Documenting Crisis Management – HELP!
From Chaos to Calm: Effective Crisis Intervention Strategies
Naomi Golan, the creator of the Golan Model of Crisis Intervention (1978), describes a crisis as a person who faces a situation in which they feel so overwhelmed they go from a state of “balance to imbalance, and ultimately back again.”
Crises are often life-altering events. Common examples are the diagnosis of a serious illness, sexual assault, eviction, job loss, the death of a loved one, or a natural disaster.
Almost all clinicians deal with crisis management at some point in their career. Unfortunately, training in crisis work often comes after encountering a client in crisis. The clinician may be intuitively adept at helping the client go from “imbalance to balance,” but does not know there is a model to follow, and proper documentation often falls short.
Documenting the Essential Elements of Crisis Management
The requirements for documenting what happens during a crisis management session are essentially the same as for any therapy session except that this is a time to include more detail rather than less.
Client Presentation: Clearly describe the client’s presenting problem, including symptoms, behaviors, and level of distress.
Safety Assessment: Document your assessment of the client’s immediate and long-term safety, including any risk factors identified.
Intervention Strategies: Detail the specific interventions implemented, linking them to the six-step crisis intervention model described below.
Client Response: Describe the client’s response to interventions, including any changes in mood, behavior, or distress levels.
Collaboration and Referrals: Document any consultations with other professionals or referrals made for additional support.
Treatment Plan Updates: It may be necessary to update the treatment plan. Reflect on the crisis and how it impacts the overall treatment plan.
Guidance on Documenting Crisis Management Interventions
Burl Gilliland and Richard Keith James (1977) developed a six-step model of crisis intervention strategies. It is a frequently used systematic process of listening, responding, and guiding a person from imbalance to balance so they can take constructive action.
By understanding the six-step crisis intervention model and incorporating best practices into your documentation, you can navigate these challenging situations with confidence.
Crisis intervention is not process-oriented, but action-oriented, situation focused (Aguilera, 1998; Pollin, 1995), and focused on the present. The process starts with three listening steps and ends with three action steps. Assessment is part of every step. The skills involved are active listening, empathy, authenticity, understanding, prioritizing, and goal setting.
Isabel is a high energy 22-year-old recent college grad with her first professional job. She is in therapy to help her deal with unrelenting anxiety focused on her job. She has a history of marijuana abuse. She has been making good progress. But today was different.
Isabel and I met in person. She stormed into my office, didn’t make eye contact, seemed tangential, and was talking so fast I struggled to understand what was troubling her. “My whole life is falling apart!” What I thought was going to be another typical session, turned into crisis management.
Step 1: Define the Problem
The client is usually experiencing overwhelming fear and anxiety. The goals of this step are to form a bond with the client and help the client identify the core issues they need to solve or at least minimize. Active listening and non-judgmental curiosity are essential.
Isabel’s mom had been diagnosed with breast cancer. Her parents were divorced and the whole family was estranged from the father. Isabel lives at home with her mom and two siblings, ages 10 and 14. She is terrified she won’t be able to take care of her siblings and run the house working a full-time demanding job while her mom endures eight months of treatment. She felt alone with no support and unable to ask for help. Her worries about keeping her job took a nosedive. So did her ability to focus on her work.
Two interventions used for Step 1:
- Asked clarifying questions to help Isabel identify the problem, gain clarity about the situation, and understand the impact on her life.
- Verbalized Isabel’s point of view to show I understood and so she would feel heard.
Client Response and Assessment:
Once Isabel was able to verbalize what happened and what she feared, she was able to make eye contact. Though still highly anxious, it appeared she started to feel a little calmer and less alone.
Step 2: Ensure Safety
Since safety is essential, the goal of this next step is to ensure that the client cannot harm self or others. This step requires a careful assessment of the client’s immediate and long-term risk of harm to self or others.
At first, Isabel was highly anxious, catastrophizing, and tangential. There was concern about relapse and marijuana use that might impair her judgement. Her siblings’ safety was also concerning.
Two interventions used for Step 2:
- Asked about substance use and engaged Isabel in a mini mental status exam to determine her ability to engage in developing a plan and finding solutions.
