A Case of Critical Incident Counselling

Author: Grahame Smith

Wilma is a 36-year-old married mother of 4 children. Wilma has been divorced previously and was subjected to psychological and physical abuse by her former partner. Much of the abuse issues had been resolved previously in counselling 12 months earlier. Wilma gave permission for C to contact her former counsellor to obtain relevant information on her earlier difficulties.

Currently she appears to be happily married to her husband Bill. She does not appear to suffer from any major health issues. She works as a casual employee of a Care Organisation in a country area, performing the role of a night supervisor in a hostel for mentally challenged adults. Wilma has only been in this position for a short time. She explained that her employer had provided induction training but had not covered particularly well the issue of how to manage aggressive clients.

She explained that very recently she had been subjected to a critical incident at work having to face a violent client going through prescribed psychotic drug withdrawal, who suffers from violent mood swings, paranoia and what appears to be bipolar depression. At one point Wilma had to lock herself in her office to protect herself from the out of control client. The client was hallucinating, threatening violence and swearing. She had to call for police assistance and then attempted to protect her other clients from harm while waiting for police. Wilma contacted me for assistance, as she felt traumatised by the incident.

Wilma explained that she now doubted her abilities to do her job effectively in the future, was fearful about going back to work and blamed herself for not bringing the client under control. She believed her actions had put her other clients at risk, and she felt inadequate because she fell apart emotionally after she had called the police. She also explained she found it difficult to even cope with hearing sirens from an ambulance or police car (but she admitted that this reaction was now fading).

In a previous session (12 months earlier), a Personality Need Type Profile was prepared for Wilma. She was assessed as having a moderate to strong “D” Type needs (a stronger need to achieve), which means that her recent attempt to start her career again after having children is important for her in meeting her current career goals. The critical incident she experienced has damaged her self-esteem and shaken her confidence in her ability to be successful in her chosen career.

Thus some of the presenting issues caused by Critical Incident Stress (C.I.S) as revealed by Wilma were seen to be:

• Doubting her abilities to do her job effectively
• Being fearful about going back to work
• Blaming herself for not bringing the client under control
• She believed her actions had put her other clients at risk
• Felt inadequate because she fell apart emotionally after she had called the police
• Hypersensitive to loud noises coming from sirens (ambulance or police cars).
• Overall loss of self esteem and reduced professional confidence levels

Background Information

So what is the source of this type of stress, which requires effective intervention as soon as possible after the event has occurred? Such stress can come from what is called a ‘critical incident’, such as a sudden death in the line of duty, serious injury from a shooting, a physical or psychological threat to the safety or well being of an individual or group regardless of the type of incident.

A critical incident can involve any situation or events faced by emergency service personnel and health workers, or an individual, which causes a distressing, dramatic or profound change or disruption in their physical or psychological functioning. Often there are very strong emotions attached to these events, which have the potential to interfere with the person’s ability to function either at the crisis scene or away from it (Davis, 1993).

When a person has been exposed to a critical incident, either briefly or long-term, this exposure can have considerable impact on their ability to function. Over time researchers began to find evidence that emergency workers, public service personnel and people responding to crisis situations, rape victims, abused spouses and children, stalking victims and media personnel, as well as individuals who were exposed to a variety of critical incidents (e.g. fire, earthquake, floods, industrial disaster, workplace violence) all developed short-term crisis reactions.

Following on from these stages, four recovery tasks are recommended to be followed during counselling (Tunnecliffe 2002).

1. Stabilisation – shield person from further threat.
2. Management – meet their needs.
3. Mobilisation – assist and encourage the person to take back control.
4. Restoration – assist person to normalise their functioning.

Session Content

In the session, C sought Wilma’s permission to ask questions about the incident she had experienced while at work. Wilma said that she was prepared to do that, but the thought of talking about it upset her. C told Wilma she was doing very well and suggested she take her time in telling her story. This encouraged Wilma to continue with her story.

C asked Wilma if there had been any other times in her life where she had experienced the concerns she now was going through. Wilma replied: “I have experienced similar fears during a past relationship where I was abused. I have not had this fear for many years”. C asked Wilma how she had resolved these past fears. “I got through them through counselling and with my new husband’s support”. C congratulated Wilma on her courage in talking about her past fears and also on wanting to talk about her recent frightening event at her work.

C said that counselling seemed to have helped Wilma in the past and she agreed that it had helped a lot. C then asked her if she believed it could help her now, and Wilma said that she thought it would.

C then asked her to describe what happened on the night of the incident. Wilma said: “I was on duty that night and in charge of the hostel. One man who has been a problem in the past was very angry. He became violent as he was going through what (I was told later) was called a “prescribed psychotic drug withdrawal”. This man suffered from violent mood swings, paranoia and bipolar depression. He was screaming at the top of his lungs about how he was going to hurt someone, he was swearing and hurling abuse into the air.”

C said this must have been very frightening for her; Wilma replied: “I was terrified, I was so worried he may hurt another client or even myself. I tried to calm him down but I couldn’t.”

C then asked Wilma a scaling question to measure the anxiety levels she was feeling at the moment. C asked Wilma on a scale of 1 – 10, where 1 is no anxiety and 10 is a great deal of anxiety, what she was feeling at the moment. Wilma: “I am feeling quite anxious, about 7 or 8. C again reassured Wilma that she was doing very well.

