CO MMUNITY PSY C H OLOGY

Necessary Conditions for Crisis Intervention Programs

Providin g for people In psyc hological c rises Is a major theme Ln community men-
tal health. Since crisis intervention te nds to be brief. more people can be served
by a limited s taff. Moreover, cris is services reach sectlons,QJ" the populalk>n who
neithe r know. value, nor seek conventional psyc hothe rapyl!_n the crisis state peo-
ple both seek reUef from immediate dis tress and ways of deaUng wilh intolerable
situation s. althou gh they m ay not be psychologically minded nor motivated to-
ward personality change) By the standards of psyc hothera py, the goals of crisis in-
terve ntion are limited. !>Lt their potential extended impact is great.
Effec tive crisis intervention programs require important c hanges in clinic
practice. These have been slow to develop. Thus. McGee ( 1968) notes: "Despite a
broadened outlook toward c risis in terve ntion. our overall orientation in this area Is
related to a fairly traditional model havin g to do with intake and psychothera py.
amon g other thin gs. The typical stance of a mental health agency is to wait until
the individual in crisis a ppears for help. Once this occurs his problem is evalu-
ated. and he is offered some form of psychotherapy. A s yet, approaches to crisis
intervention do not s ufficiently e mphasize the concepts of outreach and consulta-
tion" ( McGee. 1968. p. 323 ). He proposes that clinics make greater e fforts to
reach out to people in need. partJy through cons ultation and education in the
community. Organizin g a good crisis unit-indeed. any community-oriented se r-
vice-requires special attention to matters of location. availability. setting, staff
mobility, and fun c tions, amon g othe rs. that are of lesser importance in traditional
clinics. A number of these m atters will now be con sidered.

CLOSENESS TO THE COMMUNITY

The fac ility shou ld be geographically and psychologicaUy close to the com -
munity it serves. It should be known and respec ted by pote ntial clients and signif-
icant others in their social environme nt . Under condition s of s tress. no one is
Inclined to travel distances to seek help nor to be happy in allen settings. This is
partic ularly true for the lower-class person whose psychological Ufe-space is more
limited and fo r whom travel outside of the immediate neigh borhood may be
fri ghtening. The fac ility should not on ly be located in the neighborhood. but as
much as possible be staffed by people from the neighborhood and/or familia r with
its ways. The black client is Ukely to be more responsive to a settin g which has a
signilkant number of black staff. Communication as well as the morale of the
foreign-born client depends on the availability of people who speak his lan guage.
T he nature of the larger instilution with which the clinic is affiliated sign ifi-
cantly affects the likelihood that clients wiJJ seek its services. Although fine
"walk-in " clin ics have been developed within large metropolitan hospitals and on
universit y <.:am puses (see Tanenbau m. , 966. for a good account of this develop-
ment ). eac h of these settings evokes attitudes which may be barriers 10 the poor
and uneducated. The hospital connotes illness and death and. in its psychiatric
wm g. msanh y and incarceration ; the un iversity. intellectualit y and ex peri-
mentation, with limited regard fo r human welfa re. In urba n slums. "storefront "
clinics have been developed to make them immediate ly accessible. geographjcaJJy
and psyc hologically, to the resident popu lation .

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Principles and Methods of Community Intervent ion C HAP. 18

