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Stressful events, or crises, are a common part of life. They may be social, psychological, or biological in nature, and there is often little that a person can do to prevent them. As the largest group of health care providers, nurses are in an excellent position to help promote healthy outcomes for people in times of crisis. 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. Knowledge of crisis intervention techniques is an important clinical skill of all nurses, regardless of clinical setting or practice specialty.

Catharsis The release of feelings that takes place as the patient talks about emotionally charged areas Clarification Encouraging the patient to express more clearly the relationship between certain events Suggestion Influencing a person to accept an idea or belief, particularly the belief that the nurse can help and that the person will in time feel better. Reinforcement of behavior Giving the patient positive responses to adaptive behavior Support of defenses Encouraging the use of healthy, adaptive defenses and discouraging those that are unhealthy or maladaptive Raising self-esteem Helping the patient regain feelings of self-worth Exploration of solutions Examining alternatives ways of solving the immediate problem 1

Crisis intervention Is a short-term therapy focused on solving the immediate problem. Crisis An emotionally stressful event or traumatic change in a person's life.

Word Origin & History

Crisis c.1425, from Gk. crisis "turning point in a disease" (used as such by Hippocrates and Galen),

Chinese language crisis represents two symbols they are,danger,opportunity DEFINITION A crisis is defined as a situation or event in which a person feels overwhelmed or has difficulty coping. A crisis might be caused by an event such as the death of a family member, the loss of a job, or the ending of a relationship. During such times people experience a wide range of feelings, and each person's response to a crisis is different. It is normal to feel frightened, anxious, or depressed at such a time. Responses to crisis A typical crisis intervention progresses through several phases. It begins with an assessment of what happened during the crisis and the individual's responses to it. There are certain common patterns of response to most crises. An individual's reaction to a crisis can include emotional reactions (fear, anger, guilt, grief), mental reactions (difficulty concentrating, confusion, nightmares), physical reactions (headaches, dizziness, fatigue, stomach problems), and behavioral reactions (sleep and appetite problems, isolation, restlessness). Assessment of the individual's potential for suicide and/or homicide is also conducted. Also, information about the individual's strengths, coping skills, and social support networks is obtained.

Characteristics of a crisis
A crisis usually occurs suddenly when a person, family, or a group is inadequate prepared to handle the event or situation. Normal coping method fails, tension raises, and feelings of anxiety, fear, guilt, anger, shame, and helplessness, may occur. Most crisis, unless the result of a natural or manmade disaster are generally short in duration, lasting 24 to 36 hours. Crisis rarely last longer than 3to 4 weeks whereas the period recovery from a disaster like hurricane may involve several years.

Crisis theory Historical background

The concept of crises and early formulations of crisis theory originated in the field of preventive psychiatry in the early 1940s.

Preventive psychiatry:
It is concerned with the maintenance of mental health and the prevention of mental illness. Specialists in this filed used psychoanalytic theory as a base for a theoretical framework that explored brief intervention for persons having stressful life experiences. Foremost among those involved in preventive psychiatry was Eric Lindeman. Lindeman studied the bereavement seen in the surviving relatives and friends of the hundreds of people who died in the disastrou7s Coconut Grove nightclub fire in Boston in 1943. He hypothesized that numerous threatening situations might arise in a persons life and that the person either adapts to the situations or fails to adapt and has impaired functioning. Later, in the early 1960s, Gerald Caplan defined crisis theory and described crisis intervention. He utilized principles of preventive psychiatry- primary. Secondary and tertiary prevention- as a basis for his work.

Primary prevention:
He viewed it as a vehicle for promoting mental health and reducing mental illness. Interpersonal action involves helping people deal with specific stress such as death or job loss.

Secondary prevention:
Caplan saw secondary prevention as a means of reducing the number of existing cases of mental illness through early diagnosis and treatment. Secondary prevention includes screening programs, prompt referral, improvement in the use of diagnostic tools, and prompt treatment.

Tertiary prevention:
It was seen as a vehicle for reducing the rate of chronic disability resulting from mental illness. Tertiary prevention includes rehabilitation programs designed to restore the person to a maximum level of well-being. Tertiary prevention includes both primary and secondary prevention insofar as it aims at prevention and reduction of chronic disability and its inherent crises through maximum rehabilitation


Human Organism

State of equilibrium

State of disequilibrium Need to restore equilibrium

Balancing factors present

Disturbances in one or more balancing factor

Realistic Perception of the event:

Distorted perception of the event:

Adequate situational support:

Inadequate situational support:

Adequate defense and/or coping skills: Resolution of problem:

Inadequate defense and/or coping skill: Problem unresolved: Crisis not resolving:

Crisis resolving: Achieving equilibrium

No 1. 2. Phases Precrisis Initial impact or shock occurs (may last a few hours to a few days) Description State of equilibrium or well-being High level of stress Inability to reason logically Inability to apply problem-solving behavior Inability to function socially Helplessness Anxiety Confusion Chaos 3. Crisis occurs (may last a brief or prolonged period of time) Possible panic Inability to cope results in attempts to redefine the problem, avoid the problem, or withdraw from reality Ineffective, disorganized behavior interferes with daily living Denial of problem Rationalization about cause of the situation Projection of feelings of inadequacy onto others 4. Recoil, acknowledgement, or beginning of resolution occurs Resolution, adaptation, and change continues Occurs when the person perceives the crisis situation in a positive way successful problem-solving occurs. Anxiety lessens Self-esteem rises 6 Acknowledges reality of the situation Attempts to use problem-solving approach by trial and error Tension and anxiety resurface as reality is faced Feelings of depression, self-hate, and low self-esteem may occur.


Post crisis begins

Social role is resumed. May be at a higher level of maturity and adaptation due to acquisition of new positive coping skills, or may function at a restricted level in one or all spheres of the personality due to denial, repression, or ineffective mastery of coping and problem-solving skills. Persons who cope ineffectively may express open hostility, exhibit signs of depression, or abuse alcohol, drugs, or food. Symptoms of neurosis, psychosis, chronic physical disability, or socially maladjusted behavior may occur.

Types of Crises
Three types of crises can be identified: anticipated maturational crises of the life cycle, unanticipated situational crises, and unanticipated social crises.

