Crisis Intervention
Emotional First Aid
Training
Session 1
Crisis Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 1
Crisis Crisis Intervention
Intervention
Session
1
“When written in Chinese, the word 'crisis' is composed of
two characters. One represents danger and the other
represents opportunity.” John F. Kennedy
The term “crisis” derives from the Greek word “krisis” which
means decision or turning point.
What is a Crisis?
The origins of crisis theory are usually attributed to Erich Lindemann’s classic
study of grief reactions (Lindemann, E., 1944, Symptomalogy and management
of acute grief. American Journal of Psychiatry 101, p. 141-148).
It was Lindemann’s work that is considered the starting point for the development
of crisis theory and a definition of what a crisis is for an individual.
While origins of crisis theory are attributed to Lindemamann, the work of Gerald
Caplan is the foundation for the work that is done in Emotional First Aid (Caplan,
G. 1964, Principles of Preventative Psychiatry, Basic Books, Inc. New York).
A Crisis is provoked when a person faces a problem, usually precipitated
by an event or situation, for which they appear not to have an immediate
solution and that a resolution to the problem cannot be resolved the usual
methods of problem solving.
A Crisis is considered an upset of a steady or homeostatic emotional state.
Crisis is also understood as a period of psychological disequilibrium,
experienced as a result of a hazardous event or situation that constitutes a
significant problem that cannot be remedied by using familiar coping
strategies
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 2
Crisis Intervention
It is vital to understand that a Crisis Reaction is not viewed as “Pathology”
or that something is wrong with the person. Crisis Reactions are “normal”
responses to upsetting and overwhelming events.
An acute disruption of psychological homeostasis in which one's usual coping
mechanisms fail and there exists evidence of distress and functional
impairment. The subjective reaction to a stressful life experience
that compromises the individual's stability and ability to cope or function. The
main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but
two other conditions are also necessary: (1) the individual's perception of the
event as the cause of considerable upset and/or disruption; and (2) the
individual's inability to resolve the disruption by previously used coping
mechanisms. Crisis also refers to "an upset in the steady state." It often has
five components: 1. a hazardous or traumatic event, a 2. vulnerable or
unbalanced state, 3. a precipitating factor, 4. an active crisis state based on
the person's perception, and the 5. resolution of the crisis.
In plain English:
Crisis throws people off balance-emotionally, spiritually, cognitively
(thinking) and maybe physically.
The question isn’t “What is Wrong with You” rather, “What Has Happened
to You?”
There are three common threads in all crises:
1. A Precipitation Event
2. Perception of the Event
3. Individual’s usual Coping Methods (inadequate)
The three types of Crisis
1. Precipitating Event Crises-This has an identifiable beginning. Often the
Event is interpreted by the person in crisis as being the “last straw” or a
seemingly minor happening at the end of a long list of stressful events.
2. Situational Crises-These are accidental or unexpected and usually happen
by some environmental factor. Some examples are Natural Disaster,
Victims of Violent Crime, Having to Move, Divorce, and Unemployment.
3. Developmental Crises-These are associated with moving from one
developmental life stage to another. Childhood to Adolescents,
Adolescents to Adulthood, Young Adulthood, Middle Adulthood, and Late
Adulthood can all create crises.
There are four stages of a crisis reaction:
1. An initial rise in tension occurs in response to an event
2. Increased tension disrupts daily living
3. Unresolved tension results in depression
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 3
Crisis Intervention
4. Failure to resolve the crisis may result in psychological breakdown
It is assumed that after a period of time the crisis will pass or be resolved in some
manner. This solution may be healthy or unhealthy, and it is believed, in the
Crisis Intervention literature that the type of solution that is reached will have
implications for the individual’s future functioning. Successful solution of life
crises is seen as resulting in greater confidence in the individual, a greater level
of emotional maturity, and the added benefit of increased strength to deal with
future life stresses. In fact, a person’s present state of mental health can be
viewed as a product of the manner in which a series of crises have been solved
in the past.
Based on the following information, I truly believe this reality:
• It is my belief that before there is a mental illness or
disorder, there is a negative crisis reaction to a life
event-I believe we can save thousands from mental
illness by helping them cope with crises events, and
walk with them through the development of coping skills
that would “work at the front-end” of a mental illness,
saving thousands from mental health services.
Numerous studies reveal that exposure to prolonged cumulative stressors
are more difficult to resolve than accidents or natural disasters. Although
some single-exposure crisis events can be difficult to resolve, experiences
that result in the most serious mental health problems are those that are
prolonged, deliberate, or repeated frequently over a period of several years.
We Don’t Have a Vote!
As an Emotional First Aider, and even as a friend or family member, it is
important to remember that when it comes to someone who is facing a crisis, we
do not have a vote. In other words, we do not get to decide whether one person’s
crisis rises to a level that we believe to be a crisis.
We do a great disservice if we are dismissive about a crisis because it wouldn’t
rise to the same level for us.
A Crisis is a “Self-Defined” experience!
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 4
Crisis Intervention
Our role as Emotional First Aider’s is not to predict, deny, or define another
person’s crisis, we are to pay attention and engage people who are, by their
own definition, in crisis.
Crises does strange things to people, making us think, feel, and behave in ways
that are out of character with who we truly are. In that same context, be sure to
walk with individuals in crisis letting them define for you what is a crisis.
Phases
and
Stages:
From
Impact
to
Resolution
In the Crisis Intervention literature, an individual’s progress through a crisis
follows a fairly well defined model of phases and stages. Those are described
here:
• Outcry- the first reaction to a threatening event is the outcry, an almost
reflexive emotional reaction such as weeping, panic, screaming, fainting,
or moaning
• Denial- refers to a blocking of the impact. It usually is experienced with
emotional numbing, not thinking of what happened, or “making yourself
busy” so to act as if the event had not occurred.
• Intrusiveness- includes the unconscious flooding of thoughts and distress
about the event. The flood of thoughts that accompany the intrusive phase
may include statements, spoken or unspoken, about the loss and its
impact (“I can’t go on”). This is when they reach out to someone or get
noticed by an Emotional First Aider.
A Quick Note: Some individuals skip the denial phase and move directly to an
intrusive phase. Others vacillate back and forth between these two states
• Working through- is the process in which the thoughts, feelings, and
images of the crisis experience are expressed, identified, and openly
talked about. Some individuals progress and work through these feelings
and experiences naturally, whereas others do so only with outside help.
• Completion- is the final phase of the crisis experience and refers to an
integration of the crisis experience into the individual’s life. The individual
has accepted the “new normal.”
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 5
Crisis Intervention
I prefer William Worden’s
Four Tasks of Grief to
Elisabeth Kubler-Ross’s Five
Stages of Grief, because it is
my opinion that Kubler-
Ross’s theory is specific to
those who are facing death
rather than someone who
has lost a loved one to
death.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 6
Crisis Intervention
“Normalizing” someone’s process of grief will “give them permission” to
fully feel all they are feeling at whatever loss they are experiencing.
As an Emotional First Aider, remember that Generalizations and
Assumptions impede communication with the Person in emotional crisis,
as well as, hinder their grief process.
Crisis Intervention Versus Traditional Counseling
There are many differences between traditional counseling and crisis
intervention. However, the overall differences rest in purpose, setting, time, and
intervention plan.
It is crucial for professionals to understand the purpose of crisis counseling, as it
differs from that of traditional counseling, in order to intervene appropriately.
