mental health crisis intervention case study

Vera Institute of Justice

Case study: cahoots.

Eugene, Oregon

Jackson Beck

Melissa Reuland

Amid national conversation in recent months about reducing policing’s footprint in behavioral health matters, the Crisis Assistance Helping out on the Streets (CAHOOTS) program in Eugene, Oregon, has received particular attention as a successful and growing alternative to on-scene police response. Staffed and operated by Eugene’s White Bird Clinic, the program dispatches two-person teams of crisis workers and medics to respond to 911 and non-emergency calls involving people in behavioral health crisis—calls that in many other communities are directed to police by default. CAHOOTS units are equipped to deliver “crisis intervention, counseling, mediation, information and referral, transportation to social services, first aid, and basic-level emergency medical care.” [ ] White Bird Clinic, “CAHOOTS FAQ,” accessed August 18, 2020, https://whitebirdclinic.org/ca... . All services are voluntary. If the situation involves a crime in progress, violence, or life-threatening emergencies, police will be dispatched to arrive as primary or co-responders. [ ] Ibid. CAHOOTS teams deliver person-centered interventions and make referrals to behavioral health supports and services without the uniforms, sirens, and handcuffs that can exacerbate feelings of distress for people in crisis. They reduce unnecessary police contact and allow police to spend more time on crime-related matters. Eugene police may also request assistance if they arrive on-scene and determine that a CAHOOTS team can help resolve a situation.

This case study explains how CAHOOTS teams are funded, dispatched, staffed, and trained—and how a long-term commitment between police and community partners has cemented the program’s success.

Funding CAHOOTS through the police

The City of Eugene has long supported CAHOOTS through the Eugene Police Department (EPD) budget as an essential part of the community’s crisis response system, beginning in 1989 when EPD funded the first CAHOOTS shift. [ ] Tatiana Parafiniuk-Talesnick, “In Cahoots: How the Unlikely Pairing of Cops and Hippies Became a National Model,” The Register-Guard , October 20, 2019, https://www.registerguard.com/... . In June 2016, the Eugene City Council increased the program’s funding by $225,000 per year to allow for 24/7 service. [ ] Ellen Meny, “CAHOOTS Starts 24-Hour Eugene Service in January 2017,” KVAL, December 12, 2016, https://kval.com/news/local/ca... . Funding increases have continued over the last few years to allow for overlapping, two-van coverage as the call volume for CAHOOTS has grown. [ ] City of Eugene Police Department, “CAHOOTS,” https://www.eugene-or.gov/4508/CAHOOTS .

After years of working with police in Eugene, White Bird expanded CAHOOTS services to the neighboring community of Springfield in 2015, when Lane County administered an Oregon Health and Human Services grant for the program. [ ] Parafiniuk-Talesnick, “In Cahoots,” 2019; Tim Black, operations coordinator, CAHOOTS, April 17, 2020, telephone call. Between Eugene and Springfield, CAHOOTS is now funded at around $2 million annually—about 2 percent of their police departments’ budgets. [ ] Anna V. Smith, “There’s Already an Alternative to Calling the Police,” High Country News , June 11, 2020, https://www.hcn.org/issues/52.... .

Dispatching CAHOOTS for ‘better customer service’

A key element of White Bird’s partnership with police is that CAHOOTS staff carry a police radio that emergency dispatchers use to request their response to people in crisis on a special channel. The channel can get “overwhelmed,” Eugene officer Bo Rankin explained, by the increasing number of requests for CAHOOTS teams. [ ] Officer Bo Rankin, Eugene Police Department, February 25, 2020, telephone call. Of the estimated 24,000 calls CAHOOTS responded to in 2019, only 311 required police backup, and in Eugene, CAHOOTS teams resolved almost 20 percent of all calls coming through the city’s public safety communications center. [ ] Black, September 10, 2020, email; and Trevor Bach, “One City’s 30-Year Experiment with Reimagining Public Safety,” U.S. News & World Report , July 6, 2020, https://www.usnews.com/news/ci... .

Of the estimated 24,000 calls CAHOOTS responded to in 2019, only 311 required police backup...

The center is housed in EPD and tasked with receiving and dispatching all police, fire, and CAHOOTS calls. [ ] Marie Longworth, communications supervisor, Eugene Police Department, May 4, 2020, telephone call. With the CAHOOTS program embedded in Eugene’s communications system, Eugene dispatchers are empowered to use this non-police alternative to handle non-police issues.

The police department and CAHOOTS staff collaboratively developed criteria for calls that might prompt a CAHOOTS team to respond primarily, continuing to adapt them based on experience; the protocol is used as a guide rather than a rule. For example, when a call arrives at Eugene’s communications center, through either 911 or the community’s non-emergency line, call-takers listen for details that might fit these criteria. As Eugene communications supervisor Marie Longworth put it, sending CAHOOTS rather than police is often regarded as “better customer service” for community members requesting assistance for themselves or others. [ ] Ibid.

Official Eugene communications protocol for CAHOOTS

Longworth also notes that CAHOOTS’s relationships in the community help dispatchers connect people with appropriate responders. The communications center sometimes gets direct requests for CAHOOTS. In other cases, because of their familiarity with community members and their specific needs, CAHOOTS teams have demonstrated comfort taking on calls that would otherwise go to police. [ ] Ibid.

Staffing and training

Robust recruitment and training underpin the success of CAHOOTS teams. CAHOOTS medics typically bring EMT certifications and experience within fire departments. CAHOOTS crisis workers may have undergraduate degrees in a human services field, but some people bring experience working crisis lines or in shelters, whereas others have lived experience with behavioral health conditions. Increasingly, the program has sought multilingual candidates who can help extend the reach of CAHOOTS services to Latinx communities. [ ] Black, April 17, 2020, call. CAHOOTS team members undergo a months-long training process, in cohorts whenever possible. In addition to at least 40 hours of class time, new staff complete 500 to 600 hours of field training—specific timelines depend on cohort needs—before they can graduate to exclusive, two-person CAHOOTS teams.

Although most EPD officers receive CIT training, CAHOOTS staff take on a more specialized set of issues and benefit from extensive field training focused on crisis incidents. [ ] Rankin, February 25, 2020, call; Rankin, September 10, 2020, email. The CAHOOTS training process is incremental, ranging from field observation to de-escalation to the nuts and bolts of working with police radios, writing reports, coordinating with service partners, and starting and ending shifts. [ ] Black, April 17, 2020, call.

White Bird also engages CAHOOTS trainees in a mentorship process that lasts throughout their careers with the organization, with the understanding that they take on difficult work and need outlets to process experiences together to carry out their jobs. [ ] Ibid. The practice demonstrates the importance of wellness for first responders and community members alike.

Sustained and inclusive collaboration

Over time, CAHOOTS and police have developed strategies for supporting one another as calls evolve on-scene and require real-time, frontline collaboration. As noted above, requests for service involving a potentially dangerous situation will require early police involvement, but officers may engage alternative responders once the scene is stabilized and they have gathered more information about what the person in crisis needs. For example, Eugene officers can request assistance when they determine that CAHOOTS-led de-escalation might resolve a situation safely for all parties involved, especially when a call appears to involve underlying substance use or mental health issues.

In addition to bringing expertise in behavioral health-related de-escalation to a scene, CAHOOTS teams can drive a person in crisis to the clinic or hospital. This transportation, which must be voluntary, eliminates the indignity of a police transport, which necessitates the use of handcuffs per standard police protocols. [ ] Rankin, February 25, 2020, call.

More rarely, CAHOOTS teams may determine that police involvement is needed when they gather more information, or as a situation evolves on-scene. If they respond to calls involving people who pose a danger to themselves or others, CAHOOTS teams may see the need for an involuntary hold without the authority to carry one out. [ ] Black, April 17, 2020, call. For example, a person may be so severely intoxicated that they cannot care for themselves and will not consent to a sobering center. [ ] American College of Emergency Physicians, “Sobering Centers,” https://www.acep.org/by-medica... . In this case, CAHOOTS staff might call in patrol officers to execute an emergency custody order. For mental health calls that end in involuntary hospitalizations such as these, CAHOOTS vans follow patrol vehicles to the emergency department to share their transfer sheet, which lists observations of and items discussed with the community member. This facilitates continuity of care for the client. [ ] Black, April 17, 2020, call.

Collaboration between EPD and CAHOOTS extends beyond emergency response. Over the last few years, EPD has introduced the Community Outreach Response Team program to deliver case management for people experiencing homelessness who often come to the attention of emergency services. [ ] Rankin, February 25, 2020, call; see also Cameron Walker, “Police Collaboration Effort Works to Keep Downtown Eugene Safe,” KVAL-TV, August 10, 2016, https://kval.com/news/local/po... . As part of this program, the police have partnered with CAHOOTS to bring their behavioral health expertise to bear on community members who continue to experience frequent contact with the police. EPD has found that this collaborative problem-solving work complements Eugene’s ongoing efforts to support alternative first responders. [ ] Sergeant Julie Smith, Eugene Police Department, March 11, 2020, telephone call.

Close collaboration among government and community partners—including schools, shelters, and behavioral health providers—enables CAHOOTS to respond to a wide variety of situations and to assist police and other agencies with behavioral health emergencies when appropriate. [ ] White Bird Clinic, “CAHOOTS FAQ.” Such partnerships during program planning and throughout program implementation are essential to the success of efforts to improve local crisis response systems. CAHOOTS Operations Coordinator Tim Black stressed that the organization’s success did not happen overnight; there were many small, but important, details to address and a wide range of stakeholders to engage for effective implementation. “You want to make sure you have everyone who could possibly have an opinion about this topic at the table,” he explained. [ ] Black, April 17, 2020, call. It is important to include detractors of the police department in program planning, as getting these partners’ input is critical to program success. Officer Rankin noted that CAHOOTS staff themselves can be “strongly against police in many ways,” but it is “nice having all the line people trying to come up with solutions together.” [ ] Rankin, February 25, 2020, call.

Still, the Eugene and Springfield communities are more than 80 percent white, making them racially homogeneous compared to many cities. [ ] United States Census Bureau, “Quickfacts Eugene, Oregon,” https://www.census.gov/quickfacts/eugenecityoregon; and United States Census Bureau, “Quickfacts Springfield, Oregon,” https://www.census.gov/quickfa... . “There’s a lot of privilege that comes along with having a healthy enough relationship with police that you can contact them,” Black acknowledged, and Eugene is now exploring a separate phone line for CAHOOTS that would be disconnected from the police department. [ ] Black, April 17, 2020, call; and Molly Harbarger, “Police Cuts Give Portland Alternative First Responder Program a Boost—But Can it Respond to the Moment?” The Oregonian , July 4, 2020, https://www.oregonlive.com/cri... . This is a vital consideration for implementing crisis response programs where relationships between police and communities of color are historically characterized by tension and distrust. Programs may find success by grappling with this distrust directly and engaging a wide variety of partners to reach communities with the greatest need. [ ] See for example Jumaane D. Williams, Improving New York City’s Responses to Individuals in Mental Health Crisis (New York: New York City Public Advocate, 2019), https://www.pubadvocate.nyc.go... .

CAHOOTS credits being embedded in the community’s emergency communications and public safety infrastructure for much of its impact, while stressing that the program’s ultimate objective is to reduce policing’s overall footprint. White Bird’s website states, “CAHOOTS is designed to provide an alternative to police action whenever possible for non-criminal substance abuse, poverty, and mental health crisis.” [ ] White Bird Clinic, “CAHOOTS FAQ.” According to Black, the program aims to reduce opportunities for people to become justice-involved and lose their rights. Working with the police has made this possible: “By no means do we [ignore] what other public safety personnel are doing,” he explains. “We try to use our privilege in the public safety system to fight for compassionate and responsive services.” [ ] Black, April 17, 2020, call.

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How a Crisis Intervention Provides Mental Health Support

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What Causes a Crisis?

How crisis intervention works.

• Potential Risks

Crisis intervention is a short-term (usually single session) technique used to address an immediate mental health emergency, stabilize the individual in crisis , and create and implement a safe, appropriate plan for next steps and future treatment.

Although crisis intervention can be used in therapy if a client presents in an emergency, crisis hotlines also offer this service using appropriately trained volunteers or employees.

A mental health crisis can occur for many different reasons. By definition, we often do not know when a crisis may occur, and we might not be able to wait for a regularly-scheduled therapy appointment or standard business hours to address it.

Stressful and Traumatic Events May Lead to Crisis

When a person experiences a highly-stressful or traumatic event , they can go into crisis afterward because they cannot process what happened independently. Crisis intervention can help determine what they need to do to ensure their immediate safety, de-escalate their feelings, and make a plan for appropriate resources and ongoing treatment.

If someone experienced a traumatic event a long time ago, they can still go into crisis if they are triggered in the present moment. Crisis intervention can help them return to the present moment, process the trigger, and manage their symptoms until they can connect with their treatment team.

People with various mental health diagnoses, including mood disorders, psychotic disorders, or substance use disorders might experience a sudden, acute increase in their symptoms. They can benefit from crisis intervention to ensure immediate safety, utilize appropriate coping skills, and connect with ongoing treatment options.

Someone who experiences suicidal ideation can experience a crisis if they feel that they might act on these thoughts. Crisis intervention addresses any specific triggers for these thoughts and manages the individual’s safety.

Effective crisis intervention involves connecting to the person in crisis and talking them through specific steps to ensure their immediate safety as well as make appropriate plans for future care.

Many crisis resources utilize a six-step model developed by Dr. Richard James. This model includes the following six steps:

• Define The Problem. In this stage, the responder establishes a connection with the person in crisis and helps them articulate their crisis as well as what caused it, using active listening and empathy.
• Ensure Client Safety . This includes making sure that the client is in a safe place and is not at risk for immediate harm, both self-inflicted and abuse by another person.
• Provide Support. Once the client is physically safe and the responder understands the nature of the problem, the responder helps determine appropriate options for both immediate and long-term support.
• Examine Alternatives . The responder encourages the client to explore options for people who care for and want to help them, coping skills they can use in the moment, and appropriate re-frames or new ways of looking at the problem.
• Make Plans. In this stage, the client and responder develop specific plans for how to implement the chosen alternatives, focusing on realistic and manageable steps that the client can take.
• Obtain Commitment. Finally, the responder helps the client commit to these steps. This includes putting the plan in writing so that the client knows what they need to do and can remember what helped them during the crisis.

These steps help the client work through the emergency both in the moment and by taking steps to get further support in place in the future. Getting ongoing support in place can prevent future crises.

Impact of Crisis Intervention

Outpatient crisis intervention services can give clients the option to work through an immediate crisis in a safe environment without requiring hospitalization . It can assess risk level and connect clients to services that can help them in the moment. Typically, crisis intervention services are free to use and therefore accessible to anyone regardless of income or financial means.

Phone and text-based crisis hotlines allow clients to access services from anywhere because they do not have to travel to a specific location to access support. Research has shown consistent outcomes for both phone and text-based hotlines.

When clients have access to crisis resources that they can use at any time, they can sometimes avoid a higher level of care or hospitalization for mental health needs. Crisis support can provide a safety net for the client in between their other treatments.

Potential Risks of Crisis Intervention

Let's take a look at some potential risks of crisis intervention.

Crisis Intervention Is Not a Substitute for Therapy

Crisis intervention only addresses the immediate emergency and is not a substitute for therapy services. While most crisis hotlines are free to use, it can be difficult for people in rural areas or those with low income to access and afford ongoing treatment and support.

If a client’s only accessible option is crisis support , they are unlikely to see improvement in their symptoms.

Crisis intervention is a tool, but no one tool can fix everything. People need access to a variety of resources in order to get the support that they need.

Crisis Responders May Not Know How to Deal With Every Situation

Not all crisis resources are created equal. Responders do not need an advanced degree or licensure in order to provide crisis intervention. This makes crisis intervention accessible, as responders can be trained quickly. However, responders might not feel equipped to manage a client’s needs or have the knowledge to make appropriate referrals.

This occurs most frequently with suicidal clients and can lead to the client not getting appropriate follow-up care.

There Is No Prior Therapeutic Rapport

Although crisis intervention can effectively help a client through a difficult time, clients are connected with whichever respondent is available rather than a provider that they know well. This can create an added challenge for clients who have difficulty trusting new providers.

Help Is Limited If a Client Remains Anonymous

Finally, some crisis hotlines allow users to be anonymous . While this can help clients feel more comfortable sharing, this means that the responder cannot verify their location or put them in touch with emergency services if the need arises.

A Word From Verywell

Several qualified crisis resources exist if you are experiencing a mental health crisis. If you are experiencing suicidal ideation, substance dependence, abuse, domestic violence, or another crisis, help is available. Asking for help can be difficult, especially if you are in crisis, but support is available.

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database .

Wang D, Gupta V. Crisis Intervention . In:  StatPearls . Treasure Island (FL): StatPearls Publishing; April 28, 2022.

James, RK; Gilliand BE. Crisis Intervention Strategies. 8th Edition. Cengage Learning; 2016.

Mazzer K, O'Riordan M, Woodward A, Rickwood D. A systematic review of user expectations and outcomes of crisis support services . Crisis . 2021;42(6):465-473. doi:10.1027/0227-5910/a000745

Substance Abuse and Mental Health Services Administration (SAMHSA). National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit .

Gould MS, Kalafat J, HarrisMunfakh JL, Kleinman M. An evaluation of crisis hotline outcomes part 2: Suicidal callers . Suicide and Life-Threatening Behavior . 2007;37(3):338-352. doi:10.1521/suli.2007.37.3.338

By Amy Marschall, PsyD Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.

Community-Based Crisis Services, Specialized Crisis Facilities, and Partnerships With Law Enforcement

Information & authors, metrics & citations, view options, defining crisis, behavioral health emergencies and intersection with the justice system.

The Crisis Intervention Team (CIT) Model

The crisis continuum: community-based alternatives to hospitals, eds, and jail, someone to talk to: 988 and crisis contact centers, someone to respond: mcts, multidisciplinary response teams (mdrts), and law enforcement co-responder teams, a place to go: specialized crisis facilities, medical capability., behavioral acuity., high-intensity and high-acuity crisis programs (locus level 6)., ed-affiliated crisis programs (locus level 6)., inpatientlike, subacute, and extended observation units (locus level 5 or 6)., lower intensity and lower acuity crisis stabilization units (locus level 5)., behavioral health urgent care and walk-in crisis clinics (locus level 4 or below)., after the crisis: postcrisis care, crisis systems versus crisis services.

Addressing Racism and Inequity

Conclusions, information, published in.

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Wisconsin Case Study: Supporting Youth Mental Health through Crisis Stabilization Facilities

Across America, the alarming increase in youth behavioral health needs is considered a public health crisis.[1] The behavioral health system is challenged to meet the needs of youth, which has resulted in youth seeking treatment and services in emergency departments or institutional settings that inadequately address their needs. Some states are responding to these challenges by establishing youth crisis receiving and stabilization facilities as alternatives to these settings.

Youth crisis receiving and stabilization facilities are one core component of the crisis continuum of care.[2] These facilities are intended to work in conjunction with the other crisis components — crisis call centers, mobile response teams, and post-crisis support — to more effectively meet the needs of individuals experiencing a behavioral health crisis.[3] NASHP’s brief “ Leading State Priorities and Considerations for Youth Crisis Receiving and Stabilization Facilities ” explores states’ opportunities, challenges, and key considerations for implementing youth crisis receiving and stabilization facilities.

This case study will focus on Wisconsin’s efforts to establish youth crisis stabilization facilities (YCSFs) as a community-based alternative to inpatient hospital and institutional settings to support the state’s youth in receiving timely and appropriate mental health crisis services.