Maturational (anticipated normative)

Crises that occur in response to stresses inherent in predictable life transitions and events

Infancy, early childhood, school age, adolescence, young adulthood, adulthood, middle adulthood, late adulthood Marriage, parenthood, job changes, retirement, last child leaving home, menopause Death of significant person, physical or mental illness, job loss, divorce, birth of a premature or 7

Situational (unanticipated)

Crises that occur when unanticipated events threaten a persons biological, social, or

Social (unanticipated)

psychological integrity Crises that occur with uncommon, unanticipated events that involve multiple losses or extensive environmental changes

disabled child Flood, fire, earthquake, civil riot, volcanic eruption, nuclear contamination, violent crime

1. Maturational Crises
Maturational crises, sometimes called developmental crises, are predictable life events which normally occur in the lives of most people. A persons life is continually changing because of the ongoing process of maturation.

The onset of a maturational crisis is gradual and occurs over time as the person moves through a period of change. Such transitional periods are characterized by internal disequilibrium and disorganized behavior. The person may experience mood swings and variations of normal behavior in terms of roles and relationships.

1. The success with which previous life transitions have been mastered. If

previous stages of maturational change have been mastered successfully, the residue of unresolved developmental issued is minimized and the person in able to move on to the next transition with a firmer foundation for future growth. People who have unresolved maturational issues from the past often experience greater stress in current life transitions that involve old unfinished business than people who are not burdened or vulnerable in this way. Unresolved maturational issues include dependency and authority conflicts, value conflicts, sexual-identity confusion, and lack of capacity for emotional intimacy. Examples of these unresolved maturational issues are outlined in Table 22-3. 8

2. Adequate role models. These provide the person with examples of how to act in the new role. Teachers, parents, mentors, and peers are examples of people who can act as role models. 3. Interpersonal resources. These offer the person a cast of characters with whom to try out new behavior and skills in the attempt to achieve role changes. 4. The degree to which others accept or resist the new role. This influences the ease with which role changes are made. The greater the resistance of others, the more difficulty the person experience in making the change. Example: Mr.Jack, 68 years old came to the crisis clinic with the complaints of a nervous stomach, insomnia, and fatigue. His symptoms had begun 1 month before, after he was forced into retirement by business reverse that resulted in the unexpected sale of a previously successful business. All of Jacks friends and acquaintances still worked, as did his wife. His lifetime involvement with work had left little time for or interest in the development of recreational pastimes. He now found himself sitting at home each day by himself with little to do besides read the newspaper and watch television. Although he did little each day he felt exhausted and nervous. He felt directionless, useless, and lonely. he consulted his family doctor for his nervous stomach, and she referred him to the crises clinic. ASSESSMENT An older man who was having difficulty dealing with an abrupt transition into retirement. His self-worth was tied to his involvement with work, and he was unprepared with alternative interests to provide meaning in his life. He had no situational supports or role models to ease the transition. His former coping methods were ineffective in the situation.

Maturational stage
Infancy Early childhood

Crisis Stressors
Separation at birth Separation from symbiotic relationship Giving up certain pleasures Conforming to social demands Separation and autonomy Gender and sexual identity Separation from the nurturing person Interaction with new authority figures Formation of peer relationships Group cooperation Change in body image Consolidation of psychosexual identity Heterosexual relationships Educational demands Parent-child separation Independence from parental supports Preparation for work and career Commitment to intimate relationships or parenthood Psychosexual maturity Pursuit of career goals Marital or other intimate relationships Sexual relationships Childbearing and child rearing Independence and interdependence Launching of children or empty-nest syndrome Work stressors (promotion end of the line, loss 10

School age


Young adulthood


Middle adulthood

of job, retirement) Illness or death of a parent Physical changes Late adulthood Changes in marital status Unproductive, less valued role of the retiree Declining physical health problems Loss of spouse and peers Economic problems Loss of independence

2. Situational Crises
Situational crises occur when unanticipated events threaten a persons biological, social, or psychological integrity. There is an accompanying degree of disequilibrium. The persons coping mechanisms become ineffective, or chosen solutions prove to be impractical. The stressful event involves a fundamental loss or deprivation which threatens the persons selfconcept. A situational crisis is precipitated by the loss of systematized support that had enhanced the persons feelings of security and control and was essential to maintaining the integrity of the self-concept. Examples of situational crises include loss of a loved one, loss or change of a job, change in financial status, geographic move, school failure, divorce, unwanted pregnancy, birth of a premature or disabled child, and physical or mental illness. Each of these crises has the potential to create stress, initiate grieving, threaten feelings of self-worth, create conflict and role change among family members, and precipitate loss of emotional support system. Example Patty A., age 19, comes alone to the general hospital emergency room on a Saturday night. She paced the waiting room in an agitated manner, crying and muttering to herself. When interviewed by the triage nurse, she complained of abdominal pain and two missed menstrual periods. As she spoke, she began to sob, 11

saying that she was afraid that she was pregnant. She was afraid to tell her parents because theyd throw her out. She was afraid to tell her boyfriend because he would insist that they get married and she did not want to marry for that reason. She attended a local community college and did not know what she would do with a baby if she had one. She did not want to quit school and did not know if she wanted an abortion. He finished by sating, My head is in a whirl. I never had so much to decide, and I have no one to talk to who could help me. ASSESSMENT An unmarried young woman, with no situational supports, attempting to make major decisions about commitments, roles, and lifestyles with no previous coping experience in this or a related area.

3.Social Crises
Social crises are accidental, uncommon, and unanticipated crises that involve multiple losses or extensive environmental change. Examples of social crises are natural disasters such as fires, floods, volcanic eruptions, and earthquakes; national disasters such as wars, riots, racial persecution, and nuclear contamination; and violent crime such as rape and murder. Social crises do not commonly occur in the everyday lives of people. When they do occur, the stress level is so high that the coping resources of each person are maximally challenged. Tyhurst in his study of individual responses to community disasters found that victims experience three overlapping phases.

