Addiction Research and TheoryAugust 2008; 16(4) 305–307.docx

Addiction Research and Theory
August 2008; 16(4): 305–307
Editorial
The Hierarchy of Needs and care planning in addiction
services: What Maslow can tell us about addressing
competing priorities?
D. BEST
1
, E. DAY
1
, T. McCARTHY
2
, I. DARLINGTON
3
,
& K. PINCHBECK
1
1
Department of Psychiatry, University of Birmingham,
Birmingham, B15 2QZ UK,
2
National Treatment Agency, Hercules House, London, UK, and

3
Homeless Link, London, UK
(Received 17 December 2007; accepted 18 December 2007)
‘‘It is quite true that man lives by bread alone – when there is
no bread. But what happens
to man’s desire when there is plenty of bread and when his belly
is chronically filled? At once
other (and ‘higher’) needs emerge and these, rather than
physiological hungers, dominate
the organism. And when these in turn are satisfied, again new
(and still ‘higher’) needs
emerge and so on. This is what we mean by saying that the basic
human needs are organised
into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375)
The recent publication of a series of documents providing
guidance for practice in the
drug misuse treatment field in the UK (Orange Guidelines,
Department of Health, 2007)
has raised questions as to the exact role of the ‘drug worker’.
Guidance from the National
Treatment Agency highlights the central role of key working
and case management within
drug treatment, and NICE guidelines about psychosocial

treatments for drug user
emphasises the effectiveness of brief and targeted interventions
over broader and more
humanistic psychological approaches. This will feel like a
dramatic change in direction for
many staff working in the field, and will not sit easily with
many of them. However, such a
strategy is part of a series of moves to standardise the quality of
drug treatment services in the
UK, and support for this broad strategy comes from a well
established source.
Abraham Maslow proposed his theory of a ‘Hierarchy of Needs’
in a paper entitled
A Theory of Human Motivation in 1943, and this is presented
graphically below. Although
later in his career, Maslow focussed increasingly on higher-
order needs and the relationship
Correspondence: Professor David Best, Department of
Psychiatry, University of Birmingham, Queen Elizabeth
Psychiatric
Hospital, Birmingham, B15 2QZ, UK. E-mail: [email protected]
ISSN 1606-6359 print/ISSN 1476-7392 online � 2008 Informa
UK Ltd.
DOI: 10.1080/16066350701875185

between self-actualisation and transcendence, from an
addictions treatment perspective we
should turn our attention to the base of the pyramid (Figure 1).
What is frequently described as a model of motivation, and
utilised in workplace theories
of staff functioning and drive, has considerable ramifications
for the treatment of individuals
with complex and multi-axial problems. The presenting needs of
drug users accessing adult
treatment services are frequently bewildering in their
complexity, often involving multiple
substance use, physical and psychological health problems,
relationship and family
difficulties and little stability provided by reliable
accommodation, regular employment or
non-using friendship networks. As Robins has argued in her
discussion of Vietnam veterans
returning to the US, ‘drug users who appear for treatments have
special problems that will
not be solved just by getting them off drugs’ (Robins 1993, p.
1050).
As Maslow went on to argue in the 1943 article, ‘If all other
needs are unsatisfied, and the

organism is then dominated by the physiological needs, all other
needs may become simply
non-existent or be pushed into the background. It is then fair to
characterise the whole
organism by saying simply that it is hungry, for consciousness
is almost completely pre-
empted by hunger’ (Maslow 1943, p. 372). The parallels with
drug-seeking are obvious, as
they are with the basic physiological problems associated with
drug deprivation, withdrawals,
craving and anhedonia. At initial treatment presentation, it is
therefore, likely that other key
issues are masked, and that only where equally pressing
deprivations, most likely those
caused by homelessness or significant mental or physical
morbidities, are met will these arise
as presenting needs.
There are two fundamental implications of the model for the
delivery of treatment – that
lower-level interventions must precede higher-order ones, and
second that higher-order
needs are unlikely to emerge in the initial contact stages. This
has fundamental implications
for what we are trying to achieve in drug treatment services and

places huge importance on
care planning and review as core components of the treatment
process. In other words, the
major emphasis on comprehensive assessment is misplaced
according to a hierarchy of needs
model, where needs other than the most urgent are unlikely to
emerge. Thus, it is only
through treating care planning as treatment that it is realistic to
expect a treatment journey to
be effective. As clients and workers manage the basic
physiological needs (through
prescribing, detoxification and so on), can treatment start to
look at issues of safety, then
belonging, esteem and addressing more spiritual needs.
Figure 1. The Hierarchy of needs.
306 D. Best et al.
The second implication of this model is for what treatment
workers do. While managing
the immediate physical distress of addiction is paramount, the
hierarchy of needs would
suggest that any further gains in treatment are predicated on a
care planning approach that is

not ‘addiction-specific’ but is trans-disciplinary and grounded
on the client’s emerging
pattern of needs. It would suggest that for many clients what is
needed initially is case-
support rather than ‘psychological change’ and clients will be
sceptical about the benefits of
counselling if their needs are not compatible with the middle
and higher-order levels of the
pyramid. For many clients, the key tasks will be around benefits
and housing, access to
psychiatric services and GPs, and with little need for targeting
lasting change in drug use
until these issues have been addressed.
However, it is not clear that statutory treatment services are
geared to this kind of
generic case working, with key worker appointment systems
based on an unrealistic model
of ‘therapeutic intervention’. As Carroll and Rounsaville (2003)
have argued, there are now
more than a dozen well-evidenced psychosocial interventions
with credible evidence bases,
yet their deployment is inconsistent and implementation fidelity
is poor. Part of this is

because we do not always account for the stage of the client (for
which the hierarchy offers a
heuristic method) and the abiding needs that should shape the
care planning process and, at
a team level, should shape workforce planning and team
training. The hierarchy of needs
also offers a model for clinical supervision and performance
management of services. The
aim of treatment should be a ‘hierarchical journey’ with care
plan reviews addressing
transitions in the level of need to be addressed and creating
resulting action plans.
Furthermore, in a drug treatment system dominated by
maintenance prescribing, it is a
model for change – the stabilising goal of maintenance is viable
for those struggling to
address safety and physiological needs, but once these are
achieved in a sustainable way,
then the rationale for maintenance is likely to diminish and
continued change, through
escalating the hierarchy, which should become a more primary
goal.
References
Carroll K, Rounsaville B. 2003. A vision of the next generation

of behavioral therapies research in the addictions.
Addiction 102(6):850–862.
Department of Health (England) and the devolved
administrations 2007. Drug Misuse and Dependence: UK
Guidelines on Clinical Management. London: Department of
Health (England), the Scottish Government,
Welsh Assembly Government and Northern Ireland Executive.
Maslow A. 1943. A theory of human motivation. Psychological
Review 50:370–396.
Robins L. 1993. Vietnam veterans’ rapid recovery from heroin
addiction: A fluke or normal expectation. Addiction
88:1041–1054.
The Hierarchy of Needs and care planning 307
Environmental Health Perspectives • VOLUME 116 | NUMBER
9 | September 2008 A 395
M
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s
Ph
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to
Disaster Response
Mental Health Effects among WTC Rescue and
Recovery Workers
The attacks on the World Trade Center (WTC) on 11 September
2001 exposed thousands of emergency responders and other
recov-
ery workers to a unique mix not only of airborne toxic
pollutants
but also psychological stressors. The physical consequences
such as
persistent respiratory ailments have been documented
previously
[e.g., EHP 114:1853–1858 (2006)]. The latest report from a 5-
year
study of health effects among WTC rescue and recovery workers
describes a higher level of lingering mental health problems
among
t h e s e w o r k e r s t h a n i n t h e g e n e r a l p o p u l a t

i o n [ E H P
116:1248–1253; Stellman et al.].
More than 10,000 WTC workers completed several standard
mental health questionnaires 10–61 months after the attacks.
About
90% of the respondents worked at the WTC site during the first
2 weeks after 9/11, and the majority remained onsite for 3
months
or longer. On the basis of an analysis of their responses, and in
the
absence of a clinical evaluation, the researchers classified
11.1% of
workers with probable post-traumatic stress disorder (PTSD),
8.8%
with probable depression, 5.0% with probable panic disorder,
and
62% with substantial stress reactions (such as nightmares, flash-
backs, and insomnia). Overall, mental health problems declined
gradually from 13.5% to 9.7% among WTC workers during the
course of the study.
The incidence of PTSD in WTC workers, which parallels that
reported in soldiers returning from combat duty in Afghanistan,
was about 4 times higher than that for the general population in
the
United States. Probable PTSD was associated with having lost
family members or friends in the attacks; those with probable
PTSD had a 17-fold greater likelihood of reporting disruption of
family, work, and social life. About half those with probable
PTSD
also experienced probable panic disorder, depression, or both.
Workers with probable PTSD also perceived their children as
having more psychological symptoms (such as clinginess or
trouble

