A Methodologie Approach to Crisis Therapy SHELDON H. KARDENER,
M . D . * | Los Angeles,
Calif.
Resistance to using limited goal, brief psychotherapy often rests upon the mythology that a patient's problems must require a great deal of time for resolution. This paper offers a suitable rationale and methodology for psychotherapists to exercise their enormous capacity to assist patients effecting meaningful change in a brief time period.
Resistance by psychotherapists to the use of psychotherapy that is limited to from one to six visits often centers about a subliminally present and perhaps too widely accepted mythology within the psychiatric subculture that problems presented by patients will invariably require a great deal of time for satisfactory resolution. Insofar as this attitude represents an uncertainty of approach on the therapist's part in evaluating and delineating short-term goals, this paper attempts to offer a suitable rationale and methodology for such an approach. So armed, it is hoped that therapists will come to feel more comfortable with exercising their enormous capacity to assist patients in initiating and effecting meaningful change in a brief period of time. HISTORY
Frequently there is a misconception that brief psychotherapeutic maneuvers were invented to meet increasing demands for psychiatric help in a limited supply market. Quite to the contrary, the burgeoning demand created an opportunity for the greater application of techniques which had been previously explored (1-3). Freud's famous case of brief crisis intervention with Gustav Mahler would qualify him as being less "Freudian" than some of his subsequent adherents (4). Of the early psychoanalytic pioneers Ferenzi and Rank experimented with active intervention and timelimited therapy, as well (5, 6). The advent of World War I I created an opportunity for the rediscovery and refinement by Grinker and Spiegel (7) of brief treatment techniques described—although not widely applied—in World War I . Unquestionably, the work of Lindemann (1) in 1944, studying the loss reactions by victims' relatives of the Coconut Grove fire, marks a formal beginning of the investigation of reactions to, and treatment of, crisis situations. Subsequent work by Lindemann and Caplan (2) laid the substantial foundation 1
•Adjunct Associate Professor of Psychiatry, University of California, Center for the Health Sciences, Los Angeles, Calif. 90024. 4
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5
for the application of brief treatment techniques currently used in meeting the contemporary demand for psychotherapy. I t should be made quite clear that crisis treatment is not just what to do until the doctor comes, but rather is a specific treatment modality of great value if appropriately applied at a very special time in a patient's life. Furthermore, it is important to recognize that such brief therapy is not the antithesis of long-term treatment. In fact, the very sense of success and accomplishment a patient experiences from such treatment may encourage him to consider favorably either undertaking a more extensive course of therapy or reutilizing therapy at a future time if needed. THEORY
A crisis state exists whenever an individual initially utilizes coping styles to resolve a life problem (hazard) which diminishes his prior level of functioning (8). The repertory of coping styles available is often artificially limited due to an emotional regression, at the time of the hazard's occurence, to a childlike perception of solution potentials. If the behavior models from childhood (most often those presented by parents) represent coping only in a negative fashion with healthy potentials ignored, the subsequent child part of the adult repeats this pattern of artificially optionless negative coping with life's hazards (9). This occurs even though each and every new hazard brings with it the potential for using a broad range of positive coping styles. It is for this reason each hazard incorporates both danger and opportunity; danger in that old styles will, again, be reinforced through yet another application; opportunity in the unique chance to resolve a life problem in a significantly better way. I t is this very emotional regression which occurs at the time of a hazard that alters one's usual character armor (10) and creates receptivity to change (11). However, one's tolerance for the absence of some coping style is brief—usually less than two weeks. Resolution of the hazard will occur, for better or worse within four to six weeks (8). A delay of more than two weeks in seeing a patient may well mean the loss of this spontaneously generated receptivity, necessitating more extensive therapy—if the individual is still willing to accept therapy (12). While "timé specificity" is a critical factor, of equal importance is the second variable of "dynamic specificity." The therapist must be willing to both identify the acute dynamics which precipitated the initial breach in the personality defenses and to hold in abeyance concentration upon perhaps equally important but less acute aspects of the patient's personality (13). Relief of distress and improved functioning may occur through the nonspecific aegis of the relationship, emotional catharsis, placebo effect, suggestions, spontaneous forces and/or magical expectations (14). The sue-
6
AMERICAN JOURNAL OF P S Y C H O T H E R A P Y
cess and sense of accomplishment a patient experiences in achieving even limited goals creates a willingness to utilize therapy for more extended purposes in the future, if needed. Many therapists view the initial contacts with a patient as evaluative only, emphasizing more chronic long-term treatment goals, thereby missing this "golden" opportunity for more immediate benefits. Avnet's study (15) exemplified therapists' a priori bias that long-term treatment was the only effective mode. I t is as though these therapists believed no treatment was preferable to short-term therapy! The indefensibility of this posture was shown in the study cited. Avnets' findings were confirmed by Katzenstein's study (16) which showed 80% of patients receiving some form of brief therapy felt improved; 70% of their therapists concurred in rating the patients improved; only 20% of the patients not treated reported improvement. METHODOLOGY