Simply, the goal of traditional counseling is to increase functioning, whereas the
goal of crisis counseling is to decrease suffering and increase stabilization in
order to refer the person on for longer term counseling. Imagine a car accident in
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 7
Crisis Intervention
which an individual may have experienced a severe medical trauma. It is
essential for the EMT to stabilize the patient to prevent further injuries prior to
transferring (referring) the patient to a surgeon at the hospital.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 8
Crisis Intervention
9
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson
Crisis Intervention
Fundamentals of Working with those in Emotional Crisis
The underpinnings of working with individuals in crisis begin with
determining, based on assessment efforts, how best to approach them to
deescalate the crisis.
In other words, we need to assess whether the situation calls for us to be
directive, nondirective, or collaborative.
Directive approaches call for us to “direct” or lead the person in crisis in a
specific direction. Individuals in crisis are typically scattered and unable to plan
beyond their current situation. Therefore, providing some form of direction may
help. For example, if someone is highly uncertain, spontaneous, or ambiguous
and, at the same time, unable to get out of a crisis state, providing direction could
provide immediate, though temporary, relief to feelings surrounding the crisis
situation.
Nondirective approaches allow the person in crisis to come up with the
directives while the crisis counselor facilitates that process. If the individual is at a
place where he or she can make rational decisions, even though he or she is still
in a state of crisis, a nondirective approach may empower the person to make
progress toward de-escalation. For example, asking those in crisis who were
recently victimized by a flood “What might be of most help to you now?” allows
them to respond with specifics, rather than having you guess what was needed.
The thought process and response of such a person may also empower them to
feel like they are regaining some control over their own lives.
A Collaborative approach focuses on showing the person in crisis that you are
there, with them, on the journey toward stabilization and normalcy.
People in crisis need to know that there are others not only to provide help but
also to decrease isolation and increase resource allocation.
Collaborative approaches are considered a blending of directive and nondirective
approaches—but with a flavor of togetherness. In other words, a collaborative
approach provides support and a sense of working together toward a common
goal.
Examples of directive, nondirective, and collaborative approaches in crisis
situations can be seen on the next page.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 10
Crisis Intervention
EXAMPLE 1
• I want you to put the gun down. (directive)
• Let’s chat about how you feel about putting the gun down. (nondirective)
• I want to help, but knowing you have that gun in your hand
scares me. Can you put the gun down for me so I can help you
more? (collaborative)
E XAMPLE 2
• Calm down. (directive)
• How might you calm yourself down? (nondirective)
• Boy, I’m really upset. Let’s try and calm down for a bit. (collaborative)
EXAMPLE 3
• I am calling the police. (directive)
• Would calling the police help? (nondirective)
• If I bring you the phone, would you call the police? (collaborative)
A common theme in crisis intervention literature is the chief goal is to help
the person regain the level of functioning that existed immediately prior to
the crisis event. However, given the reality, someone may never return to
pre-crisis functioning, however, they do return to emotional homeostasis
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 11
Crisis Intervention
First-Order Intervention-Psychological First Aid
• A woman asks the crisis hotline volunteer if she should try to break down
the door at her boyfriend’s apartment. She is afraid he might have taken
pills in an attempt to commit suicide.
• A twelve-year-old boy calls his Youth Pastor from a phone booth: “Dad
beat me up again. I’m afraid to go home.”
• A bank teller confesses to his supervisor that “marital problems” are the
cause of his recent poor performance at work. Five days ago his wife left
him. He has been drinking heavily ever since.
• A Pastor is asked to talk with two young parents in the emergency room of
a general hospital. They’ve just learned that their four-year-old son died
after being struck by a car.
Each of the helpers represented in these cases—hotline worker, youth pastor,
bank supervisor, and pastor—is faced with the challenge of giving emotional first
aid to a person or family in crisis. We recall from the table on the previous page
that these first-order interventions are short, and can be provided by a wide
range of community helpers, and are most effective early in the crisis.
Five Components of Psychological First Aid
The Five Components of Psychological First Aid are outlined below:
• Making psychological contact
• Examining dimensions of the problem
• Exploring possible solutions
• Assisting in taking concrete action
• Following up to check progress.
Table 3.2 lists the components as well as the helper behavior and objectives
involved in each step of the model.
Making Psychological Contact
Some people describe this component as empathy or “tuning in” to a person’s
feelings during a crisis.
In the present context, it means listening for both facts and feelings (what
happened, as well as how the person feels about it), and using reflective
statements so the person knows we have really heard what has been said.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 12
Crisis Intervention
In the disorganization and upset of a crisis, often the newness or strangeness of
the experience is the most frightening part. The helper’s first task, then, is to
listen for how the person’s views the situation, and communicate whatever
understanding emerges.
Table 3.2 lists the central helper behaviors involved in making psychological
contact, for example, inviting the person to talk, listening both for what happened
(facts) and the person’s reaction to the event (feelings), making reflective
statements, and so on.
When feelings are obviously present (nonverbal cues), though not yet put into
words and thereby legitimized, helpers gently comment on this: “I can sense by
the way you talk how upset you are about what has happened,” or, “It seems that
you also are very angry about what has happened, and rightly so.”
The helper’s task in this component is to not only to recognize these
feelings but also to respond in a calm and controlled manner, resisting the
tendency to become caught up (becoming anxious, angry, or depressed) in
the intensity of the person’s feelings.
There are several objectives for making psychological contact. The first is for the
person in crisis to feel heard, accepted, understood, and supported, which in turn
leads to a reduction of the intensity of the emotions.
Psychological contact serves to reduce the pain of being alone during a crisis,
but it actually aims for more than this. By recognizing and legitimizing feelings of
anger, hurt, fear, etc., and thus reducing emotional intensity, energy may then be
redirected toward doing something about the situation.
Exploring Dimensions of the Problem
The second component of psychological first aid involves assessing the
dimensions or parameters of the problem.
Inquiry focuses on three areas: immediate past, present, and immediate
future.
Immediate past refers to events leading up to the crisis state, especially the
specific event that triggered or precipitated the crisis (the death of a loved one,
unemployment, injury, separation from spouse).
Inquiry about the present situation involves the “who, what, where, when, how”
questions of an investigative reporter. We need to find out who is involved, what
happened, when it happened, and so on.
This is most often accomplished by simply having the person tell the story
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 13
Crisis Intervention
The main objective of this second aspect of psychological first aid is to work
toward a rank ordering of the person’s needs within two categories:
1. Issues that need to be addressed immediately
2. Issues that can be postponed until later.
In the confusion and disorganization of the crisis state, people often
attempt to deal with everything all at once.
Many times there is little awareness of what must be dealt with right away and
what can wait a few days, weeks, or even months.
An important role for the helper, then, is to assist in this sorting-out
process.
Examples of issues that might need immediate attention would be: finding a
place to spend the night, talking a person out of killing himself tonight, or “buying
time” in a family dispute so everyone can talk again in a less heated moment.
Later needs cover anything that does not need to be taken care of in the next
several hours or days and might include such things as a need for legal
assistance, marital counseling, individual crisis therapy, vocational rehabilitation,
and the like.
Examining Possible Solutions
The third component of psychological first aid involves identifying a range of
alternative solutions to both the immediate needs and the later needs identified
previously.