The Youth Mental Health Crisis in Wisconsin

Nationally and in Wisconsin, the need for youth behavioral health services is well-documented. Across the U.S., youth diagnosed with anxiety, depression, and other behavioral health challenges increased over a five-year period from 2016 to 2020 .[4] In Wisconsin, over one-third of all students surveyed (33.7 percent) reported feeling sad or hopeless almost every day for more than two weeks in a row, a statistically significant increase of 5.2 percentage points since 2019 and the highest rate since the Youth Risk Behavior Survey was first administered.[5] Additionally, 18.1 percent of all students in the state seriously considered attempting suicide in the past 12 months, the highest rate since 2003.[6]

In Wisconsin, young people up to age 25 were identified as a specific population group falling through the gaps in the behavioral health system.[7] Between 2013 and 2017, suicide was the second leading cause of death among 10- to 19-year-olds .[8] Females ages 15 to 17 had the highest rates of emergency department visits and hospitalization stays for self-harm injuries from 2016 to 2017.[9] In 2019, Wisconsin had an average of 490 individuals served by one mental health provider in a county , if the population were equally distributed across providers.[10] In addition, the psychiatrist supply for the state could only meet 19 percent of the need for services.[11]

Establishing Youth Crisis Stabilization Facilities in Wisconsin

In response to the ongoing mental health crisis, Wisconsin passed legislation in 2017 to establish YCSFs.[12] They were promoted as a new community-based residential treatment option for youth experiencing a mental health crisis.[13] Wisconsin Statute 51.042 establishes YCSFs in the state, defined as “a treatment facility with a maximum of eight beds that admits a minor to prevent or de-escalate the minor’s mental health crisis and avoid admission of the minor to a more restrictive setting.”[14] The impetus for implementing YCSFs in Wisconsin was to provide youth and their families access to crisis stabilization services in the community, within a reasonable distance from their homes, and to avoid high-cost acute care in inpatient hospital settings. In 2018, the Wisconsin Department of Health Services (DHS) Learning Collaborative for Crisis Intervention and Emergency Detention developed a toolkit that provides strategies and approaches , including crisis stabilization facilities, on how to support people experiencing a mental health crisis in the community.[15] A 2019 Wisconsin DHS survey of all counties on crisis intervention services found that 21 counties had no options for crisis stabilization services and 62 percent of counties said the closest option for crisis stabilization services was outside their county.[16]

Youth Crisis Receiving and Stabilization Facilities

Outlining the certification process for youth crisis stabilization facilities and program services.

Wisconsin Administrative Code § DHS 50 authorizes Wisconsin DHS to certify YCSFs and defines the YCSF requirements for certification of facilities, program components (i.e., policies, personnel, training, services offered, etc.), and the facility’s physical elements.[17] Wisconsin YCSFs can be publicly or privately owned. Applicants wanting to operate a YCSF must complete a two-step certification process, with an initial application submitted to DHS Division of Care and Treatment Services. Following approval of the first step, applicants must complete a second step that entails background checks ,[18] an application (form DHS 50) ,[19] and fee payment [20] to DHS Division of Quality Assurance. Once approved, a YCSF certification does not expire and is valid until it is suspended or revoked.

Wisconsin’s YCSFs are one component of a coordinated continuum of care. They are intended to provide a safe and supervised place to prevent an impending crisis, emergency mental health services during a crisis, and a step-down option from a higher level of care before youth return home.[21] Admission to a YCSF requires written informed consent of youth or a legal representative. In addition, all Wisconsin YCSFs must provide certain services (see box below).

Wisconsin’s Minimally Required Services for All YCSFs [22]

• A structured therapeutic setting supervised by a clinical coordinator
• Therapeutic and skills-building interventions that will help youth avoid future crises
• Care coordination services provided by a qualified care coordinator
• Discharge planning to support the successful reintegration of youth into family, community, and school activities and to prevent recurrence of a crisis

How Wisconsin Is Operating State-Funded Youth Crisis Stabilization Facilities

Wisconsin YCSFs are eight-bed facilities, and youth may stay up to 30 days; however, the average length of stay is only a few days.[23] A team of trained professionals provide counseling and care for youth to help them manage their mental health crisis and divert them from an inpatient hospital admission. YCSF services must be trauma-informed, strengths-based, and culturally responsive, and YCSFs must encourage involvement of families and caregivers.[24],[25] Wisconsin YCSFs currently operate with two qualified licensed staff (e.g., psychiatrist, clinical social worker) per shift at all times, and the programs are supervised by a clinical coordinator in a structured therapeutic environment, which meets regulatory requirements.[26],[27] Staffing to meet the minimal requirements, including ensuring 24/7 and night-shift coverage, can present operational challenges. Staffing challenges may also present a hurdle to opening additional YCSFs to increase access to youth crisis stabilization services in other counties and communities where they are currently nonexistent. Certification waivers or variances may have to be considered to address barriers to this staffing approach and to maintain program operations.[28]

Currently, Wisconsin has two state-funded YCSFs that have been in operation for approximately two years; the populations that are served differ across facilities.[29]  Lad Lake Masana is in the southeastern part of the state in Milwaukee County, one of the largest and most populous urban areas in the state. North Central Health Care is in Marathon County, which is also urban and in central Wisconsin. The maximum age for both facilities is 17. Lad Lake Masana serves girls ages 13–17, and North Central Health Care serves both girls and boys ages 17 and younger. Both Wisconsin YCSFs serve youth residents across county lines.

Funding Wisconsin’s Youth Crisis Stabilization Facilities Requires a Multifaceted Approach

The implementation of Wisconsin’s YCSFs has required a multipronged financing strategy of federal and state funds. The state funds YCFSs through the federal Substance Abuse and Mental Health Services Administration’s Community Mental Health Services Block Grant , Bipartisan Safer Communities Act , Consolidated Appropriations Act , state general purpose revenues, and Medicaid. Medicaid covers a percentage of YCSF services, which are reimbursed through a crisis daily per diem reimbursement rate or a crisis hourly professional billing reimbursement rate.

Wisconsin as a Model for Other States

Many states are considering crisis stabilization facilities as a strategy to provide services in a community-based setting to youth experiencing a behavioral health crisis and to address the ongoing youth behavioral health crisis across the country. States interested in designing and implementing a youth crisis stabilization facility may consider using Wisconsin’s approach as a model. New York also provides an innovative state approach, which is described in NASHP’s companion study “ Supporting Youth Behavioral Health Through Crisis Receiving and Stabilization Facilities: New York Case Study .”

[1] “Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory,” U.S. Department of Health and Human Services, December 2021. www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf . 

[2] “National Guidelines for Behavioral Health Crisis Care Best Practices Toolkit,” Substance Abuse and Mental Health Services Administration, February 24, 2020. www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf .

[3] “National Guidelines for Behavioral Health Crisis Care Best Practices Toolkit,” 2020

[4] U.S. Department of Health and Human Services. “New HHS Study in JAMA Pediatrics Shows Significant Increases in Children Diagnosed with Mental Health Conditions from 2016 to 2020,” press release, March 14, 2022. www.hhs.gov/about/news/2022/03/14/new-hhs-study-jama-pediatrics-shows-significant-increases-children-diagnosed-mental-health-conditions-2016-2020.html .

[5] Wisconsin Department of Public Instruction. “Data Shows Wisconsin Students Face Significant Mental Health and Emotional Challenges,” press release, December 6, 2022 https://dpi.wi.gov/news/releases/2022/youth-risk-behavior-survey-wisconsin-mental-health .

[6] Wisconsin Department of Public Instruction. “Data Shows Wisconsin Students Face Significant Mental Health and Emotional Challenges,” press release, December 6, 2022 https://dpi.wi.gov/news/releases/2022/youth-risk-behavior-survey-wisconsin-mental-health .

[7] Vigna AJ, Connor T. “The 2019 Behavioral Health Gaps Report for the State of Wisconsin,” Madison, Wisconsin: University of Wisconsin Population Health Institute, October 2020. https://uwmadison.app.box.com/s/gbdrrm4ktk2ljwm80kac9rrk3zksyi02 .

[8] “Suicide in Wisconsin: Impact and Response,” Prevent Suicide Wisconsin, September 2020. www.dhs.wisconsin.gov/publications/p02657.pdf .

[9] “Suicide in Wisconsin: Impact and Response,” 2020.

[10] “2021 Fact Sheet Addressing Shortages in the Mental Health Workforce,” Wisconsin Office of Children’s Mental Health, February 2021. https://children.wi.gov/ Documents/ ResearchData/ OCMH%202021%20 Fact%20 Sheet%20 Addressing%20 Shortages%20 in%20 the%20 Mental%20 Health%20 Workforce.pdf .

[11] “Wisconsin 2019 Health Care Workforce Report,” Wisconsin Hospital Association, October 2019.  www.wha.org/ WisconsinHospitalAssociation/ media/ WHA-Reports/ 2019- WHA- Workforce- Report.pdf .

[12]“Youth Crisis Stabilization Facility,” Wisconsin Legislative Fiscal Bureau, Joint Committee on Finance, May 16, 2017. https://docs. legis. wisconsin.gov/ misc/ lfb/ budget/ 2017_19_biennal_budget/ 102_budget_papers/ 358_health_services_youth_crisis_stabilization_facility.pdf .

[13] “Youth Crisis Stabilization Facility and Peer-Run Respite Center for Veterans,” Wisconsin Legislative Fiscal Bureau, Joint Committee on Finance, May 2019. https://docs.legis.wisconsin.gov/ misc/ lfb/ budget/ 2019_21_biennial_budget/ 102_budget_papers/ 410_health_services_youth_crisis_stabilization_facility_and_peer_run_respite_centers_for_veterans.pdf .

[14] Wisconsin State Statute. Mental Health Act, § 51.042 Youth Crisis Stabilization Facilities (passed 2017). https://docs.legis.wisconsin.gov/statutes/statutes/51/042 .

[15] “Toolkit for Improving Crisis Intervention and Emergency Detention Services,” Wisconsin Department of Health Services, Division of Care and Treatment Services, August 2018.  www.dhs.wisconsin.gov/publications/p02224.pdf .

[16] “Crisis Intervention Services Survey Summary,” Wisconsin Department of Health Services, Division of Care and Treatment Services, November 2021. www.dhs.wisconsin.gov/publications/p03135.pdf .

[17] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50 .

[18] “Background Check: Overview.” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/misconduct/backgroundchecks.htm .

[19] “Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50,” Wisconsin Department of Health Services, accessed June 22, 2022. www.dhs.wisconsin.gov/library/collection/f-02564 .

[20] “Mental Health, Youth Crisis Stabilization Facilities (DHS 50): Initial,” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/regulations/mh/youth-crisis-stab-fac.htm

[21] “Crisis Services: Youth Crisis Stabilization Facilities.” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/crisis/ycsf.htm .

[22] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/11 .

[23] Wisconsin Department of Health Services. “Crisis Services: Youth Crisis Stabilization Facilities.”   www.dhs.wisconsin.gov/crisis/ycsf.htm .

[24] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/05/4 .

[25] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/05/5 .

[26] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/07 .

[27] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/09 .

[28] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/04 .

[29] “Crisis Services: Youth Crisis Stabilization Facilities,” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/crisis/ycsf.htm .

Acknowledgements

This case study was written by Robin Buskey. Several NASHP staff contributed to the case study through input, guidance, or draft review, including Karen VanLandeghem, Heather Smith, Zack Gould, and Veronnica Thompson. NASHP extends its thanks and appreciation to Jason Cram and Elizabeth Rudy of the Wisconsin Department of Health Services and the Health Resources and Services Administration, Maternal and Child Health Bureau, for their review.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. government.

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The Six-Step Crisis Intervention Model Explained

When an individual experiences a crisis, the proper response can make a life-saving difference. Mental health professionals must understand these nuanced situations and enact steps to bring the patient back to a healthy place. One model that can guide these responses is Gilliland's six-step crisis intervention strategy. By moving through the steps with care and concern for the individual, mental health professionals can help guide the person in crisis away from dangerous actions and toward their pre-crisis state.

We'll take a closer look at this crisis intervention model and how crisis workers can use it to assist their clients.

Table of Contents

Step 1: Define the Problem

Step 2: ensure the individual's safety, step 3: provide support, step 4: explore alternatives, step 5: make plans, step 6: obtain commitment, the benefits of the six-step crisis intervention model, tips for using the six-step crisis intervention model, when to use the six-step crisis intervention model, implementing the six-step crisis intervention model, download our comprehensive crisis intervention toolkit.

What is the Six-Step Crisis Intervention Model?

According to the creators of the six-step model , a crisis occurs when someone perceives or experiences an event or situation as intolerable, with demands that exceed their current resources and coping mechanisms. When this happens, they need assistance to regain control and stabilize. The six-step model enlists a systematic process of listening and responding to empower the individual and help them return to their pre-crisis psychological state. Assessments occur at every step, and the crisis worker listens attentively to make their evaluations.

The six steps involved in this method include three listening-oriented steps and three action-oriented steps. The first three focus on listening.

Step number one asks the crisis worker to define the problem. This first stage establishes a connection between the crisis worker and the client as they begin discussing the issue. To fully understand the situation and form a bond with the client, the crisis worker implements:

• Active listening:  Active listening requires placing your full attention on the client, demonstrating acceptance and removing biases. The crisis worker must understand the client's perspective without allowing their feelings to get in the way. This type of listening also helps improve the relationship between the two parties.

• Empathy:  Practicing empathy is about taking someone else's point of view and showing them that you understand them. It asks you to remove any judgment or biases and accept the patient as a whole person, not define them by their current situation. It also requires being in the present and putting the other person and their feelings first. Empathy is essential throughout the six-step process, especially when establishing the relationship.
• Genuineness: People can often tell when you aren't being genuine. In a crisis, this can quickly paint you as untrustworthy and break down the relationship between crisis worker and client. Speak genuinely but carefully and solidify your position as a trustworthy partner in their mental health.
• Understanding: You also need to show the client that you understand their situation. You may use language that confirms you understand the problem or relate to their issue somehow.

The crisis worker should look at the problem from the client's point of view. They should try to understand where the client is coming from and their available resources, such as coping skills or caring friends and family.

A vital part of any crisis intervention plan is ensuring the individual cannot harm themselves or others. At this stage, the crisis worker conducts suicide risk assessments and homicide risk assessments. You may evaluate factors like agitation or the client's potential for causing harm.

Another important step here is controlling the individual's access to dangerous items. These can be as clear-cut as firearms or as subtle as office supplies, like staplers and paper cutters. The client's location and the resources of the mental health crisis system will make a big difference in this step.

For example, an inpatient psychiatric client likely has far less access to harmful items than a client being treated through a mobile care unit. That client might be able to use a variety of dangerous instruments and lack supervision when the crisis worker leaves.

The crisis worker must help transition the client into a safe environment before they can work on the next steps.

In the third step, the crisis worker shows the client that they accept and care for them. They'll discuss the problem and offer support for meeting basic needs. These might come in the form of:

• Emotional support: The crisis worker must express emotional support through statements that illustrate empathy, trust, and care. Emotional support can also come from trusted friends and family.
• Instrumental support: Instrumental support refers to services and aid, like shelter and food. Fulfilling basic needs is a necessary prerequisite for the problem-solving that occurs in the next three action steps.
• Informational support: By providing informational support, the crisis worker offers advice and suggestions. You might teach the individual about healthy coping strategies or reassure them that many resources are available.

The goal of these supports is to set the person up so they can understand the options available for dealing with the situation.

As we switch gears into the action steps, step four is about finding new solutions and navigating possibilities. The crisis worker collaborates with the person in crisis to explore these options. If their coping skills are weaker, the crisis worker may need to offer more assistance at this step, but it's important to draw on assessments first to understand the client's capabilities.

Other elements that the crisis workers might draw on during this step include situational supports, like people in the individual's life who care about them or coping mechanisms that can help them through the situation so they can move into the problem-solving stage.

During this step, it's necessary to use and cultivate positive, constructive thinking patterns. The crisis worker may need to spend some time helping the client reframe their thoughts in more positive ways.

With trust established and options explored, it's time to make a plan. During step five, the individual and the crisis worker continue to collaborate, building a plan with clear, concrete steps that will help the client regain control. These plans must be realistic and achievable.

They should empower the client, making them feel like they can accomplish the tasks and take ownership of the recovery process. This step relies heavily on collaboration with the client because it helps them take control, using their existing resources and capabilities.

The individual's plan should be detailed and straightforward. It might involve referrals and resources like people or groups that can help the client, such as support groups, medical providers, or food banks.

The last step is to obtain commitment. Getting commitment might be as simple as asking the client to verbalize the plan or as complex as writing up a document and having both parties sign it. In either case, the crisis worker needs to confirm that the client fully understands the plan and feels capable of following through.

The crisis worker should also make plans to follow up with the client. You can create a sense of accountability and, of course, help ensure the client's well-being. If the client needs further care, the crisis worker can also make referrals.

Crisis intervention is a powerful tool. An unmanaged crisis can lead to significant psychological stress, which can link to major depressive disorder or other mental health conditions. Crisis intervention has proven efficacy in preventing mental illness from developing and helping to treat patients currently suffering from one.

Studies have even shown that emergency departments with crisis intervention teams saw reduced return visits and shorter durations of stay. They reduced the number of repeat admissions and found that the interventions were more effective than standard care in improving the patient's mental health.

We know that crisis intervention can be a critical part of improving psychiatric case outcomes. The six-step model emphasizes two distinct components of helping someone with a problem — listening and taking action. It covers vital steps of crisis intervention, like creating a bond with the client, identifying resources, and guiding them toward a healthy solution. It also offers a clear, systematic approach that helps ensure the crisis worker accomplishes the tasks that can help the client.

Although the six-step crisis model is fairly straightforward, it still requires the nuance demanded of crisis intervention. Some things to keep in mind when using the six-step crisis model include:

• Accurate assessments: This strategy is based on the results of your assessments. They must be accurate. Crisis workers must remember that every person and situation is unique. Generalizations can lead to dangerous errors that divert the treatment plan. Robust assessment tools can be particularly useful in the six-step strategy.
• Empowerment: Crises occur when a person loses control and feels unsafe. The six-step model focuses on restoring that power through collaboration. The crisis worker should maintain an open mind when problem-solving and look for routes that help the person regain control. A heavy-handed approach might be necessary for some patients, but they should contribute to the best of their ability.
• Action-oriented strategizing: Crisis intervention is focused on action and the situation at hand. Crisis workers should recognize the impacts of the situation, anticipate its effects and help the client create a plan. Each step in the process should be geared toward that end goal.
• Focus on the present: Similarly, crisis intervention offers immediate support. Unlike long-term solutions like psychotherapy, the crisis worker must provide immediate support, like coping skills that the patient can use right away or access to resources that they can use to quickly return to the pre-crisis state.
• A holistic view of the client: The crisis worker needs to maintain their holistic view of the client, considering the whole person instead of separating them from their cognitive and emotional function.

Crisis intervention is an immediate, short-term response to mental, physical, emotional and behavioral distress. It is not a long-term option like psychotherapy or similar treatments. The goal is to restore the person's functioning to before the crisis and reduce the opportunity for long-term trauma. It aims to help the client get access to assistance, support and resources that help them become stable.

