Working with individuals and

families
Module V
 Module V
• Therapeutic approach to working with individuals
and families (In brief):
• Behavioural theory
• Transactional analysis
• Client centered approach
• Family therapy
• Gestalt approach
• Crisis intervention and disaster management-
meaning and psychological aspects
Client Centered approach
 Person-Centered
Therapy

a-s.clayton.edu/egannon/Notes/PSYC%203120/Person-Centered%20Theory.ppt
 The Life of Carl Rogers
(1902-1987)
• Born the fourth of six children
• Mother was a devout Christian (Protestant) and was very strict on Carl
and his siblings, although he has described his family relationships as
“warm and close”
• Carl was socially introverted as he was discouraged from playing
• He developed an active imagination and focused on academics.
Because his family lived on a farm, Carl had many chores, therefore
becoming very independent and self-disciplined
• As a college student, he was selected to go to Beijing for the “World
Student Christian Federation Conference.” There, he was exposed to
different religious philosophies and began to question his own
religious beliefs. This experienced shaped his views on human
behavior
• Rogers joined the staff at the Western Behavioral Sc0iences Institute
in La Jolla, California in 1964
• His theory became widely known during the 60’s and 70’s as the
progression of psychotherapy into the humanistic movement
The Person-Centered Approach
• A humanistic theory—each of us has a
natural potential that we can actualize and
through which we can find meaning
• Shares with existentialism a focus on
respect and trust for the client
 Humanism vs. Existentialism…
• Humanism and Existentialism BOTH:
• Respect for client’s experience and trust in
clients ability to change
• Believe in freedom, choice, values,
personal responsibility, autonomy,
meaning
 Humanism vs. Existentialism…
Existentialism Humanism
• Clients come into • Clients do not suffer
counseling because from anxiety in
they are facing creating an identity
anxiety in trying to • Clients need to
construct an identity believe that they have
in a world without the natural potential
intrinsic meaning to actualize
 The Concept of the
“Third Force”
• 1st Force—
Psychoanalysis
• 2nd Force—
Behaviorism
• 3rd Force—
Existentialism and
Humanism
 The Role of the Therapist
Necessary and Sufficient Conditions for Change

• Congruence—genuineness, one’s behavior

congruent with emotions
• Empathy—accurate ability to view the world from
client’s perspective
• Unconditional Positive Regard—acceptance, caring
***Remember these if you remember nothing else
from this lecture!!!***
 Growth Experiences
• Therapy is only one relationship that can
foster growth
• Growth occurs naturally when one is in a
situation with the proper conditions to
encourage that growth (i.e., metaphor of
the acorn)
• The therapist’s job is to set the stage, and
then the client is able to do what is
necessary for positive growth and change
 Goals of Person-Centered
Therapy
• Increase the • Create the conditions
independence and necessary for positive
integration of the growth
client • Develop openness to
• Focus on the person, new experiences,
not the problem trust in themselves,
internal source of
evaluation, and
willingness to
continue growing
 It should be noted…
• A major aspect of person-centered therapy
is the belief that the therapist should not
chose the goals of the client, but instead
help the client define and clarify their own
goals
• Goals should be expected to change as
the client progresses through counseling
 Important Points
• The relationship between client and
therapist is everything in person-centered
therapy
• The relationship is characterized by equality
• The therapist need not have any special
skills or knowledge
• Diagnosis and collecting background history
is not necessary
 The Process of Therapy
• There are no real techniques, other than
listening, empathizing, understanding, and
responding to the client
• The client’s self-assessment is of primary
importance
• There are no specific stages to the process, as it
is all about the client’s own process of change
and growth, which must happen at their own
pace
 Rogers’ Contributions
• Emphasized that the
therapeutic
relationship is the
primary agent of
growth
• Created a style of
therapy that can be
used by various
helping professionals
 Limitations and Criticisms
• Most now feel these conditions are
necessary but not sufficient
• Can become supportive without
challenging the client, which makes
change difficult
• Places limits on therapist’s behavior within
the session, such as limiting their teaching
or guiding role
 Multicultural Perspective
• Has been applied to numerous cultures
and settings
• The core conditions are based on this
culture, and can be difficult to apply to
other cultures
• Some clients may want more structure or
guidance than this approach provides
 Family Therapy
(Refer workshop notes)
Gestalt approach
 The word “gestalt”
 Wholeness
 Completion
 Gestalt psychologist studied perception
 The whole is greater than the sum of its parts
 Perceptual system strives for completion and
closure
 At any given time, certain things are figure
(prominent, stand out) and other things are
ground. 21
The whole is greater than the
sum of its parts.

22
Striving for completion and wholeness

Proximity

Closure

Similarity Continuity 23
Figure-ground effect

24
 Perls: Gestalt therapy – Individuals seek
balance/equilibrium through awareness
 In humans, our awareness determines our
sense of what’s right for us. Similar to OVP
 Awareness - gives us a sense of direction
and motivation to become more fully who
we are.

