MENTAL HEALTH CRISIS INTERVENTION PROCESS

Crisis intervention is a short-term therapy (usually a single session) that aims to help an individual deal with an event that is presently occurring and that is producing emotional, mental, physical, and behavioral distress or problems. Crisis intervention is appropriate for all ages and can take place in a wide range of settings.

The goals of mental health crisis management are to:

• Ensure the physical safety and emotional stability of the person experiencing a mental health crisis
• Reduce the intensity of emotional, mental, physical, and behavioral reactions to the crisis in order to avoid further deterioration of the person’s mental status and development of serious long-term problems
• Assist in recovery from crisis and the return to a precrisis level of functioning
• Assist in the development or enhancement of more effective coping skills and support system
• Assist in building self-awareness and self-confidence
• Teach prevention strategies for self-harm
• Ensure that services are clinically appropriate and in the least intense or restrictive setting
• Provide assistance and referral for ongoing care
  (Halter, 2022)

Triage Considerations

Triage refers to the assessment that takes place when a patient first makes contact with a health service. Triage may occur in many settings, including an emergency department, community mental health clinic, ambulance call-out, primary care setting, telephone hotline, crisis center, individual’s home, school, homeless shelter, and jail. Mental health triage tools are clinician-administered scales that specify signs or symptoms, propose a corresponding response, and determine priority categories based on the level of perceived acuity.

The aims of triage are to:

• Determine if the person is at risk for self-harm or harm to others
• Establish priority for response
• Provide support when and where it is needed so that individuals will not require hospitalization but can be stabilized and linked to less urgent levels of care
• Determine what intervention is best suited for the person and to whom the person should be referred
  (State of California, 2023)

In every crisis event, triage must address both safety concerns and immediacy challenges. This is accomplished most often utilizing a triage assessment tool that offers step-by-step guidance (see box below).

MENTAL HEALTH TRIAGE TOOL

Acuity	Typical presentation
(Adapted from Zun, 2016; Australia DHA, 2009)
Immediate	Definite danger to life (self or others) Violent behavior Possession of weapon Extreme agitation or restlessness Bizarre/disoriented behavior Reported recent violent behavior
Emergency (Requires treatment within 10 minutes)	Probable risk of danger to self or others Extreme agitation or restlessness Physically/verbally aggressive Confused/unable to cooperate Hallucinations/delusions/paranoia Requires restraint/containment High risk of absconding/not waiting for treatment Reported attempt or threat of self-harm
Urgent (Requires treatment within 30 minutes)	Possible danger to self or others Agitation/restlessness Intrusive behavior Confusion Ambivalence/not likely to wait for treatment Reported suicidal ideation Presence of psychotic symptoms Presence of mood disturbance
Semi-urgent (Requires treatment within 60 minutes)	No immediate risk to self or others No agitation/restlessness Irritable without aggression Cooperative Gives coherent history Pre-existing mental health disorder Symptoms of anxiety/depression without suicidal ideation
Nonurgent (Requires treatment within 2 hours; referral to an appropriate community resource)	No danger to self or others Cooperative, communicative, follows instructions Known chronic psychotic symptoms Pre-existing nonacute mental health disorder

TRIAGE FOR CHILDREN AND ADOLESCENTS

The HEADS-ED is a mental health screening tool used with children and adolescents ages 6–18 years who are presenting for primary care or for mental health crisis care. HEADS-ED can be completed within a few minutes by a healthcare practitioner or allied health professional (e.g., crisis worker, school counselor). The tool includes seven components of a patient history, giving a concise picture of the main concerns, and a total score that can indicate overall severity of symptoms. On the basis of this score, the clinician can make determinations as to the patient’s disposition and follow-up, which may include:

• Immediately providing a meaningful score (a score of 8 or a suicidality score of 2 indicates that a mental health consultation should be obtained)
• Suggesting whether a consultation for inpatient services may be required
• Identifying appropriate local community resources based on the needs identified that will facilitate continuity of care

