in 1906 by the Salvation Army in London, England, and the National Save-a-Life League in New York City; between 1968 and 1972, almost 200 suicide prevention programs were established throughout the United States (Knox & Roberts, 2008; Roberts, 2000). Federal funding from the National Institute of Mental Health established the Disaster Relief Act of 1974, which provided support for brief crisis services to victims of disaster as well as training

for professionals who provided crisis intervention services (Parad & Parad, 1990).

Throughout the 1960s and 1970s, social workers expanded upon the pioneering work of Lindemann and Caplan by further conceptualizing and integrating key concepts of cri- sis theory and intervention into social work practice. Rapoport (1962, 1967) advocated that clients have rapid access to crisis intervention services and developed the phases of engagement, assessment, and goal setting in crisis intervention services (Roberts, 2000). Golan (1978) delineated the components of “the crisis situation” (p. 7), described later in this chapter. Strickler (1965) identified similarities between crisis intervention and social casework and also recommended that the short-term, focused nature of crisis intervention required modifications in traditional casework practices. Parad & Caplan (1960) and Hill (1958) applied crisis theory and intervention to social work practice with families (Ell, 1996). Other important social work contributors included Kaplan (1962, 1968); Jacobsen, Strickler, and Morely (1968); and Smith (1978, 1979). Parad and Parad (1968a; 1968b) conducted a major descriptive study of 1,656 cases that provided evidence, from both clients’ and clinicians’ perspectives, that demonstrated planned, short-term crisis-oriented treatment as an effective intervention.

Key Concepts of Crisis Theory

Naomi Golan (1978) conceptualized the “crisis situation” (p. 7) as composed of five components: the hazardous event, the vulnerable state, the precipitating factor, the state of active crisis, and the stage of reintegration or crisis resolution (pp. 63–64). Golan described these five components of the “crisis situation.”

The Hazardous Event

The hazardous event is a specific stressful event occurring in a period of relative stability. Changing the previous state of stability, it may initiate a chain of events that further disrupt the previous state of equilibrium. Hazardous events can be anticipated and predictable, resulting in developmental crises, which are experienced during normative developmental stages such as adolescence, aging (adulthood) and retirement,

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or the birth or adoption of a child. In contrast to developmental crises, situational crises are unanticipated or unexpected and are often sudden, such as job loss, parental divorce, sexual assault, sudden death, a school shooting, a hurricane, or a terrorist attack.

The Vulnerable State

The vulnerable state describes the individual’s immediate and longer-term response to the hazardous event. Common distressing reactions include anxiety, depression, mourning, shame, guilt, anger, and cognitive or perceptual confusion, as well as potentially positive feelings of hope, challenge, and excitement.

The Precipitating Factor

The precipitating factor is the “straw that breaks the camel’s back” (Golan, 1978, p. 66), or the factor in a chain of events that can convert the vulnerable state into a state of disequilibrium.

The State of Active Crisis

The state of active crisis describes the disequilibrium that occurs once an individual’s previous coping mechanisms have broken down. In this state, predictable responses are experienced, including physical, emotional, and cognitive imbalance, as well as preoccupation with the events that led to the crisis. During the state of active crisis, previous defensive and coping mechanisms are ineffective, and individuals are typically highly motivated to accept and utilize assistance. As aptly described by Rapoport (1967), “A little help, rationally directed and purposefully focused at a strategic time, is more effective than more extensive help given at a period of less emotional accessibility” (p. 38). Individuals do not remain in this state of active crisis indefinitely. The time frame for the state of active crisis is variable, though it is time- limited, often described as lasting from one day to four to six weeks (Regehr, 2011).

Two pathways lead to a state of active cri- sis: the precipitating factor can activate a previous vulnerable state that may have been caused by a prior hazardous event(s) or the precipitating factor may be same as the hazardous event. For example, the September 11th terrorist attacks were for some individuals the precipitating fac- tor that activated a vulnerable state created by

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a previous hazardous event(s), while for others, the September 11th terrorist attacks were the precipitating factor.

The Stage of Reintegration

or Crisis Resolution

The stage of reintegration or crisis resolution is the final component in the “crisis situation,” during which individuals struggle to master a cognitive perception of what has occurred, as well as release and accept feelings related to the crisis. In the final stage of reintegration and resolution, new patterns of coping are developed and environmental supports are identified and utilized, which can include access to, and use of, social work intervention (Mirabito & Rosenthal, 2002; Rosenthal-Gelman & Mirabito, 2005).