1. Period of impact 2. Period of recoil 3. Posttraumatic period


During social crises mental health workers must reach out to the community and intervene with a large number of people. Example In a small city of 75,000, it had been raining heavily for 3 day. Power failures were widespread, and telephone lines were down in several parts of town. Many rivers and streams had over flowed, flooding many main streets. People were wondering how the dam at the edge of the city would hold in this downpour. They reassured each other by saying, the old dam has been there for a hundred years it has withstood worse than this. Many people left their homes to move to higher ground. Others, however stayed clinging to the belief that, It could not happen to us. They sat by their radios and waited and listened in the darkness. Early on the fourth morning, people were awakened by a deafening roar. A huge torrent of water was pouring downhill, overturning everything in its path. People raced to second floors attics and roofs. It was too late to get away. They watched neighboring houses break loose from their foundations. They heard the screaming voices of friends and neighbors, adults and children alike, who clung to anything that would keep them afloat in the churning water. The massive flood caused by the dam break destroyed houses, stores, and schools everything in its path was ruined. Hundreds of people were trapped and drowned in their houses or trying to escape, especially those living in the lower parts of town. Survivors many of whom had failed to save their loved ones, slowly made their way to higher ground, where they found makeshift emergency shelters. Many appeared numb, in shock many could not describe in a coherent way what had happened. They sat rigidly still, paced agitatedly, or busily involved them selves in rescue work. Some wept hysterically about lost family members, homes, and business others were unnaturally calm and contained still others alternated between the two affective states. Many people had sustained physical shock and needed minor or extensive medical treatment. Rescue assistance arrived by helicopter, because the city was cut off from other transportation routes. The critically injured were evacuated to regional medical centers those less seriously injured remained in


emergency shelters. The unhappy task of cleaning up the city began finding and burying the dead, cleaning debris, fixing the dam, and rebuilding the city. ASSESSMENT Unanticipated natural disaster which destroyed a city and resulted in the death of hundreds. Following the impact phase, emergency interventions were instituted to deal with shock and acute disorganization. In the posttrauma phase, survivors will have to be observed for later sequelae such as persistent intense fear phobias about weather apathy depression despair, preoccupation with thoughts of dead relatives guilt about survival vivid memories and dreams constricted living patterns diffuse rage reactions. Such behaviors would be the evidence of ineffective mourning, anxiety, and intense feelings of helplessness and lack of control. PHASES OF DISASTER


The reality period of in what

which Calm, effective action; shock has confusion, or paralyzing fear

people are hit with the and confusion; hysteria, happened. This phase lasts from a few minutes to 1 or Recoil 2 hours. The period in which there Looking for connection with is at least a temporary support systems such as suspension of the initial surviving friends or stresses of the disaster. relatives; desire to be taken Lives are no longer in care of; desire to share the danger, although many horror of the experience; stresses remain, including weeping gradual awareness of the Post trauma full impact of the disaster. The period in which Guilt, nightmares, anger, survivors become fully frustration, anxiety reactions, aware of what occurred reactive depressions, 14

during the impact phase- psychotic episodes loss of families, homes, belongings, security. Resolution of loss and reconstruction of lifestyle will occur to lesser and greater degrees. This phase can last for the rest of a persons life.

Classification According to Severity

Situational and maturational crises also can be classified based on the severity of the precipitating events. A classification system developed by Burgess and Baldwin (1981) systematically describes six types of crises based on the severity of the situation. Each classification is briefly summarized below. 1. Class 1: Dispositional or situational crisis in which a problem is presented with a need for immediate action, such as finding housing for the homeless during subzero temperatures 2. Class 2: Life transitional or maturational crisis that occurs during normal growth and development, such as going away to college or experiencing a planned pregnancy. 3. Class 3: situational crisis due to a sudden, unexpected, traumatic event or disaster, such as the loss of a home during a hurricane or earthquake 4. Class 4: Maturational or developmental crisis involving an internal stress and psychosocial issues, such as questioning ones sexual identity or lacking the ability to achieve emotional independence 5. Class 5: Situational crisis due to a preexisting psychopathology, such as depression or anxiety, that interferes with activities of daily living (ADL) or various areas of functioning 15

6. Class 6: Psychiatric situational crisis or emergency, such as attempted suicide, drug overdose, or extreme agitation, resulting in unpredictable behavior or the onset of an acute psychotic disorder

Behaviors Commonly Exhibited After a Crisis

Anger Apathy Backaches Boredom Crying spells Diminished sexual drive Disbelief Fatigue Fear Flashbacks Forgetfulness Headaches Helplessness Hopelessness Insomnia Intrusive thoughts Irritability Labiality Nightmares Numbness Overeating or under eating Poor concentration Sadness School problems Self-doubt Shock Social withdrawal Substance abuse Suicidal thoughts Survivor guilt Work difficulties

Crisis Intervention
Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems 16

Crisis intervention is a short-term therapy focused on solving the immediate problem. It is usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. Often the person advances to a level of growth that is higher that the precrisis level because new ways of problem solving have been learned. It is important for the nurse to remember that cultural attitudes strongly influence the communication and response style of the crisis worker. These attitudes are deeply ingrained in the processes of asking for, giving, and receiving help. They also affect the victimization experience, so it is essential to understand and respect the cultural values of the victims. Specific cultural factors to be considered in crises intervention include the following: Migration and citizenship status Gender and family roles Religious belief systems Child-rearing practices Use of extended family and support systems The age of the survivors is also important for the nurse to consider when providing crisis intervention. Responses to stressor events differ across the life span. Therefore age appropriate interventions are most effective in helping survivors return to their previous level of functioning (Adams etal, 1999; Ball and Allen, 2000). For example, 4-year old children may best express themselves through play, whereas adolescents may best work through crisis issue in peer group discussions.

Crisis intervention has several purposes. It aims to reduce the intensity of an individual's emotional, mental, physical and behavioral reactions to a crisis. Another purpose is to help individuals return to their level of functioning before the crisis. Functioning may be improved above and beyond this by developing new coping skills 17

and eliminating ineffective ways of coping, such as withdrawal, isolation, and substance abuse. In this way, the individual is better equipped to cope with future difficulties. Through talking about what happened and the feelings about what happened, while developing ways to cope and solve problems, crisis intervention aims to assist the individual in recovering from the crisis and to prevent serious longterm problems from developing. Research documents positive outcomes for crisis intervention, such as decreased distress and improved problem solving.

