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CRISIS A crisis is a disturbance caused by a stressful event or a perceived threat. The persons usual way of coping becomes ineffective in dealing with the threat,causing anxiety. Definition Crisis is defined as occuring when a person faces an obstacle to important life goals that is, for a time, insurmountable through the utilization of customary methods of problem solving. A period of disorganisation ensues ,a period of upset during which many abortive attempts at solution are made. (Caplan) A sudden event in ones life that disturb homeostasis during which usual coping mechanism cannot resolve the problem. (langerquist) Historical development An early crisis theorist Erich lindemann conducted a classical study in the 1940s on the grief reactions of the close relatives of victims who died in the coconut grove night club fire in Boston(USA). This study formed the foundation of crisis theory and clinical intervention. Lindmann was convinced that, even though acute grief is a normal reaction to a distressing situation, preventive interventions could eliminate or decrease serious personality disorganisations and devastating psychological consequences from the sustained effect of severe anxiety. He believed that same interventions that were helpful in bereavement would prove just as a helpful in dealing with other types of stressful events and proposed a crisis intervention model as a major element of preventive psychiatry in the community. In the early 1960s Gerald Caplan(1964) further elaborated crisis theory and outlined crisis intervention strategies. Since that time our understanding of crisis and effective intervention has continued to be refined and enhanced by numerous contemporary clinicians and theorists. In 1961 a report of the joint commission of the mental illness and mental health addressed the need for community mental health centres throughout the country. This report stimulated the establishment of crisis services, which are now an important part of mental health programmes in hospitals and communties. Donna auguilera and Janice Mesnick (1970) provided a framework for nurse for crisis assessment and intervention, which has grown in scope and practice. Auguilera(1998) continues to set a standard in the practice of crisis assessment and intervention. Roberts seven stage model of crisis intervention (2000) is a more contemporary model that is useful in helping individual who have suffered from an acute situational crisis as well as people who are diagnosed with acute stress disorders. The devastating effect of the 9/11 world trade centre terrorist attack emphasized the need for crisis assessment and intervention by community mental health providers throughout the

country to deal with all types of crisis experienced by people who had been traumatised; victims, families, rescue workers and observers( Behrman,2002; everly, 2000; Howard and Goelitz, 2004; Lowry and lating 2002) Types of crisis 1.Maturational crisis (developmental crisis) These are developmental events requiring role changes. They are predictable events in the normal course of life such as leaving home for the first time , getting married,having a baby and beginning a career. Maturational crisis is a stage in life where adjustments and adaptations,new responsibilities and life patterns are necessary. Movement from childhood days to young adulthood presents the crisis of adolescence,movement from middle adulthood to old age possess the crisis of ageing and is often called as midlife crisis 2. situational crisis These can be accidental ,unanticipated or unexpected events like loss of a job, death of a loved one,unwanted pregnancy, divorce, severe physical or mental illness etc. A situational crisis poses a threat or challenge to an individual persons physical emotional or social integrity. Whether these events precipitate a crisis depends on factors like degree of support from their friends and family,persons general emotional and physical status, and a persons ability to understand and cope with the meaning of the stressful event. 3.Adventitious crisis Adventitious crisis or crisis of disaster is unplanned and accidental events resulting from i. A natural disaster (eg:flood,fire,earthquake) ii. A national disaster(acts of terrorism, war,riot) iii. A crime of violence (eg:rape,assault or murder) PHASES OF CRISIS DEVELOPMENT Caplan (1964)identified 4 phases of crisis Phase 1 The individual is exposed to a precipitating stressor. Anxiety increases and the person uses problem solving techniques and defense mechanisms in an effort to solve the problem and lower anxiety.
Phase 2 When previous problem solving techniques do not reveal the stressor ,anxiety increases further

and produce feelings of extreme discomfort. Individual functioning become disorganised Phase 3

If the trial and error attempts fail,anxiety can escalate to severe and panic levels. All possible resources are called upon to resolve the problem and relieve discomfort. New problem solving techniques maybe used and if effective, resolution may occur at this phase Phase 4 If the resolution does not occur at previous phases ,tension mounts beyond a further threshold. Anxiety reaches to panic levels. Cognitive functions are disordered,emotions are labile and behaviour may reflect the presence of psychotic thinking. Crisis responses If the resolution does not occur or coping skills are not satisfactory,the anxiety increases to a panic state .both psychiatric and psychologic responses can occur. Psychiatric responses Organic mental disorders secondary to head injury, toxic exposure,illness and dehydration Acute stress disorder Adjustment disorder Substance abuse Major depression PTSD generalized anxiety disorder Psychological or behavioral responses grief reactions family violence self directed violence Donna Aguilera and Janice Mesnick (1970) provided a framework for nurses for crisis assessment and intervention. Aguilera (1998) suggest that whether or not an individual experiences a crisis depends on 3 factors

