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INTRODUCTION

The term crisis derives from the Greek word krisis which means decision or
turning point. This definition of the word as a decisive stage that has important
consequences in the future of an individual or a system, has been preserved up to our
days and has provided the frameworkfor the development of the theory and practice of
crisis intervention. Crisis intervention is a relatively new field in community
psychology. Its origins are usually dated in the 1940's and 1950's with Lindemann
'spioneering work on grief and bereavement after the Coconut Grove Club fire in
Boston and with the work of Caplan at Harvard University. The 1960's and 1970's
were periods of further elaboration of crisis theory and intervention with the
development of suicide prevention centres, hot lines)), crisis centres and other
agencies. New conceptualizations of services and important innovations in the
intervention area were developed during this period (McGEE, 1974). In the last few
years, efforts have concentrated on the evaluation crisis intervention programs and on
further developing crisis intervention practice.
DEFINITION
Caplan (1964) initially defined a crisis as occurring when individuals are confronted
with problems that cannot be solved. These irresolvable issues result in an increase in
tension, signs of anxiety, a subsequent state of emotional unrest, and an inability to
function for extended periods.
James and Gilliland(2005) define crises as events or situations perceived as intolerably
difficult that exceed an individuals available resources and coping mechanisms.
Roberts (2000) defines a crisis as a period of psychological disequilibrium,
experienced as a result of a hazardous event or situation that constitutes a significant
problem that cannot be remedied by using familiar coping strategies

CHARACTERISTICS OF A CRISIS
The following are characteristics of crisis event
The event precipitating the crisis is perceived as threatening.
There is an apparent inability to modify or reduce the impact of stressful events.
There is increased fear, tension, and/or confusion.
There is a high level of subjective discomfort.
A state of disequilibrium is followed by rapid transition to an active stateof crisis.
There may be physical danger, which should be your first priority
You and your staff may suffer from confusion, friction, pressure and stress
Key staff may be unavailable
It may be difficult or impossible to carry out your usual daily activities
External support may be needed (e.g. from emergency services or neighbouring
businesses)

There may be a lack of clear information about what is happening


There may be limited time in which to make decisions about what to do
Attention from your stakeholders, customers and the media may be intense
news may travel fast, shaping the public perception of the crisis and how it
is being handled.
CRISIS STAGES
Caplan was the first to describe the main stages of a crisis reaction.
The contributions of later theorists have been based on Caplan's work
and have basically consisted on a restatement of his phases. According
to CAPLAN(1 964) most crisis reactions follow 4 distinct phases:
1. In the initial phase - The individual is confronted by a problem that
poses a threat to his homeostatic state: the person responds to feelings
THEORY AND PRACTICE OF CRISIS INTERVENTION 127
of increased tension by calling forth the habitual problem-solving measures
in an effort to restore his emotional equilibrium.
2. Escalation-There is a rise in tension due to the failure of habitual problemSolving measures and the persistence of the threat and problem. The person's
functioning becames disorganized and the individual senses feelings
of upset and ineffectuality.
3. Crisis With the continued failure of the individual's efforts, a further
rise in tension acts as a stimuli for the mobilization of emergency and
novel problem-solving measures. At this stage, the problem may be
redefined, the individual may resign himself to the problem or he may
find a solution to it.
4. Personality disorganizationIf the problem continues, the tension mounts
beyond a further threshold or its burden increases over time to a breaking point.
The result may be a major breakdown in the individual's mental and social.
BALANCING FACTORS
In her seminal work on crisis, Donna Aguilera (1998) noted that the
equilibrium of people in crisis is significantly affected by three balancing factors:
their perception of an event, their support system, and their coping mechanisms.
Perception of an event refers to the importance of a problem to the individual in
crisis and includes such things as health, career, financial status, and reputation.
system refers to the resources possessed by the person in crisis, such as other
people the individual trusts who can provide support and assistance during a time
of need.

