Psychiatric Annals

The articles prior to January 2011 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

Crisis Theory: a formulation

Ralph G Hirschowitz, MB, ChB

Abstract

1. Hansell, N.; Wodarczyk, M. and HandlonLathrop, B. Decision counseling method: Expanding coping a! crisis m transit. Archives of General Psychiatry 22:5 (May, 1970), 462-467.

2 Hirschowitz, R. G. Two Psychiatric Hospitals in Transition: Studies of Staff Behavior. Mimeo: Laboratory of Community Psychiatry, Harvard Medical School, September. 1972 (accept for publcation by Hospital and Community Psychiatry).

3. Kubler-Ross, E On Death and Dying. New York: Macmillan. 1969.

4. Lindemann, E. Symptomatology and management of acute grief. American Journal ot Psychiatry 101 (1944), 141-148.

TABLE 1*

RATING LIFE CHANGES

TABLE 2

CRISIS SEQUENCE…

Crisis theory, like general systems theory, is a basic conceptual tool in preventive mental health work. The study of what happens during a crisis has advanced our understanding of personality development and change, and models derived from crisis theory can illuminate many issues of development and adaptation in more complex units such as the family and the organization.

In mental health work, crisis is regarded as a state of temporary disequilibrium, precipitated by inescapable life change events. Crises are by definition temporary because personality systems are self-sealing, tending to correct for crisis-induced imbalance in a few weeks. Disequilibrium refers todisruptionof theusual steadystate pattern, when the organism has to respond to internal or external change. This general pattern disruption is manifested by cognitive uncertainty, psychophysiological symptoms, and emotional distress.

LIFE CHANGES

The life changes that give rise to crises may be easily identified or quite elusive. Sometimes apparently insignificant precipitating events are symbolically linked to unresolved conflicts, amplifying and distorting the response to present events. The state of crisis may also occur before the change actually occurs, in anticipation of it. Past, present and future may thus blur in predisposing to, precipitating, and perpetuating the crisis.

As shown in Table 1, life changes which produce crisis usually occur in relationships with significant other human beings. For crisis to occur, a "no exit" situation is required - the demand for change must, by definition, be inescapable. The situation can neither be changed nor avoided. The signs of crisis mean that the individual has a relatively inadequate set of coping skills to master the demands for life change; the more adequate his coping capacity, the fewer are the signs of crisis that will occur.

An adequate coping repertoire is both general and specific. Low vulnerable individuals have the capacity, similar to ego strength, to orient themselves rapidly and plan decisive action in response to change. They can mobilize emergency problem-solving mechanisms and use external resources for assistance. High vulnerable individuals, on the other hand, become rapidly disoriented when confronted with change. They may experience paralysis of thought or will, unable to plan action or seek assistance. Specific coping skills derive from previous experience with similar problems; unfortunately, situation-specific skills do not generalize well to dissimilar situations, and the number of identical crises in an individual's life is small. This reflects the old truism that as soon as you learn to do something well, you do not need to do it any more.

DESCRIPTION OF THE CRISIS STATE

Crises occur in such times of immediate or anticipated transition as the developmental crises described by Erikson and the accidental or situational crises described by Caplan and Lindemann. It also includes Rapoport's "critical role transitions" and the "transition states" described by Tyhurst. Crisis affects many dimensions of human function; cognitive, emotional, volitional and interactional patterns are all disrupted. Psychophysiological and appetite patterns alter, and habituai defense patterns may be exaggerated to the point of parody.

Cognitively, there is uncertainty, impaired concentration, and preoccupation with the past. Illusory perception is common, as are slips of the tongue and cognitive slippage. Emotional responses become labile and include fear, nervousness, tension, fatigue, hostility and depression. Use of habitual defenses or tension-reducing behavior indicates the anxiety that is present, either overt or covert. Ambivalence may paralyze the will to the point of total indecision.

Behavior lacks habitual balance and perspective. Interaction with others is influenced by increased dependency needs. Some individuals who tend towards counter-dependent behavior may exhibit withdrawal-avoidance, while others may display dependence to such an extent that it is mislabeled "regressive" - particularly when it is expressed by demanding or clinging behavior.

Any change process involves the promise of gain and the certainty of loss. Loss may be experienced in relationship to people, objects, physical health, social status or values, and always habitual attachments and orientations are lost while new attachments are being worked out. In understanding and mastering the change process, therefore, a comprehension of the dynamics of loss is important. A paradigm is provided by Kubler-Ross' studies of death and dying/' She describes a predictable sequence in response to news of fatal illness, proceeding through overlapping phases of shock, denial, anger, bargaining, depression and acceptance. In studying sudden deaths, Lindemann1 has described the dazed state, physiological disruption, preoccupation with the image of the deceased, emotional distress and guilt of the mourner.