Set the Tone as moving from Problem Talk to Solution
Talk (More details to follow)
As Table 3.2 indicates, the helper takes a step-by-step approach, asking first
about what has been tried already, then getting the person in crisis to generate
alternatives, followed by the helper’s adding other possibilities
Following from a basic principle of crisis intervention, we get people to do
as much as they can for themselves, even if only in generating alternatives
about what to do in this particular situation.
The premise is that helplessness can be checked by encouraging the person’s to
generate ideas about what to do next, that is, helping the person operate from a
position of strength rather than weakness.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 14
Crisis Intervention
This can evolve from asking questions about how the person has dealt with
previous problems. Only after exploring the person’s suggestions does the
counselor join in a brainstorming process to generate other solutions to
the problem.
Two other process issues deserve to be mentioned here. The first is the
importance of coaching some individuals to even consider the idea that
possible solutions exist.
The counselor may have to structure the discussion with comments like: “Let’s
just consider what if you were to (talk to her, go home tonight, call child welfare,
call your parents, etc.). What might happen?”
In such cases, the counselor makes room in the first-aid process for untried, pre-
maturely rejected options, and guides the crisis client in fully considering them.
Similarly the person can be asked, “What kind of solutions might someone else
try? Think of some- one who might know what to do—what would that person’s
ideas be?”
A second issue is the importance of examining obstacles to implementation of a
particular plan, for example, nonassertive manner as an obstacle to face-to-face
confrontation of spouse, or lack of car as hindrance to keeping an appointment
for individual counseling.
Counselors cannot leave such issues to chance. Instead, they think ahead
to possible obstacles and make it their responsibility to see that these are
addressed before an action plan is set in motion.
Taking Concrete Action
Relating directly to the action and goal orientation of crisis intervention, the fourth
component of psychological first aid involves helping the person to take some
concrete action to deal with the crisis.
The objective is actually very limited, no more than taking the best next step
given the situation. According to Table 3.2 this means implementing the agreed
upon immediate solution(s) aimed at dealing with the immediate need(s).
The action step may be as simple as an agreement to meet again the next day,
or as complicated as initiating emergency hospitalization.
It is important to remember that we want the person to do as much as
he/she is capable of doing.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 15
Crisis Intervention
Depending upon two major factors (lethality and capability of the person in crisis
to act on his or her own behalf), the helper takes either a facilitative or directive
stance in helping the person deal with the crisis.
If the situation is high in lethality (danger to the person, himself, or to someone
else), or if the person is not capable of taking care of him/herself (is drunk, or so
emotionally distraught as to be incapacitated), then the helper’s stance is
directive.
When there is no danger to self or others, and when a person, though
emotionally distraught and disorganized, is still capable of doing such things as
driving home, calling a spouse, enduring a long weekend, then the helper’s role
is more facilitative than directive.
Following Up
The last component of psychological first aid involves eliciting information and
setting up a procedure to allow for following up to check progress.
As Table 3.2 indicates, the main helper activity here is to specify a
procedure for person in crisis and helper to be in contact at a later time.
Follow up can occur through a face-to-face meeting, or by telephone. It is
important to specify who will call whom, or who will visit whom, as well as the
time and place of contact.
All of this fits into what might be called a “contract for recontact.” Psychological
first aid is not complete until such procedures have been agreed upon.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 16
Crisis Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 17
Crisis Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 18
Crisis Intervention
A Confirming Crisis Intervention Model
Crisis Intervention Guidelines
Every crisis is different, but all crises require immediate intervention to interrupt
and reduce crisis reactions and restore affected individuals to pre-crisis
functioning.
Crisis interventions provide victims with emotional first-aid targeted to the
particular circumstances of the crisis. Several guiding principles are involved in
crisis intervention; some key principles are outlined on the following page
• Making an accurate assessment is a critical aspect of a crisis response
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 19
Crisis Intervention
because it guides the intervention. Although situations may be similar,
each person is unique; therefore, care must be exercised to avoid over-
generalizing.
• The ability to think quickly and creatively is crucial. People under crisis
sometimes develop tunnel vision or are unable to see options and
possibilities. The Emotional First Aider must maintain an open mind in
order to help explore options and solve problems in an empowering
manner with those affected. People in crisis already feel out of control;
when opportunities to restore control present themselves, they should be
grasped quickly.
• The Emotional First Aider must be able to stay calm and collected. It
requires the ability to maintain empathy while simultaneously avoiding
subjective involvement in the crisis.
• Crisis intervention is always short term and involves establishing specific
goals regarding specific behaviors that can be achieved within a short time
frame.
• Crisis intervention is not process-oriented. It is action-oriented and
situation-focused.
• Crisis intervention prepares People in emotional crisis to manage the
feelings of a specific event. Emotional First Aider’s help People in
emotional crisis to recognize an event’s impact and anticipate its
emotional and behavioral consequences. In addition, those in emotional
crisis learn to identify coping skills, resources, and support available to
them. They learn to formulate a safety plan in an effort to cope with the
current and anticipated challenges the event presents.
• A crisis is characterized by loss of control and safety. This loss makes it
incumbent on the Emotional First Aider to focus on restoring power and
control in the Person in emotional crisis internal and external environment.
• The goal is not to ask exploratory questions, but rather to focus on the
present (“here and now”). The Emotional First Aider merely acts as an
emotional support at a time when self-direction may be impossible.
Emotional First Aider’s do not attempt to change those in emotional crisis,
but serve as catalysts for their discovery of their own resources, which
they can then use to accomplish their goals.
• Since crisis intervention is the first intervention that a Person in emotional
crisis may encounter after a calamity, the goal is always to reestablish
immediate coping skills, provide support, and restore pre-crisis
functioning.
Roberts’ Seven-Stage Crisis Intervention Model
A quick visual of Robert’s Seven Stage Crisis Intervention Model is shown on the
next two pages. We will follow this blueprint as our work with People in emotional
crisis. Each stage is further expanded and discussed on the next page with a
visual of the model.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 20
Crisis Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 21
Crisis Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 22
Crisis Intervention
As a process, crisis therapy involves facilitating experiences that include:
reflecting on the event and its meaning to the person in crisis, expressing
feelings, maintaining at least a minimum degree of physical well-being
during the crisis, plus making behavioral and interpersonal adjustments
appropriate to the situation. We can refer to all of this as “Working
Through” the crisis
To suggest that the goal of crisis therapy includes integrating the event into the
fabric of life simply means that for the crisis to be resolved, the event and its
aftermath must eventually take their places alongside the other life events and
markers in the person’s life, forming one part of an evolving life experience.
The opposite of this practical integration is intentionally compartmentalizing it,
blocking it out of awareness, pretending it did not happen or somehow denying
its existence. While such denial or blocking is often part of early reactions to a
crisis event, ultimate resolution of the crisis experience must move past this
reaction toward integrating the experience with other life experiences. Even for
traumatic experiences such as rape, loss of a limb, or loss of a loved one, the
eventual resolution hopefully will find the crisis victim able to say or think
something similar to the following:
“Yes, that happened to me. I suffered a great deal. I went through
emotional pain, felt upset, and even thought at times I could not go on. I
talked about it, expressed my feelings, made use of friends, and found
that with this, and the passage of time, the event no longer has the same
hold on me that it did in the beginning. I even find that some parts of my
life which were previously dormant (particular friendships) have been
strengthened in positive ways. My outlook on life has changed from being
dismal to appreciating what I still have and the new strengths I have
found. And now? The emotional scars are healing, though they’re still
there. Yes, I can remember; I know what I went through. But the whole
thing is becoming just one of many experiences that make up my total life.