sleeping) and behavioral problems than workers without PTSD.
Alcohol-related problems also were abundant in the study
group.
More than 17% reported symptoms of probable alcohol abuse.
Nearly half reported drinking more heavily than usual during
the
period they worked at rescue and recovery efforts, and months
later a
third were still drinking more than usual.
The authors conclude that the variety of persistent mental health
problems in responders “underscores the need for long-term
mental
health screening and treatment programs targeting this
population.”
Following future environmental disasters, they write, mental
health
problems are virtually certain to accompany physical effects of
toxic
exposures. Rescue and recovery workers therefore should
receive
behavioral health evaluations as well as medical evaluations to
reduce
adverse health and social consequences. –Carol Potera
“Metal Detector” Gene May
Influence Lead Absorption
Variants Predict Higher Blood Lead Levels in
Children
An estimated 310,000 U.S. children between ages 1 and 5 have
ele-
vated blood lead levels despite efforts to reduce lead in the
environ-
ment. Research in the past decade has begun to focus on factors
that

could make some children more susceptible to lead poisoning
even at low levels of exposure. A new study explores one such
pos-
sible factor—gene variants that influence lead absorption—
linking
variants in two iron metabolism genes to higher blood lead
levels in
children [EHP 116:1261–1266; Hopkins et al.].
When researchers analyzed umbilical cord blood from 422 chil-
dren in Mexico, they found that the presence of two variants of
the
hemochromatosis (HFE ) gene—HFE C282Y and HFE H63D—
predicted blood lead levels 11% higher than those in children
not
carrying the variants. Moreover, the presence of either HFE
variant
combined with a variant form of the transferrin (TF ) receptor
gene—TF-P570S—predicted blood lead levels 50% higher than
in
children with none of the variants.
Although the HFE and TF genes normally regulate iron metabo-
lism, they may also influence blood lead levels because lead—
like
iron—is a divalent metal. Thus, the two metals can be
“mistaken”
for each other during metabolic processes. The HFE gene
regulates
iron-binding proteins, including TF, and variant forms of this
gene
sometimes induce hemochromatosis, a disease characterized by
increased intestinal absorption of iron that contributes to
abnormally
high iron stores in adulthood.

The authors hypothesized that the HFE variants might similarly
increase absorption of lead, a hypothesis supported by the
results of
this study. TF interacts with HFE to form a complex that down-
regulates iron absorption. However, TF-P570S may interact
with
the HFE variants in ways that heighten metal absorption rates.
Study results showed the TF and HFE variants produced higher
lead levels than those predicted by either HFE variant alone.
Previously published research by these investigators has shown
that having the HFE variants predicted lower blood lead levels
in
elderly men compared with men without the variants. The
contrast-
ing findings, the authors speculate, may reflect age-specific
differences
in body iron stores and in the variants’ effect on lead
metabolism.
Among children with low iron body stores and high iron needs,
the
variants predicted higher blood lead levels. But as iron stores
accumu-
late with age, the variants down-regulated iron and lead
absorption,
leading to progressive declines in blood lead levels. The study’s
key
implications are twofold: first, that children with variant iron-
metabolizing genes may be especially susceptible to the effects
of lead
at low exposure levels, and second, that genetic variants may
increase
risk at one life stage and decrease it at others. –Charles W.
Schmidt

Science Selections
A worker surveys the WTC site,
25 September 2001
Latina Mothers' Perceptions of Mental
Health and Mental Health Promotion
Elizabeth M. Vera and Wendy Conner
Latina mothers' perceptions of mental health and factors that
promote/restore
mental health were explored in this qualitative study.
Participants discussed
the importance of community, safety, and financial stability in
addition to
conventional factors that are related to mental health.
Implications for working
with urban Latinas and their families are discussed.
En este estudio cualitativo se exploraron las percepciones de las
madres
Latinas sobre Salud Mental y los factores que la
fomentan/restablecen. Las
participantes discutieron acerca de la importancia de la
comunidad, la se-
guridad y la estabilidad financiera además de otros factores
convencionales
relacionados con la salud mental. Se discuten las implicaciones
para el trabajo

con Latinas residentes en núcleos urbanos y sus familias.
T
he underutilization of mental health services by people of color
has
been well documented (Akutsu, Snowden, & Organista, 1996;
Padgett,
Patrick, Burns, & Schlesinger, 1994; Pumariega, Glover,
Hölzer, &
Nguyen, 1998). Although availability of mental health services
undoubtedly
affects utilization, rates of utilization differ among ethnic
groups even when
access to services is similar across ethnic groups (Alvidrez,
1999). One aspect
of understanding the causes of underutilization is examining the
cultural ap-
propriateness of available services. This contention is supported
by policies
such as the Multicultural Counseling Competencies (Roysircar,
Arredondo,
Fuertes, Ponterotto, & Toporek, 2003) and the Guidelines on
Multicultural
Education, Training, Research, Practice, and Organizational
Change for Psychologists
(American Psychological Association, 2003), which offer
recommendations
for adapting services to meet the needs of diverse constituents.
Understanding cultural beliefs and values of ethnic groups is
important to the
development of treatment approaches that are culturally
congruent. In the case
of Latino clients, much has been written about the cultural
characteristics of

this population. For example. Marin and Marin (1991)
characterized Latinos
as (a) group oriented, (b) valuing harmonious interpersonal
relationships,
(c) loyal to family, (d) deferent to authority figures or revered
relatives, and
(e) valuing traditional gender roles. On the basis of this
information, group
and family-based modalities of counseling might be viewed as
culturally ap-
propriate for Latino clients (Falicov, 1996), primarily because
of the systemic
nature of conceptualizations that may appeal to members of
collectivist or
interdependent cultures (Triandis, 1988). Although such
treatment approaches
Elizabeth M. Vera, School of Education, and Wendy Conner,
Department of Counseling Psychology, both
at Loyola University Chicago. Correspondence concerning this
article should be addressed to Elizabeth
M. Vera, School of Education, 820 N. Michigan Avenue, Loyola
University Chicago, Chicago, IL 60611
(e-mail: [email protected]).
© 2007 American Counseling Association. All rights reserved.
2 3 0 JOURNAL OF MULTICULTURAL COUNSELING AND
DEVELOPMENT • October 2007 • Vol. 35
may be effective with this population. Latino clients'
perceptions of whether
counseling is a culturally appropriate option is directly related
to their utiliza-

tion rates. This issue may be particularly relevant to tailoring
mental health
services to meet the needs of Latina women. Given that women
often attend
to the emotional needs of the families, understanding their
perceptions of
mental health and help-seeking behaviors are important to
understanding
treatment decisions of Latino families.
pnrpnsp of tbp stnHy
Increasing the field's knowledge of how women of color in
general, and those
who are mothers in particular, conceptualize mental health and
its maintenance
may be informative to the development of culturally relevant
individual and
family mental health promotion and remediation efforts.
Because mothers are
often the "monitors" of their children's emotional needs, their
perceptions of
mental health and related interventions would have implications
for working
with Latinas and their families. It is not assumed that being a
mother, per se,
would affect the mental health beliefs and experiences of
service provisions
of Latinas. However, given the powerful role that many Latina
mothers have
in protecting the mental health of their families, this population
was the
focus of the present investigation. This study was guided by an
interest in
the participants' beliefs about the following issues: (a) How is
mental health
understood or conceptualized by urban Latina mothers? (b)

What factors
affect mental health, both positively and negatively? and (c)
What formal
and informal methods of help seeking are used for the mental
health needs
of Latina mothers and their family members?
rpipvant litpratnrp
In comparison with the amount of literature on Latina women, a
relatively
larger body of research exists on women of color in general and
their deci-
sions to use mental health services. Several recent studies have
examined the
help-seeking attitudes, explanations of psychological disorders,
and coping
strategies of women of color (Alvidrez, 1999; Brodsky, 1996).
Alvidrez found
that, for low-income women of color, the likelihood of making
an appoint-
ment to see a mental health professional was predicted by
problem type,
beliefs about the origin of mental health problems, and having a
friend or
family member who had sought services. In her sample, stigma
regarding
psychological problems and preference for informal means of
help seeking
were not found to be relevant predictors of seeing a mental
health profes-
sional. Alvidrez's study was very helpful in clarifying some of
the factors that
lead women of color to seek the assistance of mental health
professionals,
but it did not explore a wide range of precipitating events that
might result

