CRISIS MANAGEMENT WORKSHOP Module 1 INTRODUCTION TO CRISIS

Objectives 1. To familiarize participants with the concept of crisis. 2. To identify sources of crisis. 3. To identify, list and understand different types of crisis. 4. To learn about the importance of subjective perception and meaning of crisis and its impact on coping.

Definition of a stress
Biological language Stress means anything constituting a threat, real or apparent which would adversely affect the organism Madders, J (1980) Psychological language Stress refers to the demands made on an organism to adopt Madders, J (1980) Stress is an imbalance between the perceived demands placed on an individual and his/her perceived capability to deal with the demands Cox, T (1978) Both languages combined Stress is a pattern of emotional state and physiological reactions occurring in situations where individuals perceive threats to their important goals which they may be unable to meet. Baron, R.A.and Greenberg, J(1980).

1.

Concept of crisis
Crisis can be viewed in various ways but most definitions emphasize that crisis can be a turning point in a persons life. (i) Two definitions by Caplan (1964) A crisis is a transitional period or a turning point in life. At present the individual concerned with the opportunity for acquiring greater mastery and for achieving personality growth on the one hand or, on the other hand, the risk of increasing vulnerability and mental breakdown.

A crisis is the experience of being confronted with an unfamiliar obstacle in lifes path. The familiar resources and past experience of the individual come under test. The individual may need help insurmounting the obstacle and continuing his/her life journey successfully. Janosik (1986) defined crisis as a phenomenon that always combines danger with opportunity. The element of danger is introduced when a precipitant event (stressor) creates tension unrelieved by ordinary behaviours. The tension levels rise when unusual coping measures prove inadequate. Band and Ollison (1974)

(ii)

(iii)

Crisis is a subjective reaction to a stressful life experience, one so affecting the stability of the individual that the ability to cope or function may be seriously compromised. From these definitions, we learn that a crisis presents a challenge to customary habits and if successfully met, it becomes a stimulus to fruitful innovation and further development. But if the persons customary methods of problem- solving fail and or if the individual receives inadequate help in meeting impasse, he becomes disorganized and may develop an acute anxiety state, depression, or other disabling disorder. The common point in these definitions, is that crisis can be a turning point in someones life.

NATURE OF CRISIS
Caplan (1946) describes the experience of a crisis in three successive phases: (i) Impact

During this phase, the individuals customary coping methods fail and signs of stress and strain appear. The person may experience a feeling of bewilderment and confusion. He /she may try to ward off the event, pretending it did not really happen after all. He may engage in attempts to lead his /her normal life which proves ineffective.

(ii) Recoil This phase is characterised by increasing evidence of disorganization. The person/subject is in the grip of uncomfortable emotion eg. Anger, guilt, shame, and his or her attention maybe withdrawn from the concerns of every day existence. Meaningless activity and incompetent functioning serves to increase tension and lead to feeling of impotence. Physical signs and symptoms appear eg. Agitation, fatigue, insomnia. (iii) Adjustment and adaptation

If resources within and around the individual can be mobilized the problem is reduced oreven removed. A breakthrough instead of a breakdown may be achieved by simply finding a new view, or a different definition of the problem. A fresh angle can bring a novel solution. It may be necessary to adopt an active process of resignation and a conscious reduction of demands. Things that cannot be changed or accepted as inevitable. Alternative ways of satisfying needs may appear.

2. Sources of crisis
Crisis develops when an event or a series of events takes place in a persons life. Factors generating crisis include external stressors and internal stressors. External stressors Traumatic events: events or situations of extreme danger that are outside the range of usual human experience eg. Natural disasters such as earthquakes, floods, man made disasters such as war, nuclear accidents, train accidents, physical assault such as rape or attempted murder. Life changes: changes in our lives require readjustment whether they are negative such as divorce or positive changes such as arrival of a new baby. NB: intensity of stress induced by a given life change depends on the individuals personal history and present life circumstances. Eg a divorce in an unhappy marriage can be a positive change and a birth of a new baby can be a negative change if the pregnancy is unwanted. Daily hassles: hassles are irritating things that happen in everyday life. They are ountless minor sources of stress characterised by a relative low intensity and high frequency of occurrence. They summation has a negative impact on our health. Environmental conditions: eg temperature, air, pollution, noise, squalid place, these environmental sources do not appear to be as potent as other stressors, but apparently contribute to our overall level of stress.