HEADS-ED SCREENING TOOL

Component	Question	Responses (Score) 0=No action needed 1=Needs action but not immediate 2=Needs immediate action
(Cappelli et al., 2020)
H – Home	How does your family get along with each other?	Supportive (0) Conflicts (1) Chaotic (2) Dysfunctional (2)
E – Education	How is your school attendance?	On track (0) Grades dropping (1) Absenteeism (1) Failing (2) Not attending school (2)
A – Activities	How are you getting along with your friends?	No change (0) Reduced activities (1) Peer conflicts (1) Fully withdrawn (2) Significant peer conflicts (2)
D – Drugs and alcohol	How often have you been using alcohol or other drugs?	None (0) Infrequently (0) Occasionally (1) Frequently (2) Daily (2)
S – Suicidality	Do you have any thoughts of wanting to kill yourself?	No thoughts (0) Ideation (1) Plan (2) Apparent attempt made (2)
E – Emotions, behaviors, thought disturbance	How have you been feeling lately?	Mildly anxious (0) Mildly sad (0) Mild acting out (0) Moderately anxious (1) Moderately sad (1) Moderate acting out (1) Significantly distressed (2) Unable to function (2) Out of control (2) Bizarre thoughts (2)
D – Discharge resources	Are you getting any help, or are you waiting to receive help?	Ongoing (0) Well connected (0) Receiving some (1) Not meeting needs (1) None (2) On wait list (2) Noncompliant (2)

Crisis Intervention Communication

The goals of crisis intervention communication are to:

• Establish rapport
• Identify the most important concern at that moment
• Assess the person’s perception of the problem
• Facilitate the person’s expression of emotion
• Teach the person necessary self-care skills
• Recognize the person’s needs
• Implement interventions designed to address the needs
• Guide the person toward identifying a plan of action to reach a satisfying and socially acceptable resolution
  (Wayne, 2023)

In order to be effective in the process of intervention with an individual in crisis, it is essential that the clinician use effective communication techniques. The most essential of these are active listening skills. Active listening involves listening with all the senses and:

• Directly seeing the person
• Hearing the person’s voice as they speak
• Observing how the person’s speaking and presence makes the listener feel

Through active listening, the listener communicates both verbally and nonverbally that they are interested in what the other person is saying while also actively verifying one’s understanding with the person. It is the ability to completely focus on a speaker, understand the speaker’s message, comprehend the meaning of the information, and respond effectively. The practice of active listening is complex, as each skill involved is used concurrently with the others while also trying to remain empathetic and objective. Active listening is, essentially, a form of feedback.

ATTENDING/ACKNOWLEDGING

It is important to provide verbal awareness of the speaker and to convey an interest in what the speaker is saying. This provides an invitation to continue to talk.

Examples:

• “Uh-huh.”
• “Oh?”
• “When?”
• “Really?”
• “I see.”
• “Yes.”

Nonverbal awareness is also an important element of active listening. SOLER is a mnemonic for establishing good nonverbal communication with a person (see table below).

SOLER

S	Sitting and squarely facing the person
O	Open posture (e.g., not crossing arms in front of the body)
L	Leaning toward the person to indicate interest in what they are saying
E	Maintaining good eye contact
R	Maintaining a relaxed posture

Nonverbally, the listener conveys interest by nodding, and smiling. Small smiles combined with nods can be powerful in affirming that messages are being heard and understood. Because eye contact can be intimidating and culturally specific, it is essential to gauge how much is appropriate. It is often best to use eye contact along with smiles and other nonverbal messages.

Another nonverbal technique is referred to as mirroring. This may involve the automatic reflection of the facial expressions of the speaker and can indicate empathy. The slight mirroring of posture or gestures can build rapport as well. Mirroring may also include speech pacing, vocabulary choices, volume and tone of voice, and speech patterns. Mirroring, however, must be genuine to be effective (Wayne, 2023; Ernstmeyer & Christman. 2022).

CLARIFYING

Clarifying involves seeking information to make clear that which is not meaningful or that which is vague in order to avoid making assumptions that understanding has occurred when it has not. It is the ability to reflect back to the speaker the words and feelings expressed in order to ensure that they have been understood correctly and that both the speaker and listener agree on a true representation of what has been said.