The individuals perception of the event The availability of situational supports The availability of adequate coping mechanisms

The effect of balancing factors in a stressful event, paradigm by Augeurele is given below

CRISIS INTERVENTION Crisis intervention is a brief ,focused,and time-limited treatment strategy that has been shown to be effective in helping people adaptively cope with stressful events.

Crisis intervention is a short term therapy focused on solving the immediate problem, usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. According to Aguilera the goal is resolution of an immediate crisis.The minimum therapeutic goal is psychologic resolution of the immediate crisis and restoration to atleast the precrisis level of functioning. A maximum goal is improvement in functioning above precrisis level The therapist role is direct supportive and as an active participant. The therapist become a part of the individuals life situation. The individual is unable to problem solve, so requires guidance and support to help mobilize the resources needed to resolve the crisis. Crisis intervention take place in both inpatient and outpatient settings.
In a study conducted in US. Two groups of young adults were followed for two and a half years

after their first psychiatric hospitalizations. The first group received traditional modes of treatment; the second group was hospitalized after the institution of a crisis intervention program. The authors compared the outcomes of the two groups to test whether crisis intervention could reduce long-term hospital dependency without producing alternate forms of psychological or social dependency. They found that crisis intervention did reduce hospitalization throughout the second group's follow-up period without an increase in other indices of disability. PHASES OF CRISIS INTERVENTION: ROLE OF THE NURSE Aguilera(1998) describes four specific phases in crisis intervention. 1. Assessment 2. Planning of therapeutic intervention 3. Intervention 4. crisis resolution and anticipatory planning Assessment: the first phase is the assessment of the individual and his problem to identify the precipitating event and the crisis that made him seek professional help. The therapist assess for any suicidal or homicidal risk for the patient. If needed referral is made to a psychiatrist for consideration of hospitalisation. The nurse collect data about the nature of the crisis and its effect on the patient ,to develop intervention plan. Assess the balancing factors important in the development and resolution of crisis like Precipitating event or stressor Patients perception of event or stressor Nature and strength of the patients support systems and coping resources Patients previous strength and coping mechanism Precipitating event

The initial task is to assess the individual or family and the problem. The more clearly the problem can be defined, the better chance that an effective solution will be found. To identify the precipitating event, the nurse should explore the patients needs and the events that threaten those needs. Patients perception of event or stressor Cognition or subjective meaning of a stressful event plays a major role in determining both the nature and degree of coping behaviours. Difference in cognition ,in terms of the events threat, account for a large differences in the coping behaviours. If the events is perceived realistically, the relationship between the event and feelings of stress will be recognised patients support systems and coping resources The patients living situation and supports in the environment must be assessed to determine the resources available to the person. Does the person live alone or with family? With whom is the person close? Assessing the persons coping resources is vital in determining whether hospitalization would be more appropriate than outpatient crisis therapy. If there is a high degree of suicidal or homicidal risk along with weak outside resources ,hospitalization may be more safer. Coping mechanisms The patient,strength and previous coping mechanisms are assessed. The nurse should also note the absence of other possible successful mechanisms. Has the patient handled other crisis? How was anxiety relieved? Was any physical activity used to relieve tension? Nursing diagnosis: based on following risk for self directed violence risk for other directed violence related to anger anxiety related to sense of unknown fear related to sense of precipitating event hopelessness related to sense of inability to recover from crisis powerlessness related to sense of being overwhelmed ineffective coping related to inability to handle the situation sleep pattern disturbance related to sense of inability to overcome the crisis chronic low self esteem related to lack of self confidence social isolation related to lack of interest impaired social interaction related to fear or threat caregiver role strain related to inadequate coping mechanisms spiritual distress dysfunctional grieving related to actual or perceived object loss

Outcome The expected outcome of nursing care is that the patient will recover from crisis event and return to precrisis level of functioning. Relevant outcomes for a person expecting a crisis include coping, decision making, role performance and stress level. Planning of realistic client outcomes is done together with client or family. Realistic outcomes are made to fit with the personal values and culture. Without clients involvement, the outcome criteria may be irrelevant or unacceptable solutions to the persons crisis.

