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Article Excerpt
The frequency of serious client crises confronting human service professionals has escalated to such proportions that crises have been referred to as an "occupational hazard" in the professional literature. Nearly a third of all practicing mental health counselors can expect to encounter the suicide of a client at some point in their careers; nearly two thirds should anticipate a client's suicide attempt (Schwartz & Rogers, 2004). Violent behavior in school-age children has more than doubled in the past 20 years, and the violent acts they commit have become significantly more dangerous (McAdams, 2002; McAdams & Lambe, 2003). The occurrence of severe psychiatric disorders (e.g., schizophrenia, bipolar disorder, panic disorder, obsessive-compulsive disorder) has doubled since 1985, making them the largest and fastest-growing diagnostic category for federal programs providing assistance to individuals with disabilities (Torrey, 2002). Community and school counselors often provide the first line of intervention for persons in psychological and emotional crisis and in need of specialized interventions and support methods (American School Counselor Association, 2000; Lester, 2002). Despite this, there is a curious absence in counselor preparation, certification, supervision, and ethical practice standards of a consistent or comprehensive guideline for crisis prevention/intervention and postcrisis recovery.
National and state standards for professional counseling address the need for attention to crisis preparation and appropriate response; however, they do not specify the type or level of attention necessary to minimize the risk of crises and maximize the effectiveness of crisis intervention and the potential for full postcrisis recovery among all those affected. For example, in its current standards for counselor preparation, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) specifies that counselors possess "knowledge of prevention and crisis intervention strategies" (CACREP, 2001, Section B.7.). The standards do not indicate what type or minimum level of knowledge and skill proficiency are necessary for effective crisis response.
In granting the National Certified Counselor credential, the National Board for Certified Counselors (NBCC) does not require counselors to be trained specifically in crisis response; rather, it specifies in its ethical code that counselors "offer only professional services for which they are trained or have supervised experience" (NBCC, 1997, p. 2). By definition, the practice of professional counseling includes crisis response (U.S. Department of Labor, 2003); thus, an NBCC expectation of formal counselor preparation in crisis response is clearly implied in this ethical standard. Licensure standards for counselors vary from state to state. However, as increasing numbers of state licensing bodies align their preparatory and proficiency criteria with the CACREP and NBCC criteria, respectively, a similarly imprecise licensing standard for crisis response competency can be anticipated.
The Ethical Guidelines for Counseling Supervisors of the Association for Counselor Education and Supervision (ACES) specify that "procedures for contacting the supervisor, or an alternative supervisor, to assist in handling crisis situations should be established and communicated to supervisees" (ACES, 1993, p. 2). The importance of supervision in client crisis response is made clear in this guideline; the specific role of supervision in crisis response is not.
National standards for ethical counseling practice are similarly nonspecific with regard to the counselor's role in responding to client crisis response. Most applicable is Standard C.2. of the American Counseling Association's (ACA) Code of Ethics, which prohibits counselors from performing their role without adequate preparation (ACA, 2005, p. 9). Without further elaboration in the Code, a required but un defined standard of acceptability has once again been set for counselors in the performance of their named responsibility in crisis response.
* The Risks of Inconsistency
The absence of a consistent and comprehensive conceptual framework for serious client crises in professional counseling poses a risk for the profession on several levels. Of foremost concern is that without a conceptual framework, there can be no assurance that counselors are adequately prepared to perform a core aspect of their service to clients. Recent research findings suggest that, in fact, counselors may not be prepared. For example, studies of practicing high school counselors have found that up to two thirds of these professionals believe that they could not recognize a student at risk for suicide (King, Price, Telljohann, & Wahl, 2000). Surveys of practicing mental health counselors have reported similar percentages of counselors who believe that they are unprepared to anticipate or manage violent behavior in clients, despite the high probability that these professionals will encounter such behavior (Shields & Kiser, 2003). These concerns about preparedness for client crisis response have been voiced by counselors having a wide range of education and experience (McAdams & Foster, 2000).
A second concern is an unnecessary risk of malpractice litigation. Listed among the major causes for successful malpractice suits brought against mental health service providers in the United States is "incorrect treatment--e.g., using treatments the therapist was not qualified to perform by lack of training or experience" (American Psychological Association, 2003, p. 436). Counselor performance in crisis response is and will remain unnecessarily vulnerable to legal scrutiny until specific standards for counselor education and, subsequently, "qualification" in crisis response are more clearly identified.
A third, and often underestimated, risk is potential detriment to the personal and professional development of the responding counselors. In the aftermath of major crises such as a client's suicide or physical violence, counselors have reported feelings of guilt, sadness, anger, and increased fear in dealing with at-risk clients; these feelings remained at intrusive or even debilitating levels for years after the event (LaFayette & Stern, 2004; McAdams & Foster, 2000, 2002). The risk of psychological and professional impairment has been shown to be especially great when crises occur while the counselor is a student or novice who is less able to balance a sense of personal failure against limitations inherent in the counseling process (McAdams & Foster, 2002; Trimble, Jackson, & Harvey, 2000).
Fortunately, research has shown that precris is education and rehearsal can reduce the risks of negative outcome in client crisis response. Professional "survivors" of client suicide and serious client violence have reported consistently that preparation for the crises is a prerequisite for competent intervention, coping with crisis impact, and moving forward in the professional's personal and professional lives (Kanel, 2003; McAdams & Foster, 2000, 2002). Some survivors who were well-prepared in advance for a crisis and supported adequately in its aftermath have even reported that the impact of the experience was ultimately positive, yielding such outcomes as heightened awareness of their own limitations and general sensitization to factors that predispose individuals to experience critical incidents (Kleespies, 1993; McAdams & Foster, 2002). Effective preparation, thus, can be a critical factor in determining crisis outcome. This finding highlights the need for a consistent and well-informed conceptual framework for client crisis response in counseling.
* The Preparation, Action, Recovery (PAR) Framework
In developing such a framework, much can be learned from the existing research literature regarding the two mental health emergencies that are dreaded most by mental health professionals: client violence and client suicide (Allen et al., 2002; McAdams & Foster, 2000). Client violence has been shown to occur not as a spontaneous, isolated event, but rather as an unfolding sequence of interrelated and often recurring events of which the crisis episode is but a single part (Breakwell, 1997; Treishman, Whittaker, & Brendtro, 1971; Walker, Colvin, & Ramsey, 1995). The primary phases in this sequence or cycle of violence include (a) predisposing or precipitant events, (b) events defining the crisis itself, and (c) events specific to crisis aftermath, with each phase requiring appropriately matched counselor responses aimed, respectively, at crisis prevention, deescalation, and recovery.
Research in the area of client suicide has suggested a similar sequential progression toward crisis conditions and a need for differential assessment and intervention during each phase of the crisis, specifically onset, occurrence, and aftermath (Laux, 2002). Unique to the crisis of client suicide, however, is the irremediable loss of the client and the especially pressing need in crisis aftermath for a shift in counseling focus from client to survivor (including counselor) recovery. Client suicide studies have called attention to the potentially damaging impact of any serious crises on attending clinicians and to the need for varied forms of support for clinicians before, during, and after a crisis episode (McAdams & Foster, 2000). The research findings have prompted the development of structured models to prepare clinicians for crisis impact and assist them in personal and professional recovery (Brown, 1987b; Haley, 2004; Kleespies, 1993).
By integrating current knowledge...
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