MCC 670 – Crisis & Trauma

In chapter eight, Ingram (2012) describes five hypotheses that are useful in addressing crises that require “immediate…intervention” (p117). Each of these hypotheses is described below:
  1. An Emergency Hypothesis (CS1), is a situation in which an individual is experiencing homicidal and/or suicidal ideation. An example might be if you are seeing a new client for the first time, and they state they are experiencing suicidal thoughts. A careful assessment in this situation is essential, and the patient’s safety becomes a priority alongside mandatory reporting considerations.
  2. Situational Stressors (CS2) refer to life situations and/or stressors that are in excess of an individual ability to cope. One example might be a very contentious divorce. The loss of a significant relationship, financial strain and restructuring of a family environment can be overwhelming.
  3. Developmental Transitions (CS3) – refer to crises associated with normal human development. Erickson’s developmental theory is useful here as an underlying theoretical perspective for this hypothesis.
  4. Loss and Bereavement (CS4) – As someone who has works in healthcare I’m aware of the crisis associated with the death of a loved one. The grief and morning process occur in stages very much as Kubler-Ross describes
  5. Trauma (CS5) – As I understand trauma, it is an experience that changes how an individual perceives oneself and the world around them. Examples can include anything from rape, natural disaster, combat experience, child abuse, or even vicarious trauma experienced by emergency service worker.

The First Decision….

“Is this someone who needs an immediate, active intervention in order to prevent harm in the client or to others, or can I safely conduct my usual intake and therapy procedures.  There are two errors that must be avoided: (1) failing to prevent serious consequences, including death, destructive actions, and long term pathology by not promptly responding in crisis mode and, (2) pathologizing a condition that, while painful and debilitating, is best understood as a normal, expectable response to the stressors, transitions, and traumas of daily life (Ingram, 2012, p. 117)”  

A careful reading of the five hypotheses in chapter eight is useful in determining the nature of a client’s “crisis” and the associated needs. For all individuals, it is essential to assess for the presence of an emergency situation that produces a concern for the client and/or others. In the instance that a client expresses homicidal and/or suicidal ideation a thorough assessment is necessary. An examination of relevant stressors, suicide plan, presenting symptoms and past history, are key elements of a suicide risk assessment (Ingram, 2012, p120). Homicidal ideation also requires careful assessment and raises mandatory reporting concerns. Finally, evidence of child abuse also requires careful assessment and mandatory reporting. In order to adhere to all legal and ethical obligations, it is essential to be knowledge of the laws in your state and the ACA code of ethics.

In the event that a situation is not a true emergency, guidelines for the situational stressors and trauma hypotheses are useful.  Ingram, (2012) states these to hypothesis are based on crisis intervention literature which notes that “distressing impairment” (p. 117) of this magnitude are a byproduct of either situational stressors or developmental transitions.    Crises of this nature can be described as developing in the following stages:

  1. “STAGE ONE:  Rise in tension & stress.
  2. STAGE TWO: Unsuccessful coping.
  3. STAGE THREE:  Unsuccessful mobilization of emergency solutions.
  4. STAGE FOUR:  Disorganization & Crisis (Ingram, 2012, p. 118).”

Finally, while bereavement may be classified as a developmental transition Ingram, (2012) notes that there are theoretical models specifically designed to address this issue.  Trauma is also addressed as a separate hypothesis in acknowledgement of the obvious fact that stress and trauma are different things.

Emergency (CS1)

Summary & Key Ideas

In this instance, “the client presents an emergency [and] immediate action is necessary.  [It] must always be considered in first session to prevent serious consequences of not taking action”  (Ingram, 2012).  What follows are examples of situations in which this hypothesis may be applicable:

  1. Homicidal & Suicidal Risk.
  2. Mandated Reporting Requirements [i.e. abuse].
  3. Grave illness requiring immediate medical care.
  4. impaired judgment/disability & unable to care for basic needs.

In other words, is the client a danger to himself and/or others?  Are they unable to perform basic ADL’s? Ingram, (2012), suggests that practitioners know the mandatory reporting laws in their state, and how this pertains to confidentiality limits.  Additionally, when feasible consulting with a colleague or supervisor is essential.

Is this Hypothesis a Good Match

This hypothesis is ideally suited for situations in which a person is a danger to self and/or others.  It is also useful in situations where someone is unable to care for their own basic needs.  This hypothesis should be considered during the first session due to the potential negative consequences.

