Ms Ang Bee Lian, 22 May 2015
Being able to carry out crisis intervention work is one of the basic skills that social workers are trained for. But what exactly does this involve? Oftentimes, the context for delivering help or intervention matters and a social worker will be quick to learn that it is not simply about applying a set of steps from a standard operating procedure. Different contexts would require different kinds of intervention and response. For example, in the area of child protection, the intervention and support of the police are oftentimes central to the safeguarding of the interest of children. In the area of elder abuse and neglect, the key intervention would be to get them to accede to receive medical help when needed.
There are a variety of situations that call for an emergency response. However, most of them tend to involve mental illness or mental health concerns. While only trained mental health professionals can diagnose mental illnesses, frontline social workers are expected to recognize behaviours that are indicative of a person suffering from a mental illness or in crisis, with a special emphasis on those that suggest potential violence and/or danger.
Responding to situations involving such individuals requires a crisis team to make difficult judgments about the mental state and intent of the individual. It often requires intervention with the support of the police who may use special police skills, techniques, and abilities to effectively and appropriately resolve the situation, while avoiding unnecessary violence and potential civil liability.
The goal in such contexts is to de-escalate situations safely for all individuals involved when it is reasonable, practical, and consistent with established safety priorities. De-escalation refers to a deliberate attempt to reduce the necessity or intensity of force to resolve a confrontation. The aim is to attempt to resolve such incidents in as constructive and as humane a manner as possible.
A team responding to a crisis should first assess the risk to themselves, the person involved, and any other people involved before determining a course of action. Many persons affected by mental illness or in crisis are not dangerous and some may only present dangerous behaviour under certain circumstances or conditions. Being calm while being alert and sensitive to the mental state of the person involved is critical. Oftentimes, the energy and vibes generated on-site can escalate the situation. In determining the risk, the team should assess the situation using as much information that can be gathered as possible, be it from previous knowledge or from the scene itself.
When responding to persons showing abnormal behaviour or symptoms of mental illness or mental health crisis, the crisis team should consider the following actions to manage the situation for the safety of all at the scene:
i. Evaluate the nature of the situation and the necessity for police intervention or other referrals.
ii. If police intervention is necessary, evaluate if contact should be made by phone or in person. In some situations, it is necessary to plan ahead on how the police can intervene should there be violent behaviour that requires the police to restrain the person. The police may also be called when there is a subject who threatens to jump from a flat or set fire at a scene.
In determining the appropriate resolution for a person in crisis, the crisis team should consider the totality of the circumstances, including the behaviour of the person with a suspected mental illness or developmental disability and/ or the safe transportation of the affected person to a facility to receive services. The following are possible resolutions to the incident:
i. Escorting the affected person to a mental health agency for evaluation, care and treatment.
ii. Having a mental health professional attend to the affected person onsite and to arrange for follow-up meetings.
iii. Assuring the individual in crisis throughout the incident that all interveners have an appropriate level of training and competence.
It is possible that a crisis is de-escalated and the person is not removed from the home. This may be the case when it is assessed that taking the person away immediately may result in undue safety risks.
While behaviours that represent an imminent danger certainly indicate the need for a certain level of emergency response, the behaviours presented may be responses to events that have been accumulating for some time. Situations involving mental health crises may follow trajectories that include intense feelings of personal distress (eg. anxiety, depression, anger, panic, hopelessness), obvious changes in functioning (eg. neglect of personal hygiene, unusual behaviour) or life events (eg. disruptions in personal relationships, support systems or living arrangements, loss of autonomy or personal rights, victimization).
Helping one to regain a sense of control over thoughts, feelings and events that seem to be spinning out of control may be a priority for an individual in a mental health crisis or a person who has been abused or neglected. Staff interventions that occur without opportunities for the individual to understand what is happening and to make choices among options may reinforce feelings that control is being further wrested away. The individual’s resistance to this may be inaccurately regarded as additional evidence of his or her incapacity to understand the crisis situation.
Training for crisis intervention work should include being able to enable a person to make choices, where reasonable, even when in a crisis situation. Informed decision-making in this context is not simply a matter of apprising the individual of the risks and benefits associated with various interventions. It is also about having an understanding among staff that a sub-optimal intervention that a person chooses may reinforce personal responsibility, capability and engagement which can produce an even better outcome. The choices are not just limited to the use of medication and may include the individual’s preferences for other approaches that can be used when crisis assistance is required. The urgency of a situation may also limit the options available. Post-crisis recovery plans or advance directives developed by the individual with assistance from crisis experts are important to avoid a recurrence of a similar crisis.
Services provided should be congruent with the culture, gender, race, age, health, literacy and communication needs of the individual being served. Training for crisis intervention work should also include understanding of how an individual experiences a crisis, how to engage the affected person in the resolution process and how to work in a culturally sensitive way.
An individual who is in crisis is also in a state of heightened vulnerability. It is important that those responding to the crisis are well versed in the individual’s rights, eg. the right to confidentiality, the right to legal counsel, the right to be free from unwarranted seclusion or restraint, the right to leave and the right for a minor to receive services without parental notification. It is good that appropriately trained advocates are available to provide the needed assistance. Whether true or not, many individuals with serious mental illnesses have come to regard mental health crisis interventions as episodes where they feel that their rights are being trampled upon or ignored and their voice unheard. Meaningfully enacting values of shared responsibility and recovery requires that the individual have a clear understanding of his or her rights and access to the services of an advocate. It is also critical that crisis responders do not give the impression that an individual’s exercise of rights is a hostile or defiant act.
Adults, children and older adults with serious mental or emotional problems often have histories of victimization, abuse and neglect, or significant traumatic experiences. Their past trauma may be in some ways similar to the mental health crisis. It is essential that crisis responses evaluate an individual’s trauma history and the person’s status with respect to recovery from those experiences.
Similarly, it is critical to understand how the individual’s response within the current crisis may reflect past traumatic reactions and what interventions may pose particular risks to that individual based on that history. Because of the nature of trauma, appropriately evaluating an individual requires far more sensitivity and expertise than simply asking a series of blunt and potentially embarrassing questions about abuse using a checklist. It requires establishing a safe atmosphere for the individual to discuss these issues and to explore their possible relationship to the crisis event.
Certain individuals seem to experience recurrent crises that may activate emergency services or land them repeatedly in the A&E department or with the police. They may also be known as “frequent users” or “high-end users” of services. In some settings, processing these individuals through repeated admissions within relatively short periods of time becomes so routine that full reassessments are not conducted. Instead, clinical evaluations simply refer back to assessments and interventions that were conducted in previous (unsuccessful) episodes of care or admissions. Recurrent crises should signal a need for a fresh and careful reappraisal of approaches, including engagement with the individual and his or her support network.
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MS ANG BEE LIAN
Director-General of Social Welfare