Examples:

• Listener: “I am not quite sure I understand. Can you tell me …?”
• Listener: “Do you mean that …?”
• Listener: “Are you telling me …?”
• Listener: “Are you saying …?”
• Listener: “Have I heard you correctly?”

Clarifying uses restating and paraphrasing to show an understanding of what the speaker has said and to help the speaker evaluate feelings by hearing them expressed by someone else.

Restating is repeating the main idea expressed in approximately or nearly the same words the patient has used, while paraphrasing involves the use of other words to reflect back to the speaker what has been said. When paraphrasing, it is essential that the listener does not ask questions, is nondirective, and is nonjudgmental. It shows the speaker that the listener is attempting to understand what has been said.

Examples:

• Speaker: “I don’t sleep. I stay awake all night.”
• Listener (restated response): “You don’t sleep, you stay awake all night.”

or

• Listener (paraphrased response): “You have difficulty sleeping.”

When restating and paraphrasing, it is important to observe for nonverbal and verbal cues that confirm or refute the accuracy (Videbeck, 2020).

EMOTIONAL LABELING

During a mental health crisis, a person’s feelings may often be confusing and hard to define. Some people experience greater difficulty labeling their emotions than others do. The less aware a person is of their emotions, the less likely they may be able to regulate them.

Emotional labeling allows the listener to apply a tentative label to the feelings the person is expressing or implying by words and actions. Labeling emotions lets the speaker know they are being heard and helps the person make sense of their emotions and gain some control. The simple act of thinking about and then labeling an emotion can distract from and disrupt the intensity. It is important not to assume one knows how another person feels. It is helpful to ask if a label is correct.

Examples:

• Listener: “You sound very frustrated. Is that right?”
• Listener: “Am I correct in saying that you feel overwhelmed by everything?”
• Speaker: “I’m stuck out in the middle of the ocean.”
• Listener: “You’re feeling alone or deserted. Is that true?”

It is important that the speaker’s emotions are validated and not minimized. Labeling and acknowledging emotions help to restore equilibrium (Ernstmeyer & Christman, 2022; Videbeck, 2020).

PROBING SKILLS

Probing skills involve questioning, and the most useful forms of questions are open-ended. These types of questions encourage exploration and begin with probing words such as when, what, where, how, or who. They elicit more and fuller information than closed-ended questions by requiring more than a simple yes or no answer. The use of open-ended questions encourages the individual to continue to talk. It is also important to avoid “why” questions, as they may be interpreted as accusations, resulting in the person feeling defensive. Why questions may also imply that the person should know something that they may not know.

Examples:

• Listener: “What were you thinking/feeling?”
• Listener: “How did you act?”
• Listener: “When did that happen?”
• Listener: “Where did you go afterward?”
• Listener: “Whom did you go with?”
  (Ernstmeyer & Christman, 2022)

EFFECTIVE PAUSES/SILENCE

Part of effective communication includes the use of silence and waiting or pausing before speaking. The listener does not verbally respond after the person makes a statement, although they may nod or use other nonverbal communication to validate the person’s message. Silence allows the person to take control of the discussion. Most people are not comfortable with silence and will talk in order to fill it. Therefore, a period of silence may encourage a person to continue speaking. Silence can also be used to emphasize a point just before or just after saying something important (Erstmeyer & Christman, 2022).

“I” MESSAGES

“I” messages can be used to convey feelings, concerns, needs, and expectations without making the other person feel attacked. “You” messages tend to put people in defensive positions, whereas an effective “I” message places the responsibility and focus on the communicator instead of the recipient. “I” messages allow people to know in a nonthreatening way how the other person feels, why they feel that way, and what the patient can do to remedy the situation. Clinicians use this technique to refocus the patient or when the clinician is being verbally attacked.

Examples:

• Listener: “I feel uncomfortable when I’m spoken to that way. Please don’t yell at me.”
• Listener: “I need to better understand what I heard you say. Tell more about that.”

Fogging is a related empathic technique used to slow down a potentially explosive situation. It is a way to accept critical remarks by using “I” messages. When a patient is being critical, the listener accepts the criticism, or part of the criticism, even if it is untrue and repeats it back to the speaker.

