Still another demonstration of fuzzy thinking was the idea that using power is inherently evil. What we really meant was abusing power, not using power. Thus fuzzy thinking, combined with role-blurring, contributed to the chaos Ms. Doyle described. For years the health field, including mental health, has discounted administration and management as second-rate activities, whether at the front-line treatment unit level or at middle or top management levels of the treatment organization. Thus the health field has tended to ignore the body of knowledge available to guide the development of health service organizations. As one consequence, organizational experiments such as the one described by Ms. Doyle continue to be carried out, to the detriment of all concerned-especially to the patients or clients receiving the services compromised by organizational ineptitude. An essential feature of effective organization and
management of health service delivery is what we and others call organizational preventive maintenance, which is analogous to the preventive maintenance of equipment and machinery. Such built-in organizational preventive maintenance allows for systematic input of every staff member’s contributions of relevant information and skills, aimed at the early detection of trends and problems before crises occur. Problem-solving in a crisis-oriented situation is likely to be a less rational and a more emotional process that is ultimately dysfunctional for all concerned. We suggest that Ms. Doyle’s mental health center staff were beginning to achieve the kind of control of their program afforded by preventive maintenance approaches when the tide turned. We commend Ms. Doyle for writing about an all-toocommon experience. Perhaps readers will learn from this experience and from other material in the literature before embarking on similar, ill-fated ventures.tm
Defi n ing the Differences Between Crisis Intervention and Short-Term Therapy R. STUART, PH.D. Clinical Psychologist KEMSEY J. MACKEY, A.C.S.W. Coordinator, Outpatient Department St. Clare’s Hospital Mental Health Denville, New Jersey MARIAN
Center
Using the model of “person plus stress yields reaction,” the authors discuss the differences between crisis intervention and short-term treatment, including psychiatric emergencies. In emergency treatment the central focus is on the reaction, or symptoms, while in crisis intervention the emphasis is on the stress and its quick resolution. In short-term treatment the focus is on the person and exploration of behavior patterns and feelings. The authors believe that the number of crisis cases handled by a therapist must be limited because of their exhausting
nature.
UThe proliferation in the past decade
The authors’ address Health Center, St. Jersey 07834.
of community mental has made psychiatric
is Outpatient
Clare’s
Hospital,
Department,
Pocono
health centers services more
Community
Road,
Denville,
Mental
New
available to the general public. Many of the centers provide crisis intervention and short-term psychotherapy without a clear understanding of the differences between the two modalities. The differences need to be delineated in order to facilitate more effective treatment. The term crisis intervention suggests that treatment is provided at a time when a patient or family is experiencing a particular crisis. A crisis is usually thought of as an emergency of some sort or a situation of acute stress. It is a time when a great deal of change is being experienced or perceived by the patient, who feels incapable of coping without help. Short-term therapy has been described in the literature as brief or time-limited therapy, ranging from one session up to two years of treatment. One way to apply those concepts is through the use of a model that provides direction for clinical understanding of the patient and his presenting problem. The model assumes that person plus stress yields reaction. Person includes everything the patient presents about himself-demographic data, family background, previous coping mechanisms, developmental history, value systems, and beliefs. Stress is the situation that the person is experiencing. Reaction represents the re-
VOLUME
28
NUMBER
7 JULY
1977
527
In crisis intervention the focus is on the stress, while in shortterm therapy the focus is on the person. The goal of shortterm therapy is not just alleviation of symptoms,
but examination of behavior patterns. sponse to the stress, which is manifested through a variety of psychiatric symptoms. A psychiatric break may be a reaction to overwhelming stress and may require immediate medical and psychiatric intervention. Sleep disturbances, withdrawn behavior, severe anxiety, and clinical depression are other possible reactions. The interaction of the three elements of the modelperson, stress, and reaction-forms the basis of the clinical diagnosis. The type of intervention can be chosen after assessing which element appears to be the most highly charged. Obviously, if the patient’s reaction will create a danger to himself or other individuals, emergency psychiatric treatment must be initiated to provide immediate relief. In that case the reaction is the critical element. If the degree of stress and its urgency are primary, crisis intervention becomes the treatment of choice. Such stress must be experienced subjectively by the patient and confirmed objectively by the therapist. If, however, the stress is not the primary concern as realistically assessed by the therapist, short-term therapy may be the appropriate alternative, since its focus goes beyond the stress and onto the person.
