Chat with us, powered by LiveChat I need each of the following questions answered in 200 words each SWK208- Generalist Practice I | Max paper

I need each of the following questions answered in 200 words each  

SWK208- Generalist Practice I 

Lesson 7 Discussion 

George is a 23-year-old, Caucasian male who is referred to a Social Worker at his community college. George reports that since the beginning of the semester he has experienced a lack of motivation. George further reports that his anxiety has also increased as he worries his lack of motivation will impact his ability to pass his classes this semester.

Using the 4-step, Task-Centered Practice Model, please discuss how you would apply this model to the vignette above. (IN 200 WORDS)


What is Evidence-Based Practice:

Solution Focused Brief Therapy: (Links to an external site.) (Links to an external site.)

Task Centered Practice: (Links to an external site.)

How Do Social Workers Use Task Centered Practice? (Links to an external site.)

Lesson 8 Discussion 

Mark is a 7-year-old, African American boy who is meeting with a Case Manager/Social Worker. Mark was detained by Child Protective Services due to abuse/neglect by his parents and is currently living with his grandparents. Mark has difficulty communicating his thoughts and feelings about the abuse/neglect he experienced.

Using the readings or additional research, please identify an intervention that could be appropriate to help Mark with expressing his thoughts/feelings. Please discuss the following:

· Why did you select this intervention?

· Discuss how this intervention would benefit Mark related to his presenting problem?

· Please discuss any cultural considerations.

(IN 200 WORDS)

SWK103- Social Work and Deviant Behavior

Lesson 7 Discussion A

Application of Theory: Provide two examples to your classmates on how the Labeling theory explains deviant behavior. There is no minimum length, just be sure to provide two examples with explanations. (IN 200 WORDS)

Lesson 7 Discussion B

Is deviance simply a consequence of labels and the labeling process? Explain your answer and support it with examples. 

This discussion should be a minimum of 1 page (IN 200 WORDS)

Lesson 7 Discussion B

Rank the following deviant acts on a scale of 1 (least deviant) to 10 (most deviant) and respond to the questions at the end.
_____ Stealing food from a grocery store to feed your family
_____ Illegally downloading a song to play as a DJ where you would get paid
_____ Killing a man who is found to be responsible for the death of your child
_____ A woman who sexually assaults a man at a party
_____ Using one’s status as CEO to control the flow of profits to your own bank account
_____ Buying a DVD copy of a bootleg theater film on the street
_____ Buying a PlayStation 5 and attempting to resell it for twice the original cost.
_____ Coming to this country without proper documentation
_____ Leaving a dog in a car on a hot day
_____  A doctor who influences patients to use a pharmaceutical for personal benefit

1. Which of these norm violators would be least likely to escape any stigma associated with knowledge of their deviant act? Why?
2. Which of these norm violators, if never caught, would be most likely to continue violating this norm, and transition from a label of primary to secondary deviant?
No minimum length but be sure to fully explain your answers to the two questions. 

(IN 200 WORDS)


Lesson 7 Discussion 

After you complete this unit’s readings and videos, think about the second video’s presentation of class definition. Max Weber’s idea of class is more about the opportunities available to a person, not so much the work that they do. Do you agree with this idea more than Marx’s definition of class? Also, why do you think that it is so difficult to agree on definitions of class in the United States? (IN 200 WORDS)


CrashCourse. (2017, September 18). The Impacts of Social Class: Crash Course Sociology #25 [Video]. YouTube.

CrashCourse. (2017, September 11). Social Class & Poverty in the US: Crash Course Sociology #24 [Video]. YouTube.


Journal of Creativity in Mental Health, 5:158–176, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 1540-1383 print/1540-1391 online
DOI: 10.1080/15401383.2010.485090

WCMH1540-13831540-1391Journal of Creativity in Mental Health, Vol. 5, No. 2, May 2010: pp. 0–0Journal of Creativity in Mental Health

Resolving Child and Adolescent Traumatic
Grief: Creative Techniques and Interventions

Resolving Child and Adolescent Traumatic GriefM. Edgar-Bailey and V. E. Kress

Youngstown State University, Youngstown, Ohio, USA

This article presents a review of creative interventions that can be
helpful in facilitating the resolution of traumatic grief in children
and adolescents. Traumatic grief is conceptualized as a condition
in which a person loses a close loved one (e.g., a parent or a sib-
ling) in a traumatic manner, and ensuing trauma-related symp-
toms disrupt the normal grieving process. The presented creative
interventions will be conceptually linked to an evidence-based,
cognitive behavioral treatment model that can be used in address-
ing traumatic grief. The creative interventions presented will
include the use of writing, storytelling, drawing, commemorating,
and ritualizing in relation to traumatic grief.

KEYWORDS grief, traumatic grief, children, treatment, counseling,
trauma, creativity

It is estimated that 3.5% of U.S. youth—children and adolescents under the
age of 18—have experienced the death of a parent (Social Security Adminis-
tration, 2000). The leading causes of death for men and women living in the
United States aged 35 to 54—the most common age range of parents—
include heart attacks, homicide, suicide, traffic accidents, and other
accidents (World Health Organization, 2009). The unanticipated and often
traumatic nature of these leading causes of parental death raises the ques-
tion of how children cognitively process the traumatic aspects of their loss,
in addition to navigating the typical grief process.

The loss of a parent can impact a child in a variety of clinically signifi-
cant ways, and as such, the Diagnostic and Statistical Manual of Mental

Address correspondence to Victoria E. Kress, Department of Counseling and Special
Education, Youngstown State University, Beeghley Hall, Youngstown, OH 44555, USA.
E-mail: [email protected]

Resolving Child and Adolescent Traumatic Grief 159

Disorders (DSM) V-Code of Bereavement can be used when the focus of
clinical counseling attention is related to the loss of a loved one (American
Psychiatric Association, 2000). In addition, while there are great cultural
variations, some people present for counseling with severe traumatic grief
symptoms that are similar to a major depressive disorder (MDD). When
these depressive symptoms last less than 2 months, they are typically coded
and considered typical bereavement unless they affect the person’s func-
tioning to the point that an MDD diagnosis is warranted. Although the DSM
provides a basic assessment system that can be used to diagnose bereave-
ment, a number of more detailed conceptualizations relate to the under-
standing of bereavement and grief.

Adult complicated bereavement refers to a condition in which bereave-
ment is complicated due to the nature of losing a relationship that provided
significant security and dependency for the bereaved (Cohen & Mannarino,
2004). In complicated bereavement, trauma symptoms and separation
distress ensue upon the loss of the relationship (Prigerson, Shear, & Jacobs,
1999). Childhood complicated bereavement or complicated grief is a
construct designed to reflect a clinical syndrome that focuses on separation
distress and yearning as the central features of the condition (Brown et al.,
2006). Childhood and adolescent traumatic grief (CTG; the focus of this
article) is conceptualized as a condition in which a child or adolescent loses
a close loved one in a traumatic manner and subsequently develops trauma-
related symptoms. These trauma symptoms are conceptualized as disrupting
the typical grieving process (Cohen & Mannarino, 2004).