Planning and Implementation. The alternative solutions to the problem are explored and the steps for achieving the solutions are identified. The nurse decides which environmental support do engage or strengthen and how best to do this as well as deciding which of the patient coping mechanism to develop and to which to strengthen. Nursing interventions can take place on many levels using a variety of techniques.There are 4 levels of crisis intervention that represent a hierarchy from the most basic to most complex.

Generic approach General support ge General support

Individual approach


Environmental manipulation

environmental manipulation

Environmental manipulation It includes interventions that directly change the patients physical or interpersonal situation. These interventions provide situational support or remove stress. Important elements of this intervention are mobilizing the patients supporting social systems and serving as a liason between patient and social support agencies. For eg. A person who has trouble in coping with her 6 children may temporarily send a few to the grand parents house.involving the patient in family and group therapy provides environmental manipulation for the purpose of providing support.

General support General support includes interventions that convey a feeling that the nurse is on patients side and will be helping the person.The nurse uses warmth, acceptance ,empathy caring, and reassurance to provide this type of support. Generic approach It is designed to reach high risk individuals and large groups as quickly as possible. It is applied to all people ,faced with similar type of crisis. The expected course of particular type of crisis is studied and mapped out. The intervention is then set up to ensure that the course of crisis results in an adaptive response. Grief is an example of crisis that needs generic approach. Interventions following an acute stress are sometimes referred to as debriefing. It consist of ventilation of feelings within a context of group support, normalisation of responses and education about psychological reactions to traumatic events. In brief generic approach emphasizes Specific situational and maturational events Intervention oriented to crisis related to specific events Intervention carried out by non mental health professionals.

Critical incident stress debriefing

CISD is an intervention directed towards a group that has experienced a crisis. It consisists of a7 phase group meeting that offers individuals the opportunity to share their thoughts and feelings in a safe and controlled environment. Debriefing is an important step for staff in coming to terms with overwhelming violent or disasterous situations once they are over. The phases of CISD are 1. Introductory phase Purpose of meeting is explained Overview of the debriefing process is provided Participants are motivated Confidentiality is assured Guidelines are explained Team members are identified Questions are answered 1. Fact phase Facts of the incident are discussed Participants introduce themselves Participants are asked to explain how they were involved in the incident and what happened from their perspective. 1. Thought phase Every one is asked to discuss his or her first thoughts of the incident 1. Reaction phase

Talk about the worst things about the incident What they would like to forget and what was most painful 1. Symptom phase Participants describe their cognitive ,physical, emotional or behavioural experiences and describe any symptoms they felt following the experience 1. Teaching phase The normality of the symptoms is acknowledged Anticipatory guidance is offered regarding future symptoms Stress management techniques 1. Reentry phase Debriefing team members answer the questions Inform and reassure Provide handouts and other written materials Information on referral resources Summarize the debriefing experience with encouragement ,support and appreciation

Individual approach It is a type of crisis intervention similar to the diagnosis and treatment of a specific problem in a specific patient. The nurse must understand that particular patient characteristic that led to the present crisis and must use the intervention that is most likely to help the patient develop an adaptive response to the crisis. It is particularly useful in combined situational and maturational crisis. The individual approach is also used when the course of crisis cannot be determined and if resolution not achieved by generic approach. Interventions aim at facilitating cognitive and emotional processing of the traumatic event and improving coping. It emphasize the need for greater depth of understanding of bio psychosocial process,interventions carried out only by mental health professionals. It includes:

restore psychological safety provide information correct mis attributions restore and support effective coping ensure social support

The intervention is not designed to change the personality structure but to restore a person atleast to the precrisis level of equilibrium. The time since onset of crisis is determined,which is usually 1-2 weeks before the client seek help. Determine :

How much the crisis has disrupted the persons life and the effect of the disruption on others The coping skills that he used successfully in the past but not using present Support available from other people Alternative methods of coping that can be used

Morley suggest some useful interventions

Helping the individual to gain an intellectual understanding of his crisis:

the therapist describe about the relationship between the hazardous situation in his life and the extreme disequilibrium he is experiencing Helping individual to recognize his feelings to which he may not have access: an immediate goal of intervention is to reduce tension by making the individual recognize the real feelings and bring them to open. Frequently he may have suppressed these real feelings. Exploration of coping mechanisms Assist the person to examine alternate ways of coping. New coping mechanisms are sought and tried for the successful resolution of the problem. Re opening the social world When the crisis is precipitated by the loss of a significant person, introducing new people to fill the gap may be effective, if supports and gratifications provided by the lost one can be achieved to a similar degree by the new relationships. NURSING INTERVENTIONS