Key Concepts of Disaster Theory

“Disaster” is defined by Golan (1978) as “a collective stress situation in which many members of a social system fail to receive expected conditions of life, such as safety of the physical environment, protections from attack, provision of food, shelter, and income, and the guidance and information necessary to carry on normal activities” (p. 125). Disaster is followed by three predictable phases: (1) the impact, (2) recoil and rescue, and (3) recovery phases, (Hoff, Hallisey, & Hoff, 2009; Raphael, 2000).

Victims experience the reality of the disaster in the impact phase, during which they are concerned about their survival in the immediate present. One sees a wide variety of common reactions during this phase, ranging from people remaining calm and organized, to becoming shocked, confused, hysterical, and paralyzed with fear (Hoff, Hallisey, & Hoff, 2009). In the aftermath of a disaster, victims may be surprised that they were able to function as well as they did during the impact phase.

Rescue activities begin during the recoil and rescue phase. The wide range of common physical and emotional reactions during this phase includes denial, shock, numbness, flash- backs, nightmares, grief and sadness related to potentially devastating loss, anger, despair, and hopelessness (Raphael, 2000). Survivors of the disaster may feel relief and elation, though these reactions are difficult to accept if destruction

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and devastation have occurred. “Survivor guilt” may be experienced if death or injury occurs that they were unable to prevent, or if they do not understand why they survived while others died (Lifton, 1982).

During the recovery phase, individuals and the community face the complex task of returning to a new state of “normal.” A primary goal during this prolonged phase is to regain a pre-crisis state of equilibrium. At the outset, individuals and communities may experience an outpouring of altruism and interpersonal connectedness in response to the disaster. Following this initial stage, referred to as the “honeymoon period,” a period of disillusionment frequently occurs in which realities of the devastation and loss brought about by the disaster must be faced and resolved (Mirabito & Rosenthal, 2002; Raphael, 2000).

Key Concepts About Trauma and Traumatic Events

Types of Trauma

Traumatic events are extraordinary situations that are likely to evoke significant distress in many people. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM- 5; American Psychiatric Association, 2013), defines traumatic events as “exposure to actual or threatened death, serious injury, or sexual violence” (p. 271) by direct experience, witnessing it, learning that it occurred to others, or experiencing repeated exposure to the details of it. Traumatic events include exposure to war, physical assault, childhood physical abuse, threatened or actual sexual violence and abuse, being kidnapped or taken hostage, terrorist attacks, torture, natural or human-made disasters, and severe motor vehicle accidents (American Psychiatric Association, 2013, p. 274).

Traumatic stressors may be discreet, one- time events, “Type I trauma”; or ongoing, chronic life circumstances, “Type II trauma.” Type I traumas are acute, “single-blow” traumatic events such as suicide, homicide, sudden accidental death, rape/sexual assault, acute ill- ness, transportation accidents, natural disasters, (e.g., tornadoes, hurricanes, earthquakes, and wildfires), and rare overwhelming events,

such as school shootings, hostage takeovers, or terrorist attacks.

Type II trauma, also known as “complex trauma,” is defined as multiple, repetitive, and continuous trauma (Terr, 1991), such as ongoing physical or sexual abuse, domestic violence, community violence, war, genocide, experiences of combat or concentration camps, being a prisoner-of-war, or the victim of political torture (Courtois & Ford, 2009). Type II trauma may be perpetrated by an individual known by, or related to, the victim, and can be accompanied by a betrayal of trust in primary relation- ships (Courtois & Ford, 2009). Complex trauma can have significantly detrimental effects on emotional and behavioral regulation and stability; the ability to think, learn, and concentrate; impulse control; self-image; and attachment relationships with others. Complex trauma is associated with a wide range of problems, including addiction, chronic physical conditions, depression and anxiety, self-harming behaviors, and other psychiatric disorders (National Child Traumatic Stress Network, http://www.nctsn.org,

2014). Treatment for complex trauma includes a range of trauma-specific service models for children, adolescents, and adults (Jennings, 2008). For example, trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based approach for the treatment of complex trauma that develops resiliency-based coping skills with children and adolescents and utilizes active parental involvement to support the treatment goals (Cohen, Mannarino, & Murray, 2011).

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a syn- drome of persistent reactions following a traumatic stressor that is diagnosed when a combination of symptoms in four categories have persisted for one month or more and when the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013). The four categories of post-traumatic symptoms identified in the DSM-5 (American Psychiatric Association, 2013) include: (1) intrusion symptoms, (2) persistent avoidance, (3) negative alterations in cognitions and mood, and (4) hyperarousal and reactivity.