Internal stressors Frustration: is the result of being unable to satisfy a motive it occurs when ones thriving are thwarted by obstacles that block progress towards a desired goal. Frustration often lead to self-devaluation making the individual feel that he has failed in some way or is incompetent. Conflict: is related to frustration. Conflict is the state in which two or more motives or need cannot be satisfied because they interfere with one another. The requirement of one precludes the satisfaction of the other(s). It arises when two goals are equally attractive eg. Two good job offers or when two inner needs are in opposition. The necessity of making choices involves cognitive and emotional strain. Pressure: This is encountered in the course of our everyday life. In many cases it is a question of pressure to achieve specific goals, to behave in a particular way or to intensify effort. For some people, the most intense pressures are self imposed due to inner motivations Butcher et al (1988). Different types of crisis Two categories of crisis have been identified. Developmental crisis: refers to the belief that on individuals personality develops through a number of phases/ transitional periods, which causes emotional upset at the time. This kind of crisis is one which cause emotional upset at the time. This kind of crisis is one, which most people are familiar with or must face on their way through life. Developmental crisis includes: The first day at school. Leaving home. Getting married. Retrial from work, Accidental / situational crisis refers to hazards in life which are less expected. These include physical illness or injury, loss of employment, failure in business, divorce.

3.

SUBJECTIVE PERCEPTION AND MEANING OF CRISIS

It is important to note that the crisis is not the situation itself (e.g being victimized/raped), rather it is the persons perception of and response to the situation. The most important precipitant of a crisis is stressful situation (a stressor), but 5 other condition are also necessary to have a crisis state they characterize person in crisis. (i) (ii) (iii) Perceiving a precipitant event as being meaningful and threatening. The individual views the stressful as one that will lead to considerable upset and disruption Appearing unable to modify or lessen the impact of stressful event with traditional coping methods. Experiencing increased fear, tension and or confusion.

(iv) (v)

Exhibiting a high level of subjective discomfort Proceeding rapidly to an active state of crisis a state of disequillibrum

Duration of crisis The experience of a crisis is always accompanied by a state of disequilibrium, which is characterised by confusing emotion erratic behaviours, and somatic complaints. Paraid and Caplan (1960) that crises have a peak. As the individual reaches this peak, tension increases and stimulates the mobilization of previously hidden strengths and capacities. They urge timely intervention to help the individual cope successfully with the crisis situation. A relatively minor force, acting for a relatively short time, can switch the balance to one side or another to the side of mental health or the side of mental illhealth. In order for the individual to be able to endure and survive, crisis must inevitably decrease. That is all crisis are limited in duration in most cases a crisis is resolved within 4 8 weeks. This means that the person has accomplished certain psychological tasks, has mastered negative feelings, and has demonstrated ability to cope by taking actions. If no satisfactory resolutions takes place, the individual risk precipitation into the state of major disorganization that we call mental illness. 4. Vulnerability or factors influencing the severity of crisis Why do some people experiencing one stressful event after another not breakdown whereas others are seriously upset by even low-level stressor? Predictability and controllability, social support personality characteristics and culture are variables that mediates the effects of stressors (i) Predictability and controllability Stressful events are less harmful when they are predictable than when they are not. Predictability allows the individual to initiate some sort of preparatory process that act to lessen the effects of the stressor also the sense of being in control of stressful events reflects feeling of competence, hence reduces the severity of stress. Social support According to one old saying misery loves company. This statement implies that it is better to face stressful situation with others and with their support rather than staying alone. Cohen and Willis (1985) indicate that people who have many social ties live longer and are less apt to succumb to stress related health problems. Having someone to talk to, receiving advice from, being cheered and reassured by, bolster self-esteem, reduce feelings of helplessness and increase confidence in ones ability to cope.

(ii)

(iii)

Personality characteristics Personality make up age, sex, occupation, culture and economic status determine the extend to which a potential stressor becomes a real stressor and actually induces crisis. This involves cognitive evaluation of the stressor and its meaning to the individual who faces it. Type A personality is a pattern of behaviour characterised almost importantly by intense competitiveness, hostility, overwork a sense of time urgency and difficult in relaxing. Individuals of type a personality are prone to the harmful effects of stress because they interpret events in a stress provoking way. They perceive stress as a threat to their security rather than a challenge and an opportunity for growth.

MODULE 2: REACTION TO CRISIS

OBJECTIVES

1. 2. 3.