It is important to note that most children and adolescents who
experience the loss of a loved one do not develop long-term symptoms of
posttraumatic stress disorder (PTSD) or CTG (Brent, Perper, & Moritz, 1993;
Brent et al., 1995; Worden & Silverman, 1996). Thus, CTG is not a typical or
expected reaction to a traumatic loss and should not be treated as such
(Cohen & Mannarino, 2004). In other words, it is necessary to provide the
appropriate bereavement interventions and not to over-pathologize a
client’s experience. Currier, Holland, and Neimeyer (2007) suggest that the
tendency for some mental health professionals to pathologize bereavement
can contribute to a decrease in applying established grief interventions and
thus delay effective intervention. When a child experiences CTG, the
trauma-related symptoms associated with the death take precedence over
the child’s experience of the loss (Cohen & Mannarino, 2004). In these situ-
ations, the child can be inhibited—sometimes indefinitely—toward the end
of normal grieving, and thus, resolving and integrating the loss he or she
has encountered becomes problematic.

There is a paucity of literature related to the use of specific interventions
that can be helpful in intervening with CTG. This article will present a
review of creative interventions that can be helpful in facilitating the resolution
of traumatic grief in children and adolescents. Because cognitive-behavioral

160 M. Edgar-Bailey and V. E. Kress

therapy (CBT) is an evidence-based approach to treating CTG (Cohen &
Mannarino, 2004), the presented creative interventions will be linked—
theoretically—to this model. More specifically, the creative interventions
presented will include the use of writing, storytelling, drawing, commemo-
rating, and ritualizing in relation to treatment of traumatic grief. Examples of
specific creative techniques that counselors may employ in addressing CTG
will be presented.


Much of the treatment literature related to addressing CTG focuses on the
use of either play therapy or CBT (Brown, Pearlman, & Goodman, 2004;
Cohen & Mannarino, 2004; Salloum & Overstreet, 2008; Webb, 2003). CBT,
and more specifically, trauma-focused cognitive behavioral therapy
(TFCBT), is widely considered to be the most effective, evidence-based
approach to treating CTG (Cohen & Mannarino, 2004), and as such, in this
article, it will be the theoretical model used to support the use of creative

A combination of trauma-focused and grief-focused interventions dem-
onstrate the largest reduction of PTSD and depressive symptoms in children
and adolescents with CTG symptoms (Layne et al., 2001). Trauma-focused
interventions focus on affective expression skills, stress management skills,
creation of the child’s trauma narrative, and cognitive processing (Cohen &
Mannarino, 2004). Grief-focused interventions focus on talking about death,
mourning the loss, addressing ambivalent feelings, preserving positive mem-
ories, redefining the relationship, committing to other relationships, and
meaning-making out of the loss (Cohen & Mannarino, 2004). Trauma- and
grief-focused interventions typically both include joint parent-child sessions.

TFCBT is a demonstrated effective treatment for decreasing an array of
child psychological problems (Cohen & Mannarino, 1996, 1998). Many mal-
leable risk factors and protective factors for bereaved youth are related to
cognitions and can be increased or decreased—as appropriate—using CBT
interventions (Haine, Ayers, Sandler, & Wolchik, 2008). For example,
enhanced self-esteem can be facilitated by creating positive self-statements/
self-talk related to general or bereavement-specific themes. Alternatively,
exploring the problems created by negative self-statements can encourage
the use of more hopeful cognitive schemas. CBT can also be used to focus
on increasing a child’s adaptive beliefs regarding control. Healthy control
beliefs involve recognition of the inability to control uncontrollable events
and recognition of events that are under one’s control (Haine et al., 2008).

Before beginning CBT-related creative interventions, it is important to
assess and enhance a client’s ability to self-regulate emotional reactions and
thus to self-soothe. Early childhood experiences of trauma, especially

Resolving Child and Adolescent Traumatic Grief 161

ongoing traumas, affect the development of the brain’s lower regulatory
areas (brainstem and diencephalons). Perry and Hambrick (2008) assert that
primitive coping mechanisms developed early in life due to trauma create
an oversensitive stress response that will make even the best CBT interven-
tions difficult to use. Therefore, Perry and Hambrick (2008) suggest that
when counseling this population, it is first necessary to focus on issues of
arousal, impulsivity, self-regulation, and attention by using somatosensory
activities that provide new “patterned neural activation necessary for reorga-
nization” (p. 42). These interventions could include promoting sensory-
based, calming activities such as music, regulated movement, or yoga
(Krout, 2007; Perry & Hambrick, 2008). After improvements have been
made in these lower regulatory systems, it is more appropriate to work
toward goals that use the cortical and limbic brain systems, such as improv-
ing relational issues, gaining insight, and focusing on shifting cognitions.
Thus, prior to the application of the cognitive interventions discussed in this
article, it may be necessary to help children and adolescents develop their
emotion-regulation capacities. Crenshaw (2007) discusses this in terms of
creating a sense of safety, primarily through establishing a safe and secure
counseling space and a strong therapeutic relationship founded in a genu-
ine connection with the child. The aforementioned goal can be achieved by
using soothing music, peaceful imagery, and controlled breathing in ses-
sion. Krout (2007), in a review of research on music listening to facilitate
relaxation, found that although research is not conclusive, in general, music
that is chosen by clients is more effective than counselor-generated selec-
tions. Therefore, due to the subjectivity involved, it is best if counselors
allow clients to make music selections.

Counselors who choose to use CBT-related creative interventions with
clients must also be adequately prepared before the implementation of such
techniques (Ponniah & Hollon, 2009). Ehlers et al. (2010) noted that to
obtain the maximum desired impact, it is important that therapeutic tech-
niques be competently delivered. Based on past training and experiences,
counselors may require a different amount of formal training and practice to
gain a sufficient understanding and ability to use certain therapeutic tech-
niques. However, it is imperative that every counselor reaches a level of
mastery before using the techniques presented in this article (Benish, Imel,
& Wampold, 2008). CBT-based creative interventions can create a strong
reaction within clients, and counselors should be fully prepared and capa-
ble to help clients manage these reactions.


In this article, as related to a CBT foundation, creative interventions that
facilitate shifts in clients’ cognitions and meanings related to the traumatic

162 M. Edgar-Bailey and V. E. Kress

loss will be emphasized. Children experiencing CTG may feel as though
they have lost control and are often inhibited from progressing through the
grieving process due to their trauma-related symptoms (e.g., reexperiencing
and hyperarousal; Cohen & Mannarino, 2004). Using creative interventions
can facilitate a sense of control by allowing clients to have choices in how
the grief treatment is approached; regardless of the intervention chosen, the
child is able to garner a sense of control by choosing the words, colors, and
artistic mediums used and the topics to be explored.

Reminiscing, an ability necessary for resolving uncomplicated bereave-
ment, is often inhibited in CTG due to disturbing images that come to mind
when children think about their lost loved one (Cohen & Mannarino, 2004;
Pynoos, 1992). Creative arts provide an opportunity for children to create
visual and tangible alternatives to disturbing images. Creative interventions
also provide opportunities for the counselor to identify cognitive distortions
related to a child’s sense of responsibility for the trauma, ideas regarding
future safety, and feelings of guilt and shame (Cohen & Mannarino, 2004).
The ability to create something of beauty, or even just a new and different
image, opens the door to the possibility of cognitive shifts and the construc-
tion of different meanings related to the traumatic loss. The use of creative
arts enhances the creation of personal meaning as the child’s own unique
imprint is imbedded in the work.

Interventions using creative modalities are helpful, as people are often
able to express feelings or experiences through creative venues such as
poems, drawings, and songs in a way they are not able to express verbally
(Crenshaw, 2005; Webb, 2003). Clients with CTG often struggle with con-
necting to a wide range of painful and complicated feelings; an expansive
continuum of modalities helps the clients connect with these experiences.
Singing, dancing, and other movement techniques may help to connect
someone’s mental, physical, emotional, and spiritual experiences, and these
creative modalities often provide rich material that can be used in
counseling (Webb, 2003). Although a functional level of affect modulation
in a child is recommended before beginning creative interventions
(Crenshaw, 2007; Perry & Hambrick, 2008), using creative interventions
later in counseling can also enhance affect regulation.