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Intrusion symptoms include recurrent, involuntary, and intrusive distressing memories of the traumatic event, such as distressing dreams, intense psychological distress or physiological reactions to internal or external cues (triggers) related to the traumatic event, and dissociative reactions (e.g., flashbacks, dreams, nightmares) in which individuals can visualize the traumatic event and feel as if it is happening again (American Psychiatric Association, 2013). Dissociation can serve as a protective mechanism in the aftermath of a traumatic event to shield the individual from the full realization of the horror that has occurred. With dissociation, the individual is unable to remember details of a traumatic event, or experiences numbness or disbelief that the trauma occurred.

Persistent avoidance includes conscious and purposeful avoidance of distressing memories, thoughts, and feelings, and of situations, places, and people associated with the traumatic event. In efforts to avoid strong feelings that may be overwhelming, individuals may be reluctant to return to places where a trauma occurred and may consciously avoid talking about a traumatic event.

Negative alterations in cognitions and mood

include:

Inability to remember an important aspect of the traumatic event(s); Exaggerated negative beliefs about oneself, others, or the world; Persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the individual to blame himself/herself or others; Persistent negative emotional states (e.g., fear, horror, anger, guilt, shame); Decreased interest or participation in significant activities; Feelings of detachment from others; Inability to experience positive emotions. (American Psychiatric Association, 2013, pp. 271–272)

Hyperarousal and reactivity symptoms include alterations in arousal and reactivity associated with the traumatic event. Symptoms include “Irritable behavior and angry out- bursts; Reckless or self-destructive behavior; Hypervigilance; Exaggerated startle response; Problems with concentration; Sleep disturbance” (American Psychiatric Association, 2013, p. 272). In the aftermath of a traumatic stressor, people frequently report having difficulty sleeping, an increased startle reflex, and

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“jumpiness” or anxiety, including fear that the traumatic event could happen again.

Acute stress disorder (ASD) includes the same symptoms as PTSD; however, symptoms are present for three days to one month following exposure to the traumatic event. The DSM-5 (American Psychiatric Association, 2013) includes distinct criteria for symptoms and reactions pertaining to children six years old and younger. Frequently, PTSD coexists with other psychiatric disorders such as anxiety, depression, conduct disorders, and sub- stance abuse. As described by Santucci (2012), “While comorbidity among psychiatric disorders is high, with PTSD it appears to be the rule rather than the exception” (p. 124).

Many traumatic events include the threat or actuality of death, and almost all deaths involve trauma as well as grief. Many of these deaths are by suicide, homicide, or sudden accidents, and many involve violence, which can elicit both trauma and grief reactions. When grief and post-traumatic symptoms are both present, post-traumatic reactions must be attended to first, before the grieving process can proceed (Nader, 1997).

Reactions to Trauma and Predictors of Distress

Although traumatic events are defined as extraordinary situations that are likely to evoke significant distress in a large proportion of the population, many individuals experience only mild, transient responses and symptoms in response to trauma. For those who are resilient in the face of traumatic events and do not develop post-traumatic symptoms, stress can lead to adaptive and constructive psycho- logical growth (Bonanno, 2004). While many people who experience positive outcomes from traumatic events utilize social work intervention and support, others handle traumatic stress with their own natural support systems (Mirabito & Callahan, 2016).

Three key variables that predict the intensity of post-traumatic reactions are the meaning of the event to the individual, the amount of past exposure to trauma, and the level of social sup- port available (Webb, 1994). The meaning that an individual attaches to a traumatic event

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is particularly important in predicting and understanding her or his response (Lazarus & Folkman, 1984). Individuals who attach malignant meanings to traumatic events have higher levels of distress, while those who are able to find benevolent or positive meanings in these events fare better. Furthermore, there appears to be a natural inclination to try to find some positive meaning in the aftermath of a trauma, and eventually many people find satisfaction in having survived and in having done the best they could under the circumstances.

Another key factor that has an impact on the outcome of traumatic experiences is the amount of prior trauma an individual has experienced. Individuals who have experienced multiple traumas, a lack of family support, or other risk factors such as mental health or other emotional concerns are more likely to be severely affected by trauma. Conversely, individuals who have protective factors, such as stable and supportive environments, and who possess the personal qualities of “resilience” or “hardiness” are better able to withstand stressful events.