The six-step model can be used in many situations, but some common triggers for crises include:

• Family situations: Some family situations — like child or spousal abuse, unplanned pregnancy or serious or chronic illness — can cause stress and lead to a crisis.
• Economic situations: Financial strain from the loss of a job, eviction, theft, medical expenses, gambling or poverty can trigger many crises based on the sudden or chronic financial strain they create.
• Community situations: An individual's community can also contribute to their mental state. For example, someone facing violence in their neighborhood, poor housing or inadequate community resources might experience a crisis.
• Significant life events: Some events often viewed as happy situations can paradoxically trigger crises. These might include marriage, the birth of a child or a promotion at work. Other significant events, like raising a rebellious adolescent, losing a loved one or seeing a grown child leave the nest can also cause a crisis.
• Natural elements: Plenty of natural disasters can trigger crises, such as floods, hurricanes and fires. They might involve harm to a loved one or the destruction of possessions, creating states of distress. Even seemingly minor events, like a bout of gloomy or hot weather, can put someone into a crisis state.

Some signs that someone is in crisis and may need the help of an intervention strategy include:

• Feelings of hopelessness.
• Difficulty eating or sleeping.
• Depression.
• Neglected personal hygiene.

Symptoms can vary widely, but remember that a crisis intervention plan is generally warranted when the situation exceeds the patient's resources and coping skills.

Implementing the six-step crisis intervention model will look different for various providers, such as inpatient crisis teams or mobile crisis response units. Still, completing the six steps typically requires robust documentation to ensure appropriate billing procedures , patient assessment, and follow-up care. Without the proper documentation solution, you might be spending too much time on paperwork and not enough time on the client. Or you might completely neglect your notes. To make the process easier, use a documentation platform that allows for quick, intuitive note-taking.

ICANotes is that platform, offering a cloud-based solution for mobile, inpatient, or outpatient crisis intervention. It eliminates the busy work, allowing you to focus on your patient and their acute problems without ignoring necessary documentation procedures. ICANotes mental health EHR software also supports a range of other tasks, like billing, reporting, referrals, e-prescribing and scheduling . From initial suicide risk assessments to referrals to other mental health professionals, ICANotes simplifies the entire process.

If the six-step crisis intervention model is part of your practice, ICANotes can help. With intuitive note-taking features and an array of assessment tools, you can successfully follow the patient-centered approach of this model. Collect all the information you need to make an accurate evaluation and help the patient move forward. To learn more about ICANotes and how it can help you with the 6-step model, explore its features or reach out to us today for more information!

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Diagnosing Eating Disorders: Treatment Options and Referrals

Understanding Post Traumatic Stress Disorder and Grief

Benefits of Outsourcing Mental Health Billing Services

Navigating Diagnostic Challenges: Borderline Personality Disorder vs Bipolar Disorder

Managing Transference and Countertransference in Therapy

• https://www.counseling.org/resources/library/Selected%20Topics/Disaster/vistas06.03.pdf
• https://positivepsychology.com/active-listening/
• https://www.mentalhealthfirstaid.org/2021/08/practicing-empathy-as-a-mental-health-first-aider/
• https://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml
• https://www.ncbi.nlm.nih.gov/books/NBK559081/
• https://www.dshs.wa.gov/esa/social-services-manual/crisis-intervention
• https://www.samhsa.gov/find-help/disaster-distress-helpline/warning-signs-risk-factors
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• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Nine

• Case Study 1

Also in this section

• Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource
• Process Recording
• Criteria for Validation: Process Recording
• Criteria for Phase of Relationship: Process Recording
• Journaling Activity
• Safety and Comfort Plan Template
• Advocacy Groups for Mental Health in Canada
• Tips for Engaging Lived Experience
• Glossary of Terms
• Case Study 2
• Case Study 3
• Case Study 4
• Case Study 5
• Case Study 6
• Case Study 7
• Case Study 8
• Case Study 9

Teresa is a 32-year-old woman in your practice who frequently misses her appointments, and at other times shows up without an appointment, often in crisis. She currently uses alcohol and tobacco, and has started to use street drugs.

As you have developed a therapeutic relationship with Teresa, you learn that she grew up in a household with a violent father who frequently assaulted her mother, her siblings and herself. Although now estranged from her father, the impact of his violence presents itself on a daily basis as Teresa struggles to cope with the trauma she experienced.

Teresa left school early, has few marketable skills and has never been able to hold a job for more than three months. Teresa receives $606 per month from Ontario Works and has no money left for food or other essentials at the end of the month. She is currently in a relationship with a man whom you suspect may be violent

Student Questions

What are your next steps with Teresa? How do you go about providing trauma-informed care?

• Is a crisis intervention required?
• What are some other interventions you could take to improve Teresa’s health in this situation that include addressing health inequities and structural drivers of the conditions of daily life, such as the inequitable distribution of power, money and resources?

Educator elaborations

• Assess Teresa’s mental status and history of mental health care; explore her substance use and whether it places her at high risk for self medication and suicide; explore issues of violence in her life, income support and her housing situation.

Discussion Topics

• Cultural competency and mental illness
• Trauma informed care
• Crisis intervention
• Social determinants of health
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What Research on Crisis Intervention Teams Tells Us and What We Need To Ask

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Developed over 30 years ago, the Crisis Intervention Team model is arguably the most well-known approach to improve police response to individuals experiencing mental health crisis. In this article, we comment on Rogers and colleagues' review (in this issue) of the CIT research base and elaborate on the current state of the evidence. We argue that CIT can be considered evidence based for officer level outcomes and call level dispositions. We then discuss the challenges that currently make it difficult to draw conclusions related to arrest, use of force, and injury related outcomes. More research, including a randomized, controlled trial is clearly needed. But we caution against focusing narrowly on the training component of the model, as CIT is more than training. We encourage research that explores and tests the potential of CIT partnerships to develop effective strategies that improve the mental health system's ability to provide crisis response and thus reduce reliance on law enforcement to address this need.

There continues to be a great deal of much-warranted attention on strategies to improve police responses to individuals with mental illnesses and those experiencing mental health crises. The Crisis Intervention Team (CIT) model, which was developed over 30 years ago, is arguably the most well-known approach to address this issue. As discussed by Rogers and colleagues, 1 a growing body of research suggests that the CIT model is effective for at least some of its articulated goals. We have previously argued that it can be considered evidence-based for officer-level outcomes such as improved knowledge about mental illnesses; enhanced attitudes about mental illnesses, individuals living with mental illnesses, and treatments for mental illnesses; self-efficacy during interactions with persons with mental illnesses; use of force preferences; and call-level outcomes related to linkage to mental health services. 2 But evidence is more mixed or lacking for “rare event” outcomes related to arrests, injury, and deaths. In this commentary, we briefly describe the CIT model, and then discuss the current state of CIT research laid out by Rogers et al . 1 We will then elaborate on the challenges presented in conducting research on the model, which also have implications both for drawing conclusions from the available evidence and for future research. We argue that a full conceptualization of the model will push us to ask different questions and to consider the danger in limiting our focus to making law enforcement better prepared to intervene in mental health crises rather than shifting responsibility for this function to the mental health system and thereby minimizing the role that law enforcement needs to play in the provision of mental health care.

The Crisis Intervention Team (CIT) Model

Rogers et al. 1 aptly describe the origins of the CIT model following the shooting of a man experiencing a mental health crisis by a Memphis police officer. They note that the original articulated goal was to improve safety in police encounters, which was a key concern on the heels of that tragedy. The University of Memphis CIT Center, Memphis Police Department, National Alliance on Mental Illness, and CIT International also list goals related to improving police responses to people in crisis and diverting individuals from the criminal justice system when appropriate. Until recently, increasing transports of persons in crisis to hospital emergency departments was considered an improvement in response (and it still is if it avoids an unnecessary arrest or leaving someone in need of care without proper linkages). As emergency departments have become overwhelmed, however, there is recognition that they are not an ideal place to address mental health crises. Indeed, over time, the stated goals of CIT have become more nuanced and now include developing more robust community-based crisis-response systems that minimize both the role of law enforcement and the need to utilize emergency departments. 3

Rogers et al. 1 also cover several of the Core Elements of the model: CIT training for a select group of officers, training of communications and dispatch personnel and special coding processes for dispatched calls, and a centralized mental health facility for easy drop-off. What is often overlooked or mentioned only in passing is the foundational element of strong and ongoing community partnerships. These may be evidenced by a steering committee that is formed to initially implement a CIT program and continues to meet and support ongoing operations of the program. Indeed, the “T” of CIT is not “Training,” as suggested in the title of the Rogers et al. article; rather, it is “Team.” Team refers to the community collaboration (including local law enforcement, local mental health advocacy groups, local mental health services, and oftentimes many other stakeholders) that works to improve the local crisis-response system, of which officer training is one element. While generally not examined in CIT research, this foundational collaboration is believed to be essential to successful implementation of the CIT model. 3

What Does the Existing Research Tell Us?

Rogers and colleagues 1 state that “most of the studies on CIT involve analysis of the planning, deployment, and procedural functioning of the CIT process itself, including the selection, training, operations, and measurement or self-report of CIT-trained officers” (Ref. 1 , p xxx). This statement seems overly dismissive and suggests an absence of research that has rigorously examined important outcomes of CIT. It is difficult to know what studies were reviewed by the authors, but it appears that they failed to consider a number of them in drawing conclusions. For example, Rogers et al. 1 are correct when they indicate that we have evidence of CIT training's effectiveness for “increasing officer satisfaction,” though it would be more accurate to indicate that the evidence supports CIT's effectiveness for improving other, more important officer-level outcomes in terms of knowledge, attitudes, self-efficacy, force preferences, and decision-making. 2 The authors failed to report on the most robust and large-scale study in this area, in which Compton et al. 4 , 5 recruited 586 police officers from six police agencies that had implemented CIT; 251 of those officers had previously received CIT training, at a median of 22 months before the in-depth research assessment. Officers spent about three hours completing an extensive battery of measures. Compared with non-CIT officers, CIT-trained officers had greater knowledge about mental illnesses and their treatments, better attitudes (across 17 different domains), greater self-efficacy, lesser stigma, better de-escalation decisions, and better referral decisions. Effects were apparent, even at a median of 22 months after the training, and even when controlling for age, gender, years having served as an officer, years of education, officers' extent of personal experience with the mental health system, and empathy. These are much more robust findings than “increased officer satisfaction.” Additionally, while Rogers et al . 1 indicate “some positive but mixed outcomes or trends toward statistical significance, in terms of increased diversion to psychiatric services” (Ref. 1 , p xxx), there is actually good, statistically significant evidence from several studies that CIT increases the use of mental health service linkages to resolve mental health-related encounters. 2 , 5 There is also evidence that these effects are strongest when officers self-select into the specialist role 6 and in areas with greater availability of mental health services. 7

The evidence of CIT's impact on safety outcomes is limited. While we did not find a direct effect of CIT on use of force in one of our own studies, we did find that CIT officers used less force with more resistant subjects. 8 Likewise, the evidence of CIT's impact on injuries is understandably very limited given that injuries are rare. In terms of outcomes related to arrest, findings are mixed, with some studies indicating reductions of arrests of persons with mental illnesses and others finding no effect.

The lack of strong evidence for the impact of CIT on arrest and safety outcomes has led some to conclude that CIT is not effective. For example, the National Institute of Justice's CrimeSolutions.gov 9 rated CIT as not effective for the outcomes of processing offenders (arrest) and use of force based on a meta-analysis by Taheri that included five studies. 10 This rating was broadcast in the Office of Justice Programs' Daily Digest Bulletin (November 20, 2018) with the heading “Crisis Intervention Teams Rated: Crisis Intervention Teams Do Not Reduce Arrest, Use of Force, or Officer Injuries.” Given the many difficulties identifying appropriate studies to include in the meta-analysis, which Taheri herself discusses in her article, 10 applying meta-analytic methods was likely premature, as are the conclusions drawn by CrimeSolutions.gov. More recently, in their systematic review of the research on police-mental health interventions that included CIT, Kane and colleagues note, “Due to the limited and varied research evidence in this field, it was not appropriate to produce a GRADE table of findings to identify relevant results, nor was it possible to pool data from included studies nor conduct a meta-analysis” (Ref. 11 , p 111). Thus, for arrest and safety outcomes, we cannot yet draw conclusions.

As researchers working in this area for some time now, we have struggled to examine the impact of CIT on arrest, use of force, injuries, and deaths. There are a number of factors that have made this very difficult. First, each of these outcomes occurs relatively infrequently (and for deaths, extremely infrequently) in the course of police work. Low base rates mean that large samples are needed to detect effects. This would seem simple because police agencies document many aspects of police work, such as arrests and uses of force. One might think that we should be able to pull the relevant call data from agency data systems, but many agencies do not have codes that are used consistently to identify calls involving a mental health crisis or a significant mental health component. Those working to implement such coding struggle with the appropriate definition of a mental health call and getting officers to use those codes reliably. This makes it difficult to examine patterns of arrests, force, and injuries in mental health-related calls in a single agency; furthermore, comparing data across agencies is hampered by significant variation in data systems and coding practices. Additionally, while measurement of arrest is straightforward, definitions of force and policies around what, when, and how force is documented are not uniform. For example, in some communities, use of handcuffs is documented as a use of force, and in many cases, when officers transport a person for psychiatric evaluation, agency policy requires the use of handcuffs. In these programs, if CIT officers are doing more transports, they may be using force (by this definition) as often as or more often than their non-CIT counterparts because they are taking more steps to get individuals in crisis into care.

It is even more difficult to consider the impact of CIT on lethal encounters between persons with mental illnesses and police. While extremely tragic, such events are complex and occur rarely. Rogers et al. point out that “studies have not shown consistent benefit in terms of a reduction in the risk of mortality or death during emergency police interactions” (Ref. 1 , p xxx), but it is not clear what studies they are referencing. We know of no such studies.

Recent attention to police shootings has led to work to improve tracking of these incidents nationally. To test the impact of CIT on such events, however, we will need to be able to measure CIT implementation. This leads to an additional challenge of conducting and considering research on CIT. We know there is significant variation in CIT implementation, with some communities only training a group of officers (or mandating the training for all), and others that work to build partnerships and implement the full model. To date, there is no fidelity tool to support measurement of this variation. Such a tool, if rigorously developed and tested, would be useful to the field.

According to the model and one of its founders, Retired Major Sam Cochran, “CIT is more than just training” (Ref. 12 , p 3); nevertheless, much of the available research on the effectiveness of CIT, our own included, may have perpetuated the misunderstanding of CIT as primarily a training model. It is much more feasible to conduct rigorously designed research in a single agency or training academy and compare officers who are CIT trained with those who are not than it is to compare across agencies with and without CIT programs. Such a comparison would require agreements with a large number of agencies and extensive resources, complicated by the lack of good, consistently coded administrative data within and across agencies. There are, however, studies that have examined outcomes both before and after CIT program implementation in single programs, including one using a time series design conducted by Kubiak and colleagues 13 that found an increase in transports to a crisis triage center following implementation (this study was not included in the Rogers et al. review).

Rogers et al. express a concern that “with the thousands of CIT programs deployed, there may be a publication bias in terms of a reduction in the likelihood of publication or dissemination of studies identifying a null effect or adverse cost increases or shifts associated with a specific CIT program” (Ref. 1 , p xxx); yet, there is no evidence supporting this. The vast majority of CIT programs do not conduct research, consider publication of any data, or disseminate studies.

More research, including a randomized controlled trial, is clearly needed. This, of course, begs the question of what should be randomized. Randomizing officers to the training may be feasible, but this approach suffers from the narrow focus on CIT as a training program. Randomizing calls to a CIT response or not would be operationally very difficult and potentially unethical (unless the other condition is another specialized model such as a co-responder team) given the evidence that we do have for the benefits of CIT. Randomizing agencies to implement CIT or not would require a larger number of agencies of adequate size (or a very large agency with many precincts) willing to let researchers dictate when and if they implement CIT. While a randomized controlled trial would be informative, practical and rigorously designed studies have given good evidence of CIT's effectiveness and have emphasized where evidence is currently lacking, which is very different from being ineffective.

What About Opportunity Costs?

Rogers and colleagues 1 note the potential opportunity costs of spending money on CIT programs that might otherwise be spent on alternative services such as street triage (which involves clinician-officer teams), increased funding for assertive community outreach programs, or psychiatric beds. This is a rather abstract argument given that money saved in law enforcement budgets is not generally available to be transferred to the mental health system. It also misses the fact that CIT programs implemented with fidelity develop partnerships between law enforcement, mental health, and advocacy that work together to coordinate existing services, identify system gaps, and garner resources to develop needed mental health services.

While we hope to continue to do research on CIT and related models, we worry about the opportunity cost of focusing so much on the law enforcement component of CIT and other police-based interventions (e.g., embedded co-response teams) that we and others in this field will fail to explore and test the potential of CIT partnerships to develop effective strategies that improve the mental health system's ability to provide crisis response and thus reduce reliance on law enforcement to address this need. CIT International emphasizes this as a goal of CIT programs in its newly released publication, “Crisis Intervention Team (CIT) Programs: A Best Practice Guide for Transforming Community Responses to Mental Health Crises.” 3 Research is needed that conceptualizes CIT as an organizational and community-level intervention and examines its effectiveness not only for improving officer and call-level outcomes, but also for system-level outcomes related to reducing the role of law enforcement in a mental health crisis-response system.

Disclosures of financial or other potential conflicts of interest: None.

• © 2019 American Academy of Psychiatry and the Law
• Rogers MS ,
• McNiel DE ,
• Watson AC ,
• Compton MT ,
• Bakeman R ,
• Broussard B ,
• Ottati VC ,
• Morabito MS ,
• 9. ↵ CrimeSolutions.gov : Practice profile: crisis intervention teams (CITs) . Available at: https://crimesolutions.gov/practicedetails.aspx?id=81 . Accessed September 13, 2019
• Shokraneh F
• Comartin E ,
• Milanovic E ,

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Claire Malengret and Claire Dall'Osto

This chapter provides a foundation for understanding the nature of a crisis, how a person may be impacted by a crisis, and the models, processes, and strategies a crisis counsellor uses to assess and intervene when people in crisis seek help and support. With an emphasis on how crisis intervention differs from other counselling interventions, a case study is provided with the aim to help the reader reflect on and apply relevant crisis models of assessment and intervention learned in this chapter. Further differentiation is made between crisis stressors resulting in exposure to a traumatic event and ongoing traumatic stress responses requiring long-term counselling, psychiatric services, or specialised mental health intervention. Due to the nature of crisis work, there is a high prevalence of burnout and work-related stress in this field. As such, counsellors working in crisis work need to practice self-care, regular clinical supervision, and the continuing maintenance of the counsellor’s general health and wellbeing.

Learning Objectives

• Describe the nature of crisis.
• Identify the types of crisis.
• Recognise and understand common emotional, physical, behavioural, and cognitive reactions of people in crisis.
• Analyse the major theories underpinning crisis counselling interventions.
• Examine the importance and role of the therapeutic relationship within crisis counselling.
• Apprehend the ethical implications and professional issues of crisis intervention.
• Identify trauma definitions, assessment, and treatment approaches.
• Identify and reflect on your own personal history and experiences of crisis, including responses.
• Recognise and understand the impact of crisis counselling work on the counsellor and the need to implement self-care practices and stress management strategies.

Introduction

We live in a world where millions of people are confronted with crisis-provoking events each year that they cannot cope with or resolve on their own and, therefore, will often seek help from counsellors. Examples of crisis-inducing events include natural disasters such as bushfires, sexual assaults, terrorist attacks, the death of a loved one, a suicide attempt, domestic violence, relationship breakdown, retirement, promotion, and demotion, change in school status, pregnancy, divorce, physical illness, unemployment, and more recently, a world pandemic. These situations can be a turning point in a person’s life—either one of growth, strength, and opportunity or health decline, dysfunction, and emotional illness (Roberts & Dziegielewski, 1995; Roberts, 2005; Hoff et al., 2009). When people experience a crisis, it is the support they receive during and immediately after the crisis that often plays a crucial part in determining the impact of the crisis on their lives (France, 2014). Therefore, it is imperative crisis counsellors have the understanding, skills, and knowledge to offer a short-term intervention that assists people in crisis to cope, stabilise and receive the support and resources they need.