25
 Awareness - identifies our most pressing
need and gives us options (choice) in
determining how to meet our needs
 “Awareness is curative.”
 If we can become fully aware of sensations,
feelings, perceptions, and behavior then we
can integrate these better.

26
 Lack of awareness and neurosis
 Phony layer - pretend to be something we are not, play
games
 Phobic layer - avoid recognizing aspects of ourselves,
prefer to deny, fear of rejection, humiliation
 Impasse layer - we are stuck, don’t think we can do
anything differently
 Implosive layer
 Explosive layer
 The neurotic lacks awareness, self responsibility, and
self regulation.
27
 What causes neurotic development?
 Infant needs environmental support
 Freeing ourselves from environmental support is life’s
greatest challenge
 Others want to tell us what to be - they use the stick or
hypnosis
 We/children face dilemma - letting others do for us
and tell us what to do and be so we won’t experience
frustration OR staying with the frustration and
learning to do and be what we want to do and be even
though it may be difficult.
28
 Perl’s believes that children are “stuck” when they are
spoiled and do not experience sufficient frustration
 Spoiled children use resources to control the environment
so they won’t have to grow and change and do that which
is hard
 They play games, ex. helpless, to manipulate others to do
for them what they think they can’t do for themselves
 They want environmental support when they need to be
self supporting and self regulating
 We must stop playing roles and games and actualize our
potential.
29
 Other things neurotics do:
 Live in the past
 Retrospective character, many regrets an unfinished situations
 Live in the future where we fantasize and worry about what
might happen
 Prospective character, can’t stop worrying, must plan, plan,
plan, worry, worry, worry
 Worrying and planning are a form of thinking which can be
carried to an extreme. Stop! Come to your senses and
experience the present moment
 We must live fully in the present. The here and now is the only
reality we have. We must live fully each moment.

30
 What was Perls trying to make Gloria AWARE
of in the therapy session?
 What are you doing, feeling, sensing right now.
Focus on nonverbals –body, gestures
 Frustrate Gloria – motivate her to find lost potential
 Do not explain- provide opportunities for her to
discover herself
 Awareness of inconsistencies. Do not have to cover
up your fear with a smile
 Awareness of games
 How she avoided because of fear. Could not get
beyond impasse. 31
 Awareness of polarities: closeness-distance.
want respect/don’t deserve respect love/hate,
good me/bad me, hard working/lazy, top dog
(what one thinks one should do)/ underdog
(what one wants to do)
 Guilt/resentment. Guilt is resentment and anger
turned inward on yourself
 Playing the projection – Play Perls demanding
respect. What would he say. “I am you.”.

32
 Goals of Therapy
 Move from environmental support to self support
 Become complete and integrated due to increased
awareness
 Live in the present
 Complete unfinished business
 Become more spontaneous, live each moment as if it
were a glorious moment
 Take personal responsibility, become confident and
assertive, realize your potential, don’t take any crap.
33
 View of Human Nature
• Self-reliance and reintegration
• Dialogue b/w client and therapist (therapist has no
agenda
• Spontaneous; here and now experience
• Human nature is rooted in existential philosophy,
phenomenology, and field theory
• Individuals have the capacity to self-regulate in their
environment
• The process of “reowning” parts of oneself that have
been disowned
 The Now
• Existential & Phenomenological – it is
grounded in the client’s “here and now”
• Initial goal is for clients to gain awareness
of what they are experiencing and doing
now
– Promotes direct experiencing rather than the
abstractness of talking about situations
– Rather than talk about a childhood trauma the
client is encouraged to become the hurt child
 The Now
• Ask “what” and “how” instead of “why”
• Our “power is in the present”
– Nothing exists except the “now”
– The past is gone and the future has not yet arrived
• For many people, the power of the present is
lost
– They may focus on their past mistakes or engage in
endless resolutions and plans for the future
 Unfinished Business

• Feelings about the past are unexpressed

– These feelings are associated with distinct memories
and fantasies
– Feelings not fully experienced linger in the
background and interfere with effective contact
– Pay attention on the bodily experience because if
feelings are unexpressed they tend to result in
physical symptom
• Result:
– Preoccupation, compulsive behavior, wariness
oppressive energy and self-defeating behavior
– Solution: get in touch with the stuck point.
 Contact and Resistances to
•
Contact
CONTACT – interacting with nature and with other
people without losing one’s individuality
– Contact (connect) and Withdrawal (separate)