Coping mechanisms are skills or methods people use to reduce anxiety and solve
problems, such as reasoning, meditation, physical exercise, sleep, and denial.
CRISIS IN RESPONSE TO A STRESSFUL SITUATION DEPENDS UP ON
THE FOLLOWING THREE FACTORS
The individuals perception of the event- if the event is perceived realistically, the
individually is more likely to draw upon adequate resources to restore equilibrium.
If the perception of the event is distorted, attempts at problem solving are likely to
be ineffective, and restoration of equilibrium goes unresolved
The availability of situational supports-Aguilera stated situational supports are
those persons who are available in the environment and who can be depended on
to help solve the problem without adequate situational support during a stressful
situation, an individual is most likely to feel overwhelmed and alone.
The availability of adequate coping mechanisms-when a stressful situation occurs,
individuals draw up on behavioural strategies that have been successful for them
in the past. If these coping strategies work, a crisis may be diverted. If not,
disequilibrium may continue and tension and anxiety increase .
PARADIGM: THE EFFECT OF BALANCING FACTORS IN A STRESSFUL
EVENT:

TYPES OF CRISES
Although crises arise from many different sources, most healthcare professionals agree
there are at least three causal categories of crises: maturational, situational, and
adventitious (rare/unexpected/disastrous).
MATURATIONAL CRISES
Maturational crises have to do with the predictable transitions individuals
experience as they move from one stage of human development to another. In his
classic text, Erik Erikson (1963) identified eight stages of maturity delineated by
developmental tasks:
Infancy
Early childhood
Preschool

School age
Adolescent
Young adult
Mature adult
Late adulthood
He declared that each of these stages constitutes a crisis in personal growth and
development. For example, toddlers are developing autonomy and self-esteem and
may have a temper tantrum when they do not get what they want. Having a child and
retiring from the workforce are also situations that will cause major changes in what
an individual and/or family have previously considered normal. Taking a wait and
see approach has the potential to exaggerate the impact of the event.
Maturational crises are predictable and can be prepared for and prevented.
Proactively identifying actual or possible changes that the event will cause and then
taking steps to become more prepared for those changes can minimize the disruption.
For example, a young couple can take parenting classes to help prevent pediatric
head trauma that could result from shaking their infant out of frustration during a
period of uncontrollable crying.
SITUATIONAL CRISES
Situational crises arise from an external source and are events or circumstances
that threaten the physical, social, and psychological integrity of individuals. These
events may originate in the physical body as a result of disease or injury or in social
or emotional situations, such as the loss of a job or death of a child. Sometimes
maturational and situational crises occur at the same time, and occasionally, one
crisis triggers another, compounding the problem.
For example, a teenage boy and girl are attracted to one another and experiment
with sexual intimacy. When the menstrual period of the girl is late, both adolescents
are thrust into a state of emotional disequilibrium as they experience both the
maturational crisis of adolescence and the situational crisis of a potential pregnancy.
The actions they take to resolve the crisis may thrust them into even greater
confusion and tumult.

ADVENTITIOUS CRISES
Adventitious crises have been called events of disaster. They are rare,
unexpected happenings that are not part of everyday life and may result from 1)
natural disasters, such as floods, fires, and earthquakes; 2) national disasters, such as
airplane crashes, riots, and wars; 3) interpersonal disasters, such as assault and rape;
and 4) acts of terrorism.
The National Incident Management System (NIMS) provides a systematic
approach to the work necessary during such disaster situations (FEMA, 2013).
Training material for Community Emergency Response Teams (CERT) can be found
on their website (see Resources at the end of this course)
crisis are periods of psychological and behavioural upset precipitated by life
hazards that usually inflict significant losses on the individual (e.g. accident). Caplan
has used Erikson's classification in his theoretical development of crisis reactions. He
has emphasized that developmental and accidental crises are transitional periods that
present the individual. with both an opportunity for personal growth as well as for
deterioration.
BALDWIN (1978) has developed a classification of emotional crises
that includes six types of crisis situations:
1. Dispositional crises produced by problematic situations that can
be remediated through an appropriate management such as making a
referral, providing information and/or education, making administrative
changes, etc.
2. Crises of anticipated life transitions, that reflect normal life transitions
over which the person may have little control.
3. Crises resulting from traumating stress, which are precipitated by
externa1 stressors or situations that are unexpected, uncontrolled and
emotionally overwhelming.
4. Maturational/developmental crises, that result from attempts to
deal with interpersonal situations that reflect interna1 unresolved problems.
5; Crises reflecting psychopathology, in which pre-existing or current
psychopathology complicates their resolution.
6. Psychiatric emergencies, in which general functioning is severely
impaired.
Potential Crisis Situations
Common Crisis Situations