The first step of crisis intervention is assessment. At this time data about the nature of the crisis and its effect on the patient must be collected. From these data, an intervention plan will be developed. People in crises experience many symptoms, Sometimes; these symptoms can cause further problems. For example, problems at work may lead to loss of a job, financial stress, and lowered self-esteem Crises also can be complicated by old conflicts that resurface as a result of the current problem, making crises resolution more difficult. For example, q woman who was orphaned at an early age may have more difficulty resolving a crisis precipitated by the work injury of her husband than a woman who had not suffered an earlier loss. Although the crisis situation is the focus of the assessment, more significant and long-standing problems may be identified by the nurse. It is important, therefore, to identify which areas can be helped by crisis intervention and which problems must be referred to other sources for further treatment. During this phase the nurse begins to establish a positive working relationship with the patient. A number of balancing factors are important in the development and resolution of a crisis and should be assessed: Precipitating event or stressor Patients perception of the event or stressor Nature and strength of the patients support systems and coping resources Patients previous strengths and coping mechanisms 18

Precipitating Event

To help identify the precipitating event, the nurse should explore the patients needs, the events that threaten those needs, and the time at which symptoms appear. Four kinds of needs that have been identified are related to self-esteem, role mastery, dependency, and biological function. 1. Self-esteem is achieved when the person attains successful social role experience. 2. Role mastery is achieved when the person attains work, sexual, and family role successes. 3. Dependency is achieved when a satisfying interdependent relationship with others is attained. 4. Biological function is achieved when a person is safe and life is not threatened. The nurse determines which needs are not being met by asking the patient to reflect on issues of self-image and self-esteem, the areas of life that are considered a success, ones relationships with others, and the degree of safety and security in life. The nurse looks for obstacles that might interfere with meeting the patients needs. What recent experiences have been upsetting? What areas of life have had changes? Coping patterns become ineffective and symptoms appear usually after the stressful incident. When did the patient begin to feel anxious? When did sleep disturbances begin? At what point in time did suicidal thoughts start? If symptoms began last Tuesday, ask what took place in the patients life on Tuesday or Monday. As the patient connects life events with the breakdown in coping mechanisms, an understanding of the precipitating event can emerge. Perception of the Event The patients perception or appraisal of the precipitating event is very important. What may seem trivial to the nurse may have great meaning to the patient. An overweight adolescent girl may have been the only girl in the class not invited to a dance. This may have threatened her self-esteem. A man with two unsuccessful marriages may have just been told by a girlfriend that she wants to end their relationship; this may have threatened his need for sexual role mastery. An 19

emotionally isolated, friendless woman may have had car trouble and been unable to find someone to give her a ride to work. This may have threatened her dependency needs. A chronically ill man who has had a recent relapse of his illness may have had his need for biological function threatened.

Support Systems and Coping Resources The patients living situation and supports in the environment must be assessed. Does the patient live alone or with family or friends? With whom is the patient close. And who offers understanding and strength? Is there a supportive clergyman or friend? Assessing the patients support system is important in determining who should come for the crisis therapy sessions. It may be decided that certain family members should come with the patients so that the family members support can be strengthened. If the patient has few supports, participation in a crises therapy group may be recommended. Assessing the patients 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 a safer and more effective treatment. Coping Mechanism Next, the nurse assesses the patients strengths and previous coping mechanisms. How has the patient handled other crises? How were anxieties relived? Did the patient talk out problems? Did the patient leave the usual surroundings for a period of time to thinks through from another perspective? Was physical activity used to relieve tension? Did the patient find relief in crying? Besides exploring previous coping mechanisms, the nurse also should note the absence of other possible successful mechanisms.


The next step of crisis intervention is planning; the previously collected data are analyzed and specific interventions are proposed. Dynamics underlying the present crisis are formulated from the information about the precipitating event. 20

Alternative solutions to the problem are explored, and steps for achieving the solutions are identified. The nurse decides which environmental supports to engage or strengthen and how best to do this, as well as deciding which of the patients coping mechanisms to develop and which to strengthen. The expected outcome of nursing care is that the patient will recover from the crisis event and return to a precrisis level of functioning. A more ambitious expected outcome would be for the patient to recover from the crisis event and attain a higher than precrisis level of functioning and Improved quality of life. Nursing intervention can take place on many levels using a variety of techniques. There are four levels of crisis intervention-environmental manipulation, general support, generic approach, and individual approach-that represent a hierarchy from the most basic to the most complex (Shields, 1975) (Figure 14-2). Each level includes the interventions of the previous level, and the progressive order indicates that the nurse needs additional knowledge and skill for implementing high-level interventions. It is often helpful to consult with others when deciding which approach to use. Environmental manipulation Environmental manipulation 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 liaison between the patient and social support agencies. For example, a patient who is having trouble coping with her six children may temporarily send several of the children to their grandparents house. In this situation some stress is reduced. Similarly, a patient having difficulty on his or her job may take a week of sick leave to be removed temporarily from that stress. A patient who lives alone may move in with his or her closest sibling for several days. Likewise, involving the patient in family or group crisis therapy provides environmental manipulation for the purpose of providing support. General support


General support includes interventions that convey the feeling that the nurse is on the patients side and will be a helping person. The nurse uses warmth, acceptance, empathy, caring, and reassurance to provide this type of support.

Generic approach The generic approach is designed to reach high-risk individuals and large groups as quickly as possible. It applies a specific method to all people faced with a similar type of crisis. The expected course of the particular type of crisis is studied and mapped out. The intervention is then set up to ensure that the course of the crisis results in an adaptive response. Grief is an example of a crisis with a known pattern that can be treated by the generic approach. Helping the patient to overcome ties to the deceased and find ne patterns of rewarding interaction may effectively resolve the grief. Applying this intervention to people experiencing grief, especially with a high-risk group such as families of disaster victims, is an example of the generic approach. Interventions following an acute stress are sometimes referred to as debriefing. Originally a military concept, debriefing is used as a therapeutic intervention to help people recall events and clarify traumatic experiences. Interventions consist of ventilation of feelings within a context of group support, normalization of responses, and education about psychological reactions to traumatic events. Although debriefing may be effective for some individuals, research findings about its effectiveness following extreme stress are inconclusive. Thus further research is needed before it can be endorsed as an evidence-based practice (Kaplan, Iancu, and Bodner, 2001). Individual Approach The individual approach is a type of crisis intervention similar to the diagnosis and treatment of a specific problem in a specific patient. The nurse must understand the specific patient characteristics 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. 22