JOURNAL OF MULTICULTURAL COUNSELING AND
DEVELOPMENT • October 2007 • Vol. 35 2 3 1
in a woman seeking services in the first place. Additionally, the
role of larger
systemic factors such as poverty or community in jeopardizing
the mental
health of women was not explored.
Brodsky (1996) examined the role of poverty and community
factors in
the mental health and resiliency of low-income African
American women.
Resiliency is defined as the ability to persevere in the face of
obstacles (Mas-
ten, 2001). Brodsky found that, for women who see the
community as a
burden as opposed to a resource, distancing from the community
was seen
as a coping mechanism that enhanced resiliency and mental
health. Her
findings challenged the extant literature that found community
involvement
and belonging to be related to positive mental health for women
of color
(McMillan & Chavis, 1986). Yet the findings could have been a
function of
social class rather than the ethnicity of the participants. In other
words,
Brodsky's participants' residence in an impoverished
neighborhood, not their
ethnic backgrounds, was most likely what influenced their
perceptions of

the neighborhood as unsafe. The most distinctive aspect of
Brodsky's study
is that it is one of the only investigations in which women of
color were
interviewed about the relevance of community and
neighborhood factors
in relation to mental health and resiliency.
Other than the aforementioned studies, there has been relatively
little re-
search done on mothers' perceptions of mental health, barriers
to treatment,
or mental health promotion. We found even less research on
Latina mothers'
perceptions of mental health. One recent study (Christie-Mizell,
Steelman,
& Stewart, 2003) focused on ethnic differences in perceptions
of maternal
distress and neighborhood disorder in a nonclinical sample of
mothers. That
study found that Mexican American and African American
mothers perceived
higher levels of neighborhood disorder than did their White
counterparts
and that perceived neighborhood disorder was significantly
predictive of ma-
ternal distress (a finding that was exacerbated for African
American mothers
by number of children).
However, the majority of extant research on Latina mothers has
focused on
mothers whose children have identified psychological or
behavioral disorders
or on the mental health problems of the mothers themselves
(Ainsenberg,

2001; La Roche, Turner, & Kalick, 1995; Pavuluri, Luk, &
McGee, 1996; Raviv,
Raviv, Propper, & Fink, 2003). In general, this research has
used survey re-
search that limits responses to predetermined categories of
mental health
problems and resources. This is problematic because women of
color often
have alternative conceptualizations of mental health problems
and appropriate
responses to such problems (Alvidrez, 1999). The paucity of
more discovery-
oriented research underscores the need for additional empirical
studies that
address Latina mothers' general perceptions of mental health
barriers and
attitudes toward help seeking. A qualitative research approach
was selected
for this study to generate such discovery-oriented data.
This study used narrative inquiry (Guba & Lincoln, 1985) as a
qualitative
methodology to investigate perceptions of and attitudes toward
mental health
in a sample of resilient, urban Latina mothers. In narrative
inquiry, first-person
accounts of experience form the narrative text of this research
approach (Mer-
riam, 2002). The goal of narrative inquiry is to make sense of
experience by
communicating and constructing meaning (Chase, 1995). The

interpretation
of narrative data involves the identification of thematic
categories that are
descriptive (vs. interpretive) and are allowed to emerge from
the data using
an open-coding process (Miles & Huberman, 1994; Strauss &
Corbin, 1990).
Narrative inquiry differs from other approaches to qualitative
research, such
as grounded theory, in that it aims to describe experience as
opposed to de-
velop and provisionally verify theory contained in the data
(Merriam, 2002).
Given the limited research on Latina mothers' perceptions of
mental health,
it would be premature to construct theory. Narrative inquiry is
appropriate
when discovery of phenomena is the goal of the study.
Whereas past studies (Alvidrez, 1999; Landrine & Klonoff,
1994) have largely
used quantitative approaches to understanding mental health
conceptual-
ization and patterns of service utilization in women of color
(e.g., symptom
and resource checklists), existing surveys often fail to
incorporate protective
factors or processes that may promote mental health, not
jeopardize it. The
decision to use a qualitative, discovery-oriented approach was
also based on
the anticipation of illuminating protective factors or factors that
are important
to maintaining mental health.
metboH

PARTICIPANTS
Participants in this study were 10 Latina mothers who resided in
a low-income
neighborhood in a large, midwestern, urban community.
Participants were
nominated by their children's school administrators, by
community leaders,
and by other parents whose children attended the local public
elementary
school. The criteria for nomination were women who were
perceived as suc-
cessful in overcoming challenges of raising healthy children
(i.e., an example
of resiliency) and living in a low-income environment. The 10
mothers who
were selected for participation, then, were not thought to be
representative
of parents in general or Latina mothers as a group, but rather
were thought
to be potentially effective spokespersons for resilient Latina
mothers in the
community. This participant selection procedure has been used
in other
studies (e.g., Brodsky, 1996).
Mothers ranged in age from 30 to 43 years. Six were first-
generation Mexican
immigrants who had lived in the United States for more than 10
years (rang-
ing from 10 to 18 years). Of the remaining four participants,
three were born
in the continental United States and were of Argentinian, Puerto
Rican, and

multiracial ethnic backgrounds. One mother was born on the
island of Puerto
Rico. All mothers had worked outside their homes in positions
that ranged
from paid employment as secretaries to volunteer work as
teacher's aides or
crosswalk guards. No specific data were gathered on the
incomes earned by
the participants because it was determined through consultation
with leaders
in the community that such a question would be viewed as
culturally inap-
propriate. Seven of the mothers were married to the fathers of at
least one
of their children, and three were in nonmarital, cohabitating
relationships.
The number of participants' children ranged from one to three.
The ages of
the children ranged from 18 months to 12 years.
The mothers were invited to participate in the study by the
primary investi-
gator (first author) at a time that was convenient for them in
their children's
school setting. Mothers who were employed by or volunteered
at the school
received permission from the principal to participate in the
interviews during
their workdays. Informed consent was obtained prior to the
beginning of the
interviews, and the participants were assured that the
information gathered

was anonymous and that pseudonyms would be used in the
description of
the findings. After the interviews were completed, gift
certificates to a local
grocery store were offered to participants as tokens of gratitude.
No incentive
was offered to mothers when they were invited to participate.
PROCEDURE
Individual interviews were conducted for this study by a
bilingual, doctoral-
level psychologist (first author) in English, or Spanish, or both
languages,
depending on the preferences of the participants. Interviews
lasted approxi-
mately 30 minutes and were guided by the following open-
ended questions,
derived from a review of previous literature: (a) "How do you
understand the
term mental health?" with a follow-up probe, "For example,
what would be some
of the characteristics of people who have good mental health?"
(b) "What are
the kinds of things that help people to stay mentally healthy?"
(c) "What are
the kinds of things that can damage or threaten mental health?"
(d) "What
would be acceptable ways to address a mental health problem in
your com-
munity?" (e) "What is available to people in the community
right now that
helps promote and maintain mental health?" and (f) "What are
things that
are not available right now but would be beneficial in
promoting and main-

taining mental health for people in the community?"
DATA ANALYSIS
Individual interviews were transcribed from audiotapes, and the
transcripts
were initially reviewed by the participants for accuracy.
Secondary interviews
were scheduled with the participants after the narrative data had
been ana-
lyzed and categorized by the coders. At the time of the follow-
up interviews.
participants were able to comment on the extent to which the
categorization
of their individual responses appeared appropriate and to
elaborate on their
initial responses. This process was used to enhance the
credibility and validity
of the data obtained. Additionally, in an effort to minimize
personal bias, the
interviewer kept field notes, which were later compared against
the results
of the final analysis.
Two independent coders identified emergent descriptive themes
from the
transcribed interviews in this study. One of the coders was a
White, female
graduate student who had previous clinical and research
experience working

with Latinos, and the other was a Latina professor. The themes
were then
compared and integrated into an initial list of coding categories.
Once a final
list of themes was constructed, two additional coders tested the
reliability of
the coding scheme. These secondary coders were White, female
graduate stu-
dents. Each coder had been trained in qualitative research and
data analysis
in the course of their studies, and neither was involved in the
planning of this
study. The decision to use these additional coders was part of a
strategy to
increase the relative objectivity of the data analysis and to
prevent researcher
bias from influencing the results. The secondary coders
categorized samples
of the data into the existing schema with a 90% success rate.
Discrepancies in
categorization were discussed until consensus was achieved.
Narrative samples
were then selected from the interviews to illustrate themes.
Illustrative sample
responses were attributed to participants using only pseudonyms
and brief
demographic descriptors.
results
WHAT DEFINES MENTAL HEALTH?
Participants described a variety of characteristics of mentally
healthy people,
such as stability and happiness. One repeating theme in all 10
interviews was
the interpersonal nature of mental health. Harmonious