An incident in San Francisco's Chinatown shows how proximity and com-

munity integration might discourage as well as encourage the use of clinics. A
group of Chinese-American me ntal health workers, associated with various agen-
cies in the larger community. voluntarily developed a unit in the heart of Chin a-
town in which short-term psychotherapy is offered by Chinese staff in the various
Chinese dialects as well as in English. They reasoned that realistic language
problems. the cohesiveness of the community, its concern with its own problems.
and cultural resistance to taking them to the outside world, would encourage
many to go to the ir own clinic where they might resist involvement with "Cauca-
sian" agencies. Indeed they were correct; many did. But others did not, and
beca use of the same cultural factors. The new clinic was everybody's business.
Who came and went. and to a fair degree, what went on, was widely known in
this close community. Shame of being identified as a patie nt and a desire for
privacy kept them away or led some to seek referrals to agencies where they could
be more anonymous. The general principle that systems for the delivery of mental
health services must be congruent with community values remains true; the spe-
cific principle that services should be in and of the community is shown here to
require more subtle interpretation.
Thus far, we have considered the importance of having a facility physically
and socially close to its community as a condition for effective crisis intervention.
But there is another aspect of the issue of proxim ity, i.e .. closeness to the place
where crises are likely to occur, and where intervention can occur in the natural
setting of the crisis without shifting to anothe r scene. An example of this kind of
program is provided by one of the projects of the Harvard Laboratory of Commu -
nity Psychiatry which was concerned with the crisis surrounding the birth of a
premature baby. and which involved contact with the mother while she was still
in the obstetric ward, after she returned home. but while the infant remained in
the nursery. and after the infant came home ( Kaplan and Mason, 1960). Each of
these phases had ils particular psychological issues: first, recognizing without in-
appropriate denial the possibility of the baby's death, and dealing with the accom-
panyin g feelin gs of self-blame and inadequacy; second. sustainin g hope for sur-
vival and preparing necessary care. during the separation; and, third, establishin g
a mothering relationship after the disruption of the premature birth and separa-
tion. and perhaps copin g with possible congeni tal abnormalities.
A number of aspects of such a project should be noted : ( 1) The work is
anchored in the setting, in this case an obstetric service. in which clinicians are
known and immediately available. No "referral" is necessary. and consultation is
right at hand for nurses and physicians: ( 2) With experience. more subtle signs of
crises can be recognjzed and more appropriate actions taken : and (3) In the same
process. clinical research of importance to the further understanding of crisis
states can be conducted. For example. what kinds of emotional reaction, in which
sequence . over what time, occur ? What personality and social conditions djspose
to more or less intense reactions? Since a number of similar people are un dergo-
ing similar experiences. a natural experiment exists : answering such q uestions
builds a firmer understanding of the particula r crisis and its management. which
together with other comparable experiments contributes to better conceptualiza-
tion of crisis behavior generally.

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IMMEDIATE AVAILABILITY OF SERVICE

Delay between the on set of a c risis and contact with the c risis ~ rvice must
be min imized. Ideally. clinic al worke rs a re a vaila ble on a twe nt y- four-ho ur basis
to see patie nts m, e me rgenc ies a rise. Unlike co nventiona l clinic prac tice. cris is
services ca.nnot a llow delays due to the mech an ics of makin g appointme nts . wa it -
in g for a n available ho ur. or administrative process in g. Immediate ac tio n is
needed and intennediate stages have to be minim ized or e limina ted . C risis ser-
vices a re ofte n ··waJk-in c linics"' which require no prior a ppointme n t. S uicide
prevenlio n services do a great part of the ir wo rk o n the te le phone (S hneidman .
1972 ). The principle in all these cases is to be the re whe n the pa tie nt needs he lp.

MOBILITY

C risis inte rve ntio n reql! ireS th at s taff leaves the co nfines of the clinic for the
community. This may in volve accompanying police. family me mbers. ministers.
or o the r ca re ta ke rs to the scene of c rises. The clinician cannot wa il passively for
peo ple in need to come to him. Man y will ne ver arrive. o the rs will come too la te.
C risis-orie nted clinician s sho uld also pa rtic ipate in the work of se ttin gs whe re
proble ms cluste r. for example . by co nsult in g 10 schools o r med ic:aJ se rvice s. The
c linic itself rem ains a base. and a necessary one for ma ny kind s of the rapeutic
tran sactio ns. but its bounda ries should be fl e xible. It s ho uld be easy fo r those in
need to come in a nd easy fo r s taff to go out. In the apt phrase of a Be rke ley col-
le ag ue. il should be a "clinic without walls.··