CRISIS
INTERVENTION
Gerald Caplan provides a rationale for the effectiveness of crisis intervention.’ He suggests that each person functions within a specific range of effectiveness and satisfaction. There is a continuum of functioning that ranges from people who perform at an ineffective level to those who are well adjusted and adaptive and enjoy living. Most people remain at a certain general level of functioning, with fluctuations in response to experiences and manageable life stress. In a crisis, there is an overwhelming amount of stress experienced. Caplan states that regardless of the nature or degree of stress, some resolution occurs within four to six weeks, and it may have favorable or unfavorable consequences for later functioning. A good resolution, with adequate help and within the critical period, results in the individual’s functioning at a higher level of adjustment. Conversely, if no help is available or is not
provided at the critical time, the individual will resolve the crisis at the cost of subsequent lower functioning. The concepts of crisis and emergency need to be clarified. A psychiatric emergency is one type of reaction to a crisis, and indeed the most intense reaction requiring immediate intervention to prevent dire consequences. An emergency for a patient is a subjective state in which he feels he cannot deal with the situation without immediate help. Reality has little to do with the patient’s perceived stress. While an emergency is experienced by the patient as an inability to cope, a crisis is the time of great change or impending change, requiring unfamiliar responses. In a crisis, great stress is placed on an individual or a family system that previously functioned in a certain way. There is a demand for reaction as changes force the system to make some kind of adjustment. Often there appears to be no satisfactory response available, and ineffectual or regressive behavior becomes apparent. Pittman suggests seven steps to consider when providing crisis intervention services.2 The first step is to intervene immediately; that helps to alleviate the symptoms by offering a supportive presence. Next, the situation must be seen as one involving the whole family and must be accurately defined. This second step, problem definition, involves u nderstanding the nature of the crisis. It must be determined whether the situation is overt or covert, habitual or unique, situational or having to do with permanently altering family structures. The importance of correctly defining the problem is critical in the assessment of stress and its appropriate resolution. For example, treating temporary stress as though it were permanent could result in heightened distress as well as an inappropriate reaction. The third step is helping the family focus on the current situation rather than reactivating old conflicts. The question of Why now? is most predominant. Fourth, there is the need to alleviate the acute symptoms. Often the therapist’s calm, objective inquiry into the situation is all that is needed to relieve excessive anxiety. Sometimes, however, medication is an appropriate choice for one or more family members. Having accurately assessed the problem, the therapist proceeds to the fifth step, helping the family explore possible solutions. Here the focus is on defining the problem not only in terms of its particular characteristics but also as involving the whole family. Faulty resolutions that will result in more stress must be avoided. Placing blame is not a resolution of a problem, nor will divorce settle a family dispute over finances. Possible solutions must be discussed rationally rather than acted on precipitately. Patients should be cautioned not to make irrevocable decisions that do not have to be made or to create more change in their lives than is absolutely necessary. The sixth step in the crisis resolution is the work
2 1
York
528
G. Caplan, City,
Principles
of Preventive
Psychiatry,
Basic
Books,
1964.
New
1973,
HOSPITAL
&
COMMUNITY
PSYCHIATRY
F.
S.
Pittman,
the
Defining pp.
Family
219-227.
III,
“Managing
Crisis,”
Acute
Seminars
Psychiatric
In
Psychiatry,
Emergencies:
Vol.
5,
May
The time boundaries for intervening productively in a crisis put pressure on the therapist Faced with two or three such cases in immediate succession, the therapist begins to feel battleweary. involved with overcoming the natural resistance to change. In exploring solutions, it becomes apparent that different family members will have to make some adjustments in attitudes or behavior. They may need several sessions with the therapist to help them accept the changes as beneficial for everyone involved. The final step is termination. In crisis intervention, satisfactory resolution of acute distress is the focus. Once the crisis is resolved, the contract is finished. Further contact between therapist and patient would require negotiation of a new contract, since prolonging the intervention would imply a different treatment modality.
SHORT-TERM
THERAPY
In crisis intervention the central element is the stress, while in short-term therapy the focus is primarily on the person. What are the patterns and characteristics that influence the person to react to the current stress in a particular way? The current dysfunction may or may not be related to an observable, definable event; rather it may relate more to his view of himself and his past coping patterns, which are currently failing him. The goal of short-term psychotherapy is not merely alleviation of symptoms, but also examination of patterns of behavior. The patient becomes aware that his characteristic ways of reacting are no longer suitable. In the short-term treatment modality, he is helped to say “These are my habits, the ways I react. They served me in the past but now are no longer helpful. How can I start to rework these patterns?” Through this process the patient learns to communicate more clearly and to focus on himself and his responsibility for satisfying his own needs. One of the advantages of short-term therapy is that by definition there is a beginning, a middle, and an end that the patient can relate to. A therapy contract specifying a certain number of sessions allows the therapist and the patient to focus on the most salient issues. (In our mental health center short-term therapy is considered to be up to 12 sessions of individual therapy and up to six months of group therapy.) Implied in this approach is the therapist’s ability to assess how many sessions are needed to bring about a positive resolution. The goal of the treatment may be insight, enhancement
of problem-solving skills. In any event, image, his conscious sponsibility for his
THE
ability, or improved socialization the focus is on the person-his selfpatterns of behavior, and his reown actions.