Table

TABLE 1*RATING LIFE CHANGES

TABLE 1*

RATING LIFE CHANGES

The two overlapping processes in crisis have been captured by the Chinese ideogram which depicts crisis as danger-plus-opportunity. Danger refers to the pain attending detachment from what is lost or about to be lost, while opportunity refers to the process of reconstructing a new world of activities and relationships. These processes are inextricably wed, since evidence suggests that the construction of a new universe of objects and attachments cannot be successfully achieved until the mourning process has been substantially completed.' Crisis intervention thus requires a focus on detachment in the early phases of crisis, and upon reconstruction and re-attachment in the later phases.

Table

TABLE 2CRISIS SEQUENCE

TABLE 2

CRISIS SEQUENCE

THE CRISIS SEQUENCE

Many authorities, including CapIan, Bowlby, and Tyhurst, have described the phases of crisis. We have synthesized their descriptions to evolve a sequence consisting of impact, recoil-turmoil, adjustment and reconstruction.

Duration of phases. Impact is a state of dazed shock accompanying the assimilation of distressing news, most intense when the change is undesired and unexpected. Its duration varies from a few hours to a few days. It is followed by recoil-turmoil which continues for one to four weeks; the task of eventual reconstruction may require many months for completion.

These time periods are of course approximate, influenced in any individual case by the forces within the personality, the subjective meaning of the life-change event, and the availability of external assistance.

During the impact phase the individual is numbed, existing in Time Present. As he assimilates the news, he is preoccupied with Time Past, absorbed with what has been and mourning for a world now permanently changed. As detachment tasks are completed, he begins to explore new relationships and test solutions to the problems that confront him. The perspective then moves towards Time Future.

The emotional state. Certain emotions occur with predictable regularity. In the impact phase, the individual is propelled by emergency fight-flight responses; caught between these, he may show "frozen" behavior. In the phase of recoil-turmoil, emotions include rage, anxiety, depression, guilt and shame, which may be expressed (by weeping, open anger, deliberate intoxication, etc.) or concealed behind facades of over-control, detachment, and busy attention to other aspects of life. When the individual moves towards adjustment and reconstruction, his painful feelings become muted, and are gradually tempered with hope about the future. He begins to feel within himself: "All is not lost" and "Life must go on."

Cognitive patterns. During impact, the individual is disoriented and distractable. The level of consciousness fluctuates; dysmnesia, disorientation, perplexity and impaired perception all may occur. In severe crises, an acute brain syndrome may be mimicked. As the individual moves through recoilturmoil, his mental activity becomes more focused and normal cognitive functions return.

HEALTHY AND UNHEALTHY CRISISCOPING

The individual who copes well has at least some of the following characteristics:

- He is able to deal simultaneously with both the affective dimensions of his experience and the tasks which confront him. He is aware of his painful emotions and gives them appropriate expression, but he does not engage in interminable catharsis or ventilation. As he expresses his pain, he frees energy for mastery of his environmental challenges. Crisis mastery proceeds by the conversion of uncertainty into manageable risk. We consider this process of situational mastery to be crucial. When the life change is anticipated, this "intelligent worry work" can begin in advance, with significant diminution of the intensity of crisis. Programs of "anticipatory guidance" or "emotional prophylaxis" incorporate these principles of anticipatory planning and action rehearsal.

- He has the ability to acknowledge his increased dependency needs and to seek, receive and use assistance.

- He can tolerate uncertainty without resorting to impulsive action.

- He values the active mastery of environmental challenges and recognizes their value in understanding and personal growth.

- In coping with anxieties, he uses defenses and modes of tension relief which do not have destructive consequences.

The person who copes badly, on the other hand, has some or all of these traits:

- He exhibits excessive denial, withdrawal, retreat or avoidance, with fantasy replacing or merging with reality.

- His behavior is often impulsive, and he ventilates his rage on vulnerable, relatively powerless family members who lend themselves to being scapegoats.

- He meets his dependency needs by excessive clinging or counter-dependent avoidance of assistance. These patterns resemble the behavior of separated infants described by Bowlby as "protest-despair" or "detachment." These actions are either annoying or indicate to others that the individual neither wants nor needs help; thus they do not usually evoke ministration responses from others.

- He denies and over-controls his emotions, with eventual eruption of suppressed feelings.

- His malcoping may assume the form of the "hopelessness-helplessness-giving up" syndrome described by Engel and his co-workers.

- He may resort to hyper-ritualistic behavior which serves little or no purpose.

