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Subject:
Crisis intervention (Psychiatry) (Study and teaching) Social work education (Methods)
Education (Methods) Authors:
Gelman, Caroline Rosenthal Mirabito, Diane M.
Pub Date:
09/22/2005 Publication:
Name: Journal of Social Work Education Publisher: Council On Social Work Education Audience: Academic; Professi onalFormat: Magazine/Journal Subject: Education; Sociology and social work Copyright: COPYRIGHT 2005 Council On Social Work EducationISSN: 1043-7797
Issue:
Date: Fall, 2005 Source Volume: 41 Source Issue: 3 Topic:
Event Name: World Trade Center and Pentagon Attacks, 2001 Geographic:
Geographic Scope: United States Geographic Code: 1USA United States Accession Number:
139433531 Full Text:
THE INCREASINGLY SIGNIFICANT LEVEL OF TRAUMA and
crisis in the populations traditionally served by social workers, coupled with the challenges we have faced from the events of September 11 and the subsequent war on terrorism (see, for example, Galea, Ahern, Resnick, Kilpatrick, Bucuvalas, Gold, & Vlakov, 2002), support the critical need for classroom instruction that prepares students to
respond immediately to multiple-client systems in crisis (Graziano, 2001; J. Miller, 2002a). Studies of social work field training concur that the growing challenges of contemporary practice require social workers to assume a variety of roles and intervene at multiple levels with people who are experiencing severe psychosocial stressors and crises (Bocage, Homonoff, & Riley, 1995; Jarman-Rohde, McFall, Kolar, & Strom, 1997; Plionis, Bailey-Etta, & Manning, 2002; Reisch & Jarman-Rohde, 2000).
This paper provides social work educators with both a conceptual framework and rich practice vignettes that integrate key theoretical aspects of generalist practice and crisis intervention for teaching social work students intervention with individuals, families, groups, organizations, and communities in situations of crisis and disaster. This framework will be applied to vignettes of social work practice undertaken by the authors, their students, and colleagues following the events of September 11, 2001, in New York City. The authors first present and explain how key elements of
generalist practice and crisis intervention are integrated. They then apply this integrated approach to vignettes with client systems of all sizes from diverse socioeconomic and ethnic groups--ranging from college students to disenfranchised immigrants and disempowered employees--all of whom were affected by the events of September 11. Through these vignettes, the authors illustrate how key elements of generalist practice and crisis intervention are brought together so that social work students learn a model of intervention that they can apply in work with their clients who experience crises.
The generalist approach, mandated by the Council on Social Work Education (2001), provides a highly relevant framework for social work intervention in dealing with situations of crisis and disaster because it addresses all systems and levels of intervention, integrates practice, policy, and research, and is based on the fundamental social work tenet of "starting where the client is." Crisis intervention is an equally essential practice approach in these situations because of its immediate, active, and directive focus on restoring client systems to their previous level of functioning by capitalizing on the heightened motivation, capacity, and opportunity engendered by crisis (Ripple, Alexander, & Polemis, 1964).
Social work practice undertaken in response to the events of September 11 was chosen to illustrate how to teach crisis intervention from a generalist perspective for several reasons. Because everyone in this country experienced the events of September 11 either directly or indirectly, the practice vignettes provide compelling examples of the diverse roles generalist practitioners assume across micro, mezzo, and macro levels of intervention. The illustration of all three levels of practice is especially important, because as noted by Abel and Kazmerski (1994), an increased focus on micro-level practice in social work education has eroded macro-level curriculum content. Moreover, the use of vivid and contemporary examples to illustrate fundamental social work concepts and skills renders the material highly relevant and accessible to students (Carter, 2000; Fellin & Brown, 1989; Whipple, 2001). Finally, the use of examples of practice undertaken by classroom instructors allows educators to model what they are teaching, highlights for students the importance of integrating theory with practice, and underscores the crucial roles that social workers have assumed and can continue to take in response to situations of crisis and disaster (Anderson, Ressler, &
Wallace, 2002; Malekoff, 2001; J. Miller 2002b). Results of a recent survey indicate that students perceive instructors who have current practice experience as being more effective teachers and role models and report that these instructors engage in classroom behaviors that help students apply and integrate their classroom learning more successfully (Knight, 2002).