Example:

• Speaker: “You’re so stupid!”
• Listener: “Yes, I can see that you don’t think I’m that smart.”

The word yes takes the person by surprise, slows them down, and reduces tension. The listener is not agreeing that they are stupid; rather they are acknowledging that the speaker thinks so (Ernstmeyer & Christman, 2022; Revolution, 2023).

SUMMARIZING

Summarizing involves restating major ideas expressed, including feelings. Progress is reviewed, and important ideas are pulled together. Summarizing establishes a basis for further discussion. Summarizing offers the person permission to make corrections if they feel that is necessary.

Example:

• Listener: “These seem to be the main ideas you’ve expressed.”
  (O’Bryan, 2022)

Theories and Models of Crisis Intervention

A model is used to describe the application of a theory to a crisis situation. It is the conceptual framework for all aspects of preparing for, preventing, coping with, and recovering from a crisis. By viewing events through a model, crisis counselors are able to make contact with a person and to better apply best practices.

THEORIES OF CRISIS MANAGEMENT

Theories of crisis management include:

• System Crisis Theory: States that all crises have to do with the relationships people have with one another or their relationship to a traumatic event
• Adaptational Theory: Implies that a person who can change their negative attitude toward a situation can overcome their crisis
• Interpersonal Theory: Encourages people to gain personal control of a situation rather than relying on others for support or validation
• Ecological Theory: Deals with crises on a massive scale, usually resulting from a natural disaster, and considers the impact of the crisis on people as well as their environment
  (Hull, 2023)

MODELS OF CRISIS INTERVENTION

Common elements of crisis counseling are part of all models of crisis intervention. These include:

• Assessment of the person’s current situation. This is done by asking questions and actively listening to the person’s responses in order to define their problem. It is important for the counselor to be empathic, accepting, and supportive during this process.
• Education to help the person to understand their situation and recognize that what they are experiencing is normal. The counselor emphasizes that a person’s reaction is temporary and that they will eventually be able to return to normal functioning.
• Developing an action plan for the person to deal with the crisis. This involves developing a set of skills, including stress relief and positive thinking, that the person can use now and in the future.
• Offering nonjudgmental support. This is the most important part of crisis intervention. The person must know they are accepted and feel reassured that they will get the help they need, whether directly from the person intervening or through referral to other resources.
  (Hull, 2023)

There are many crisis intervention models available for the crisis counselor to utilize, all of which abide by the following common principles:

• Simplicity: People in crisis respond best to simple measures; these have the best chance of having a positive effect.
• Brevity: Psychological first aid needs to remain short, from minutes up to one hour in most cases.
• Innovation: Creativity is important since specific instructions do not exist for every case or circumstance.
• Pragmatism: Impractical suggestions can cause the person to feel more frustrated and out of control.
• Proximity: The most important thing about proximity is that support must be given in a safe zone.
• Immediacy: Crises demand rapid interaction, and delays can undermine the effectiveness of support services.
• Expectancy: Setting up expectations of a reasonable positive outcome helps the person know that, although the situation is overwhelming right now, most people can and do recover from crisis experiences.
  (Grace College, 2020)

INTERVENTIONS

SAFER-R

One of the most commonly used interventions, SAFER-R helps patients return to their mental baseline following a crisis. It is based on the same principles as other methods but outlines them in a more concise manner (see table below).

SAFER-R MODEL

Element	Description
(Wang & Gupta, 2023)
S – Stabilize	Introduce oneself, establish rapport, meet basis needs, and reduce stressors.
A – Acknowledge	Allow the person to tell their “story.”
F – Facilitate understanding	Frame reactions as normal; reinforce cognitive processing.
E – Encourage adaptive coping	Assess the person’s ability to function; explore and identify coping skills; develop a plan for immediate action.
R – Restore functioning	Assess emotions, appearance, alertness, and speech.
R – Referral	As appropriate

ABC

ABC model of crisis intervention involves practices that use reframing of perception of events. By helping a person to change the way they see the event, a crisis worker can do the work of intervention in a short amount of time (see table below).

