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Re-conceptualizing the Experience of ‘Crisis’ at the Walk-In

This note is meant to spark conversation, and foreground the tensions and possibilities that emerge when we meet with people at the walk-in counselling clinic who express a compromised sense of personal safety, overwhelming life circumstances, and/or struggle to see the possibilities for their future. I want to recognize that these conversations can be messy- that is slow to progress, difficult to know how to proceed at times, yet have great possibility. While the walk-in counselling clinic is not a substitute for crisis services that provide personal risk assessment, many will attend indicating they are ‘at risk of harm to themselves’. A difficulty is that ‘in crisis’ is somewhat self-defined. Services would rather benefit from clear-cut definitions as a means to match service to the situation however the world full of perceptions does not work that way. When we are working with ‘perception’ and ‘meaning making’ definitions are more fuzzy or obscured than precise. Given this the walk-in counselling clinic is a venue in which people can find assistance and shore up safety. It remains that we must respond to eminent danger as expeditious as possible.

Note:Standards of clinical practice and protocol change over time, and no technique or recommendation is guaranteed to be safe or effective in all circumstances. This presentation will provide a venue to be introduced to ideas and practices in the field of psychotherapy and mental health; it is not a substitute for apprenticeship training, peer review and/or clinical supervision.

Defining risk:

  • A danger of physical harm to self or others

Ex) I’m suicidal, I don’t want to be hear any more, I wish I was dead

  • A danger perceived by someone other than the person (including therapist) of danger to self or someone else

Ex) I could cut until I can’t cut anymore,

  • Self-perceived lack of control over emotions.

Ex) I just can’t stop crying, I wish I would never wake up again.

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Limiting stories:

Stories we hold about ourselves can be limiting in regards to what experiences get noticed and taken up into storylines that sustain people. Some ‘master narratives’ have people more vulnerable to death by suicide and it can be useful to familiarize with these plotlines as warning that safety may be compromised, vulnerable, or fleeting. Some of these plot lines can include:

  • A storied sense of personal burden to those they care about.
  • An eclipsed vision of the possibilities that lie ahead for one’s life.
  • Conclusions about who one is such as worthless, a failure, unlovable
  • A theme of compromised belonging and connection
  • A theme of no way out of a situation such as a sense of being trapped
  • Plotline of hopelessness- little sense of an ability to influence the situation paired with no ideas about what to do

Contextual concerns:

  • Relational isolation- cut off from community and relationships through spatial and social separation.
  • The means/ability to carry out an act such as access to weapons, pills, knives, etc.
  • Severe oppression through relationship, social structures, poverty, racism, etc.
  • Past attempts and loss of family members by suicide
  • An impoverished circle of care/support

Ideas important to us:

  • Meaning making: We are involved in a process of meaning making with the people consulting to us. As such new meanings can be developed and old meanings re-negotiated.
  • Binary thinking: Important to escape the binary of ‘in crisis’/ ‘not in crisis’. Escaping binary views allows for multiple meanings, experiences and identities to be discussed (Fook 2002, p. 13). It helps us to understand that someone arriving noting they are ‘suicidal’ does not reflect a fixed static state.
  • Timing: Although the safety issue is foremost, the time to address it is negotiable and many times most useful to address nearing or at the end of the broader therapeutic conversation. It is anticipated that by the end of the session the person may be standing in the territory of a more preferred identity from which new options for proceeding come available to consider and employ. Or as a problem is externalized and related to context rather than as an aberration of ones mind more options may also come available.
  • Personal agency: The project is to find ways that sponsor personal agency (ability to direct ones own life) rather than solely providing external control.
  • Co-develop safety plans: Nearing the end of the session we can invite the person and family into co-creating safety plans that are contextually relevant. These are plans informed by the person and family, archived for them in their own words, and given to them in a take home document.
  • Circles of care and concern are co-develop: With the person involved we can co-identify and co-create circles of care including people who will shoulder up the person in distress and assist with ensuring safety should the distress become overwhelming. These persons can include close relations, friends, and professionals who may play a temporary part in shouldering the person up.