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The vignettes presented can be used to structure both didactic and collaborative, problem-based learning through discussion and role-plays in the classroom. This learning strategy allows for deep engagement with the material, leading to greater understanding and ability to apply critical concepts to other situations (Wilkerson & Gijselaers, 1996). In addition, instructors are encouraged to use examples from their own and their students' practice, which might include work with individuals, families, groups, and communities affected by natural disasters such as earthquakes and floods, man-made disasters such as arson, or violent crimes such as school shootings.
Key Elements of Generalist Practice and Crisis Intervention
As mandated by the Council on Social Work Education (2001), students are introduced to key elements of generalist social work practice (Kirst-Ashman & Hull, 1999; Miley, O'Melia, & DuBois, 2001; Poulin, 2000). These include:
1. The person-in-environment perspective as the theoretical underpinning guiding assessment and intervention.
2. Multiple levels of intervention--micro, mezzo, and macro--based on a thorough assessment.
3. The capacity to assume diverse roles, such as direct service provider, case manager, educator, program developer, advocate, and researcher, as indicated by the assessment of needs.
4. The integration of direct practice, policy, and research through the assumption of these multiple roles.
5. Practice conceptualized as consisting of five stages: Engagement, assessment, and the planning, implementation, and evaluation of interventions.
In keeping with these components of generalist practice, social workers view each situation in context and intervene at the different system levels affected using a wide repertoire of roles and skills. Rather than being constrained by a particular method or modality of intervention, such as individual or group counseling, the type and location of interventions is based on a careful assessment of needs. This process allows the practitioner to think broadly, flexibly, and creatively about practice.
To respond effectively to populations increasingly affected by psychosocial stressors, students are provided with a strong foundation in crisis intervention. The key elements of crisis intervention that are introduced include:
1. Definition of crisis as a state of acute emotional disequilibrium during which individuals are often more receptive and better able to utilize professional intervention (Hoff, 2001).
2. Delineation of the phases of a crisis: The hazardous event, vulnerable state, precipitating factor, state of active crisis, and reintegration or crisis resolution (Golan, 1978).
3. Discussion of common and expectable emotional, cognitive, physical, and interpersonal responses to trauma and of disorders that can occur as a result of trauma, such as post-traumatic stress disorder (PTSD) (Ell, 1996).
4. Immediate, active, and directive interventions such as education, clarification, and reassurance about normative, expectable reactions to trauma designed to reduce symptoms, provide support, and return clients to their highest possible level of functioning (Parad & Parad, 1990).
The Integration of Generalist Practice and Crisis Intervention
In applying crisis intervention skills from a generalist perspective, students are taught to intervene immediately, actively, and directively from a client-centered, problem-focused perspective, differentially applying a wide repertoire of skills at varying system levels depending on context, setting, and need. A person-in-environment perspective guides the practitioner to seek support for the client, be it an individual, family, group, organization, or community, not only from inner, but also environmental, resources.
In crisis situations, the practitioner intervenes at whatever level is necessary--micro, mezzo, or macro--to help the client system return to the previous state of equilibrium. The practitioner takes on multiple roles, including direct service provider helping clients express their emotions, educator providing practical information, case manager securing tangible support, and advocate or broker mobilizing available social and environmental systems. In carrying out these diverse roles, the social work practitioner may move from direct practice to developing policies and programs, identifying areas for further study, and subsequently undertaking needed evaluation and research (Padgett, 2002).
The five stages of generalist practice take on special characteristics in situations of crisis and disaster. Engagement, assessment, and the planning, implementation, and evaluation of interventions all occur in an expeditious manner so that prompt assistance is provided to the client, capitalizing on the window of opportunity afforded by the client's receptivity to helping efforts engendered by crises.