ABC MODEL

Element	Description
(Lyons, 2023)
A – Develop a strong rapport	Use basic active-listening skills
B – Identify the nature of the crisis and alter perceptions (the most important phase of the crisis intervention model)	Identify the precipitating event, the person’s perspective of the event, subjective distress, current and previous functioning Provide new ways for the person to think about, perceive, and process the information
C – Offer coping skills	Encourage and listen to the person’s ideas for coping before offering one’s own ideas Plan for follow-up of some type

Robert’s Seven-Stage Crisis Intervention Model (R-SSCIM)

Robert’s intervention model identifies seven stages a person will usually pass through on the way to stabilization, resolution, and mastery (see table below).

R-SSCIM

Stage	Description
(Black & Flynn, 2021; & Nalbo, 2020)
1. Psychological and lethality assessment	Using an interviewing style that allows information to come out as a narrative, assess the situation and determine if there is any risk of lethality or imminent danger. A quick psychosocial assessment is completed, which includes: Environmental support and client stressors Medical needs and medications Current use of drugs and alcohol Internal and external coping methods The person’s suicide history Presence of suicidal thoughts and feelings Strength of psychological intent to inflict deadly harm Access to a means of self-harm, such as drugs or a firearm How lethal the suicide plan is Whether the person is in imminent danger as a target of domestic violence, a violent stalker, or sexual abuse In cases of imminent danger, emergency medical or police intervention is often necessary. (See also “Assessing for Risk of Harm to Self or Others” below.)
2. Make contact and establish rapport	To establish rapport, a sense of genuine concern, care, respect, and acceptance of the person must exist. This requires behaviors and traits of the crisis counselor to help create a sense of trust. Some prominent strengths include: Good eye contact Nonjudgmental attitude Creativity Flexibility Positive mental attitude Reinforcing small gains Resiliency
3. Identify the major problems or crisis precipitants	Crisis intervention focuses on the person’s problems that led to the current crisis, prioritizing the problems to be addressed and determining how the situation escalated to become a crisis. This also aids in understanding the person’s coping style.
4. Deal with emotions and feelings	During this time, a crisis worker allows the person to express feelings and explain their story about the current crisis. The crisis counselor relies on active listening skills, gradually working challenging responses into the dialogue. Responses can include giving information, reframing, interpretations, and playing “devil’s advocate.” In this role, examples can be used to draw different insights and conclusions. Challenging responses help to loosen the person’s maladaptive beliefs and consider other behavioral options.
5. Generate and explore alternatives	This stage is often the most difficult to accomplish. If stage 4 has been achieved, the person in crisis has probably worked through enough feelings to re-establish some emotional balance. This is the time to offer the person options and to collaborate on determining what will work for them. It is important to keep in mind that alternatives are better when they are generated collaboratively and “owned” by the person.
6. Implement an action plan	At this point, strategies become integrated into an empowering treatment plan or coordinated intervention, The action plan taken at this stage is critical for restoring the person’s equilibrium and psychological balance. Another aspect to this stage is the cognitive dimension, which involves making some meaning out of the crisis event by asking questions such as, “Why did it happen? What does it mean? Who was involved? How did actual events conflict with expectations? What responses (cognitive or behavioral) to the crisis made things worse?” Working through the event is important in order to gain mastery over the situation and for being able to cope with similar situations in the future.
7. Follow-up	Follow-up contact with the person after the initial intervention is done to ensure the crisis is on moving toward resolution and to evaluate the post-crisis status of the person. This evaluation can include: Physical condition of the person (e.g., sleeping, nutrition, hygiene) Cognitive mastery of the precipitating event Assessment of overall functioning (social, spiritual, employment, academic) Satisfaction and progress with ongoing treatment Any current stressors and how those are being handled Need for possible referrals

Assessing for Risk of Harm to Self or Others

Individuals experiencing a mental health crisis are always assessed for the risk of harm to self or others. In a facility setting, the routine practice of asking all patients to undress and don a gown serves as a nonconfrontational way to search for weapons.