It is essential in crisis treatment to determine what specifically caused the patient to seek help at the time of the initial presentation. Rarely is it necessary to review in great detail his life beyond the two-week period preceding the patient's initial request for help. More often a detailed exploration of the prior 24 to 72 hours' sequence of events will usually suffice in revealing the precipitating hazard. This is best done by the therapists's seeking a reasonable answer to the question, "Why does the patient come for help now?" The usual type of psychiatric history with its attendant focus upon past events will not yield this vital information. In a sense, it is the search for the "straw which breaks the camel's back" which is most elucidative of the vitally needed information. A simplified and rapid method for making this evaluation is based upon categorizing life experiences into essentially four "worlds" as follows: A. The Work-School World B. The Familial World This is subdivided to include parental-sibling relationships on the one hand and spouse-children relationships on the other. G. The Social World This also subdivides to include friends and social relationships of the same and opposite sex. D. The Intrapsychic World This is best evaluated by including questions regarding sleep and dream patterns in addition to the usual mental status questions when indicated. In reviewing each of these "worlds" with the patient, the therapist looks
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7
for evidence of an actual, fantasied, or anticipated change occurring during the defined critical period of time. Although valuable information may be gathered regarding chronic difficulties during this assessment, the question to be answered remains, "Is this event, or sequence of events, what caused the patient to seek help now?" Chronic difficulties which reflect no recent change, while contributory, are less likely to be the salient factors sought. The therapist must guard against the past being used as a defense against the present. Secondary ramifications of immediately preceding changes may not be the prime target for intervention, that is, an individual who lost his job and then retreated from relationships with friends will more likely benefit from a primary focus of attention upon vocational issues rather than explorations of friendship patterns. The first three "worlds" defined are of an interpersonal nature as compared to the fourth intrapsychic world. This is not to imply a singular separation of the interpersonal from the intrapsychic experience. However, it is of clinical importance to note that when, despite diligent investigation, no precipitating event can be identified in the interpersonal spheres, the very earliest evidence of an impending psychotic decompensation may be occurring. This may be best measured by acute changes in sleep and dream patterns during the few nights preceding the patient's first asking for help. A careful exploration of these "worlds" permits delineation of that area in the individual's life most in flux and, therefore, most available for change. The initial goal of therapy thus becomes defined. A meaningful psychotherapeutic goal must be both mutually agreeable and achievable. Mutual agreeability means the patient acknowledges that the goal selected defines the area of greatest immediate distress, and the therapist agrees that this desired goal is one with which he can concur from the standpoint of professional ethics and competence. The second element, achievability, accounts for factors which might impose limitations on the therapeutic contact, such as time, finances, treatment facilities, patient and therapist availability. These two characteristics of a therapeutic goal constitute the treatment contract a therapist makes with the patient. Insofar as is possible, the contract should constitute an overt and understandable communication between therapist and patient early in the first therapy contact. Our surgical colleagues learned long ago to establish a hierarchy of therapeutic goals from the most acute to the more chronic needs of a patient and not to bring to bear their therapeutic skills without full and informed consent nor to stray, other than in life and death situations, into areas not specifically agreed to by the patient. I t is perhaps time we as psychotherapists exercised the same good judgment and extended the same respect to our patients. " . . . the proper aim of the study of things is to increase our under-
8
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standing of them, the better to control them; the proper aim of the study of man must be to increase our understanding of him, the better to be able to leave him alone!" (17). Once the contract has been agreed upon, the therapist turns next to that treatment modality which will be most efficacious. This implies that shortterm therapists must be reasonably conversant with a variety of treatment modalities or seek appropriate collaborative consultation. I t is the responsibility of the therapist to fit therapeutic methods to the needs of a given patient and his particularly desired goal and not the patient's responsibility to fit a unimodule therapist! The range of techniques in achieving the initial goal encompasses all of the known and usual modalities from environmental manipulation, family, drug, behavior conditioning, or hypnotherapies to psychodynamically oriented psychotherapy, to name but a few. Regardless of the modality utilized, all therapeutic intervention techniques are designed to facilitate meaningful change. The choice of any particular method should always be predicated upon the best possible understanding of the patient's needs and the psychodynamic specificity of the contracted goal. All too frequently therapists are reticent to verbalize, even to themselves, a dynamic formulation hypothesis for fear they may be wrong. Paradoxically, it is impossible to make any kind of therapeutic intervention without having distilled, albeit unconsciously perhaps, some kind of a formulation of the patient's problem from even the briefest initial contact (18, 19). Effective short-term psychotherapy demands that the therapist verbalize that formulation, if only at least to himself, so he may then most appropriately communicate with the patient, elicit patient participation, and select the treatment approach likely to be effective for the patient's immediate needs (20). Wolberg's (14) statement that therapist passivity is the anathema of brief psychotherapy encompasses not only the therapist's behavior vis-à-vis the patient but also the therapist's hesitancy to clearly hypothecate dynamics and then subject these hypotheses to test via appropriate therapeutic intervention techniques. This inherent demand coupled with a lack of experience with a suitable methodology may account for the tremendous resistance on the part of some psychotherapists to engage in the exciting experience of brief psychotherapy. By the very definition of brevity, one cannot wait until all the facts speak for themselves. For this reason, close supervision by experienced therapists is especially essential with this modality for the successful training of beginning crisis therapists. After the "why now?" factors have been delineated, the initial goal defined, and the appropriate treatment instituted, there remains a fourth and final step. Once the contracted goal is achieved, therapy should either ter-