I am ready to go on now. I can, of course, think back and even feel what it
was like. At times I can even relive some of the experiences and the
hurtful feelings. The bulk of the working through, however, is over. I’m
ready to face the future.”
(Slaikeu K.A. (1984). Crisis intervention: A handbook for practice and research
Allyn & Bacon Inc., New York, NY)
Stage 1-Assess Lethality
Stage 1 is about asking the question “Are you having thoughts of Suicide” or “Are
you thinking about killing yourself.”
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 23
Crisis Intervention
We will discuss this in great detail in our next lesson on Suicide Prevention and
Intervention.
This part of the work of Emotional First Aider’s is about assessing for lethality. Is
the Person in emotional crisis a risk to themselves or someone else?
Safety is the goal during Stage 1
Rather than grilling the Person in emotional crisis for assessment information, the
sensitive Emotional First Aider uses an Active Listening style that allows this
information to emerge as the Person in crisis’s story unfolds.
A good assessment of risk of suicide or harm is likely to occur in the process of
creating a conversational environment where the Person in emotional crisis feels
heard and understood. So understand that in the Roberts model, Stage I—
Assessment and Stage II—Rapidly Establish Rapport are very much intertwined,
and gaining further understanding about the Person in emotional crisis’s risk of
suicide can overlap into Stage 2.
Stage 2-Establish Rapport
Another term we use in face-to-face counseling is “Therapeutic Alliance.”
Through Active Listening, empathy, understanding, and a text conversation
where there is no judgment, the Person in emotional crisis is able to provide
answers that are needed to asses for lethality from Stage 1 and identify problems
as in Stage 3.
The Emotional First Aider, through Active Listening, creates a space for the
Those in emotional crisis to tell their story where not only does the
Emotional First Aider hear it, but also the Person in crisis can hear and
understand their story.
Stage 2 is the foundation in which all other work is done with the Person in crisis.
In fact, this crisis intervention model isn’t linear, but is fluid and is
intertwined
Rapport is facilitated by the Emotional First Aider providing genuineness,
respect, and acceptance of the Person in emotional crisis.
Stage 3-Identify Major Problems
Stage 3 of Robert’s Crisis Intervention Model focuses on the Person in emotional
crisis’s current problems, which are often the ones that precipitated the crisis.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 24
Crisis Intervention
One strategy is to ask, “What has happened that has made you feel so
overwhelmed?” What is key during this stage is understanding the problem from
the Person in crisis’s point of view.
Additional Useful Questions to ask during Stage 3: “How do/did you feel about
that?” “What are/were you thinking?” “What is/was that like for you?” Keep them
open! “What else is there about that?”
Avoid the Why Question
Two primary tasks of Stage 3 is to see the problem of the Person in crisis from
their perspective, allowing the Person in crisis to hear themselves tell their story,
and second task, is providing the Emotional First Aider with information so that a
resolution to the problem can be formulated.
Seek to understand the problem that led the Person in emotional crisis to the
crisis.
Stage 4-Deal with the Feelings
The Emotional First Aider makes every effort to allow the Person in emotional
crisis to express their feelings, to vent and heal, and to explain her or his story
about the current crisis situation.
Gently the Emotional First Aider eventually works challenging responses into the
crisis-counseling dialogue. Challenging responses can include giving information,
reframing, interpretations, and playing "devil's advocate." Challenging responses,
if appropriately applied, help to loosen a person’s' maladaptive beliefs and to
consider other behavioral options.
One example is when the Person in crisis says, “No one cares about me/I have
no friends.” The Emotional First Aider can paraphrase, “So you haven’t had
anyone in your life that has cared about you?” This causes the Person in crisis to
recall someone in their life who has cared and might bring back into focus that
person into their life at the time of crisis.
What is vital in this stage is to allow the Person in emotional crisis to vent, share
their hurts, pain, and discouragement; feelings brought on by the problem, which
led to the crisis.
Stage 5-Explore Alternatives
In the current state of the Person in crisis, their coping skills have been maxed
out, they feel as if they have only one option (i.e. suicide) or no options at all, and
they get stuck in tunnel vision and get stuck in an endless merry-go-round of
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 25
Crisis Intervention
trying to solve the problem the same way. We know this to be insanity, “Wanting
different results while do the same thing.”
Collaboration through Brainstorming with the Person in crisis is the Best Practice.
It is vital that the Emotional First Aider not provide alternatives to the Person in
crisis, but rather ask “what do you think would happen if you (an alternative the
Emotional First Aider has in mind)? In doing this, it makes the Person in
emotional crisis feel as if they are making the choice to change their situation.
Avoid Telling a Person in emotional crisis what to do
We will be discussing evidence-based solution focused ways to resolve a crisis in
another lesson.
Keep in mind during Stage 5 that the Person in crisis doesn’t need a long
list of alternatives. Where they are currently, in crisis, it is best to have a
short list, maybe one or two things that the Person in crisis can do to
change their current situation.
Amplifying Solution Talk: Solution talk addresses what aspects of life the
Person in crisis wants to be different and the possibilities for making those things
happen. The task of the Emotional First Aider is to encourage the Person in
emotional crisis to provide as much detail as possible to amplify what will be
different in his life after his problem is solved.
Difference Questions (What is Different Now when you are going through a
crisis to times when you were not going through a crisis?)
• Are there times when the problem does not happen or is less serious?
When? How does this happen?
• Have there been times in the last couple of weeks when the problem did
not happen or was less severe?
• How was it that you were able to make this happen?
• What was different about that day?
• If your friend (teacher, relative, spouse, partner, etc.) were here and I were
to ask him what he noticed you doing different on that day, what would he
say? What else?
We will do more training in Solution Focused Text Counseling in another lesson.
Stage 6-Develop an Action Plan
A hallmark of people in crisis is the feeling of losing control. Therefore, it is vital
that the Emotional First Aider help the Person in emotional crisis to gain control
over the feeling of being in chaos and this happens by developing an action plan.
Stage 6 flows logically and directly from Stage 5-Exploring Alternatives.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 26
Crisis Intervention
The foundation idea, like the one mentioned in Stage 5, is that the work you
do with those in emotional crisis is Collaborative. They must feel they are
putting together the plan so in future moments of crisis they have
developed some better coping skills.
An Action Plan for someone is crisis is about the short-term and is about
restoring some balance and stability back into a life that seems out of control.
Most plans in Crisis Intervention are measured in minutes, hours, or days, not
weeks, months or years. Do not make long-term Action Plans, rather short-term
action plans.
In Step 6, after the Action Plan has been established, restated, and summarized,
the Emotional First Aider asks for a commitment to the one or two actions steps
the Those in emotional crisis has developed. They verbally make a commitment
to you as the Emotional First Aider that they will carry out the alternatives talked
about in Stage 5.
As an Emotional First Aider, do not under any circumstance impose a
commitment on someone in emotional crisis. The commitment must be
free, voluntary, and believed to be doable. If there is hesitation about
carrying out the Action Plan from those in emotional crisis, explore the
issue through open-ended questions.
Stage 7-Follow-Up
This task will be easy using the Follow-Up feature of the web-based platform.
Follow-Up with the Person in emotional crisis should be very short-term. In other
words, a proactive text message to the Person in emotional crisis the next day, or
not longer than two days, will reinforce to the Person in emotional crisis that we
are still walking with them through the crisis.
