The following sections on eclectic knowledge, staying focused, treatment approaches, and techniques explain how to work with families beyond the initial assessment phase. A team approach to crisis intervention is desirable because each team member can develop some expertise in one or more of the following theories and in the best techniques to be used with differing client populations and crisis situations.
No one crisis intervention method will work with all clients, or even all the time with any one client. There are many different family structures, compositions, and culturally related belief systems. The eclectic crisis worker tries to understand and respect these diversities in families.
In this chapter, various interconnecting theories are mentioned as they relate to an eclectic practice base. Practitioners must be flexible and willing to use any theoretical approach or technique that will work to benefit and stabilize a family in crisis. Articles and books have been written about the efficacy of eclectic practice in working with families.50 Such a viewpoint is expressed by the following quote from Crisis Intervention Book 2: The Practitioner’s Sourcebook for Brief Therapy:
The crisis counselor’s basic task is to help clients change those affective (feeling), cognitive (thinking), and behavioral (doing) patterns that hinder effective value clarification and rule making and to encourage constructive communication and appropriate role behavior. Thus, it is essential to develop a judiciously eclectic approach that attends to these domains of human functioning (feeling, thinking, and doing) in order to help persons in crisis mobilize the resources that will unblock and enhance performance in these vital areas.51
Concrete services complement rational-emotive therapy,52 behavioral therapy,53 or any theoretical approach. Environmental stresses and lack of resources add to the family’s feeling of being overwhelmed. Concrete services, which lessen the pressure in one area of the family’s life, can free energy for setting and achieving other problem-solving goals.54
Sometimes the major stressors in a family may be rather obvious, and it is merely a matter of helping the family focus on one problem at a time, such as applying for food stamps and looking for a better paying job because family income is insufficient, perhaps contributing to these quarrels and violence. In addition to focusing on food stamps and employment, there must also be a focus on stopping the abuse, which requires development of anger-management skills, appropriate channeling of anger, more open and respectful communication of feelings in the family, and enhancement of the adults’ relationship. In the above example, there may be only two goals: (1) Improve family income resources and (2) enable parents to use disciplinary practices that do not harm the child. Both of these goals require several action steps, but the focus of intervention remains on the two goals. After the intervention ends, additional anger-management work may be sought through therapists who provide such individual or group treatment.
On the other hand, some families have a multitude of stressors, some chronic and some acute, plus the accusation of abuse or neglect. The family may bombard the crisis worker with medical, legal, financial, housing, transportation, and school-related problems. The crisis worker can easily feel overwhelmed and want to begin working on all problems at once. That is a perfect formula for failure, because there will not be enough time and energy to do everything. As one family said, “We were trying to work on everything at once because we thought we had to fix it all in order to be acceptable people. We had a lot of agencies working with us, and each one wanted us to change something. Nobody ever told us to focus and fix one thing before going on to another.”
Crisis intervention, like brief therapy, focuses on helping the family choose their goals and how they will go about attaining them. The crisis worker may feel that other problems are more important, and it is acceptable to discuss them, but what is finally chosen as the primary concern should be clearly the family’s choice. This approach empowers the clients with the feeling that they can be in charge of their destiny. For instance, if the family members complain about each other and various agencies, the crisis worker should encourage them to explain what they would like to change that is within their control, as opposed to changing the agencies. In other words, encourage them to redefine a complaint as a goal.55 Many clients waste their energy trying to force others to change, rather than concentrating on the one thing within their control, themselves. Once the primary goal, and maybe one to three others, is established, every meeting with the family will focus on the goal. Homework between meetings should clearly focus on the goal as well.
It is essential to listen closely for what is important to the family. What ideas do they have for finding solutions? This is a good predictor of success since a focus on the family’s concerns can free new energy for finding solutions to other problems, one or two at a time. The family also learns to think flexibly in a problem-solving mode, thereby increasing their confidence regarding ability to cope with future stress. To assure this sense of mastery, the crisis worker should take time to “celebrate” or enjoy each accomplishment with the family.