To identify and list different reactions to crisis To familiarise with the principles of adjustment To understand different mechanism of coping

Activity
(1) (2) Participants identify the most frequent type of crisis they encounter in their daily life. The trainer records their responses on a flip chart Participants identify their reaction(s) to crisis situations. The trainer records their response on a flip chart (3) Participants brain storm on how they would respond to someone in a crisis. The trainer records their response on a flip chart.

1.

Reactions to Crisis

We tend to react to crisis situations as a whole, that is, a crisis produces both psychological and physiological reactions.

1.1

Physiological Reactions
same way under any threat ,be it in the form of an infection ,injury, a tumour or psychological stress. Regardless of the source of General Adaptation Syndrome Stress, the body mobilises its defence to ward off threat in a pattern referred to by Selye as the

Selye ( 1976),a Canadian medical researcher found that the body reacts in much the

( GAS) which follows three stages : Alarm reaction: The body s initial response to threat or stress is to mobilize its stored resources. The sympathetic division of the autonomic nervous system diverts blood away from digestion and into the skeletal muscles, increases perspiration and prepares the body for a physical struggle. The endocrine glands pump epinephrine and

other hormones into the blood stream that aid the actions of the autonomic nervous system and increase levels of blood sugar. When stress is intense or prolonged, theses bodily changes give rise to general muscle tension. stomach aches, headaches and other feelings of illness. Resistance stage: The body s resources have now been fully mobilized and resistance to the stress is high. However, this resistance is costly in terms of resources and new stressors encountered ( physical and psychological) will strain already depleted resources and leave the person more vulnerable to physical stress ( disease). The individual s resources have been exhausted and resistance to the stress is lowered. In the case of prolonged exposure to severe physical stress ( illness) death can occur during this stage. Prolonged psychological stress can result in death if the person whose resources are depleted, becomes clinically depressed and suicidal.

Exhaustion stage:

1.2

Psychological Reactions
These include anxiety, irritability, disturbance in sleep patterns, changes in appetite, loss or gain of weight, decreased libido Impaired cognition such as difficulties with memory, judgement and concentration

Examples of erroneous thinking Overgeneralization this is the process of reaching a general conclusion based on a few specific bits of evidence. A person who has failed one exam and concludes that he/she will never pass any exam would be over generalizing Arbitrary inference this is the logical error of reaching a conclusion based on little or no logical evidence the conclusion is arbitrary. For example, if you received an invitation to have lunch with your boss, would you conclude that the boss was going to gently break the news to you that you will be fired? Some people reason in this arbitrary way concluding that every thing means something bad. Magnification / minimization - When a lady sitting next to you says that your ears have an interesting point at the top would you magnify this statement and blow it out of proportion? (No wonder everybody hates me I have huge ears!) Or if you receive a heartfelt compliment

from a friend do you minimize it to nothing (Lynne just says nice things to me because she feels sorry for me) these examples illustrates the process of magnification and minimization. Personalisation is the erroneous pattern of reasoning in which external events are seen as being related to you when there is no logical reason for doing so e.g. concluding that one is presence in a particular place cause storm to occur. Absolutistic thinking thinking in all or nothing terms either something is absolutely wonderful or everything is absolutely terrible eg you fail to graduate at a University but end up involved in a successful business enteprise but you still conclude that you are a failure.

Anger which is a common emotional reaction to stress may lead to aggression.. Agression involves behaviour that is intended to hurt someone either physically or verbally. The frustration aggression hypothesis assumes that whenever a persons effort to reach a goal is blocked, an aggressive drive is induced and motivates behaviour to injure the object or the person causing the frustration (Atkinson et al 1990;362). Aggression can be directed to the source of frustration or displaced to an innocent person or object when the source of frustration is so powerful that an attack would be dangerous.

A person in crisis may also respond by withdrawal and apathy which in turn can deepen into depression. Seligman et al (1980) explain this reaction of giving up with the term learned helplessness. Learned helplessness relates to the attribution an individual makes about a negative event. It is not the event per se that is the problem but how the person interprets it which creates the feeling of helplessness.

Preoccupation with the stressor and decreased energy levels.

2.