The patient interview setting should be private but not isolated. The patient and clinician may be seated roughly equidistant from the door, or the clinician may sit between the patient and the door. The patient, however, should not sit between the clinician and the door. Ideally, two exits should be available, and doors should swing outward. The clinician should have unrestricted access to the door and should never sit behind a desk (Moore & Moore, 2023).

ASSESSING RISK FOR SUICIDE

The purpose of a suicide risk assessment is to determine a patient’s risk and protective factors, with a focus on identification of targets for intervention.

A suicide risk assessment includes:

• Performing a clinical evaluation
• Identifying risk-enhancing factors
• Identifying risk-reduction factors
• Employing clinical judgment

Different kinds of organizations and settings may use different screening tools. The following table lists examples of validated, evidence-based screening tools:

SUICIDE RISK ASSESSMENT TOOLS

Tool	Setting	Questions/Areas Addressed
(ZeroSuicide, 2022)
Columbia-Suicide Severity Rating Scale (C-SSRS) Screening Version	For all ages in general healthcare settings; used by individuals trained in its administration	Suicidal ideation Intensity of ideation Suicidal behavior Actual suicide attempts
Suicide Behavior Questionnaire-Revised (SBQ-R)	Self-report questionnaire for use in ages 13 to 18	Lifetime suicide ideation and/or suicide attempt Frequency of suicidal ideation over the past 12 months Threat of suicide attempt Self-reported likelihood of suicidal behavior in the future
Ask Suicide-Screening Questions (ASQ)	For patients ages 10 to 24 in emergency departments, inpatient units, and primary care facilities	“In the past few weeks, have you wished you were dead?” “In the past few weeks, have you felt that you or your family would be better off if you were dead?” “In the past week, have you been having thoughts about killing yourself?” “Have you ever tried to kill yourself? If yes, how?”
Patient Safety Screener-3 (PSS-3)	Validated for those ages 18 and older; consists of three items (with one follow-up question depending on the patient’s response to the third item)	“Over the past 2 weeks, have you felt down, depressed, or hopeless?” “Over the past 2 weeks, have you had thoughts of killing yourself?” “In your lifetime have you ever attempted to kill yourself?” If yes, “When did this happen?”

Once it has been established that an individual is having suicidal thoughts or has attempted suicide, a complete assessment of suicidal thinking and behavior, including the nature and extent of the risk, should be obtained (ZeroSuicide, 2022).

ASSESSING FOR RISK FOR HARM TO OTHERS

The risk for harm to others increases in adolescence, with a peak from late teens to early 20s, then a dramatic reduction in the late 20s and a slow reduction until the 60s, when there is another dramatic reduction. A history of violence or risk to others is vitally important to ascertain. It is also important to remember that some risks are specific with identified potential victims (RCPsych, 2020).

Risk assessment tools provide a standard against which to evaluate individuals for potential harm to others, enabling all healthcare providers to share a common frame of reference and understanding. One such tool is described in the box below.

ASSAULT AND HOMICIDAL DANGER ASSESSMENT TOOL

Key to Danger	Immediate Dangerousness to Others	Typical Indicators
(CDC, 2020b)
1	No predictable risk of assault or homicide	No assaultive or homicidal ideation, urges, or history of same Satisfactory support system Social drinker only
2	Low risk of assault or homicide	Occasional assault or homicidal ideation (including paranoid ideas), with some urges to kill No history of impulsive acts or homicidal attempts Occasional drinking bouts and angry verbal outbursts Satisfactory support system
3	Moderate risk of assault or homicide	Frequent homicidal ideation and urges to kill but no specific plan History of impulsive acting out and verbal outbursts while drinking, on other drugs, or otherwise Stormy relationship with significant others Periodic high-tension arguments
4	High risk of homicide	Has a homicidal plan and available means History of substance abuse Frequent acting out against others but no homicide attempts Stormy relationships and much verbal fighting with significant others Occasional assaults with significant others
5	Very high risk of homicide	Has a current high-lethality plan Available means History of homicide attempts or impulsive acting out Feels a strong urge to control and “get even” with a significant other History of serious substance abuse Possible high-level suicide risk