:common nursing interventions include:

assess for any suicidal, homicidal thoughts or plans initiate necessary precautions to safeguard the patient or others at risk of physical harm encourage expression of feelings in a non destructive manner take initial steps to make client feel safe and to lower anxiety Provide an atmosphere of support. assist in identification of precipitants and dynamics of crisis listen carefully(make eye contact,give frequent feedback to make sure you understand, summarise what client said at the end.) identify needed social support and mobilize the most needed first provide guidance about how to develop and maintain support systems identify needed coping skills(problem solving, relaxation ,assertiveness,job training, newborn care, selfesteem raising) assist in identification of personal strength and abilities that can be used in resolving crisis introduce the patient to persons who have successfully undergone the same experience plan with client interventions acceptable to both client and counsellor. Assist in identification of alternative courses of action in resolving the crisis Assist in formulating a time frame for implementation of the chosen course of action Assist in evaluation of the possible consequences of various courses of action Plan regular follow up to assess clients progress Evaluate whether the crisis has been resolved by the chosen course of action Plan with the patient how adaptive coping skills can be used to deal with crisis in future

Techniques of crisis intervention

Catharsis the release of feelings that take place as the client talks about emotionally charged area. The nurse does not discourage emotional outburst by the patients and see them as positive release of feelings.the nurse asks open ended questions and repeats the patients words so that more feeling is expressed. Clarification encouraging the patient to express more clearly the relationship among certain help the patient gain a better understanding of feelings and how they lead to a crisis. Suggestion- influencing a person to accept an idea or belief that the nurse can help and that the patient will in time feel better. It points out alternatives or new ways of looking at things. Reinforcement of behaviour giving the person positive responses to adaptive and healthy behaviour. Support of defenses encouraging the use of healthy adaptive defenses and discouraging those that are unhealthy or maladaptive. Defense mechanisms help to cope with stressful situations and to maintain self esteem and ego integrity. Raising self esteem helping the patient regain feelings of self worth. The nurse should help the patient gain feelings of self worth by communicating confidence that he can find solutions to problems. Exploration of solutions examining alternate ways of solving the immediate problem. The nurse and patient actively explore solutions to the crisis.

crisis resolution and anticipatory planning The therapist reinforces those adaptive coping mechanisms that the individual has used successfully to reduce tension and anxiety. Assistance is given to make realistic plans for the future and analyse how the present experience may help in coping with future crises. Evaluation In the last phase the nurse and the patient evaluate whether the intervention resulted in a positive resolution of crisis. Questions concerned include Has the expected outcome achieved? Have the needs of patient that were threatened by the event met? Have the patients symptoms decreased or been resolved? Does the patient have adequate support systems and coping resources? If the goal are not met the nurse and patient return to the first step and progress to the phases again.

SETTINGS FOR CRISIS INTERVENTION Nurses working in many settings deal with patients in crisis. Hospitalizations are stressful for patients and families and can precipitate crisis. Nurses working in obstetric ,paediatric,geriatric or adolescent settings can see patients and families in maturational crisis.

Emergency rooms and critical care settings are flooded with crisis cases. People with suicide attempt,survivors of sudden cardiac arrest, crime and accident victims etc. In large population centers there is a growing use of emergency rooms, crisis centers, ERs, emerge-centers and crisis mental health triage centers to handle urgent and emergency problems. Managed care organizations are contracting with community mental health programs, HMOs, insurance companies and public health plans to provide crisis services in large population centers. The main purpose of these contracts is to pool resources and help insure there is an available and cost effective place for police, ambulances, families and friends to take people during a mental health crisis or psychological emergency. Community and home health nurses intervene in family crises. A child who refuses to go school ,a person who refuse to learn to take insulin and a family with a dying member at home are candidates of crisis interventions. Nurses in community mental health centers ,department of psychiatry,managed care clinics ,schools, occupational health centers, long term care facilities and home health agencies may come across patients in crisis. MODALITIES OF CRISIS INTERVENTION Crisis intervention modalities are based on the principle that health care team must go out to patients than wait for them to come. Mobile crisis programs Mobile crisis team provide frontline individuals,families ,and communities. Group work Crisis groups follow the same steps that individual intervention follows. The nurse and group help the patient solve the problem and reinforce the patients new problem solving behaviour. The group act as a support system for the patient and is of particular benefit to socially isolated people. interdisciplinary crisis intervention to