Adjustment

Adjustment can be viewed as a first step towards resolution of a crisis. It involves putting things into perspective. Positive adjustment at the cognitive level means reframing the circumstance which brought the

stressful situation. Reframing involves helping people in crisis situations to think about themselves and their difficulties in a different and more creative way eg a counselor may reframe a clients indecision as a necessary period of contemplating or an intuitive wisdom about going slow when faced with a complex issue. 2.1. Is Adjustment a state or process? The state concept of adjustment implies that the person as a whole is either adjusted or maladjusted. This is rather simplistic view of adjustment. The process concept of adjustment focuses on the effectiveness of adjustment as measured by how well a person copes with the ever changing circumstances.

2.2.

What are the characteristics of effective adjustment?

Accurate perception of reality Ability to express feeling - capacity for self control Good interpersonal relationships Ability to cope with stress

Accurate perception of reality Distortion of reality? - An individual may distort reality to suite ones own desires and motives. There are times when people want to hear or see something so much that they actually believe that they have heard about it. How realistic are ones goals? Sometimes you find that you might either change/ modify your goals eg somebody with poor grades in science may not expect to study medicine One of the most important aspects of all accurate perceptions of reality is the ability to conceive the consequences of your action and to guide your behaviour accordingly Ability to express feelings -ability to express a wide range of emotion. Some people are afraid to express certain feelings. -Ability to be in control of emotions. Reaction to provocation some people responds with extreme anger, moodiness or depression. -Importance to become aware of your feelings eg.anger, fear. Once you have identified the emotion consider options on how that emotion should be expressed. What is the most constructive way. Emotionally healthy people are able to feel and express the full spectrum of emotions and feelings however their expression of emotion is both realist and under their control

Good interpersonal relations Well-adjusted people are able to achieve appropriate degree of intimacy in their social relationships. There are various aspects of interpersonal relations such as attraction, friendship, love, and sexuality A person who is not able to feel and express emotion has either to give in to others or will often resist accepting what others have to offer, this results in loneliness. Most of us do not like to be alone we spent most of our lives in the company of other people A positive self image How do we perceive ourselves? You can find out by answering the question, who am I? Does your self-appraisal include only positive or only negative aspects? What do you do about these aspects of yourself that you do not like? Is the way that other people perceive you agree with the way that you perceive yourself. When these perceptions are not in agreement the individual is likely to be maladjusted. One of the characteristics of positive adjustment is to view oneself in a positive manner Self-perceptions are learnt and can be modified

Ability to cope with stress Coping is a set of behavioural and psychological skills that an individual employs in response to or as a result of adapting to an experience (Barofsky, 1981). There are two main ways of coping: problem-focused coping and emotional focused coping

Problem focused coping

The focus is on the problem. A person evaluates the situation and does something to change or avoid it.

Emotional focused coping

Focuses on the emotional response to the problem. The individual tries to reduce anxiety without dealing directly with the anxiety-provoking situation. Emotional focused strategies do not alter the stressful situation they simply change the way a person perceives and

thinks about it. Freud used the term defense mechanism to refer to unconscious process aimed at defending a person against anxiety by distorting reality in some way . Examples of defense Mechanisms
Repression wishes, thoughts or memories, which are too frightening or painful, are excluded from conscious awareness. Since repression is never completely successful and repressed material threaten to leak through into awareness anxiety is the first signal and the individual employs a defense mechanism to keep repressed impulses from awareness. Freud believed that repression of certain childhood impulses is universal ( Oedipus and Electra conflict). Repressed material continue to influence behaviour slips of the tongue, dreams. ii. Rationalisation means finding logical but false reason for behaviour eg. concept of sour grapes. Rationalisation serves two purposes it reduces own disappointment when we fail to reach the goal ( I didnt want it anyway) and provides us with acceptable motives for our behaviour. Rationalization serves as an excuse my mother didnt wake me up iii. Projection - this is a mechanism that protects us from recognising our own undesirable wishes or needs by them to other people. I want to go to bed with him - he wants to go to bed with me. A man with homosexual impulses may project them to others. iv. Reaction formation thoughts needs and feelings are repressed and their opposites are expressed. Mother who didnt want her child became over protective. Someone who has many nasty thoughts and desires may adopt attitudes. v. Denial when external reality is too unpleasant or harmful to face individual may deny that it exists. The parents of child that has died may refuse to admit that everything is wrong because they cannot tolerate the pain. Less extreme forms of denial can be seen in individuals who constantly ignore criticism, fail to perceive that others are angry with them or disregard all kind of clues suggesting that a mamage partner is having an affair. Sometimes denying facts may be better than facing them. In severe crisis, denial may give the person time to face facts eg. A victim of a stroke or spinal cord injury might give up altogether if they are fully aware of the seriousnes of their conditions. Denial can have adoptive value. On the other hand the negative effects may delay seeking help in the case of denial important symptoms of disease. vi. Displacement Freud felt that displacement was the most satisfactory way of handling aggressive and sexual impulses. The basic drives cannot be changed but the object towards which a drive is directed can. The displacement of a person is true impulse, desire or emotion is replaced by a safer one. Instead of directing aggression towards a daughter a mother can feel anger towards the teacher. sublimation means that sexual and aggressive impulses are displaced into activity as poetry, art, aggressive feelings may be displaced with sex. vii. Identification is the opposite of projection. Identification is tendency to increase personal feelings of worth by taking characteristics of someone viewed as successful. We all identify with other people and groups in a great variety of relations, with parents, relative, teachers basketball players or movie stars. Identification involves modeling our behaviour