relationships within
the family, providing support to others, and fostering
interdependence were
associated with positive mental health. Every participant talked
about the
connection between parental and child mental health. Parents
were viewed as
role models who "taught" their children how to be healthy
people. To quote
one of our participants, "happy parents make happy children."
Interpersonal components of mental health were not discussed
to the exclu-
sion of individual factors. Hope and optimism were identified as
components
of positive mental health. Daria, a 30-year-old mother of two,
stated,
I give my kids a hard time. I tell them that if you have a bad
attitude, you are going to
have a bad day. Everything is in your mind. If you expect [to
have] a good day, look
forward to going to school, then you will have a good day. It is
up to you. No one else
determines this.
WHAT PROMOTES MENTAL HEALTH?
Environmental influences on mental health constituted another
category of
factors that promoted mental health. Having access to tangible,

economic,
and social resources was seen by eight participants as critical
influences on
the mental health of families in the community. Participants
recounted sto-
ries of families who lost their homes because of fires or who
were forced to
move in with other families because of unexpected job loss.
Although these
events were associated with threatening mental health, the
social resources
provided by neighbors were cited as "protective." Cristina, a 43-
year-old
mother of three, stated.
Lots of families struggle here, and if they recover, it is because
someone was there for
them. Most of the time, it is other families that step in to be
there. But when families
reach out to neighbors who [have] stumbled, amazing things can
happen.
Not only were a lack of financial resources a concern for
participants, but
also the availability of community-sponsored resources were
concidered an
important protective factor for half of the participants. The
availability of re-
sources such as safe recreational areas was seen as a factor
promoting mental
health for families. Jacinia, a 34-year-old mother of two, stated.
What promotes mental health? To me, it's day care centers, a
close-by job, park district
programs. (Interviewer. How do these help promote mental
health?) When you can

provide for your kids and don't feel guilty about not being with
them or wonder if they
are safe, you have peace of mind. Knowing your kids are safe is
having mental health.
On a similar note, neighborhood factors such as affordable
housing were
linked to maintaining mental health. Carolina, a 30-year-old
mother of two,
told a story about a family that had become homeless because of
gentrification
in the neighborhood, which had prompted local landlords to
raise rents. She
concluded that "if you lose your home, everything is up for
grabs. You go to a
shelter, you move in with another family, but everything
changes. This is why
parents have to come together to fight gentrification and other
threats."
Using community resources on a regular basis was viewed as an
avenue to
promoting mental health for Latina women in the community in
particular.
Linda, a 30-year-old mother of two, stated.
Especially for Latinas, we don't need to sit home alone in the
house. If you can't get a
job, while your kids are in school, you need to stay active,
involved with people, caring
for your kids, yes, but also going to church, exercising,
volunteering, whatever you can
get yourself into.
Community-sponsored programs for families and youth were
mentioned

by half the participants as resources that can protect mental
health. Yet one
participant, Linda, a 30-year-old mother of two, expressed a
concern that
there were misperceptions of some of the existing programs that
affected
how much they were used by the community members:
A lot of parents see the rec[reation] centers and aren't sure if
they are really good for
their kids. They think, "What if this is where the gang bangers
hang out?" even if it is
not true. It is really important for parents to know that it is safe
for your kids here.
Mistrust due to perceived community dangers was mentioned as
an issue
that prevented some members of the community from taking
advantage of
available programs, although such problems have the potential
to enhance
family mental health. These responses reflected an awareness of
formal mental
health services in the community but underscored the
importance of such
resources being trustworthy and safe.
WHAT THREATENS MENTAL HEALTH?
Many conventional threats to mental health were identified in

response to this
question. All participants listed divorce, drugs, conflict,
neglect, illness, and
abuse as life events that are highly disruptive to one's mental
health. Half of the
participants gave equal emphasis to lack of resources and
negative community
influences. For example, a lack of opportunities to "stay busy"
with one's family
was mentioned as a threat to mental health. Additionally, gangs
and related
violence in the community were listed as factors threatening
mental health in
families. Cristina, a 43-year-old mother of three, stated.
Some of the things in the street that families are exposed to . . .
that kind of negativity
is a hard thing to overcome. You take the little ones to the park
and sometimes you get
nervous 'cause of who else is there. Maybe something is about
to go down, you don't
know. But having to worry about what you don't expect, that is
a problem.
In addition to safety, direct family influences were seen as
affecting the
mental health of children. Seven participants discussed concerns
about the
community's number of teenage parents viewed as being ill-
equipped to
provide for their children's emotional needs. For parents in
general, not
spending time with one's family was identified as contributing
to a climate that
threatens mental health. In some cases, the reasons for this were
economic.

Three participants discussed situations in which parents worked
two or three
jobs and were never physically present when their children were
home. All
participants described the Stressors of being single parents that
compromise
one's ability to be emotionally present in the family. Linda, a
30-year-old
mother of two, stated.
Lots of parents in this community are literally not there for
their kids. The kids go home
to an empty house every day. Others start out being there but
can't handle all the pres-
sure of being alone with the kids and fall through the cracks.
You are hanging in there,
holding a job, paying rent, and one day it gets to be too much
and it all falls apart.
Whether absence was defined as physical or emotional, being
unavailable to
one's family members was viewed as an important threat to
mental health.
WHAT ARE ACCEPTABLE WAYS TO RESTORE MENTAL
HEALTH?
Many informal and formal mechanisms for addressing mental
health prob-
lems were discussed by the participants. The importance of
consulting with

trusted individuals, such as family, friends, clergy, or peers in
the community,
was discussed by eight participants. Five of these participants
described such
individuals as "mentors," or people who have different
perspectives on situ-
ations whose advice would be valuable and welcomed.
The general issue of trustworthiness was mentioned in all of the
conversa-
tions. Given that the problems discussed by the participants
were of a more
personal nature (i.e., family problems), participants stressed the
importance
of finding someone who could protect their privacy. The theme
of trustwor-
thiness extended to the participants' openness to formal sources
of support
as well. In terms of formal strategies to address mental health
problems,
participants listed counselors, social workers, and psychologists
as being good
resources, especially if they were "known quantities." School
counselors and
psychologists affiliated with the participants' children's schools
were seen as
potential resources. All participants seemed knowledgeable
about the clinics
in the community that offered mental health services and
mentioned several
by name. The formal sources of support were identified as
preferred over
informal resources only when the problem was of a large
enough magnitude
and informal resources were insufficient.

WHAT RESOURCES ARE AVAILABLE AND WHAT ARE
NEEDED?
None of the participants reported concerns about the overall
quality of the
resources currently available to the community, but half
reported that the
quantity and availability of such resources could be greatly
expanded. The
existing community resources appeared to be underutilized by
families either
because of safety concerns or because parents lacked the
initiative to locate
such resources. Claudia, a 35-year-old mother of one, stated.
There are opportuniues for families to get help when they need
it and to stay involved
in things that are good for them, but you have to look for those
things. They are not
everywhere or delivered on a plate to you. You have to check
things out and get it.
This Statement illustrates the participants' sentiments that it was
up to par-
ents not only to be aware of what is available but also to be
active in pursuing
and evaluating the quality of resources for their families.
In addition to community programs, four participants expressed
a desire
for mental health professionals to be active members of the
community. The
importance of mental health professionals knowing the strengths
and needs
2 3 8 JOURNALOF MULTICULTURAL COUNSELING AND

DEVELOPMENT «October 2007 «Vol. 35
of the community, as opposed to intervening only when
problems arise, was
discussed. Cristina, a 43-year-old mother of three, stated.
If counselors could be a part of the community, part of an effort
to prevent problems
from the beginning, walking in the shoes of the community, it
would be better than
waiting to step in until it is too late to do much. We need
partners to walk with us.
disrnssinn
The results of this investigation are consistent with several
other studies that
have found mental health to be perceived as influenced by
individual, family,
and environmental factors, specifically by women of color and
Latinas in par-
ticular (Christie-Mizell et al., 2003; Jenkins & Cofresi, 1998).
However, these
data suggest that several types of individual, family, and
community resources
are viewed as assets that promote mental health for Latinas and
their families.
Participants in the study were family and community focused in
how they
conceptualized mental health and which preventative resources
they viewed
as related to the maintenance of mental health. There were
several occasions
when individual psychological resources (e.g., positive attitude)
were men-

tioned as important determinants of mental health, but the
themes identified
from the data reflect a distinct focus on family and community
influences.
This may because, as mothers, these Latina participants were
more oriented
to aspects of family and parenting than would be women
without children.
Participants' ethnic heritages may also shape their worldviews
to be more
collective, regardless of whether they were parents (Marin &
Marin, 1991;
McNeill et al., 2001). The low-income status of the
neighborhood combined
with the collective orientation of the participants may have
exacerbated the
importance of community, as was found in Brodsky's (1996)
study.
These narratives support the past work of feminist theorists
(Mattis, 2002)
documenting that worldviews of women in general are relational
in nature.
The implications for psychologists and counselors working with
urban Latina
mothers and their families, especially those who reside in low-
income, urban
communities, are multiple. First, adopting a systemic, relational
focus in the
delivery of mental health services is supported by these data
and past literature
(Falicov, 1996; i.e., family and group-based interventions).
Second, attending to
the larger social context in the provision of services (e.g.,
community resources,
family income needs, public spaces in which families can spend