This type of crisis intervention can be effective with all types of crises. It is particularly useful in combined situational and maturational crises. The individual approach is also helpful when symptoms include homicidal and suicidal risk. The individual approach also should be applied if the course of the patients crisis cannot be determined and if resolution of the crisis has not been achieved using the generic approach. Interventions are aimed at facilitating cognitive and emotional processing of the traumatic event and at improving coping. Five core interventions to assist survivors of acute stress are as follows (Osterman and Chemtob, 1999): Restore psychological safety Provide information Correct misattributions Restore and support effective coping Ensure social support

A General Model of Intervention and Crisis Counseling Make Psychological Contact and Establish the Relationship.
Establish rapport by conveying genuine respect and acceptance of the client. The client also needs assurance and reinforcement that he or she may receive help. If this step is omitted, the client will not feel respected and will be resistant to counseling.

Examine the Dimensions of the Problem to Define the Problem.

Identify the precipitating event, previous coping methods, and lethality. Focus on the now and how, rather than the then and why. Use open-ended questions. Explore Feelings and Emotions. It is therapeutic for the client to vent and express feelings and emotions in an accepting, supportive, private, and non-judgmental setting. The crisis intervener must actively listen. Explore and Assess Past Coping Attempts. 23

Identify and modify the clients coping behaviors at both the preconscious and conscious levels. Coping responses must be brought to the conscious level and to educate the client in modifying maladaptive coping behaviors. Explore how certain situations are handled: intense anger, loss of a loved one, disappointment, failure, etc. Help the client understand how they have been coping and why it has not worked. If this step is omitted, the client may continue using maladaptive coping behaviors that continue not to work.

Generate and Explore Alternatives and Specific Solutions.

Clients need help conceptualizing more adaptive coping responses to the crisis. If the client has little introspection or personal insights, the clinician needs to take initiative and suggest coping methods.

Restore Cognitive Functioning Through Implementation of an Action Plan.

Help the client focus on why a specific event leads to a crisis state and, simultaneously, what the client can do to master the experience and be able to cope with future events. This is done in three stages: 1. The client needs a realistic understanding of the crisis and what led to the event. Understand what happened, why it happened, who was involved, and the final outcome. 2. Understand the specific meaning of the event, how it conflicts with expectations, life goals, and belief system. The clinician should note cognitive errors, distortions, irrational beliefs, and help the client discover them. 3. Reconstructing, rebuilding, and replacing irrational beliefs with new cognition. Provide new info through homework assignments or referrals to others who have lived through and mastered a similar crisis, such as a support group.

Clinician should leave her door for client to come back for future sessions. Often, unforeseen events conjure up images and old feelings surrounding (i.e. the anniversary of the event). 24

Therapeutic Techniques Used in Crisis Intervention

The nurse should be creative and flexible, trying many different techniques. These should be active, focused, and explorative techniques that can facilitate achieving the targeted interventions. Some of these include catharsis, clarification, suggestion, and reinforcement of behavior, support of defenses, raising self-esteem, and exploration of solutions. The intervention must be aimed at achieving quick resolution. The nurse also must be active in guiding the crisis intervention through its various steps. A passive approach is not appropriate because of the time limitations of the crisis situation. A brief description of these techniques follows.

Is the release of feelings that takes place as the patient talks about emotionally charged areas. As feelings about the events are realized, tension is reduced. Catharsis is often used in crisis intervention. The nurse solicits the patients feelings about the specific situation, recent events, and significant people involved in the particular crisis. The nurse asks open-ended questions and repeats the patients words so that more feelings are expressed. The nurse does not discourage crying or angry outbursts but rather sees them as a positive release of feelings. Only when feelings seem out of control, such as in cases of extreme rage or despondency, should the nurse discourage catharsis and help the patient concentrate on thinking rather than feeling. For example, if a patient angrily talks of wanting to kill a specific person, it is better to shift the focus to a discussion of the consequences of carrying out the act rather than to encourage free expression of the angry feelings.

Is used when the nurse helps the patient identify the relationship between events, behaviors, and feelings. For example, helping a patient see that it was after being passed over for a promotion that he or she felt too sick to go to work is clarification. Clarification helps the patient gain a better understanding of feelings and how they lead to the development of a crisis. 25

Is influencing a person to accept an idea or belief. In crisis intervention the patient is influenced to see the nurse as a confident, calm, hopeful, empathic person who can help. BY believing the nurse can help, the patient may feel more optimistic and less anxious. It is a technique in which the nurse engages patients emotions, wishes, or values to their benefit in the therapeutic process. Suggestion is a way of influencing the patient by pointing out alternatives or new ways of looking at things.

Reinforcement of behavior
Occurs when healthy, adaptive behavior of the patient is reinforced by the nurse, who strengthens positive responses made by the patient by agreeing with or positively acknowledging those responses. For example, when a patient who has passively allowed himself or herself to be criticized by the boss later reports asserting himself or herself in a discussion with the boss, the nurse can commend the patient on this assertiveness.

Support of defenses
Occurs when the nurse encourages the use of healthy defenses and discourages those that are maladaptive. Defense mechanisms are used to cope with stressful situations and to maintain self-esteem and ego integrity. When defense deny, falsify, or distort reality to the point that the person cannot deal effectively with reality, they are maladaptive. The nurse should encourage the patient to use adaptive defenses and discourage those that are maladaptive. For example, when a patient denies that her husband wants a separation despite the fact that he has told her so, the nurse can point out that she is not facing facts and dealing realistically with the problem. This is an example of discouraging the maladaptive use of the defense mechanism of denial. If a patient who is furious with his boss writes a letter to his bosss supervisor rather than assaulting his boss, the nurse should encourage the adaptive use of the defense mechanism of sublimation. In crisis intervention, defense are not attacked but rather are more gently encouraged or discouraged. When defense are attacked, the patient cannot maintain self-esteem and ego integrity. Also the immediacy of crisis intervention does not 26

allow enough time to replace the attacked defenses with new ones. Returning the patient to a prior level of functioning is the goal of crisis intervention, not the restricting of defenses.