Integration of various approaches is required to help families accomplish their goals. These approaches, as described below, include: community system and use of community resources; multiple impact or multimodal; cognitive-behavioral or rational-emotive; task-centered; family treatment; and eclectic.
Total family involvement is of paramount importance to crisis intervention. Similarly, successful crisis workers find that coordination and involvement of all available community agencies and resources are of paramount importance to successful resolution of most crises. System-centered or person-in-situation perspectives place less emphasis on pathology and more on the interaction of the client with environmental systems.
When addressing the needs of families in crisis, close cooperation between community services assures the maximum benefit from utilization of resources. Poor communication and lack of coordinated efforts between health, legal, social service, education, volunteer, and church-related resources can create extreme frustration for families who are in crisis. For instance, many clients have grown to distrust agencies that promise cooperation from other organizations. Often, they have been told that an agency would help, only to learn that they are ineligible, must go on a waiting list, must subscribe to the helper’s value system, or must accept a substitute service. Even worse, some clients have been criticized and humiliated for not understanding agency eligibility requirements.
To provide stability and consistent support for families, crisis workers can guide them to appropriate organizations and services, but it helps when crisis workers give the name of a specific person rather than simply a telephone number. During the initial crisis, crisis workers may even need to accompany the clients to appointments. As the family begins to stabilize, members can be expected to take more individual initiative. As a support system, the crisis worker should always be available by phone or beeper. Advocacy for clients, helping them access and use resources, dramatically enhances the therapeutic relationship.
Abusive families’ diverse needs require services from a plethora of organizations, since no one agency controls and delivers investigation, crisis intervention, concrete services, long-term treatment, and the variety of health, social, legal, housing, education, employment, mental health, spiritual, welfare maintenance, and other necessary service components for successful crisis resolution. So-called “wrap-around” services provide whatever the family thinks it needs in order to stabilize. Obviously, this requires strong, collaborative efforts among community resources. As Fandetti states in Issues in the Organization of Services for Child Abuse and Neglect, “Children at risk of placement because of abuse and neglect require tight rather than confused and loosely organized networks of service, interlocked rather than fragmented services and agency policies.”56
Respite child care from a parent aide, day-care placement, a baby sitter, or recreational agency placement may give the parents the free time needed for relief of tension and time to focus on themselves. Medical attention, Alcoholics Anonymous or Narcotics Anonymous meetings, or a contact regarding better housing may reduce day-to-day stress. Development of a joint service treatment plan with the family, CPS, and other crisis workers demonstrates how various resources can cooperate to everyone’s satisfaction.
Throughout crisis intervention, the crisis worker must make repeated contacts with other providers. Division or disagreement between agencies will feel like rejection to clients who experience chaos and disorganization not only as emotionally hurtful but also as irreversible.
The crisis-intervention team, a child and family advocacy organization, or a social service agency needs to assume leadership in bringing community organizations together to develop trust and exchange information on missions and programs. If possible, a community committee should be developed to study gaps in services and coordinate existing services. This is more a responsibility for administrative personnel, but every person who is concerned about families in crisis needs to advocate for coordination and collaboration and participate in both formal and informal coordinating committees.
The value of the multiple-impact approach, using many crisis workers, has been recognized for well over a decade,57 as has the efficacy of a generalist-specialist team for dealing with family and community-wide dysfunction.58 The generalist-specialist team model incorporates professionals with specialized training, such as child development, sexual abuse assessment, or behavioral management, along with team members who are broadly trained so that consultation is maximized for all team members. Ultimately, to be effective, the team needs to maintain strong relationships with public and community service systems which address additional child and family needs.59
Several programs have demonstrated that multiple impact and multimodal interventions are effective with even the most chaotic families.60
Multiple Impact Therapy (MIT) assigns therapists, students, or volunteers to each family member for an hour or so of assessment and on-going treatment. The initial session may be with the entire family and with the many therapists assigned to each member, and there may be some individual time spent with specific family members. Ultimately, all family members and all therapists come together. Family members may be asked to observe while each therapist role plays a family member, who sits by the therapist, saying what the family member feels and wants from other family members. If a family member feels misrepresented, a timeout may be called for consultation with the therapist who is representing him or her. The therapist uses “I” messages to express how things in the family look from his or her perspective as a family member. This process takes several hours since family members are encouraged to say how they feel, what else they want to clarify, and what they want to work on in the future.