• RESISTANCE TO CONTACT – the defenses we

develop to prevent us from experiencing the
present fully
– Five major channels of resistance:
• Introjection • Deflection
• Projection • Confluence
• Retroflection
 Contact and Resistances to
Contact
• Introjection: uncritically accept others’ belief
and standards without thinking whether they
are congruent with who we are
• Projection: the reverse of introjection; we
disown certain aspect of ourselves by
assigning them to the environment
• Retroflection: turning back to ourselves what
we would like to do to someone else
– Directing aggression inward that we are fearful to
directing toward others.
 Contact and Resistances to
Contact
• Deflection: A way of avoiding contact and
awareness by being vague or indirect.
– e.g., overuse of humor
• Confluence: less differentiation between the self
and the environment.
– e.g., a need to be accepted---to stay safe by going
alone with other and not expressing one’s true feeling
and opinions.
• Clients are encouraged to become increasingly
aware of their dominant style of blocking contact
 Energy and blocks to energy
• Pay attention to where energy is located, how it
is used, and how it can be blocked
• Blocked energy (resistance):
– Tension some part of the body; numbing feelings,
looking away from people when speaking, speaking
with a restricted voice
• Recognize how their resistance is being
expressed in their body
• Exaggerate their tension and tightness in order
to discover themselves
 Therapeutic Goals
• Increasing Awareness and greater choice
• Awareness includes knowing the environment,
knowing oneself, accepting oneself, and being
able to make contact.
• Stay with their awareness, unfinished
business will emerge.
 Therapist’s function and Role
• Increase clients’ awareness
• Pay attention to the present moment
• Pay attention to clients’ body language,
nonverbal language, and inconsistence
b/w verbal and nonverbal message (e.g.,
anger and smile)
• “I” message
 Client’s Experience in Therapy
• Therapist  no interpretation
• Client  making their own interpretation
• Three-stage (Polster, 1987)
– Discovery (increasing awareness)
– Accommodation (recognizing that they have a
choice)
– Assimilation (influencing their environment)
Relationship Between Therapist and
Client
• The quality of therapist-client relationship
• Therapists knowing themselves
• Therapists share their experience to clients in
the here-and-now
• Therapist Use of self in therapy
 Therapeutic techniques and
procedures
• The experiential work
– Use experiential work in therapy to work through the
stuck points and get new insights
• Preparing client for experiential work
– Get permission from clients
– Be sensitive to the cultural difference (e.g., Asian
cultural value: emotional control)
– Respect resistance (e.g., express emotionsfear of
lose control, could not stop, or weakness)
 Therapeutic techniques and
procedures
• Increase awareness about the incongruence
between mind and body (verbal and
nonverbal expression)
• The internal dialogue exercise
• Making the rounds
• Rehearsal exercise
• Exaggeration exercise
• Staying with the feeling
• The Gestalt approach to dream work
 Therapeutic techniques and
• procedures
The internal dialogue exercise
– Top dog (critical parent) and underdog (victim)
– Empty-chair (two sides of themselves)
• Making the rounds
– Go around to each person and say “What makes it
hard for me trust you is……”
• Rehearsal exercise
– Reverse the typical style (e.g., behave as negative as
possible)
 Therapeutic techniques and
procedures
• Rehearsal exercise
– May get stuck when rehearsing silently or internally
– Share the rehearsals out load with a therapist
• Exaggeration exercise
– Exaggerate gesture or movement, which usually
intensified the feelings attached to the behavior and
makes the inner meaning clearer.
• Staying with the feeling
– Go deeper into the feelings they wish to avoid
 Therapeutic techniques and
procedures
• The Gestalt approach to dream work
– Not interpret or analyze dreams
– Bring dream back to life as though they were
happening now
– The dream is acted out in the present to become
different parts of the dream
– Projection: every person or object in the dream
represents a projected aspect of the dreamer.
– Royal road to integration
– Dreams serve as an excellent way to discover
personality
– No remember-refuse to face what it is at that time
From a multicultural perspective
• Contributions
– Work with clients from their cultural
perspectives
• Limitations
– Focus on “affect”
• Asian cultural value: emotional control
• Prohibiting to directly express the negative feelings
to their parents.
 Summary and Evaluation
• Contributions
– Present-centered awareness
– Pay attention on verbal and nonverbal cures
– Bring conflicts or struggles to actually experience their
conflict and struggles
– Focus on growth and enhancement
– See each aspect of a dream as a projection of
themselves
– Increase awareness of “what is”
– Empirical validation for the effectiveness
 Summary and Evaluation
• Limitations
– Ineffective therapists may manipulate
the clients with powerful experiential
work
– Some people may need psycho-
education
Crisis intervention
 DEFINITIONS OF CRISIS
• Caplan (1960) defines crisis: brief episode of
psychological unbalance which occurs when
the subject is faced with a problem that cannot
be solved or avoided.
• Triggers of a crisis:
- traumatic events
- life changes entailed by the life cycle
 CRISIS
 Stressful event or perceived threat + lack of
efficient coping skills, resulting in emotional
unbalance
 Limited in time: 1-6 weeks
 During the crisis, the subject asks for help
 During the crisis, the subject is more compliant
to external intervention
 The evolution in crisis depends on the timing of
the intervention
 COPING AND CRISIS
• Stages of coping in crisis:
 Stage I. Immediate response: astonishment,
denial
 Stage II. Emotional reactions: anxiety, anger,
guilt, regression, depression
 Stage III. Resolution: acceptance, planning the
future
Model of crisis (G. Caplan, 1961)
THREAT EMOTIONAL BALANCE