What is a crisis?

When a person experiences a crisis, they experience severe disruption of their psychological equilibrium and are unable to use their usual ways of coping. This then results in a state of disequilibrium and impaired functioning (Lewis & Roberts, 2001; Roberts, 2005). Because the person is unable to draw on their everyday problem-solving methods during a crisis, and there is a sense of diminished control over the events and limited options, they may experience confusion or bewilderment (Hendricks, 1985; Pollio, 1995).

Crisis states are temporary, lasting from hours through to an estimated six weeks, as the body cannot sustain being ‘off balance’ or in a state of disequilibrium, indefinitely. Resolving a crisis effectively may take some months, and this may involve learning new skills, reappraising the situation differently, or adapting to the new situation. Because people may resolve the crisis in a maladaptive or adaptive manner, some may be impacted by various mental health conditions such as depression, substance abuse, or post-traumatic stress disorder (PTSD) (Roberts, 2005).

There are four types of crises that a person may experience and include:

• developmental crisis or crisis in the life cycle (adjustments to transitions such as ageing, parenting)
• situational crisis (sexual assault, natural disaster, car accident)
• existential crisis (inner turmoil or conflicts in relation to the way a person lives their life, and views of their meaning and purpose)
• systemic crisis (the impact of colonisation on our First nations’ people or the 2009 Victorian ‘Black Saturday’ bushfires) (James & Myer, 2008).

Crisis is in the eye of the beholder

It is important to note the difficult task of defining a crisis. This is due to the subjectivity of the concept. Although the main reason for a crisis is usually preceded by a traumatic or hazardous event, it is imperative to realise that the individual’s perception of the event and their inability to cope with the event are two other conditions to consider. Focusing only on the event itself also suggests that one can categorise a crisis but that all people may respond in the same manner to a particular event. Thus, it is not the actual event that activates a crisis state, but how a person interprets or perceives these events, how they cope, and the degree to which they have access to social resources, that determine how they respond. In other words, crisis is in the eye of the beholder (Hoff et al., 2009; Hoffer & Martin, 2020).

This perception is influenced by several factors in a person’s life, such as personal characteristics, biological, gender, culture, attachment style, previous life experiences, social context, personal values, level of resilience, influences, availability of social support, previous trauma, and history of major mental illness (Loughran, 2011; Roberts & Ottens, 2005). It is also important to understand that people who are reacting to a crisis are not necessarily showing pathological responses but normal crisis responses to an abnormal event (Bateman, 2010; Hobfoll et al., 2007; James, 2008).

Principles and characteristics of crisis

The following principles and characteristics help to create an understanding of the nature of a crisis, and emphasise not only the important work of a crisis counsellor but the values and philosophical assumptions that need to guide their practice:

• crisis embodies both danger and opportunity for the person experiencing the crisis
• crisis contains the seeds of growth and impetus for change
• crisis is usually time limited but may develop into a prolonged crisis if the person experiences a series of stressful situations after the crisis
• crisis is often complex and difficult to resolve
• a crisis counsellor’s experiences of crisis in their personal life may greatly enhance their effectiveness in crisis intervention
• quick fixes may not be applicable to many crisis situations
• crisis confronts people with choices
• emotional disequilibrium or disorganization accompany crisis
• the resolution of crisis and the personhood of crisis workers interrelate (James, 2008, p. 19).

Learning activity 1

• How do you think your previous life experiences of crisis may increase your effectiveness as a crisis counsellor?
• What personal qualities do you possess that may enhance an intervention that you use with a person who has experienced a crisis?
• What are the risks of having unresolved crisis experiences as a counsellor, and how might this impact your effectiveness in crisis work?

Common reactions to a crisis

Listed here are some of the common reactions a person might experience, which are normal responses given the abnormality of the event they have experienced.

Table content sourced from Massazza et al ., (2021) used under a CC BY licence and Wahlström et al ., (2013) used under a CC BY-NC licence.

Learning activity 2

Imagine your life on a timeline from when you were born up until today. On this timeline, plot the most important or critical events (positive or negative) in your life that were turning points or changed you in some way.

• Looking at the critical events on your timeline, which events would you see as a crisis?
• How did those events change you?

What is crisis counselling?

Crisis counselling is an immediate response to people experiencing overwhelming events and may prevent the potential negative impact of psychological trauma. It focuses on the here and now, dealing with the immediate presenting needs at the point of crisis, and providing emergency psychological care to assist in helping the person return to an adaptive level of functioning (Flannery & Everly, 2000; Hobfoll et al., 2007).

The key goals that underpin crisis counselling frameworks and models are:

• meeting the person who is experiencing a crisis where they are at
• assessing and monitoring the person’s level of risk
• assisting them in mobilising of resources
• stabilising (by reducing distress
• improved or restored adaptive functioning (where possible) (Roberts & Ottens, 2005).

The difference between crisis counselling and other counselling interventions

Crisis counselling is different to the provision of ongoing therapeutic support. Because crisis counselling offers short-term strategies to prevent damage during and immediately after the person has experienced a crisis or devastating event, it requires that the counsellor be more active and directive than usual (James, 2008). Ongoing counselling may follow on from crisis to ensure the long-term improvement of a person’s mental health and wellbeing, but this is not the goal of crisis counselling. Instead, the goal is to provide a responsive and timely intervention to return a person to previous levels of functioning through the implementation of mobilising necessary resources, including the facilitation of links to these resources (Flannery & Everly, 2000). Given crisis counselling is the implementation of a short-term measure of support, it is often referred to as brief intervention or brief therapy. The timeframe for crisis counselling is between six to ten weeks and is guided by specific relevant models, guiding principles, and actions (Hendricks, 1985).

Case study: A bushfire crisis

You are part of a mobile service team who travels to a fire-affected area to provide support to individuals, families and emergency services workers affected by the recent bushfires. You arrive at a regional town that has just been devastated by catastrophic bushfires. A recovery centre has been set up at the local town hall and 700 individuals and families are presently seeking support at this recovery centre. You are assigned to Brett (35), a cattle farmer whose property, livestock, and beloved dog were lost in the fires. Brett is a third-generation cattle farmer on his family property. Within the first few minutes of meeting him, you observe that recalling these events for him results in constant tearfulness, and a questioning of what he could have done to be more prepared to have a different outcome. Brett explains that he has not slept in several days, and if he does sleep, he has nightmares. He also expresses to you that he does not know what the future holds for him now. Brett explains that he cannot focus for very long because he finds it difficult to believe this has happened to him. You observe that Brett appears to be numb and detached and unable to articulate his narrative in a linear and clear manner. Brett explains that he feels concerned for his ten employees who are no longer able to support their families. He also mentions that recently he went through a divorce which he felt devastated by at the time.

Learning activity 3

• From Brett’s reactions, what suggests that he is experiencing a crisis?
• What is the contributing factor that disrupts Brett’s equilibrium most? Is it the nature of the crisis event itself or the way Brett responds?
• Are there any risk factors to consider in Brett’s case?

Traumatic stress, crisis, and trauma

The term crisis is not interchangeable with traumatic stress and trauma. Dulmus and Hilarski (2003) explain a person is in a crisis state when they have experienced a situation or event and they have been unable to cope with it by utilising their usual coping mechanisms to lessen the impact of the event. This results in the person entering a state of disequilibrium (Roberts & Ottens, 2005).

Traumatic stress is when a crisis or event, such as child abuse, rape, combat trauma, and catastrophic natural disasters, overwhelms normal coping skills and is perceived as life-threatening (Behrman & Reid, 2002). Trauma can be defined as ‘… an experience of extreme stress or shock that is/or was, at some point, part of life’ (Gomes, 2014).

It is adaptive and normal for a person who has been exposed to a traumatic event to exhibit some anxiety in the early stages as this enables them to maintain vigilance as a way to increase safety. Others may feel numb after being exposed to a traumatic event. This is also an adaptive and normal response as much-needed insulation is provided to a person’s psychological system after the traumatic event (McNally et al., 2003). Those who do experience a traumatic injury can suffer from long-lasting consequences that impact them physically, cognitively, emotionally, and financially (Herrera-Escobar et al., 2021).

It is common for acute stress symptoms to be experienced after a traumatic event. When a person is exposed to a threat, neurotransmitters and hormones inform a physical response. The sympathetic nervous system is activated through a series of interconnected neurons that initiate a fight or flight response. The body releases glucose and adrenalin, increases heart rate and respiration, and remains in a state of high alert to manage any additional threat. At this point in time, the person is trying to make sense of their experience and is often feeling afraid and vulnerable as they attempt to rationalise what just occurred. Anxiety, loss of appetite, irritability, sleep difficulties, concentration difficulties, and hypervigilance can occur whilst in this physiological state. Warchal and Graham (2011) further explain that a person can have recurrent and involuntary memories of the traumatic event. A heightened state of arousal makes it difficult for them to respond normally, make decisions, and complete paperwork to link them to resources. Walsh (2007) explains that most people adapt and cope and therefore do not suffer long-term disturbance.

Post-traumatic stress disorder

Ongoing therapeutic support is required if a person continues to experience feelings of helplessness, intense fear or horror, re-living the traumatic event, hypervigilance, or emotional numbness. Norris et al. (2002) identified ongoing support to include long-term counselling or psychiatric services, or specialised mental health intervention. People generally possess enough resilience to circumvent the development of trauma symptoms that inform a formal trauma diagnosis, such as post-traumatic stress disorder. The DSM5-TR classifies PTSD as an anxiety disorder that can develop after exposure to a traumatic event (American Psychiatric Association [APA], 2022). Rosenman (2002) reported that 57% of the Australian population reported a lifetime experience of a specified trauma. There are four different categories PTSD can be clustered into: (1) recurrent re-experiences of the traumatic event in the form of intrusive thoughts, nightmares, or flashbacks; (2) numbing and avoidance of trauma-related stimuli; (3) hyperarousal and reactivity; and (4) alterations in cognitions and mood (APA, 2022).

The origins and development of crisis counselling interventions

The research and development of crisis intervention originates in the 1940’s when the reactions of people whose loved ones had died in a fire at a nightclub in Boston in 1943 were recorded and studied by psychiatrist Erich Lindemann and his colleagues (Lindemann, 1944). Another psychiatrist, Gerald Caplan, expanded on this work and developed a four-stage model of crisis reactions (or phases of reactions that a person in a crisis may experience) which have formed the foundation for later contributions from theorists in crisis counselling. Caplan (1961, 1964) describes these phases as follows:

Phase 1 : increase in tension and distress from the crisis-inducing event

Phase 2 : there is an escalation in the disruption of the person’s life as they are stuck and cannot resolve the crisis quickly

Phase 3 : the person cannot resolve the crisis through their usual problem-solving methods

Phase 4 : the person resolves the crisis by mental collapse or deterioration, or they partially resolve it by adopting new ways of coping.

Erikson’s (1963) stage model of developmental crises and Roberts’ (1995) seven-stage crisis intervention model have led to the development of numerous crisis intervention models, particularly in the last two decades. Erikson’s focus was on World War II veterans’ disconnect from their culture together with the confusion associated with the traumatic war experiences rather than focusing on men suffering from repressed conflicts. Erikson assessed that veterans were experiencing confusion of identity about what they were and who they were in direct opposition to the lens of repressed conflict being used during this time period.

Characteristics of the crisis counsellor

The crisis counsellor’s ability to remain calm and simultaneously avoid subjective involvement in the crisis is crucial. This means that crisis counselling may not be suitable for every counsellor (Shapiro & Koocher, 1996). A crisis counsellor should communicate in a manner that is patient, sensitive, self-aware, and compassionate. Other characteristics and behaviours include warmth, understanding and acceptance, being available but not intrusive or controlling, trustworthy, empathic, caring, displaying effective listening skills, encouraging the person seeking appropriate referrals and support, and being able to maintain confidentiality (Bateman, 2010; Rainer & Brown, 2011; Westefeld & Heckman-Stone, 2003).

The crisis counsellor aims to establish a therapeutic relationship as they do in general counselling, however in crisis counselling, they do so in a shorter time-frame period. Other crisis intervention skills include encouragement, basic attending and listening skills, reflection of emotions, and instilling hope (cf. Ivey & Ivey, 2007; James, 2008).

Key crisis interventions

As mentioned previously, crisis intervention provides the opportunity for the crisis counsellor to help facilitate an independent decision-making process with the client by promoting them as the agent of change in their life and assisting them to identify and utilise their own resources (France, 2014).

When determining if crisis intervention is the most relevant intervention, several categories are to be considered. These include:

• a cumulative effect
• the impact on a person
• their family and community
• the unexpectedness and duration of the event or situation; and
• a person’s level of control over the event or situation (Hendricks, 1985).

Critical incident stress debriefing

Developed in 1974 by Jeffrey T. Mitchell, critical incident stress debriefing (CISD) or psychological debriefing is a seven-phase supportive crisis intervention process that was initially used with small groups of first responders such as firefighters, paramedics, and police officers to help them manage their reactions and distress following their exposure to a traumatic event (Mitchell, 1983). Over time, CISD became an intervention used with groups outside of emergency services, such as hospitals, businesses, schools, community groups and churches. However, although CISD is used extensively, current research shows mixed results for the use of this intervention with some findings suggesting that it is ineffective in preventing post-traumatic stress disorder (PTSD) symptoms and even contributing to the worsening of stress-related symptoms in individuals who received this type of intervention (Bledsoe, 2003).

The next section will address assessment in crisis intervention followed by an outline of two key crisis interventions, Roberts’ seven-stage model of crisis intervention and psychological first aid, and an application of these interventions to Brett’s case.

Assessment in crisis intervention

The responsibility of the crisis counsellor is to conduct a structured assessment in a timely and responsive manner to assess whether psychological homeostasis has been disrupted, there is evidence of dysfunction and distress, and usual coping mechanisms are not able to be utilised. Assessment is ongoing throughout the intervention process and allows the crisis counsellor to evaluate the person’s affective and cognitive state, and behavioural functioning. By assessing these three areas, the crisis counsellor can evaluate and monitor how adaptively or maladaptively the person is functioning, including whether they are a danger to themselves or others, and then apply the most appropriate intervention (James, 2008).

Listed below are examples of what a crisis counsellor is looking for across the three domains when assessing people who have experienced a crisis:

• Do they appear to be emotionally overwhelmed or severely withdrawn?
• Is what they are saying coherent and logical or are they not making sense?
• When observing their behaviours, are they pacing? Are they having difficulty breathing?
• Are they able to sit calmly?
• Are they unresponsive?

When people express suicidal ideation or have a plan to suicide, it is crucial to conduct a rapid suicide risk assessment which includes gathering information by inquiring about the following:

• How long they have been having suicidal thoughts?
• Have they made any suicide attempts in the past?
• Have they recently sought help?
• Do they have a plan to suicide?
• If they do have a plan, do they have access to the means to carry out this plan?

Further information and guidelines on suicide risk assessment can be found at the end of this chapter in the Recommended referral and resources list section. There is also a specific chapter in this book related to suicide.

Helplines – phone counselling and support

There is a range of organisations in Australia that provide support for people who are in crisis and need to talk to someone about their distress. Due to their convenience, accessibility, affordability, and relative anonymity, these helplines are a common form of crisis support.

Lifeline Australia 13 11 14

beyondblue  1300 22 4636

Mensline Australia 1300 78 99 78

Kids Help Line   1800 55 1800

1800RESPECT 1800  737 732

Roberts’ seven-stage crisis model

Roberts’ (1995, 2005) seven-stage model of crisis intervention is a cognitive-behaviourally based, systematic, and structured model used for crisis assessment and intervention. It is a common model used by crisis counsellors to help people build and restore their ways of coping and improve their problem-solving skills that a crisis may evoke.

With a focus on strengths and resiliency, these sequential stages can be applied to a broad range of crisis situations and are as follows:

• plan and conduct a thorough assessment including, danger to self and others, imminent danger, lethality
• make psychological contact, establish rapport and rapidly establish the collaborative relationship by showing genuine respect for the individual and having a non-judgmental attitude
• identify major problems or the dimensions of the problems including the precipitating event
• encourage exploration of feelings and emotions including active listening, reassurance and validation
• generate and explore alternatives including untapped resources and new coping strategies
• develop and formulate an action plan
• plan follow-up and leave the door open for booster sessions which may occur three to six months later (Roberts, 2005, p. 21).

Psychological first aid

Identified as the first level of post-incident short-term care, psychological first aid is an evidenced-based model that provides emotional and practical support to individuals, groups, and communities impacted by a natural disaster, catastrophic event, traumatic or terrorist event, or another emergency situation (Australian Red Cross & Australian Psychological Society, 2010; Ruzek et al., 2007). The aim of psychological first aid is to help people reduce their initial symptoms, have their current needs met, and support them in implementing adaptive coping strategies.

Psychological first aid meets the following four basic standards:

• Consistent with evidence and research on risk and resilience following trauma (that is, evidence-informed)
• Applicable and practical in field settings (compared with a medical/health professional office somewhere)
• Appropriate for developmental levels across the lifespan (e.g., there are different techniques available for supporting children, adolescents, and adults)
• Culturally informed and delivered in a flexible manner, as it is often offered by members of the same community as the supported individuals (Ruzek et al., 2007).

Psychological first aid is based on the understanding that, just as natural disasters, catastrophic events, traumatic or terrorist events, or other emergency situation differ vastly from each other, so do the psychological reactions of individuals, groups and communities experiencing them. Because some of these reactions can interfere with an individual’s ability to cope and manage the crisis, psychological first aid can help in their recovery. Psychological first aid has five basic elements that are to promote:

• self-efficacy (self-empowerment)
• connectedness
• hope (Hobfoll et al., 2007).

Case study: Crisis intervention

Roberts’ seven-stage model of crisis intervention

Using Roberts’ (2005) seven-stage model as an intervention with Brett, your first step is to conduct a psychosocial and lethality assessment. As he tells his story to you, you need to gather information such as whether he has any emotional support, any medical needs, how he is coping, and whether he is currently using any drugs and/or alcohol. Assessing any imminent danger and ascertaining whether Brett may be at risk of suicide is also a priority in this initial stage. Although in this case, Brett may not talk about having suicidal thoughts (i.e., suicidal ideation) or have a suicide plan, he does say, “I don’t know what the future holds for me now”, which at this point would prompt a probing question in checking what he means. It would be important to consider other risk factors, such as previous mental health issues, being socially isolated, or recently experienced a significant loss (for example, Brett has recently divorced which may be a risk factor in his case).

The second stage is about building rapport with Brett which you may have established already from taking the time to be present and hear his story in the assessment stage. This stage is crucial in developing a therapeutic relationship with Brett and, therefore, it is important you show a genuine interest in his story, respect and accept him, and also display fundamental qualities and characteristics of a crisis counsellor as discussed earlier in the chapter.

Crisis intervention is focused on the major problems, so in this next stage, you are wanting to find out why Brett has sought help now. This might seem obvious as you might assume it is the devastation of the fire. This may not be the priority issue, therefore, at this point you are not only finding out about the event that ‘was the last straw’ but you are also helping Brett prioritise the problems to work through. It is important that you gain an understanding of why those problems make it a crisis for him.