- Asked about other family and friends who cared about her and her siblings so she would feel less alone.
Client Response and Assessment:
Isabel was not using marijuana. Though she was still reactive, she was less tangential. She identified two people in her life who cared about her and her siblings.
Step 3: Provide Support
It is important for the client to feel understood and cared about to reduce feeling alone. The goal of this step is to de-escalate heightened emotions, so the client enters a calmer state, and moves to Step 4 where she can start to collaborate on problem solving.
Two interventions used for Step 3:
- Provided messages of hope to facilitate belief in her future.
- Suggested Isabel looks into Family Medical Leave and other resources, so she and her family could get basic needs met.
Client Response and Assessment:
Isabel recognized that systems were in place to help her deal with the frightening situation and was visibly calmer.
Step 4: Explore Alternatives
The goal is to develop emotional and situation support, new ways of thinking, and to navigate new possibilities. It’s a collaborative exploration of options that empowers the client to be an active participant in the decision-making, so they start to regain a sense of control. Potential alternatives include developing positive and constructive thinking patterns and assessing and developing coping skills.
Two interventions used for Step 4:
- Explored and built on Isabel’s existing coping skills to help her recognize her own strengths.
- Practiced appropriate ways of communicating so Isabel felt able to ask for help.
Client Response and Assessment:
Isabel reconnected with the coping skills she learned. She reported feeling interested in finding ways to deal with the situation. Isabel was now ready to develop a plan of action.
Step 5: Develop an Action Plan
The goal of this step is to develop a plan of action with clear, concrete, realistic, and achievable steps that empower the client to maintain control. The plan is collaborative and considers the client’s strengths, resources, and support system identified in the previous steps.
Two interventions used for Step 5:
- Helped Isabel break down the goals into small manageable action steps, so her plan was realistic and doable.
- Helped Isabel identify barriers to achieving her goals and ways to deal with the barriers.
Client Response and Assessment:
Isabel was much calmer and reported she was ready to implement her plan.
There was one more important step.
Step 6: Obtain Agreement and Commitment
The goal of this step is for the client to take ownership of the process and feel like they can follow through with the plan despite inevitable challenges. It’s important to reinforce the client’s ability to implement the plan and overcome potential obstacles.
Two interventions used for Step 6:
- Engaged Isabel in writing and signing the plan as a demonstration of her agreement and commitment.
- Discussed follow-up plans to create a sense of accountability.
Client Response and Assessment:
Isabel reported she was scared but ready to implement the step-by-step plan we developed together.
Because her mother’s treatment for cancer was going to last at least eight months, I updated Isabel’s treatment plan.
Crisis management is hard work. Documenting it shouldn’t be.
Clinicians often tell me that one of the hardest parts of writing a progress note is identifying and clearly writing interventions and the clinical justification for them.
That’s why Documentation Wizard® developed 68 intervention prompts to guide you through the process of documenting – and justifying – crisis intervention. The Crisis Management Intervention Prompts were written using behavioral language that everyone can relate to and these interventions can apply to any therapeutic modality used. Rooted in the proven framework of Gilliland and James’ six-step crisis intervention model, the prompts provide a structured approach to navigate these complex situations. While this is not a definitive list, nor is it designed to replace crisis intervention training, this list of intervention prompts gives the clinician a solid foundation for crisis management documentation. By offering clear guidelines and rationale for each step, these prompts empower clinicians to document effectively while prioritizing client care.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard® training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 3 attorneys and a bioethicist and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years.
Bibliography
Aguilera, D. (1998). Crisis intervention: Theory and methodology (8th ed.). St. Louis, MO: Mosby.
Gilliland B.E., James R.K. (1993) Crisis Intervention Strategies. 2nd edition. Thomson Brooks/Cole Publishing Company.
James R.K., Gilliland B.E. (2017) Crisis Intervention Strategies, 8th edition. Cengage Learning.
Gilliland, B.E. (1982) Steps in crisis counseling. Memphis: Memphis State University, Department of Counseling and Personnel Services.
Goland, Naomi (1978) Treatment in Crisis Situations. Simon & Shuster.