THERAPIST’S
ROLE
In general, it is our impression that the amount of the therapist’s direct supportive involvement should be closely correlated with the degree of crisis presented by the case. All treatment has supportive elements, whether it is emergency intervention or long-term, uncovering therapy. However, when emergency or crisis intervention is the treatment of choice, therapy becomes more overtly supportive and calls for more direct involvement by the therapist. Generally the shorter the time available for treatment, the greater the amount of direct intervention needed on the part of the therapist. When more time is available, the therapist is able to become less directive. The time boundaries for intervening productively in a crisis put pressure on the therapist. Outpatient treatment of a patient in a serious crisis always poses a potential danger for the therapist. When resolution of one patient’s problem is followed immediately by one or two other serious cases, the therapist starts to feel battle-weary. Often therapists feel responsible for arriving at particular solutions for the patient, rather than helping alleviate stress through support and providing directions for effective problem-solving. Another potential hazard is the emotional response felt by therapists under pressure from crisis cases. Rosenbaum and Beebe have observed that those treating suicidal patients can feel contagious exhaustion.” They state, Endless ambivalence, vengeful dependency, repetitive pressure for reassurance, and frustrating denial wear out those who want to help. Passive negativism is so exasperating that it regularly elicits lecturing and rejection.’ Their statements underscore our viewpoint that the number of crisis cases handled by any therapist must be limited. Short-term treatment, while not producing the same level of stress as crisis intervention, nevertheless places demands on the therapist. The therapy contract defines the issues to be considered within a specific time frame. Therapists must not allow themselves to be seduced into exploring interesting but tangential rnaterial,U ‘ ‘
‘ ‘
‘
C.
Crisis,
VOLUME
P.
Rosenbaum
Clinic,
28
J.
and
E.
and Consultation,
NUMBER
7 JULY
Beebe, McGraw-Hill,
1977
III,
Psychiatric New
York
Treatment: City,
1975.
529
management of health service delivery is what we and others call organizational preventive maintenance, which is analogous to the preventive maintenance of equipment and machinery. Such built-in organizational preventive maintenance allows for systematic input of every staff member’s contributions of relevant information and skills, aimed at the early detection of trends and problems before crises occur. Problem-solving in a crisis-oriented situation is likely to be a less rational and a more emotional process that is ultimately dysfunctional for all concerned. We suggest that Ms. Doyle’s mental health center staff were beginning to achieve the kind of control of their program afforded by preventive maintenance approaches when the tide turned. We commend Ms. Doyle for writing about an all-toocommon experience. Perhaps readers will learn from this experience and from other material in the literature before embarking on similar, ill-fated ventures.tm
Defi n ing the Differences Between Crisis Intervention and Short-Term Therapy R. STUART, PH.D. Clinical Psychologist KEMSEY J. MACKEY, A.C.S.W. Coordinator, Outpatient Department St. Clare’s Hospital Mental Health Denville, New Jersey MARIAN
Center
Using the model of “person plus stress yields reaction,” the authors discuss the differences between crisis intervention and short-term treatment, including psychiatric emergencies. In emergency treatment the central focus is on the reaction, or symptoms, while in crisis intervention the emphasis is on the stress and its quick resolution. In short-term treatment the focus is on the person and exploration of behavior patterns and feelings. The authors believe that the number of crisis cases handled by a therapist must be limited because of their exhausting
nature.
