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Crisis
Crisis
How to Help Yourself and Others
in Distress or Danger

Lee Ann Hoff

1
1
Oxford University Press is a department of the University of
Oxford. It furthers the University’s objective of excellence in research,
scholarship, and education by publishing worldwide.

Oxford New York

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in the UK and certain other countries.

Published in the United States of America by

Oxford University Press
198 Madison Avenue, New York, NY 10016

© Oxford University Press 2014

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the prior
permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights organization.
Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

A copy of this book’s Catalog-in-Publication Data is on file with the Library of Congress
ISBN 978–0–19–936416–9

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To victim-survivors of the April 15, 2013 Boston Marathon bombing; first respond-
ers and their healers; and to millions of others injured or killed in disasters of
human origin, war, terrorism, and horrific violence worldwide over centuries and,
tragically, continuing apace.
On April 15, 2013, I was working on drafts of this book’s chapters on victim-
ization and perpetrators of violence. The terrorist attack left me nearly incapable
of productive work as I struggled to write meaningfully for others while follow-
ing the terrorist attack in the Boston neighborhood where I lived for 24 years.
In remembrance of those who died in that terrorist attack and the millions of oth-
ers in ethnic, religious, and political strife across our troubled world, and to make
meaning out of the Boston Marathon bombing, I have arranged for this violence
prevention goal through universities and colleges where I have affiliations.
A percentage of royalties that may accrue from this book will be dedicated to
support scholarships for students with their potential for making a difference on
the tragic and continuing saga of global violence. To some extent, this plan allevi-
ates my flashes of feeling powerless in the face of so much violence worldwide.
Scholarship recipients will be eligible with this provision: Awardees must success-
fully complete at least one university/college course, directed study, or conduct
a research or training project on crisis, violence, and abuse issues grounded in a
human rights perspective and the principle of education as prevention and interven-
tion. Priority for scholarship eligibility will be given to students disadvantaged by
poverty, gender, race, ethnicity, sexual identity, or religion-based hatred. The plan
will be augmented and continued in my estate planning. Persons interested in join-
ing this prevention cause may contact www.crisisprograms.org
This plan is rooted in my education and research on social justice issues and
crisis care, plus the healing process from vicarious traumatization in caring for
victims, writing about crisis and violence, and periodic flashbacks to my personal
trauma history.
Peace!
Lee Ann Hoff
Boston, Massachusetts
March 2014
CON TEN T S

Acknowledgments  ix

Introduction: Building on a Rich History   1

PART I: People in Crisis: How Do They Feel, Think, and Act,

and How Can We Help?
Chapter 1—Life Crises: How to Avoid Danger and Grasp Opportunity   13
Crisis is a common life experience, not a psychiatric “disorder”
Chapter 2—Recognizing Different Faces of Distress on the Road
to Full-Blown Crisis   30
Knowing the difference between everyday upsetting events and life-or-death danger
Chapter 3—What to Do: How to Cope and Avoid Disastrous
Crisis Outcomes   54
When to seek professional help without shame
or asking your friend to play “therapist”

PART II: Life-Threatening Crises: Suicide, Abuse, and Violence

Toward Others
Chapter 4—A Cry for Help: Suicide and Other
Self-Destructive Behaviors  81
What everyone needs to know about clues to suicide and that
there is no such thing as absolute prediction
Chapter 5—Victimization by Violence, Sexual Assault, and
Emotional Abuse  115
Healing from the crisis of victimization by violence or verbal abuse
Chapter 6—The Violent and Abusive Person: Preventing Violence Is
Everybody’s Business   143
Violence and abuse: A major health and social issue worldwide
PART III: Crises Arising From Unexpected Stressful Events and
Life Cycle Passages
Chapter 7—Threats to Health Status From a Serious Illness
or Accident  173
Connecting the dots between serious medical events and emotional crisis
Chapter 8—Loss of Job, Home, and Financial Security   205
Coping with accidental and preventable loss of essentials in everyday life
Chapter 9—Life Cycle Changes, Loss and Growth: From Birth
to Death  241
Navigating and growing through challenges across the life cycle
Conclusion: Vision for Global Action: Research, Education,
and Practice  298
Learning from history, together we can make a difference across several fronts