A Brief Narrative Ear

  • We “gain a sense of people through their expressions of life [italics added] not through speculations of their biology and psychology”(Geertz, 1986)
  • “Expressions of life” become the focus of interest as they represent meanings forged in the day-to-day living of a life.
  • Every expression is plural
  • People’s lived experience is the point of entry for our investigation, joint exploration and mutual discovery.
  • We listen for what the story can teach us about the persons own ‘know-how’ and local knowledge- the skills, abilities, hopes, preferences for life and relationships, conclusions reached about life and relationships specific to them.

Listening Doubly

As we hear the story of pain, distress, conflict, etc., we continue to listen for expressions that speak to what people give value to. “Listen for signs of what the person has continued to give value to in life despite all that they have been through…” (White, 2003).

We listen for what their expressions of life say about what’s important to them, their preferences, hopes, beliefs, moral codes, commitments that all can be brought into stories in the making. (See White 2003)

Non-structural listening

“Through non-structuralist enquiries we become fascinated with the particularities of people’s lives, their actions that are an expression of certain intentions, commitments, principles, hopes, dreams, passions, and beliefs” (White, 2006, pp. 118).

Listening for what is not said but implied

In sharing what an experience is - it is implied what it is not. We are listening for discernment. We understand a ‘complaint’ as an action. This absent but implicit (White 2003) provides entry points to many offshoots to possibility.

The Experience of Crisis as a Rite of Passage:

  • Re-conceptualizing ‘crisis’ as a rite of passage. White and Epston 1990 propose understanding the experience of crisis as relating to “…some aspect of a transition in a person’s life (p. 7.)”.
  • This transition can be both a shifting in someone’s role as well as identity.
  • Understanding the experience of crisis as shaped by a transition in life we are oriented by the analogy of the ‘rite of passage’ (van Gennep, 1961, Turner, 1969).
  • The rite of passage analogy highlights three phases in a transition- separation, liminal, and reincorporation.

Separation Phase: suggests a departure from the known and familiar, releasing an old life, separating from a status, the beginning of a journey, in a sense, towards difference. Within this phase there may be preparations made, a readying, and the packing of tools or aids for the journey ahead.

Liminal phase: is often accompanied by struggle, confusion, and disorganization and discomfort. It is a time of seeking clarity and of a becoming. One’s status or identity comes under review and possibly revision.This is a storehouse of possibilities. You are between statuses or roles.

Reincorporation phase: marks a moment of arrival somewhere more preferred, at some new status leading to new proposals for action.

Thus the rite of passage analogy shapes several kinds of questions available to us in a single session. White and Epston 1990 p.8 highlight several domains of inquiry informed by these phases “…that invite persons to determine:

a)What the crisis might be telling them about what they could be separating from that was not viable for them- perhaps certain negative attitudes that they have towards themselves or that others have towards them, or expectations and prescriptions for their life and relationships that they experience as impoverishing;

b)What clues the crisis gives about the new status and roles that could become available to them

c)When, how, and under what circumstances these new roles and status might be realized”.

Lipchik, E. (2002). Beyond technique in solution-focused therapy: Working with emotions and the therapeutic relationship. New York: The Guilford Press.

Fook, J. (2002). Social Work: Critical theory and practice. Sage Publications, CA

Turner, V. (1969). The Ritual Process: Structure and anti-structure. Aldine.

Van Gennep, A. (1961). The Rites of Passage. University of Chicago Press

White, M. & Epston, D. 1990: Narrative Means to Therapeutic Ends. New York: W.W. Norton.

White, M. (2003). Narrative practice and community assignments. The International Journal of Narrative Therapy and Community Work, No.2.

White, M., & Morgan, A. (2006). Narrative therapy with children and their families. Adelaide, South Australia: Dulwich Centre Publications.

Scot J. Cooper RP Brief Narrative Practices,  Canada

(web site)  (e-mail)905-765-5956 (phone)