UThe proliferation in the past decade
The authors’ address Health Center, St. Jersey 07834.
of community mental has made psychiatric
is Outpatient
Clare’s
Hospital,
Department,
Pocono
health centers services more
Community
Road,
Denville,
Mental
New
available to the general public. Many of the centers provide crisis intervention and short-term psychotherapy without a clear understanding of the differences between the two modalities. The differences need to be delineated in order to facilitate more effective treatment. The term crisis intervention suggests that treatment is provided at a time when a patient or family is experiencing a particular crisis. A crisis is usually thought of as an emergency of some sort or a situation of acute stress. It is a time when a great deal of change is being experienced or perceived by the patient, who feels incapable of coping without help. Short-term therapy has been described in the literature as brief or time-limited therapy, ranging from one session up to two years of treatment. One way to apply those concepts is through the use of a model that provides direction for clinical understanding of the patient and his presenting problem. The model assumes that person plus stress yields reaction. Person includes everything the patient presents about himself-demographic data, family background, previous coping mechanisms, developmental history, value systems, and beliefs. Stress is the situation that the person is experiencing. Reaction represents the re-
VOLUME
28
NUMBER
7 JULY
1977
527
In crisis intervention the focus is on the stress, while in shortterm therapy the focus is on the person. The goal of shortterm therapy is not just alleviation of symptoms,
but examination of behavior patterns. sponse to the stress, which is manifested through a variety of psychiatric symptoms. A psychiatric break may be a reaction to overwhelming stress and may require immediate medical and psychiatric intervention. Sleep disturbances, withdrawn behavior, severe anxiety, and clinical depression are other possible reactions. The interaction of the three elements of the modelperson, stress, and reaction-forms the basis of the clinical diagnosis. The type of intervention can be chosen after assessing which element appears to be the most highly charged. Obviously, if the patient’s reaction will create a danger to himself or other individuals, emergency psychiatric treatment must be initiated to provide immediate relief. In that case the reaction is the critical element. If the degree of stress and its urgency are primary, crisis intervention becomes the treatment of choice. Such stress must be experienced subjectively by the patient and confirmed objectively by the therapist. If, however, the stress is not the primary concern as realistically assessed by the therapist, short-term therapy may be the appropriate alternative, since its focus goes beyond the stress and onto the person.
CRISIS
INTERVENTION
Gerald Caplan provides a rationale for the effectiveness of crisis intervention.’ He suggests that each person functions within a specific range of effectiveness and satisfaction. There is a continuum of functioning that ranges from people who perform at an ineffective level to those who are well adjusted and adaptive and enjoy living. Most people remain at a certain general level of functioning, with fluctuations in response to experiences and manageable life stress. In a crisis, there is an overwhelming amount of stress experienced. Caplan states that regardless of the nature or degree of stress, some resolution occurs within four to six weeks, and it may have favorable or unfavorable consequences for later functioning. A good resolution, with adequate help and within the critical period, results in the individual’s functioning at a higher level of adjustment. Conversely, if no help is available or is not
provided at the critical time, the individual will resolve the crisis at the cost of subsequent lower functioning. The concepts of crisis and emergency need to be clarified. A psychiatric emergency is one type of reaction to a crisis, and indeed the most intense reaction requiring immediate intervention to prevent dire consequences. An emergency for a patient is a subjective state in which he feels he cannot deal with the situation without immediate help. Reality has little to do with the patient’s perceived stress. While an emergency is experienced by the patient as an inability to cope, a crisis is the time of great change or impending change, requiring unfamiliar responses. In a crisis, great stress is placed on an individual or a family system that previously functioned in a certain way. There is a demand for reaction as changes force the system to make some kind of adjustment. Often there appears to be no satisfactory response available, and ineffectual or regressive behavior becomes apparent. Pittman suggests seven steps to consider when providing crisis intervention services.2 The first step is to intervene immediately; that helps to alleviate the symptoms by offering a supportive presence. Next, the situation must be seen as one involving the whole family and must be accurately defined. This second step, problem definition, involves u nderstanding the nature of the crisis. It must be determined whether the situation is overt or covert, habitual or unique, situational or having to do with permanently altering family structures. The importance of correctly defining the problem is critical in the assessment of stress and its appropriate resolution. For example, treating temporary stress as though it were permanent could result in heightened distress as well as an inappropriate reaction. The third step is helping the family focus on the current situation rather than reactivating old conflicts. The question of Why now? is most predominant. Fourth, there is the need to alleviate the acute symptoms. Often the therapist’s calm, objective inquiry into the situation is all that is needed to relieve excessive anxiety. Sometimes, however, medication is an appropriate choice for one or more family members. Having accurately assessed the problem, the therapist proceeds to the fifth step, helping the family explore possible solutions. Here the focus is on defining the problem not only in terms of its particular characteristics but also as involving the whole family. Faulty resolutions that will result in more stress must be avoided. Placing blame is not a resolution of a problem, nor will divorce settle a family dispute over finances. Possible solutions must be discussed rationally rather than acted on precipitately. Patients should be cautioned not to make irrevocable decisions that do not have to be made or to create more change in their lives than is absolutely necessary. The sixth step in the crisis resolution is the work
2 1
York
528
G. Caplan, City,
Principles
of Preventive
Psychiatry,
Basic
Books,
1964.