Index  307

[ viii ] Contents
ACKNOW L ED GMEN T S

As we go to press, I am reminded again of the struggles and victories of the people

in crisis I have met over decades of practice, research, teaching, and consultation.
From these patients, their families, and their therapists and counselors, I have
learned so much about the suffering and triumphs of people facing the danger
and opportunity of crisis.
The key features of this book are the stories of diverse persons from a range
of stressful or dangerous situations, disguised here for privacy. They and their
providers have found meaning in sharing their experience so that others, helped
by a book like this, might learn and benefit from the lifelong lessons of both posi-
tive and negative crisis outcomes—how to avoid negative outcomes, and what
to do to promote positive ones. From these stories I have been affirmed in one of
my mantras: education as prevention. To all of these people I am deeply grateful.
Also central to this book are the lessons and wisdom of brilliant teachers, liter-
ary sources, and role models I have been blessed with for learning the basics of cri-
sis care—its theoretical and cross-cultural foundations, and how to apply practice
ideals among diverse persons in hospitals, mental health and crisis clinics, and in
peoples’ homes. My gratitude for these opportunities is deep and lasting.
The contextual and interdisciplinary focus of this book did not emerge from
formal interdisciplinary education alone. My immersion in teaching, work-
shops, and practice with students and practitioners led to the dream of this book.
Experience with students and practitioners in nursing, social work, psychology,
policing, and pastoral care yielded wisdom and examples for this book—not only
the positive outcomes we hope for our clients but also the affirmation of the cen-
trality of collaboration, teamwork, and support among crisis workers themselves
in such a challenging field. This team approach has left an indelible mark on me
and many others about how best to help oneself and others in crisis situations.
In workshops and formal university classes in the United States, Canada, and
countries in Africa, South America, and Europe, I have met brave and generous
people who have shared their experiences in personal and professional venues.
Across this diverse landscape, I thank each and all, as without them, there would
be no book like this.
 Turning to the nitty-gritty of producing the book, I thank anonymous review-
ers and my friends and colleagues who encouraged me during the process of
actualizing what was only a dream through the challenges, setbacks, and finally
the finish line. Some of you—Annie Leguern, my sister Marie Hoff, Lisa Brown,
Judith Leconte, Betty Cragg—read sections of the book that presented particular
challenges and shared valuable insights to making this a better book. Others—
David Blumenkrantz, Cathleen Getty, Jesse Jones, Donna Bivens, Larry Kistler,
Paul Marcus, Paula Finneran, Thalia Sidoroupolos, Susan Forward, and John
Taylor—listened and offered support through dilemmas toward the finish line,
while Jean Harnois, Claudia Ellis, and Don Peavy helped during the book’s
beginning phase. To each of you I am very grateful.
Last but not least, I thank Dana Bliss, my editor at Oxford University Press,
who did so much to keep the spark alive from dream to completion. Dana, your
wisdom, guidance, constructive critique, and support through the routine and
rough spots mean more than I can fully express here. Thanks also to Brianna
Marron at Oxford University Press, the Newgen KnowledgeWorks production
team in India, and others behind the scenes for technical assistance, design, the
marketing process, and for keeping me on track with deadlines. Without such
teamwork, this book would never have seen the light of day. My special thanks
to each and all.

Lee Ann Hoff

Boston
April 2014

[x] Acknowledgments
Introduction
Building on a Rich History

CHAPTER OUTLINE

Experiential and Scientific Background Supporting the Book’s Goals   2

Moving Forward with Kinks in the Road   4
Danger and Opportunity of Crisis and Overcoming Stigma   5
Organization  7
Who Should Read this Book?   7
References  8

C risis signals opportunity and potential danger. The term is used in spiritual,
social, and political domains. Here it refers to a psychological state—an
acute emotional upset in which one’s usual problem-solving ability fails. The
opportunities? Learning, growth, and gaining strength to deal with future
upsets. Some dangers could be health decline, suicide, violence, or substance
abuse. Crisis typically occurs in response to an identifiable traumatic experience,
for example, a serious accident, divorce, death of a loved one, or victimization by
violence.
In itself, a crisis experience does not imply a psychiatric “disorder,” although
persons with true mental illness are more vulnerable than others to upsetting life
events signifying crisis. Support is needed during crisis to enhance positive out-
comes and avoid negative ones. Without it, substance abuse, mental illness, and/
or violence toward self and others may be the unfortunate but often preventable
endpoint of crisis resolution.
This book is meant for anyone facing the danger and opportunity of crisis. It is
dedicated to people like Joan and Tom Brown, the distraught parents of Gary, age
16, who was arrested after killing two of his classmates with a gun brought from
home. Interviews with the grieving classmates and teachers revealed that Gary
was a lonely kid. As an only child of upper-middle-class parents, he possessed
a lot of luxury items others kids envied, and he was also teased for his eccentric
ways. One of Gary’s classmates, who felt sorry for him, heard him say once: “I’m
fed up and just not gonna take these guys teasing me anymore.” Noteworthy here
is that verbal clues like Gary’s typically precede violent action.
Tragic as Gary’s case is, it is, unfortunately, far too common. Years after the
shock of school and other mass shootings fades, the cases of not just teenagers
but also adults in crisis continue to rise at an alarming rate. National newspapers
and local broadcasts are awash with stories of violent crime, fatal domestic abuse,
or other tragedies. Whether they make the evening news or not, these cases can
serve as a red flag signaling distress, crisis, and life-threatening behavior—pat-
terns often picked up only after a tragedy occurs. They can also lead to stemming
the tide of violence in our personal relationships, family, and community.
Despite advances in crisis and community mental health services for persons
like Gary and his parents, and public information on varied crisis topics, there
are far too many crises such as the Brown family experienced. Crises like these
might be prevented through education and widespread knowledge about resolv-
ing life-threatening crises early on in a positive direction at home, school, the
workplace, and neighborhoods.
This book is intended to fill a gap between college textbooks and my vision of
what is needed by readers such as Gary’s parents. It offers information, advice, and
guidance aimed at healthy crisis resolution and preventing suicide and violence
toward others. A more detailed book (primarily for college and graduate students
in health and social sciences) is People in Crisis: Clinical and Diversity Perspectives,
now in its sixth edition1 and representing decades of research and practice in the
field. As the crisis field gains momentum, many health and social service providers
have benefited from a crisis course or continuing education seminars. But such
academic sources typically do not reach the broader general readership.
As a translation of sorts, this book draws on the People in Crisis (PIC) text for
major content. Its main message is for the lay reader and others who are not crisis
specialists but often are the first contact in a crisis situation, for example, par-
ents, teachers, clergy, police, and school counselors. It supports crisis education
beyond college students and how to help one’s self, family, and others in distress
or danger.
Having lived through and learned from several life crises, and deeply con-
cerned about people in crisis, I hope the book will be helpful to many others.