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minate or a subsequent new goal with its attendant parameters of mutual acceptability and achievability should be explicitly defined. This fourth phase is essential if positive reinforcement of the gains made in therapy is to be emphasized. Failure to reach the designated goals requires thorough re-evaluation by both the therapist and the patient. This is true with any form of unsuccessful treatment, regardless of the particular modality. T h e ideal treatment situation would consist of a multiphasic relationship, beginning with the crisis intervention model for the initial goal and progressing to additional goals with mutual consent, if necessary. One must always be propitious in setting positive expectations and reinforcing the healthy aspects of the patient's capacity to function from the very first contact, during the treatment, upon termination, and if making recommendations for subsequent therapy (21). Case 1
Mr. A., a twenty-eight-year-old, single male came to the emergency room exhibiting gross psychotic behavior consisting of "word-salad" speech, anxiety, selfnegating auditory hallucinations, and paranoid delusions. Past history revealed a psychotic decompensation at the age of sixteen followed by long-term hospitalization and subsequent outpatient treatment with drug management until the age of twenty-four. For the preceding four years he had been maintained on phenothiazines, worked as a quasi-supervisor in a sheltered workshop, and was contentedly living in a board-and-care home. He had specifically not wanted nor sought any additional psychotherapy during these four years. Traditional diagnostic evaluation would label him a chronic paranoid schizophrenic with acute re-exacerbation of his latent psychotic symptoms. The crisisoriented "why now?" history revealed that, following his regular routine, he had boarded a bus to go to the workshop only to find that he had no token or money to pay the fare. The loss of his positive coping style represented by his work precipitated all of his chronic anxieties of feeling worthless and bad as a person. This hazard was dealt with by utilizing the only alternative coping style previously available—psychotic withdrawal. A call to the caretaking people revealed that they had dry-cleaned his pants and had neglected to tell him his tokens had been removed. The importance of an adequate supply of tokens was pointed out to both the patient and the caretakers. In addition, it was suggested to the patient, without any expectation of implementation at present, that he could have asked the bus driver or other patrons with whom he regularly rode for the loan of a token. His medications were increased, and he was asked to return the next day. His concerns at the next appointment centered about a conviction that the people at the workshop would not want him to return because he had missed the previous day. He feared his "voices" were right in their negation of him. The therapist, with the patient's permission, called the workshop and learned that they would welcome the patient's return whenever he was ready. He went back to work that afternoon. His prior level of functioning had been regained without the reinforcement of psychotic withdrawal as a coping style. This was a modest goal
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which left the patient at a marginal level of functioning. At the same time, it was all that the patient wanted for the present. His crisis therapy experience was one which indicated to him that long-term hospitalization was not necessarily the only intervention psychiatric contact had to offer. The therapist was willing to accept a limited goal and could respect the level of compensation Mr. A. had achieved for his pathology.
Case 2 Miss B., a twenty-two-year-old secretary, single, was seen in psychiatric consultation following a gastric lavage for an overdose of sleeping pills. The history was consistent with a chronic schizoid personality manifested by limitations in social relations. She had never sought psychiatric help in the past. A review of her recent life situation revealed that she had broken up with her first and only boy friend the night before. He had been a source of support and encouragement for her in deciding to leave a very hostile and personally degrading home environment. The hazard was clearly the loss of this important relationship; however, it did not explain why 24 hours had elapsed before the overdose event. Further exploration revealed that she had utilized a positive coping style in the form of talking to someone about the hazard. Although consistent with the emotional regression created by the hazard, she unfortunately chose her mother as the one with whom to speak the next day. Her mother was singularly unsupportive, accusing the girl of being a "whore" who "probably slept with every boy in town" and just got what she "deserved" for having left home. Although the patient could acknowledge that this interaction was predictable, she had behaved as if she were only the small child she once had been who could turn only to her mother when she hurt, even though this meant more pain. The total frustration of not gaining any relief from her distress left her feeling that there was no other coping style left but suicide. The therapist's review of her current relationships revealed one girl friend whom she had known for a long time and who seemed like a good resource the patient had overlooked as an alternative person with whom to speak. This girl friend was contacted and proved most responsive, coming to the emergency room and offering to take the patient home and be with her. The patient returned to work within a few days. Subsequent therapy visits focused upon the feelings of loss of her boy friend, the identification of a need for increased social relationships, and the exploration of available resources for implementing social contacts. She was seen for five visits over a six-week period of time during which significant progress occurred. She desired no further therapy, but rather wished to continue implementing her social progress with the support of an expanding new group of friends. She acknowledged that at some future time she might again wish to consult a therapist and was given reassurance that she was welcome to do so.