On a daily basis, situations arise that have the potential to adversely affect Special
Olympics business and reputation. When such situations develop, it is important for
the staff or volunteer who first learns of the situation to immediately inform his/her
supervisor. It is also important that volunteers are aware of what is considered to be a
potential crisis situation.
It is recommended that key volunteers receive the listing of potential crisis situations
so they may determine when to contact the appropriate Special Olympics contact.
Possible Crisis Situations and Levels of Impact
In the event of a crisis situation at any level, it is critical that the appropriate Special
Olympics Program staff or volunteers are contacted. It is also critical that the Crisis
Communications Manager is also contacted to determine how to communicate the
appropriate message to key publics and Special Olympics constituents.
Level 1
A minor incident or accident
Delayed event (but to be held the same day)
Sick participant not requiring hospitalization
Injured participant/spectator/volunteer treated on-site or taken to the
emergency room but released
Minor venue property damage
Severe weather watch
Level 2
A serious incident, accident or situation

Canceled event
Postponed event
Moved event/change of venue
Injured or ill participant/spectator/volunteer requiring hospitalization
Food poisoning/contamination
Allegations of wrongdoing by or arrest of a participant
Allegations of wrongdoing by or arrest of a spectator/volunteer/staff/guest or
celebrity (if financial, see level 3)
Missing participant
Illegal use of drugs/alcohol

Major venue property damage


Transportation accident
Severe weather warning
Honored Guest concerns, e.g.: crowds, protection, threats Contact Special
Olympics Regional Office Regional Office contacts Special Olympics
headquarters
Protests/Demonstrations Contact Special Olympics Regional Office
Regional Office contacts Special Olympics headquarters
Allegations or actions against an organization that impacts Special Olympics
(i.e., Paralympics, INAS) Contact Special Olympics Regional Office
Regional Office contacts Special Olympics headquarters
Attack by the media against Special Olympics or constituents Contact Special
Olympics Regional Office Regional Office contacts Special Olympics
headquarters
Negative campaigning against Special Olympics or Special Olympics-involved
party Contact Special Olympics Regional Office Regional Office contacts
Special Olympics headquarters
Alleged discrimination against Special Olympics participant within or outside of
Special Olympics Contact Special Olympics Regional Office Regional
Office contacts Special Olympics headquarters

Level 3
A critical incident or situation
All situations considered Level 3 should follow these channels of communications:
Special Olympics Program office Contact Special Olympics Regional Office
Regional Office contacts Special Olympics headquarters
National/State or Provincial declared emergency (e.g., natural disaster, power
outage, terrorist attack).
Actual impact of severe weather (e.g., hurricane, tornado)
Flood (if it shuts down office operations)
Bomb threat
Contagious health threat or outbreak
Missing participant or volunteer under suspicious circumstances
Death of a participant
Death of spectator or volunteer
Fire
Criminal activity

Financial fraud or fundraising scandal


Sexual abuse
SUDDEN CRISIS
We define a sudden crisis as a disruption in the company's business that occurs without
warning, including fires, explosions, natural disasters and workplace violence and may
adversely impact:

Employees, investors, customers, suppliers or other publics


Offices, plants, franchises or other business assets
Revenues, net income, stock price, etc.
Reputation
Here are some examples of a sudden crisis:

A business-related accident resulting in significant property damage that will


disrupt normal business operations

The death or serious illness or injury of a manager, employee, contractor, customer,