EXPERIENTIAL AND SCIENTIFIC BACKGROUND SUPPORTING

THE BOOK’S GOALS

This book was born in several streams of learning, clinical experience with vari-
ous distressed persons, research, and teaching about crisis and violence preven-
tion in my career as a nurse-anthropologist.

[2] Introduction
 First among these learning streams was on the road to my bachelor’s degree
in nursing with fear of flunking the Anatomy and Physiology course, a poten-
tial crisis occasion that could have cost me the degree. In the course lab, I was
nearly frozen with dread of touching and dissecting frogs, while my college team-
mate struggled to master the theory base. So we struck a deal: She would do my
dissecting, and I would help her with the conceptual base. Our team approach
resulted in a better outcome for both of us—just as in effective crisis care!
During the second stream, I worked as a therapist and manager in a hospital
psychiatric ward, a period coinciding with US national survey data supporting the
National Institute of Mental Health ideal of 24-7 crisis services available nation-
wide and close to home in all communities. During this same era, I was deeply influ-
enced by the theoretical work and publications of three giants in the field: Harry
Stack Sullivan’s Interpersonal Theory of Psychiatry served as a firm base for commu-
nity mental health and a centerpiece of psychotherapy for acutely distressed per-
sons;2 Hildegard Peplau’s nurse–patient relationship theory;3 and Gerald Caplan’s
Principles of Preventive Psychiatry4 provided a baseline for crisis theory and practice.
Applying Peplau’s theory, I guided the nurses to plan for at least a half hour
during day and evening shifts for one-to-one interaction with their assigned
patients in addition to administering medications, doing safety checks, and
related nursing tasks. This approach had a noteworthy result: Upon discharge,
distressed patients needing support typically called the hospital asking to speak
with their nurse. Observing this pattern, I considered: If these discharged psychi-
atric patients need someone to talk with in middle of the night, what about others
in crisis who had never been hospitalized?
As a consequence, under this assumption, the entire team and hospital
administration opened our 24-hour telephone service as a crisis hotline avail-
able to all distressed persons in our community—not just for our discharged
patients—with linkage to follow-up and comprehensive mental health service.
The Los Angeles Suicide Prevention Center was “ground zero” and a model for
other communities nationwide. Still today, and influenced by the Samaritan
movement in London, trained volunteers (not psychiatric specialists) remain
typical as first-contact providers responding 24/7 to suicidal and other dis-
tressed callers. This was the forerunner to today’s front-page telephone direc-
tories that routinely include hotline numbers for suicidal and other dangers
(National Suicide Prevention Lifeline: 1-800-273 TALK [8255]). It lays the
foundation for community-based face-to-face crisis services across the United
States and many other countries.
Together, these experiences and an interdisciplinary literature base led to
my vision for this book, an evidence-based resource that translates the People in
Crisis college text for nonspecialists in crisis care—lay readers, front-line health
and social service providers, pastors, and public safety officers. Increasingly, these
dedicated workers need reliable information for supporting people in their every-
day crisis encounters at home, work, and in the community.

