Crisis Theory & Intervention: History, Indication, and Effectiveness

Crisis theory’s efficacy can be understood through the interventions and multi-theories associated with it. Individuals in crisis, particularly those experiencing trauma, show high levels of success when therapists utilize crisis theory. The multi-theoretical approach allows this theory to be used in therapy with a variety of issues and from various backgrounds, including persons in the military, persons from different cultures, socioeconomic status, and educational achievement due to the flexibility and adaptability of the interventions.

Crisis theory and intervention has existed since the 1900s, and arguably before then.

Since humans have had the ability to recognize suicidal and behavioral changes in other humans due to various events, they have been applying crisis theory regardless of the existence of a formal name.

According to James and Gilliland, “crisis” is a broad and subjective term used to describe a situation which affects an individual in an excruciating way due to various life, environmental, and psychological stressors. Human behavior is largely impacted by unexpected and uncontrolled life events that can be so egregious, they lack comprehension.

Because of the variation in people and human issues, crisis theory interventions are derived from many theoretical perspectives, such as Ego Psychology, Behavior Theory, and Cognitive Theory. It is important to recognize the crisis event, how the theory is applied, use of the theory, and individuals who most benefit from using this perspective.

Historical Origins of Crisis Theory

As a field, social work developed from a recognition that humans need specific interventions when life stresses become acute or compounded over time leading to debilitating conditions, such as Post Traumatic Stress Disorder (PTSD). Social workers were among the first to determine the interventions for severe distress needed to be treated differently than other disorders or diagnoses. T.W. Salmon’s research about World War I (WWI), and later Kardiner and Spiegel’s research during World War II (WWII) determined that the three principles of crisis intervention are: immediacy, proximity, and expectancy.

Crisis theory was just emerging as the widely used contemporary theory — during WWII and the Great Depression, these principles gained traction in mental health to aid in the adjustment of those displaced or impoverished. Furthermore, a need emerged to assist those in the armed forces that faced horrors unimaginable while serving their country.

Eventually, Erich Lindemann and Gerald Caplan of Massachusetts General Hospital would formalize crisis theory in the 1940s and set the practice tenets, which is so prevalent today. This event initiated the drive to theorize crisis which led to the Mental Health Centers Act of 1963. With the policy’s implementation, asylums and psychiatric hospitals were converted to community health centers, and eventually community services boards, due to the new understanding that crisis can be acute, pervasive, and lead to negative coping mechanisms.

The three most notable events to shape crisis intervention were the advent of Alcoholics Anonymous (AA), The National Organization for Women (NOW), and the Vietnam Veteran’s movements of the 1970s. Grassroots movements were shaped around a common theme: desiring help and intervention for specific critical incidences but not receiving this. Even though these organizations’ goals were not shaped around crisis management specifically, they assisted in bringing issues, such as PTSD, to the attention of clinicians. This allowed for the creation of interventions such as Mobile Crisis Units, suicide prevention hotlines, and Critical Incident Stress Management Teams.

Major Tenets of Crisis Theory

From observation alone, one can assess an individual’s behavior. While many factors are involved in understanding human behavior, resiliency is the most common dynamic in determining how a person reacts to and copes with crisis, and will be discussed further in the context of each crisis type. Primarily, there are three categories of crisis: developmental, situational, and existential, which each reflect unique identifiers.

Developmental Crises

Developmental crises occur from naturally occurring stages and milestones in life that may create stress due to transition from one stage to another. The major tenet behind this idea is framed in Erik Erikson’s psychosocial stages of development in which life events directly correlate with expected normative stressors. An example of this would be graduating from college and preparing for adulthood, or giving birth to a first child. According to Walsh, when these events occur, an individual with little resilience may face significant stress regarding their identity and be unable to cope without clinical intervention and learning skills to manage the stress. Persons with higher levels of resiliency may not react to stress negatively at all, however, because they have learned how to cope, become stoic in their identities, and are not challenged by such life events.

Situational Crises

Situational crises — events that one cannot control, prevent, or otherwise anticipate — are perhaps the most common occurrences. It is for this reason that a multi-theoretical approach is necessary when managing crisis. James and Gilliland assert that it is the unpredictability of these events that shape the outcomes because of a shift in values and beliefs after the traumatic event occurs. Because of the sudden and acute nature of these events, resiliency is of utmost importance to allow an individual to either grow, maintain equilibrium, or freeze. Though these patterns are evident in other classifications of crisis, they are most prevalent in situational crisis according to Lewis and Roberts.

Firstly, individuals with high levels of resiliency may grow based on the development of new strengths and coping skills acquired through therapy, intervention, or modeling. Most individuals experience an equilibrium period in which they are not completely socially functional and regressed to the way they were prior to the event. Despite the new knowledge and experience, most people can carry on and readjust without any major changes or perpetual crisis states. An individual with low levels of resiliency may freeze and never move past the trauma. The freeze state is unique in that it can occur even in those with high levels of resiliency if the nature of the trauma is severe enough. Examples of this include aggravated sexual assault that is either committed by or victimized by a military service member during times of direct combat.

Existential Crises

Lastly, existential crises are perhaps the most frustrating and challenging for persons to cope with and accept. Existential crises confront value and belief systems directly due to inner turmoil surrounding the event. The individual’s entire life narrative may be turned upside down by such events leaving them scrambling to make sense of their identities. Examples of existential crises can include finding out about being adopted, or learning that a marriage that was held in high regard was fraught with affairs and turmoil, thus changing the view of marriage, or life itself, at that point time.