Finally, social support plays an important role in protecting an individual from the severest impact of traumatic stress. Numerous studies of normative and traumatic stress have demonstrated that individuals with supportive families and friends cope with trauma more effectively than those without supportive social networks.

Social Work Intervention

in Crises, Trauma, and Disasters

Practice Principles for Crisis Intervention

Parad and Parad (1990) define crisis intervention as “A process for actively influencing psychosocial functioning during a period of disequilibrium in order to alleviate the immediate impact of disruptive stressful events and to help mobilize the capabilities and resources of the persons affected by the crisis” (p. 4). Goals of crisis intervention include managing the immediate crisis, and strengthening the coping and problem-solving strategies of the individual, family, group, organization, or community for the future. The practitioner intervenes at whatever level is necessary—micro, mezzo, or

macro-to help the client system return to the previous state of equilibrium. As noted earlier, while the goal of crisis intervention is to return to the pre-crisis level of functioning, some individuals achieve either a higher or lower level of functioning in the aftermath of a crisis.

Crisis intervention uses the strengths perspective that is central to social work practice to help individuals mobilize their own strengths, assets, and capacities as well as to identify the resources and supports that exist in their environments, including within families, social networks, neighborhoods, and communities. In combination with the strengths perspective, an empowerment approach is used to help clients access and use inner and environmental resources. Ego psychological techniques are also utilized to assess the individual’s level of functioning, coping, and adaptation (Mirabito & Rosenthal, 2002).

Consistent with the social work strengths and empowerment approaches and ego psychology concepts, intervention in situations of cri- sis, trauma, and disaster employs the following key practice principles (Ell, 1996; Rosenthal- Gelman & Mirabito, 2005):

• Help is provided immediately, including out- reach to populations who may not otherwise seek assistance. For example, in the case of a school shooting or natural disaster affecting the entire community, active outreach, such as home visits to isolated residents or holding community meetings, may be provided to reach all community members who are in need.

• Interventions at the time of the crisis or disaster are time-limited and brief. Since the “cri- sis state” is time-limited, often lasting four to six weeks, interventions are focused on the immediate crisis with referral for longer-term services, as needed.

• The social worker takes an active, often directive, role in helping efforts. During the assessment process, the practitioner engages quickly and explores sensitive and potentially difficult areas, such as abuse and neglect, violence, suicidality, and dying or death.

• The primary goal of intervention is the reduction of symptoms and a return to the earlier state of equilibrium. While the focus

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of intervention is on the immediate problems, crises can reactivate past, unresolved problems, and provide a “second chance” to rework earlier problems reactivated by the current crisis (Goldstein & Noonan, 1999; Mirabito & Rosenthal, 2002).

• Interventions include a combination of counseling to handle emotional concerns, the pro- vision of practical information and concrete community resources, and the mobilization of social and environmental support systems.

• The expression of feelings, symptoms, and worries is encouraged. Intervention strategies such as education, clarification, and reassurance about the normative, expectable reactions to crisis and trauma help individuals reduce their intense fear and anxieties.

• Strategies for problem-solving and effective coping are encouraged and supported to help individuals return to a state of equilibrium.

The immediate, time-limited nature of crisis intervention requires that engagement, assessment, and interventions all occur in an expeditious manner to ensure that prompt assistance is provided. This approach capitalizes on the “win- dow of opportunity” during which individuals often are considerably more receptive to helping efforts. A rapid, thorough, and focused assessment is needed to determine pre- and post-crisis functioning, including the coping styles and skills individuals have used to handle previous stress- ful life events, crises, and preexisting vulnerable states. Emotionally charged areas of functioning are directly and thoroughly explored, including any potential for self-harm and violence, abuse and neglect, use and abuse of alcohol and drugs, sexual assault, and loss or grief. In situations such as physical and sexual abuse, self-harm, violence, drug and alcohol abuse, rape, and natural or man-made disasters, it is particularly important to assess and ensure clients’ emotional and physical safety, and to collaborate with and engage reliable and supportive individuals, in order to develop detailed safety plans to protect clients.

Case Illustrations of Social Work Skills and Roles in Crisis Situations

Social work practitioners take on multiple roles in crisis intervention, including direct service

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provider to help clients express their emotions; educator to provide practical information and psychoeducation; case manager to obtain and coordinate community resources for concrete and mental health services; and advocate and broker to mobilize existing social and environ- mental support systems. The challenges of crisis intervention require that social workers develop skills to provide focused, direct, and in-depth assessments; be effective in taking a