time together)
as it affects mental health and well-being is supported by these
data and other
studies (Rosado & Elias, 1993). Third, a focus on preventive
interventions and
connecting families with community resources may be an
important supplement
to more traditional service delivery (i.e., therapy; Vera &
Speight, 2003). In ad-
dition, informal support services within community institutions
(e.g., support
groups) may also be viewed favorably by Latina mothers, a
finding supported
by previous literature (Rhodes, Contreras, & Mangelsdorf,
1994).
Fourth, the ahility to form ongoing, collahorative relationships
within
the community may he a key to decreasing the underutilization
of services
hy Latina mothers and their families. Participants in this study
empha-
sized the importance of trustworthiness and familiarity in the
utilization
of formal community services. Although many service providers
may
work in agencies or schools that are located within the
communities,
the extent to which they are viewed as insiders versus outsiders
may he
an important issue influencing decisions to seek services. It may

he that
the issue of trust is exacerhated hy acculturation in that more
accultur-
ated participants would have preferred the use of services by
unknown
professionals, as is more typical of traditional therapeutic
services. This
interpretation may he supported hy flndings from another study
of La-
tina mothers, which found that private psychologists were
preferred to
school-hased psychologists in seeking treatment for their
children (Raviv
et al., 2003). However, Raviv et al. suggested that their flndings
reflected
their participants' strong distrust in puhlic systems. Thus, trust
was a
consistent theme in hoth sets of findings. Outreach into the
community
through involvement in local schools, places of worship, or
community
organizations may enhance the trustworthiness and credibility
of service
providers with populations that historically have underutilized
formal
services. These recommendations are supported by existing
literature
(Vera & Speight, 2003).
The implications of this study must be tempered in that the
participants were
spokespersons of a unique community. Philosophically,
qualitative data are
not intended to be generalizable. However, when discussing
recommendations
to mental health practitioners, it is important to consider the

opinions of the
participants as part of an emerging picture of perspectives on
mental health
from historically underserved constituents. In this instance, the
perspectives
were those of urban Latina mothers residing in a low-income
neighborhood.
Their perspectives may diverge from those of other urban
women or other
women of color. It is important to keep these considerations in
mind when
evaluating the validity of the data.
These data contribute to the dialogue of how to make counseling
services
more culturally relevant. Future research should focus on
clarifying the
interaction of ethnicity and socioeconomic status as they affect
mothers'
perceptions of mental health and service provision. Also, it
would be
valuable to systematically study the impact of a variety of
community-
based services (e.g., prevention programs, family recreation) on
the
overall mental health and functioning of low-income Latino
families
and other families of color. In the quest of professionals in the
field for
answers to these questions, larger problems of the
underutilization of
psychological services by people of color and racial disparities
in mental
health problems might be better understood.

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Most experts in crisis intervention (e.g., James & Gilliland,
2005; Kanel, 2003; Slaikeu, 1990) believe Lindemann ush-
ered in the modern era of this field with his research on survi-
vors of the 1942 Coconut Grove Fire in Boston, Massachu-
setts. Since that time, crisis intervention has continued to
grow, with a virtual explosion of literature addressing the topic
beginning approximately two decades ago (James & Gilliland,

2005). It was at this time that posttraumatic stress disorder
(PTSD) first appeared in the Diagnostic and Statistical Manual
of Mental Disorders (3rd ed., DSM-III; American Psychiatric
Association [APA], 1980). Examples of other issues contrib-
uting to the development of the field of crisis intervention are
the increase of violence (Bureau of Justice Statistics, 2000),
recognition that crisis events can be the source of long-term
mental health problems (Salzer & Bickman, 1999), belief that
treatment can prevent psychological problems from develop-
ing (Ursano, Grieger, & McCarroll, 1996), the growth of man-
aged care organizations (Myer & James, 2005), and the lack
of nearby family support (Myer, 2001). These issues are among
the many that have resulted in the growth of crisis interven-
tion as a subspecialty in the mental health field.
However, the primary focus of crisis literature has been
on giving aid and support, which is understandable given
that the first concern in the aftermath of a crisis is always to
provide assistance (McFarlane, 2000), not to conduct sys-
tematic research (Raphael, Wilson, Meldrum, & McFarlane,
1996). Experts in crisis intervention have focused on practi-
cal issues such as developing intervention models that man-
age postcrisis reactions (Paton, Violanti, & Dunning, 2000),
with little attention being given to the development of theory
(Slaikeu, 1990). Slaikeu stated that crisis theories are more
like a cluster of assumptions, rather than principles based on
research that explain or predict the effect of crises on indi-
viduals. Ursano et al. (1996) agreed, stating that clinical
observations and implications derived from mediators of
traumatic stress have guided interventions, rather than
theory. Although these efforts have increased the understand-
ing of the nature of crises, a need exists to mold these as-
sumptions and observations into theory.
In this article, we propose a theoretical model for under-
standing the impact of a crisis. Specifically, we offer a for-

mula that goes beyond the traditional individualistic fo-
cus of crisis intervention to view the effects of a crisis
within the framework of a contextual model. Crisis in con-
text theory (CCT) does not diminish the importance of the
individual but rather provides an ecological perspective
that allows the appreciation of an individual in crisis. First,
we outline background information that led us to construct
this theory. Included in this section are personal observa-
tions and a brief discussion of literature that describes con-
cepts helpful in constructing an ecological crisis theory.
Second, we introduce CCT using a formula based on three
premises demarcating the impact of a crisis. A diagram is
included in this section that illustrates the idea of crisis in
context. Third, we conclude by suggesting areas requiring
additional study. As with any fledgling theory, research is
needed for revisions and enhancement.
Background
The events of the terrorist attacks of September 11th, 2001,
served as a catalyst for our belief that the development of a
crisis theory must move beyond examining effects on the indi-
vidual. After working with survivors of this tragedy, we found
that an individualistic focus limited our ability to understand
survivors’ experiences and to offer them assistance. Research
conducted with survivors of the September 11th attacks sup-
ports our observation, indicating that the social context of in-
tervention must be considered to implement interventions that
are effective (McNally, Bryant, & Ehlers, 2003). Ecological
factors also had an impact on these people and needed to be
accounted for in the treatment process. Experts also recognize
a growing need to include ecological factors in understanding
the impact of crises (e.g., James & Gilliland, 2005; Stuhlmiller
& Dunning, 2000). The concept of an ecological perspective is
based on the idea that crises do not happen in a vacuum but are
shaped by the cultural and social contexts in which they occur
(Deiter & Pearlman, 1998; van der Kolk & McFarlane, 1996).

Rec-
Rick A. Myer, Department of Counseling, Psychology, and
Special Education, Duquesne University; Holly B. Moore,
Depart-
ment of Counseling, Indiana University of Pennsylvania.
Correspondence concerning this article should be addressed to
Rick
A. Myer, Department of Counseling, Psychology, and Special
Education, School of Education, Duquesne University,
Pittsburgh,
PA 15282 (e-mail: [email protected]).
Crisis in Context Theory:
An Ecological Model
Rick A. Myer and Holly B. Moore
This article outlines a theory for understanding the impact of a
crisis on individuals and organizations. Crisis in
context theory (CCT) is grounded in an ecological model and
based on literature in the field of crisis intervention
and on personal experiences of the authors. A graphic
representation denotes key components and premises of
CCT, while a proposed formula summarizes the theory.
Recommendations for future research are also included.
84140
Myer & Moore
ognizing that crises occur in a context that includes individuals
and
the systems in which the individuals reside is essential in ad-

vancing the field of crisis intervention.
A critical issue in the development of this model involves
maintaining focus on the individual while balancing this
focus with a consideration of the system. This concept is
different from systems theories in that systems theories gen-
erally do not view an individual apart from the system
(Gladding, 1998). In systems theory, the system is the point
of intervention, not the individual (Kadis & McClendon,
1998). Difficulties experienced by the individual are a con-
sequence of problems being experienced by the system.
Whereas this belief can be true for CCT, the individual and
the system must also be considered separately. A causal chain
of individual and system influence cannot explain all prob-
lems resulting from a crisis (Gladding, 1998). Stated differ-
ently, not all difficulties are dependent on the system, but
linear causality does account for a proportion of an
individual’s experience of the crisis. For example, indi-
viduals and organizations in the vicinity of the World Trade
Center on September 11th, 2001, encountered numerous
independent as well dependent problems. The difficulties
occurring internally for a person exposed to a disaster such as
the terrorist attacks of September 11, 2001, cannot be wholly
explained as a result of problems within a system. In addition,
problems being experienced by organizations located in that
area are not necessarily a result of any action on the part of the
individual. CCT recognizes that problems resulting from a cri-
sis can be independent and dependent at the same time.
Additional support for crisis in context is found in
Bronfenbrenner’s (1995) theory of life span development
and Lewin’s (1951) field theory. Through a review of re-
search literature and his own research, Bronfenbrenner (1995)
developed the hypothesis that human development is the
product of an interaction among process, person, context,
and time. Using these concepts to understand the impact of