Case 3 Mr. C , a fifty-four-year-old, never married, recently promoted, telephone installation consultant was brought for an evaluation by his employer who com-
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11
plained that the patient was becoming increasingly lethargic and unable to concentrate. The history revealed that the patient had worked successfully as a "trouble shooter" for outdoor telephone units for about 20 years. His present supervisor had begun his employment at the same time as the patient and had subsequently moved into management ranks. It was as a "special favor" that the supervisor had arranged a promotion for the patient from his blue collar job in which he had contentedly worked essentially as a loner and never in contact with customers to a white collar job which brought him into direct customer contact. There was no question in anyone's mind about the patient's technical ability to handle the job; however, for the month following the promotion the patient's ability to function was rapidly diminishing to the point of complete withdrawal three days after he failed to keep his first "solo" appointment. Examination revealed a markedly depressed man who had begun experiencing early morning awakening, loss of appetite, and tremulousness. There was no prior psychiatric history. Neurologic evaluation was negative. He responded favorably when asked if he would prefer to return to his former occupation but expressed concern at disappointing his friend, the supervisor. A conjoint session was arranged at the third meeting at which the patient—with the therapist's guidance— could express his appreciation for the new job opportunity but could also express his desire to return to his prior position. The supervisor was helped to understand the situation and subsequently facilitated the patient's transfer without any embarrassment to the patient. The fourth follow-up session revealed the patient to be free of symptoms and back to his previously satisfactory state of emotional health. Case 4
Mr. D . illustrates the importance of evaluating those factors which bring a patient for help, even though the evaluation may not subsequently alter the choice of treatment. He was a fifty-seven-year-old, married salesman who, six months earlier, had lost a major line of goods to a younger man. His entire sales territory became markedly constricted. When he came to the emergency room, there was all of the classic evidence of a severe, agitated involutional depression. The patient complained he had not slept "for the past six months." There was concern about his suicidal potential. The decision was made to hospitalize the patient. He was very uncertain about hospitalization, wanting to return home to think about it. The therapist emphasized the need for hospitalization but felt the patient was not committable under current involuntary commitment law. Assurances of close telephone contact were obtained. During the next two days, telephone calls by the therapist finally convinced the patient of the importance of hospital admittance which was then arranged for that day. He was greatly relieved upon admission and made good initial contact with the staff. Immediately following a telephone call in the late evening from the patient's wife, he retired for the night. Despite reasonable bed checks by the staff that night, he succeeded in strangling himself to death without leaving his bed. A subsequent review of this case from the "why now?" standpoint revealed that
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on the morning of his first contact, his wife had left the want ads circled with a note that he had better get one of those jobs that day. She had had to get a job to support them six months earlier when he stopped working and began "moping" around the house. She accused him of simply being "lazy" and had begun for the prior two or three days to bring increasing pressure to bear upon him. His uncertainty regarding admission was due to the wife's telling him he was only running away by going to a hospital. When he finally made the decision to seek relief by coming to the hospital, it was not initially for his chronic symptoms but rather from the acute marital pressure. This was not clearly identified because his chronic state was sufficient to explain his symptoms. It can only be speculated that if the acute precipitating circumstances of the wife's unrelenting pressure had been clearly explored and appropriately labeled, a great deal of intervention could have occurred following the wife's telephone call to the hospitalized patient. The identification of the "why now?" factors would not have altered the treatment modality used nor changed the diagnostic formulation but surely would have provided a vital, supplemental acute focus for immediate therapeutic attention. SUMMARY
All psychotherapists have in common the desire to assist a patient in recognizing the way meaningful options in his life situation are being ignored and repetitive maladaptive behavior perpetuated. This is true regardless of their theoretical frame of reference or the therapeutic methods employed. Crisis therapy takes special advantage of time' and dynamic specificity factors to assist a patient in reaching such recognition and to utilize alternative, more adaptive options. This paper outlines a methodologic approach, useful in evaluating the precipitating factors which acutely bring a patient to seek therapy and from which a therapeutic contract may evolve which facilitates significant change in a brief period of time. REFERENCES
1. Lindemann, E . Symptomology and Management of Acute Grief, Am. J. Psychiat., 101:141, 1944. 2. Caplan, G. Principles of Preventative Psychology. Basic Books, New York, 1964. 3. Parad, H . J . , Ed. Crisis Intervention: Selected Readings. Family Service Association of America, New York, 1967. 4. Trilling, L . and
Marcus, E . , Eds.
The
Life
and Work
of Sigmund
Freud.
Basic Books, New York, 1961, p. 279. 5. Glover, E . Review of Further Contributions to the Theory and Technique of Psychoanalysis by S. Ferenzi. Int. J. Psychoanal., 8:417, 1927. 6. Ferenci, S. and Rank, O. The Development of Psychoanalysis. Nervous and Mental Disease Publ., Washington, D.G., 1925. 7. Grinker, R. R. and Spiegel, J . P. the Zone of Combat. Manual
Philadelphia, 1944,
Management of N euro psychiatric Casualties in of Military Nueropsychiatry. B. W. Saunders,
A METHODÖLOGIC A P P R O A C H TO C R I S I S 8. Caplan, G.
THERAPY
An Approach to Community Mental Health.
13
Grune & Stratton, New
York, 1961. 9. Kardener, S. H . Convergent Internal Security Systems—A Rationale for Marital Therapy.
Family Proc,
9:83,
1970.
10. Reich, W. Character Analysis. Noonday Press, Farrar Straus, New York, 1963. 11. Morley, W. E . Treatment of the Patient in Crisis. West. Med., 3:77, 1965. 12. Dewees, R. F., Johnson, R. F., Sarvis, M. A., and Pope, S. T . An Open Service in a University Psychiatric Clinic. Ment. Hyg., 47:57, 1961. 13. Harris, M. R., Kalis, B., and Freeman, E . Precipitating Stress: An Approach to Brief Therapy. Am. J. Psychother., 17:465, 1963. 14. Wolberg, L . R. The Technique of Short-Term Therapy. In Short-Term Therapy, Chapter 6. Wolberg, L . R., Ed. Grune & Stratton, New York, 1965. 15. Avnet, H . H . How Effective is Short-Term Therapy? In Short-Term Therapy, Chapter 1, Wolberg, L . R., Ed. Grune & Stratton, New York, 1965. 16. Katzenstein, C. The Effectiveness of Crisis Therapy. Unpublished Ph.D. Dissertation. University of Chicago, March, 1971. 17. Szasz, T . S. An Unscrewtape Letter: A Reply to Fred Sander. Am. J. Psychiat., 125:1432, 1969. 18. Gauron, E . F. and Dickinson, J . K . The Influence of Seeing the Patient First on Diagnostic Decision Making in Psychiatry. Am. ]. Psychiat., 126:199, 1969. 19. Sandifer, Jr., M. G., Hordern, A., and Green, L . M. The Psychiatric Interview. The Impact of the First Three Minutes. Am. J. Psychiat., 126:968, 1970. 20. Jacobson, G. F . Some Psychoanalytic Considerations Regarding Crisis Therapy. Psychoanal. Rev., 54:649, 1967. 21. Aldrich, C. K. Brief Psychotherapy: A Reappraisal of Some Theoretical Assumptions. Am. J. Psychiat., 125:585, 1968.