to someone else.

Module 3
CRISIS MANAGEMENT: ASSESSMENT

Objectives
To identify, list and apply skills required for the assessment of crisis To identify the areas of assessment To recognize the relationship between different patterns of behaviour in crisis with suicide risk To learn how to discuss suicide with a person at risk in a comfortable manner To formulate the problem(s) which trigger the crisis. An overview of assessment
These are many innumerable types of crisis that can be experienced by different people (eg. Attempted suicide, loss of a loved one, unwanted pregnancy and financial problems. In most cases the circumstances are usually beyond the normal human experiences. Individuals reactions are varied and generally a counselor attempting to offer help to these people should; Remain calm Help the client to tell their story and express feelings Be supportive Have empathy Deal with the present problem in a more practical way to help the client through the crisis period Refer to other professionals when necessary. To shed light an assessment of issues of someone in a crisis we look at deliberate self-harm. The suggestions we give may be modified to suit an individual crisis. In the assessment of deliberate self-harm assessment will be granted by general aims on one hand and specific enquiries to the other.

General aims
Immediate risk of suicide. Subsequent risk of further deliberate self harm or suicide Any current medical or social problems Encourage the patient to undertake a constructive review of his problem and of the ways he can deal with them himself

Specific enquiries The interview is directed to five questions 1. What were the patients intentions when he harmed himself? 2. Does he now want to die? 3. What are the patients current problems 4. Is there a psychiatry disorder 5. What helpful resources are available to this patient? What were the patient s intentions when he harmed himself? Planning precautions against discovery? Help sought? Lethality of method? Final act note? Will? Does the person now want to die? Pleased to have recovered? Wishes he had died? What are the current problems? Intimate relationship with spouse? Or another person? Relation with children and other relatives Employment? Finance? Housing legal problems? Social isolated, bereavement etc. drugs alcohol Is there psychiatric disorders History + MSE Depression? Alcoholism? Personality disorders dementia? schizophrenia? What are the patients resources? Capacities to solve own problems? His material resources? Help that others may provide? Past ability to solve problems? Availability of help? Is there a continuos risk of suicide? Is there a risk of further non-fatal self-harm?

Parasuicide interview
First establish the purpose of the interview Nature of the attempt Establish; events in the 48 hours preceding the attempted degree of planning, Isolation Suicide note Reasons for the attempt Use of alcohol or drugs Actions after the attempt Previous attempt The presence of these factors suggest the serious nature of the attempt

Clarification of current difficulties

It is important to explore the difficulties experienced by the patient areas worth exploration in this request may include

 Nature of the problem Any recent changes? Which may be psychological or physical Relationship with partner, family, children work or friends

Personal background
Having explored the difficulties, move on to discussing the patients family history, early life and development, schooling, behaviour problems, occupation personal relationship, sexual history, children past medical history, previous psychiatry history previous personality. These help to tell a story about your patient.

Coping
Proceed to explore the patients current copying resources, which include personal and external saving assets their previous ways of coping with difficulties.

Examination of mental state

Note the patient appearance and behaviour mood stream form and content of thought, any possessions, abnormal perceptions and cognition

List of current difficulties

Discuss the patients difficulties and come up with a list Assess any further help required, problem solving or prevention measures. Consider who else should be involved. Make a contract with the patient that should they find it difficult they should contact the therapist or other agencies. Finally terminate the contract and agree on follow.