Children and adolescents often have conflicted feelings related to their
loss, and the use of creativity in counseling can be an excellent way to help
them identify and manage these feelings. A child can express painful emo-
tions through creative arts and still maintain a protective distance from his
or her own personal experience. Clients need to acknowledge and better
understand their sometimes-conflicting feelings about the deceased (e.g., “I
love and miss my parent, yet I am angry at him/her for leaving me”).
Depending on the client’s developmental level, he or she may find it
difficult to understand that he or she can have diametrically opposed
feelings about the deceased (Crenshaw, 2007). Detaching from emotions is

Resolving Child and Adolescent Traumatic Grief 163

detrimental for a child’s future relationships, and connecting with their emo-
tions is essential to their healing (Crenshaw, 2007). On a more practical
level, engaging in creative activities may enhance a child’s skill set in
language and communication, and specific artistic skills may contribute to
feelings of positive self-esteem and self-worth.

The social isolation experienced by some bereaved people—especially
those whose loss circumstances are particularly traumatic—can be helped
with creative interventions that promote self-expression (O’Connor,
Nikoletti, Kristjanson, Faaaai, & Willcock, 2003). The ability of a child to
trust an adult enough to express painful emotions is a key component to
breaking down feelings of isolation, mistrust, and cynicism. Expressing
these emotions can be extremely difficult for a child, and expressive thera-
pies can assist in this process (Crenshaw, 2007). When the subject matter
associated with the traumatic event is particularly stigmatizing (i.e., suicide
or criminal activity) or if the family unit and/or culture in which the child
lives does not openly embrace the topic for discussion, the use of symbol-
ism and metaphor connected to creative arts can provide the child with a
sense of liberation from an emotionally repressive environment. Creative
arts allow children to expose themselves to the traumatic aspects of their
loss through the lens of personal ownership of their work. These experi-
ences may promote a strengthened internal locus of control and enhance
the child’s perception that he or she can cope with grief and loss.

TFCBT treatment goals of decreasing avoidance behaviors related to
triggers of the traumatic event may be better achieved when engaging a
child in a therapy process incorporating pleasurable and purposeful creative
activity. Jensen-Doss, Cusack, and de Arellano (2008) stated that it is imper-
ative that therapists who deliver treatment through this modality have ade-
quate training that will allow them to use this technique effectively.
Workshops are an acceptable and effective way for counselors to gain the
necessary training and preparation for the use of TFCBT, but more
extensive on-the-job training and consultation are also recommended
(Jensen-Doss et al., 2008).


In this section, specific creative counseling interventions will be introduced
and described. Ways in which these creative interventions can be used in
conjunction with CBT when addressing traumatic grief will be addressed. It
is important to note that none of these techniques are intended to stand
alone as a means of treating CTG, but rather, they serve as tools to enhance
CBT-based therapy and the resolution of traumatic grief. Supplemental
techniques provide maximum effectiveness when used in conjunction with
a strong understanding of CBT (Benish et al., 2008; Ehlers et al., 2010;

164 M. Edgar-Bailey and V. E. Kress

Ponniah & Hollon, 2009). A well-developed understanding of CBT and spe-
cific CBT-related creative techniques can be achieved through workshops,
seminars, consultation, or trainings; the necessary intensity and frequency of
these educational techniques will vary with each counselor (Jensen-Doss
et al., 2008).

Writing and Drawing Trauma Narratives

In their model of TFCBT for treating CTG, Cohen and Mannarino (2004)
suggest having the client develop a trauma narrative. This technique
includes cognitively processing the traumatic event(s) at length and spe-
cifically addressing the “worst moment” in an attempt to raise the client’s
tolerance for experiencing the reality of such events. After the client
describes the “worst moment” in session, the counselor should review
any thoughts the client has that are inaccurate or unhelpful. The client
also needs to understand how these distorted thoughts may have affected
his or her behavior and feelings in the situation (Cohen & Mannarino,
2004). If a child experiences a high level of reactivity, previously taught
relaxation techniques should be employed. Increased tolerance, in con-
junction with emotion regulation and stress management training, is
believed to reduce the likelihood of the child engaging in destructive
avoidance behaviors in response to future traumatic triggers (Cohen &
Mannarino, 2004).

One way to punctuate the telling of the narrative is to write about the
experience. Eppler and Carolan (2005) discuss how using narratives or talk-
ing about one’s traumatic experiences and/or biblionarratives, such as when
a client writes about their traumatic experiences, can help counselors better
assess and understand the client’s relationship to the experience and can
facilitate meaningful client cognitive shifts.

Writing about the story can deepen the reprocessing of the events.
After the child shares his/her verbal story with the counselor, the written
story is completed and discussed. A biblionarrative storyboard template
can be provided to assist in the writing process that includes prompts
such as:

Before my mom/dad died . . . ;
When I found out my mom/dad died . . . ; and
Now when I think about my mom/dad . . . (Eppler & Carolan, 2005,
p. 36)

These prompts are intended to be open ended and provide direction to the
child’s story while allowing the child to be the driving force in the story’s
construction. If the child should appear stuck, the counselor can ask more
general prompts, such as, “Who else was involved?” or “What happened

Resolving Child and Adolescent Traumatic Grief 165

next?” This intervention can assist in the cognitive reprocessing of events
prior to, during, and after the traumatic event. Coping skills and social sup-
ports can be identified as well. By paying special attention to the child’s
word choice in the narrative, the counselor can use the same words to join
with the clients, or the counselor can reframe language to cast a new light
on the situation (Eppler & Carolan, 2005). Additionally, drawing a trauma
narrative is another means of enhancing the trauma narrative experience.
Especially with younger children who cannot write, drawing the trauma
narrative can provide a means of facilitating cognitive shifts.

Through the use of verbal prompts, life stories/narratives can be rewrit-
ten or redrawn from stories of tragedy to stories of hope. Counselors can
ask their clients to rewrite the narrative as they believe it will be in the near
future when they have healed more. Regardless of the modality employed,
the construction and cognitive processing of the trauma narrative provides a
systematic order to cognitively process traumatic material that is often over-
whelming and confusing to a child. Understanding the cognitive triangle, or
the interconnected relationships between thoughts, feelings, and behaviors,
is an essential aspect of resolving traumatic grief (Cohen & Mannarino,
2004). Specifically, it is important for children to understand how their
negative/problematic feelings and behaviors may be related to cognitions
about the trauma that are inaccurate or unhelpful. When there is awareness
of such relationships, there is opportunity to modify the distorted cognitions
(Cohen & Mannarino, 2004).

These writing and drawing techniques can be used with clients individ-
ually or with other family members. Using this technique with different
family members can provide the counselor with insight into the varying per-
spectives of family members as well. Using the technique with the family as
a whole can demonstrate family dynamics and foster an emotional connect-
edness amongst members as they work on a common task. The counselor
can use prompts like, “What will the family do when the grief is not so
intense?” to foster hope and a solution focus. The counselor can use the
biblionarrative technique in a family session to assess boundaries, commu-
nication styles, unwritten family rules, and other dynamics (Eppler &
Carolan, 2005). Before using creative arts interventions in this way, counse-
lors should have clinical competency and/or supervision in family interven-
tions and should be skilled in incorporating a systems approach (Kissane,
Bloch, McKenzie, McDowall, & Nitzan, 1998).