M . D . * | Los Angeles,
Calif.
Resistance to using limited goal, brief psychotherapy often rests upon the mythology that a patient's problems must require a great deal of time for resolution. This paper offers a suitable rationale and methodology for psychotherapists to exercise their enormous capacity to assist patients effecting meaningful change in a brief time period.
Resistance by psychotherapists to the use of psychotherapy that is limited to from one to six visits often centers about a subliminally present and perhaps too widely accepted mythology within the psychiatric subculture that problems presented by patients will invariably require a great deal of time for satisfactory resolution. Insofar as this attitude represents an uncertainty of approach on the therapist's part in evaluating and delineating short-term goals, this paper attempts to offer a suitable rationale and methodology for such an approach. So armed, it is hoped that therapists will come to feel more comfortable with exercising their enormous capacity to assist patients in initiating and effecting meaningful change in a brief period of time. HISTORY
Frequently there is a misconception that brief psychotherapeutic maneuvers were invented to meet increasing demands for psychiatric help in a limited supply market. Quite to the contrary, the burgeoning demand created an opportunity for the greater application of techniques which had been previously explored (1-3). Freud's famous case of brief crisis intervention with Gustav Mahler would qualify him as being less "Freudian" than some of his subsequent adherents (4). Of the early psychoanalytic pioneers Ferenzi and Rank experimented with active intervention and timelimited therapy, as well (5, 6). The advent of World War I I created an opportunity for the rediscovery and refinement by Grinker and Spiegel (7) of brief treatment techniques described—although not widely applied—in World War I . Unquestionably, the work of Lindemann (1) in 1944, studying the loss reactions by victims' relatives of the Coconut Grove fire, marks a formal beginning of the investigation of reactions to, and treatment of, crisis situations. Subsequent work by Lindemann and Caplan (2) laid the substantial foundation 1
•Adjunct Associate Professor of Psychiatry, University of California, Center for the Health Sciences, Los Angeles, Calif. 90024. 4
A METHODOLOGIG A P P R O A C H TO C R I S I S T H E R A P Y
5
for the application of brief treatment techniques currently used in meeting the contemporary demand for psychotherapy. I t should be made quite clear that crisis treatment is not just what to do until the doctor comes, but rather is a specific treatment modality of great value if appropriately applied at a very special time in a patient's life. Furthermore, it is important to recognize that such brief therapy is not the antithesis of long-term treatment. In fact, the very sense of success and accomplishment a patient experiences from such treatment may encourage him to consider favorably either undertaking a more extensive course of therapy or reutilizing therapy at a future time if needed. THEORY
A crisis state exists whenever an individual initially utilizes coping styles to resolve a life problem (hazard) which diminishes his prior level of functioning (8). The repertory of coping styles available is often artificially limited due to an emotional regression, at the time of the hazard's occurence, to a childlike perception of solution potentials. If the behavior models from childhood (most often those presented by parents) represent coping only in a negative fashion with healthy potentials ignored, the subsequent child part of the adult repeats this pattern of artificially optionless negative coping with life's hazards (9). This occurs even though each and every new hazard brings with it the potential for using a broad range of positive coping styles. It is for this reason each hazard incorporates both danger and opportunity; danger in that old styles will, again, be reinforced through yet another application; opportunity in the unique chance to resolve a life problem in a significantly better way. I t is this very emotional regression which occurs at the time of a hazard that alters one's usual character armor (10) and creates receptivity to change (11). However, one's tolerance for the absence of some coping style is brief—usually less than two weeks. Resolution of the hazard will occur, for better or worse within four to six weeks (8). A delay of more than two weeks in seeing a patient may well mean the loss of this spontaneously generated receptivity, necessitating more extensive therapy—if the individual is still willing to accept therapy (12). While "timé specificity" is a critical factor, of equal importance is the second variable of "dynamic specificity." The therapist must be willing to both identify the acute dynamics which precipitated the initial breach in the personality defenses and to hold in abeyance concentration upon perhaps equally important but less acute aspects of the patient's personality (13). Relief of distress and improved functioning may occur through the nonspecific aegis of the relationship, emotional catharsis, placebo effect, suggestions, spontaneous forces and/or magical expectations (14). The sue-
6
AMERICAN JOURNAL OF P S Y C H O T H E R A P Y
cess and sense of accomplishment a patient experiences in achieving even limited goals creates a willingness to utilize therapy for more extended purposes in the future, if needed. Many therapists view the initial contacts with a patient as evaluative only, emphasizing more chronic long-term treatment goals, thereby missing this "golden" opportunity for more immediate benefits. Avnet's study (15) exemplified therapists' a priori bias that long-term treatment was the only effective mode. I t is as though these therapists believed no treatment was preferable to short-term therapy! The indefensibility of this posture was shown in the study cited. Avnets' findings were confirmed by Katzenstein's study (16) which showed 80% of patients receiving some form of brief therapy felt improved; 70% of their therapists concurred in rating the patients improved; only 20% of the patients not treated reported improvement. METHODOLOGY