Module 4
CRISIS MANAGEMENT: HELPING PROCESS Objectives

To familiarize participants with counseling issues in crisis support. To acquire skills and techniques in helping someone in crisis. To apply the counseling skills in various stages of the helping process. To familiarize participants with managing parasuicide cases.

MANAGEMENT OF A CRISIS IN GENERAL

Most people in a crisis have specific needs and therefore help should be tailored to suit these needs The aim of treatment, therefore is to enable the individual to resolve the difficulties that led up to the act (eg self harm) further, the individual should be able to deal with any future crisis without resorting to further self harm. Treatment is usually psychological and social and rarely pharmacological is required In treatment one should encourage the patient to consider what steps to take to resolve each of the problems identified You then need to formulate a practical plan for tackling the problem one at a time. The counselor should encourage the patient to do as much as possible for herself. In the case of interpersonal problems you need to interview the other person at first alone and then have some joint interviews later with the patient There is need to the issue that if self harm follows a bereavement, the first step is say pathetic listening while patients express his feelings and then encourage the patient to seek ways of gradually rebuilding his file without the cost. The counselor should exchange self-help on the patient.

Management of crisis Reaction to individual to acute stress situation Has physical, psychological and social aspects A breakdown of an individual, an individuals or familys normal homeostatic pattern

Components of acute crisis intervention

1. Identifying what the crisis is 2. working on the area and how to develop specific ways to stop the crisis 3. mobilizing appropriate supportive figures and institutions with the community to help the patients 4. having sufficient time, personal and follow up capacity to carry the person or his family through the crisis Any crisis has precipitating causes, and identifies these causes and the methods by which these factors can be modified to prevent further crisis are as important as successful treatment of the acute crisis. Write staff and persons who are part of the persons who are part of the persons environment to an effective long-term solution to the problem.

MANAGENENT OF PARASUICIDE
Assessment procedure divides patients in three groups a) 10% need immediate in patient treatment SUPERINTENTEND b) about 25% require no special treatment respond to temporary difficulties and has no risk of repetition c) 2/3 require out patient treatment aim of treatment is to enable the patient to resolve the difficulties that led up to the act of self harm Second aim is to deal with any future crisis without resorting to further self-harm. Problem: once patients leave hospital, they are dismissed to take part in any treatment.

Treatment
Psychological and social, pharmacological seldom required Encourage patients to consider what steps to take to resolve each of the problems Formulate a practical plan for tackling them one at a time (Encourage patients to do as much as possible for himself)

 Interview the other person(interpersonal problems) at first alone and then in a few joint with the patient) If self harm follows a bereavement first step is sympathetic listening while patient expresses his feeling of this and then encourage the patient to seek ways of gradually rebuilding his life without the lost person (emphasis on self help) SPECIAL PROBLEMS Patient refusing assessment interview others to exclude serious suicidal risk of psychiatric disoder May consider detention under compulsory order Frequent repeaters the risk of eventual death is high. Agree a clear plan whereby the patient is rewarded for constructive behaviour, arrange continuous support by one person Delayed complications Deliberate self laceration: difficulties in expressing feelings formal psychotherapy is seldom helpful. Aim at gaining patients confidence and increase self esteem encourages alternative method of relieving tension eg. exercise

MODULE 5 RESOURCING NETWORKING Objectives: 1. To familiarize with the available resources in the community for caregivers

List of helpful institutions and NGOs CONNECT School Psychological Services St Giles Island Hospice Cancer Centre Student Health Centre University of Zimbabwe Main Campus Childline Child Protection Society Family Support Trust Musasa Project New Start Centre for Pre and Post HIV testing and counselling Pregnancy Support Centre Child and Law Foundation 04 705079 04 333820 04 704691-3 04 707481-2 04 3303211 04 734252 04 710024-5 04 668056-7 04 725881 04 706531 04 721541

UNIVERSITY OF ZIMBABWE DEPARTMENT OF PSYCHIATRY MEMORANDUM

FROM: TO: Re: Olivia Mangwiro All Staff Members Review of the Crisis Support Training Modules DATE: 09/11/2004 EXT: 2268

I will leave two copies of the Crisis Support Training Modules with the secretary, for circulation. Each member of staff has a maximum of two days to look at the modules. When you have finished reviewing the module please leave the modules with the secretary. Thank you Yours sincerely

Olivia Mangwiro ( Ms) Crisis Support Co- ordinator

Circulation of the Crisis Support Training Modules

Name Date Collected Date returned