Raising self-esteem
Is a particularly important technique. The patient in a crisis feels helpless and may be overwhelmed with feelings of inadequacy. The fact that the patient has found it necessary to seek outside help may further increase feelings of inadequacy. The nurse should help the patient regain feelings of self-worth by communicating confidence that the patient can find solutions to problems. The nurse also should convey that the patient is a worthwhile person by listening to and accepting the patients feelings, being respectful, and praising help-seeking efforts.

Exploration of solutions
Is essential because crisis intervention is geared toward solving the immediate crisis. The nurse and patient actively explore solutions to the crisis. Answers that the patient had not thought of before may become apparent during conservations with the nurse as anxiety decreases. For example, a patient who has lost her job and has not been able to find a new one may become aware of the fact that she knows many people in her field of work whom she could contact to get information regarding the job market and possible openings. Techniques of Crisis Intervention

Technique: Catharsis
Definition: The release of feelings that takes place as the patient talks about emotionally charged areas Example: Tell me about how you have been feeling since you lost your job.

Technique: Clarification
Definition: Encouraging the patient to express more clearly the relationship between certain events Example: Ive noticed that after you have an argument with your husband you become sick and cant leave your bed. 27

Technique: Suggestion
Definition: Influencing a person to accept an idea or belief, particularly the belief that the nurse can help and that the person will in time feel better. Example: Many other people have found it helpful to talk about this and I think you will, too.

Technique: Reinforcement of behavior

Definition: Giving the patient positive responses to adaptive behavior Example: Thats the first time you were able to defend yourself with your boss and it went very well. Im so pleased that you were able to do it.

Technique: Support of defenses

Definition: Encouraging the use of healthy, adaptive defenses and discouraging those that are unhealthy or maladaptive Example: Going for a bicycle ride when you were so angry was very helpful because when you returned you and your wife were able to talk things through.

Technique: Raising self-esteem

Definition: Helping the patient regain feelings of self-worth Example: You are a very strong person to be able to handle this situation, too.

Technique: Exploration of solutions

Definition: examining alternatives ways of solving the immediate problem Example: You seem to know many people in the computer field. Could you contact some of them to see whether they might know of available jobs?





Childrens Protective Services Domestic Violence Crisis Center Kids-in-Crisis Center Life Crisis Center Parents-in-Crisis Center Rape Crisis Center 28

Sexual Assault Crisis Center Suicide Crisis Center Youth Crisis Center Workplace Crisis Center

ROLE OF NURSE IN -Crisis Events

Basic Needs: Provide liaison to social agencies. Physical Deficits: Attend to physical emergencies. Refer to other health care providers as necessary. Psychological Effects Shock - Attentively listen to telling of the crisis details. Confusion -Give nurturing support; permit regression. Denial -permits intermittent denial; identify patients primary concern. Anxiety -Provide structure, enact anti anxiety interventions. Lethargy/heroics- Encourage sublimation and constructive activity. Coping - Encourage patients favored, adaptive coping mechanism; emphasize rationalization, humor, sublimation. Self-efficacy -Support patients previous successes and belief in own abilities, dilute irrational self-doubts, emphasize power of expectations to produce results. Support- Add social supports to the patients world, provide professional support, refer for counseling when necessary, help patient develop new coping strategies.

Protective Factors


Crisis intervention modalities are based on the philosophy that the health care team must be aggressive and go out to the patient rather that wait for the patients to 29

come to them. Nurse working in these modalities intervene in a variety of community settings, ranging from patients homes to street corners.

Mobile Crisis Programs

Mobile crisis teams provide front-line interdisciplinary crisis intervention to individuals, families, and communities. The nurse who is a member of a mobile crisis team may respond to a desperate person threatening to jump off a bridge in a suicide attempt, an angry person who is becoming violent towards family members at home, or a frightened person who has barricade himself in an office building. By defusing the immediate crisis situation, lives can be saved, incarnations and hospitalizations can be avoided, and people can be stabilized (Zeal berg, Hardestry, and Tyson, 1998; Steadman et al, 2001; Gou et al,2001). Mobile crisis programs throughout the country vary in the services they provide and the procedures they use. However, they are usually able to provide onsite assessment, crisis management, treatment, referral, and educational services to patients, families, law enforcement officers, and the community at large. Studies of mobile crisis services show favorable outcomes for patients and families and lower hospitalization rates.

Mobile Crisis Teams and Police BACKGROUND: Relatively little is known about the differences in outcome between police and mobile treatment team responses to psychiatric emergencies. The effectiveness and efficiency of 73 mobile crisis team interventions and 58 police interventions were retrospectively examined. RESULTS: Of the psychiatric emergencies handled by the mobile crisis program, 55% were managed without psychiatric hospitalization for those in crisis compared with28% of the emergencies handled by police intervention. The average cost was 30

23% less for persons who received the mobile crisis intervention. Both consumers and police officers gave positive ratings to the mobile crisis program. IMPLICATIONS: Mobile crisis programs can decrease hospitalization rates for persons in crisis and can provide cost effective psychiatric emergency services compared to regular police intervention for individuals experiencing psychiatric stress.

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 behavior. The nurses role in the group is active, focal, and present oriented. The group follows the nurses example and uses similar therapeutic techniques. The group acts as a support system for the patient and is therefore of particular benefit to socially isolated people. Most crisis groups focus on people who have common traits or stressors. For examples, groups have been established for children and parents to decrease traumatic distress after children had become victims of extra familial sexual abuse. Crisis groups are short term groups that also utilize the problem solving method of crisis intervention. People are referred to crisis groups after severe and panic level anxiety has been reduced with other crisis intervention methods.

Leaders and members of crisis groups have several tasks

1. The nurse acts as a leader and role model for effective problem solving. 2. Group members assist each other in problem resolution. They encourage exploration of felling and solutions to problems.


3. The group provides an arena for experimentation with new behaviors. Group members reinforce the clients new problem solving behaviors. 4. The group acts as a support system for the client. The aspect of the group is particularly useful for clients without a peer of family network. 5. The group can be used to give feedback to members about their behavior. This is important because often there will be striking parallels between the way the client acts in the group and his or her problematic behavior patterns in everyday life. Example After two group sessions, it became obvious that Mitch K. would challenge and argue any point made by a group member. The major reason for Mitchs crisis was that at age 50 he was extremely lonely and had no lasting relationships. The members commented on his behavior in the group and questioned him about a relationship between his argumentativeness and his inability to sustain relationships.