For crisis treatment beyond the first day or two, only one crisis worker may be assigned or, if it seems necessary, more than one. This is when well-trained students or volunteers can be an extremely cost-effective part of the continuing process. Even if only one crisis worker is assigned for ongoing treatment with the family, there is now a cadre of consultants who know the family from firsthand experience.
Some authors find that “the literature clearly indicates that multimodal interventions tailored to the subjects’ deficits should be implemented rather than [provision of one type of program (e.g., parent education)] that emphasizes one or two factors for all abusers.” They add that family, community, and social supports are part of adequate interventions.61
Clients’ belief systems and their thought processes can contribute to their abusive or victimized behaviors. Cognitive behavioral therapy assumes that clients have irrational, maladaptive beliefs that require cognitive restructuring.62 Behavior therapy is effective in child management, parenting, and parent training and, more recently, in shaping adult behavior. Many authors have outlined specifics of behavioral assessment and treatment.63
Briefly, cognitive behavioral therapy is designed to identify specific, undesirable target behaviors through listening to the opinions of individual family members and the family as a group. The listener attempts to identify the antecedents to undesirable behavior (what set it off). New instructions, or new behavior by other family members or a certain family member, replace the antecedents. Desirable responses are agreed upon through a contract with family members. Reinforcements are provided when family members exhibit a desirable response, and consequences are provided if behavior is undesirable. Consistency is critical in both the approval (reinforcements) and disapproval (consequences) of behavior. Positive results, or bonus reinforcements such as family outings or free meals, can be given when behavioral objectives are achieved. Consistency and follow through are essential to success.64
Task-centered methods of treatment seem to merge well with crisis intervention theory and practice, with research indicating that these methods are effective with a broad range of clients. Uncontrolled studies on the effectiveness have been conducted in medical, family, child guidance, psychiatric, school, corrections, and public-welfare settings. Controlled studies in a school system and a psychiatric clinic in southside Chicago rendered very positive results, as did a suicide prevention study and group treatment of delinquent youth.65 Contracting, task planning, incentives, and homework assignments, which keep families practicing communication and problem-solving tasks between meetings with the crisis worker, are effective in moving the family toward independence and nonabusive behaviors.
In conventional family treatment, therapists permit situations to develop which demonstrate how the family interacts and functions. The therapist then tries to engage the most influential members to assure their active involvement in ongoing treatment. Just as in crisis intervention, active listening comes first.
As with crisis intervention the major focus is on the family system rather than one individual. In no way, however, does this prevent the therapist from being aware of assigned family roles (“he is the mentally ill one”), scapegoating (“he is the cause of our problems”), or triangulation (“detouring” of parental problems through the child) within the family.
Family secrets, myths, enmeshment, dyads, triads, and schisms give clues to why the family has become so dysfunctional and what was brewing underneath the surface before the crisis-precipitating event.66
Family treatment is inseparable from crisis intervention, and, in addition to being more cost effective for most children and families, family preservation is more desirable than separation.
In an eclectic team approach, team members use their varied knowledge and expertise to assess and manage the presenting crisis. Using their different perspectives, team members work with the family during the initial crisis response, developing a brief treatment plan with specific strategies to foster crisis resolution and healthy family functioning. If only one team member establishes direct contact with the family in crisis, that member consults with other members to ensure that assessment, treatment planning, and treatment techniques incorporate the full team’s knowledge and experience.
Interdisciplinary teams, composed of individuals who are eclectic in their training and perspectives, bring a plethora of possible resources and resolutions to any crisis situation. The team’s varied perspectives, in conjunction with the clients’ innate resources or strengths, are powerful forces that support the clients in steadily lifting themselves out of the crisis. Note that the intervention team strives to not do the work “for” the clients. Instead, the eclectic knowledge is shared with the clients, enabling them to choose problem-solving strategies that restore their sense of well-being and ability to cope.
