Crisis Intervention Trauma and Intimate Partner Violence

Robert E. Feinstein and Abby Snavely

Chapter contents

Development of Crisis Intervention, Trauma,

Ecological Map

1031

and Disaster Theory

1022

Problem-Focused or Symptom-Oriented Treatment

1031

Historical Considerations

1022

Coping Skills and Adaptive Problem Solving

1032

Current Understanding of the Crisis

1023

Crisis Resolution Strategy

1032

Intimate Partner Violence

1023

Intimate Partner Violence Approach

1032

Evaluating the Crisis or Disaster

1025

General Recommendations

1033

Normal Equilibrium State and Stressors

1025

Screening

1033

Crisis State

1026

Treatment of Intimate Batterers

1033

Acute Crisis Resolution and Adaptation to the Crisis (Within 6 Weeks)

1027

Couples

1033

Sequelae of Crisis, Trauma, or Disaster (6 Weeks to Lifetime)

1027

Safety Planning

1034

Previous Psychiatric Illness or Personality Disorder

1027

Documentation and Reporting

1034

Selective Past History

1027

Other Trauma Treatments

1035

Crisis Intervention Treatment in the Office Setting

1029

Medications for Symptoms of Psychiatric Disorders

1035

Basic Approach

1029

Conclusion

1036

Timeline

1030

encouragement of the patient to return to normal daily functioning as soon as possible. A crisis typically last 6 weeks and can resolve spontaneously. Crisis resolution depends on the severity of the crisis, personal reaction, support system, and effects on the community.

• A crisis is a brief psychological upheaval, precipitated by a stressor, resulting in an inability to cope, adapt, or function in daily life.

• A crisis may resolve with improved functioning, a return to baseline, or may be stabilized at a lower level of functioning.

Family medicine physicians are frequently asked to assist a patient who is in a crisis, whether a life-threatening illness, intimate partner violence, suicide attempt, job loss, loss of insurance, depression, panic attack, or bipolar episode. In this emotional state of crisis, the patient feels panicked, helpless, and overwhelmed and cannot perform basic activities involving work, family relations, and even daily living. Urgent safety concerns surround patients with acute medical conditions, as well as those with suicidal ideation and victims of violence. Many family physicians feel unprepared to offer patients practical help during a general office visit.

The crisis intervention approach provides both a theory and a treatment model that can be readily applied to patients in crisis or to victims of intimate partner violence. This chapter describes the general principles of crisis intervention theory and treatment, as well as crisis evaluation and treatment of intimate partner violence, which is a pervasive and often underrecognized public health problem.

Development of Crisis Intervention, Trauma, and Disaster Theory

Historical Considerations

• Crises can be effectively treated. Three core principles of crisis treatment are (1) the expectation that the patient will recover, (2) the provision of immediate treatment, and (3) the encouragement of the patient to return to normal daily functioning as soon as possible. A crisis typically last 6 weeks and can resolve spontaneously. Crisis resolution depends on the severity of the crisis, personal reaction, support system, and effects on the community.

• A crisis is a brief psychological upheaval, precipitated by a stressor, resulting in an inability to cope, adapt, or function in daily life.

• A crisis may resolve with improved functioning, a return to baseline, or may be stabilized at a lower level of functioning.

Thomas Salmon (1917), a British military physician during World War I, was asked to evaluate severe "shell shock" (traumatic neurosis), which was producing psychological paralysis in Allied soldiers. In this first medical description of the psychological effects of war, Salmon noted that French soldiers suffered fewer psychological casualties than British soldiers. Three factors seemed to account for the French advantage: (1) French soldiers were told that they could expect to recover from their psychological traumas; (2) soldiers received immediate psychological treatment, close to the battlefront; and (3) soldiers were returned to battle as quickly as possible. These principles became the cornerstone of modern crisis theory and disaster management strategies. Patients entering crisis treatment can expect to be treated immediately, in their natural environments, with an expectation that they will recover from the crisis or disaster. Efforts should be made to return patients to their normal life and community as soon as possible.

Eric Lindemann (1944) applied and expanded Salmon's theories. He studied the acute grief reactions of persons who lost family members in the Coconut Grove fire in Boston, which claimed 500 lives. Lindemann discovered that normal

Key Points people surviving such a horrific experience would develop an emotional crisis of pain, confusion, anxiety, and temporary difficulty in daily functioning. Also, he discovered that the psychological trauma caused by the crisis had little relation to preexisting psychopathology, and that only a small group of the victims declined to a lower level of functioning. Generally, the outcome of the crisis was most closely related to the severity of the stressor, personal reaction to the trauma, effect of trauma on the person's family and friends, and degree of community disruption. Lindemann found that most crisis survivors recovered spontaneously within 6 weeks.

Erik Erikson (1959), a sociologist, introduced the idea of a life cycle composed of developmental stages and developmental crises. His eight stages were seen as normative processes during which age-specific psychological tasks, transitions, and crises were routinely encountered. A difficulty or inability to negotiate a stage successfully affects the ability to progress to the next stage. For example, an adolescent seeks an adult identity and redefines social roles that emphasize peer relationships and increasing autonomy from parents. Those who do not successfully traverse adolescence develop a childlike dependence on parental figures and often have difficulty developing a career, getting married, or developing autonomous social relations.

Other crisis practitioners have expanded Erikson's basic concept of eight developmental crises to include other crises such as leaving home for the first time, the midlife crisis, and parents' experience of the "empty nest syndrome." For many patients, a transition from one life phase to the next, such as marriage, divorce, retirement, or an illness, may bring the potential for a new developmental crisis.

Gerald Caplan (1961, 1964) synthesized many of these earlier ideas into modern crisis theory and treatment. He defined the crisis state as a brief, personal, psychological upheaval precipitated by a stressor, or "hazard." A precipitant produces emotional turmoil so that the person is temporarily unable to cope, adapt, or function in daily activities. Caplan demonstrated that a crisis implies the potential for danger and an opportunity for growth. Although subscribing to Linde-mann's theories of acute precipitants, Caplan believed that a person's preexisting psychiatric condition could influence the development, evolution, and resolution of a crisis. A crisis may be based on the failure of a person's individual coping style and ability to adapt. Caplan confirmed that most acute crises resolve in about 6 weeks, with four possible outcomes: improved functioning, functioning restored to precrisis levels, incompletely restored functioning with a susceptibility to the development of future crises, or a severely impaired but stable level of lower functioning. He corroborated Lindemann's findings that some people cope with a crisis by spontaneously and flexibly developing new coping or problem-solving styles. Caplan developed a crisis treatment focus on development of better coping mechanisms and adaptations to life's traumas.

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