In stage four of this model (i.e., encourage exploration of feelings and emotions) you are actively listening to Brett’s story, allowing him to express and vent his feelings, and giving him the opportunity to articulate what it is about the situation that is making it difficult for him to cope. You may challenge some of his responses by giving him correct information and reframing his statements and interpretations about the situation.

Generating and exploring alternatives (stage 5) can be ‘tricky’ as the timing needs to be appropriate to help Brett explore options in moving forward to resolve the crisis. If you have established rapport, listened to his story, and Brett feels heard and understood, he may be more open to this. A strategy may include asking Brett, “How have you coped in the past when you’ve been through a crisis and felt the same way you do now?”.

Stage six includes implementing an action plan to address some of the problems he has identified, for example, making an appointment with his general practitioner regarding the poor sleep patterns he is experiencing. This stage also involves asking questions that may help Brett make meaning from the crisis such as, “Why did this happen?”, “What does it mean?”, “What are the alternatives that could have been put in place to prevent the event?”, “Who was involved?”, and “What responses to the crisis potentially made it worse (cognitively and behaviourally)?” (Roberts & Ottens, 2005).

The final stage is planning to follow up with Brett two to six weeks later in order to evaluate if the crisis is being resolved, and to also check his physical and cognitive state, how his overall functioning is, any stressors and how he is handling them, and any referrals to external agencies such as housing, medical, legal etc. You may also schedule a ‘booster’ session a month after this crisis intervention has been completed.

The application of psychological first aid to the case study requires an expansion of the five core principles of psychological first aid. In your immediate work with Brett, the intervention includes efforts to:

•  reduce his distress by modelling calm, and making Brett feel safe and secure
• identify and assist Brett with his current needs
• establish a human connection with Brett
• facilitate Brett’s social support
• help Brett understand the disaster and its context
• help Brett identify his own strengths and abilities to cope
• foster belief in Brett’s ability to cope
• give Brett hope
• assist with early screening for Brett needing further or specialised help
• promote adaptive functioning in Brett
• get Brett through the first period of high-intensity and uncertainty
• set Brett up to be able to naturally recover from an event
• reduce the chance of post-traumatic stress disorder for Brett (Australian Red Cross & Australian Psychological Society, 2010, p. 11).

Brett is a 35-year-old independent Australian male farmer who may believe that expressing emotions or feelings is a sign of weakness. Bleich et al. (2003) explain that when an individual believes they are weak, “going crazy” or believes there is “something wrong with me”, an effective strategy in the intervention is to normalise and reassure Brett “you are neither sick nor crazy; you are going through a crisis, and having a normal reaction to an abnormal situation”. It is important to remind Brett that he is safe in order to minimise his vigilance. Promoting calm for Brett, immediately after his rural town was devastated by catastrophic bush fires, can assist Brett to foster positive emotions. It is advisable to intervene and limit Brett’s exposure to media coverage as this may trigger negative emotional states. The challenge for you is to convince Brett that he does not need to be as vigilant and limit media exposure as all day exposure is too much (Fredrickson, 2001).

The crisis counsellor and self-care

In their book, The Resilient Practitioner, Skovholt and Trotter-Mathison (2016) offer their insights and research on burnout and compassion fatigue for those in the helping profession and emphasise the importance of implementing self-care strategies in its prevention. Given the demands of the work of a crisis counsellor and the risk of vicarious traumatisation, protective and proactive approaches are imperative in the sustainability and vitality of a career where one is working intensely with human suffering and adversity. Tools and approaches, such as frequent supervision, high commitment to self-care, creating a personal balance of caring for self and caring for others, proactively and directly confronting stressors at work and at home, and ensuring that one has enriching relationships and activities outside of the work environment, are essential components in professional wellness and in the prevention of burnout and compassion fatigue (Adamson et al., 2014; Skovholt & Trotter-Mathison, 2016).

Learning activity 4

The development of a self-care plan can assist the crisis counsellor in supporting their wellbeing, reducing stress, and sustaining positive mental health in the long-term.

List five self-care strategies that you might use to promote and enhance your mental health and wellbeing

Counsellor reflections

Due to the nature and intensity of the role, crisis counselling may not be a suitable specialisation of counselling for every counsellor. Based on my experience, this type of work requires a counsellor to have the ability to remain calm and operate in a systematic and rational manner whilst assessing a client’s level of instability and distress. Building rapport quickly with a client facing a crisis is vital to the effectiveness of the intervention, which highlights again how important it is for the crisis counsellor to show acceptance, empathy, and genuineness to the client.

Working as a frontline crisis counsellor is demanding, and, therefore, it is imperative that ongoing support and clinical supervision are received to minimise and manage compassion fatigue and vicarious trauma. Additionally, I have found that a strong commitment to self-practices such as mindfulness, yoga, and muscle relaxation have reduced work-related stress and burnout over the years.

This chapter has provided a brief foundation for intervening with people who have experienced a crisis. With a primary focus on psychological first aid and Roberts’ seven-stage model of crisis intervention, and an application of these models to a case study, this chapter has covered the essentials in understanding the nature and types of crisis, the common reactions of a person who has experienced a crisis, and the impact of ongoing traumatic stress responses that require long-term counselling intervention. A list of other supports available, referrals and resources are included at the end of this chapter for your information and further reading.

Recommended referral and resources list

Australian Psychological Society: Psychological first aid . This resource is a useful guide to supporting people affected by a disaster. The guide provides an overview of the implementation of best practices in psychological first aid as an immediate intervention following a traumatic event or disaster.

Suicide risk assessment . Working with the suicidal person Clinical practice guidelines for emergency departments and mental health services (Department of Health, Melbourne, Victoria, 2010).

Guidelines for integrated suicide-related crisis and follow-up care in emergency departments and other acute settings (2017).

Other Resources for telephone and online crisis support:

• Life in Mind : Australian suicide prevention services.
• Standby : Support after suicide. Face-to-face and telephone support.

Other counselling resources

Psychological first aid : This video [11:07] provides information on the application of psychological first aid to assist individuals to reduce stress symptoms and assist in meeting an individual’s basic needs and identify resources to aid in a healthy recovery, immediately following a crisis, such as a personal crisis, natural disaster, traumatic event or natural disaster.

Glossary of terms

compassion fatigue— a state of feeling emotional and physically exhausted from helping people who are distressed or traumatised resulting in a diminished ability to show compassion or empathise

crisis — a time of intense difficulty or danger

hypervigilance — being in a state of increased alertness where one is sensitive to surroundings

intervention — the action or process of intervening

model — describes how counsellors can implement theories

stress — a state of mental or emotional strain or tension resulting from adverse or demanding circumstances

principles — a fundamental truth or proposition that serves as the foundation for a system of belief or behaviour or for a chain of reasoning

reaction — something done, felt, or thought in response to a situation or event

suicidal ideation — thoughts of wanting to take one’s own life or suicide

theory — a plausible or scientifically acceptable general principle offered to explain a hypothesis or belief

therapeutic relationship — refers to the consistent and close association that exists between the counsellor and client. This is also known as a therapeutic alliance.

trauma — a deeply distressing or disturbing experience

vicarious trauma — trauma symptoms that a counsellor may experience as a result of the ongoing exposure to trauma stories from their clients

Reference List

Adamson, C., Beddoe, L., & Davys, A. (2014). Building resilient practitioners: Definitions and practitioner understandings. The British Journal of Social Work, 44 (3), 522-541. https://doi.org/10.1093/bjsw/bcs142

American Psychiatric Association. (2022).  Diagnostic and statistical manual of mental disorders. Text revised (5th ed.). https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

Australian Red Cross and Australian Psychological Society. (2010).  Psychological first aid:   An Australian guide .

Bateman, V. L. (2010) The interface between trauma and grief following the Victorian bushfires: Clinical interventions beyond the crisis, Grief Matters: The Australian Journal of Grief and Bereavement, 13 (2), 43- 48.

Behrman, G., & Reid, W. J. (2002). Post trauma intervention: Basic tasks.  Brief Treatment and Crisis Intervention, 2 , 39-47.

Bledsoe, B. E. (2003). Critical incident stress management (CISM): Benefit or risk for emergency services. Prehospital Emergency Care, 7 (2), 272-279.

Bleich, A., Gelkopf, M., & Solomon, Z. (2003). Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel.  Journal of the American Medical Association,   290 (5) 612-616.

Caplan, G. (1961). An approach to community mental health. Grune and Stratton.

Caplan, G. (1964). Principles of preventative psychiatry. Basic Books.

Department of Health, Melbourne, Victoria (2010). Working with the suicidal person: Clinical practice guidelines for emergency departments and mental health services . www.health.vic.gov.au/mentalhealth

Dulmus, C. N., & Hilarski, C. (2003). When stress constitutes trauma and trauma constitutes crisis. The stress–trauma-crisis continuum.  Brief Treatment and Crisis Intervention, 3 , 27-35.

Erikson, E. (1963). Childhood and Anxiety (2nd ed.). Norton.

Flannery, R. B., & Everly, G. S. (2000). Crisis intervention: A review . International Journal of Emergency Mental Health, 2 (2), 119-125.

France, K. (2014). Crisis intervention: A handbook of immediate person-to- person help (6th ed.). Charles Thomas Pub.

Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broader-and-build theory of positive emotions.  American Psychologist , 56 , 218-226.

Hendricks, J. E. (1985). Crisis intervention: Contemporary issues for on-site interveners . Charles C Thomas.

Herrera-Escobar, J., Osman, S., Das, S. Toppo, A, Orlas, C., Castillo-Angeles, M., Rosario, A., Janjua, M., Arain, M., Reidy, E., Jarman, M., Nehra, D., Price, M., Bulger, E., & Haider, A. (2021). Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review. Journal of Trauma and Acute Care Surgery , 90 (5), 891–900. https://doi.org/10.1097/TA.0000000000003108

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A. M., & Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence.  Psychiatry, 70 (4), 283-315.

Hoff, L. A., Hallisey, B. J., & Hoff, M. (2009). People in crisis: Clinical and diversity perspectives (6th ed.). Routledge.

Hoffer, K., & Martin, T. (2020). Prepare for recovery: Approaches for psychosocial response and recovery. Journal of Business Continuity & Emergency Planning , 13 (4), 340–351.

Ivey, A. E. & Ivey, M. B. (2007). Intentional interviewing and counseling: Facilitating client development in a multicultural society (6th ed.). Thomson.

James, R. K. (2008). Crisis intervention strategies (6th ed.). Thomson.

James, R. K., & Myer, R. A. (2008). Crisis counseling. In F. T. L. Leong, E. M. Altmaier, & B. D. Johnson (Eds.), Encyclopedia of counseling (Vol. 2, pp. 544-548). Sage.

Lindemann, E. (1944). Symptomology and management of acute grief. American Journal of Psychiatry, 101 , 141-148.

Loughran, H. (2011). Understanding crisis therapies: An integrated approach to crisis intervention and post-traumatic stress. Jessica Kingsley Publishers.

Lewis, S., & Roberts, A. R. (2001). Crisis assessment tools: The good, the bad and the available.  Brief Treatment and Crisis Intervention, 1 , 17-28.

Massazza, A., Brewin, C. R., & Joffe, H. (2021). Feelings, thoughts, and behaviors during disaster. Qualitative Health Research, 31 (2), 323-337. https://doi.org/10.1177/1049732320968791

McNally, R., Bryant, R., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress?  Psychological Science in the Public Interest,   4 , 45–79.

Mitchell J. (1983). When disaster strikes…the critical incident stress debriefing procedure. Journal of Emergency Medical Services , 8 (1),36–39.

Myer, R. A. (2001). Assessment for crisis intervention: A triage assessment model. Brooks/Cole.

Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001.  Psychiatry ,  65 (3), 207–239. https://doi.org/10.1521/psyc.65.3.207.20173

Pollio, D. E. (1995). Use of humour in crisis intervention. Families in Society: The Journal of Contemporary Human Services , 76 (6), 376-384.

Rainer, J., & Brown, B. (2011). Crisis counseling and therapy. Routledge.

Roberts, A. R. (Ed.), (1995). Crisis intervention and time-limited cognitive treatment . Sage.

Roberts, A. R. (2005). Bridging the past and present to the future of crisis intervention and crisis management. In A. R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment, and research (3rd ed., pp. 3–34). Oxford University Press.

Roberts, A. R., & Dziegielewski, S. F. (1995). Foundation skills and applications of crisis intervention and cognitive therapy. In A. R. Roberts (Ed.), Crisis intervention and time-limited cognitive treatment (pp. 3–27). Sage.

Roberts, A. R. & Ottens, A. J. (2005). The seven-stage crisis intervention model: A road map to goal attainment, problem solving and crisis resolution.  Brief Treatment and Crisis Intervention, 1, 17-28.

Rosenman, S. (2002). Trauma and posttraumatic stress disorder in Australia: Findings in the population sample of the Australian National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, 36 (4), 515-520. https://doi.org/10.1046/j.1440-1614.2002.01039.x

Ruzek, J., Brymer, M., Jacobs, A. K., Layne, C., Vernberg, E. M., & Watson, P. J. (2007). Psychological first aid.  Journal of Mental Health Counseling , 29 (1), 17–49.

Shapiro, D. E., & Koocher, G. P. (1996). Goals and practical considerations in outpatient medical crises intervention. Professional Psychology: Research and Practice, 27 (2), 109-120. https://doi.org/10.1037/0735-7028.27.2.109

Silva, S. M. G. (2014). Engaging touch & movement in somatic experiencing trauma resolution approach. International University for Graduate Studies. https://www.stiftung-traumatherapie.com/fileadmin/stiftung/information/forschung/Punkt1_Punkt2_engaging-touch-and-movement-in-se-trama-resolution-approach-dissertation-bySoniaGomes-2014.pdf

Skovholt, T. M., & Trotter-Mathison, M. (2016). The resilient practitioner: Burnout and compassion fatigue prevention and self-care strategies for the helping professions . Routledge.

Wahlström, L., Michélsen, H., Schulman, A., Backheden, H., & Keskinen-Rosenqvist, R. (2013). Longitudinal course of physical and psychological symptoms after a natural disaster. European Journal of Psychotraumatology, 4 (1), Article 21892. https://doi.org/10.3402/ejpt.v4i0.21892

Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience.  Family Process, 46 (2), 207-227.

Warchal, L. R., & Graham, L. B. (2011). Promoting positive adaptation in adult survivors of natural disasters.   Adultspan Journal , 10 (1), 34–51.

Westefeld, J. J., & Heckman-Stone, C. (2003). The integrated problem-solving model of crisis intervention: Overview and application. The Counselling Psychologist, 31 (2), 221- 239.

Author Information

Claire Malengret FDRP, B.Ed.,M.Couns., GDM, Family Dispute Resolution, Cert IV TAE, PACFA Reg. (Clin.), MHE prac. 21971, Accredited Supervisor (PACFA, AAOS)

Claire is currently the National Clinical Advisor at an Australian non-for-profit organisation that supports young people and their families who have been impacted by chronic illness. With over 15 years experience in education, counselling and organisational development roles, Claire is passionate about coming alongside people, building trust and transparency, and supporting them to grow their skills and build capability. She is a clinical counsellor, accredited supervisor, an endorsed mental health practitioner, and certified family dispute resolution practitioner who holds a Master of Counselling, a Graduate Diploma in Management, and a Bachelor of Education.

Claire Dall’Osto BSocSc (with Distinction), GradCertPrac(Client assessment & Case management), GradCertPrac(Statutory child protection), Dip(Couns), Dip(Just), CertIV(Train&Assess)

Claire has been working in the child protection industry within the government and NGO sector for 15 years, and has gained expert experience, knowledge, and skills in the child protection and foster care systems. She has worked with biological parents, foster and kinship carers, and children who have experienced harm, abuse, trauma, grief and loss, attachment disruptions, mental health issues, and behaviour and conduct problems. Claire has provided crisis intervention in refuges, providing specialist support, and safe and secure accommodation for women and children escaping domestic and family violence, as well as providing specialist trauma counselling for people who have experienced domestic and family violence, and sexual assault.

Common Client Issues in Counselling: An Australian Perspective Copyright © 2023 by Claire Malengret and Claire Dall'Osto is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• v.101(52); 2022 Dec 30

Collaborative mental health care: A narrative review

Christopher reist.

a University of California, Irvine, Irvine, CA

b Veterans Affairs Long Beach Healthcare System, Long Beach, CA

Incia Petiwala

c Carbon Health Technologies, Inc, Oakland, CA

Jennifer Latimer

Sarah borish raffaelli, maurice chiang, daniel eisenberg.

d University of California, Los Angeles, Los Angeles, CA

Scott Campbell

e Department of Psychiatry & Behavioral Neurosciences, Cedars-Sinai Medical Care Foundation, Los Angeles, CA.

The Collaborative Care model is a systematic strategy for treating behavioral health conditions in primary care through the integration of care managers and psychiatric consultants. Several randomized controlled trials have demonstrated that Collaborative Care increases access to mental health care and is more effective and cost efficient than the current standard of care for treating common mental illnesses. Large healthcare systems and organizations have begun to adopt Collaborative Care initiatives and are seeing improved treatment outcomes and provider and patient satisfaction. This review discusses current research on the effectiveness and cost-efficiency of Collaborative Care. In addition, this paper discusses its ability to adapt to specific patient populations, such as geriatrics, students, substance use, and women with perinatal depression, as well as the significance of measurement-based care and mental health screening in achieving improved clinical outcomes. Current data suggests that Collaborative Care may significantly improve patient outcomes and time-to-treatment in all reviewed settings, and successfully adapts to special patient populations. Despite the high upfront implementation burden of launching a Collaborative Care model program, these costs are generally offset by long term healthcare savings.