Eclecticism allows crisis workers to determine which theoretical approach, or combination of approaches, fits the crisis situation best. For instance, the task-centered approach draws from behavioral, communications, problem-solving, and family-therapy models, and assigns “homework” to clients. On the other hand, the cognitive behavioral approach is particularly effective in changing behavior of children and is one of the major theories for work with adults as well.67 Cognitive theory encourages clients to think through problems and to plan solutions thoughtfully, believing that “emotions, motives, goals, and behavior are conscious phenomena that are usually the consequences of thought.”68
Other approaches are considered, as well, by the eclectic team. For example, the family-treatment approach focuses on failures of role performance as a parent or spouse, and considers role confusion and role reversal to be present in sexual and physical child abuse cases.69
Transactional analysis was founded on the belief that people have the power to think, act, and make positive changes, allowing them to feel OK about themselves and others.70 Systems theory is akin to ecological and family-centered approaches in that it is concerned about the individual and family in the social environment.71 Existentialism emphasizes the uniqueness of each client and each situation and allows for openness, empathy, and honest-but-respectful feedback to clients. Existentialists use “provocative contact” in assertively provoking “hard-to-reach” clients toward wanting change in their lives. This offers clients an opportunity to at least consider the use of behavior modification in making specific behavior or symptom changes.72
Gestalt theory does not hypothesize about unobservable systems in the client’s life, but may ask the client to reenact his or her perceptions of them.73 Gestaltists look for patterns or descriptions of interactions, which are not working, as opposed to diagnoses or labels. Similarly, client-centered theory is opposed to diagnosing and labeling, believing that families are capable of knowing and shaping what is best for them.74
Special treatment techniques such as humor, generalization, self-disclosure, storytelling, limit-setting, and instillation of hope are effective in crisis intervention. By understanding client resistance, treatment outcomes are further enhanced.
It is imperative for crisis workers to set aside time for client social activities and fun. Many clients have never had fun. Good professional role models demonstrate a funloving sense of humor from time to time.
It is also helpful for crisis workers to respond to their own mistakes with humor. When a verbal or tactical error is made in front of clients, crisis workers need to demonstrate their comfort in laughing at themselves. This helps clients relax and realize that professionals are not perfect and that they may be able to laugh at their own mistakes someday, too. Words of caution are warranted here, however. Some clients are prone to concrete interpretation of humor. In other words, if professionals laugh at themselves or encourage clients to, these clients may feel emotionally degraded. Some clients are ultrasensitive to teasing and require months of addressing past trauma or verbal abuse before they can understand the subtleties of humor.
Generalization is another good technique to use with clients in crisis. Saying “we all get angry and don’t know how to express it sometimes” is more effective than implying that clients get angry and professionals never do.
Clients need positive role models, but they are relieved to know that professionals are human and sometimes struggle with emotions. The caution here is for the crisis worker to focus on the clients’ needs, rather than to vent personal frustrations. To tell a story or two on how the crisis worker or someone else overcame similar problems, however, may be helpful to clients. Crisis workers can test whether self-disclosure is appropriate by honestly questioning, “am I doing this for my benefit or is it for the clients’ benefit?”
All models of crisis intervention emphasize respect for the clients’ culture and value systems. Every model also emphasizes the importance of listening closely (for hours) to what the clients are saying. This helps establish rapport but, more importantly, determines what the family is motivated to do. It respects the family’s wishes rather than imposing the crisis worker’s wishes or needs on the family.
In respecting and being accepting of clients, but not their inappropriate behavior, it may be necessary to say specifically that child abuse and neglect are never acceptable. Many clients need that directive because proper family values were not instilled during their childhoods. Certain clients misinterpret crisis worker acceptance of them as full agreement with their abusive actions. It may be necessary to state frequently that child maltreatment is never an acceptable behavior. If not clarified, clients may assume that the crisis worker approves of such behavior. When encouraging clients to discontinue corporal punishment, for example, it is best to give specific instructions on use of “timeout” for young children, choices and natural consequences for older children, and the need for parents to learn active parenting skills.