C then asked Wilma another scaling question to measure her fear of going back to work. Wilma said: “I am feeling quite fearful about that, a 7”. C again told Wilma she was doing very well and encouraged her to continue.

C then asked Wilma what she did next. Wilma: “I decided to put all the other clients in their rooms and told them to stay in their rooms. I then managed to avoid him in the hallway and locked myself in the office; then I called the Police”.

C asked Wilma what she said to the Police; Wilma: “I told them I was terrified of the man and that I thought he would hurt someone if they didn’t come soon.”

C could see Wilma was becoming quite upset so stopped the discussion and gave Wilma a drink of water. C told Wilma she was very brave and was doing a great job in describing what had happened to her. During this time Wilma cried. C validated her right to be upset and explained to Wilma that anyone else going through a similar experience would find it terrifying. Wilma said: “I was so scared, I thought he was going to hurt someone and I couldn’t stop him. I failed them all, my employer and myself”.

C then asked Wilma to describe her reasons for the steps she took that night. Wilma: “Well, he was so big I knew I couldn’t do anything physically, so I decided to hide the other clients in their rooms to keep them safe. To protect myself I locked myself in the office. Not knowing what else to do I called the Police and then my boss”. C assured Wilma that she had done the right thing.

C asked Wilma to describe what both the Police and her boss had said to her. Wilma hesitated for a moment and then said: “The Police told me they knew about this man already because he had caused problems in the past and they said they would come straight to the hostel. My boss told me I had done the right thing and would come immediately to help me.”

C then asked Wilma whether any of her clients got hurt, to which Wilma replied that none were harmed in the incident.

C then asked Wilma what she knew of her employer’s rules in regard to her ‘duty of care’ responsibilities in relation to what had happened.

Wilma took some time before answering this question. She had made it clear she blamed herself for failing to stop the man, and also felt she had failed her charges and her employer.

Finally she said: “I guess they would expect me to protect myself and the clients”. C then asked Wilma if she had been able to do this. Wilma said: “Yes, if I look at it that way, then I did do the right thing”. C agreed that she had.

C again congratulated Wilma on her courage and quick thinking during the confrontation with the violent client.

C then asked Wilma the same scaling question to measure her current anxiety levels. Wilma said that she was feeling much more at ease, about a 3.

One of the key areas C was determined to examine was the definition of ‘duty of care’ and what Wilma’s employer expected from her. From what Wilma described, she had confused her responsibility to manage challenging behaviours with violent behaviours. C was able to demonstrate to her that she had actually correctly discharged her duty of care. By attempting to calm the client initially and when this failed, successfully getting the rest of her clients into their rooms, and then locking herself into her office and calling for police assistance she had in fact fulfilled her duty of care. Once she realised this, her self esteem rose significantly.

C asked Wilma to consider her emotional reaction at the time of the incident and asked her if she regarded her reaction as inappropriate. Wilma: “Yes, at the time I did. I was just so scared”. C then asked her if her fear had stopped her from doing her job correctly; Wilma said: “No, I guess it didn’t”. C then asked Wilma how she thought other people might react in a similar situation, and Wilma said that she thought most people would be scared, too.

This realisation validated her right to be fearful, and she was then able to see that her emotional reaction was a normal response to an abnormal situation.

C then asked Wilma how her husband had reacted to the incident. Wilma said he had been very supportive, but he didn’t want her to go back to work unless her safety at night was assured.

C asked Wilma what she thought should be done about making her workplace more safe. Wilma: “I have already asked my boss to review our policy on how to manage difficult and violent clients. I told her that this would help me to return to work. I think it is a positive step.”

C then asked Wilma about her initial training and induction into her job. Wilma said that she didn’t get a great deal, just one day of orientation. C explained that under the Occupational Health & Safety legislation her employer had an obligation to provide her with a skill base to help her manage difficult and violent clients. Wilma felt that knowing this gave her a better base from which to discuss with her boss ideas for improving the safety arrangements for the night shift.

C then asked Wilma the scaling question again to measure her anxiety levels about going back to work. Wilma said that she was feeling much more at ease about it, probably a 3.

Towards the end of the counselling session, C requested that they take a break before summarising the goals and outcomes for Wilma. C used the break to prepare some feedback to give to Wilma.

At the end of the session Wilma and C further explored some goals she would work towards when she left the session. They agreed that Wilma would:

• Sit down with her boss and go through the incident using a new safety policy as a guide.
• Seek further training in how to manage difficult and/or violent clients.
• Ensure that she takes the full two weeks leave offered by her employer.
• Monitor her sleeping patterns and anxiety levels and seek medical assistance if necessary.
• Request Employee Assistance Program intervention if necessary as supplied by her employer.

At the end of the session Wilma felt more comfortable with how she saw herself, recognising that her reactions were normal and that she was not a workplace failure.

References

• Davis, J. A. (March, 1993). On-site critical incident stress debriefing field interviewing techniques utilized in the aftermath of mass disaster. Training Seminar to Emergency Responders and Police Personnel, San Diego, CA.
• Tunnecliffe.M. (2002). Key Elements of Crisis Counselling. A paper presented at the Convention of the Critical Incident Stress Foundation of Australia, Melbourne 2002.