Neimeyer (1999) provides several strategies that facilitate the cognitive or
meaning reconstruction that is critical to the traumatic grieving process.
Children need to integrate their traumatic experiences into a broader mean-
ing for their life appropriate to their cognitive developmental level. This

166 M. Edgar-Bailey and V. E. Kress

involves recognizing how the loss has affected and changed their person-
hood, as well as acknowledging the stable aspects of themselves, which
were not changed by the loss (Andrews & Marotta, 2005; Cohen &
Mannarino, 2004). Identifying themes of a hopeful and optimistic nature
and transforming traumatic events into pieces of a larger, more hopeful
“story” of the client’s life can facilitate meaning reconstruction (Neimeyer,
1999). An epitaph, a short text honoring a deceased person, is one such
strategy. Although the epitaph itself is a short statement, if it is to help in
facilitating meaning reconstruction, it should be created with contemplation
for the complexity of the experience it commemorates (Neimeyer, 1999).
Epitaphs can be used as a new cognition to interrupt unhelpful cognitions
regarding the loss. Creating epitaphs is one way of clarifying the meaning of
a loss in the form of a brief affirmation regarding the meaning of the rela-
tionship. The creation of this short statement of meaning can be something
a client is able to access and easily remember, and it provides a quick
connection to a source of strength when painful emotions arise.
Although the process of creating an epitaph can take time, the brevity of
the statement makes it accessible for younger children with limited writ-
ing skills. Although all epitaphs are personalized, some examples are
provided here:

Hush my dear, be still, and rest: An angel guards your bed.
A mother’s love will inspire me for all days.
Happy memories of my brother can never be removed from my heart.

Acrostic Poems

Poetry therapy has been effectively used in conjunction with CBT to assist
clients in processing the totality of a loved one’s life, not just the traumatic
circumstances surrounding the death (Mazza, 2001; Stepakoff, 2009).
Acrostic poems are one of many facilitated/guided expressive forms used
by poetry therapists that provide an outlet for containing strong emotions
via a written format (Stepakoff, 2009). This technique is useful in CTG
because it focuses attention on commemorating the loved one in positive
images that may counterbalance the traumatic imagery associated with the
death (Stepakoff, 2007). First, the loved one’s name is written vertically
down the side of the page, then each letter of the name is used to begin a
line that captures a positive quality or memory of the loved one (Stepa-
koff, 2009). Following is an example of an acrostic poem developed by
the first author:

Smile spread across a room
Always knew how to comfort a friend
Silly and serious

Resolving Child and Adolescent Traumatic Grief 167

Hopeful about the future
A connection to joy coming from within

A discussion of memories of the loved one may help the client identify
appropriate descriptive words that can be used with this activity. Clients
may also be invited to develop accompanying pictures that visually depict
their acrostic poem.

Unfinished Sentences/Writing Prompts

Unfinished sentences or sentence stems are a way to engage younger
children in a writing activity that elicits discussion of emotion-laden topics
(Robinson, Rotter, Robinson, Fey, & Vogel, 2004; Sandler et al., 1996). These
writing prompts are most useful when they foster an understanding of the
cognitive triad. Sentence stems should help the child make connections
between their thoughts, feelings, and behaviors. These activities can facili-
tate cognitive processing and reframing of irrational and/or unhelpful cogni-
tions. Following are some examples of unfinished sentences:

When I (see, pass by, hear) _______, I think about________, and I
During the ______, I was scared when______.
When I heard that _____, I felt______.
The times when I feel most sad about my parent’s death are_______.
(Robinson et al., 2004; Sandler et al., 1996)

Counselors can also develop sentences unique to their clients based upon
information the counselor is attempting to garner or encourage the client to

Life Imprints

One way to memorialize a deceased loved one is to trace his or her imprint
on the life of the bereaved (Neimeyer, 1999). By exploring the impact of the
lost loved one on the child’s perceptions, behavior, and manner of commu-
nicating, a dialogue is opened up regarding the cognitive connections
between feelings and behavior. Understanding the cognitive triangle can
help children improve affective modulation, problem-solving, and social
skills, which are essential components of TFCBT (Cohen & Mannarino,
2004). Crenshaw (2007) also stresses the importance of the counselor to not
focus solely on what has been lost but to emphasize the aspects of attach-
ment between the client and the deceased that are timeless. These lessons
may include lessons learned, values internalized, and the influence of the
deceased upon the client’s life. Neimeyer (1999) provides a template to

168 M. Edgar-Bailey and V. E. Kress

facilitate this task and he suggests having clients address the following in
relation to the deceased:

The person whose imprint I want to trace is _____.
This person has had the following impact on _____.
My mannerisms and gestures _____.
My way of speaking and communicating _____.
My hobbies and pastime activities _____.
My basic personality _____.
My values and beliefs _____.
The imprints I would most like to affirm and maintain are _____.
The imprints I would most like to let go of or change are _____. (p. 76)

The last two items on the template lend themselves to exploring ambiv-
alent feelings that a client may be experiencing related to the deceased.
Because youth often tend to identify with one emotion to the extreme, it is
important for the counselor to help them put conflicting emotions into a
meaningful and balanced perspective (Crenshaw, 2007). It can be empow-
ering for the child to explore their choices and determine which legacies
they want to hold onto and which they want to relinquish.


Daily journaling about traumatic loss and emotional/cognitive/physical
reactions to the loss can …

The Seven-Stage Crisis Intervention Model: A

Road Map to Goal Attainment, Problem

Solving, and Crisis Resolution

Albert R. Roberts, PhD

Allen J. Ottens, PhD

This article explicates a systematic and structured conceptual model for crisis assessment

and intervention that facilitates planning for effective brief treatment in outpatient

psychiatric clinics, community mental health centers, counseling centers, or crisis

intervention settings. Application of Roberts’ seven-stage crisis intervention model can

facilitate the clinician’s effective intervening by emphasizing rapid assessment of the

client’s problem and resources, collaborating on goal selection and attainment, finding

alternative coping methods, developing a working alliance, and building upon the client’s

strengths. Limitations on treatment time by insurance companies and managed care

organizations have made evidence-based crisis intervention a critical necessity for millions

of persons presenting to mental health clinics and hospital-based programs in the

midst of acute crisis episodes. Having a crisis intervention protocol facilitates treatment

planning and intervention. The authors clarify the distinct differences between disaster

management and crisis intervention and when each is critically needed. Also, noted is the

importance of built-in evaluations, outcome measures, and performance indicators for all

crisis intervention services and programs. We are recommending that the Roberts’ crisis

intervention tool be used for time-limited response to persons in acute crisis. [Brief

Treatment and Crisis Intervention 5:329–339 (2005)]

KEY WORDS: crisis intervention, lethality assessment, establish rapport, coping,

performance indicators, precipitating event, disaster management.

We live in an era in which crisis-inducing
events and acute crisis episodes are prevalent.
Each year, millions of people are confronted
with crisis-inducing events that they cannot

resolve on their own, and they often turn for
help to crisis units of community mental health
centers, psychiatric screening units, outpatient
clinics, hospital emergency rooms, college
counseling centers, family counseling agencies,
and domestic violence programs (Roberts,
Imagine the following scenarios:

� You are a community social worker or
psychologist working with the Houston

From Rutgers, The State University of New Jersey (Roberts)

and Northern Illinois University (Ottens).
Contact author: Albert R. Roberts, Professor, Criminal

Justice, Faculty of Arts and Sciences, Rutgers, The State

University of New Jersey, Lucy Stone Hall, B wing, 261
Piscataway, NJ 08854. E-mail: [email protected]


Advance Access publication October 12, 2005


ª The Author 2005. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:
[email protected]

Police Department to deliver crisis
intervention services to police, emergency
responders, and survivors of Hurricane
Katrina who just arrived at the Houston
Astrodome disaster shelter. It is midnight
and one of the survivors (who was
brutally raped 1 week prior to Hurricane
Katrina) wakes up screaming and
throwing things at the young man in the
cot next to hers. You were walking out the
door to drive home and get a few hours
sleep, but instead you are called on the
loudspeaker to defuse the acute crisis
episode and provide crisis intervention

� You are a crisis consultant to a large
Fortune 500 corporation, and a volatile
domestic violence-related shooting
took place last week at the corporate
headquarters. The employee assistance
counselor, the director of training, the
director of strategic planning, and the
director of disaster planning want you to
provide crisis intervention training to all
employee assistance counselors and all
corporate security officers.