Long-term follow-up can be done throughout the course of the year by
scheduling follow-up reminders in the crisis intervention report on the web-based
platform.
Six-step model of Crisis Intervention
Emotional First Aiders’ will need to address the level of distress and impairment
of the person in emotional crisis in crisis by responding in a logical and orderly
manner.
Training in the use of a standardized model for intervening in crisis situations can
help the Emotional First Aider to be aware of the elements of an effective
response to crisis, and to intervene in a way that appropriately supports the
Emotional First Aider through the crisis.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 27
Crisis Intervention
A six-step model for crisis intervention is one framework that crisis professionals
may implement to respond to crisis. The model focuses on listening, interpreting
and responding in a systematic manner to assist a person in crisis return to their
pre-crisis psychological state to the extent possible.
Emphasis is placed on the importance of listening and assessment throughout
each step, with the first three steps focusing specifically on these activities rather
than on taking action. At any point, emerging safety considerations that present
the risk of the person in emotional crisis being hurt or killed should be addressed
immediately.
The model involves the following steps:
1. Defining the problem to understand the issue from those in emotional
crisis’s point of view. This requires using core listening skills of empathy,
genuineness and acceptance.
2. Ensuring person in emotional crisis safety. It is necessary to continually
keep person in emotional crisis’s safety at the forefront of all interventions.
This means constantly assessing the possibility of physical and
psychological danger to those in emotional crisis as well as to others.
Assessing and ensuring safety are a continuous part of the crisis
intervention process.
3. Providing support, by communicating care for the person in emotional
crisis, and giving emotional as well as instrumental and informational
supports.
Acting strategies are used in steps 4, 5, and 6. Ideally, these steps are
[implemented] in a collaborative manner, but if the person in emotional crisis is
unable to participate, it may be necessary to become more directive in helping
them mobilize their coping skills.
Listening skills are an important part of these steps, and the counselor will
mainly function in nondirective, collaborative, or directive ways, depending
on the assessment of the person in emotional crisis.
4. Examining alternatives, which may be based on three possible
perspectives: a) supporting the person in emotional crisis to assess their
situational resources, or those people known to the person in emotional
crisis in the present or past who might care about what happens to them;
b) helping the person in emotional crisis to identify coping mechanisms or
actions, behaviors, or environmental resources that they might use to help
them get through the present crisis; and c) assisting the person in
emotional crisis’s to examine their thinking patterns and if possible, find
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 28
Crisis Intervention
ways to reframe their situation in order to alter their view of the problem,
which can decrease their anxiety level.
5. Making a plan led by the person in emotional crisis, which is very detailed
and outlines the persons, groups and other referral resources that can be
contacted for immediate support. Provide coping mechanisms and action
steps that are concrete and positive for the person in emotional crisis to do
in the present. It is important that planning is done in collaboration with the
person in emotional crisis as much as possible, to ensure they feel a
sense of ownership of the plan. It is important that the person in emotional
crisis does not feel robbed of their power, independence, or self-respect.
The most important issues in planning are the person in emotional crisis’s
sense of control and autonomy. Planning is about getting through the
short-term in order to achieve some sense of equilibrium and stability.
6. Obtaining commitment. Control and autonomy are important to the final
step of the process, which involves asking the person in emotional crisis to
summarize the plan through text message. In some incidents where
lethality is involved, the commitment may be texted and realized by both
individuals. The goal is to enable the person in emotional crisis to commit
to the plan, and to take definite positive steps toward re-establishing a pre-
crisis state of functioning. The commitments made by the person in
emotional crisis need to be voluntary and realistic. A plan that has been
developed only by the Emotional First Aider will be ineffective.
Moving from Problem Focused Questions to Solution-
Focused Questions-Problem Talk to Solution
Talk
People prefer Solution-Focused questions and respond to them because they are
future-focused, affirm their strengths and skills and help them to move forward
with their agenda.
Be careful to use these questions after you have heard and understood the
person in emotional crisis. Their deep depression may cause them to have a
hard time using these Solution Focused Questions
It is important however not to overdo questioning or it can feel like an
interrogation.
Being fluent in speaking solution-focused language requires the practitioner to
listen carefully to the person and connect with the possibilities, stated or implied
in their responses. The other major intervention is questioning, of which the
following are examples.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 29
Crisis Intervention
To Negotiate Goals
• What needs to happen here today to make you think this conversation was
worthwhile?
• What are your best hopes for this conversation today?
• What will be the first signs for you and (others) that things are moving in
the right direction?
• What are the benefits for you in achieving your goal?
• What makes you think now is a good time to make some changes?
To Identify Resources
• Thinking of a recent difficult time you’ve had, how did you manage
to come through it?
• What did you/ they find helpful?
• What was unhelpful?
• How do you/ they talk themselves through difficult situations?
• What do you know about yourself (or your situation) that reassures
you that you can deal with this?
To Motivate
Scaling questions are great ones to help the person and you understand
where they are at, and what it might take to get them unstuck!
• On a scale of zero to ten, with ten meaning that you would do almost
anything to achieve your goal and zero being hardly anything, where
would you put yourself today?
• How confident are you that you already have the ability to achieve your goal?
• Can you find evidence for this?
• How will you know that this is a good time to make a start at least?
To Focus on the Future
• Imagine one night when you are asleep, something amazing
happens and the problems that have been worrying you disappear. Since
you are asleep you don’t know that this has happened. When you wake up
in the morning and go about your day, what will be the first signs for you
that things have improved?
• Do you think that any of these things have happened to you recently,
even for a short while?
• If I were to meet you in a few months time and you were
to tell me that things were getting better, what would
you tell me had happened?
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 30
Crisis Intervention
To Maintain Progress
• What do you think you need to do/ think / remember to give you a
chance of keeping on solution track?
• What will you say to yourself if you have a set back?
• What will be the best way of handling a set back?
• What will be helpful / unhelpful?
• How will other people know that you need help at that point?
• How will you overcome any obstacles that come in the way?
• Should plan A not work what’s plan B?
To Increase Self-Awareness
• What does it say about you that you managed to do that (when
person has achieved something)?
• Did you know you could do that?
• Where did you learn to do that? Have you done it before?
• Has anyone else noticed that you have done this?
• What do they think about it?
To Develop Strategies
• What could you do about the things over which you do have control
and how could you accept the things you can’t change?
• What have you tried so far that you know does not work?
• Do you know anything that worked for anyone else in this situation?
• How would you advise a friend who was having this problem?
• What is the smallest step you could take in the next 48 hours, which would
be helpful?
Solution-Focused Interviewing Skills & Questions
Open-Ended Questions
“Can you tell me about your relationship with your parents vs. “Do you like
your parents?” (Forced choice requiring yes or no response). “Tell me about
your parenting experience. “Who are your supports and how do they help
you?” Note: identify and reflect to the individual any strengths or positive
qualities a person in crisis may reveal in their responses to the open-ended
questions.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 31
Crisis Intervention
Summarizing
Periodically state back to the person in crisis his/her thoughts, actions, and
feelings.
Tolerating and Using Silence
Allow 10, 15, 20 seconds or so to allow a person in crisis to come up with
their own responses. Avoid temptation to fill in silence with advice.
Self-disclosure
Not recommended. Better to look for solutions within the person’s frame of
reference.
Complimenting
Acknowledging the person’s strengths and past success.
Affirming the person’s Perceptions
A perception is some aspect of a person’s self-awareness or awareness of
his/her life.