visitor, etc. as the result of a business-related accident

The sudden death or incapacitation of a key executive


OPERATIOAL CRISIS
Rogue employees may cause companies share prices to dip sharply in the short term
but it is the slow-drip of bad news caused by operational crises such as environmental
disasters that do most damage to company value.
Scandals that can be characterised as behavioural, such as illegal price-fixing or rogue
trading, can cause share prices to lose as much as half their value on the day news
breaks. But most companies can recover this loss within six months, new research
shows, highlighting the importance of how bad news is managed.
By contrast, events that go to the core of a companys operations, such as an oil spill
or product recall, may not have such a dramatic short-term effect but may be more
insidious in the longer term, according to an analysis of 78 major crises suffered by
publicly listed companies around the world since 2007.
NATURAL DISATER
A natural disaster is a major adverse event resulting from natural processes of the
Earth; examples include floods, volcanic eruptions,earthquakes, tsunamis, and other
geologic processes. A natural disaster can cause loss of life or property damage, and
typically leaves some economic damage in its wake, the severity of which depends on
the affected population's resilience, or ability to recover.
An adverse event will not rise to the level of a disaster if it occurs in an area without
vulnerable population. In a vulnerable area, however, such as San Francisco, an

earthquake can have disastrous consequences and leave lasting damage, requiring
years to repair.
In 2012, there were 905 natural disasters worldwide, 93% of which were weatherrelated disasters. Overall costs were US$170 billion and insured losses $70 billion.
2012 was a moderate year. 45% were meteorological (storms), 36% were hydrological
(floods), 12% were climatological (heat waves, cold waves, droughts, wildfires) and
7% were geophysical events (earthquakes and volcanic eruptions). Between 1980 and
2011 geophysical events accounted for 14% of all
FINANCIAL CRISIS
The term financial crisis is applied broadly to a variety of situations in which some
financial assets suddenly lose a large part of their nominal value. In the 19th and early
20th centuries, many financial crises were associated with banking panics, and many
recessions coincided with these panics. Other situations that are often called financial
crises include stock market crashes and the bursting of other
financial bubbles, currency crises, and sovereign defaults. Financial crises directly
result in a loss of paper wealth but do not necessarily result in changes in the real
economy.
Many economists have offered theories about how financial crises develop and how
they could be prevented. There is no consensus, however, and financial crises continue
to occur from time to time.

CRISIS INTERVENTION
Crisis Intervention is emergency psychological care aimed at assisting individuals in
a crisis situation to restore equilibrium to their bio psychosocial functioning and to
minimise the potential for psychological trauma.
The priority of crisis intervention and counselling is to increase stabilization. Crisis
interventions occur at the spur of the moment and in a variety of settings, as trauma
can arise instantaneously. Crises are temporary, usually with short span, no longer than
a month, although the effects may become long-lasting.
Crisis Intervention is the emergency and temporary care given an individual who,
because of unusual stress in his or her life that renders them unable to function as they
normally would, in order to interrupt the downward spiral of maladaptive behavior and
return the individual to their usual level of pre-crisis functioning.
DEFINITION

Crisis can be defined as ones perception or experiencing of an event or situation as an


intolerable difficulty that exceeds the persons current resources and coping
mechanisms.
PRINCIPLES OF CRISIS INTERVENTION
Establish a Relationship
The counsellor must establish rapport and trust with the addicted client and his
support system to begin the process from crisis to recovery. The client will trust the
counsellor who offers him respect and hope for change, provided the client is willing
to admit there is a problem and he desires the change. Even if the client desires
change, he will resist help if a trusting relationship is not established first. The
counsellor may help the family to schedule an intervention, which may help open the
door for the counsellor to establish a working relationship with the client.
Assess and Define
The client and the counselor work together to assess the situation and define the
problem. The counselor may employ questionnaires, assessment processes and direct
counseling with the client. The counselor may also discuss any previous methods the
client has tried to make changes in her life and addictive behavior.
Process the Trauma Cycle
Next, the client and counselor discuss any precipitating events that pushed the client
to choose addictive coping mechanisms. The counselor will employ active and
compassionate listening as the client expresses her emotional response to life events.
This process must occur in a nonjudgmental environment where the client feels safe
and free to share.
Problem Solving
The client and the counselor may discuss a variety of options the client can use to
move from the current situation toward recovery. The counselor will often know
options the client and support system are unaware of. The client and the support
system may explore each alternative and determine which alternative is most in line
with the resources and needs of the client.