- His rest-work cycle is poorly regulated, due to the inevitable fatigue of the crisis state.

- He may rely on "magic by mouth," with recourse to pain-reducing substances such as drugs or alcohol, or an addictive pattern of compulsive food intake.

- He cannot ask for help, or use it when it is offered.

OPPORTUNITY FOR DEVELOPMENT: CRISISASTHELEVER

Caplan has emphasized that crisis is a state of dis-integration in which habitual patterns become blurred. When re-integration occurs, it may be at a higher level of personality expansion or a lower level of personality restriction. Healthy outcomes depend on active confrontation and mastery of the crisis. Crises, both developmental and situational, thus provide leverage points to promote personality expansion.

In crisis, personality and family systems become more open, with their boundaries more permeable. The individuals become temporarily more dependent upon others for understanding, emotional support, and guidance in solving real, identifiable problems and finding innovative solutions. The experience of successful coping builds ego strength and confidence about dealing with future crisis situations. And unless the crisis is one that is socially censured, there is little or no "shame tax" to be paid for seeking help from others.

Helping agencies can be especially effective when they provide timely intervention in crisis, because they can achieve significant outcomes without major resource investments. Fortunately skills in crisis intervention are not restricted to professional specialists. The requisite skills seem to include sensibility, sensitivity, calmness and confidence. Mature individuals, professional or lay, can also draw on their own experience and conventional social wisdom in order to provide help in crisis.

CRISIS INTERVENTION

This article is primarily an introduction to crisis theory; we have not emphasized its application to practice. However, theory serves practice, and our ventures in crisis counseling modify and advance theory. We therefore conclude by sharing some of what we have learned about intervention.

The goal of crisis intervention is to promote mastery, which should lead to action directed towards the tasks generated by environmental change. For the intervenor, this requires a sequence of technical steps described by Hansell as "decision counseling."'1 These steps involve: identifying the problems generated by demands for change; listing of action alternatives; building a decision model; applying the model in choosing between alternatives; and designing plans for action. The decision counselor should remain involved while the individual acts on these plans, so that they can evaluate responses and correct any errors.

Maximum leverage is achieved by intervention in the immediate heat of crisis - as close as possible to the crisis-precipitating event in both space and time.

The counselor should understand and meet dependency needs, and communicate to the client that these are legitimate. Professionals need have no fear of increasing dependency. The individual in crisis is only temporarily more dependent, and he should be encouraged to remain close to a helping agent.

The prime responsibility is for the counselor to help the individual examine his changed situation. Guidance is task-focused, and the temptation to take over the problem, prescribe solutions, or take action on one's own is rigorously avoided. As demands for change become clearer, the intervener's stance should communicate hope, concern and confidence about an eventual successful outcome.

All family resources should be mobilized, so that household responsibilities are fairly distributed and everyone maintains a decent balance of rest and work. Where indicated, the intervenor should use his influence to link members of the extended family network to the individual or family in crisis. Some crisis situations tend to dismember families, and in these the intervenor should mobilize needed outside resources, such as homemakers, to keep the family together.

The effective crisis intervenor facilitates the expression and understanding of the painful emotions that accompany a crisis. Most of all, he functions as a role model; his concern and confidence that "you will work this through" support and sustain hope.

CONCLUSION

Crisis theory illuminates our understanding of the processes by which living systems simultaneously maintain stability and adapt to environmental change. The models thus generated are particularly relevant not only for individuals but also for organizations struggling in turbulent, changing environments. Crisis intervention principles can help such systems adapt with a minimum of strain and prevent needless human casualties. We have chronicled elsewhere" the dreary consequences of failure to understand the crises of organizations in transition. Organizational leaders can master problems of environmental uncertainty by using crisis theory, which has a significant contribution to offer in achieving the mastery of change.

BIBLIOGRAPHY

1. Hansell, N.; Wodarczyk, M. and HandlonLathrop, B. Decision counseling method: Expanding coping a! crisis m transit. Archives of General Psychiatry 22:5 (May, 1970), 462-467.

2 Hirschowitz, R. G. Two Psychiatric Hospitals in Transition: Studies of Staff Behavior. Mimeo: Laboratory of Community Psychiatry, Harvard Medical School, September. 1972 (accept for publcation by Hospital and Community Psychiatry).

3. Kubler-Ross, E On Death and Dying. New York: Macmillan. 1969.

4. Lindemann, E. Symptomatology and management of acute grief. American Journal ot Psychiatry 101 (1944), 141-148.

TABLE 1*

RATING LIFE CHANGES

TABLE 2

CRISIS SEQUENCE

10.3928/0048-5713-19731201-06

Sign up to receive

Journal E-contents