Telephone Contacts
Crisis intervention is sometimes practiced by telephone or Internet communication, rather than through face-to-face contacts. When individuals in crisis use the telephone or internets, it is usually when they are at the peak of their distress. Nurses working for these types of hotlines or those who answer emergency telephone calls or electronic mail may find themselves practicing crisis intervention without having visual cues to rely on. Referrals for face-to-face contact should be made, but often, because of the patients unwillingness or inability to cooperate, the telephone or internet remain the only contact (Ottenstein,2002). A variety of listening skills must therefore be emphasized in the nurses role. Most emergency telephone and Internet services have extensive training programs to teach this specialized type of crisis intervention. Manuals written for the crisis worker include content such as suicide-potential rating scales, community resources, drug information, guidelines for helping the caller or crisis worker discuss concerns, and advice on understanding the limitations of the crisis workers role. 32

Disaster Response
As part of the community, nurses are called on when situational crises strike the community. Floods, earthquakes, airplane crashes, fires, nuclear accidents, and other natural and unnatural disasters precipitate large numbers of crises (weaver et al, 2000). It is important that nurses in the immediate post disaster period go to places where victims are likely to gather, such s morgues, hospitals, shelters, and areas surrounding the disaster site.

Victim Outreach Programs

Although crisis intervention is not considered the appropriate treatment for serious consequence of victimization, such as posttraumatic stress disorder (PTSD) or depression, it is very useful as a community support for victims in the immediate aftermath of crime and may provide an important link for referral to more comprehensive services when needed.

Emergency room crisis counseling

The nurse working in the emergency room continually encounters people in crisis. Daily the nurse observes attempted suicides, rape and assault victims, accident victims and their familys people with sudden onset illness such as a heart attack and people with chronic anxiety who present with a myriad of physical symptoms. All these people are candidates for crisis intervention. The role of the nurses in the emergency room is to assess and define the problem. The nurse can then implement brief intervention measures such as approaches designed to reduce anxiety. If the nurse is not in a position to work with the client on an ongoing basis, a referral for crisis therapy in another setting can be made.

Home visits


Home visits are usually made by the community health nurse.


community health nurse observes and assesses clients in their own environment. Potential high risk families can be observed identified, and referred. Families with new babies, sick members, a recent death or divorce, or a history of difficulty in coping are among those potentially in need of crisis intervention. The nurse often has an ongoing relationship with the family and can intervene effectively in a crisis using interventions described. Home visits are also made by crisis teams from crisis centers to obtain additional information about the clients home situation or to reach a client with whom contact is unobtainable in any other way frequently telephone contact with a highly suicidal caller who is unwilling to come to the crisis center will result in an immediate home visit by the crisis team

Family crisis therapy

Family crisis therapy utilizes a temporary, brief therapy model that is problem focused. It does not delve into general family issues and problems. Rather, it focuses on specific problem that a family is currently encountering. Family crisis therapy involves the entire family unit. The family is viewed as a system, with family members involved in an interactive process. A crisis affecting any family member affects all members, producing shifts in the family balance. Thus, the crisis is defined as a family problem regardless of whom the family identifies as having the problem. For example If a young child is afraid to go to school and wants to stay home with the mother, it is assumed that the mother participates in the process because of her loneliness and need for this child to remain overly close, The father may participate by traveling extensively for business and being home only on weekends. The child, lonely for the father and sensitive to the mothers upset about these frequent absences, moves closer to the mother in order to have emotional needs met and to calm the mothers upset feelings. Intervention is directed at giving the family tasks that will restructure the dysfunctional interaction and role patterns. The father would be instructed to take charge of getting the child ready to o to school and to spend more relationship time with the child. The mother would be instructed to do some other 34

task not involving the child while this was taking place. The family members are taught other ways of meeting each others needs, so that they can take responsibility for change.

Health Education
Although health education can take place during the entire crisis intervention process, it is emphasized during the evaluation phase. At this time the patients anxiety has decreased, so better use can be made of cognitive abilities. The nurse and patient summarize the course of the crisis, and the intervention is to teach the patient how to avoid other similar crises. For example, the nurse helps the patient identify the feelings, thoughts, and behaviors experienced following the stressful event. The nurse explains that if these feelings, thoughts, and behaviors again experienced, the patient should immediately become aware of being stressed and take steps to prevent the anxiety from increasing. The nurse then teaches the patient way to use these newly learned copying mechanisms in future situations.


Emergency room, Critical care settings in the Hospitals Community and home health with in their own environment Community mental health centers Psychiatry OPD Occupational Health Centers Obstetric and pediatrics settings Geriatric home Schools and Colleges


Crisis Intervention for Children and Adolescents

Childhood and adolescent development can be significantly altered as a consequence of exposure to a disasters or a crisis. The entire family is affected. Trauma can change the way children view their world. Assumptions about safety and security are challenged. Their reactions will depend upon the severity of the trauma, their personality, the way the cope with stress, and the availability of support. It is not uncommon for children to regress both behaviorally and academically after a trauma. The emotional responses of adolescents mirror those of adults. However, differences include profound changes in their attitudes towards life and their future. These attitudes often triggers risk-taking behaviors that, if prolonged, can have secondary effects such as sleep disturbances, poor school performance, and lowered self-esteem (Bensing, 2003).

Assessment of Children and Adolescents in Crisis

To assess a child or adolescent in crisis, the nurse needs to have a working knowledge of the theories of personality growth and development (see Chapter 24). Assessment focuses on psychosocial abilities, specifically intellectual, emotional, and social development (Mitechell & Rensik, 1981).