Mobilizing Resources
Once a plan is formulated, the counselor works with the client and support system to
begin implementation. The counselor may help the client move directly to treatment
by helping to arrange for in-house care and transportation. If the choice is to use outpatient treatment, the counselor may continue to work with the client.
Termination of Agreement
Once the client moves into a treatment program, the counselor can terminate the
client-counselor relationship so the treatment program can work with the client. The
counselor may continue to work the support system to help them recover and avoid
enabling the client into further addictive behavior.
CRISIS INTERVENTION GUIDELINES
Every crisis is different, but all crises require immediate intervention to
interrupt and reduce crisis reactions and restore affected individuals to precrisis
functioning. Crisis interventions provide victims with emotional first
aid targeted to the particular circumstances of the crisis (Rosenbluh, 1981).
Several guiding principles are involved in crisis intervention; some key principles
are outlined below (Shapiro & Koocher, 1996).
Making an accurate assessment is the most critical aspect of a crisis response
because it guides the intervention. A wrong decision in response to a crisis can
be potentially lethal. Although situations may be similar, each person is unique;
therefore, care must be exercised to avoid overgeneralizing.
The ability to think quickly and creatively is crucial. People under crisis
sometimes develop tunnel vision or are unable to see options and possibilities.
The crisis responder must maintain an open mind in order to help explore
options and solve problems in an empowering manner with those affected.
People in crisis already feel out of control; when opportunities to restore control
present themselves, they should be grasped quickly.
The responder must be able to stay calm and collected. Crisis work is not
suitable for everyone. It requires the ability to maintain empathy while
simultaneously avoiding subjective involvement in the crisis.
Crisis intervention is always short term and involves establishing specific
goals regarding specific behaviors that can be achieved within a short
time frame. For example, in response to a suicidal client, a therapist
may increase the frequency of therapy sessions until the clients ideation
subsides. Management, rather than resolution, is the objective of crisis
interventions.

Crisis intervention is not process-oriented. It is action-oriented and


situationfocused Crisis interventions prepare clients to
manage the sequelae of a specific event. Therapists help clients recognize an
events impact and anticipate its emotional and behavioral consequences.
Furthermore, clients learn to identify coping skills, resources, and support
available to them. They learn to formulate a safety plan in an effort
to cope with the current and anticipated challenges the event presents.
A crisis is characterized by loss of control and safety. This loss makes it
incumbent on the helper to focus on restoring power and control in the clients
internal and external environment (Yassen & Harvey, 1998).
The goal is not to ask exploratory questions, but rather to focus on the present
(here and now). The crisis responder merely acts as an emotional support at
a time when self-direction may be impossible (Greenstone & Leviton, 2002).
Therapists do not attempt to change clients, but serve as catalysts for clients
discovery of their own resources, which they can then use to accomplish their
goals (Saleebey, 1997).
Since crisis intervention is the first intervention that a client may encounter after
a calamity, the goal is always to reestablish immediate coping skills, provide
support, and restore pre-crisis functioning.
Crisis intervention requires responders to possess familiarity with the work
setting.The ability to direct people to local shelters and other safe places and to
offer help in locating loved ones is crucial in this work.
Viewing the client holistically, rather than isolating the individuals emotional
and cognitive functioning, will provide insight into the resources and support
available to the victim.
A solid training in crisis intervention (with a focus on identifying suicidal and
homicidal ideation) as well as experience in counseling is indispensable.
Finally, although crises are universal and affect people from all cultures,
culture mediates how individuals and communities express crisis reactions
and how they ask for and accept help (Dykeman, 2005). Since culture defines
individuals pathways to healthy adjustment and how they reconstruct their
lives after a crisis, the crisis responder has to be multiculturally competent.
Approaches
Integration of various approaches is required to help families accomplish their goals.
These approaches, as described below, include: community system and use of
community resources; multiple impact or multimodal; cognitive-behavioral or
rational-emotive; task-centered; family treatment; and eclectic.