They include a person’s thoughts, feelings, behaviors, and experiences.
Affirmation of the person’s perceptions is similar to reflective listening in form,
but does not isolate and focus on the feeling component per se, but on the
person’s larger awareness. (Examples; “uh-huh”, “sure”, “of course”, or “I can
understand why you want to have a place of your own, away from your
family”).
Working with the person in Emotional Crisis Negative or Inaccurate
Perceptions
Perceptions, even negative ones like suicide or assaultive behaviors should
be explored for the purpose of understanding the full context. “What’s
happening in your life that tells you that hitting or suicide might be helpful in
this situation?”
Some perceptions may be obviously inaccurate and reflect a person’s denial of
a problem.
Example “I don’t have a drinking problem,” despite several DUI citations. Or,
“I don’t have an anger problem,” despite arrests for assault or disorderly
conduct.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 32
Crisis Intervention
Indirect or Relationship questions can be useful in working with the distorted
perception. “If your spouse (children, probation officer, family member, etc.)
were here, what might she or he say about your drinking or how you express
your anger?”
Avoid an immediate educative or dissuading response to negative or
inaccurate perceptions. Listening and understanding are the practitioner’s first
obligations.
Returning the Focus to the Person
A person in crisis tends to focus on the problem and/or what they would like
others to do differently. In the Solution-Focused approach, the person is
encouraged to return the focus to themselves and to possible solutions:
Examples include the following:
• My kids are lazy. They don’t realize that I need help
sometimes.” “What gives you hope that this problem can
be solved?”
• “I wish my parents would get with it. A 10:00 pm curfew on
weekends is ridiculous.”
• “When things are going better, what will your parents notice you
doing differently?”
• “My teachers are too hard. If they would back off all the homework
and give more help my grades would improve.”
• “What is it going to take to make things even a little bit better?”
• “If my boss would stop criticizing me and treating me like a child I could
be more productive.”
• “If your boss was here and I was to ask him what you could do differently
to make it just a little easier for him not to be so critical, what do you
think he would say?”
Amplifying Solution Talk (Difference Questions)
Solution talk addresses what aspects of life the person wants to be different
and the possibilities for making those things happen. The task of the
practitioner is to encourage the individual to provide as much detail as possible
to amplify what will be different in his life after his problem is solved.
Exception Questions
Exceptions are those occasions in the person in emotional crisis’s lives when
their problems could have occurred but did not – or at least were less severe.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 33
Crisis Intervention
Exception questions focus on who, what, when and where (the conditions that
helped the exception to occur) - NOT WHY; should be related to individual
goals.
• Are there times when the problem does not happen or is less serious?
When? How does this happen?
• Have there been times in the last couple of weeks when the problem
did not happen or was less severe?
• How was it that you were able to make this exception happen?
• What was different about that day?
• If your friend (teacher, relative, spouse, partner, etc.) were here and I
were to ask him what he noticed you doing different on that day,
what would he say? What else?
Coping Questions
Coping questions attempt to help the individual shift his/her focus away from
the problem elements and toward what the person is doing to survive the
painful or stressful circumstances. They are related in a way to exploring for
exceptions.
• What have you found that is helpful in managing this situation?
• Considering how depressed and overwhelmed you feel how is it that you
were able to get out of bed this morning and make it to our appointment
(or make it to work)?
• You say that you’re not sure that you want to continue working on your
goals. What is it that has helped you to work on them up to now?
Scaling Questions
Scaling questions invite the individuals to put their observations, impressions,
and predictions on a scale from 0 to 10, with 0 being no chance, and 10 being
every chance. Questions need to be specific, citing specific times and
circumstances.
• On a scale of 0 to 10, with 0 being not serious at all and 10 being the
most serious, how serious do you think the problem is now?
• On a scale of 0 to 10, what number would it take for you to consider the
problem to be sufficiently solved?
• On a scale of 0 to 10, with 0 being no confidence and 10 being very
confident, how confident are you that this problem can be solved?
• On a scale of 0 to 10, with 0 being no chance and 10 being every
chance, how likely is it that you will be able to say “No” to your
boyfriend when he offers you drugs?
• What would it take for you to increase, by just one point, your likelihood
of saying “No”?
• What’s the most important thing you have to do to keep things at a 7 or 8?
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 34
Crisis Intervention
Indirect Relationship Questions
Indirect questions invite the person to consider how others might feel or
respond to some aspect of the person’s life, behavior or future changes.
Indirect questions can be useful in asking the individual to reflect on narrow or
faulty perceptions without the worker directly challenging those perceptions or
behaviors.
Examples:
• “How is it that someone might think that you are neglecting or
mistreating your children?” “Has anyone ever told you that they
think you have a drinking problem?”
• “If your children were here (and could talk, if the children are infants or
toddlers) what might they say about how they feel when you and your
wife have one of those serious arguments?’
• “At the upcoming court hearing, what changes do you think the judge
will expect from you in order to consider returning your children?”
• “How do you think your children (spouse, relative, caseworker,
employer) will react when you make the changes we talked about?”
The Miracle Question
The “Miracle Question” is the opening piece of the process of developing well-
formed goals. It gives people in crisis permission to think about an unlimited
range of possibilities for change. It begins to move the focus away from their
current and past problems and toward a more satisfying life.
“Now, I want to ask you a different kind of question. I want you to imagine a time
in the future when the problem is solved. All the present barriers are gone. So,
when this miracle happens what will be different that will tell you that this
positive future has happened and the problem is solved?”
Alternate Phrasing of the Miracle Question
“Now, I want to ask you a question. I want you to imagine a time in the future
when the problem is solved. All the present barriers are gone. So, when this
happens what will be different that will tell you that this positive future has
happened and the problem is solved?”
Follow-Up Questions
Through follow-up questions, the interviewer further extends and amplifies the
impact of the miracle by a series of questions designed to guide the individual
in exploring the implications of the miracle in the person’s life.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 35
Crisis Intervention
Examples:
• “What will be the first thing you notice that would tell you that a miracle
has happened, that things are different?”
• “What might others (mother, father, spouse, partner, siblings, friends,
work associates, teachers, etc) notice about you that would tell them
that the miracle has happened, that things are different or better?”
• “Have there been times when you have seen pieces of this miracle
happen?” “What’s the first step that you can take to begin to make this
miracle happen?”
• “When you wake up next Monday, Wednesday and Friday I would like
you to imagine that the miracle has happened. Then try to respond by
letting your feelings and behavior reflect that the miracle has happen
5 Steps to Finding Solutions Quickly
When time is limited, this brief, focused format may prove helpful. It needs"
customizing to the needs of the situation.
Step One
• “Could you put the issue / problem into one or two words?"
• “Could you put those words into one or two sentences?"
• “Could you tell me briefly what the problem is?"
Acknowledge the person’s concerns and don’t rush into providing solutions. In
addition, avoid getting bogged down in detail.
Step Two-Convert problem statements into goals.
• “What will be different about the situation when it’s better?"
• “After we’ve talked what would you know / be able to do?"
Step Three
• “In terms of how near you are to achieving the goal, on a scale of 0 to 10,
with ten being you are already there and 0 being the opposite, where
would you say you are now?"
• “Where do you need to get to?"
• “How would you know that you had moved up one point on the scale?"
• “Can we agree one small step you could take to achieve this?"
Step Four-Once you have identified the small step, then ask:
• “What would need to happen for that to happen?"