It is essential in crisis treatment to determine what specifically caused the patient to seek help at the time of the initial presentation. Rarely is it necessary to review in great detail his life beyond the two-week period preceding the patient's initial request for help. More often a detailed exploration of the prior 24 to 72 hours' sequence of events will usually suffice in revealing the precipitating hazard. This is best done by the therapists's seeking a reasonable answer to the question, "Why does the patient come for help now?" The usual type of psychiatric history with its attendant focus upon past events will not yield this vital information. In a sense, it is the search for the "straw which breaks the camel's back" which is most elucidative of the vitally needed information. A simplified and rapid method for making this evaluation is based upon categorizing life experiences into essentially four "worlds" as follows: A. The Work-School World B. The Familial World This is subdivided to include parental-sibling relationships on the one hand and spouse-children relationships on the other. G. The Social World This also subdivides to include friends and social relationships of the same and opposite sex. D. The Intrapsychic World This is best evaluated by including questions regarding sleep and dream patterns in addition to the usual mental status questions when indicated. In reviewing each of these "worlds" with the patient, the therapist looks
A M E T H O D O L O G I C A P P R O A C H TO C R I S I S T H E R A P Y
7
for evidence of an actual, fantasied, or anticipated change occurring during the defined critical period of time. Although valuable information may be gathered regarding chronic difficulties during this assessment, the question to be answered remains, "Is this event, or sequence of events, what caused the patient to seek help now?" Chronic difficulties which reflect no recent change, while contributory, are less likely to be the salient factors sought. The therapist must guard against the past being used as a defense against the present. Secondary ramifications of immediately preceding changes may not be the prime target for intervention, that is, an individual who lost his job and then retreated from relationships with friends will more likely benefit from a primary focus of attention upon vocational issues rather than explorations of friendship patterns. The first three "worlds" defined are of an interpersonal nature as compared to the fourth intrapsychic world. This is not to imply a singular separation of the interpersonal from the intrapsychic experience. However, it is of clinical importance to note that when, despite diligent investigation, no precipitating event can be identified in the interpersonal spheres, the very earliest evidence of an impending psychotic decompensation may be occurring. This may be best measured by acute changes in sleep and dream patterns during the few nights preceding the patient's first asking for help. A careful exploration of these "worlds" permits delineation of that area in the individual's life most in flux and, therefore, most available for change. The initial goal of therapy thus becomes defined. A meaningful psychotherapeutic goal must be both mutually agreeable and achievable. Mutual agreeability means the patient acknowledges that the goal selected defines the area of greatest immediate distress, and the therapist agrees that this desired goal is one with which he can concur from the standpoint of professional ethics and competence. The second element, achievability, accounts for factors which might impose limitations on the therapeutic contact, such as time, finances, treatment facilities, patient and therapist availability. These two characteristics of a therapeutic goal constitute the treatment contract a therapist makes with the patient. Insofar as is possible, the contract should constitute an overt and understandable communication between therapist and patient early in the first therapy contact. Our surgical colleagues learned long ago to establish a hierarchy of therapeutic goals from the most acute to the more chronic needs of a patient and not to bring to bear their therapeutic skills without full and informed consent nor to stray, other than in life and death situations, into areas not specifically agreed to by the patient. I t is perhaps time we as psychotherapists exercised the same good judgment and extended the same respect to our patients. " . . . the proper aim of the study of things is to increase our under-
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standing of them, the better to control them; the proper aim of the study of man must be to increase our understanding of him, the better to be able to leave him alone!" (17). Once the contract has been agreed upon, the therapist turns next to that treatment modality which will be most efficacious. This implies that shortterm therapists must be reasonably conversant with a variety of treatment modalities or seek appropriate collaborative consultation. I t is the responsibility of the therapist to fit therapeutic methods to the needs of a given patient and his particularly desired goal and not the patient's responsibility to fit a unimodule therapist! The range of techniques in achieving the initial goal encompasses all of the known and usual modalities from environmental manipulation, family, drug, behavior conditioning, or hypnotherapies to psychodynamically oriented psychotherapy, to name but a few. Regardless of the modality utilized, all therapeutic intervention techniques are designed to facilitate meaningful change. The choice of any particular method should always be predicated upon the best possible understanding of the patient's needs and the psychodynamic specificity of the contracted goal. All too frequently therapists are reticent to verbalize, even to themselves, a dynamic formulation hypothesis for fear they may be wrong. Paradoxically, it is impossible to make any kind of therapeutic intervention without having distilled, albeit unconsciously perhaps, some kind of a formulation of the patient's problem from even the briefest initial contact (18, 19). Effective short-term psychotherapy demands that the therapist verbalize that formulation, if only at least to himself, so he may then most appropriately communicate with the patient, elicit patient participation, and select the treatment approach likely to be effective for the patient's immediate needs (20). Wolberg's (14) statement that therapist passivity is the anathema of brief psychotherapy encompasses not only the therapist's behavior vis-à-vis the patient but also the therapist's hesitancy to clearly hypothecate dynamics and then subject these hypotheses to test via appropriate therapeutic intervention techniques. This inherent demand coupled with a lack of experience with a suitable methodology may account for the tremendous resistance on the part of some psychotherapists to engage in the exciting experience of brief psychotherapy. By the very definition of brevity, one cannot wait until all the facts speak for themselves. For this reason, close supervision by experienced therapists is especially essential with this modality for the successful training of beginning crisis therapists. After the "why now?" factors have been delineated, the initial goal defined, and the appropriate treatment instituted, there remains a fourth and final step. Once the contracted goal is achieved, therapy should either ter-