1. Introduction

Among the various models of integrated mental health care, the Collaborative Care model (CoCM) stands out as an evidence-based way to improve patient outcomes, team collaboration, and provider satisfaction in primary care settings, with more than 80 randomized controlled trials supporting its efficacy across multiple psychiatric conditions. [ 1 ] CoCM can play a crucial role in increasing access to mental health care within the primary care setting, where only 50% of patients with a mental health disorder are recognized, and only 12.5% of those are properly treated. [ 2 ] Patients treated with collaborative interventions reach a diagnosis and initiate treatment within 6 months 75% of the time; this is in contrast to treatment as usual, where less than 25% of patients receive appropriate care within the same time frame. [ 3 ] Importantly, a recent review of randomized controlled trials examining remote CoCM teams found 9 published studies that collectively support the effectiveness of the model in treating a range of behavioral health conditions, including many mood and anxiety disorders. [ 4 ] The importance of integrated mental health is now more relevant than ever, with President Joe Biden emphasizing the importance fully integrated and accessible behavioral and physical healthcare in his 2022 Strategy to Address our National Mental Health Crisis. [ 5 ]

CoCM has been shown to improve access to behavioral health services, deliver patient-centered behavioral and physical health care in the same setting, and improve overall clinical outcomes. [ 1 ] Critical to achieving these benefits are 5 key components: population-based care, measurement-based care (MBC), care management, psychiatric consultation, and brief evidence-based psychotherapy. [ 2 ] While each component is crucial, MBC is of particular importance; by itself, incorporating MBC strategies has been linked to improved patient outcomes and faster treatment times. [ 3 , 4 ]

Several models of primary care-based collaborative mental health treatment exist, including: Screening, Brief Intervention and Referral to Treatment, the Collaborative Chronic Care Model, Primary Care Behavioral Health, and Co-location of Services. [ 6 ] While having some similarities to these models, the CoCM model is unique in that it focuses resources on an identified patient population suffering from mental health concerns, utilizes an integrated care manager with mental health training, and incorporates decision-support and case review by a psychiatrist. The CoCM model relies on algorithmic, stepped care with systematic follow-up and monitoring of patients. [ 7 , 8 ] Furthermore, CoCM specifically relies on close coordination and communication between medical and mental health providers, whereas other models such as Co-location of Services do not afford the same depth of relationship. [ 9 ]

In the typical CoCM, a Behavioral Health Care Manager (BHCM) serves as the lynchpin of the program. When the Primary Care Provider (PCP) initiates a patient referral into CoCM, the BHCM performs an initial evaluation to ascertain the presenting problem and create a provisional diagnosis to review with the consulting psychiatrist. The BHCM utilizes a registry to keep track of all patients and prioritize those for regular review. After conducting a case review with the consulting psychiatrist, the BHCM provides the suggested treatment plan to the referring PCP, who reviews and executes upon the treatment plan. (Fig. ​ (Fig.1 1 ) [ 12 ] Concurrently, BHCMs can provide brief, evidence-based psychotherapy, including problem-solving therapy, motivational enhancement therapy, or behavioral activation in addition to brief psychosocial interventions to support treatment; these interventions may include encouraging medication adherence, scheduling follow-ups, and providing referrals to specialty care as appropriate. In addition, the BHCM is tasked with implementing and coordinating other care recommendations, longitudinal symptom monitoring and liaising with both the PCP and consulting psychiatrist. If implemented with these core components, this model of care can improve both mental and physical outcomes, with little to no net change in primary health care costs. [ 10 ] In fact, real world studies suggest that CoCM can substantially reduce overall cost of care by improving clinical outcomes. At Blue Cross Blue Shield of Michigan, the average time for participants in their program to reach remission from depression was 16 weeks, compared with 52 weeks for traditional direct care approaches. In addition, Blue Cross Blue Shield of Michigan is tracking towards a 2-3x reduction in medical spending for enrolled patients within 3 years across 190 clinics. [ 11 ]

Typical pathway for CoCM. Reprinted with permission from the University of Washington Advanced Integrated Mental Health Solutions Center. CoCM = Collaborative Care model.

CoCM improves the patient experience by allowing for care to be delivered in a “down the hall” manner, with the patient working with known providers already trusted with managing other medical issues. This can address the stigma that some patients may experience and reduce the opportunity for noncompliance with treatment. Much of the existing literature discusses the implementation and outcomes of CoCM in the primary care context. Beyond traditional primary care populations, however, there are specific groups that may benefit from CoCM, including college students, obstetrics and gynecology (OBGYN) patients, geriatric patients, and those in substance abuse treatment programs. Although less studied in these settings, CoCM has been demonstrated to be effective for populations in which mental health needs are inconsistently addressed. In this review, we discuss the unique adaptations of CoCM and the evidence supporting its cost effectiveness in these populations in addition to the important role of MBC and screening.

The literature search for this review was performed through a comprehensive overview of multi-disciplinary journal databases and subject specific databases pertaining to Collaborative Care in primary health care settings. Articles used included academic peer reviewed clinical, meta-analysis and observational studies. Other types of content such as government information was briefly used to gather background information. Search terms used to find literature included article keywords, the special populations discussed in this paper, and title words. After a thorough literature search on clinical and economic effects of collaborative care, data was collated to discuss the efficacy of collaborative care on specific populations.

3. Discussion

3.1. student health: expanding access and utilization of mental healthcare in university settings.

As with primary care, there is a significant unmet need for mental health services in collegiate settings. It is estimated that 17% of students experience serious psychological distress [ 13 ] but less than half receive treatment. [ 14 ] This is not surprising given that half of adult psychiatric illnesses, including major depression, anxiety disorders, and substance abuse, start by age 14, with 75% presenting by age 25. [ 15 ] These individuals face persistent symptoms that negatively impact academic performance, graduation rates, and future income, and lead to increased rates of substance misuse and social dysfunction. [ 16 ] Alarmingly, trends show a worsening of mental health among college students in recent years. [ 17 ] Two large databases (the National College Health Assessment and the Healthy Minds Study) showed rates of depression, anxiety, nonsuicidal self-injury, suicidal ideation, and suicide attempts markedly increased from 2007 to 2018, with rates doubling over that period in many cases. The steepest increase was observed between 2014 and 2018. This highlights the need to better understand the barriers students face. One factor to consider is how the availability of on campus services affects utilization. A survey of nearly 40,000 students found that of the 20% of students who had used mental health services while attending college, half used on-campus resources, whereas the other half used off-campus services. Older, white, full-time, and female students were more likely to use these services.

As a model to address some of these challenges, CoCM is becoming increasingly widespread in collegiate settings. A survey conducted in 2007 found that 26% of respondents identified their institution as actively implementing some form of integrated behavioral healthcare system on campus. A more recent study including mostly 4-year public and private schools [ 18 ] reported that this has now risen to 46%. Many nonintegrated student health centers have reported making referrals to specialty mental health care and coordinating care between departments despite not having formal Collaborative Care services. However, there were still lower levels of shared treatment planning, clinical collaboration, and information sharing being reported in nonintegrated centers as compared to explicitly integrated centers.

Universities and colleges nationwide have increasingly begun to interrogate the benefits of Collaborative Care. One example is the National College Depression Partnership at New York University, which demonstrated that the Collaborative Chronic Care Model for depression can be implemented successfully in campus health centers through a learning collaborative approach. [ 19 ] The initiative involved a cumulative total of over 40 colleges and universities starting in 2006 but has not been active in recent years.

While there are no studies that examine the cost effectiveness of CoCM programs specifically in student health settings, providing mental health treatment can yield economic benefits in the form of increased graduation rates. One report estimated that for every dollar invested in prevention and early intervention programs, there was a net societal benefit of $6.49. [ 20 ] The Healthy Minds initiative has developed a return-on-investment tool to assist colleges in understanding the benefits of implementing comprehensive mental health services, including CoCM. [ 21 ]

In summary, there is a tremendous and growing need for mental health services in the college setting. A report by the American Council on Education [ 22 ] made 4 recommendations for colleges and universities regarding mental health on campus. Three of these are explicitly addressed by CoCM: implementing routine assessment, enhancing accessibility of clinical services, and integrating mental health promotion and prevention. Additionally, a recent Consensus Report by the National Academies, Sciences, Engineering, and Medicine on student mental health included the following recommendation: “colleges and universities should make behaviorally focused mental health services more readily available in primary care settings to facilitate students’ access to care and improve coordination between mental health and primary care providers, both on campus and in telehealth services.”

3.2. Women’s health: perinatal depression as a case study in the application of CoCM

During the childbearing years, many women receive primary care services through an OBGYN provider. These services include routine monitoring of labs, health screening and maintenance of immunizations. To this end, women’s health settings present ample opportunities for CoCM, given the parallels to primary care. Perinatal depression (PPD), however, is unique to women’s health and is a common but underdiagnosed complication of childbirth that affects as many as 23% of women. There has been renewed focus on PPD because of its high prevalence and due to the emergence of new treatments. Therefore, this serves as a good example for discussing the potential impact of the CoCM. PPD is associated with pregnancy complications, impaired maternal-infant bonding, and a host of other negative consequences for both mother and child. The suicide rate has been estimated to be between 2.0 and 3.7 deaths per 100,000 live births [ 23 ] and is a leading cause of maternal mortality in the first 12 months postpartum. PPD often goes unrecognized because changes in sleep, appetite and libido can be attributed to normal pregnancy and postpartum changes. Even when PPD is identified, patients receive insufficient or no treatment. In a study of 122 women in a cohort of 1125 postpartum women who were diagnosed with PPD, only 12% had received psychotherapy and 3% had received medication at the 3 month follow-up following initial diagnosis. [ 24 ] While most obstetricians recognize the value of managing depression, they lack the tools required for screening and the training and resources needed for follow up care, often relying on specialty referrals, which oftentimes lack availability. [ 25 ] Most women between the ages of 18 and 44 have limited access to specialized care; the majority only have access to OBGYNs or PCPs, making CoCM an attractive integrated treatment solution. [ 26 ]

CoCM has been successfully implemented in several women’s health settings. The MOMCare intervention is a Collaborative Care strategy that has received the most research attention among this population. This approach was tested in the Medicaid population and differs from standard interventions that are typically provided by a team of public health social workers, nurses and nutritionists, who oftentimes inconsistently screen mothers for depressive symptoms. [ 27 ] Instead, the MOMCare intervention functions similarly to the traditional CoCM model, with care managers closely collaborating with the patient and a psychiatrist on medication and therapy management, while also monitoring patient progress throughout the maternal journey. [ 27 ] When compared to standard treatment, MOMCare is more effective in guiding patients to remission, reducing the severity of depression, and enhancing patient satisfaction; 48% of patients receiving MOMCare achieved or sustained remission for PPD. [ 27 ] In addition, providers expressed satisfaction seeing their patients follow through with their referrals and receive more specialized care. [ 28 ] Similar findings have been reported from studies using other collaborative approaches, with women reporting less depression symptoms, higher treatment satisfaction, and more successful antidepressant therapy. This is likely because, despite their comfort in screening for PPD, OBGYNs assess their confidence in treating depression and providing antidepressant advice as less than internists or family doctors. [ 25 ]

Although several studies demonstrate CoCM’s superior clinical outcomes for PPD as compared to treatment as usual, CoCM is oftentimes more expensive, with MOMCare costing approximately $1737 per course of treatment, while the direct cost of care without specialized intervention is approximately $570. [ 26 ] Patient monitoring and care management are significant components of CoCM, hence, the increased costs associated with staffing. [ 25 ] Despite the higher cost, women who received MOMCare experienced more depression-free days than their counterparts. [ 26 ] While the value of a depression-free day can vary across groups, a study by Epperson [ 29 ] showed that mothers with untreated PPD had significantly higher annual direct total all-cause medical and pharmaceutical spending than matched controls without PPD ($19,611 vs $15,410), driven primarily by more outpatient visits. When examined more broadly, PPD had an impact on the entire household, not just on the affected mother. This translates into significant all-cause family medical and pharmaceutical spending during the first year following childbirth ($36,049 vs $29,448) and an average of 16 more outpatient visits across the family unit as compared with unaffected households.

In summary, an integrated approach to the care for women with perinatal depression has substantial benefits. Evidence indicates improved clinical outcomes, patient and provider satisfaction, and overall quality of care. Although a collaborative approach may have higher direct costs than the current standard of care, this expense is minimal compared to the impact PPD has on the total cost of care, and the long term burden that untreated PPD has on a mother and her family.

3.3. Geriatric health: CoCM as a key part of a whole health solution

The primary care settings are often ideal for screening and treating mental health conditions among older adults. Amongst the geriatric population, nearly 30% report depression or anxiety to their PCPs, with the greatest burden in Hispanic and Asian populations (32–35). Many older adults have a stigmatized perception of mental health treatment and are therefore reluctant to seek specialized care. [ 30 ] As a result, primary care presents a critical opportunity for the detection and treatment of mental health disorders in older adults. Like OBGYNs, providers in geriatrics often lack training and time to diagnose and treat mental health conditions, creating another barrier for patients needing care. Studies have shown that CoCM can effectively address this care gap. [ 31 – 35 ]

In the last decade, CoCM has been increasingly utilized to care for older adults within primary care. A 2006 [ 36 ] study demonstrated that older participants assigned to a collaborative intervention reported a 23% reduction in their depressive symptoms, better adherence to medication, and improved satisfaction and quality of life compared to those receiving standard care. The Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking (BRIGHTEN) program is another well-known study that supports the efficacy of CoCM. This program integrated empirically supported primary care collaboration approaches and tailored them for delivery to a geriatric population via in-person and/or virtual care. The BRIGHTEN intervention utilized a virtual interdisciplinary team to screen and treat depression in older adults in outpatient primary and specialty medical clinics. Key findings included an increased number of self-referring patients, a significant decrease in depressive symptoms, and improved communication among providers. [ 34 ]

The BRIGHTEN initiative has also demonstrated improved minority participation in mental health treatment, which has historically proven to be challenging. nonwhite elders, the majority of geriatric patients, are more prone to reporting somatic complaints, and hold negative views on mental health diagnoses and treatment. Instead of seeing a specialist, these adults felt more comfortable entering a program through primary care. [ 31 , 34 ] Importantly, older people who received Collaborative Care reported feeling listened to and cared for, and some rated these positive interactions as more effective than pharmacotherapy. [ 32 ]

Beyond improved clinical outcomes, there is evidence that using CoCM when treating elderly patients with neurocognitive disorders, which frequently coexist with behavioral disorders, can reduce medical costs and save provider time. [ 37 ] Early identification of mental health conditions can lower costs for health systems and patients in the form of reduced hospital admissions, emergency visits, and more drastic medical interventions later in the course of the disease. [ 38 ] In addition, CoCM has been associated with lower ambulatory cost in elderly populations. [ 39 ] While implementation of CoCM can increase overall healthcare costs in the first year, that figure drops in later years, suggesting that an early investment in mental health care results in long term cost savings. [ 40 ]

In summary, Collaborative Care appears to be an effective intervention to improve clinical outcomes in any population. CoCM also offers greater mental health accessibility and opportunities for better detection of mental health conditions. Additional research is required to assess patient outcomes and provider experience using Collaborative Care in a geriatric setting to provide a holistic account of the benefits and challenges.

3.4. Treatment for substance abuse

Nearly 20 million people in the United States suffer from a substance abuse disorder and do not receive adequate treatment. Those who seek treatment mostly do so in the primary care setting. [ 41 ] This presents an opportunity for the millions of patients who do not otherwise receive treatment due to inadequate access to care and stigma. Patients receiving substance abuse treatment commonly have comorbid psychiatric conditions such as depression and anxiety. Treatment of these conditions has been shown to improve health outcomes related to substance abuse. [ 42 ] Early diagnosis and behavioral intervention can result in faster treatment times and higher remission rates. Numerous studies have suggested that integrated treatment for comorbid mental health conditions is superior to individual, siloed treatment plans. [ 43 ]

A team-based approach that involves a BHCM, consulting psychiatrist, PCP, and substance use care manager is necessary for CoCM to be effective. [ 44 ] In some cases, the behavioral and substance use care manager can be the same person if they are trained appropriately. CoCM functions well in this setting because PCPs tend to lack the time, resources and skill with behavioral interventions required for long term treatment with a substance abuse patient. [ 44 ] PCPs frequently refer their patients to substance abuse specialists. However, fewer than 35% of patients follow through with these referrals, with patients citing clinical differences in treatment decisions and varying wait times as reasons they do not follow through. [ 45 ] Thus, there is a significant opportunity to increase access to care and compliance using CoCM.

One of the unique advantages of CoCM is that it targets substance abuse and behavioral health symptoms simultaneously through 2 collaborative providers on the same team, reducing the burden on the PCP, and improving collaboration. [ 44 ] It is no surprise, therefore, that 86% of primary care practices agree that training related to substance abuse treatment would be helpful for their clinical staff. [ 41 ] CoCM for substance abuse can increase the number of patients treated by giving PCPs more time and resources [ 44 ] ; in fact, 1 study reported a 375% increase in patients treated in primary care once CoCM was implemented. [ 46 ]

In addition, patients treated for substance abuse via CoCM report greater abstinence from alcohol and drugs than patients receiving treatment as usual. [ 47 ] Individuals participating in a trial on opioid addiction treated with Buprenorphine and a collaborative intervention were more likely to have successful outcomes and remain in treatment as compared to patients treated with Buprenorphine alone. [ 48 ] One caveat, however, is that as a result of increased staffing needs, a health system must be prepared for a near-term increase in their costs for the employment and training of care managers. While there is currently limited research examining the cost effectiveness of CoCM in treating substance abuse, studies demonstrating higher patient remission rates suggest that CoCM lowers the total cost of care in the long run.

In summary, research has demonstrated that CoCM is effective in treating substance abuse in primary care settings. Patients reported increased access to care and clinicians noted higher remission rates. More research is required to assess CoCM’s cost effectiveness for patients with substance abuse problems.

3.5. Measurement-based care and screening

Many people diagnosed with mental health conditions never receive treatment, which is a common finding across all the populations examined in this paper. Although CoCM has been shown to improve access to care, we suggest that the first step in addressing the treatment gaps is MBC and population-level screening. Numerous studies have demonstrated that routine screening for mental disorders enables early detection and intervention. Current efforts to improve screening include the utilization of different screening tools such as the Patient Health Questionnaire (PHQ-2 and PHQ-9). [ 49 ] A meta-analysis of 14,760 adults has validated the use of the PHQ-2 and PHQ-9 as reliable and effective measures to detect depression in primary care. [ 50 ]

Equally important to screening, MBC can be described as the evaluation of patient symptoms at any stage of treatment to inform treatment choices. [ 51 ] MBC acts as a critical component of any population health strategy and is an accepted practice for many medical conditions such as diabetes or hypertension, where objective measures reflecting the state of health of the population are easily available. Challenges to the routine use of MBC include the complex processes required to initiate systematic routine data collection and administrative burden such as increased time and paperwork combined with limited resources. [ 52 ] In addition, barriers to implementing MBC have been identified at both the patient (e.g., concerns about how information is being used) and provider level (e.g., over-valuing clinical judgment).

Ultimately, both these components are essential to gauge CoCM’s effectiveness as they enable clinicians and care managers to continuously monitor patient progress. Monitoring patient data consistently leads to better results, increased patient-provider contact, and increased treatment fidelity. For instance, reliance on clinical judgment may fall short in identifying poor treatment responses, which could result in the continuation of ineffective treatment. However, if screening and assessment of patient symptoms are performed frequently and consistently, the treatment plans can be adjusted when necessary.

4. Conclusion

Launching CoCM requires investment in population health tools such as registry and tracking systems, low-burden population screening software, and interoperability with legacy electronic medical record systems. In addition, adequate staffing is critical; providers must be trained on CoCM, BHCMs hired, and consulting psychiatrists identified, suggesting a considerable investment of time and money. However, these upfront costs are generally offset by longer-term health care savings vis-a-vis lower overall healthcare utilization, better medical treatment adherence, etc. As CoCM becomes more widely accepted and implemented, reimbursement is becoming more universal, with CMS and most commercial payers approving reimbursement for CoCM services. Organizations can use this growing emphasis on collaborative interventions to implement these novel, evidence-based, and cost-effective models of care. CoCM presents opportunities for healthcare systems to have a greater impact on clinical outcomes and therefore a greater ability to take on risk. It is critical that payors consider these services preventative, reducing the cost burden and barriers to entry for enrollment. Early data suggests that enrollment and treatment compliance increase by over 50% by eliminating patient financial responsibility (such as copayment or coinsurance).

The unique strength of CoCM is its ability to adapt to the unique concerns of specific populations, such as students, geriatric patients, women’s health, and substance abuse treatment. Historically, it has been difficult to diagnose and treat mental health conditions in these populations. Fortunately, CoCM provides innovative treatment options that enhance patient access and outcomes. In addition, the use of MBC and screening contribute to the effectiveness of CoCM by promoting early intervention and ongoing treatment.

In the pursuit of the Quadruple Aim of Healthcare, CoCM has the potential to play a significant role and continues to gain momentum as an evidence-based model of care. At its core, CoCM is a population health strategy that delivers value-based care with a focus on patient experience. Studies of CoCM have shown increased provider satisfaction and increased provider confidence in managing behavioral health problems. The implementation of CoCM lags far behind given the substantial body of empirical evidence supporting its use. Greater implementation of CoCM in a variety of clinical settings may be a creative solution to the growing mental health pandemic.