I n t roduct ion [3]

MOVING FORWARD WITH KINKS IN THE ROAD

Yet, since the early 1980s, with widespread inadequate funding of mental health
services close to home, for many in acute distress, the nearest hospital emer-
gency room has emerged as the first resort and a “revolving door” for many
psychiatric patients. The sometimes scant training of front-line health provid-
ers compounds this sad scenario in crisis care. A major challenge is assuring a
smooth transition from crisis intervention in emergency situations (or during
typical 15- to 20-minute primary care visits) to important follow-up counseling
or psychotherapy. 5
The professional psychiatric literature and even magazines like Time and The
New Yorker address this interconnected socioeconomic and politicized process.
The lack of early intervention can lead to lethal crisis outcomes. Another serious
outcome of these shortcomings is the use of physical and chemical restraint of a
vio lent patient—sometimes the major intervention in high-risk situations.
And so, to another stream of this book’s birth. Struck by the travel and learn-
ing bug, the outcomes of crisis care workshops conducted on several continents,
responding to my affinity for diversity issues, and deeply influenced by the Peplau,
Sullivan, and Caplan giants in the psychiatric/ mental health arena, I was lucky
to study social anthropology abroad that included immersion in social network
theory. My doctoral dissertation research with abused women and their families
in metro Boston uncovered the sociocultural context of domestic violence and
how to prevent it.6
Coupled with this research was my day job teaching police and nurses (typi-
cal first-contact providers) the basics of crisis care and violence prevention. That
experience has been pivotal to writing about crisis, violence, and suicide and how
these topics are so deeply intertwined.7 Building on my Crisis and Suicidology
Fellowship clinical practicum at Johns Hopkins University and ride-along expe-
rience with Los Angeles police, a key observation emerged: the wide gap in col-
laboration between psychiatric crisis specialists and front-line police work.
Similar ride-along experience with Boston police officers affirmed the
importance of teamwork in crisis care. Clearly, responding to domestic vio-
lence and related crises reveals not only the danger to police but also their
frustration with such policing challenges. At this interface between police and
professional psychiatric work I saw a deep hole: While public order and safety
will always be the primary work of police, they may find themselves filling in
by default when 24/7 professional crisis services are not readily available. This
staffing issue appears as a frustrating loop in the “revolving door” of psychiat-
ric treatment: premature discharge, readmission during crisis and discharged
again, as the cycle continues.
Beyond this common emergency experience and revolving door is one of
society’s serious drug problems: abuse or misuse of prescription medications. It
also speaks to the severe stress and danger toward police and hospital emergency

[4] Introduction
staff caring for seriously disturbed or out-of-control patients. A related hazard
in this scenario is the overreliance on psychotropic drugs for desperate patients
brought by police or arriving alone from the streets. When time and staffing
are short, chemical restraint with powerful drugs is often the first resort for
a potentially dangerous patient, with little time for listening to the plight of
desperate persons. Several pages of this book are devoted to this issue, espe-
cially for front-line professionals and well-intentioned but frustrated family
members seeking help for a loved one (see Chapter 1). Journalists Pete Earley 8
and Robert Whitaker 9 present vivid accounts of the personal and social costs
when psychiatric and mental health care (beyond psychotropic drug use) is not
readily accessible.
The nationwide massive discharge of patients from psychiatric hospitals, cou-
pled with insufficient funding of community mental health services, has threat-
ened further development of mental health service ideals from the 1960s and
1970s.10 Currently, with tragic and highly publicized gun-related deaths, injuries,
and other crises, it seems clear that at least some of these deaths might have been
prevented—this, especially if we close the gap in what appears as a knowledge
deficit in detecting early danger signals of possible injury to self and others, and urge
people to seek crisis care as early as possible. Responding to these needs, a major
aim of this book is to close this knowledge gap for a broad range of readers—from
first responders to the general public.

DANGER AND OPPORTUNIT Y OF CRISIS AND

OVERCOMING STIGMA

The task of helping people heal from stressful life events, the wounds of war, and
other trauma to prevent suicide or violence whenever possible is very challeng-
ing for someone who cares but does not recognize danger clues early on or know
best responses to high-risk crisis situations. Also, a short office visit with health
providers may not be enough to prevent tragic crisis outcomes, so we should
never hesitate to ask for whatever help is needed, and that help should be eas-
ily accessible 24/7 in every community. Clearly, awareness of subtle clues to
life-threatening crises is everybody’s business at home, at work, and in schools,
as Gary’s case illustrates.
Typically and unfortunately, as press accounts of violence reveal, distress
signals were there, but observers did not take them seriously or know how to
respond and engage professional helpers. It wasn’t until after it was too late that
Gary’s fellow students reported Gary’s boasting about his knowledge of Internet
sites for purchasing weapons. He had also frequently asked the forensic science
teacher about the best way to cover up a murder.
Together, these were missed clues and opportunities for crisis intervention
and violence prevention. Apparently no one thought to seek guidance from

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