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minate or a subsequent new goal with its attendant parameters of mutual acceptability and achievability should be explicitly defined. This fourth phase is essential if positive reinforcement of the gains made in therapy is to be emphasized. Failure to reach the designated goals requires thorough re-evaluation by both the therapist and the patient. This is true with any form of unsuccessful treatment, regardless of the particular modality. T h e ideal treatment situation would consist of a multiphasic relationship, beginning with the crisis intervention model for the initial goal and progressing to additional goals with mutual consent, if necessary. One must always be propitious in setting positive expectations and reinforcing the healthy aspects of the patient's capacity to function from the very first contact, during the treatment, upon termination, and if making recommendations for subsequent therapy (21). Case 1
Mr. A., a twenty-eight-year-old, single male came to the emergency room exhibiting gross psychotic behavior consisting of "word-salad" speech, anxiety, selfnegating auditory hallucinations, and paranoid delusions. Past history revealed a psychotic decompensation at the age of sixteen followed by long-term hospitalization and subsequent outpatient treatment with drug management until the age of twenty-four. For the preceding four years he had been maintained on phenothiazines, worked as a quasi-supervisor in a sheltered workshop, and was contentedly living in a board-and-care home. He had specifically not wanted nor sought any additional psychotherapy during these four years. Traditional diagnostic evaluation would label him a chronic paranoid schizophrenic with acute re-exacerbation of his latent psychotic symptoms. The crisisoriented "why now?" history revealed that, following his regular routine, he had boarded a bus to go to the workshop only to find that he had no token or money to pay the fare. The loss of his positive coping style represented by his work precipitated all of his chronic anxieties of feeling worthless and bad as a person. This hazard was dealt with by utilizing the only alternative coping style previously available—psychotic withdrawal. A call to the caretaking people revealed that they had dry-cleaned his pants and had neglected to tell him his tokens had been removed. The importance of an adequate supply of tokens was pointed out to both the patient and the caretakers. In addition, it was suggested to the patient, without any expectation of implementation at present, that he could have asked the bus driver or other patrons with whom he regularly rode for the loan of a token. His medications were increased, and he was asked to return the next day. His concerns at the next appointment centered about a conviction that the people at the workshop would not want him to return because he had missed the previous day. He feared his "voices" were right in their negation of him. The therapist, with the patient's permission, called the workshop and learned that they would welcome the patient's return whenever he was ready. He went back to work that afternoon. His prior level of functioning had been regained without the reinforcement of psychotic withdrawal as a coping style. This was a modest goal
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which left the patient at a marginal level of functioning. At the same time, it was all that the patient wanted for the present. His crisis therapy experience was one which indicated to him that long-term hospitalization was not necessarily the only intervention psychiatric contact had to offer. The therapist was willing to accept a limited goal and could respect the level of compensation Mr. A. had achieved for his pathology.
Case 2 Miss B., a twenty-two-year-old secretary, single, was seen in psychiatric consultation following a gastric lavage for an overdose of sleeping pills. The history was consistent with a chronic schizoid personality manifested by limitations in social relations. She had never sought psychiatric help in the past. A review of her recent life situation revealed that she had broken up with her first and only boy friend the night before. He had been a source of support and encouragement for her in deciding to leave a very hostile and personally degrading home environment. The hazard was clearly the loss of this important relationship; however, it did not explain why 24 hours had elapsed before the overdose event. Further exploration revealed that she had utilized a positive coping style in the form of talking to someone about the hazard. Although consistent with the emotional regression created by the hazard, she unfortunately chose her mother as the one with whom to speak the next day. Her mother was singularly unsupportive, accusing the girl of being a "whore" who "probably slept with every boy in town" and just got what she "deserved" for having left home. Although the patient could acknowledge that this interaction was predictable, she had behaved as if she were only the small child she once had been who could turn only to her mother when she hurt, even though this meant more pain. The total frustration of not gaining any relief from her distress left her feeling that there was no other coping style left but suicide. The therapist's review of her current relationships revealed one girl friend whom she had known for a long time and who seemed like a good resource the patient had overlooked as an alternative person with whom to speak. This girl friend was contacted and proved most responsive, coming to the emergency room and offering to take the patient home and be with her. The patient returned to work within a few days. Subsequent therapy visits focused upon the feelings of loss of her boy friend, the identification of a need for increased social relationships, and the exploration of available resources for implementing social contacts. She was seen for five visits over a six-week period of time during which significant progress occurred. She desired no further therapy, but rather wished to continue implementing her social progress with the support of an expanding new group of friends. She acknowledged that at some future time she might again wish to consult a therapist and was given reassurance that she was welcome to do so.