Automatic resolution of
the problem-situation
INCREASE OF PSYCHOLOGICAL
STAGE 1 TENSION
(brief, unnoticed)
Problem-solving
strategies
FURTHER INCREASE OF
PSYCHOLOGICAL TENSION
STAGE 2 (acknowledged)

New problem-solving
strategies

PSYCHOLOGICAL DISTRESS
STAGE 3
(anxiety, discomfort)

SEVERE PSYCHOLOGICAL
STAGE 4 TENSION, DISORGANISATION,
SYMPTOMS, UNBALANCE, CRISIS
 TYPES OF CRISIS
1. MATURATIONAL CRISIS
– Periods in life which entail changes in social
roles, biological and social pressures;
– Adolescence, marriage, birth of a child,
retirement;
– Adolescence: maturational crisis –
originality, hormonal and psychological
unbalance
 TYPES OF CRISIS
2. SITUATIONAL CRISIS
– A specific external event disrupts the
internal psychological balance of the
individual;
– Holmes & Rahe Scale:
Death of spouse, divorce
Illness, accidents
Pregnancy, childbirth
Sexual dysfunction …
 SITUATIONAL CRISIS
1. The experience of loss (of a loved one, of self-
esteem, of normal functioning, of status, of
job…)
2. Issues concerning change (transition in
Romania, marriage, birth of a child, moving,
change of job…)
3. Interpersonal issues (family conflicts)
4. Environmental factors (polution, work
environment…)
 TYPES OF CRISIS

3. CATASTROFIC CRISIS (SOCIAL)

– accidental, unusual, unexpected: fire,
earthquake, flood, kidnapping, nuclear
accidents…
– They do not occur in any subject’s life
– Severe stress, requiring maximal coping
strategies and abilities
CATASTROFIC CRISIS - STAGES

• Impact
• Heroic stage
• “Honeymoon” stage
• Disillusionment stage
• Reconstruction, reorganisation
CATASTROFIC CRISIS - STAGES
Impact: shock, extreme fear; poor/ distorted
assessment of reality, and self-destructive behaviour
Heroic stage: Cooperative spirit between friends,
neighbours, and emergency teams; constructive
activity at this time may help overcome anxiety and
depression but excessive activity can lead to "burnout"
Honeymoon: 1 week-several months after the disaster;
the need to help others is sustained; psychological
problems may be overlooked
Disillusionment: 2 months to 1 year; disappointment,
resentment, frustration, anger; victims often begin to
show hostility toward others
Reconstruction: Individuals admit that they must come
to grips with their own problems; they begin to behave
in a constructive manner
THE CONSEQUENCE OF
UNRESOLVED
CRISIS→SUICIDE!!!!
 SPECIFIC GOALS OF CRISIS
INTERVENTION (Korchin)
a) Releasing the psychological tension and
distress (anxiety, despair, confusion,
agitation)
b) Restoring the level of functioning and activity
that the subject had prior to the crisis
c) Reassuring the subject that the coping
resources (internal, external) and support are
available
 TECNIQUES OF CRISIS
INTERVENTION
1. Abreaction – remembering the highly
emotionally charged events decreases the
tension: "ventilation of emotions";
2. Clarifying – encouraging the subject to
rationalize the relationship between previous
life events and current situation;
3. Suggestion – persuasive discourse in order to
improve personal and overall situation;
4. Manipulation – employing patient’s emotions
and desires in the therapeutic process;
 TECHNIQUES OF CRISIS
INTERVENTION
5. Positive reinvestment - positive answers to
patient’s successful adaptive behaviors;
6. Supporting effective defense mechanisms that
maintain integrity of the ego;
7. Encouraging the increase of self-esteem –
regaining the purpose of living, reassuring the
subject of his/her value and meaning;
8. Exploring solutions – finding specific alternative
solutions and problem-solving through
teamwork;
PROBLEM-SOLVING SEQUENCE
IN CRISIS INTERVENTION
 Step-by-step sequence:
a) Assessment of severity of crisis
b) Planning the actions according to available
resources
c) Intervention
d) Reassessment of the situation and planning of
future actions
 If the specific goal has not been attained after
these 4 steps, the crisis team has to start over
and retrace the 4 actions.
 a) ASSESSMENT
 The first action in crisis intervention:
assessment of the subject and of triggers
 The therapist gathers specific information
concerning the triggering event
 The current risk for suicide and violence are
assessed
 If the assessment indicates that
hospitalization is not required, the therapist
may proceed with the intervention
 b) INTERVENTION PLANNING
 The decisive factor in planning: the time passed from
the outbreak of crisis (commonly: the event occurs
1-2 weeks prior to the subject’s “cry for help”)
 The impact of the event on subject’s life
 The impact on people close to the subject
 Coping styles previously (but not currently)
employed by the subject in difficult situations
 Time required for intervention
 Size and structure of the intervention team
 First specific actions
 Estimated time until the first signs of improvement
 c) INTERVENTION
1. First contact with the person in crisis
2. Employing a set of specific questions in order
to find out specific information about the case
3. Involving the family, facilitating communication
4. Accurate assessment of the situation, drawing
up a “therapeutic contract” between all parties
involved
5. Inventory of the problems and establishing
priorities
 FIRST CONTACT