Students are trained to conduct a thorough and focused assessment of needs within the entire client system, identifying problems that require resolution, and determining at which levels of intervention change efforts should be planned and implemented. Specific skills taught include assessment of coping styles in previous situations of crisis, assessment of pre-existing vulnerable states, and the exploration of emotionally charged and difficult areas prevalent in crises, such as suicidality, grief, and loss. Finally, students are introduced to the concept of vicarious traumatization (O'Halloran & Linton, 2000; Ryan, 1999; Sexton, 1999) and taught about the importance of training, support, and supervision in mitigating its potential effects (Dane, 2002; Miller, 2001; Miller, 2002b; Tosone, Bialkin, Campbell, Charters, Gieri, Gross et al., 2003).
The primary goal of intervention in crisis situations is the reduction of symptoms and the strengthening of problem-solving strategies and effective coping. Interventions on both individual and collective levels focus on providing practical information, tangible support, and assistance to help people mobilize and further develop support systems.
The outcomes of interventions are assessed, monitored, and evaluated to identify individuals who may require more intensive professional assistance.
Teaching Crisis Intervention From a Generalist Perspective: Case Studies From 9/11
In the classroom, this integrative framework combining core principles of generalist practice and crisis intervention is illustrated for students through case studies of actual interventions undertaken by social workers with a variety of client systems in the aftermath of September 11. The remainder of this article presents practice vignettes at the micro level with individuals, families, and groups; at the mezzo level within a large organization; and at the macro level within the community. After a description of each case study, the authors provide a set of questions for classroom discussion that allow for exploration of potential ways of intervening in each situation. The actual interventions utilized are then presented, providing the class with opportunities to critically assess and evaluate practice outcomes.
In addition, we provide a set of teaching points highlighting salient concepts of generalist practice and crisis intervention that can be applied to vignettes generated by instructors' and students' cases. Students are asked to consider the forms of crisis that their clients, who are often members of vulnerable, disenfranchised, marginalized, or at-risk populations, experience in their daily lives and how crisis intervention using a generalist social work practice approach might serve them. The vignettes, questions for classroom discussion, and teaching points are all intended to maximize opportunities for didactic instruction, classroom discussion, and development of practice skills through the role-playing of different outcomes.
Micro Level Practice
Assessment and Intervention With Individuals: University Counseling Center
Ursula. Ursula, a 28-year-old Croatian graduate student, was brought to the counseling center by her professor 9 days after the attacks on the World Trade Center. Ursula presented in a state of acute anxiety and depression, stating that she was concerned she might hurt herself. Ursula had been hospitalized 3 days before September 11 because of a miscarriage. During her hospitalization, she experienced unexpected cardiac problems, for which she
was treated. Upon discharge, 2 days after the attacks, Ursula began to feel increasingly depressed, had nightmares about the attacks, and reported recurrent thoughts about hurting herself, including hearing voices that told her to harm herself.
Ursula had moved to New York City 5 years earlier from the former Yugoslavia, where she had experienced the effects of war for many years. In addition to recounting her memories of living in a war-torn country, Ursula reported that her father had physically abused her on a daily basis between the ages of 13 and 18. During the time of the abuse, Ursula made two suicide gestures, including ingestion of pills and an attempt to cut her wrists with a razor. At that time, Ursula was taken to an emergency room, but she did not receive any treatment for depression.
Classroom Discussion Questions
* How might the social worker engage Ursula and conduct a focused biopsychosocial assessment and mental status exam, including exploration of depression and suicidality?
* How would the social worker assess and intervene in relation to the effect of past trauma and current stressors on Ursula's functioning?
* How would the social worker determine the need for a psychiatric evaluation? What factors would be considered?
* How would the social worker develop a concrete plan for safety as well as a plan for Ursula to receive ongoing mental health services?
* How could Ursula's support system be mobilized and utilized?
Actual Social Work Interventions
The social worker engaged Ursula by communicating clear concern about her safety and well-being. She identified that the purpose of their meeting was to ensure Ursula's safety, assess her needs, and arrange for future services.
Concerned about the level of depression that Ursula was reporting, the social worker assessed not only the immediate crisis of her suicidality but also the history and course of her depression and other trauma she had experienced in the past. In addition, the social worker conveyed understanding and empathy regarding the hardship and distress Ursula had experienced recently as well as in the past.
