U.S. Department of Health & Human Services
Substance Abuse and Mental Health Services Administration

The Center for Mental Health Services


CRISIS COUNSELING AND MENTAL HEALTH TREATMENT—SIMILARITIES AND DIFFERENCES
Note: This is the second in a series of program guidance documents developed to ensure consistency in addressing key program issues in the Crisis Counseling Training and Assistance Program (CCP). The Crisis Counseling Training and Assistance Program is funded by the Federal Emergency Management Agency (FEMA) under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act. On behalf of FEMA, the Center for Mental Health Services (CMHS), Emergency Mental Health and Traumatic Stress Services Branch (EMHTSSB) provides technical assistance, program guidance and oversight. To download this document or order other publications, please visit our website at www.mental health.org/cmhs/EmergencyServices/index.htm.

PURPOSE				
This program guidance outlines the similarities and differences between crisis counseling and mental health treatment in the context of the FEMA/CMHS Crisis Counseling Assistance and Training Program (CCP). It describes the scope and limitations of crisis counseling services and identifies key questions agencies and counselors should consider when deciding whether to refer an individual to mental health treatment services.

WHAT IS CRISIS COUNSELING?
For over twenty-five years, the Crisis Counseling Program has supported short-term interventions with individuals and groups experiencing psychological sequelae to large-scale disasters. These interventions involve the counseling goals of assisting disaster survivors in understanding their current situation and reactions, assisting survivors in reviewing their options, providing emotional support, and encouraging linkages with other individuals and agencies who may help survivors recover to their pre-disaster level of functioning. The assistance is focused upon helping disaster survivors cope with their current situation. Until there are contradictory indications, the program draws upon the assumption that the individual is capable of resuming a productive and fulfilling life following the disaster experience if given support, assistance, and information at a time and in a manner appropriate to his or her experience, education, developmental stage and culture.
The goal of crisis counseling is to assist individuals in coping with the psychological aftermath of the disaster, mitigate additional stress or psychological harm, and to promote the development of understanding and coping strategies that individuals may be able to call upon in the future. While always cognizant of those with special needs, the thrust of the Crisis Counseling Program since its inception has been to serve people responding normally to an abnormal experience. By serving such a broad spectrum of people, the program may encourage the use of mental health services by reducing discrimination and stigma associated with receiving them. 

WHAT IS MENTAL HEALTH TREATMENT?
In contrast to the crisis counseling services provided through the CCP, mental health treatment, as typically defined within the mental health community, implies the provision of assistance to individuals for an existing pathological condition or disorder. In this context, it involves providing a variety of interventions following the assignment of a diagnosis consistent with the most recent edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or another similar assessment tool. This diagnosis is made following an evaluation and/or psychological testing by a licensed mental health professional. Typically, the mental health professional and client will discuss various treatment options and agree to certain interventions and treatment goals. Common interventions include the treatment of mental disorders, personality reconstruction, development of insight into a wide variety of historical and current life experiences, and resolution of unconscious conflicts. During treatment, the provider maintains a documented treatment plan and record. The mental health professional is licensed by the State and is protected by, and is subject to, a wide variety of legal matters including malpractice, informed consent to treatment, confidentiality, and patient/therapist privilege. Since the CCP does not provide “therapy” in the traditional sense, program managers and outreach workers should assume that their conversations with disaster survivors would not be considered “privileged” by a court of law.
The outline below provides a basic description of the differences between traditional mental health services and the Crisis Counseling Program. These key differences between traditional mental health practice and crisis counseling influence the way services are provided. 

“*Traditional” Mental Health Practice 	Crisis Counseling 
?	Is often office based. 
?	Focuses on diagnosis and treatment of a mental illness. 
?	Attempts to impact the baseline of personality and functioning. 
?	Examines content. 
?	Encourages insight into past life experiences and their influence on current problems. 
?	Has a psycho-therapeutic focus. 	?	Is primarily home and community based. 
?	Focuses on assessment of strengths, adaptation of existing coping skills and development of new ones. 
?	Seeks to restore people to pre-disaster levels of functioning. 
?	Accepts content at face value. 
?	Validates the appropriateness of reactions to the event and its aftermath and normalizes the experience. 
?	Has a psycho-educational focus. 
*Traditional mental health practice takes many forms. These descriptions are intended to provide examples for contrast rather than to describe the full range of traditional mental health practice.
 
USE OF MENTAL HEALTH PROFESSIONALS AS CRISIS COUNSELORS
Training and experience as a mental health professional in the traditional system does not guarantee that an individual will be an effective crisis counselor. While there are numerous examples of mental health professionals who have functioned exceptionally well as crisis counselors, there are also many examples of situations where this has not been the case. The most effective mental health professionals serving on crisis counseling teams have the following characteristics:
?	They can assimilate a revised conceptualization of mental health services that is often different than their training and traditional function. (e.g. lack of diagnosis, interventions in very non-traditional settings, role ambiguity);
?	They are comfortable working with paraprofessionals or trained nonprofessionals; and
?	They are able to incorporate crisis counseling theory and practice into the theoretical construct that usually guides their practice (e.g. psychoanalytical, cognitive/behavioral, insight oriented approaches).

SCOPE OF THE CRISIS COUNSELING PROGRAM
The scope of the crisis counseling program includes the provision of crisis counseling services to individuals adversely affected by major disasters. In addition, it includes provision for training those hired by the crisis counseling programs and other community members who may deal with disaster survivors and would benefit from this type of knowledge. Training has proven to be a critical element of the program, particularly as it assists the crisis counselors in understanding the scope and boundaries of their roles as well as when it is appropriate to refer individuals to mental health treatment. Behaviors associated with generalized anxiety disorder, adjustment disorders, dysthymic disorder, substance abuse and perhaps eating and phobic disorders are commonly seen after a disaster. Yet, it is suggested that the Crisis Counseling Program coordinators train their outreach workers on how to approach individuals who may be experiencing such disorders. Asking the following types of questions may help clarify if the counselor should serve or refer the individual:
?	Is the condition caused by or clearly exacerbated by the disaster?
?	Are the crisis counseling staff able to perform an adequate assessment of this individual and assure that they can defend, in an adverse legal action, the appropriateness of crisis counseling as opposed to formal treatment, as the intervention of choice?
?	Is the program’s informal recording of contact notes adequate and appropriate (as opposed to a formal treatment record) in this case?
?	Is the mental health system (of which crisis counseling is a part) the most appropriate and qualified to deal with this problem?  Primary health care providers, substance abuse providers, social services, and protective services are examples of other service systems to which crisis counselors sometimes refer.
?	Can the counselor appropriately respond to the needs of this person within the time, human resource, and skill limitations of the program?
To the extent that these questions are answered in the negative, referral is the recommended course of action. Clearly, making this type of assessment and possible referral takes time and appropriate supervision.
This program is intended to supplement State and local mental health (public and private) resources. It is expected that there will be individuals with needs that fall outside the scope and duration of the CCP. Cases that fall outside the scope of the Crisis Counseling Program should be referred to other agencies that provide mental health treatment. The criteria and methodology for referral should be well known throughout the program and consistently applied by the crisis counselors. Supervisors should provide on-going review of staff activities to assure that they are consistent with the scope and intent of the Crisis Counseling Program. 

FOR MORE INFORMATION
This program guidance was developed to ensure that the context, boundaries and strategies of the Crisis Counseling Program are consistently implemented throughout the United States. If program managers have questions regarding this guidance, they should contact their State disaster mental health program director for clarification. If the State program director needs additional guidance, he or she should contact their CMHS Project Officer.