A crisis worker’s belief in self, personal enthusiasm, and ability to instill hope are critical variables in crisis work. If the family senses that a crisis worker believes positive resolution to the crisis is possible, then family members begin to feel confident in their ability to bring about change.
Imparting hope requires crisis workers and clients to search for times in the past when the clients almost succeeded, or did succeed, in finding solutions to similar crises. Likewise, when clients are encouraged to try a new approach, rather than being blamed for failure, hope springs forth. Words such as “when” and “will” should be used rather than “if” or “maybe” when discussing plans.
When crisis workers keep their promises, clients begin to trust and to believe in change. When clients and professionals form a positive “team” that builds on client strengths, change occurs.
By objectively, nonjudgmentally, and respectfully focusing on family strengths and the immediate crisis, crisis workers can minimize client resistance during early intervention. For example, the crisis worker should state the allegations of child maltreatment and ask the family to clarify any discrepancies. Conveying hope that the allegations can be worked through if the family cooperates is effective in moving the family toward desired change. Family members need to know what they are expected to do, what consequences they are facing, and what services they will receive if they cooperate.
Crisis workers must be careful how they use their professional authority. If authority is misused, parents may experience a double message: Parents should not misuse power with their children, but professionals may misuse power with parents. Such double messages create confusion and resentment. If crisis workers expect clients to be effective parents, then they need to be role models of behavior for the parents. Anything less is likely to create new crises, further weakening the family’s level of functioning.
In periods of crisis or disorganization, people may feel more inadequate, alienated, or needy, thereby causing them to take on facades of adequacy, arrogance, or dependency. They may withdraw or they may attack, according to what they perceive as necessary for survival. They may act as if they need no help, even when they need it desperately. Whatever the clients’ facade, crisis workers must remember that families in crisis crave respect, care, and compassion. They want to regain some semblance of security and stability.
Often, CPS crisis workers complain that the “nonoffending parent” in sexual abuse cases is passive or defensive and refuses to become involved in family treatment. Instead, crisis workers need to evaluate whether the nonoffending parent has always been defensive or passive. If it is new behavior, then the nonoffending parent is merely frightened and afraid the family will be destroyed. Such fears can be honestly recognized by the crisis worker. If the defensiveness is typical behavior, the nonoffending parent will need to observe positive role modeling, have total honesty from crisis workers, and receive training on how to respond more openly. In the meantime, crisis workers need to realize that an accusation of abuse, the consequent investigation, and an influx of various strangers into the home would make anyone defensive.
By assessing the reasons for clients’ recalcitrant behavior, crisis workers can then address the clients’ needs for answers or information. They may have many remaining questions about the intervention. For example:
- What further consequences may they expect?
- What happens next?
- What is expected of the family and its members?
- Is the crisis worker a nonjudgmental, credible, honest, and respectful professional?
- What resources can the crisis worker and community offer that can help the family?
- Will the crisis worker listen to and respond to family needs?
- Does the crisis worker see any strengths in the family?
- Is the crisis worker implying that solutions to the crisis are available?
- Is there hope for the future?
Rather than believing that clients are resistant, do not want to change, are denying their problems, or are being deceitful, crisis workers need to believe clients when they express a desire to reach a solution.75 When clients seem “resistant,” it is best to assume that they are merely frightened and hesitant about trying new behaviors or the unfamiliar. They need crisis workers to be patient and listen to how they are feeling and what they suggest for relieving the crisis. If crisis workers convey that clients are the experts on what they want, and if professionals are honest with themselves about what they are feeling, then they will give clients room to make the changes that they need.