Based on an assessment of current suicidal ideation, the social worker's first priority was to develop a safety plan by obtaining a verbal contract from Ursula that she would not harm herself. The safety plan specified the actions that Ursula would take if she again felt that she might hurt herself. These included speaking with her boyfriend about suicidal feelings and, if they persisted, having her boyfriend bring her directly to the hospital emergency room. In addition, the social worker discussed with Ursula her plan to consult with the center's psychiatrist about her depressive and suicidal symptoms so that she could help Ursula develop a follow-up plan. Having secured Ursula's agreement, the social worker consulted with the psychiatrist, who agreed to provide a full psychiatric evaluation the following day.
Ursula called her boyfriend and requested that he come to the counseling center to pick her up. Together, Ursula and the social worker reviewed with Ursula's boyfriend the safety and follow-up plans that they had jointly developed, which included a complete intake evaluation with a social worker and a psychiatric evaluation scheduled for the next day.
Teaching Points
* The development of skills in:
rapid engagement and assessment of: depression, suicidality, abuse and neglect, mental status, imminent risk and safety, and client's current and past functioning;
working collaboratively with the client to thoroughly assess needs, develop a concrete safety plan, mobilize their support system, and provide referrals for future ongoing concrete and mental health services;
interdisciplinary collaboration, including how to determine the need for a psychiatric evaluation and consult with a psychiatrist regarding the client's medical and psychiatric needs.
* The importance of understanding how to assess the effect of past trauma on current functioning.
Assessment and Intervention With Families: Public School Setting
The Bell family. Emily, a 9-year-old in the fifth grade, was the only child in her elementary school to lose a parent in the World Trade Center attacks. Her father worked as an accountant in one of the financial companies. Emily has two younger brothers, Daniel, age 6, and Alex, age 4. Emily had been absent from school for 1 week following the attacks and upon returning she was aggressive and oppositional, fighting with her classmates and refusing to follow her teacher's directions. Emily's teacher had become increasingly impatient with her disruptive and attention-seeking behavior and by November requested that Emily be removed from her class.
When Emily's aggressive outbursts continued in a new classroom, the principal asked a school-based social worker to evaluate her. The social worker contacted Emily's mother to request permission to meet with Emily and also to assess how the family was coping with Mr. Bell's death. Mrs. Bell reported that despite support from her extended family, synagogue, and neighbors, she and the children were profoundly distressed. In addition, she was concerned about financial matters, as the family had been dependent on her husband's income.
Mrs. Bell was surprised that Emily was presenting behavior problems in school because at home she was sad and tearful, while Alex was exhibiting aggression. Moreover, Daniel, who had always been an anxious child, afraid of the dark, of being separated from his mother, and of going anywhere by himself, was expressing intense fears following September 11. Recently, Daniel had told her, "It's not fair that I'm never going to grow up to be a dad, and that everyone else will be big, but I am going to die." She had considered seeking help, as she was frightened and confused about the children's very different reactions and was feeling quite overwhelmed. Consequently, the social worker's phone call came at a propitious time.
Classroom Discussion Questions
* As a generalist practitioner, how would you define the client system in this case? What systems have been affected by the events of September 11? At what level(s)--micro, mezzo, macro--would you intervene?
* How would you engage and assess the family system? In conducting a comprehensive family assessment, what other information would you want to know about the strengths and needs of the family? How would you address both emotional and concrete concerns for family members? Using a person-in-environment perspective, what potential sources of support are available to the Bell family?
* If you were the school social worker, how would you assess and intervene within the school? Why? How might the school social worker have intervened with Emily's teacher and other teachers in preparation for Emily's return to school?
* What generalist social work roles does the social worker assume in this case?
Actual Social Work Interventions
The social worker met with the family over several sessions to conduct an assessment of the family system. During the course of the assessment, she normalized the wide range of responses Mrs. Bell and her children had to this extremely traumatic event. The social worker referred the Bells to a community mental health center for family counseling and a support group for families affected by September 11. In addition, Mrs. Bell gave permission for