Regret tends to be a major exacerbation of existential crisis and is most evident among persons with lower rates of resiliency who were raised to believe one way, but life events forced them to face options or choices they were not prepared for. Because of the major paradigm shift seen with these crises, freezing and avoidance are often the most common response. Individuals will deny the change and attempt to carry on as if they had achieved equilibrium and the event never occurred.

Interventions

To allow the individual to move on from the trauma and regain appropriate social function after the event, interventions are typically required. Persons are unique in the way they respond to trauma and clinical or natural support interventions. It is important to quickly note that coping and adaptive skills are paramount to the process of responding to crises.

According to Walsh, there are two primary types of coping: biological and psychological. Biological coping is reflected by the body’s ability to manage the stress without somatic expression. Stress in the body can resemble emotional, gastrointestinal distress, and sometimes even heart and blood pressure issues.

Psychological coping, on the other hand, addresses the problem-solving approaches necessary to manage difficult situations and can be both positive and negative. A positive strategy consists of using natural and social supports to reinvest with feelings of attachment and safety to allow an individual to move forward into the growth stage. A negative strategy may display disparate acts, such as avoidance, or even substance abuse in order to anaesthetize themselves against pervasive thoughts of the event.

In order to determine the most appropriate strengths-based intervention, a thorough and timely assessment must take place. This allows the clinicians to best determine the strategy they will employ, including assessing for suicide and a long-term safety plan. As mentioned earlier, crisis theory is not unique to itself, but is comprised of other theories that may best suit the needs of the individual situation. Next, ego psychology, behavior theory, and cognitive theory, will be briefly examined.

Ego Psychology

Interventions within the framework of ego psychology focus on motivating the client to resolve their own crises through the process of self-reflection, which aids them in being solution-focused. According to Walsh, these interventions are sustainment, exploration/description/ventilation, and person-situation reflection.

Sustainment focuses on achieving positive relationships through appropriate development and education with the assistance of a clinician. Everly and Mitchell asserts that peers can also be effective for positive sustainment because of the empathy demonstrated within groups, such as emergency responders, law enforcement, and military personnel.

Exploration/description/ventilation, explores managing stress through the use of emotional articulation, which can teach the client how to look outside themselves in order to solve problems and reduce cognitive distortions that can occur.

Person-situation reflection helps the client face the current crisis by directing them to self-assess their direct role in the outcomes and solutions of the intervention.

Behavior Theory

Sometimes individuals can get in their own way to the point that the behaviors exhibited are the cause of the crisis. These individuals typically struggle with both positive and negative reinforcement and how to identify them and in times of crisis. Reinforcement of appropriate behaviors is critical to this theory. According to Walsh, life skills, relaxation, coping skills, assertion, or desensitization training are necessary interventions for a clinician using behavior theory with a client in crisis because they are all highly structured, which allows for the client to feel more in control.

Cognitive Theory

In times of crisis an individual can feel lost, or as we saw earlier, existentially stuck in a moment such as a breakup or paradigm shift. These situations often happen violently or abruptly and elicit emotional reactions that the individual may not be able to fully control or understand in the moment. These reactions become assumptions that often lead to cognitive distortions that are emotional rather than rationally based.

In these moments, cognitive theory is most widely implemented, though it is often used in conjunction with behavior theory to become cognitive behavioral therapy (CBT), the most widely indicated intervention in critical situations. Although these interventions are evidence-based, clinicians using crisis theory must be adept at testing for effectiveness.

Theory Effectiveness

Theories evolve and change over time as new research is done to better aid the clinician in best practices, and this theory is no different. Though largely unchanged, different thoughts on how to best implement crisis intervention have been subject to trends in the mental health field. The debate between group and individual interventions has been long-standing and dependent on the most relevant and cogent data at the time.

Because of the multi-theoretical approach, rather than one model for conceptualizing crisis, Walsh states that there is little direct research regarding crisis intervention and its effectiveness.

This is not to say that it is ineffective, but simply that the longitudinal data is difficult to come by despite the apparent success of crisis intervention through programs, such as critical incident stress management (CISM), which are widely used as in intermediary between the crisis and individual intervention. CISM uses psychological first aid, which includes eight tenets of effectiveness: “Contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping, and linkage with collaborative services.”

According to Walsh, success related to suicide prevention was found in 14 studies with an ending result of established best practices for protocols in suicide prevention centers. In another 10 studies about psychiatric hospital outcomes, findings included a decrease in hospitalizations over time and an increase in positively associated mental health through various psychological emergency services. In addition, in various evaluation studies of programs pertaining to crisis intervention and intensive in-home services, a decrease in out-of-home placements was found, which affirms the effectiveness of these interventions despite the multi-theoretical approach.

Despite the success of this approach, criticism regarding the multi-theoretical perspective that is generally based in Erickson’s life stage continues. Furthermore, cultural considerations are severely lacking in the crisis theory literature, which raises the question of the cultural competency of clinicians that focus on crisis theory. Because most crises focus on the individual, it is easy to lose emphasis on the natural support system that also affects outcomes, which leaves the person in crisis relying on formal services.

Using crisis intervention seems to be most adequate for populations that are under constant stress (such as military personnel), persons who are victims of longstanding sexual assault, those whose lives are in constant threat of suicide, and clients who experience stressors beyond their capacity to cope.

Brienna Thompson (MSW, LCSW-A) has worked as a Trauma Specialist for the last 10 years. She earned a Master of Social Work degree from Virginia Commonwealth University. For relaxation, Brienna does Obstacle Course Races, participates in GORUCK, reads, plays soccer, snowboards, and volunteers with and counsels transitioning Marines. Brienna lives in Jacksonville, NC with her two dogs, Cara and Jedi, and her cat, Spooky.