� You are the new psychiatrist in an
inpatient psychiatric unit with 50 patients
diagnosed with co-occurring disorders;
over the weekend a patient assaulted the
psychiatric resident you are supervising.
The resident wants to be transferred to
another unit of the hospital because he
had a nightmare and cold sweats last
night. What do you do now? What
types of training should be provided to
all psychiatric residents and mental
health clinicians in order to prevent
patient–staff conflict from reaching
a crisis point?

� You are the counseling psychologist at
a state university assigned to see walk-in
emergency clients. An 18-year-old
freshman appears one afternoon and tells

you she just came from her residence hall
room and found her boyfriend in bed with
her ‘‘best friend’’ roommate. Now she tells
you she is seriously considering taking an
overdose of nonaspirin pain capsules in
their presence to ‘‘teach them a lesson.’’
How can crisis intervention help her to
find adaptive coping skills and a more
effective problem-solving approach to
her predicament?

This article delineates and discusses a system-
atic and structured conceptual model for crisis
intervention useful with persons calling or
walking into an outpatient psychiatric clinic,
psychiatric screening center, counseling center,
or crisis intervention program. A model is
a prototype of the real-life clinical process the
crisis clinician/counselor would like to imple-
ment. A systematic crisis intervention model is
analogous to establishing a road map as a model
of the actual roads, highways, and directions
one will be taking on a trip. Thus, the clinician
can visualize the implications of each proposed
crisis intervention guidepost and technique in
the model’s process and sequence of events and
make any necessary adjustments before the
program is fully operational. The model is
a series of guideposts that makes it easier to
remember alternative methods and techniques,
thus facilitating the counseling process. By
learning about each component or stage of a
model, the clinician will better understand how
each component relates to one another and
should facilitate goal attainment, problem
solving, and crisis resolution.
The focus of this article is on the clinical

application of Roberts’ seven-stage crisis in-
tervention model (R-SSCIM) to those clients
who present in a crisis state as a consequence
of an interpersonal conflict (e.g., broken ro-
mance or divorce), a crisis-inducing event (e.g.,
dating violence and sexual assault), or a preex-
isting mental health problem that flares-up.


330 Brief Treatment and Crisis Intervention / 5:4 November 2005

Crisis states can be precipitated by natural
disasters, such as Hurricane Katrina, which
took place as this article went to press.
However, there is a functional difference
between crisis intervention and disaster man-
agement. A large-scale community disaster
such as a major hurricane first requires disaster
management, then emergency rescue services.
The first two phases address the event itself,
rather than the psychological needs and
responses of those who experienced the di-
saster. For some, the event will overwhelm their
ability to cope; it is those people for whom
R-SSCIM is invaluable. We will discuss the
differences between disaster management and
crisis intervention later in this article.
Crisis clinicians must respond quickly to the

challenges posed by clients presenting in a crisis
state. Critical decisions need to be made on
behalf of the client. Clinicians need to be aware
that some clients in crisis are making one last
heroic effort to seek help and hence may be
highly motivated to try something different.
Thus, a time of crisis seems to be an opportunity
to maximize the crisis clinician’s ability to
intervene effectively as long as he or she is
focused in the here and now, willing to rapidly
assess the client’s problem and resources,
suggest goals and alternative coping methods,
develop a working alliance, and build upon the
client’s strengths. At the start it is critically
important to establish rapport while assessing
lethality and determining the precipitating
events/situations. It is then important to
identify the primary presenting problem and
mutually agree on short-term goals and tasks.
By its nature, crisis intervention involves
identifying failed coping skills and then
helping the client to replace them with adaptive
coping skills.
It is imperative that all mental health

clinicians—counseling psychologists, mental
health counselors, clinical psychologists, psy-
chiatrists, psychiatric nurses, social workers,

and crisis hotline workers—be well versed and
knowledgeable in the principles and practices
of crisis intervention. Several million individ-
uals encounter crisis-inducing events annually,
and crisis intervention seems to be the emerg-
ing therapeutic method of choice for most

Crisis Intervention: The Need for

a Model

A ‘‘crisis’’ has been defined as

An acute disruption of psychological homeo-
stasis in which one’s usual coping mecha-
nisms fail and there exists evidence of distress
and functional impairment. The subjective
reaction to a stressful life experience that
compromises the individual’s stability and
ability to cope or function. The main cause of
a crisis is an intensely stressful, traumatic, or
hazardous event, but two other conditions
are also necessary: (1) the individual’s
perception of the event as the cause of
considerable upset and/or disruption; and
(2) the individual’s inability to resolve the
disruption by previously used coping mech-
anisms. Crisis also refers to ‘‘an upset in the
steady state.’’ It often has five components:
a hazardous or traumatic event, a vulnerable
or unbalanced state, a precipitating factor, an
active crisis state based on the person’s
perception, and the resolution of the crisis.
(Roberts, 2005, p. 778)

Given such a definition, it is imperative that
crisis workers have in mind a framework or
blueprint to guide them in responding. In
short, a crisis intervention model is needed, and
one is needed for a host of reasons, such as the
ones given as follows.
When confronted by a person in crisis,

clinicians need to address that person’s distress,

The Seven-Stage Crisis Intervention Model

Brief Treatment and Crisis Intervention / 5:4 November 2005 331

impairment, and instability by operating in
a logical and orderly process (Greenstone &
Leviton, 2002). The crisis worker, often with
limited clinical experience, is less likely to
exacerbate the crisis with well-intentioned but
haphazard responding when trained to work
within the framework of a systematic crisis
intervention model. A comprehensive model
allows the novice as well as the experienced
clinician to be mindful of maintaining the fine
line that allows for a response that is active and
directive enough but does not take problem
ownership away from the client. Finally,
a model should suggest steps for how the crisis
worker can intentionally meet the client where
he or she is at, assess level of risk, mobilize
client resources, and move strategically to
stabilize the crisis and improve functioning.
Crisis intervention is no longer regarded as

a passing fad or as an emerging discipline. It has
now evolved into a specialty mental health field
that stands on its own. Based on a solid
theoretical foundation and a praxis that is born
out of over 50 years of empirical and experiential
grounding, crisis intervention has become
a multidimensional and flexible intervention
method. The roots of crisis intervention come
from the pioneering work of two community
psychiatrists—Erich Lindemann and Gerald
Caplan in the mid-1940s, 1950s, and 1960s. We
have come a far cry from its inception in the
1950s and 1960s. Specifically, in 1943 and 1944
community psychiatrist, Dr. Erich Lindemann at
Massachusetts General Hospital conceptualized
crisis theory based on his work with many acute
and grief stricken survivors and relatives of the
493 dead victims of Boston’s worst nightclub fire
at the Coconut Grove. Gerald Caplan, a psychi-
atry professor at Massachusetts General Hospital
and the Harvard School of Public Health,
expanded Lindemann’s (1944) pioneering
work. Caplan (1961, 1964) was the first clinician
to describe and document the four stages of
a crisis reaction: initial rise of tension from the

emotionally hazardous crisis precipitating event,
increased disruption of daily living because the
individual is stuck and cannot resolve the crisis
quickly, tension rapidly increases as the in-
dividual fails to resolve the crisis through
emergency problem-solving methods, and the
person goes into a depression or mental collapse
or may partially resolve the crisis by using new
coping methods.
A number of crisis intervention practice

models have been promulgated over the years
(e.g., Collins & Collins, 2005; Greenstone &
Leviton, 2002; Jones, 1968; Roberts & Grau,
1970). However, there is one crisis intervention
model that builds upon and expands the
seminal thinking of the founders of crisis
theory, Caplan (1964), Golan (1978), and
Lindemann (1944): the R-SSCIM (Roberts,
1991, 1995, 1998, 2005). It represents a practical
example of a stepwise blueprint for crisis
responding that has applicability across a broad
spectrum of crisis situations. What follows is an
explication of that model.