For instance, a nonoffending parent in a child sexual abuse case may be fearful of losing her identity as a member of an intact family; her identity as wife of a certain man; her identity as part of a neighborhood or a church; her identity as a member of a respected family; her identity as part of a household which had a good income but must now accept welfare benefits. A skillful crisis worker must be prepared to explore all of these possibilities with the parent, rather than proposing “quick” solutions, such as divorce.
If there is such a thing as resistance to change, some of the causes or sources may be:
- uncertainty about change or fear of failure;
- fear of loss of the familiar;
- lack of confidence in the crisis worker;
- lack of participation in developing crisis resolution goals;
- inability to see change as a viable alternative;
- inappropriate timing on the part of the crisis worker;
- disruption of important, existing family or social relationships; and
- belief that change equals criticism.76
Some interviewing techniques which can be used to work through client resistance include:
- active listening and reflection;
- universalizing (normalizing);
- partialization (breaking into several smaller issues) of problems, when the client presents numerous issues;
- ventilation of feelings (with closure before the interview ends);
- summarization of client feelings after extended listening;
- acceptance of the client, but not the client’s abusive or neglectful behaviors;
- logical, not rambling and disorganized, discussion;
- education or information about crisis intervention, forthcoming events, community resources, etc.;
- setting boundaries and limits on behaviors and contracting on acceptable alternatives;
- concrete services such as housing, homemaker services, and respite care;
- firm, but kind, confrontation regarding inconsistencies in the clients’ statements or behaviors;
- reframing client statements or behaviors to find the positive aspects; and
- joining client resistance by saying “why should you change?” The crisis worker should not say this regarding acts of abuse or neglect or any criminal behaviors.77
Crisis workers that maintain nonjudgmental attitudes, family involvement, and no preconceived notions about a family’s motivation have found that almost all families are open to change for the better. A well-timed, quick response reinforces solutions to a crisis in a limited period of time.
Solution-focused crisis workers are optimistic about substance-abusing, ghetto-residing, chronically disorganized, and even criminally involved families. This means that they do not box families in; they do not categorize or reject them based on their past behavior. Instead, a new, more-effective beginning is sought. Many of these families welcome the opportunity to adapt in more socially acceptable ways. They thought no one would ever give them the hope that they could change.
This is not to say that crisis workers should naively proceed as if they see no drug dealing, prostitution, theft, sexual abuse, child abuse or neglect, or spouse abuse in these families. It is rather a matter of being honest but not condescending, being a role model but not acting superior, being a bearer of hope but not bringing false hope, and being a trustworthy person even if family members are not.
Power struggles accomplish nothing of value in crisis intervention. The least cooperative families may become the most receptive to positive change within a few days, particularly if professionals accept them and help them find their strengths and their solutions to the crisis. Professional commitment and positive attitude toward short-term resolution of a crisis are sensed and appreciated by clients. They have a sense of self-worth when crisis workers ask: “What do you want to happen?” “What do you want to change?” “What do you want to do?” and similar questions that respect clients’ competence.
If crisis workers are respectful of culture and empathetic with the predicament in which families find themselves, new horizons may start to open up. For many families, crisis workers will only have time to help them stabilize, but can help them contact other therapists and agencies where client culture is honored.78 Ultimately, crisis workers who are effective listeners are so responsive to clients’ needs that there is no reason for clients to resist. This, however, takes great patience and a willingness to meet clients’ needs rather than crisis workers’ needs.
When in crisis, families’ feeling, thinking, and behavioral patterns are more likely to be positively impacted by a highly focused, eclectic team approach that uses a multitude of coordinated, community resources. Use of task-centered, cognitive behavioral approaches, along with a flexible repertoire of other theoretical approaches and techniques, allows professionals to tailor interventions according to a family’s chosen goals.
When clients choose their own goals, they do not resist making changes. For instance, if clients want interventions to end and choose ending the interventions as a goal, they may not resist modifying their illegal behavior. Professionals use special treatment techniques, such as instillation of hope, generalization, and humor to elicit additional cooperation from one or more family members.
For more information, contact the National Clearinghouse on Child Abuse and Neglect Information at firstname.lastname@example.org.
Updated on July 13, 1999, by email@example.com.