crises seems plausible. Just as Bronfenbrenner (1995) viewed
human development as a complex interface of influences on
individuals, a theory to explain reactions to crises must ac-
count for and validate interactions taking place within an
environmental context that includes individuals and systems.
Although dated, Lewin’s ideas about behavior as a function of
the total situation also validate the need for crisis theory to
take into account more than the individual. Lewin’s sugges-
tion that the individual and the world interact with and influ-
ence each other is central to understanding the impact of cri-
ses. These concepts provide a starting point from which to
develop an ecological understanding of the impact of crises
on individuals and organizations.
Crisis in Context
A graphic representation of the key concepts in CCT is pro-
vided in this section. First, we briefly describe each of the
components of the diagram. Next, the three premises of CCT
are discussed, including the elements of each premise. Re-
search and examples are provided to further explain these
premises. Finally, these ideas are incorporated into an equa-
tion for defining the impact of a crisis.
As seen in Figure 1, CCT consists of several components.
Each component represents a person or a group affected by a
crisis event. Note that the effect extends to several layers that
are interrelated. The initial layer of the model is depicted in
the figure as Individual and System
1
. The setting of the crisis
is used to identify the appropriate components in this layer.
An example of this layer would be an individual and an orga-
nization located in lower Manhattan during the terrorist at-

tacks on September 11th, 2001. Another component is the
Community in which the crisis occurs. The notion of commu-
nity may be viewed as broadly or as narrowly as the situation
warrants. Using the example of September 11th attacks, the
Community could be viewed as broadly as the world, because
that event had global implications, or as narrowly as lower
Manhattan. Generally, the narrow perspective is more useful
and realistic. System
2
in the diagram represents the system
that is most immediate to the individual. Using the same ex-
ample, System
2
would be the family of an individual who was
in lower Manhattan that day. Stakeholders
A
symbolize those
systems that are further connected to the Individual. Examples
include friends, organizations, places of worship, or schools
(if a student). Subsystems represent groups within System
1
.
For the organization in the example, these might include de-
partments such as marketing, public relations, bookkeeping,
customer service, or satellite offices of the organization. Fi-
nally, Stakeholders
B
represent those systems that are also con-

nected to System
1
but are outside the system itself. Examples
for a business could include customers, stockholders, suppli-
ers, or venders such as public utilities and telephone service
providers. The potential for overlap or dual roles among the
components in the diagram exists. Therefore, components can
appear in more than one place on the model.
FIGURE 1
Layers and Interactions of Crises
84 141
Crisis in Context Theory
Three key premises constitute CCT. Considered together,
these premises provide a powerful tool for conceptualizing
the impact of crises. The usefulness of these premises is not in
the ability to predict, rather in the capacity to isolate factors
that influence the overall impact of the crisis (Bronfenbrenner,
1995). These premises are based on research conducted by
others as well as on our own personal experience.
Premise 1: Layers of a Crisis
Individuals and systems experience the impact of crises in
layers. The layers are dependent on two elements: (a) physical
proximity to the disaster with respect to physical distance and
(b) reactions that are moderated by perception and the mean-

ing attributed to the crisis event.
Support for the idea of layers in relation to the impact of a
crisis occurs throughout crisis literature. From a family
perspec-
tive, van der Veer (1998) referenced the hierarchy of suffering,
or
differences in reactions to the crisis, that occur among family
members in refugee situations. A hierarchy of suffering refers
to
van der Veer’s research results indicating that family members
who have not been tortured or abused believe they do not have
the right to feel as traumatized as a family member who was
tortured or abused. The idea of layers in a crisis is also
prevalent
in literature related to organizational crises. Mitroff and
Anagnos (2001) described organizational structure as in-
volving layers to reflect a system’s perspective for viewing
the interactions between organizational subsystems as part
of a best practice model of crisis management. These authors
stated that effective crisis management must take into ac-
count the divergent effects of a crisis on various subsystems
within the organization. In addition, Veal (2003) maintained
that the reverberations of a crisis to all stakeholders of an
organization must be considered. For example customers of
a business should not be overlooked. Finally, Braverman
(1993) believed the determination of the circle of impact to
be the first duty of a crisis management team. Although not
stated explicitly, there is implicit support for the belief that
there is more than a surface layer of impact to every crisis.
In addition, Bronfenbrenner’s (1986) proposal of the vari-
ous elements in his ecological system of human development
supports the notion of components in layers of a crisis. In the
ecological system, Bronfenbrenner accounted for both indi-
viduals who are at the center of his theory and various systems

that surround individuals. CCT adapts this idea, modifying it
from concentric circles, with individuals being at the center, to
layers, with individuals and systems being alongside, above,
and below each other. Figure 1 depicts this concept.
The solid lines in Figure 1 represent Premise 1 of CCT.
These lines depict the connection of the crisis event to the
people or systems that have been affected. Although the
experience is unique for each person and system, under-
standing the impact of a crisis involves consideration of all
layers. Failure to consider the various layers results in miss-
ing information that influences the people and systems af-
fected by the crisis. Recognizing the unique nature of each
stakeholder’s crisis is critical in order to identify and imple-
ment appropriate interventions. Failure to recognize the
uniqueness of reactions is the primary source of ineffective
and potentially harmful interventions.
The layers of Figure 1 can be understood as tiers that are
determined by the setting of the crisis. Either the individual
or System
1
is the identified client. The setting of a crisis is
identified as the venue of the crisis event. For example, if
the crisis event takes place in a hospital, the hospital is the
setting and is denoted by System
1
. The Individual could be
any person affected by the crisis event. If a crisis occurs in a
family, the family would be System

1
and the Individual would
be a family member. For example, in the case of child abuse,
System
1
is the family and the child being abused is the Indi-
vidual. Making this distinction allows the differentiation of
individual and system reactions. As we stated earlier, this
discrimination is important because, to a degree, reactions
of individuals are independent of the system. Likewise, the
system’s reactions are in part independent from the indi-
vidual. The other layers involve the remaining components
identified in Figure 1. Each represents either individuals or
systems affected by the crisis event.
Proximity is one of the elements integral to understanding
the impact of a crisis within the context of layers. Generally
speaking, the closer an individual or system is to an event, the
more forceful the impact (e.g., Granot, 1995; Tucker,
Pfefferbaum,
Nixon, & Dickson, 2000). This idea is similar to
Bronfenbrenner’s
(1986) recognition that proximal as well as distal processes are
influential on the manner in which people mature. In his theory,
Bronfenbrenner proposed that intimate or close influences, such
as a person’s immediate family, and secondary or remote influ-
ences, such as religious training or mass media, have an impact
on human development. The idea of proximal and distal influ-
ences supports the notion that the impact of crisis events is
partially dependent on distance.
Reactions to a crisis, either by individuals or systems, are
another vital element to be considered in understanding the

impact of a crisis within the context of layers. Reactions con-
cern the perceptions of the event and meaning given to the
event, both of which are shaped by previous experience. Sup-
port for the idea that perception shapes the reaction to crisis
events is found throughout the literature (e.g., Collins &
Collins,
2005; Folkman et al., 1991; James & Gilliland, 2005; Myer,
2001; Rapoport, 1965). When reacting to a crisis, an individual
or system has a perception of the crisis situation that not only
affects the reactions to the crisis but also assigns meaning to the
crisis. Assignment of meaning, which has also been referred to
as appraisal (Folkman et al., 1991; Lazarus & Folkman, 1984),
can be determined by assessing affective, behavioral, and cog-
nitive reactions in a crisis situation (Myer, 2001). In the cogni-
tive realm, several authors (Aguilera, 1998; Hoff, 1995; Myer,
2001) have also recommended determining the affected life
84142
Myer & Moore
system of an individual or system in order to establish the
mean-
ing of the crisis for this individual or system. Myer (2001)
called
these systems life dimensions and lists four that may be affected
in a crisis: physical, psychological, social relationships, and
moral/
spiritual. For example, individuals who have been divorced sev-
eral times may not experience the same reaction as someone
who
is divorcing for the first time. Likewise, families who have had
several members who have divorced will likely perceive and