 Establishing a “normal” environment

 The subject, other people present and their
relationship with the subject are identified
 The triggering event is debated
 The therapist informs all parties involved that
they will all be required to take part in the
resolution of crisis
 SPECIFIC QUESTIONS
 About the triggering event of the crisis
 About symptoms generated by the impact with
the event
 About the subject’s coping resources in front of
psychological aggression
 Practical issues: clinical and gynecological
assessment, nutritional status…
 Events/changes within the previous 2-3 weeks
 Brief psychiatric assessment – possible
symptoms (anxiety, depression) prior to the
crisis
 FAMILY, COMMUNICATION
 Crisis (acute psychological unbalance) in a subject:
sign of disturbed family system, will also affect other
family members
 Roles in the family system will have to change in order
to accommodate the needs of the patient
 A list of problems for each family member to solve is
drawn up – this enhances the feeling of cohesion and
involvement in therapy
 Optimal communication in the family – listening to all
parties, excluding critiques, objective and sensible
assessment of alternatives to proposed solutions
 Active listening and unconditional support of the
subject by all parties involved is needed
 THERAPEUTIC CONTRACT
 The therapist expresses his viewpoint
 The connection between symptoms of subject and traumatic
events
 The necessity of admittance is assessed, according to severity
of symptoms
 Benefits and disadvantages of admittance
 Subjects without psychiatric disorders are kept in their home
environment
 A contract is drawn up with family members – responsibilities
of each party involved is detailed (family, friends, neighbors,
volunteers in NGO’s, physicians, psychologists, social worker,
nurse)
 If the situation progressively improves, regular follow-up at-
home visits continue for a predetermined period (3 – 6 weeks)
 PRIORITIES OF ACTION
 The specific problem of the subject in crisis is
avoided, if it cannot be solved in a short time
 If the problem can be solved, the specific
actions to eliminate the consequences of
“disaster” will be the focus of intervention
 The family is involved in action planning
 Multiple solutions are explored
 Tasks are divided
 All support resources are identified, mobilized
 Support resources for the therapist are
identified
 d) REASSESSMENT
 The last stage: the subject and intervention
team evaluate the degree of positive
outcomes and resolution of crisis
 The best assessment tool: level of functioning
– the extent to which the subject has returned
to the level of functioning prior to the crisis
 Inventory of specific activities, daily routine
 Coping abilities in family and professional
situations
 What is Crisis Intervention?
A process that focuses on resolution of the immediate
problem through the use of personal, social and
environmental resources.
The goals of crisis intervention are rapid resolution of
the crisis to prevent further deterioration, to achieve
at least a pre-crisis level of functioning, to promote
growth and effective problem solving, and to
recognize danger signs to prevent negative outcomes
(RNAO, 2006; Hoff, 1995)
Roles & Goals of Crisis
Workers


Support individuals and families in crisis

Mental Health Assessment

Liaise with ER physician

Liaise with Community Support

Referral-community, hospital, etc.

Liaise with psychiatrist
 Best Practice Guidelines
1. Crisis intervention is founded on a particular set
of values and beliefs, and guiding principles
2. A comprehensive holistic assessment is
performed prior to engaging in any plan to resolve
crises
3. To enhance the continuum of crisis care, the
organization continuously strives to achieve a
collaborative and integrative crisis intervention
practice model within an interdisciplinary team
4. The organization actively advocates for the
provision of quality crisis intervention care on
multiple levels including individual, family, and
community

(RNAO, 2006)
Integrative Model of Crisis Intervention

Therapeutic Communication
P D
r e
o Develop rapport c
b Maintain contact i
l s
e i
m Identify the Problem o
Explore Coping n
S Assess Risk to Life
o M
l a
v Collaborative action plan k
i Implement the plan i
n Follow up on the plan n
g g
Develop Rapport and Maintain
Contact

• Rapport, trust, and active listening

“I can see that you are very distressed. I am concerned about
you. Can you tell me what is upsetting you?”

