Psychiatry's New Approach: Crisis Intervention

IN downtown Ann Arbor, Mich., a 30year-old mother walked through a door marked Crisis Walk-in Clinic last month and confessed that she had beaten her one-year-old daughter so savagely that the child had had to be hospitalized. It was the first of nine visits, to some of which, at the clinic's suggestion, she brought her husband. Gradually, and gently, staff therapists elicited part of her story: that she had been forced into an unwanted marriage. Eventually they were able to deduce that the child was only a surrogate for an elaborate complex of wrath which involved not only her husband but her father. The mother was told only a part of this. And in three weeks, the clinic-produced, not a cure, but a dressing for an ugly emotional wound. "We haven't guaranteed she won't beat her child again," says Dr. Philip Margolis, the clinic's director. "But we may have deterred her."

Behind this modest claim lies what some observers have heralded, perhaps overoptimistically, as a third revolution in mental health. The first was the medical discovery, less than two centuries ago, that the insane were neither criminals nor possessed by demons but sick people whom chains could never heal. The second was Freud's insights into the emotional topography of the mind. The third is crisis intervention: a radical and still experimental attempt to try emotional first aid on someone who seems headed straight for a mental institution. Says Dr. Edward Stainbrook, chairman of the department of psychiatry at the University of Southern California's medical school: "The geneticist figures you're done for when you're born. The psychoanalyst figures you're done for when you're six. But the crisis intervener says you're not done for until you're dead."

Mental Band-Aids. Founded in January, Ann Arbor's storefront clinic is one of several thousand such emergency-treatment centers now operating throughout the U.S. Under a federal program launched in 1963, this census will expand even further. Their approach to mental illness seems to contradict much of prevailing psychiatric theory. Crisis intervention assumes, for instance, that the deeply disturbed patient can be snatched at the last minute from committable insanity--and that the last moment may be the best time to try. It argues that relief of the immediate symptoms of profound emotional stress is far more urgent than any investigation into their cause. In effect, it proposes to substitute emotional Band-Aids for prolonged therapy, if Band-Aids will tide the patient over an unendurable crisis in his life.

The new technique blends pragmatism with good Samaritanism. Just about anything goes, including drugs. "Sometimes you have to sock it to 'em," says Dr. Bruce Danto, director of the Detroit Psychiatric Institute's Suicide Prevention Center, a pioneer in a dramatic form of crisis intervention. "You don't have five years for the patient to come up with his own insights. You have to realize that you can't solve all the problems of the world. You just try to patch some up."

Very often, crisis calls for solutions not to be found in any textbook. At Atlanta's Grady Memorial Hospital, when relatives of an old man complained that he wandered about the house late at night, knocking over furniture and hitting them when they objected, the hospital suggested installing a night light. With this practical solution, which permitted an old man with weak kidneys to find his way to the bathroom, the family emergency passed.

Up from Boston. As a division of psychiatry, crisis intervention developed in part from a study in Boston that followed the tragic Cocoanut Grove fire of 1942, in which 492 died. Interested in emotional response to bereavement, a Boston psychiatrist, Dr. Erich Lindemann, questioned relatives of the dead. He found that the human capacity to cope with problems, which is not innate but gained through experience, often falters in a time of crisis, like the sudden loss of a loved one.

The Korean War added another chapter to the book. There it was discovered that psychiatric first aid, administered on the spot to battle-shocked soldiers, often quickly restored them to duty. On the other hand, those sent home for protracted institutional treatment responded far more slowly to intensive care. It was almost as if institutionalization itself helped confirm the patient's suspicion that something was terribly wrong.

To many advocates of crisis intervention, the unfortunate effect of hospitalization is a basic article of faith. Their objective is to obstruct the patient's progress to an institution, and they can point to some conditional evidence of success. The annual commitment rate to state mental hospitals from San Francisco, for example, has dropped from 2,887 to 119 in the past four years--a decline in which the city's expanding complex of emergency-treatment centers was a major factor. Grady Memorial Hospital, which opened a crisis center in 1968, now treats 5,000 psychiatric emergencies a year. The hospital's 36-bed mental ward, which previously was inadequate to the demand, is seldom full today.

Crisis intervention is not a panacea for mental illness. It does not benefit the patient whose emotional problems, however upsetting, are not overwhelming --the so-called normal neurotic who either applies for long-term therapy, if he can afford it, or else manages to live with his problems. Many therapists flatly reject it--and so do some patients. Says Detroit's Danto: "Often you have to talk your way in. They don't see you as the Ajax knight coming in to zap them clean."

Checkers with a Catatonic. Crisis intervention is the most successful technique developed so far by the rapidly expanding community mental-health movement. In addition to professional psychiatrists, crisis centers are staffed by a team, including nurses, social workers, lay therapists and clergymen. "The techniques we use are totally unrelated to psychoanalysis," says Dr. Barry Decker, director of clinical psychiatry at San Francisco General Hospital. "The staff takes an active role with patients. Anyone on the team might be able to set up such a rapport that they could play checkers with a catatonic the doctor couldn't even make a dent in."

At the end of this "third revolution" may lie a redefinition of insanity. Crisis intervention already implies this by assigning priority to the patient's crisis, which, at that moment, is more important than understanding what produced it. "Any time a person is desperate, something is wrong around him," says Dr. Frank S. Pittman III, director of psychiatric services at Grady Hospital. "The person says 'I am in an impossible situation' and 'I need help' in several ways--by saying it when no one is really listening, by attempting suicide, by beating up someone or by going to the hospital. They know something is wrong. And it is an enormous relief when we agree that something is wrong and when we listen."

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