assign meaning to another divorce in the family differently than
will a family that has had no member who has divorced.
Premise 2: Reciprocal Effect
An understanding of the impact of crises takes into account
that a reciprocal effect occurs among individuals and systems
affected by the event. Understanding the reciprocal effect in-
volves recognition of two elements: (a) the interactions among
the primary and secondary relationships and (b) the degree of
change triggered by an event.
The second premise critical to understanding the impact of
a crisis is the recognition of primary and secondary relation-
ships among individuals and systems affected by the event
(Dyregrov, 2001). Primary and secondary relationships may be
understood in respect to the directness or indirectness of the
interaction. Direct interactions in which no intervening com-
ponent (i.e., individual or system) mediates that connection are
primary relationships. Relationships mediated by at least one
component are secondary or indirect interactions. The setting
of the crisis also helps in understanding the concept of primary
and secondary relationships. For example, if an employee is
critically injured at the workplace, the primary relationship is
between other employees who witnessed the accident and the
organization. Employees who witnessed the accident may be-
come more cautious to avoid a similar accident, which affects
productivity and could result in a loss in profits for the
organiza-
tion. On the other hand, the organization may introduce new
safety procedures that limit employees in some manner, thereby
causing an increase in morale. Another primary relationship in
this example is between the employees who witnessed the acci-
dent and their families. Some of the employees who witnessed
the accident may decide to resign from the organization because
they are afraid of a similar accident. There is a direct impact on

the family because of the loss of income. However, a secondary
relationship in this situation involves the families of the
employ-
ees who witnessed the accident and the organization. Those who
witnessed the accident act as a go-between for the families and
the organization. An example of the impact of the accident on
the family would be if the organization would choose to close
some part of its operation temporarily or permanently. The
result
might be that individuals would have new work schedules that
could affect family life or that they might be laid off.
Bronfenbrenner’s (1986, 1995) and Lewin’s (1951) theo-
ries provide a research basis for the inclusion of primary and
secondary relationships in Premise 2. Bronfenbrenner’s
(1986) idea of proximal and distal interactions again is used
to form a basis for different types of relationships. In devel-
oping his theory of life span development, Bronfenbrenner
(1995) described the interrelationship between a person and
his or her systems. The systems in these interactions extend
beyond the immediate to include the community and the
culture in which a person lives (Bronfenbrenner, 1986;
Santrock, 1995). According to Bronfenbrenner (1986), the
interactions are reciprocal, with the individual influencing
the systems and each system having an effect on the indi-
vidual. Lewin’s understanding that behavior occurs within
the context of the total situation also supports the inclusion
of this idea in CCT. According to Lewin, the stimuli within
the context of the situation influences choices made by the
individual. There is a dynamic connection between the situ-
ation and individuals that is critical in understanding any
given characteristic of behavior (deRivera, 1976). Together,
aspects of Bronfenbrenner’s (1986, 1995) and Lewin’s theo-
ries form a foundation for this premise.

Support for the premise of reciprocal effects is also found in
business crisis management literature. Mitroff and Anagnos
(2001) described five major factors characteristic of today’s
world. One of the factors is called coupling, the idea that every-
thing everywhere is almost instantaneously connected with
and affected by everything anywhere else in the world. Myers
(1999) has agreed with this, stating that crises are an organiza-
tion-wide problem requiring systemic solutions. Braverman
(1999) identified the profound effect that crises have on em-
ployees beyond the immediate circle of victims. He describes
the impact crises have on employees and how employee-related
factors then affect the functioning of the business. Crisis man-
agement plans that do not recognize the interrelatedness within
organizations are potentially ineffective, at best, or may fail, at
worst (Mitroff & Anagnos, 2001; Myers, 1999).
The dashed lines in Figure 1 represent the reciprocal interac-
tions, both direct and indirect, in CCT. These relationships spe-
cifically highlight the need to consider the context in which
crises occur. Overlooking interactions among the components
results in a failure to fully comprehend the impact of a crisis.
All
relationships, to varying degrees, influence the overall impact
of
a crisis on any component in the model. One possibility is that
interactions can be supportive and help to lessen the impact of
the crisis (Hoff, 1995). In these situations, support may involve
more than emotional reassurance and may include providing
employees with or guiding them to helpful resources and safe-
guarding them from exploitation (Myer, 2001). However, an-
other possibility is that these interactions may be obstructive
and result in the impact of the crisis being intensified. These
negative situations can result in additional crises and compli-
cate the recovery process (Ren, 2000).
In Figure 1, System

1
and the Individual have a direct rela-
tionship. The connecting line shows that no other component
mediates the interaction, making this a primary interaction.
An example of a primary relationship with a direct interac-
84 143
tion would be our consulting interaction with the organiza-
tion in New York after September 11, 2001. Each employee
and organization in the vicinity of the World Trade Center
experienced a crisis the day of the terrorist attacks. Some
individuals watched in awe as the airliners crashed into the
buildings. Some watched in horror as people trapped on the
upper floors of the buildings jumped to their death. Others
were caught in the streets as the buildings collapsed. Many
organizations were forced to relocate to other parts of the
city. Other organizations lost valuable information and
records. The experience of the individual employees and the
organizations did not take place in a vacuum. The reactions
of the Individual directly affected System
1
, and System
1
’s
actions immediately influenced the Individual. Organiza-
tional crisis management literature (e.g., Braverman, 1999;

Mitroff & Anagnos, 2001) offers numerous examples of the
reciprocal effect of crises on individuals and organizations.
If these relationships are supportive, the impact of the crisis
can be reduced; if they are obstructive, the impact has the
potential to be more severe.
In contrast, a secondary relationship occurs when the
connection is mediated by at least one of the components.
An example of this would be the Individual mediating Sys-
tem
1
and System
2
interactions. For instance, many organiza-
tions (System
1
) located in the vicinity of the World Trade
Center returned to the area once the buildings they occu-
pied were habitable. Many of the people who worked for
these businesses were ready to return to the area. In a sense,
these people were refugees returning home (Myer, Moore, &
Hughes, 2003). However, some families of these employees
(i.e., System
2
in this situation) did not want their loved ones
returning to the area and pressured the persons to find an-
other position. The interaction in this situation was indirect
and obstructive because the Individual working for System
1

acted as a go-between with System
2
. Indirect interactions
can also be supportive. For example, some organizations
provided support for families of their employees beyond
what was obligatory (Duffy & Schaeffer, 2002; Rosoff, 2002).
The degree of change in the typical level of and ability of
individuals and systems to function must also be consid-
ered in order to understand the impact. Degree of change
concerns the amount of disruption caused in both short- and
long-term functioning (Brewin, 2001). Changes may be such
things as alteration of daily routines or change in economic
stability. All disruptions experienced by individuals or the
system’s operation are considered in this component. For
example, after the attacks of September 11th, 2001, when
organizations located in lower Manhattan had to relocate
temporarily, employees of these organizations had different
commuting schedules and routes. Often these changes
caused substantial alteration in the time it took to get to
work; usually more time was needed. This change was felt
by the organization because now employees arrived at work
later and/or left earlier. Families of the employees also expe-
rienced disruption due to the modification of departure and
return times of the employees. Whereas spouses had been able
to
leave for work at the same time prior to September 11th, one of
them now had to leave earlier because of the longer commute.
This could have a ripple effect, because less time would be
avail-
able to spend together as a family.
Premise 3: Time Factor

Time directly influences the impact of crises. Two elements of
time are (a) the amount of time that has passed since the event
and (b) special occasions such as anniversary dates and holi-
days following the event.
The third premise for the CCT concerns time. Again,
Bronfenbrenner’s (1986) work on understanding human devel-
opment provides support for the inclusion of time in our model.
According to Bronfenbrenner (1995), the impact of an event on
human development is not singular; rather, the impact is ongo-
ing and continues to exert influence on the development of
that individual. Through an extensive review of the literature,
Bronfenbrenner (1986, 1995) concluded that an event has vary-
ing degrees of impact on an individual’s development, and this
impact decreases with the passage of time. It is interesting that
Bronfenbrenner (1986) even included in his theory of human
development the influence of nonnormative events such as
severe illness, divorce, and moving. Although he included this
type of event, he did not describe the influence of the event
beyond that of human development.
Research in crisis intervention also validates the need to in-
clude the element of time in the CCT (e.g., Brewin, 2001). As
early as 1961, Caplan wrote about time playing an important
role in recovery from a crisis. Caplan stated that most people
recover from a crisis in 6 to 8 weeks, but experts now believe
the
recovery process may extend beyond that length of time
(Callahan, 1998). Callahan stated that 6 to 8 weeks were needed
for individuals to reestablish a sense of equilibrium, not to fully
recover from the impact of a crisis. The inclusion of PTSD in
the
DSM-III (APA, 1980) set the stage for the idea that more than 6
to
8 weeks are needed to recover from crisis events. Some experts