Common Reactions of a Child or Adolescent in Crisis

A child or adolescent in crisis presents a complex challenges. Depending upon the age of a child, individual needs and responses may differ with the same crisis events. Among the many events that produce a crisis state in a child or adolescents life, injury, illness, and death are considered to be the most disruptive (Mitchell & Resnik, 1981). It is natural for a child or adolescent to first experience denial that the crisis situation really happened. When the child or adolescent does respond, clinical symptoms are usually correlated to developmental stages. Clinical symptoms commonly exhibited include: 36

Excessive fears, worries, self-blame, or guilt Irritability, anger, or sadness Sleep disturbances or nightmares Weight problems resulting from loss of appetite or overeating Agitation or restlessness Somatic complaints such as headaches or stomachaches Behavioral regression or aggression Poor concentration and loss of interest in school or activities

These symptoms may range from mild to severe. A child or adolescent who is in crisis should be encouraged to process emotions or reactions within 24 to 36 hours after the traumatic events to prevent the development of PTSD.

Interventions for a Child or Adolescent in Crisis

The major functions of crisis intervention for a child or adolescent in crisis are to: Provide safety and security including freedom from fears and terrors associated with the crisis event Provide an opportunity for bonding with a professional who displays an atmosphere of open acceptance, encourages verbalization of feelings and emotions, and assists the child or adolescent in practicing coping and communication skills Provide stabilization services that will assist a child or adolescent in the return to a precrisis level of functioning Assist the child or adolescent and his or her family have precipitated the crisis


Provide linkages with community services to facilitate aftercare to process trauma and prevent the development of PTSD

Resolution of a Childs or Adolescents Crisis

Resolution of a crisis may occur in a childs or adolescents home or school, or in the community. Crisis response teams, also referred to as mobile acute crisis. Teams are available 24 hours a day 7 days a week and provide crisis counseling in homes and schools. Family members, teachers, and other concerned adults are encouraged to actively participate in the resolution of a crisis. Emergency shelters or safe houses are provided at confidential locations to provide for basic needs of a child who is the victim of domestic violence. Outreach programs provide individual support and crisis counseling to a child or adolescent experiencing difficulty at home and school because of domestic violence issues (Crossroads, 2003; Life Skills, 2003; Mitchell & Resnik, 1982; Wheeler Clinic, 2003).

The last phase of crisis interventions is evaluation, when the nurse and patient evaluate whether the intervention resulted in a positive resolution of the crisis. Specific questions the nurse might ask include the following: Has the expected outcome been achieved, and has the patient returned to the precrisis level of functioning? Have the needs of the patient that were threatened by the event been met? Have the patients symptoms decreased or been resolved? Does the patient have adequate support systems and coping resources on which to rely?

Critical thinking about contemporary Issues

Should Medication Be Included As a Crisis Intervention for Acute Traumatic Stress?


Although people who are suffering from traumatic stress may experience a range of mental health symptoms in the acute phase of the trauma, it is unclear whether all problems share the same biological characteristics. It is also unclear in the initial phases of assessment which may lose and ultimately meet criteria for a psychiatric disorder amenable to medication. Should psychopharmacological agents be offered to victims in the early stages of traumatic stress, which ones would be appropriate, and when in the process of crisis intervention would this be most helpful? Also, are there contraindications for biological intervention under some circumstances? One might begin this decision-making process by assessing precrisis symptoms (and treatments, if any), history of substance use, family history of psychiatric disorders, and the persons belief system regarding psychiatric medications. Is the symptom already of long duration and, if so, how was it treated in the past? Does the person use substances such as alcohol that could complicate his or her reaction to the crisis or assessment of the crisis impact? If there is a family history of a psychiatric disorder, the person may be at greater risk for developing that or a similar disorder. Psychopharmacological interventions may be inappropriate if many of the symptoms will be short-lived (given the fact that some medications take several weeks to work), if many of the symptoms are natural reactions to trauma rather than symptoms of psychiatric disorders, or if the medications will lead to adverse side effects and possibly stigmatize an already traumatized person. Some may argue that medications might blunt a persons cognitive abilities at a time when concentration and problem solving are important, but an important question is whether with holding a treatment from a person who may benefit from it is an ethical decision. Could medication given immediately after exposure to a traumatic event avert a chronic posttraumatic illness? There are no clear-cut answers to these questions, but crisis clinicians are best guided by a few clinical principles: What bothers this person the most? Can this problem be controlled through psychotherapeutic, environmental, or psychopharmacological interventions? 39

What treatment is most likely to make this person feel or function better? Is there a reason not to prescribe this treatment?

Answers will be governed by a careful assessment of each persons circumstances and a holistic view of care provided.

Legal Aspects of Crisis Intervention

Since 1980, the CPI has trained more than 5 million human service professionals (eg, police officers, emergency medical personnel) in the technique of nonviolent crisis intervention. As noted earlier, participants are trained to recognize an individual in crisis and prevent an emotionally or physically threatening situation from escalating out of control. Crisis intervention training helps eliminate staff confusion, develops selfconfidence among staff, and promotes teamwork (CPI, 2005). Most people are not required by law to help a person in crisis. However, certain individuals such as police officers, firefighters, and emergency medical personnel are legally responsible to provide help. In certain states, doctors and nurses are also expected to intervene during an emergency or crisis situation. Generally, these individuals are legally protected as long as they provide reasonable and prudent care according to a set of previously established criteria, and thus do not hesitate to aid people who need their help The Criteria or standards of care for a person providing crisis intervention state that the person who begins to intervention in a crisis is obligated to continue the intervention unless a more qualified person relives him or her. Discontinuing care constitutes abandonment, and the caregiver is liable for any damages suffered as a result of the abandonment. Any unauthorized or unnecessary discussion of the crisis incident by the person intervening is considered a breach of confidentiality. Touching a crisis victim without the victims permission could result in a charge of battery. However, permission can be obtained verbally or by nonverbally actions that express a desire for help. Consent also can be implied. Implied consent is permission to care for an unconscious crisis victim to preserve life or prevent further injury. Therefore,


failure to act in a crisis carries a greater legal liability than acting in favour of the treatment (Mitchell & Rensik, 1981, p.34)

Crisis is an internal disturbance that results from stressful event or a perceived threat to self integrity. Crisis theory provides a framework for viewing those stressfully life situations or events for which a persons customary methods of solving problem and making decision are not adequate. Crisis are dealt with by crisis intervention, it is an community based form of brief therapy that addresses resolution of a current stressful life events in ways aimed at helping the person develop a new ,broader array of coping skills