• Maintain ongoing contact

• Therapeutic communication skills-
validation
Active listening, paraphrasing in the individuals own words
regarding his or her description of the current situation.
 Identify the Problem &
Therapeutic Interaction
• Information collection
• Clinical judgment and expertise
• Facilitation of individual's understanding of
the crisis
• Collaborate on new ways of appraising the
situation
 Mental Status Exam
• Appearance
• Age, sex, posture, eye contact, dress,
grooming, manner, facial expression
• Motor
• Retardation, agitation, unusual movements,
gait, catatonia
• Speech
• Rate, rhythm, volume, amount, articulation,
spontaneity
• Affect
• Stability, range, appropriateness, intensity,
affect, mood
 Mental Status Exam
• Thought Content
• Suicidal or homicidal ideation, depressive
cognition, obsessions, ruminations, phobias, ideas
of reference, paranoid ideation, magical ideation,
delusions, overvalued ideas, other major themes
• Thought Process
• Coherence, logic, stream, perseveration,
neologism, blocking, attention
• Perception
• Hallucinations, illusions, depersonalization
• Insight
• Awareness of illness
Explore Coping & Collaborate on
Action Plan

• Explore new ways of problem solving

and decision making
What have you done in the past to get through difficult times?
What else can you think of to try to get through this?

• Facilitate and mobilize support

networks
 What Families Can Do
DO’S
 Remain as calm as possible
 Decrease other distractions
 Allow the person to have personal “space” in the
room
DON’TS
Don’t shout
Don’t criticize
Don’t challenge
Avoid continuous eye contact
Don’t block the doorway
Don’t argue with other people
 What Families Can Do
• Have a family crisis plan- contact SSO for more
details on crisis plans
• Keep a written record of treatments given
including dates and times
• Be polite but assertive with hospital staff
• Keep conversations to the point- ask specific
questions
• Try to form a partnering relationship between
hospital staff, the individual in crisis and yourself
 5 Stages of Successful Interventions
 Immediacy- Intervene as  Assess the situation- let
soon as possible. Goal is to the person talk, watch for
reduce anxiety. nonverbal cues, be a guide
 Assume Control - via and avoid judgements and
providing the structure the putdowns
person needs, not be  Situation Management
overwhelming them  Post crisis intervention
 Individual
approach

Generic approach

General support

Environmental manipulation
Level of crises intervention >>>

Environmental manipulation
It includes interventions that directly change the patient’s physical
or interpersonal situation. These interventions provide situational
support or remove stress. Important elements of this intervention
are mobilizing the patients supporting social systems and serving as
liaison between the patient and social support agencies.
General support:-
Includes interventions that convey the feeling that the social worker
is on the patient’s side and will be a helping person. The worker
uses warmth, acceptance, empathy, caring, and reassurance to
provide this type of support.
Level of crises intervention >>>
Generic approach
The generic approach is designed to reach high-risk individuals
and large groups as quickly as possible. It applies a specific
method to all people faced with a similar type of crisis.

Individual approach
is a type of crisis intervention similar to the diagnosis and
treatment of a specific problem in a specific patient. This type
of crisis intervention can be effective with all types of crises.
And its also helpful when symptoms include homicidal and
suicidal.
Interventions are aimed at facilitating cognitive and emotional
processing of the traumatic event and at improving coping. Five
core interventions to assist survivors of acute stress are as follows
( Osterman and Chemtob 1999 ):
* Restore psychological safety.
* Provide information.
* Correct misattributions.
* Restore and support effective coping.
* Ensure social support.
Techniques
The worker should be creative and flexible, trying many different
techniques. These should be active, focused, and explorative
techniques that can facilitate achieving the targeted interventions.
Some of these include catharsis, clarification, suggestion,
reinforcement of behavior, support of defenses, raising self-esteem,
and exploration of solutions.
The crisis worker must take an active directive role and maintain
flexibility of approach. If more complex problems are identified
that are not suitable for crisis intervention, the patient should be
referred for further treatment.
Evaluation
The last phase of crisis intervention is evaluation, when the worker
and patient evaluate whether the intervention resulted in a
positive resolution of crisis. Specific questions the worker might
ask include the following:
 Has the expected outcome been achieved, and has patient
returned to the precrisis level of functioning?
 Have the needs of the patient that were threatened by the event
been met?
 Have the patient’s symptoms decreased or been resolved.
 Is the patient using constructive coping mechanisms?
 Does the patient need to be referral for additional treatment?
 Does the patient have adequate support system and coping
recourses on which to rely?
 Settings for crisis intervention
Worker in many settings in which they see people in crisis.
Hospitalization are often stressful for patients and their
families and are precipitating causes of crises.
Emergency room and critical care settings also are flooded with
crisis cases. People who attempt suicide, psychosomatic
patients, survivors of sudden cardiac arrest, and crime and
accident victims are all possible candidates for crisis
interventions.
Community and home health work with patients in their own
environments and can often spot and intervene in family
crises.
Crisis intervention can be implemented in any setting and should
be competency skill of all workers, regardless of specialty
area.
Modalities of crisis intervention
Mobile crisis programs
Mobile crisis teams provide front-line interdisciplinary crisis
intervention to individuals, families, and communities.