• “What would you or anyone else need to do?"
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 36
Crisis Intervention
Step Five-Signal the end of your helping conversation by summarizing what the
person has already achieved and the next step they are going to take.
Key Points
• Give your undivided attention.
• Ask more, tell less
• Project calmness and confidence in your friend
• End on a positive note.
Staying Focused on Solutions
Sometimes people just want to talk and be heard, without the listener doing
anything else. On occasions people will say how helpful a meeting has been
when we have said virtually nothing.
Sometimes however people get trapped in “problem talk”. Constantly revisiting
the problem without standing back and considering possible solutions can leave
everyone frustrated, emotionally wrung-out and psychologically defeated.
So what can you do?
• Make your first response a supportive one (e.g.” It sounds as if you’ve
been having a difficult time / you feel you’ve been treated unfairly.”)
Challenging the person will be more effective once you’ve built a
supportive platform.
• Be curious about what the person is already doing to solve the problem,
rather than be curious about how they are living the problem.
• Ask coping questions, “ How did you deal with that? What helped?” Focus
on the person not the problem.
• Listen for the person’s strengths and useful strategies and reflect them
back to them. “ So despite what has been happening, you are still
managing to…”
• Slow the person down by asking to check out that you’ve understood them
properly. Avoid passive listening.
• When the person lapses back into “problem talk” bring them back on the
solution track. “So that was a problem for you. If you came into tomorrow
and it was just a little better, what would you notice?”
Two final things to help your friend who is facing an emotional crisis do, as you
help them work through it:
Create Awareness- The crisis worker attempts to bring to conscious awareness
avoided, denied, shunted, and repressed feelings, thoughts, and behaviors that
freeze persons’ ability to act in response to the crisis.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 37
Crisis Intervention
Allow for Catharsis-Cry, swear, berate, rant, rave, mourn, or do anything else
that allows them to ventilate feelings and thoughts may be one of the most
therapeutic strategies the crisis worker can employ. To do this, the crisis worker
needs to provide a safe and accepting environment that says, “It’s OK to say and
feel these things.” By doing so the crisis worker clearly says he or she can accept
those feelings and thoughts no matter how bad they may seem to be. A word of
caution here! Allowing angry feelings to continue to build and escalate may not
be the wisest course of action. Allowing for Catharsis is a strategy that is most
often used "with people who can’t get in touch with their feelings and thoughts, as
those feelings are already volcanic.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 38
Suicide Intervention
Emotional First Aid
Training
Session 2
Suicide Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 1
Suicide Suicide Intervention
Intervention
Session
2
“Did you really want to die? No one commits suicide
because they want to die. Then why do they do it? Because
we want to stop the pain.” – Tiffanie DeBartolo
“Happiness is a private club that will not let me enter.” (From
a suicide note)
“As a society, we do not like to talk about suicide.” - David
Satcher, M.D., PH.D, Surgeon General of the United States.
What is Suicide?
The scientific study of suicide-suicidology-may be said to have begun in 1957
with Ed Shneidman and Norman Farberow's publications of suicide notes (1957).
I have adopted the criteria developed by the Centers for Disease Control and
Prevention for the certification of a death as suicide, criteria that are used by
scientists and public health officials, as well as by medical examiners and
coroners.
Suicide is defined, succinctly, as a “death from injury, poisoning, or
suffocation where there is evidence (either explicit or implicit) that the
injury was self-inflicted.”
In today’s medical examination of death there are only 4 classifications for the
Mode of death:
• Natural Causes-Cause Assigned to God
• Accidental-Cause Assigned to God
• Suicide-Cause Assigned to Humans
• Homicide-Cause Assigned to Humans
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 2
Suicide Intervention
Mode of Death and Cause of Death are different. For example, Mode of Death
could be Homicide, and the cause of death could be Blunt Force Trauma.
It is not always difficult to determine that suicide has occurred. Many instances
are unequivocal (Mode of Death is Clear): a gun is nearby, distinctive powder
marks are found, a note has been written, and a psychiatric history or previous
suicide attempt is documented.
At other times the death is equivocal (Mode of Death is Unclear) and evidence
must be pieced together—from autopsy findings, toxicology studies,
psychological autopsy investigations, and statements from the deceased’s family
members, or witnesses to the death—to establish that death was, in fact, self-
inflicted. Intent must also be established.
The evidence may be explicit, that is, verbal or nonverbal expression of intent to
kill oneself, or it may be implicit or indirect, such as (we will identify signs of
suicide in a later section):
• Preparations for death inappropriate to or unexpected in the context of the
decedent’s life
• An expression of farewell or the desire to die or an acknowledgment of
impending death
• Expression of hopelessness
• Expression of great emotional or physical pain or distress
• Effort to procure or learn about means of death or to rehearse fatal
behavior
• Precautions to avoid rescue
• Evidence that decedent recognized high potential lethality of means of
death
• Previous suicide attempt
• Previous suicide threat
• Stressful events or significant losses (actual or threatened)
• Serious depression or mental disorder.”
The method of dying is also important. Coroners and medical examiners, for
instance, tend to view hanging as an almost certain indicator of suicide; this is
also true when death has resulted from carbon monoxide poisoning from the
exhaust pipe of an automobile, plastic bag asphyxiations, and fatal wrist cuttings
or throat slashings. Drowning deaths are far more debatable, however, as they
may result from suicide, accident, or murder. Indeed, most drownings are
accidental.
Deaths in single-car accidents, or head-on collisions with a large weight disparity
between vehicles, also lend themselves to equivocal interpretations about the
cause of death, as do some types of pedestrian deaths and deaths resulting from
falls from high places.
From the viewpoint of a medical examiner, a death that results from playing
Russian roulette would automatically be certified as suicide. `
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 3
Suicide Intervention
In these situations, as in other equivocal circumstances surrounding death, a
retrospective examination of the life and death of the decedent, a so-called
Psychological Autopsy, can provide critical information about intent and state
of mind.
The Psychological Autopsy is carried out by either an individual or a “Suicide
Team” that conducts extensive interviews with family members, friends,
physicians, and colleagues of the decedent in order to clarify the intent to die (if
any) and the degree to which the death was self-inflicted.
There are an estimated 25 suicide attempts for every completed suicide. And
many, if not most, people who attempt to kill themselves do so more than once.
Gender certainly plays a role in both suicide attempts and suicide. Women in the
United States are two to three times more likely to attempt suicide than men.
American men, on the other hand, are four times as likely actually to kill
themselves.
Suicide Notes: Inside the Mind of Someone Who is
Suicidal
The young boy scrawled a note and pinned it to his shirt. Then he walked to the
far side of the family Christmas tree and hanged himself from a ceiling beam.
The note was short—“Merry Christmas”—and his parents never forgot or
understood it.
In fact, few people leave suicide notes. Perhaps 1 in 4 does, and it is unclear if
these notes represent the emotional states, motivations, and experiences of
those who leave behind no written record.
The majority of all suicide notes are positive in their remarks about those they are
leaving behind.
Suicide notes in general have a concrete, stereotypic quality to them. In a series
of studies, genuine suicide notes were compared with simulated ones. The latter
were written by individuals (matched for age, gender, and socioeconomic status)
who had been asked to write suicide notes as they imagined they would write
them if they were planning to commit suicide.