Telephone contacts Crisis intervention is also practiced by telephone or internet communication rather than through face to face contacts . The nurse answer emergency call or electronic mail without direct visual cues. Referrals for face to face contacts may be made. Nurse uses a variety of listening skills in this set up. Such services have extensive training programs to teach crisis intervention. Disaster response Floods, earthquakes, airplane crashes, nuclear accidents etc. precipitates large number of crises. Nurse in the immediate post disaster period go to places and areas surrounding the disaster site. A study of world trade center rescue and recovery workers indicated that

disaster preparedness training and shift rotations , which allowed for shorter time worked,may have reduced posttraumatic stress disorder (PTSD) among workers and volunteers. The nurse can participate in mobilizing financial and other resources, managing shelter homes for the victims, ensuring that their basic needs are met with proper informations about the services and grants available to such victims. Crisis therapy during large disasters use generic approach to crisis intervention. The nurse work with families or groups rather than individuals during situational crisis so that people gain support from family or community undergoing similar stress. Victim outreach programs Although crisis intervention is not considered appropriate treatment for serious consequences of victimization,such as PTSD or depression, it is very useful as a community support for victims of crime or rape and provide referral to more comprehensive services when needed. The objective are to validate the nature of crisis ,provide empathic support ,information and legal help,identify supportive social network,referral resources and self enhancing ways of solving problems. Crisis intervention centers THRANI is a Center for Crisis Control is one of the premier health centers and research institute in Thiruvananthapuram, is a division of Foundation for Integrated Research In Mental Health, a Voluntary Organization. THRANI activities are focused on suicide prevention, HIV/AIDS/STI intervention and mental health promotion . Maithri was the first full-fledged suicide prevention center to open in Kerala in 1995 in response to the mounting suicide rates in the early nineties. The word Maithri means friendship, and true to its name, providing friendship and support to people at risk of committing suicide is one of the main goals of the organization. The motto of the organization is suicide prevention with peoples participation, and this is clearly what Maithri tries to do in Kerala. Not only does Maithri run center-based crisis intervention programs, they also have been conducting public awareness campaigns to educate people about the risks for and signs of an impending suicide. The campaigns encourage people to be on the lookout for these signs and to provide support to those who think they need it.

HEALTH EDUCATION Health education is emphasized during the evaluation phase. Nurses teach coping strategies to people at high risk to avoid development of crises. The public needs to be aware of the available services ,change their attitude so that people feel free to seek service and obtain information on how to deal with potential crisis producing problems.

BIBLIOGRAPHY 1. Varcarolis EM. Foundations of Psychiatric Mental health Nursing:A clinical approach. 2. 3. 4. 5. 6. 7.


4th ed. Philadelphia: WB saunders company; 2002. P457-462. . Townsend MC. Psychiatric Mental Health Nursing, Concepts of Care in Evidenced Based Practice.5thed.NewDelhi:Jaypee;2002p193-204 Stuart GW, Laraia MT. Principles and Practice of Psychiatric Nursing.8thed.Kundli:ElsevierPublications;2005p230-240 Aguilera DC. Crisis intervention theory and methodology .6th ed.Philadelphia:Mosby;1990 p260-80 Fortinash KM, Worret HAP. Psychiatric Mental Health Nursing.3rd ed. Missouri:Mosby Publication;2004.p.410-18. Boyd MA. Psychiatric Nursing Contemporary Practice. 3rded .Lippincott Williams and Wilkins;2005. Decker JB , Stubblebine JM. Crisis Intervention and Prevention of Psychiatric Disability: A Follow-Up Study. Am J Psychiatry 129:725729, December 1972 THRANI center for crisis control.[online].Available from http//


Human organism 10.

Stressful event

State of equilibrium

stressful event

State of disequilibrium

Need to restore equilibrium

BALANCING FACTORS PRESENT ABSENT Realistic perception of event

BALANCING FACTORS Distorted perception of event

Adequate situational support

No adequate situational support

Adequate coping mechanisms

No adequate coping mechanisms

Resolution of the problem

Problem unresolved

Equilibrium regained

Disequilibrium continues

No crisis