New
1973,
HOSPITAL
&
COMMUNITY
PSYCHIATRY
F.
S.
Pittman,
the
Defining pp.
Family
219-227.
III,
“Managing
Crisis,”
Acute
Seminars
Psychiatric
In
Psychiatry,
Emergencies:
Vol.
5,
May
The time boundaries for intervening productively in a crisis put pressure on the therapist Faced with two or three such cases in immediate succession, the therapist begins to feel battleweary. involved with overcoming the natural resistance to change. In exploring solutions, it becomes apparent that different family members will have to make some adjustments in attitudes or behavior. They may need several sessions with the therapist to help them accept the changes as beneficial for everyone involved. The final step is termination. In crisis intervention, satisfactory resolution of acute distress is the focus. Once the crisis is resolved, the contract is finished. Further contact between therapist and patient would require negotiation of a new contract, since prolonging the intervention would imply a different treatment modality.
SHORT-TERM
THERAPY
In crisis intervention the central element is the stress, while in short-term therapy the focus is primarily on the person. What are the patterns and characteristics that influence the person to react to the current stress in a particular way? The current dysfunction may or may not be related to an observable, definable event; rather it may relate more to his view of himself and his past coping patterns, which are currently failing him. The goal of short-term psychotherapy is not merely alleviation of symptoms, but also examination of patterns of behavior. The patient becomes aware that his characteristic ways of reacting are no longer suitable. In the short-term treatment modality, he is helped to say “These are my habits, the ways I react. They served me in the past but now are no longer helpful. How can I start to rework these patterns?” Through this process the patient learns to communicate more clearly and to focus on himself and his responsibility for satisfying his own needs. One of the advantages of short-term therapy is that by definition there is a beginning, a middle, and an end that the patient can relate to. A therapy contract specifying a certain number of sessions allows the therapist and the patient to focus on the most salient issues. (In our mental health center short-term therapy is considered to be up to 12 sessions of individual therapy and up to six months of group therapy.) Implied in this approach is the therapist’s ability to assess how many sessions are needed to bring about a positive resolution. The goal of the treatment may be insight, enhancement
of problem-solving skills. In any event, image, his conscious sponsibility for his
THE
ability, or improved socialization the focus is on the person-his selfpatterns of behavior, and his reown actions.
THERAPIST’S
ROLE
In general, it is our impression that the amount of the therapist’s direct supportive involvement should be closely correlated with the degree of crisis presented by the case. All treatment has supportive elements, whether it is emergency intervention or long-term, uncovering therapy. However, when emergency or crisis intervention is the treatment of choice, therapy becomes more overtly supportive and calls for more direct involvement by the therapist. Generally the shorter the time available for treatment, the greater the amount of direct intervention needed on the part of the therapist. When more time is available, the therapist is able to become less directive. The time boundaries for intervening productively in a crisis put pressure on the therapist. Outpatient treatment of a patient in a serious crisis always poses a potential danger for the therapist. When resolution of one patient’s problem is followed immediately by one or two other serious cases, the therapist starts to feel battle-weary. Often therapists feel responsible for arriving at particular solutions for the patient, rather than helping alleviate stress through support and providing directions for effective problem-solving. Another potential hazard is the emotional response felt by therapists under pressure from crisis cases. Rosenbaum and Beebe have observed that those treating suicidal patients can feel contagious exhaustion.” They state, Endless ambivalence, vengeful dependency, repetitive pressure for reassurance, and frustrating denial wear out those who want to help. Passive negativism is so exasperating that it regularly elicits lecturing and rejection.’ Their statements underscore our viewpoint that the number of crisis cases handled by any therapist must be limited. Short-term treatment, while not producing the same level of stress as crisis intervention, nevertheless places demands on the therapist. The therapy contract defines the issues to be considered within a specific time frame. Therapists must not allow themselves to be seduced into exploring interesting but tangential rnaterial,U ‘ ‘
‘ ‘
‘
C.
Crisis,
VOLUME
P.
Rosenbaum
Clinic,
28
J.
and
E.
and Consultation,
NUMBER
7 JULY
Beebe, McGraw-Hill,
1977
III,
Psychiatric New
York
Treatment: City,
1975.
529