The genuine suicide notes were much more specific about giving directives
concerning property distribution and insurance policies; more concerned about
the pain and suffering they knew would be caused by their acts; more neutral in
tone, although also more likely to express psychological pain; and more likely to
use the word “love” in their texts.
The simulated notes, on the other hand, gave greater detail about the
circumstances and thoughts leading up to the (imagined) suicide; more often
mentioned the act of suicide itself; and more often used non-offensive phrases
for death and suicide.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 4
Suicide Intervention
Suffering, hopelessness, agitation, and shame mix together with a painful
awareness of the often irreversible damage done by the illness to friends, family,
and careers (feeling as if they are a burden). It is a lethal mix.
One woman wrote in her suicide note about her unsuccessful struggle with
mental illness: “I wish I could explain it so someone could understand it. I’m
afraid it’s something I can’t put into words. There’s just this heavy, overwhelming
despair—dreading everything. Dreading life. Empty inside, to the point of
numbness. It’s like there’s something already dead inside. My whole being has
been pulling back into that void for months. Everyone has been so good to me—
has tried so hard. I truly wish that I could be different, for the sake of my family.
Hurting my family is the worst of it, and that guilt has been wrestling with the part
of me that wanted only to disappear. But there’s some core-level spark of life that
just isn’t there. Despite what’s been said about my having “gotten better” lately—
the voice in my head that’s driving me crazy is louder than ever. It’s way beyond
being reached by anyone or anything, it seems. I can’t bear it any more. I think
there’s something psychologically twisted—reversed that has taken over, that I
can’t fight any more. I wish that I could disappear without hurting anyone. I’m
sorry.”
When people are suicidal, their thinking is paralyzed, their options appear limited
or nonexistent, their mood is despairing, and hopelessness permeates their
entire mental domain. The future cannot be separated from the present, and the
present is painful beyond solace.
This sense of the unmanageable, of hopelessness, of invasive negativity about
the future is, in fact, one of the most consistent warning signs of suicide, and
what we will discuss later as Psychache!
People seem to be able to bear or tolerate depression as long as there is the
belief that things will improve. If that belief cracks or disappears, suicide
becomes the option of choice.
ON OCTOBER 29, 1995, twenty-year-old Dawn Renee Befano, a talented
Maryland freelance journalist who had suffered from severe depression for years,
killed herself. She left behind twenty-two journals, which are now in unpublished
manuscript form. Excerpts from the journal written in the weeks leading up to her
death show how unbearable her world had become, how her sense of her
options had constricted them to nonexistence, and how an agonizing, permeating
hopelessness pervaded all reaches of her mind:
October 9th. I will not last another month feeling as I do now. I do not question
that my eyes are brown, and I do not question my fate: I will die a suicide within
the next month if relief does not come relatively quick. I am growing more and
more tired, more and more desperate. I am dying. I know I am dying, and I know
it will be by my own hand.… I am so bone-tired and everyone around me is tired
of my illness. October 10th. Outside the world is crisp and blue, refreshing fall
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 5
Suicide Intervention
weather, beautiful weather. I feel like hell, trapped in a black free-fall. The
contrast between the two makes both seem more extreme. In a strange way,
however, I feel at peace, resigned to my fate. If I do not feel better by the end of
November, I have decided to choose death over madness. I know, one way or
another, that this will all be over with by the end of next month. This will all be
over and done with.… I feel everything and all is pain. I do not want to live, but I
must stick it out until my deadline. October 11th. I’m terrified. What’ll it be, death
or madness? In all honesty, living like this for another two weeks is difficult to
imagine. I can only take so much of this punishment. When I die, all I leave
behind are these journals.… I don’t think I’ll leave a suicide note; these journals
will be more than adequate.
October 17th. I can’t think. All is muddled. I want to sink into sleep, to escape. I
am so tired. To care about anything takes such a tremendous effort. The fog
keeps rolling in. I simply want the world to leave me alone, but the world slips in
through the cracks and crannies. I cannot help that. The goddamn fog keeps
rolling in. Insane. This waiting is truly testing my endurance. I cannot handle it for
much longer. I don’t want to have to handle it. Nobody around me does either.
Nobody.
October 20th. Behold, I am a dry tree.—Isaiah 56:3
October 23rd. I want to die. Today I feel even more vulnerable than usual. The
pain is all consuming, overwhelming. Last night I wanted to drown myself in the
lake after everyone in the house had gone to sleep, but I managed to sleep
through that impulse. When I awoke, the urgency had vanished. This morning,
the urgency is back. I live in hell, day in and day out. Every day, I break down a
little bit more. I am eroding, bit-by-bit, cell-by-cell, pearl-by-pearl. I am not getting
any better. “Better” is alien to me, I cannot get there. They can try acupuncture,
they can try ECT, they can try a frontal lobotomy, none of it will work. I am a
hopeless case. I have lost my angel. I have lost my mind. The days are too long,
too heavy; my bones are crushing under the weight of these days.
October 24th. I am sick, so sick. Impossibly sick.…
October 28th. So this is what the Tibetan Book of the Dead calls “bardo,” the
time between lives. I don’t have any taste for life because I am between lives. A
more optimistic way of putting things, instead of simply, I don’t want to live.… I
will not go back into a hospital. I will simply take a walk into the water. The pain
has become excruciating, constant and endless. It exists beyond time, beyond
reality, beyond endurance. Tonight I would take an overdose, but I don’t want to
be sick, I just want to be dead.
The next morning Dawn woke early. She sat at the kitchen table, ate cold cereal,
and worked on the crossword puzzle from the newspaper. After a short while,
she left the kitchen and was not seen alive again. The bed in her room was made
neatly, according to her mother. There was “a stack of thirteen library books on
the floor, and the contents of her backpack, including keys, cash, and her driver’s
license, stowed in a large envelope. Her great-grandmother’s crystal rosary
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 6
Suicide Intervention
beads were spread out on the bed.” Her body was found months later, floating in
a lake.
Postvention as Prevention
The impact of a suicide death is felt across an entire community. It is a “ripple
effect”, much like a rock thrown into a pond. The Socio-Ecological Model
provides us evidence that when a suicide death is felt in a community, it is the
optimal time to talk about Suicide Prevention.
We need to be comfortable to use Postvention (care after a suicide death) as an
opportunity to teach Prevention and Intervention Skills.
Facts about Suicide
• In 2013 (latest available data), there were 41,149 reported suicide deaths.
• Suicide is the second leading cause of death for ages 10-24.
• More teenagers and young adults die from suicide than from cancer, heart
disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic
lung disease, combined.
• Each day in our nation there are an average of over 5,400 attempts by
young people grades 7-12.
• Four out of Five teens who attempt suicide have given clear warning signs
• Currently, suicide is the 10th leading cause of death in the United States.
• A person dies by suicide about every 12.9 minutes in the United States.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 7
Suicide Intervention
• Every day, approximately 112 Americans take their own life.
• Ninety percent of all people who die by suicide have a diagnosable mental
illness at the time of their death.
• There are four male suicides for every one female suicide, but three times
as many females as males attempt suicide.
• 494,169 people visited a hospital for injuries due to self-harm behavior,
suggesting that approximately 12 people harm themselves (not
necessarily intending to take their lives) for every reported death by
suicide.
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 8
Suicide Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 9
Suicide Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 10
Suicide Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 11
Suicide Intervention
© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 12
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Emotional First Aid Training Manual Nov 2015
Discover the best professional documents and content resources in AnyFlip Document Base.
Search