Group work
Crisis groups follow the same steps that individual intervention
follows. The worker and group help the patient solve the
problem and reinforce the patient’s new problem-solving
behavior.
Telephone contacts
Crisis intervention is sometimes practiced by telephone or internet
communication rather than through face-to-face contacts. When
individuals in crisis use the telephone or internet, its usually at the
peak of their distress.

Social workers working for these types of hotlines or those who answer
emergency telephone calls or electronic mail may find themselves
practicing crisis intervention without having visual cues to relay on.

Disaster response
As part of the community, social workers are called on when situational
crises strike the community. Floods, earthquakes, airplane crashes,
fires, nuclear accidents, and other natural or unnatural disasters
precipitate large number of crises. Experts in the field of disaster
response suggest that organized plans for crisis response be developed
and practiced during nondisaster times.
Health education
Although health education can take place during the entire crisis
intervention process, it is emphasized during the evaluation phase.
At this time the patient’s anxiety has decreased, so better use can
be made of cognitive abilities. The worker and patient summarize
the course of the crisis, and the intervention is to teach the patient
how to avoid other similar crises.
 Disaster management-
Meaning and psychological
aspects of help
 Understanding disaster
Disaster is “a severe disruption, ecological and
psychosocial, which greatly exceeds the coping
capacity of the affected community” (WHO1992)

 Disaster causes sever disruption to a large extent

 Disaster disrupts the economic and psychosocial ecological
balance /stability
 Providing support is most crucial to reduce the vulnerability
 Disaster preparedness should be facilitated among the communities
Needs Spread Sheet
 The 90 % of the needs are
linked with the psychosocial
needs of the survivors.
 Most of these needs are
invisible, so they are
ignored.
 The Psychosocial care
givers have to take care of
these needs among the
survivors.
 Focus on the Psychosocial
needs will ensure better care
for the survivors
Circle Of Support
 After the disaster the normal
support system gets eroded
 It is the responsibility of the
humanitarian agencies to build
up the support the system,
revive the normalcy
 In primary level support we need
to build up individual rapport and
mobilise the resources
 In secondary level initiating the
family activity as a unit and
mobilising the support of the
group is important
 In tertiary level, mobilising of
community resources helps to
rebuild the life of the survivors
Spectrum Of Care
 Support and rebuild their shattered
lives

 Help with housing,

 Assistance for compensation,

 Paralegal aid,

 Educational help,

 Employment

 Health

 Psycho social
NORMAL DEVIANCY MODEL
NORMAL REACTION
OUTCRY
(Fear, sadness and rage)
DENIAL
(Refusing to face the memory
of the disaster
INTRUSION
(Unbidden thoughts of the
events)
WORKING THROUGH
(Facing the reality of what has
happened)
ABNORMAL REACTION
OVERWHELMED
(Swept away by the immediate
emotional reactions)
PANIC/EXHAUSTION
(From the escalated emotions)
EXTREME AVOIDANCE
(Drugs etc., to deny the pain)
FLOODED STATES
(Disturbing images and thoughts
about the event)
PSYCHOSOMATIC RESPONSES
(Bodily complaints)
Understanding reactions of stress
Reaction card shorting under
four headings
 Behavioural reactions
 Physical reactions
 Psychological reactions
 Relational changes

While working with the

survivors keep looking for
all the reactions and ask
about the same. The
understanding about the
reactions would facilitate
the better support
provision for the survivors.
Understanding the stages of
Symptoms Reactions
Normal Reaction
 Outcry
 Denial
 Intrusion
 Working through

Abnormal Reactions
 Overwhelmed
 Panic/Exhaustion
 Extreme avoidance
 Flooded states
 Psychosomatic
responses
Techniques of psycho social care
1. Ventilation
2. Empathy
3. Active
listening
4. Social
support
5. Externalizat
ion of
interests
6. Relaxation
and
recreation
7. Spirituality
Ventilation

 Allowing the survivors to

ventilate their pain is very
crucial.
 Ventilation is important for
healing of the mind.
 Make a comfortable
atmosphere where the
survivors can ventilate
his/her pent up tension.
 Developing adequate rapport
with the survivors is most
crucial for ventilation.
(the situation is like a pressure
cooker)
 Empathy

Empathy is a skill which

allow the CLW to
understand the situation
of the survivors.
Empathy is more action
oriented.
Empathy is essential to
work with the disaster
survivors and empower
them in long run.
 (The Mirror game used
to explain the empathy.)
Active listening