recognize the impact of crises as lasting throughout the lifetime
of an individual (van der Kolk & McFarlane, 1996). Other re-
search on crises has shown similar results, finding that some
people take much longer to recover (Salzer & Bickman, 1999).
An issue often discussed with respect to recovery time is the
difference between man-made and natural disasters (Lerbringer,
1997; Rubonis & Bickman, 1991). Although research has indi-
cated mixed results, it is generally believed that recovery time
for
man-made disasters is longer than that needed for natural disas-
ters (James & Gilliland, 2005). The conclusion that time has a
moderating effect on crises is irrefutable.
Thus, the first and most obvious element of the time
premise is that the passage of time moderates the impact of
crises. Again, this element is very similar to Bronfenbrenner’s
(1986) understanding of time with respect to proximal and
84144
Myer & Moore
distal influences. For most individuals and systems, the fur-
ther in time from the disaster, the less the impact and the
more likely a new equilibrium has been established. The
reestablishment of equilibrium means individuals and sys-
tems are able to function day-to-day on a routine basis
(Callahan, 1998). In the first few weeks after a crisis, indi-
viduals and systems vary in the ability to function. Issues
such as an inability to concentrate because of a preoccupa-
tion with the crisis and lability of affect are present in differ-
ing degrees for individuals (Collins & Collins, 2005; Myer,
2001). Individuals also experience a disruption in behavior

and problem-solving skills as they attempt to address the
problems associated with the crisis (James & Gilliland, 2005).
Systems are influenced by similar issues such as a break-
down of decision-making procedures (Braverman, 1999), loss
of morale (DiFonzo & Bordia, 2000), shifts in the roles and
dynamics within the system (Schermerhorn, Hunt, & Osborn,
1994), and rumors that hamper recovery (Brown, 1997; Paton,
2003). These experiences disrupt the ability to function day-
to-day on a routine basis. Individuals may forget to eat,
neglect personal hygiene, and fail to maintain relationships
(Myer, 2001). Organizations have difficulty maintaining
focus on stated goals and maintenance of productivity during
the first few weeks after crises (Myers, 1999). However, the
passage of time allows individuals and systems to regain a
new sense of equilibrium and begin to reclaim the capacity to
function in a typical manner. Individuals and systems may
still experience problems linked to the crisis, yet this disrup-
tion does not significantly interfere with daily functioning.
The second significant element of time concerns holi-
days and anniversary dates. As time passes, the impact of the
crisis that is experienced at holidays and anniversary dates
of the crisis changes as people assimilate the experience
into their lives (Echterline, Presbury, & Mckee, 2005). People
use these times to weigh the meaning of the crisis for their
lives and may reexperience the crisis as if it had just oc-
curred (Macleod, 2000; Young, 1998). They become thought-
ful about the experience, often reminiscing about positive
or negative changes (Echterline et al., 2005; James &
Gilliland, 2005; Macleod, 2000). If positive changes have
occurred, the impact of the crisis experienced at such times
is interpreted in an optimistic way. Whereas if the changes
that have resulted from the crisis are negative, the impact
experienced at these times can be problematic. In some situa-
tions, anniversary rituals sanction the remembering of the
crisis event (deVries, 1996). Examples are reading the names

of the victims at the World Trade Center site each year since
the terrorist attacks of September 11th, 2001, and the creation
of holidays such as D-Day to remember a traumatic event.
Together, the three premises of CCT can be summarized
by the following formula:
IMPACT = f (proximity, reaction, relationship, change) .
time
This formula is based on Lewin’s (1951) understanding of
behavior. In his formula, Lewin stated that behavior is the
function of a person and the environment or B = ƒ(P/E). Lewin
defined the idea of function as a link between behavior and
life space. The formula for CCT is read as follows: The impact
of a crisis is consistent with the function of the interaction of
proximity to the crisis event, the unique reaction of the indi-
vidual or system, the interactions of primary and secondary
relationships, and the degree of change, all of which are
moderated by time.
It is important to note that the components in the numera-
tor of the formula interact in a complex manner. No single
component can be considered separately; they must be
thought of as forming a gestalt, or a unified whole that is
not merely a sum of its parts. For example, close proximity
to a crisis does not mean that the impact will be signif icant
for an individual. The other components (i.e., reaction, re-
lationships, and degree of change) may function to lessen
the impact of the crisis. Conversely, an individual might
not be in close proximity to a crisis but may still experi-
ence a signif icant impact if the crisis results in a notewor-
thy change and relationships are meaningfully affected.
The role each component plays is unique for every indi-
vidual and system.
Recommendations for Research

Development of a theory that provides an explanation for
the impact of a crisis is in its infancy. CCT is an attempt to
address issues relevant to understanding the impact of cri-
ses, not a theory to predict the reactions of people or sys-
tems. We believe that CCT offers a comprehensive point of
view by incorporating an ecological perspective as a basis
for expanding and generating crisis interventions. These
interventions should be comprehensive and contextual, not
focusing solely on individuals. A particular area of need is
to address the human impact of crises on employees in orga-
nizations. Although many resources have been used to miti-
gate other problems that influence organizations while in
crisis, addressing the human impact seems to be neglected.
Research is needed to refine the concepts in CCT in order to
structure techniques and strategies that are more effective
and efficient than current interventions.
Research is needed that examines the force of the four
components in the numerator because factors or subcompo-
nents may be responsible for shaping the impact of crises.
Browning (1996) used an innovative research method that
may have implications for research in this area. In his research,
Browning was able to quantify individual commitments and
the manner in which these related to the experience of stress.
Although his research did not yield significant results, the
method captured the individuality of each participant as com-
pared with others. Another research strategy could be the de-
velopment of a self-report instrument that would examine
84 145

potential elements other than those we have identified. Quali-
tative designs may also provide valuable information on the
four components we have identified. These research designs
have become increasingly sophisticated, allowing for data to
be gathered without fear of interfering with assistance being
provided for individuals or systems in crisis.
Any research conducted, whether quantitative or qualita-
tive, should not interfere with providing assistance in times
of crisis. Generally speaking, researchers will not have ap-
proval to conduct research in the immediate aftermath of the
crisis. As a result, research will be retrospective and there-
fore will not interfere with the provision of assistance during
this time. The issue becomes finding a sensitive way of us-
ing both information gathered during the crisis and the re-
flections of those involved in the crisis. Examples of poten-
tial sources for data include crisis workers’ notes and per-
sonal reflections. If this information is used, attention to
governmental guidelines must be observed. Special care
must be used to protect the rights of people because of the
vulnerability experienced due to the crisis. Another source
of information is from the person(s) who experienced the
crisis. Again, care must be taken to ensure, as much as pos-
sible, that the crisis has been resolved in order to avoid
exploitation. Another source of information could be orga-
nizations, if any, that are providing assistance. Data gath-
ered by organizations, such as the government of the United
States, can be a rich source of information regarding the
impact of a large-scale crisis.
Research is also needed that examines the relationship of
time to the four components found in the numerator of the crisis
formula. At this point, research has not identified the reason
some people recover quickly from a crisis and others do not.
This
issue has remained a problem, particularly in the case of PTSD.

A
related area of research concerns resilience (e.g., Calhoun &
Tedeschi, 2000; Gist & Woodall, 2000; Stuhlmiller & Dunning,
2000). It may be possible to combine research on both resilience
and the components of the impact equation. Together, this re-
search may offer explanations unidentified to this point.
Research on the emergence of real-time communication
by broadcast media may also provide much needed informa-
tion on the impact of crises on individuals and systems. This
type of communication effectively compresses the world into
a neighborhood. No longer does it take weeks or days for
news to travel across the globe. Traumatic events are broad-
cast live, in real time, as they occur. Examples are the events
of the terrorist attacks of September 11th, 2001, and the
student shooting incident at Columbine High School in
Colorado. Millions of people watched these events unfold
as if they were actually in lower Manhattan or standing across
the street from Columbine High School. An even more poi-
gnant example of real-time communication was the use of
embedded journalists with the military in the most recent
war with Iraq. The journalists were able to broadcast live
coverage of firefights with the Iraqi military. The public
could hear U.S. soldiers give orders and cheer when a target
was hit. Systematic research on real-time communication
may provide valuable information for understanding the
impact of crises on individuals and systems.
CCT presents an ecological perspective for understand-
ing the impact of crises on individuals and organizations by
integrating results of research with personal observations.
The model is a departure from the more traditional per-
spective used in crisis intervention of focusing attention
solely on individuals. We hope that this introductory ex-
planation of CCT will initiate discussions that increase the

understanding of the impact of crises on individuals and
organizations. Further research is needed to refine the ideas
and concepts of CCT.
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