FLEXIBILITY ANO VERSATILITY OF PROFESSIONAL ROLES

It follows from these con side ra tio ns tha t traditional sta ff roles have to be
serio usly reconceptualjzed and reorganized. In the crisis-orie nted cente r. the
work of all disciplines converge. The re is ne ithe r Lime nor need for sepa rate and
ex te n sive medical. psychiatric o r psychologic al evalua tio n. full social histories. o r
e xte nded casewo rk or psychothe ra py: functio ns allocated amon g me m bers of the
" psyc hiatric team .. in the past. All mus e be ade pt in rapid assessme nt . brie f the ra-
peut ic inte rventio n a nd co ns ulta tion. a nd in kno wledge of community resou rces
a nd of me thods e ffec ting needed c hange. Some professiona lly dis tinc t func tion5,
re main : medic ally trained psyc hia trists are c alled o n to adminis1e r psyc hoacti ve
dru gs necessary fo r re lieving inte nse e motfons : psychologis ts face the c halle n ge
of ada ptin g a nd developin g rapid a nd foc used assessme nt tec hniques. At least.
gr ea te r coorruna tio n or the disc re te func tion s o r the dUfe reN..t profession als is
required : ideally. they sho uld be a ble lo wo rk inte rc ha n geably in 1he commo n
tasks of c n sis intervemion .
Ac tivities wh ic h see m trivial or " no nprofessionaJ .. may be of cons iderable im-
porta nce and requi re the most tho ug htful professional ,m e ntion . Thus. the te le-
phone c all or walk -in requeM for in formation. us uall y conce ived as a firs t a nd pre -
limina ry s tep 10 psycho the rapy a nd de legated 10 a rece ptionist. may be o r 1-,rr ea t
import an ce in dealin ~ w11h c risis patients . The expert. o n-the -spot judgme n t of a
trained d 1111c1a n •~ requ ired . for the future succcsi, of 1hc c1111 re inte rve ntion m ay
de pend o n it. It i~ a co mmo nplace observa tio n tha t ma ny people 111 acute distress
make o nly this fi r!-t con1ac1 and. if not immediate ly e n gaged. disappea r from view.
In o the r regards. professionaJ fu nc tions have to c ha n ge as we ll Clm1cia ns

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 Pri.nc iples and Me thods ofCommtm ity Inte rvent ion C HAP. 18

have Lo travel outside of the clinic. be prepared to give information and advice.
help direc lly with immediate social problems or colla borate ac ti\'ely with commu -
nny caretakers and other helping agencies in their solution. Amenities such as
regularly sc heduled appointments and the fift y-minute hour may be lost. For
those accustomed to the ways of con ventional clinics. 1he work of cris is interven -
tion involves importa nt organizational changes and altered professional aclivi1ies.

