Crisis Intervention: Assessment & Practical Strategies

The following brief case study illustrates how one can work with a chronic psychi­atric patient in a community mental health center using the crisis model.

Assessment of the individual and his problem
Jim, a man in his late thirties, was brought to a crisis center by his sister because, as she stated, "he was beginning to act crazy again." Jim had many prior hospitalizations, with a diagnosis of paranoid schizophrenia. The only thing Jim would say was, "I don’t want to go back to the hospital." He was told that our role was to help him stay out of the hospital if we possibly could. A medical consultation was arranged to determine if he needed to have his medication increased or possibly changed.

Information was then obtained from his sister to determine what had happened (the precipitating event) when his symptoms had started and, specifically, what she meant by his "acting crazy again." His sister stated that he was "talking to the television set . . .muttering things that made no sense . . . staring into space . . . prowling around the apartment at night," and that "this behavior started about 3 days ago." When questioned about anything that was different in their lives before the start of his disruptive behavior, she denied any change. When asked about any changes that were contemplated in the near future, she replied that she was planning to be married in 2 months but that Jim did not know about it because she had not told him yet. When asked why she had not told him, she reluctantly answered that she wanted to wait until all of the arrangements had been made. She was asked if there was any way Jim could have found out about her plans. She remembered that she had discussed them on the telephone with a girl friend the week before.

She was asked what her plans for Jim were after she married. She said that her boyfriend had agreed, rather reluctantly, to let Jim live with them.

Since her boyfriend was reluctant about having Jim live with them, other alternatives were explored. She said that they had cousins living in a nearby suburb but that she did not know if they would want Jim to live with them.

Planning the intervention
It was suggested that Jim’s sister call her cousins, tell them of her plans to get married and her concerns about Jim, and in general find out their feelings about him living with them. The call was placed, and she told them her plans and concerns. Fortunately their response was a positive one. They had recently bought a fairly large apartment building and were having difficulty getting reliable help to take care of the yard work and minor repairs. They felt that Jim would be able to manage this, and they would let him live in a small apartment above the garage.

Intervention
Jim was asked to come back into the office so that his sister could tell him of her plans to marry and the arrangements she had made for him with their cousins. He listened but had difficulty comprehending the information. He just kept saying, "I don’t want to go back to the hospital."

He was asked if he had heard his sister talking about her wedding plans. He admitted that he had and that he knew her boyfriend would not want him around—"they would probably put him back in the hospital." As the session ended he still had not internal­ized the information he had heard. He was asked to continue in therapy for 5 more weeks and to take his medication as prescribed. He agreed to do so.

By the end of the sixth week he had visited his cousins, seen the apartment where he would be living, and had discussed his new "job." His disruptive behavior had ceased, and he was again functioning at his precrisis level.

Anticipatory planning
Since Jim had had many previous hospitalizations and did not want to be rehospitalized, time was spent in discussing how this could be avoided in the future. He was given the name, address, and telephone number of a crisis center in his new community and told to visit them when he moved. He was assured that the center could supervise his medication and be available if he needed someone to talk to if he felt he again needed help.

Summation of paradigm
Jim’s sister neglected to tell him about her impending marriage, which he perceived as rejection. Because of his numerous hospitalizations, he feared that his sister would have him rehospitalized "to get rid of him." He was unable to verbalize his fears, retreated from reality, and experienced an exacerbation of his psychotic symptoms. The therapist adhered to the crisis model by focusing the therapy sessions on the patient’s immediate problems, not on his chronic psychopathology.

Personal Reflection Exercise #2
The preceding section contained information about a case study of crisis intervention with a paranoid schizophrenic client.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
How did Jim’s therapist adhere to the crisis model when addressing his crisis state? Record the letter of the correct answer the CEU Answer Booklet.