Roberts’ Seven-Stage Crisis Intervention


In conceptualizing the process of crisis in-
tervention, Roberts (1991, 2000, 2005) has
identified seven critical stages through which
clients typically pass on the road to crisis
stabilization, resolution, and mastery (Figure 1).
These stages, listed below, are essential,
sequential, and sometimes overlapping in the
process of crisis intervention:

1. plan and conduct a thorough
biopsychosocial and lethality/imminent
danger assessment;

2. make psychological contact and rapidly
establish the collaborative relationship;

3. identify the major problems, including
crisis precipitants;


332 Brief Treatment and Crisis Intervention / 5:4 November 2005

4. encourage an exploration of feelings and

5. generate and explore alternatives and
new coping strategies;

6. restore functioning through
implementation of an action plan;

7. plan follow-up and booster sessions.

What follows is an explication of that model.

Stage I: Psychosocial and Lethality

The crisis worker must conduct a swift but
thorough biopsychosocial assessment. At a min-
imum, this assessment should cover the client’s
environmental supports and stressors, medical
needs and medications, current use of drugs
and alcohol, and internal and external coping
methods and resources (Eaton & Ertl, 2000).

3. Identify dimensions of presenting problem(s)
(including the “last straw” or crisis precipitants)

4. Explore feelings and emotions
(including active listening and validation)

5. Generate and explore alternatives
(untapped resources and coping skills)

6. Develop and formulate
an action plan

7. Follow-up
plan and agreement

2. Establish rapport and rapidly establish collaborative relationship

1. Plan and conduct crisis and biopsychosocial assessment
(including lethality measures)



Roberts’ Seven Stage Crisis Intervention Model

Source: Copyright ª Albert R. Roberts, 1991. Reprinted by permission of the author.

The Seven-Stage Crisis Intervention Model

Brief Treatment and Crisis Intervention / 5:4 November 2005 333

One useful (and rapid) method for assessing the
emotional, cognitive, and behavioral aspects
of a crisis reaction is the triage assessment
model (Myer, 2001; Myer, Williams, Ottens, &
Schmidt, 1992, Roberts, 2002).
Assessing lethality, first and foremost, in-

volves ascertaining whether the client has actu-
ally initiated a suicide attempt, such as ingesting
a poison or overdose of medication. If no suicide
attempt is in progress, the crisis worker should
inquire about the client’s ‘‘potential’’ for self-
harm. This assessment requires

� asking about suicidal thoughts and
feelings (e.g., ‘‘When you say you can’t
take it anymore, is that an indication you
are thinking of hurting yourself?’’);

� estimating the strength of the client’s
psychological intent to inflict deadly harm
(e.g., a hotline caller who suffers from
a fatal disease or painful condition may
have strong intent);

� gauging the lethality of suicide plan (e.g.,
does the person in crisis have a plan? how
feasible is the plan? does the person in
crisis have a method in mind to carry out
the plan? how lethal is the method? does
the person have access to a means of
self-harm, such as drugs or a firearm?);

� inquiring about suicide history;
� taking into consideration certain risk
factors (e.g., is the client socially isolated
or depressed, experiencing a significant
loss such as divorce or layoff?).

With regard to imminent danger, the crisis
worker must establish, for example, if the caller
on the hotline is now a target of domestic
violence, a violent stalker, or sexual abuse.
Rather than grilling the client for assessment

information, the sensitive clinician or counselor
uses an artful interviewing style that allows
this information to emerge as the client’s story
unfolds. A good assessment is likely to have

occurred if the clinician has a solid understand-
ing of the client’s situation, and the client, in
this process, feels as though he or she has been
heard and understood. Thus, it is quite under-
standable that in the Roberts model, Stage I—
Assessment and Stage II—Rapidly Establish
Rapport are very much intertwined.

Stage II: Rapidly Establish Rapport

Rapport is facilitated by the presence of
counselor-offered conditions such as genuine-
ness, respect, and acceptance of the client
(Roberts, 2005). This is also the stage in which
the traits, behaviors, or fundamental character
strengths of the crisis worker come to fore in
order to instill trust and confidence in the
client. Although a host of such strengths have
been identified, some of the most prominent
include good eye contact, nonjudgmental
attitude, creativity, flexibility, positive mental
attitude, reinforcing small gains, and resiliency.

Stage III: Identify the Major Problems or
Crisis Precipitants

Crisis intervention focuses on the client’s
current problems, which are often the ones
that precipitated the crisis. As Ewing (1978)
pointed out, the crisis worker is interested in
elucidating just what in the client’s life has led
her or him to require help at the present time.
Thus, the question asked from a variety of
angles is ‘‘Why now?’’
Roberts (2005) suggested not only inquiring

about the precipitating event (the proverbial
‘‘last straw’’) but also prioritizing problems in
terms of which to work on first, a concept
referred to as ‘‘looking for leverage’’ (Egan,
2002). In the course of understanding how the
event escalated into a crisis, the clinician gains
an evolving conceptualization of the client’s
‘‘modal coping style’’—one that will likely
require modification if the present crisis is to
be resolved and future crises prevented. For


334 Brief Treatment and Crisis Intervention / 5:4 November 2005

example, Ottens and Pinson (2005) in their
work with caregivers in crisis have identified
a repetitive coping style—argue with care
recipient-acquiesce to care recipient’s demands-
blame self when giving in fails—that can
eventually escalate into a crisis.

Stage IV: Deal With Feelings and Emotions

There are two aspects to Stage IV. The crisis
worker strives to allow the client to express
feelings, to vent and heal, and to explain her or
his story about the current crisis situation. To
do this, the crisis worker relies on the familiar
‘‘active listening’’ skills like paraphrasing,
reflecting feelings, and probing (Egan, 2002).
Very cautiously, the crisis worker must
eventually work challenging responses into
the crisis-counseling dialogue. Challenging
responses can include giving information,
reframing, interpretations, and playing
‘‘devil’s advocate.’’ Challenging responses, if
appropriately applied, help to loosen clients’
maladaptive beliefs and to consider other
behavioral options. For example, in our earlier
example of the young woman who found
boyfriend and roommate locked in a cheating
embrace, the counselor at Stage IV allows the
woman to express her feelings of hurt and
jealousy and to tell her story of trust betrayed.
The counselor, at a judicious moment, will
wonder out loud whether taking an overdose of
acetaminophen will be the most effective way
of getting her point across.