Case 3 Mr. C , a fifty-four-year-old, never married, recently promoted, telephone installation consultant was brought for an evaluation by his employer who com-
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plained that the patient was becoming increasingly lethargic and unable to concentrate. The history revealed that the patient had worked successfully as a "trouble shooter" for outdoor telephone units for about 20 years. His present supervisor had begun his employment at the same time as the patient and had subsequently moved into management ranks. It was as a "special favor" that the supervisor had arranged a promotion for the patient from his blue collar job in which he had contentedly worked essentially as a loner and never in contact with customers to a white collar job which brought him into direct customer contact. There was no question in anyone's mind about the patient's technical ability to handle the job; however, for the month following the promotion the patient's ability to function was rapidly diminishing to the point of complete withdrawal three days after he failed to keep his first "solo" appointment. Examination revealed a markedly depressed man who had begun experiencing early morning awakening, loss of appetite, and tremulousness. There was no prior psychiatric history. Neurologic evaluation was negative. He responded favorably when asked if he would prefer to return to his former occupation but expressed concern at disappointing his friend, the supervisor. A conjoint session was arranged at the third meeting at which the patient—with the therapist's guidance— could express his appreciation for the new job opportunity but could also express his desire to return to his prior position. The supervisor was helped to understand the situation and subsequently facilitated the patient's transfer without any embarrassment to the patient. The fourth follow-up session revealed the patient to be free of symptoms and back to his previously satisfactory state of emotional health. Case 4
Mr. D . illustrates the importance of evaluating those factors which bring a patient for help, even though the evaluation may not subsequently alter the choice of treatment. He was a fifty-seven-year-old, married salesman who, six months earlier, had lost a major line of goods to a younger man. His entire sales territory became markedly constricted. When he came to the emergency room, there was all of the classic evidence of a severe, agitated involutional depression. The patient complained he had not slept "for the past six months." There was concern about his suicidal potential. The decision was made to hospitalize the patient. He was very uncertain about hospitalization, wanting to return home to think about it. The therapist emphasized the need for hospitalization but felt the patient was not committable under current involuntary commitment law. Assurances of close telephone contact were obtained. During the next two days, telephone calls by the therapist finally convinced the patient of the importance of hospital admittance which was then arranged for that day. He was greatly relieved upon admission and made good initial contact with the staff. Immediately following a telephone call in the late evening from the patient's wife, he retired for the night. Despite reasonable bed checks by the staff that night, he succeeded in strangling himself to death without leaving his bed. A subsequent review of this case from the "why now?" standpoint revealed that
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on the morning of his first contact, his wife had left the want ads circled with a note that he had better get one of those jobs that day. She had had to get a job to support them six months earlier when he stopped working and began "moping" around the house. She accused him of simply being "lazy" and had begun for the prior two or three days to bring increasing pressure to bear upon him. His uncertainty regarding admission was due to the wife's telling him he was only running away by going to a hospital. When he finally made the decision to seek relief by coming to the hospital, it was not initially for his chronic symptoms but rather from the acute marital pressure. This was not clearly identified because his chronic state was sufficient to explain his symptoms. It can only be speculated that if the acute precipitating circumstances of the wife's unrelenting pressure had been clearly explored and appropriately labeled, a great deal of intervention could have occurred following the wife's telephone call to the hospitalized patient. The identification of the "why now?" factors would not have altered the treatment modality used nor changed the diagnostic formulation but surely would have provided a vital, supplemental acute focus for immediate therapeutic attention. SUMMARY
All psychotherapists have in common the desire to assist a patient in recognizing the way meaningful options in his life situation are being ignored and repetitive maladaptive behavior perpetuated. This is true regardless of their theoretical frame of reference or the therapeutic methods employed. Crisis therapy takes special advantage of time' and dynamic specificity factors to assist a patient in reaching such recognition and to utilize alternative, more adaptive options. This paper outlines a methodologic approach, useful in evaluating the precipitating factors which acutely bring a patient to seek therapy and from which a therapeutic contract may evolve which facilitates significant change in a brief period of time. REFERENCES
1. Lindemann, E . Symptomology and Management of Acute Grief, Am. J. Psychiat., 101:141, 1944. 2. Caplan, G. Principles of Preventative Psychology. Basic Books, New York, 1964. 3. Parad, H . J . , Ed. Crisis Intervention: Selected Readings. Family Service Association of America, New York, 1967. 4. Trilling, L . and
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Grune & Stratton, New
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10. Reich, W. Character Analysis. Noonday Press, Farrar Straus, New York, 1963. 11. Morley, W. E . Treatment of the Patient in Crisis. West. Med., 3:77, 1965. 12. Dewees, R. F., Johnson, R. F., Sarvis, M. A., and Pope, S. T . An Open Service in a University Psychiatric Clinic. Ment. Hyg., 47:57, 1961. 13. Harris, M. R., Kalis, B., and Freeman, E . Precipitating Stress: An Approach to Brief Therapy. Am. J. Psychother., 17:465, 1963. 14. Wolberg, L . R. The Technique of Short-Term Therapy. In Short-Term Therapy, Chapter 6. Wolberg, L . R., Ed. Grune & Stratton, New York, 1965. 15. Avnet, H . H . How Effective is Short-Term Therapy? In Short-Term Therapy, Chapter 1, Wolberg, L . R., Ed. Grune & Stratton, New York, 1965. 16. Katzenstein, C. The Effectiveness of Crisis Therapy. Unpublished Ph.D. Dissertation. University of Chicago, March, 1971. 17. Szasz, T . S. An Unscrewtape Letter: A Reply to Fred Sander. Am. J. Psychiat., 125:1432, 1969. 18. Gauron, E . F. and Dickinson, J . K . The Influence of Seeing the Patient First on Diagnostic Decision Making in Psychiatry. Am. ]. Psychiat., 126:199, 1969. 19. Sandifer, Jr., M. G., Hordern, A., and Green, L . M. The Psychiatric Interview. The Impact of the First Three Minutes. Am. J. Psychiat., 126:968, 1970. 20. Jacobson, G. F . Some Psychoanalytic Considerations Regarding Crisis Therapy. Psychoanal. Rev., 54:649, 1967. 21. Aldrich, C. K. Brief Psychotherapy: A Reappraisal of Some Theoretical Assumptions. Am. J. Psychiat., 125:585, 1968.