Author contributions

Conceptualization: Christopher Reist, Maurice Chiang.

Project administration: Christopher Reist, Maurice Chiang, Incia Petiwala.

Supervision: Christopher Reist, Maurice Chiang, Daniel Eisenberg, Scott Campbell.

Writing – original draft: Christopher Reist, Incia Petiwala, Maurice Chiang.

Writing – review & editing: Christopher Reist, Incia Petiwala, Jennifer Latimer, Sarah Borish, Maurice Chiang, Daniel Eisenberg, Scott Campbell.

Abbreviations:

IP, JL, SB, and MC are employees of Carbon Health Technologies, Inc, and receive a salary and/or equity for their work. Christopher Reist is a Medical Director at Science37, and serves as the Chief Medical Officer at MindX Sciences; for both roles, Dr. Reist has received a salary and equity for his work.

The authors have no conflicts of interest to disclose.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

How to cite this article: Reist C, Petiwala I, Latimer J, Raffaelli SB, Chiang M, Eisenberg D, Campbell S. Collaborative mental health care: A narrative review. Medicine 2022;101:52(e32554).

• Open access
• Published: 24 August 2024

The impact of religious spiritual care training on the spiritual health and care burden of elderly family caregivers during the COVID-19 pandemic: a field trial study

• Afifeh Qorbani 1 ,
• Shahnaz Pouladi 2 ,
• Akram Farhadi 3 &
• Razieh Bagherzadeh 2  

BMC Nursing volume  23 , Article number:  584 ( 2024 ) Cite this article

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Metrics details

Family caregiving is associated with many physical and psychological problems for caregivers, but the effect of spiritual support on reducing their issues during a crisis is also the subject of research. The study aims to examine the impact of religious spiritual care training on the spiritual health and care burdens of elderly family caregivers during the COVID-19 pandemic.

The randomized controlled field trial involved 80 Iranian family caregivers in Bushehr City, who were selected by convenience sampling based on the inclusion criteria and divided into experimental (40 people) and control (40 people) groups by simple random sampling in 2021 and 2022. Data collection was conducted using spiritual health and care burden questionnaires using the Porsline software. The virtual intervention included spiritual and religious education. Four virtual sessions were held offline over two weeks. The first session was to get to know the participants and explain the purpose, The second session focused on the burden of care, the third on empowerment, and the fourth on mental health and related issues. In the control group, daily life continued as usual during the study.

Mean changes in existential health (3.40 ± 6.25) and total spiritual health (5.05 ± 11.12) increased in the intervention group and decreased in the control group. There were statistically significant differences between the two groups for existential health (t = 3.78, p  = 0.001) and spiritual health (t = 3.13, p  = 0.002). Cohen’s d-effect sizes for spiritual health and caregiving burden were 0.415 and 0.366, respectively. There was no statistically significant difference in mean changes in religious health ( p  = 0.067) or caregiving burden ( p  = 0.638) between the two intervention and control groups.

Given that the religious-spiritual intervention had a positive effect on existential health and no impact on religious health or care burden, it is recommended that comprehensive planning be undertaken to improve the spiritual health of family caregivers to enable them to better cope with critical situations such as a COVID-19 pandemic.

Trial registration

IRCT code number IRCT20150529022466N16 and trial ID number 48,021. (Registration Date2020/06/28)

Peer Review reports

With the global outbreak of COVID-19 on January 12, 2020, and the highly contagious nature of this virus, the World Health Organization issued protocols for limiting community interactions worldwide [ 1 ]. While individuals of all ages are susceptible to COVID-19, The high incidence of infection in older people, the greater severity of the disease, and the increased mortality are significant challenges in implementing appropriate preventive measures and future strategies to protect against this disease in the geriatric population [ 2 , 3 ]. According to the US Centers for Disease Control and Prevention, 31% of COVID-19 cases, 45% of hospitalizations, 53% of intensive care unit admissions, and 80% of COVID-19-related deaths in the United States occur in the elderly [ 4 ].

During the COVID-19 crisis, elderly people required various forms of assistance, including telephone and digital visits, with most of these services provided by family members [ 5 ], Park (2021) reported that long-term caregivers (> 1 year) had more negative somatic physical symptoms (headaches, body aches, and abdominal discomfort), worse mental health, and more significant fatigue than non-caregivers [ 6 ]. Family caregivers can only provide up to 80% of the required care to seniors with Multiple chronic conditions in the community, and they are also responsible for the majority of the costs and shoulder the related burden. This increased reliance on family caregivers has, in turn, heightened their care burden. The burden of care is a significant issue globally, with millions of individuals taking on caregiving responsibilities for their loved ones. The care burden encompasses various dimensions, including time-dependent, evolving, physical, social, and emotional aspects, making it a complex and highly individualized concept [ 7 ]. It often results from a negative imbalance between caregiving responsibilities and other obligations [ 8 ].

In Iran, like in many other countries, this burden can have profound implications on caregivers’ physical, emotional, and financial well-being. By introducing the concept of spiritual health into the discourse, we aim to shed light on a potentially overlooked aspect that could provide additional support and resilience to caregivers. Statistics indicate that caregivers who report a strong sense of spiritual well-being often exhibit lower levels of stress, anxiety, and depression, highlighting the importance of addressing this dimension in caregiving research. The existing literature on caregiver burden focuses mainly on caregiving’s physical and emotional aspects. While these studies provide valuable insights, there is a noticeable gap in understanding the role of spiritual health in mitigating the burden of care. Further exploration is needed to investigate how spiritual well-being can influence the overall caregiving experience and contribute to the well-being of the caregiver and the care recipient. In Iranians’ religious and national culture, the elderly hold a revered position and are highly respected. Reflecting on this cultural perspective, the Prophet of Islam stated, that respecting older people of my community is the same as respecting me [ 9 ]. This cultural context is evident in the fact that 86.4% of elderly individuals in Iran, according to statistics from the welfare organization, live with their children and spouses [ 10 ]. However, when caregiving responsibilities increase, they can overshadow the multiple health dimensions of the older people’s family members, including physical, psychological, social, and spiritual aspects. Coping strategies, such as spiritual-religious approaches, are often employed to manage the challenges [ 11 ].

There are two dimensions to spiritual health: religious and existential. Religious health refers to how a person understands his or her spiritual well-being when connected to a higher power. Conversely, existential health centers on an individual’s capacity for adaptation to their being, the societal landscape, and the broader environment [ 12 ]. In the past, the significance of spirituality in effectively managing stress was often underestimated; however, recent years have seen increased attention from researchers [ 11 , 13 , 14 ]. It is important to note that the understanding of spirituality is influenced by culture and religion, and its implications may vary for different individuals [ 15 ]. The current research gap lies in the lack of comprehensive studies that assess the intersection of spiritual health and care burden in the Iranian caregiving landscape. While some research exists on the broader topic of spirituality and health, there is a need for targeted investigations that consider the unique cultural and religious factors that shape the Iranian perspective on caregiving. Understanding these nuances can provide valuable insights into how spiritual care practices can be effectively integrated into support systems for caregivers in Iran. To the best of our knowledge, no previous study has investigated the impact of religious-spiritual care training on the spiritual health and care burden of family caregivers of older people during the COVID-19 pandemic. Given the critical role of nurses as caregivers for family and elderly health along with their supportive function [ 16 ], it is essential to identify caregivers at risk during critical situations and address their spiritual needs as part of community-oriented care. The study aimed to examine the impact of religious spiritual care training on the spiritual health and caregiving burden of older family carers during the COVID-19 pandemic. By thoroughly exploring the relationship between spiritual health and the caregiving burden of older family carers, we aim to identify potential strategies and interventions that can improve the well-being of caregivers and the overall quality of care provided to care recipients in Iran.

Study design

This study utilized a randomized controlled field trial design. The choice of a field randomized controlled trial for this study provides a rigorous and systematic approach to evaluating the effectiveness of a spiritual health intervention on care burden among Iranian caregivers. This design ensures internal validity, generalizability, and ethical soundness, thereby strengthening the overall quality of the research findings.

Participants and data collection

Participants were selected from the home care department of the comprehensive rehabilitation service center for the elderly in Mohammadieh, Bushehr City (affiliated with the welfare organization), and four comprehensive urban health centers in Bushehr Port, specifically Kheybar, Quds, Meraj, and Shohada centers. The inclusion criteria encompass caring for elderly individuals who showed a degree of dependence in at least one of their six daily activities, as defined by Katz’s criteria for activities of daily living (ADL). Additionally, caregivers had to possess literacy skills (reading and writing), with at least six months having elapsed since the commencement of their caregiving responsibilities. Furthermore, inclusion criteria require a family relationship between caregivers and elderly individuals in their care, cohabitation with older people, and delivering at least 40 h of care per week. Caregivers had to be at least 18-year-old Shia Muslims. The exclusion criteria dictated that the caregivers be excluded from the study under certain conditions, including the death of either the caregiver or the elderly individual during the study, refusal to continue participation in the study, the presence of neurological and psychiatric diseases, or the use of neuropsychiatric drugs, self-reported drug or alcohol addiction, or prior involvement in a spiritual-religious educational program related to elderly care.

Sample size

Based on the effect sizes observed in the studies by Hosseini et al. (2016) [ 17 ], Mahdavi et al. (2016) [ 18 ], and Moeini et al. (2012) [ 19 ], with a Type I error rate of 0.50 and a power of 80%, and using the G Power 3.1.9.2 software, the required sample size for the two-group test was approximately 80 individuals, with 40 participants in each group. Eligible elderly family caregivers were selected from available candidates and randomly assigned to either the test or control group (Fig.  1 ). Randomization was done using Random Allocation software and by a person who did not know the participants and did not know their characteristics.

Consort diagram

Instruments

The data collection instruments used in this study consisted of a demographic information form, along with the spiritual health questionnaire developed by Paloutzian and Ellison (1982) and the care burden questionnaire designed by Novak and Guest (1989).

Demographic information form

This form collected information about the caregiver, including age, number of children, family relationship to older people, level of education, occupation, income, and type of housing.

Spiritual health questionnaire (Paloutzian and Ellison, 1982)

The Spiritual Health Questionnaire, developed by Paloutzian and Ellison in 1982, is widely used to assess an individual’s spiritual well-being and beliefs. This questionnaire consists of 20 items that explore different aspects of spirituality, including beliefs, practices, values, and experiences. Participants are asked to respond to statements about spirituality on a six-point Likert scale, with responses to agree strongly or to disagree strongly. This questionnaire includes two subscales: (1) Religious well-being (10 items): This subscale assesses how an individual’s religious beliefs, values, and practices contribute to their overall well-being and sense of purpose. (2) Existential well-being (10 items): This subscale focuses on the individual’s sense of meaning, purpose, and connection to something greater than themselves, regardless of religious affiliation. Each subscale receives a score from 10 to 60. The spiritual health score is the sum of these two subscales and ranges from 20 to 120. In Iran, during the research conducted by Parvizi et al. (2000), the reliability of this questionnaire using Cronbach’s alpha coefficient was 0.82 [ 20 ]. In Hamdami et al.‘s research (2015), Cronbach’s alpha coefficient of the total spiritual health score was 0.79 [ 21 ].

Care burden questionnaire (Novak and Guest, 1989)

The Care Burden Questionnaire, developed by Novak and Guest in 1989, is a widely used instrument for assessing the burden experienced by caregivers who provide care to individuals with chronic illnesses or disabilities. Caregivers are asked to respond to a series of statements concerning caregiving burden on a Likert scale, with response options typically ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). The maximum score that can be attained on this questionnaire is 96, while the minimum score is 0. The questionnaire includes five sub-scales designed to capture a specific aspect of the burden. These include time demands, emotional stress, social isolation, financial strain, and conflicts with other responsibilities. In Iran, in the study of Abbasi et al. (2013), the Cronbach’s alpha coefficient of this questionnaire was 0.90, and its subscales ranged from 0.72 to 0.82 [ 22 ].

Baseline test

Before the intervention, research sessions were initially scheduled to occur in person; however, the coronavirus pandemic rendered it impractical to conduct face-to-face training sessions. As a result, spiritual and religious training was carried out online without impacting b behavioral therapy (CBT) and stress management techniques. It was structured to address the emotional, social, and physical dimensions of caregiver burden while simultaneously fostering coping strategies and self-care practices. The intervention framework was informed by existing research on caregiver interventions, CBT, and stress management. Studies have shown the effectiveness of psychoeducational programs in reducing caregiver burden and enhancing well-being. The incorporation of CBT techniques aimed to help caregivers identify and reframe negative thought patterns, while stress management strategies were included to help caregivers better cope with stressors.

In the test group, the intervention took the form of spiritual care based on the model of Richards and Bergin, which was aligned with Islamic teachings. This model featured six key steps: First, caregivers were guided to pay attention to spiritual-cultural sensitivities. Second, they were trained to establish an open and secure spiritual relationship. Third, potential ethical challenges were addressed. Fourth, caregivers conducted a religious and spiritual assessment of clients. The fifth step involved defining suitable goals for spiritual therapy, and the final step focused on properly implementing spiritual interventions [ 23 ]. The educational sessions covered various dimensions of the care burden, including physical, mental, social, and financial elements, as well as facets of spiritual health, which included the religious dimension (about communication with a transcendent higher power) and the existential dimension (encompassing communication with oneself, creation, and all living beings). These educational sessions were delivered via pre-recorded video presentations developed by a specialist in geriatric nursing and religious education. Participants engaged in four virtual sessions offline, conducted through WhatsApp social messenger, with two sessions held per week. Each session involved the following activities: (1) Following up on the previous session’s topics; (2) providing feedback to participants; (3) summarizing and outlining previous topics to create a connection between the topics discussed; and (4) offering explanations and summaries related to the new session’s topic. One month after the end of the intervention, test and control group participants completed the Mental Health Questionnaire and the Carer’s Burden Questionnaire again. The control group continued with their daily lives as usual throughout the study. Upon its conclusion, the educational materials on spirituality and its various concepts, which had been shared via WhatsApp Messenger, were made available in alignment with the ethical principles that govern such research. The educational content for the sessions was developed by a multidisciplinary team consisting of a nurse psychiatrist, a gerontologist, and a Specialist in Quran and Hadith. The educational content was designed and compiled by the research team to improve practical skills, stress management, self-care, and communication, based on the model of Richards and Bergin and according to the teachings of Islam and the Shia religion. To ensure the accuracy and reliability of the content, the educational materials underwent a rigorous review process involving experts from diverse fields, including caregiving, psychology, and Quranic and Hadith sciences. Feedback from caregivers and pilot testing were also used to refine and validate the content before implementation. A pilot study was conducted to test the intervention’s feasibility, acceptability, and initial effectiveness. The pilot study involved a small group of caregivers who received the intervention, and their feedback was used to refine the program before full implementation. All contributors implementing the intervention received comprehensive training on the educational content and intervention protocols. These trainings were followed daily by viewing the participants’ WhatsApp to receive educational content and listening to audio files, making daily phone calls, and asking them questions over the phone to understand the content and express their questions. The intervention was implemented by a team of trained healthcare professionals, including a social gerontologist, a nursing gerontologist, and a medical-surgical nursing student with a master’s degree. They all had relevant qualifications and expertise in mental health and caregiving support. Potential challenges for implementers could include caregiver resistance, emotional distress, not receiving training materials on time, or difficulty engaging participants. The plan for dealing with such situations included regular monitoring of caregiver progress, open communication, and flexibility in the delivery of sessions. For participants who required more specialized training or support beyond the scope of the intervention, referrals were made through telephone communication with the training session facilitators. Response data from the instruments, such as the Care Burden Questionnaire and other assessment measures, were collected through self-report questionnaires and standardized rating scales administered by trained assessors. Caregivers were asked to respond based on their experiences before and after the intervention. To handle ambiguities in the response data, assessors were trained to clarify any uncertainties or ambiguities in the questions with caregivers. This involved providing clear explanations, and examples, and ensuring that caregivers understood the questions before responding. A specific post-intervention assessment time point was established to standardize the time after the intervention for all participants. This time point was determined based on the intervention duration and the optimal timeframe for assessing the intervention’s impact on caregiver burden based on past studies [ 24 , 25 ]. Caregivers were scheduled for the post-intervention assessment at this standardized time point to ensure consistency across all participants.

Ethical considerations

This study originated from a master’s thesis in internal surgical nursing at the Faculty of Midwifery Nursing, Bushehr University of Medical Sciences, with an ethics code number of IR.BPUMS.REC.1399.042. It is also registered with the Clinical Trial Centre of Iran under IRCT20150529022466N16. The caregivers were furnished with comprehensive information about the study, encompassing its objective, methodology, potential hazards and advantages, confidentiality protocols, and their entitlement to withdraw from the study at any point. Informed consent was obtained from all participants before they participated in the study. Measures were taken to ensure the confidentiality of participants’ personal information and data collected during the study. Participants were assured that their responses would be anonymized, stored securely, and only accessed by authorized research staff.

Data analysis

Due to the peak of the Corona pandemic and the closing of universities in person, the possibility of consulting statistics professors and performing data analysis was delayed for eight months. The data collected during the study were analyzed using SPSS version 19 software. The Shapiro-Wilk test was used to check the distribution of the data. An independent t-test, or Mann-Whitney test, was used to compare quantitative demographic variables between two groups. A Chi-squared or Fisher’s exact test was used to compare qualitative demographic variables between groups. To test the hypotheses above, a paired t-test was employed to ascertain the mean of the primary variables in question, before and after the intervention in each group. An independent t-test was utilized to determine the mean of the variables between groups, and Cohen’s d was calculated as the effect size. Independent t-tests were conducted to compare the mean scores of the changes. The significance level was assumed to be less than 0.05 in all cases.

No statistically significant differences were detected between the groups in terms of demographic variables, suggesting group homogeneity ( p  > 0.05) (Tables  1 and 2 ). Regarding spiritual health, within the intervention group, the post-test average score for total spiritual health was significantly higher than the pre-test score ( p  = 0.007), in contrast within the control group, the post-test average score was considerably lower than the pre-test score ( p  = 0.003). No statistically significant differences were observed between the two groups in terms of mean posttest spiritual health scores (Table  3 ) still, changes in overall spiritual health increased in the intervention group and decreased in the control group, with statistically significant differences between the two groups ( p  = 0.002) (Table  4 ). The Cohen’s d effect size for the difference in spiritual health between the intervention and control groups was 0.415, indicating a moderate effect of the intervention (Table  3 ). Within-group analysis showed no statistically significant differences between pre-and post-test scores for total care burden in either group. Furthermore, no statistically significant differences between the two groups were observed in terms of average care burden scores ( p  < 0.05) (Table  5 ). Likewise, the average changes in care burden scores between the intervention and control groups showed no statistically significant differences ( p  < 0.05) (Table  6 ). The Cohen’s d effect size for the difference in caregiving burden between the intervention and control groups was 0.366, indicating a moderate effect of the intervention on caregiving burden, although not statistically significant (Table  5 ).