Stage V: Generate and Explore Alternatives

This stage can often be the most difficult to
accomplish in crisis intervention. Clients in
crisis, by definition, lack the equanimity to
study the big picture and tend to doggedly
cling to familiar ways of coping even when they
are backfiring. However, if Stage IV has been
achieved, the client in crisis has probably
worked through enough feelings to re-establish

some emotional balance. Now, clinician and
client can begin to put options on the table, like
a no-suicide contract or brief hospitalization,
for ensuring the client’s safety; or discuss
alternatives for finding temporary housing; or
consider the pros and cons of various programs
for treating chemical dependency. It is impor-
tant to keep in mind that these alternatives
are better when they are generated collabora-
tively and when the alternatives selected are
‘‘owned’’ by the client.
The clinician certainly can inquire about what

the client has found that works in similar
situations. For example, it frequently happens
that relatively recent immigrants or bicultural
clients will experience crises that occur as
a result of a cultural clash or ‘‘mismatch,’’ as
are ignored or violated in the United States. For
example, in Mexico the custom is to accompany
or be an escort when one’s daughter starts
dating. The United States has no such custom. It
may help to consider how the client has coped
with or negotiated other cultural mismatches. If
this crisis precipitant is a unique experience,
then clinician and client can brainstorm
alternatives—sometimes the more outlandish,
the better—that can be applied to the current
event. Solution-focused therapy techniques,
such as ‘‘Amplifying Solution Talk’’ (DeJong &
Berg, 1998) can be integrated into Stage IV.

Stage VI: Implement an Action Plan

Here is where strategies become integrated
into an empowering treatment plan or co-
ordinated intervention. Jobes, Berman, and
Martin (2005), who described crisis interven-
tion with high-risk, suicidal youth, noted the
shift that occurs at Stage VI from crisis to
resolution. For these suicidal youth, an action
plan can involve several elements:

� removing the means—involving parents
or significant others in the removal of

The Seven-Stage Crisis Intervention Model

Brief Treatment and Crisis Intervention / 5:4 November 2005 335

all lethal means and safeguarding the

� negotiating safety—time-limited agree-
ments during which the client will agree
to maintain his or her safety;

� future linkage—scheduling phone calls,
subsequent clinical contacts, events to
look forward to;

� decreasing anxiety and sleep loss—if
acutely anxious, medication may be
indicated but carefully monitored;

� decreasing isolation—friends, family,
neighbors need to be mobilized to keep
ongoing contact with the youth in crisis;

� hospitalization—a necessary intervention
if risk remains unabated and the patient is
unable to contract for his or her own
safety (see Jobes et al., 2005, p. 411).

Obviously, the concrete action plans taken
at this stage (e.g., entering a 12-step treatment
program, joining a support group, seeking tem-
porary residence in a women’s shelter) are critical
for restoring the client’s equilibrium and psy-
chological balance. However, there is another
dimension that is essential to Stage VI, as Roberts
(2005) indicated, and that is the cognitive dimen-
sion. Thus, recovering from a divorce or death of
a child or drug overdose requires making some
meaning out of the crisis event: why did it
happen? What does it mean? What are alternative
constructions that could have been placed on the
event? Who was involved? How did actual events
conflict with one’s expectations? What responses
(cognitive or behavioral) to the crisis actually
made things worse? Working through the
meaning of the event is important for gaining
mastery over the situation and for being able to
cope with similar situations in the future.

Stage VII: Follow-Up

Crisis workers should plan for a follow-up
contact with the client after the initial in-

tervention to ensure that the crisis is on its way
to being resolved and to evaluate the postcrisis
status of the client. This postcrisis evaluation of
the client can include

� physical condition of the client (e.g.,
sleeping, nutrition, hygiene);

� cognitive mastery of the precipitating
event (does the client have a better
understanding of what happened and
why it happened?);

� an assessment of overall functioning in-
cluding, social, spiritual, employment,
and academic;

� satisfaction and progress with ongoing
treatment (e.g., financial counseling);

� any current stressors and how those are
being handled;

� need for possible referrals (e.g., legal,
housing, medical).

Follow-up can also include the scheduling of a
‘‘booster’’ session in about a month after the
crisis intervention has been terminated. Treat-
ment gains and potential problems can be
discussed at the booster session. For those
counselors working with grieving clients, it is
recommended that a follow-up session be
scheduled around the anniversary date of the
deceased’s death (Worden, 2002). Similarly, for
those crisis counselors working with victims of
violent crimes, it is recommended that a follow-
up session be scheduled at the 1-month and
1-year anniversary of the victimization.

Differentiating Crisis Intervention From

Disaster Management

For those in need, the third phase of disas-
ter response—crisis intervention—usually
begins 1–4 weeks after the disaster unfolds.
Phase I is generally known as ‘‘Impact’’ and
Phase II is known as the ‘‘Heroic or Rescue’’


336 Brief Treatment and Crisis Intervention / 5:4 November 2005

phase. Phases I and II involve the disaster
management and emergency relief efforts of
local and state police, firefighters and rescue
squads, emergency medical technicians, the
American Red Cross volunteers, the Salvation
Army, and the Federal Emergency Manage-
ment Agency. The disaster and emergency man-
agement agencies focus on public safety; on
locating disaster shelters, temporary housing
units, and host homes; and on providing food,
clean water, clothing, transportation, and
medical care for survivors and their families.
After the survivors and their families are
rescued and transported to dry land and safe
shelter, the goal is to provide them with well-
balanced meals, continued medical care, sleep,
and rest. It is also critically important to help
survivors to reconnect and reunite with family
members and close friends. Then, 1–4 weeks
after surviving the loss of their home, neigh-
bors, and/or community, Phase III—crisis in-
tervention can begin—if it is requested.
Crisis intervention must be voluntary, de-

livered quickly, and provided on an as-needed
basis. A crisis is personal and is dependent on
the individual’s perception of the potentially
crisis-inducing event, their personality and
temperament, life experiences, and varying
degrees of coping skills (Roberts, 2005). A
crisis event can provide an opportunity, a
challenge to life goals, a rapid deterioration of
functioning, or a positive turning point in the
quality of one’s life (Roberts & Dziegielewski,
1995). One person with inner strengths and
resiliency may bounce back quickly after an
earthquake, tornado or hurricane, whereas
another person of the same age with a preex-
isting mental disorder may completely fall apart
and go into an acute crisis state. A young
emergency room physician might adapt well
upon reaching Atlanta or Houston, whereas
a young social worker suffering from major
depression may completely go to pieces upon
arrival at her cousin’s house in Dallas, TX.

R-SSCIM is the same for survivors of commu-
nity disaster. But we suggest that extra care be
taken in applying R-SSCIM so that the mental
health professional understands and distin-
guishes an acute stress reaction from the intense
impact of the disaster from which most people
rapidly recover. This takes skill on the surface
because both reactions often look the same.
Normal and specific reactions frequently in-
clude shock, numbness, exhaustion, …


Matthew Clair, Harvard University

Forthcoming in Core Concepts in Sociology (2018)


Stigma is an attribute that conveys devalued stereotypes. Following Erving Goffman’s early

elaboration of the concept, psychological and social psychological research has considered how

stigma operates at the micro-level, restricting the well-being of stigmatized individuals. More

recently, sociologists have considered the macro-level dimensions of stigma, illuminating its

structural causes, population-level consequences, and collective responses. This research has

identified how stigma reproduces social inequality through the maintenance of group hierarchies.