This technique would

help to facilitate the
ventilation process.
For active listing, show
your concern interest
about the survivors.
Sit at the same level,
maintain eye contact,
give non-verbal cues to
facilitate the process.
Social support
Build up the social
support after the
disaster through
psychosocial care
intervention.
Mobilize the support
within the family and
community.
Ensure use of personal
resources.
Social support is very
crucial to facilitate the
recovery.
Relaxation and Recreation
 Relaxation is helpful to
reduce the tension and
stress in body and mind.
 Most of the time after the
disaster the survivors are
not able to relax.
 Facilitate the practice of
relaxation and recreation
among the survivors.
 Organizing simple activity
like reading listening music,
watching drama can help
people to relax.
 Spirituality
Spiritual faiths are very
crucial for recovery
after the disaster.
Ensure that the
survivors could get
back to their earlier life
and practices.
Spiritual faiths should
not be imposed but
should be facilitated
among the survivors
Externalization of interest
 Find out the qualities
and interest which a
person is having.
 Allow the person to
get involved in the
meaningful work.
 Match the needs of
the situation with the
interest of the person.
 Externalization help to
get adjusted with the
changed situation
 Visibility and Invisibility
 The physical disability is very visible and the
help can be provided by all.
 The mental health needs are invisible and it
takes more time to identify the needs.
 The helper should not be frustrated in the
process of identifying the mental health needs.
Role play
22 years old women lost her
life partner in Tsunami.
She is living with her 3
years old Child.
Taking care of the child
through ICDS was
organized.
Medical care for that lady
and reference for support
to Tahasildar.
Including her in the self help
group.
 Role play
45 year old lady lost her 2 kids in tsunami is living
in temporary shelter and is depressed after the
event

• Identifying the stress and different reactions

• Building the social support at family level
• Identifying the spectrum of support available
 Role play
A 65years old lady staying alone. Her son is not taking care
of her. She keep complaining about every thing and feels
blurring of vision.

• Mobilize the support for the person.

• Identify the reasons of vulnerability,
• Help her to be comfortable within the available situation.
• Provide the support considering the umbrella of care.

• Help the son to take the responsibility.

• Mobilize the family unity through psychosocial care.
 Role play
The role play is for internalization of the skills and
the knowledge which has been provided.
The use of the PSC skills has to be emphasized
in the role play.
The holistic care has to be provided to the
survivors.
Referral has to be considered at the time of need.
The referral can be for medical care, housing,
livelihood or for any other purpose.
 COMMUNITY LEVEL HELPERS ROLE
Can lead to DISTRESS
DISASTER
AND
DISABILITY

ROLE OF COMMUNITY LEVEL HELPER

Help the people Decrease the physical Support and rebuild

understand the changes and emotional effects by their shattered lives
that they experience in
their body and mind by through
•Relaxation
•Ventilation •Externalization of •Help with housing
•Active listening •Assistance for
•Empathy interests
•Lifestyle choices compensation
•Social Support •Paralegal aid
•Health Care •Educational help
•Spirituality •Employment

All the above three lead to:

ADJUSTMENT AND MASTERY OVER EMOTIONAL DISTRESS

 Need for Stress Management
 Sleep problem occurs
 Perceived illness starts in terms of pain feeling of
tiredness
 Changes happen in relationship and behavior
 Feeling of being overwhelmed decrease
performance and productivity
 Harmonising professional needs and personal need
 Dealing with demanding situations effectively and
efficiently
 Due to stress concentration decrease
 Outcome of Stress Management
Learn damage limiting strategies

Disseminate information

Work with efficiency, discipline and increase in productivity

Harmonization of professional life and personal life is possible

Able to undertake challenges with commitment and control over

the situation
 Self Care -Stress Management
Technique
Physical activity: They were asked to walk up and
down the stair case for seven minutes and then
discussing what they are feeling.

Experience
 Fight or flight experiences
 Common physiological experiences
 Excessive palpitation/sweating
 Normal reactions to abnormal situations
 Competitiveness -
Stress Management Technique
 Be firm on your position and goal

 There will be negative pressures at the time of

disaster

 One has to ignore the outside pressure and be

focused on the goal
Consequences of Burnout

 Get exhausted
quickly
 Energy persist for
very short period
 The person cannot
work for long time
 Productivity goes
down to zero
 Even can create
disturbance for others
work
 Person becomes
insufficient
Consequences of Burnout-
Stress buffers
 Water worked as buffer and
the paper did not burn.

 The wet paper did not burn

and with stand the fire. This
like, having self control to
manage the stressful situation.

 The Dry paper burned into

ash. As the dry paper is not
having any protective
mechanism, it burned with big
flame and very quickly.

 The person taking care of self

may be very active in work for
few moths, but they fail to
carry out the long term work.
 Consequences of Burnout-
Protective Factors
 Activity-the wet cotton did not burn even after lot of trial

 The water in cotton worked as protective factor

 Damage control mechanism helps to protect self

 Develop the interest out of your job.

 Practice relaxation reading books listening music or anything of

interest which helps you to work effectively
 Protective Mechanism at
Personal Level
 C-Conviction– be convinced about what you are doing. Having your
value to work and life are important to manage your stress.

 C-Commitment-keep things in place, lead by giving example, be

committed to work assigned

 C-Challenges-learn new skills and the process of work practice and

accept the situations as it appears.
 Thanks
• Study well
• Prepare short notes with 12 to 15 points
for each topic
• For doubts and clarification call
• 9886083035