The Technique of Crisis Intervention

Al the present time. crisis inte rvention is possible in various ways. for no sin gle
model has emerged . Current practice involves adaptations of s hort-term psycho-
therapeutic and social casework techniques. particularly of the sort characterized
as ego-supportive. he re-and -now oriented . problem-centered, or reality-oriented .
Protagonis ts of crisis methods argue that they are not j ust less (or one phase of)
psychotherapy, and that the goal does not involve gainin g understandin g of con-
fl icts- partic ularly those wh ich are unconsciously rooted-nor are historical ex -
ploration. corrective emotional experiences. transference. and characte r recon-
struction important no the process. What is involved can be inferred from various
accounts. althou gh the particular process would obviously vary with the nature of
the crisis, the social circumsta nces within whic h it occu rs. the severity of the
evoked reactions. and the partic ular personality involved . In addition to direct
work with the patient. crisis intervention commonly involves cons ultation with
L!:levant others and direct efforts to alter the soc ial e nvironment.
Some general properties of the clinical process in cris is intervention can be
sketched. The immediate goals are ( 1) to relieve present distress. notably anxiety.
confusion. and hopelessness: ( 2 ) to restore the patient's previous functioning:
and (3) to help him. his family. and slgnifican1 others learn wha1 personal actions
are possible and wha1 community resources exist. Secondary, a nd more ex-
tended . goals would include ( 4 ) unders tanding the re lation of the prese nt cris is to
past experiences and pers is tent psychological problems. and (5 ) developing new
attitudes, behavior. and coping techniques that might be more effective in fu ture
~ rises.
lnitiaJJy. the clinical tran saction focuses on the crisis itself and its immedi-
ately precipitating events. By reconside ring the stressful events. new contexts
and unders tandin g can emerge. The accompanying painful affects can be re-
duced . in part by venting feelin gs and in part by comin g to see the m as under-
s tandable stress reac lions. In late r phases. the emphasis s hift s to proble m-solvin g
efforts. Previous life event s. particu larly those which were s uccessfu lly managed.
are explored to bring out the patient·s copin g resource s which m1gh1 again be
utilized or adapted in the prese nt Instance. Necessary informa110111 and advice is
given. but hopefull y in an e ffort 10 serve rather than undercu t the pa11en1 \ own
effort s at self-de terminal ion. Alternate solutions are \'isualized . n ew behaviors
re hearsed. and future conseq uences considered . Alon g wnh 1hc dominalll foc us
on the preselll dilemma, 1hcre I!> a stron~ fu ture om:n1a1ion in 1h1s form of
~ herapy.
The relation between climc1an and paue nt . central to anv thcrapeullc pro-
 CO MMUNITY PSY C H O LOGY
cess. cannot evolve slowly over time as in conventional psychotherapy . It must be
built rapidly on the basis of the patient's helplessness and confusion and his read-
iness to invest trust and hope in the clinician. Such attitudes are encouraged by
the therapist. who readily communicates his confidence, competence, and au -
thority. The clinician is necessarily more active and directive than he might be in
longer-term psychotherapy. Under such conditions, there Is the realistic possibil-
ity of inducing a complementary regressive role in the patient , in which he gain s
relief but loses independence by turning his problems and fate over to the thera-
pist. There is a paradox and dan ger here, for the relation is based on the patient's
helplessness and the therapist's authority, though its purpose is to encourage
self-respect and self-determination. If possible. such danger is averted by con-
tinued foc us on the problem-to-be-solved, the limited time available. and the pa-
tient 's own competence and capacity for autonomy. There is little discussion of
the relation itself and transfere nce elements are minimized. U nUke con venlional
psychotherapy, the end is consta ntly in view. Terminalion is explicitly expected
and dealt with . Under these conditions, the more forceful and active role of the
u herapist ls less likely LO infamllize the patient.
Typically, crisis-oriented therapy involves six to eight contact hours. Unlike
conventional practice. suc h sessions are more loosely scheduled and may be of
variable length. Patients often seen conjointly with family members or friends.
Indeed. in an experiment in one Walk-in Clinic. groups of three to six entirely
unrelated patie nts were seen by three professionals on the first occasion in a
grou p session (Tanenbaum, 1966). These people though strangers to each other
were able to verbalize their concerns as readily as comparable palients in individ-
ual sessions. They seem to gain support and to experience relief from the pres-
L- ence of others in distress.

Anticipatory Crisis Intervention

On-coming crises can ofte n be foreseen, and there is the challen ging possibility of
developin g programs for "anticipatory crisis intervention" before people are actu-
ally in distress (Caplan, 1964 ). Where it can be predicted that individuals or
groups are likely to be ex posed to a psychologicalJy threatening situation, advance
counseling can be made available. In suc h a process. likely occ urrences are de-
scribed in detail, potentially threatenin g aspec ts analyzed. probably emotional
distress considered: all to the end of reducing the novelty and shock value and of
increasing the knowledge and competence required for effective action in the ac-
tual situ ation. Through rehearsal and vicarious experience, processes similar to
what Janis ( , 958) has called "emotional innoc ulation" can occur.
There is nothing essentially new in the notion of anticipatory crisis interven-
tion. In many fami.Uar ways, people are prepared for the demands of new experi-
ences. Colleges. military services, and industrial organizations run orientation
programs for new members. Indeed. all of education has been called, more or less
acc urately. "preparation for lite." Closer to our present concern are courses in sex
educa1 ion or premarital coun seli ng intended to prepare youn g people for the

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Principles and Methods of Community Intervention C HAP. 18

hallenges of maturity. Similarly. programs for expectant parents are another fa.
millar effort to help people handle new life responsibillties. Physicians and nurses
run classes for young couples which focus on the care. feeding, and medical
problems of infants which, at the same time, address psychological issues of par-
enthood. In company with others, prospective parents acquire information and
techniques necessary for infant care, while at the same time learning about com-
mon uncertainties and common concerns. As in group therapy, sharin g anxi-
eties helps reduce them. Diapering a rubber doll rather than a live baby eases the
later task. In significant ways, prenatal courses can avert some of the problems
which might otherwise surround and follow the birth of a child.
Caplan's Peace Corps project illustrates an effort at anticipatory crisis inter-
vention utiHzing the skills and specialized knowledge of clinicians (Caplan,
1964 ). In the early 1960s, man y youn g Americans were being trained for new
tasks In distant lands, often under primitive conditions, where typically they
knew Uttle of the language or culture. For many, it was a fi rst experience abroad .
In their new roles, they often had to function in relative Isolation and to depend on
their own resources, without accustomed social supports. "Culture shock" was
predictable as they interacted with people who lived by different rules and values.
Pamphlets were written for the volunteers and group discussion held to review
the demands on them and their potential reactions. They were warned of the ef-
fects of isolation, homesic kness, and alienation, and of the clifficuJties of being
under constant scrutiny. and of living unde r new role and authority relations.
Possible actions to reUeve tensions and feelings of inadequacy were reviewed.
These effort s, Caplan believes. contributed to tlhe generally high morale and ef-
fec tive fun ctioning of the Peace Corps volunteers in the field.

