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Interviewing a person in crisis who presents psychotic and "crazy" material often is a very anxiety-producing experience. The inexperienced counselor tends to fear that if he is not careful or asks the wrong question, he may cause the client to become even more psychotic. Worse yet, he may incite the client to become violent. This, in fact, rarely occurs, unless it is with someone who is quite paranoid, and even then it is the exception rather than the rule. If the counselor pays close attention to the cues and signals that the client produces, indicating a state of irritation and agitation, there is little chance he will unwittingly provoke the client. Such body language as extreme movement, gesturing and posturing, wringing and shaking of the hands, alternately crying and laughing, and other agitated responses to the crisis situation should alert the counselor to the potential disturbing state of the client. In addition, the counselor should pay careful attention to the specific responses elicited from the client when the counselor explores particular areas. Counseling with a potentially psychotic client requires that the counselor observe closely the manner in which the client responds to the questions asked by the counselor or family member. In this context, also pay attention to such physiological cues as excessive sweating, color and flush of the face, rate and speed of breathing, etc.
Note also the manner in which the client answers the counselor’s request for information. If, for example, the counselor notices that the client wanders in his answer or brings up some bizarre or grossly unrelated material, this should signal the counselor to become more structured in his interviewing approach. If, in addition to these loose associations in the client’s responses, there is substantial evidence of very powerful emotionality, the counselor should begin to suspect a possible psychotic condition. Yet the same suspicion ought to be aroused when the client is so devoid of affect and emotional expression that he severely underplays the importance of obviously critical occurrences in his life.
The counselor must seek to avoid needless agitation of a severely disturbed client. It is not necessary to encourage such a client to ramble on endlessly without a specific purpose in mind other than expression for its own sake. The excessive provocation of an already severely disturbed person may actually contribute to his decompensation, the very outcome the crisis counselor is committed to prevent.
In the case of Shirley, the counselor had little prior information that would have prepared her for what developed during the interview. Crisis counseling frequently involves an element of surprise. The presenting problems may not always truly reflect what the counselor will actually see in the interview. While this is a time-honored principle with all forms of counseling and psychotherapy, it is particularly true in crisis work. While we do not advocate that every counselor be prepared for the worst, we do underscore vigilance and the ability to shift techniques to refocus the course of the interview in accordance with the needs of the client. On more than one occasion a client has presented himself as being in a moderate state of crisis when in actuality he was severely disturbed, revealing homicidal, suicidal, or psychotic material. Even all the preparatory information that the counselor may have prior to seeing the client may not be sufficient. A flexible stance and the ability to deal with surprises is thus a valuable skill. Simply having a concern for people and caring for them, in our view, is not enough. A combination of human concern, technical skill, and good judgment distinguishes the successful crisis counselor.
The reader should take careful note of the way in which this counselor conducted the interview. To begin with, note how she used a combination of open- and closed-end questions in accordance with needs of the immediate situation. A good example of the open-end approach is the question "What do you mean upset?" And then, shortly after that: "What are your past experiences?" Notice on the other hand that the counselor did not overuse the open-end question. Most of her questions were designed to secure specific information pertaining to the immediate crisis. For example, she asks, "Why did you go to the hospital last night?" and then, "How have you been sleeping the last few nights?"
There are also sequences of questions in which the counselor sets the tone of the interview; questions that tell the client that structure is the mode of interaction. Note the series of questions beginning with: "Could you see him?" and ending with: "What happened when you got all upset?" Having secured the necessary information, the counselor then shifted back to a more open-end approach, confident that the client could discuss the material without undue stress. Furthermore, the counselor saw no advantage in dwelling upon the specifics of the hallucinatory and delusional material. A further analysis of this material itself might have been more appropriate in a less emergent situation, but not in a crisis interview.
The skillful use of bridging techniques can be found at several points in the interview: "Thoughts of. . . ?" and "What kind of smells?" Then notice how the client is able to respond to these rather minimal cues to continue. This use of bridging also tells the counselor how well able the client is to deal with the content. in addition, it suggests to the counselor just how much structure to offer the client in the future. Remember, one of the goals is to encourage the client to develop his story at his own pace and without too much interference from the counselor. When the client is able to handle the kinds of subtle signals this counselor offers, the counselor learns a little more about his client’s mental state. This, in turn, influences the kind of treatment intervention plan that the counselor will be offering his client. If everyone who presented psychotic material were to be placed in a hospital, our mental health facilities would be even more overtaxed than they are now. And there is ample research indicating that hospitalization need not always be considered the primary mode of intervention (Mendel and Green 1967).
One question that was never cleared up during the course of the interview was whether the client’s father was her natural father or her stepfather. It was learned later that he was her stepfather. This fact might well have been clarified at the time of the interview, as it alters our perception of the problem. The incest taboo may have evoked anxiety in the counselor leading her to overemphasize the psychotic content. A further point needing clarification is whether the sexual events did in fact take place or whether they were part of the client’s psychotic delusional system. The counselor reports that by the time the stepfather information came out she was rather overwhelmed with what material she already had and didn’t think to clarify it. The sense of being overwhelmed in a case like this is a fairly typical response by crisis workers regardless of their experience.
Two final comments. First, the counselor did not inquire into the possibility of this client being a danger to herself or others, and that was an oversight. While it is not always necessary to get into the specific question of "how suicidal are you?" the counselor would have been well advised to learn more about how the client handled herself when besieged by the evil forces she described. The second point is that the counselor should have considered bringing the relative into a more active role during the evaluation and treatment process. This could have been accomplished by perhaps interviewing Shirley and her aunt together initially. If this proved too much for the client, then they could have been interviewed separately. If the counselor could not see them conjointly, then at least she could have spent time with the aunt—in a collateral way—in a separate interview. This could very well have added some factual data to those areas of discrepancy mentioned earlier. Whenever possible and appropriate, the counselor should include friends and close relatives in the crisis intervention plan. In fact, their inclusion may often provide the additional support needed to enable the client in crisis to mobilize his or her resources more fully (Getz et al. 1974). As it turned out, that was what happened in this case with regard to transportation and supervision of medication. As a final note, you may recall Beck’s (1971) frequent failure to locate a specific precipitating event among patients diagnosed as schizophrenic. The apparent lack of such an event in Shirley’s case may have been useful in making a differential assessment.
- Getz, William, Allen E. Wiesen, Stan Sue, and Amy Ayers; Fundamentals of Crisis Counseling; Lexington Books: Massachusetts; 1974
Personal Reflection Exercise #6
The preceding section contained information about strategies for requesting information during the crisis interview. Write three case study examples regarding how you might use the content of this section in your practice.