This study aimed to evaluate the impact of religious spiritual care training on the spiritual health and care burden experienced by elderly family caregivers in Bushehr during the COVID-19 pandemic. The findings of this study suggest that a religious and spiritual intervention approach can effectively promote existential health and overall spiritual well-being. However, it was observed that this approach did not yield a notable impact on religious health or care burden. The Scores for existential health and overall spiritual health increased in the intervention group after the training, while they decreased in the control group. The mean change in religious health scores between the two groups did not reach statistical significance. These findings are consistent with the study conducted by Sayyadi et al. (2018) [ 26 ], who also observed an increase in spiritual health following a religious psychotherapy intervention. In this study, most family caregivers in the experimental and control groups initially demonstrated moderate to high levels of spiritual health. Similarly, Sayyadi et al. (2018) found higher spiritual health scores in medical and nursing students compared to other student populations. To explain and interpret the consistent findings regarding the positive effects of spiritual health on caregivers in the study by Sayyadi et al. and the current study on the impact of religious spiritual care training on elderly family caregivers, we can consider several factors that may contribute to these findings: (1) Spiritual health is often associated with providing a sense of support, purpose and coping mechanisms during challenging times. Caregivers facing the stress and demands of caregiving may benefit from a solid spiritual foundation to help them navigate their roles and find meaning in their experiences. Studies may have highlighted the role of spiritual health as a resource for caregivers to cope with the emotional and psychological challenges they face. (2) Spiritual health can help to build resilience and foster hope in individuals, including caregivers. By nurturing their spiritual well-being, caregivers may develop a sense of resilience that enables them to cope with adversity and maintain a positive outlook. Studies may have observed the positive impact of spiritual health on caregivers’ resilience and hope, leading to improved well-being and outcomes. (3) Spiritual health is often linked to personal growth and making sense of one’s experiences [ 27 ]. Caregivers possessing a robust spiritual foundation may engage in meaning-making processes, facilitating the discovery of purpose and significance within their caregiving journey. Studies may have underscored the role of spiritual health in promoting personal growth and facilitating meaning-making among caregivers. These factors, alongside the consistent focus on spiritual health across studies, provide a robust framework for understanding the positive impact of spiritual health on caregivers. Recognizing the importance of spiritual well-being within the broader context of caregiver health, and integrating interventions that specifically address spiritual needs, can contribute to improved outcomes and well-being for caregivers. This is supported by the findings of both Sayyadi et al. and the present study. It is important to note that the religious health scores did not increase after the intervention in the current study. The intervention, centered on religious and spiritual care training, had a significant impact on both existential well-being and overall spiritual health. The caregiver survey of palliative care patients will likely target different aspects of spiritual well-being, such as hope and general well-being. In interpreting these results, it is essential to consider the unique components of each intervention and how they may have influenced different aspects of spiritual health. On the other hand, Casalerio et al. (2024) in the study: Promoting Spiritual Coping of Family Caregivers of an Adult Relative with Severe Mental Illness: Development and Test of a Nursing Intervention, reported that the spiritual and religious intervention for caregivers increased their spiritual health dimension and their religious dimension [ 28 ]. These contrasting religious findings with the current study suggest that the effectiveness of religious and spiritual interventions may vary depending on the specific focus and approach of the intervention. Caregivers’ responses to such interventions may be influenced by factors such as the nature of the caring role, the context of the carer’s condition, and individual preferences regarding spirituality and religiosity. Further research and tailored interventions may be needed to address the diverse spiritual needs of caregivers in different care contexts.

Regarding the care burden, the results of the current study demonstrated no statistically significant differences in the average care burden scores within and between the groups. This result contrasts with previous studies by Polat et al. (2024), Xavier et al. (2023) [ 13 , 29 ], Partovirad et al. (2024) [ 11 ], Hekmatpour and colleagues (2018) [ 30 ], Shoghi et al. (2018) [ 31 ], which showed reductions in the care burden following intervention models and the current study care burden result align with previous studies by Khalili et al. (2024) [ 32 ], Salmoirago-Blotcher et al. (2016) [ 33 ], and Karadag Arli (2017) [ 34 ]. One of the reasons why the present study did not show the same effect of spiritual and religious interventions in reducing caregiver burden as similar studies have shown is probably due to the high caregiver burden in the relevant situation. In the present study, caregiver burden had increased due to the conditions of the Corona pandemic, and reducing caregiver burden may require more extended, and more social interventions. One potential explanation for the lack of reduction in care burden scores in the current study is the influence of social interaction theory and attachment theory. These theoretical frameworks emphasize the significance of the dynamic interplay between caregiver and care recipient, particularly highlighting the role of mutual appreciation and non-violent communication in mitigating caregiver burden [ 35 ]. The physical and mental conditions of care recipients, coupled with their inability to engage in appropriate interactions with caregivers during the COVID-19 crisis, may have intensified the care burden. Furthermore, a review of similar studies reveals that most interventions aimed at reducing care burden were conducted over longer periods than our study. These studies typically involved a higher number of sessions, ranging from 8 to 12 (e.g., Mohammadi and Babaei (2018) [ 36 ], Rahgooy et al. (2018) [ 37 ], Sotoudeh et al. (2018) [ 38 ] and Salehinejad et al. (2017) [ 39 ] Consequently, the shorter duration and fewer sessions in our study may have limited the effectiveness of the intervention in reducing the care burden. Additionally, the limitations imposed by social distancing measures may have exacerbated the needs of elderly individuals, leading to an increased caregiver burden. Furthermore, a review of similar studies reveals that most interventions aimed at reducing care burden were conducted over more extended periods than our study. These studies typically involved a higher number of sessions, ranging from 8 to 12 (e.g., Mohammadi and Babaei (2018) [ 30 ], Rahgooy et al. (2018) [ 32 ], Sotoudeh et al. (2018) [ 39 ] and Salehinejad et al. Consequently, the shorter duration and fewer sessions in our study may have limited the effectiveness of the intervention in reducing the care burden.

Limitations

This study had limitations. The limitations imposed by the pandemic, including the need for social distancing, made it impossible to conduct face-to-face training sessions and deprived participants and carers of the opportunity for close, face-to-face communication during the spiritual and religious intervention. This limitation may have affected the participants’ internal beliefs, emotions, and motivations. The restrictions imposed by the pandemic, through the utilization of routine telephone communications and collaboration with pertinent academic staff, exemplify adaptability and ingenuity in maintaining communication with participants. This multi-channel approach may have helped to ensure continued engagement and support for participants throughout the intervention. Despite the challenges posed by the lack of face-to-face communication, the study managed to keep participants engaged through alternative means. The regular phone calls and coordination with the professors may have fostered a sense of connection and support, potentially enhancing participants’ overall experience and engagement with the intervention. The lack of face-to-face interaction during the spiritual and religious intervention may have limited the depth of participants’ engagement and the impact on their internal beliefs and motivations. This limitation could affect the validity of the study findings, as face-to-face communication is often crucial for building trust and rapport in interventions of this nature. The short duration of the intervention and the constraints imposed by the pandemic may have limited the generalizability of the study results. Further research utilizing more extended intervention periods and more diverse participant groups may enhance the generalizability of the findings to a broader population. Utilizing virtual platforms for interactive sessions and group discussions could facilitate the replication of the advantages of face-to-face communication and cultivate a sense of community among participants. Conducting long-term follow-up studies to track the sustained effects of spiritual and religious interventions on caregiver burden could provide valuable insights into the lasting impact and effectiveness of the intervention over time.

Based on the study, the results were mixed. The religious and spiritual intervention was effective in improving existential health and overall spiritual health but did not have a significant impact on religious health and caregiving burden. The training in religious and spiritual care was determined to be effective in enhancing the existential well-being of elderly family caregivers, as evidenced by an increase in their sense of meaning, purpose, and fulfillment in the caregiving role. The intervention demonstrated effectiveness in improving caregivers’ overall spiritual health, suggesting positive outcomes in terms of emotional well-being, connectedness, and resilience. Notwithstanding the favorable outcomes in existential and general spiritual well-being, the intervention did not demonstrate a notable impact on religious well-being and caregiver burden, underscoring domains that may warrant further investigation and the development of alternative intervention strategies. It is crucial to recognize the intricate nature of caregiving dynamics and the various ways in which spirituality and religion can impact the well-being of caregivers. The result of the study indicates that integrating religious and spiritual care training could effectively enhance the existential and holistic spiritual well-being of elderly family caregivers. Practitioners and caregivers can utilize this intervention to foster a greater sense of meaning and spiritual well-being within the caregiving context. In addition, the study highlights the importance of personalized interventions that consider individual differences in spiritual beliefs and coping strategies. In conclusion, while the religious and spiritual intervention showed promising results in improving certain aspects of the spiritual health of elderly family caregivers in Bushehr, further research is needed to address the nuances of religious health and care burden. By carefully considering these key findings and implications, practitioners and researchers can tailor interventions to better support caregivers’ holistic well-being in the face of challenges such as the COVID-19 pandemic.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Na Zhu DZ, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F. A novel coronavirus from patients with pneumonia in China, 2019. 2020:727–33. https://www.nejm.org/doi/pdf/ https://doi.org/10.1056/NEJMoa2001017

Dhama K, Patel SK, Kumar R, Rana J, Yatoo MI, Kumar A, et al. Geriatric population during the COVID-19 pandemic: problems, considerations, exigencies, and beyond. Front Public Health. 2020;8:574198. https://doi.org/10.3389/fpubh.2020.574198

Article   PubMed   PubMed Central   Google Scholar  

Zhang J, Wang J, Liu H, Wu C. Association of dementia comorbidities with caregivers’ physical, psychological, social, and financial burden. BMC Geriatr. 2023;23(1):60. https://doi.org/10.1186/s12877-023-03774-9

Shahid ZKR, McClafferty B, Kepko D, Ramgobin D, Patel R. COVID-19 and older adults: what we know. J Am Geriatr Soc. 2020;68(5):926–9. https://doi.org/.1111/jgs.16472 . Epub 2020 Apr 20. PMID: 32255507; PMCID: PMC7262251.

Moradi M, Navab E, Sharifi F, Namadi B, Rahimidoost M. The effects of the COVID-19 pandemic on the elderly: a systematic review. J Salmand: Iran J Ageing. 2021;16(1):2–29. https://doi.org/10.3389/fpubh.2020.574198

Article   Google Scholar  

Park SS. Caregivers’ mental health and somatic symptoms during COVID-19. J Gerontol B Psychol Sci Soc Sci. 2021;76(4). https://doi.org/10.1093/geronb/gbaa121 . PMID: 32738144; PMCID: PMC7454918.

Malmir S, Navipour H, Negarandeh R. Exploring challenges among Iranian family caregivers of seniors with multiple chronic conditions: a qualitative research study. BMC Geriatr. 2022;22(1):270. https://doi.org/10.1186/s12877-022-02881-3

Phillips R, Durkin M, Engward H, Cable G, Iancu M. The impact of caring for family members with mental illnesses on the caregiver: a scoping review. Health Promot Int. 2023;38(3). https://doi.org/10.1093/heapro/daac049 . PMID: 35472137; PMCID: PMC10269136.

jaafari zadeh H, SmS K, rahgozar M. Health care status of elderly people with disabilities in District 13 of Tehran Municipality and their problems. Journal of Urmia Nursing And Midwifery Faculty. 2006;4(2):67–81.

Nafei ARV, Ghafori R, Khalvati M, Eslamian A, Sharifi D, et al. Death anxiety and related factors among older adults in Iran: findings from a National Study. Salmand Iran J Ageing. 2024;19(1):144–57. https://doi.org/10.32598/sija.2023.1106.1

Partovirad M, Rizi S, Amrollah Majdabadi Z, Mohammadi F, Hosseinabadi A, Nikpeyma N. Assessing the relationship between spiritual intelligence and care burden in family caregivers of older adults with chronic diseases. 2024. https://doi.org/10.21203/rs.3.rs-4343106/v1

Davarinia Motlagh Quchan A, Mohammadzadeh F, Mohamadzadeh Tabrizi Z, Bahri N. The relationship between spiritual health and COVID-19 anxiety among nurses: a national online cross-sectional study. Sci Rep. 2024;14(1):16356. https://doi.org/10.1038/s41598-024-67523-7

Article   CAS   PubMed   PubMed Central   Google Scholar  

Türkben Polat H, Kiyak S. Spiritual well-being and care burden in caregivers of patients with breast cancer in Turkey. J Relig Health. 2023;62(3):1950–63. https://doi.org/10.1007/s10943-022-01695-2 . Epub 2022 Dec 5. PMID: 36469230; PMCID: PMC9734401.

Article   PubMed   Google Scholar  

Francesco Chirico KB, Batra R, Ferrari G, Crescenzo P. Spiritual well-being and burnout syndrome in healthcare: asystematic review. School of Medicine Faculty Publications. 2023;15(3). https://doi.org/10.19204/2023/sprt2

Rezaei H, Niksima SH, Ghanei Gheshlagh R. Burden of care in caregivers of Iranian patients with chronic disorders: a systematic review and meta-analysis. Health Qual Life Outcomes. 2020;18(1):261. https://doi.org/10.1186/s12955-020-01503-z . PMID: 32746921; PMCID: PMC7398060.

Kurtgöz A, Edis EK. Spiritual care from the perspective of family caregivers and nurses in palliative care: a qualitative study. BMC Palliat Care. 2023;22(1):161. https://doi.org/10.1186/s12904-023-01286-2

Hosseini MA, Mohammadzaheri S, Fallahi Khoshkenab, Mohammadi Shahbolaghi M, Reza Soltani F, Sharif Mohseni M. Effect of mindfulness program on caregivers’ strain on Alzheimer’s disease caregivers. Salmand: Iran J Ageing. 2016;11(3):448–55. https://doi.org/10.21859/sija-1103448

Mahdavi B, Fallahi-Khoshknab M, Mohammadi F, Hosseini MA, Haghi M. Effects of spiritual group therapy on caregiver strain in-home caregivers of the elderly with Alzheimer’s disease. Arch Psychiatr Nurs. 2017;31(3):269–73. https://doi.org/10.1016/j.apnu.2016.12.003

Moeini M, Ghasemi TMG, Yousefi H, Abedi HJIjon, Research M. The effect of spiritual care on the spiritual health of patients with cardiac ischemia. 2012;17(3):195. https://pubmed.ncbi.nlm.nih.gov/23833611/

Parvizi S, Allahbakhshian M, Jafarpour allavi M, Haghani H. The relationship between spiritual health and quality of life in multiple sclerosis patients. Zahedan J Res Med Sci. 2000;12(3):29–33. https://civilica.com/doc/963361/

Google Scholar  

Hamdami M, GHasemi jovineh R, Zahrakar K, Karimi K. The role of spiritual health and mindfulness in students’ psychological capital. Res Med Educ. 2015;8(2):2736. https://doi.org/10.18869/acadpub.rme.8.2.27

Abbasi A, Ashraf Rezaei N, Asayesh H, Shariati A, Rahmani H, Molaei E, et al. Relationship between caregiving pressure and coping skills of caregivers of patients undergoing hemodialysis. Urmia School Nurs Midwifery. 2011;10(4):533–9.

Pouladi S ss, Bahreyni M, Bagherzadeh R. The effect of spiritual-religious psychotherapy on self-concept and sense of coherence in cancer patients of Bushehr City, 2017–2018. Bushehr University of Medical Sciences.

Modarres MAS. Effect of religion-based spirituality education on happiness of postmenopausal women: an interventional study. Health Spiritual Med Ethics. 2021;8(1):44–54. https://doi.org/10.29252/jhsme.8.1.44

Jahdi F, mA B, Mahani M, Behboudi Moghaddam Z. The effect of prenatal group care on the empowerment of pregnant women. Payesh. 2014;13(2):229–34.

Sayyadi M, Sayyad S, Vahabi A, Vahabi B, Noori B, Amani M. Evaluation of the spiritual health level and its related factors in the students of Sanandaj Universities, 2015. Shenakht J Psychol Psychiatry. 2019;6(1):1–10. https://doi.org/10.22122/cdj.v6i3.332

Koburtay TJD, Aljafari A. Religion, spirituality, and well-being: a systematic literature review and futuristic agenda. Bus Ethics Environ Responsib. 2023;32(1):41–57. https://doi.org/10.1111/beer.12478

Casaleiro TMH, Caldeira S. Promoting spiritual coping of family caregivers of an adult relative with severe mental illness development and test of a nursing intervention. Healthcare. 2024;12(13). https://doi.org/10.3390/healthcare12131247

Xavier FT, Esperandio MRG. Spirituality and caregiver burden of people with intellectual disabilities: an empirical study. Int J Latin Am Religions. 2023;7(1):17–35. https://doi.org/10.1007/s41603-023-00196-8

Hekmatpour DB, EM.Dehkordi LM. The effect of patient care education on the burden of care and the quality of life of caregivers of stroke patients. Multidisciplinary Healthc. 2019;12(2):7–11. https://doi.org/10.2147/JMDH.S232970 . PMID: 30936715; PMCID: PMC6430991.

Shoghi MN, Seyedfatemi., Shahbazi B. M S. The effect of family-center empowerment model(FCEM) on the care burden of the patient of children diagnosed with cancer. 2019;20(6):1757–68. https://doi.org/10.31557/APJCP.2019.20.6.1757

Khalili Z, Habibi E, Kamyari N, Tohidi S, Yousofvand V. Correlation between spiritual health, anxiety, and sleep quality among cancer patients. Int J Afr Nurs Sci. 2024;20:100668. https://doi.org/10.1016/j.ijans.2024.100668

Salmoirago-Blotcher EFG, Leung K, Volturo G, Boudreaux E, Crawford S, et al. An exploration of the role of religion/spirituality in the promotion of physicians’ well-being in emergency medicine. Prev Med Rep. 2016;1(3):189–95. https://doi.org/10.1016/j.pmedr.2016.01.009 . PMID: 27419014; PMCID: PMC4929145.

Karadag Arli SBA, Erisik E. An investigation of the relationship between nurses’ views on spirituality and spiritual care and their level of burnout. J Holist Nurs. 2017;35(3):214–20. https://doi.org/10.1177/0898010116652974 . Epub 2016 May 30. PMID: 27241132.

Jafari M, Alipour F, Raheb G, Mardani M. Perceived stress and burden of care in elderly caregivers: the moderating role of resilience Salmand. Iran J Ageing. 2022;17(1):62–75. https://doi.org/10.32598/sija.2021.2575.2

Mohammadi F, Babaie M. The impact of participation in support groups on spiritual health and care burden of elderly patients with Alzheimer’s family caregivers. Iran J Ageing. 2012;12(19):29–37. https://salmandj.uswr.ac.ir/article-1-374-en.html

Rahgooy AF, Sojoudi M. T. Investigating the effect of the empowerment program on the care burden of mothers with children with phenylketonuria and the level of phenylalanine in the children’s serum. TEHRAN: University of Rehabilitation Sciences and Social Welfare; 2016.

Sotoudeh RPS, Alavi M. The effect of a family-based training program on the care burden of family caregivers of patients undergoing hemodialysis. Iran J Nurse Midwifery Res. 2019;24(2):144. https://doi.org/10.4103/ijnmr.IJNMR_93_18 . PMID: 30820227; PMCID: PMC6390430.

Salehi Nejad S, Azami M, Motamedi F, Bahaadinbeigy K, Sedighi B, Shahesmaili A. The effect of web-based information intervention in caregiving burden in caregivers of patients with dementia. J J Health Biomedical Inf. 2017;4(3):181–91. https://www.sid.ir/fa/VEWSSID/J_pdf/3007513960302.pdf

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Acknowledgements

We would like to express our gratitude to the Student Research Committee, the Persian Gulf Martyrs Hospital’s Clinical Research Development Center, and all the elderly caregivers who participated in this research, as their contributions were invaluable.

Research expenses by the vice president of research and the student research committee of Bushehr University of Medical Sciences, Iran, have been paid.

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Qorbani, A., Pouladi, S., Farhadi, A. et al. The impact of religious spiritual care training on the spiritual health and care burden of elderly family caregivers during the COVID-19 pandemic: a field trial study. BMC Nurs 23 , 584 (2024). https://doi.org/10.1186/s12912-024-02268-2

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