The Current Status of Crisis Intervention

At this point, crisis intervention is more an orientation and way of thinking than a
systematic body of theory, knowledge. and practice. To date. there have been few
systematic studies of process. outcome or follow -up to show how these brief trans-
actions affect people in distress and whether or not they have endurin g effects.
Clinicians Involved in the process are enthusiastic and preliminary reports
suggest that crisis-oriented brief therapy in community mental health centers
can avert hospltahzation for some patients.
Decke r and Stu bblebine ( 1972) showed that the number of psychiatric hos-
pitalizations were significanlly reduced following the institution of a crisis inter-
vention service compared to the preceding period. Moreover. after brief crisis ser-
vices, subsequent hospitalization. if required, was significantly shorter, and the
likellhood of later hospitalization was also significantly reduced . On the other
hand , in a controlled study of patients given crisis treatment compared to those
randomly assigned lo a waiting list. Gottschalk, Fox. and Bates ( 1973) fou nd no
significant difference In a variety of Indices o f psychiatric improvement ; both
groups improved and to about the same extent o ver a six -week test period. People
thus seem to recover from crisis states with or without treatme nt. though

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 CO MM UN ITY P S YC HOL OG Y
progress may be more rapid and less painful with some inte rvention. Gottschalk
and his co-workers did not find , however. that those patients who were less dis-
turbed initially. less alienated. and less disorganized , and who we re more mo-
tivated toward satisf)'ing human relations were likely 10 improve more with cris is
1reatmen1.
Cn s1s intervention is not a simple or unitary system : instead. it borrows from
different therape utic approache&. Critical questions are left unanswered : Are
there desirable or necessary therapist qualities? Are these the same or different
than those required for lon ge r-term therapy? Is it possible that the skills and
knowled ge of the expert psyc hothe rapis t might indeed block effective action in
the brief, reality-oriented encounter? Or, because of Its brevity. is greater clinical
knowledge and s kiU required for brief crisis the rapy? What is most critical in the
process-the relations hip. the actions t ake n, or the atmosphere of hope? Are
there kinds of patients or problems for which these techniques are ill-advised?
Questions such as these point up the need for detailed studies of the process
and effects of this promising but largely unproven technique. There is some un-
certainty as to what is meant by crisis. even among s taff me mbers of the Harvard
Laboratory of Community Psychiatry. which h as been the source of much of the
current thinking in the field ( Bloom, 1 g63 ).
(" Studies of life s tress and developmental crises have expanded the knowledge
necessary for the furth er development of crisis intervention methods. Such
me thods have been explored in such situa tions as the birth of a premature infant,
entry into college. s urgery and debilitating disease. death of a loved one. entry
Into marriage and maritaJ and family crises, among others (Parad. 1965). Stu-
dents of crisis intervention have been con cerned with theory and research in ego
psychology, partic ularly that which c alls attention to adaptive and coping capaci-
ties in normal development as well as under stress (e.g.. R. W. White. 1 963;
Haan. 1969: Coelho. Hamburg. and Adams. 1974). The conllnued evolution of
theory and knowled ge in these realms. combined with more precise delineation of
intervention me thods and study of their e ffects. will surely continue and lead to a
L firmer base for crisis 1heory and practice.

CONSULTATION

Definition

Consultation is emergin g as one of the major techniq ues in community psychol-

Og)'. In one or another form , consult ation is as old as clinical practice itself: it is an
inevitable by-prod uct of specialization in any area. In essence. the consult ative
process in volves one person ( the cons ultee ). who has a problem but lacks the