Treatment Planning

Ingram (2012) admits that when making a clinical decision, your best course of action is never  entirely clear!  Human beings are, by nature, complex.  Predicting someone’s future action is ultimately a your best-educated guess.   Two rules of thumb for the newbie: (1) better safe than sorry & (2) seek guidance from your clinical supervisor.  Generally speaking, this hypothesis focuses on people who (1) are a danger to themselves, (2) are a danger to others or, (3) are unable to meet their basic needs.  What follow is a quick-&-dirty list of issues you may need to wrestle with.

  1. Should I hospitalize?
  2. How can I maintain a therapeutic alliance while ensuring safety?  
  3. Risk Assessments
  4. Reporting violence & abuse 
  5. Ensuring client safety and well-being
  6. Mandatory reporting rules of law

Situational stressors – (CS2)

Summary & Key Ideas…

With this hypothesis it is important to examine whether or not the client’s symptoms are proportional to the level of stress they experience?  What are the specific stressors they are struggling with?  How well are they able to cope with the stress?  Examine any risk and/or protective factors that influence their ability to cope with stress.

Is This Hypothesis a Good Match

How does the situational stressor influence the client’s ability to cope?  Examine behavioral, cognitive, and emotional reactions to the stress.  How does the stress affect the individual’s overall well-being.  A convenient example you might compassion fatigue.

Treatment Planning

FIRST PRIORITY  Resolve the Situational Stressor that overwhelms the client’s ability to cope.  Ingram (2012), lists the following as steps for crisis intervention.

  1. “Instill Hope and give reassurance” (Ingram, 2012, p. 129).
  2. “Be in charge of the interview, provide structure, and present yourself as a problem-solving expert” (Ingram, 2012, p. 129).
  3. “Assess the crisis” (Ingram, 2012, p. 129) and help the client make sense of their situation.
  4. Allow the client an opportunity to prcess their thoughts and feelings.  
  5. Help the client to re-examine their perspective of things, (i.e. cognitive restructuring).
  6. “Develop a plan of action” (Ingram, 2012, p. 129) and help the client improve their coping skills and support system.
  7. Finally, monitor the client’s progress and plan with discharge in mind.

Developmental Transitions (CS3)

Summary & Key Ideas…

This clinical hypothesis is based on the developmental lifecycle theories that stress how humans progress through a series of stages in life!  Each stage builds on the one before it and involves a key challenge to overcome, (i.e. midlife crisis).  What follows is a list of terms and key ideas from theories upon which this clinical hypothesis is based.  It tends to focus on an individual model of development that normally occurs over a life span.  However, this developmental model must be placed within the proper cultural and historical context to be relevant to the client.  Gender differences also influence this process.

  1. “MATURATION: through the lifespan involves change, tension, stress and disruption of harmonious living, followed by periods of consolidation and stability
  2.  DEVELOPMENTAL – transitions are triggered by physical growth, psychological maturation, and social pressures and expectation
  3. STAGE – implies a fixed, linear sequence where one stage is completed before the next begins (i.e. Erickson and his concepts of disequilibrium/equilibrium).” (Ingram, 2012)

Is this hypothesis a good fit?

How does one determine if this hypothesis is a good fit?  Ingram, (2012), cautions gains utilizing this model as a preconceived model of growth but as a useful perspective upon which to evaluate an individual’s life history.  it can help us develop an understand the individual’s opportunities for growth and examine issues that were unresolved from previous developmental stages.  What follows are a few examples of common problems that this hypothesis may be a good fit for according to Ingram, (2012).

  1. “Major life decisions” (Ingram, 2012) – (for example having a baby). It can be difficult to make these decisions clearly at times.
  2. “Relationship problems” (Ingram, 2012) – working through relationships problems that develop and/or change as we grow is another developmental issue.
  3. “Cultural Deviation Distress” (Ingram, 2012) – sometimes if a person is deals with negative judgments from a culturally deviant lifestyle.  

Treatment Planning Ideas

Treatment planning should consider the person’s stage of development.  Ingram, (2012), suggests that psychoeducation be provided to help normalize the stress individuals feel when encountering a new stage in life.  Skills training can be helpful in allowing individuals to address new challenges (i.e. parenting challenges) if a skills deficit is uncovered (BL3).  Examining the client’s personal beliefs and feelings regarding the new stage in life is also useful.  Finally, where necessary, films, books, and community resources may be useful.