Future research should bridge levels of analysis, compare the micro- and macro-level causes and

consequences of stigma among different social groups, and identify the conditions that foster


Main text

Stigma is an attribute that conveys devalued stereotypes. Erving Goffman (1963, 3) classically

defined stigma as an “attribute that is deeply discrediting.” A discredited attribute could be

readily discernable, such as one’s skin color or body size, or could be hidden but nonetheless

discreditable if revealed, such as one’s criminal record or struggles with mental illness. For

Goffman, stigma is a general aspect of social life that complicates everyday micro-level

interactions—the stigmatized may be wary of engaging with those who do not share their stigma,

and those without a certain stigma may disparage, overcompensate for, or attempt to ignore

stigmatized individuals. Most people, Goffman (1963, 138) argued, experience the role of being

stigmatized “at least in some connections and in some phases of life.” Indeed, Goffman’s broad

definition of stigma incorporates many contemporary discredited attributes, including what he

defined as “tribal stigmas” (e.g., race, ethnicity, and religion), “physical deformities” (e.g.,

deafness, blindness, and leprosy), and “blemishes of character” (e.g., homosexuality, addiction,

and mental illness).

In the decades following Goffman’s articulation of stigma, psychologists elaborated stigma’s

cognitive dimensions and the processes through which it shapes micro-level social interaction.

Much of this research has focused on stigmas understood to be related to character, such as

mental illness or addiction, or stigmas stereotyped as deviant, such as homosexuality.

Psychologists have explored the evolutionary causes of stigma, with some suggesting that stigma

serves sociobiological functions by categorizing and excluding individuals who may threaten a

community through the spread of disease or perceived social disorder. In addition, social

psychologists have focused on the individual-level consequences and coping responses of those

who face stigma in daily interactions. This research has documented stigmatization’s negative

implications for self-esteem, academic achievement, mental health, and physical well-being.

Research on coping has documented how stigmatized individuals manage their stigmatized

identities and cope with specific instances of discrimination that they attribute to their stigma.

This research literature is a subset of a larger psychological literature concerned with individual

coping responses to stress more broadly. Researchers have enumerated numerous coping

responses—such as avoidance, suppression, and identity development—and have identified these

responses’ inconsistent moderating effects on stress.

Until the turn of the twenty-first century, research on stigma in sociology had been less coherent

than its counterpart in psychology. Sociologists relied on the concept when it helped to

illuminate a social phenomenon, but rarely did researchers strive to accumulate theoretical

knowledge around stigma as a fundamental social process. Link and Phelan (2001)’s review of

stigma in the Annual Review of Sociology initiated a distinctively sociological approach to the

study of stigma that since has been refined and elaborated. Drawing on Goffman but

incorporating a broader concern for the operation of power in society, Link and Phelan define

stigma as the co-occurrence of four processes: (1) labeling human differences; (2) stereotyping

such differences; (3) separating those labeled from “us”; and (4) status loss and discrimination

against those labeled. By incorporating the role of power and discrimination in their definition of

stigma, Link and Phelan articulated an approach to stigma that would enable sociologists to

consider how stigma related to fundamental sociological questions, namely those relating to the

social creation, reproduction, and consequences of social inequalities.

Sociological approaches to stigma in the ensuing fifteen years have considered the different

types of, as well as the meso- and macro-level causes, consequences, and responses to, stigma

(see Table 1). With respect to type of stigma, sociologists have focused not only on stigmas

related to character, but also—and with greater emphasis than psychologists—on stigmas related

to heritable, bounded social categories such as race and ethnicity (“tribal stigmas”). These

stigmas are related less to deviance and the violation of social norms and more so to processes of

exploitation and domination (Phelan, Link, and Dovidio 2008). Sociological research on the

causes of stigma has considered the role of the law and institutional practices in the maintenance

of stigmatization. Such practices enable stigmatized individuals’ exclusion from social networks,

neighborhoods, labor markets, the law, and politics. Here, stigma has been understood as both

cause and effect: it justifies exclusion of devalued others and, through such exclusion, reifies

devalued stereotypes. With respect to stigma’s consequences, research in public health has

considered the role of stigma as a fundamental driver of population-level health disparities

through various mechanisms; for sociologists, one main mechanism is the unequal distribution of

material resources given discrimination against stigmatized groups. Sociologists studying

responses to stigma have considered collective responses, such as social movements and legal

change, as well as what could explain variations in responses across stigmatized groups,

interactional contexts, and societies (Lamont et al. 2016).

Contemporary sociological research on stigma continues to draw inspiration from Goffman’s

core insights on the phenomenon, developing measures to understand how different dimensions

of stigma—such as courtesy stigma, structural stigma, or internalized stigma—shape inequalities

faced by different groups and their social relations. Future research on stigma could benefit from

greater comparison across stigmatized groups. Goffman articulated stigma as a general social

process, focusing on how stigmatized individuals often face similar constraints in the

management of social interactions, regardless of the particular type of stigma they face. Research

comparing the experiences, causes, and consequences of stigma across types would enable a

better understanding of the causal role of stigma in the reproduction of social inequality. Future

research could also benefit from greater exchange between psychology and sociology, especially

with respect to detailing the unique contributions of psychological mechanisms (e.g., stress) as

compared to sociological mechanisms (e.g., unequal resources) in the production of health

disparities. Finally, sociologists should develop new approaches to studying destigmatization, or

the process by which stigmatized groups become less devalued in society. Whereas

psychologists have documented the effects of stigma reduction interventions in experimental

settings, sociologists largely have been remiss to examine the external validity of such

interventions or the sociohistorical transformation of devalued attributes.

Table 1. Psychological and Sociological Approaches to Stigma along Four Categories




(Social psychology

and cultural sociology)




Physical and mental


sociobiological and



Intersubjective and

symbolic motivations,

cultural motivations,


Social closure, power,

institutional practices,

neighborhood and social


discriminatory laws


Body, mind, cognitive


Individual perceptions

and attitudes,





workplaces, nation-states,

built and natural



Mental illness, stress,

physical illness

Self-esteem, identity,

symbolic worth,



Group disparities in

mental and physical

health, in/out-group

membership, economic

and social inequality


Grit, physiological

coping, individual



withdrawal, psycho-

social resources,

cultural reframing

Social movements,


change, policy and legal



SEE ALSO: Identity; Race and ethnicity; Social Psychology; Stereotypes, Prejudice, and

Discrimination; Stratification and inequality


Goffman, Erving. 1963. Stigma: Notes on the Management of Spoiled Identity. New York:

Simon & Schuster.

Lamont, Michèle, Graziella Moraes Silva, Jessica S. Welburn, Joshua Guetzkow, Nissim

Mizrachi, Hanna Herzog, and Elisa Reis. 2016. Getting Respect: Responding to Stigma and

Discrimination in the United States, Brazil, and Israel. Princeton, NJ: Princeton University


Link, Bruce G., and Jo C. Phelan. 2001. “Conceptualizing Stigma.” Annual Review of Sociology,

27: 363-385. doi: 10.1146/annurev.soc.27.1.363

Phelan, Jo C., Bruce G. Link, and John F. Dovidio. 2008. “Stigma and Prejudice: One Animal or

Two?” Social Science & Medicine, 67: 358–67. doi: 10.1016/j.socscimed.2008.03.022

Further Reading

Clair, Matthew, Caitlin Daniel, and Michèle Lamont. 2016. “Destigmatization and Health:

Cultural Constructions and the Long-term Reduction of Stigma.” Social Science & Medicine.

doi: 10.1016/j.socscimed.2016.03.021

Pescosolido, Bernice A., and Jack K. Martin. 2015. “The Stigma Complex.” Annual Review of

Sociology, 41: 87-116. doi: 10.1146/annurev-soc-071312-145702

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