Loss and Bereavement (CS4)

Summary & Key Ideas…

The next crisis-related clinical hypothesis in the Ingram, (2012) textbook pertains to loss of a loved one or a catastrophic injury (quadriplegic).   Loss of this kind are both internal and external.  Knowledge about the stages of grieving is useful, however Ingram, (2012) cautions therapists to not a “rigid model of grieving”.  Hospice care, bereavement groups, are a few examples of resources that may be utilized.  Initial stages tend to involve feelings of shock and disbelief.  Over time feelings of pain, despair and depression can take over.  Resolving the loss can also involve swinging between denial and despair. What follows are a few related concepts…

  1. Key tasks in the grieving process:  
    1. “Accepting the reality of loss
    2. Working through the pain of grief
    3. Adjust to an environment that includes memory of loss
    4. Emotionally relocate that which was lost and move on…(Ingram, 2012)”
  2. Dual process theory for bereavement: As stated earlier, bereavement means working through feelings of shock, pain, disbelief, and despair.  It requires working through and processing feelings of loss alongside learning to cope and continue moving forward in the world.  This theory describes it as a loss orientation and restoration orientation.  
  3. Three types of complicated bereavement
    1. Chronic Type – too much focus on loss and lack of progress in restoration tasks
    2. Delayed, Inhibited / Absent – too little focus on loss with exclusive focus on restoration tasks.
    3. Traumatic type – intense and persistent confrontation with loss combined with avoidance.

Is this hypothesis a good fit?

Ingram, (2012) begins by providing a list of risk factors that are commonly associated with a complicated bereavement process: (1) the type of relationship with the deceased, (2) circumstances of death, (3) how the person copes with death, (4) other life stressors, and (5) inadequate social support.  Ideal circumstances in which to utilize this hypothesis include when an individual has difficulty coping with the loss and they are experiencing an incomplete recovery.  Examples of situations in which it may be useful can include; (1) divorce, (2) miscarriage, (3) death,(4) infertility, or (5) terminal illness.

Treatment Planning ideas…

  1. Evaluate the client’s level of distress, while providing empathy and room to process the feelings…
  2. Examine skills deficits in how the person is coping.  Consider DBT/CBT skills
  3. Provide psychoeducation on the grieving process. 
  4. Help the client cope with current relationships and life responsibilities.
  5. Restoring the client can involve revisiting experiences and promoting sense of connection to deceased. 
  6. Bereavement groups, CBT/existential/Psychodynamic (Ingram, suggestions). 

Trauma (CS5)

Summary & Key Ideas…

Click here to read a brief explanation of PTSD.  This clinical hypothesis focuses on trauma survivors who experience persistent distressing impairment as a result of traumas they have experienced. Treatment interventions can involved group therapy, spiritual interventions, EMDR, exposure therapy and CBT/DBT.  Ingram, (2012) states: “the concept of PTSD implies an etiologic process whereby pathogenic memory produces involuntary, distressing recollections in the form of intrusive thoughts, nightmares, flashbacks…etc…These recollections heighten emotional arousal….This…in turn, motivates attempts to avoid anything that might trigger recollections.”

  1. Risk factors:  “Severity of stressor, Prior vulnerability factors, Subjective Threat level, Lack of Social Support.” (Ingram, 2012).
  2. Protective factors: “effective coping skills, social support, spiritual factors, sense of self.” (Ingram, 2012).
  3. Cultural context: “Ethnocultural variables are important when assessing trauma history of survivors. Cultural factors can interfere and prevent effective interventions” (Ingram, 2012)..

How To Determine fit?

Ingram, (2012) begins by noting that trauma is harmful regardless of whether a person has symptoms of a diagnosis.  With this in mind, addressing the client’s problem first involve examining the specific symptoms they are experiencing, (trouble sleeping, emotionally numb, depressed, etc).  Then gather data about their trauma history, “avoid extremes in neglecting the topic and addressing it with insensitivity” (Ingram, 2012).

Treatment Planning Ideas…

“WARNING BEFOREHAND: Trauma interventionists need special training, competent supervision or consultation, and ongoing professional support. The need to be aware of the risk of vicarious trauma….” (Ingram, 2012).  With this in mind, my textbook provides an overview of three categories of interventiosn…

  1. “Critical stress debriefing immediately after trauma” (Ingram, 2012).
  2. “Treatment of PTSD Symptoms” (Ingram, 2012).  
  3. Treatment of complex PTSD” (Ingram, 2012). 

Treatment of PTSD requires multiple clinical hypotheses:  (1) Medical Interventions (BE2), (2) Mind-Body Connections (BE3), (3) Emotional Focus (BE4), (4) Conditioned Emotional Responses (BL2), (5) Cognitive (C1-4), (6) Spiritual Dimension (ES3), (50 Social Support (SC3).  Education/Medication/Exposure/CBT/EMDR/Relational psychotherapy.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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