A "Community Systems" and "Use of Community Resources" Approach


Total family involvement is of paramount importance to crisis intervention. Similarly,
successful crisis workers find that coordination and involvement of all available
community agencies and resources are of paramount importance to successful
resolution of most crises. System-centered or person-in-situation perspectives place
less emphasis on pathology and more on the interaction of the client with
environmental systems.
When addressing the needs of families in crisis, close cooperation between community
services assures the maximum benefit from utilization of resources. Poor
communication and lack of coordinated efforts between health, legal, social service,
education, volunteer, and church-related resources can create extreme frustration for
families who are in crisis. For instance, many clients have grown to distrust agencies
that promise cooperation from other organizations. Often, they have been told that an
agency would help, only to learn that they are ineligible, must go on a waiting list,
must subscribe to the helper's value system, or must accept a substitute service. Even
worse, some clients have been criticized and humiliated for not understanding agency
eligibility requirements.
To provide stability and consistent support for families, crisis workers can guide them
to appropriate organizations and services, but it helps when crisis workers give the
name of a specific person rather than simply a telephone number. During the initial
crisis, crisis workers may even need to accompany the clients to appointments. As the
family begins to stabilize, members can be expected to take more individual initiative.
As a support system, the crisis worker should always be available by phone or beeper.
Advocacy for clients, helping them access and use resources, dramatically enhances
the therapeutic relationship.
Abusive families' diverse needs require services from a plethora of organizations,
since no one agency controls and delivers investigation, crisis intervention, concrete
services, long-term treatment, and the variety of health, social, legal, housing,
education, employment, mental health, spiritual, welfare maintenance, and other
necessary service components for successful crisis resolution. So-called "wraparound" services provide whatever the family thinks it needs in order to stabilize.
Obviously, this requires strong, collaborative efforts among community resources. As
Fandetti states in Issues in the Organization of Services for Child Abuse and Neglect,
"Children at risk of placement because of abuse and neglect require tight rather than

confused and loosely organized networks of service, interlocked rather than


fragmented services and agency policies."
Respite child care from a parent aide, day-care placement, a baby sitter, or recreational
agency placement may give the parents the free time needed for relief of tension and
time to focus on them selves. Medical attention, Alcoholics Anonymous or Narcotics
Anonymous meetings, or a contact regarding better housing may reduce day-to-day
stress. Development of a joint service treatment plan with the family, CPS, and other
crisis workers demonstrates how various resources can cooperate to everyone's
satisfaction.
Throughout crisis intervention, the crisis worker must make repeated contacts with
other providers. Division or disagreement between agencies will feel like rejection to
clients who experience chaos and disorganization not only as emotionally hurtful but
also as irreversible.
The crisis-intervention team, a child and family advocacy organization, or a social
service agency needs to assume leadership in bringing community organizations
together to develop trust and exchange information on missions and programs. If
possible, a community committee should be developed to study gaps in services and
coordinate existing services. This is more a responsibility for administrative personnel,
but every person who is concerned about families in crisis needs to advocate for
coordination and collaboration and participate in both formal and informal
coordinating committees.
The Multiple Impact or Multimodal Approach
The value of the multiple-impact approach, using many crisis workers, has been
recognized for well over a decade, as has the efficacy of a generalist-specialist team
for dealing with family and community-wide dysfunction. The generalist-specialist
team model incorporates professionals with specialized training, such as child
development, sexual abuse assessment, or behavioral management, along with team
members who are broadly trained so that consultation is maximized for all team
members. Ultimately, to be effective, the team needs to maintain strong relationships
with public and community service systems which address additional child and family
needs.
Several programs have demonstrated that multiple impact and multimodal
interventions are effective with even the most chaotic families.

Multiple Impact Therapy (MIT) assigns therapists, students, or volunteers to each


family member for an hour or so of assessment and on-going treatment. The initial
session may be with the entire family and with the many therapists assigned to each
member, and there may be some individual time spent with specific family members.
Ultimately, all family members and all therapists come together. Family members may
be asked to observe while each therapist role plays a family member, who sits by the
therapist, saying what the family member feels and wants from other family members.
If a family member feels misrepresented, a timeout may be called for consultation with
the therapist who is representing him or her. The therapist uses "I" messages to express
how things in the family look from his or her perspective as a family member. This
process takes several hours since family members are encouraged to say how they feel,
what else they want to clarify, and what they want to work on in the future.
For crisis treatment beyond the first day or two, only one crisis worker may be
assigned or, if it seems necessary, more than one. This is when well-trained students or
volunteers can be an extremely cost-effective part of the continuing process. Even if
only one crisis worker is assigned for ongoing treatment with the family, there is now
a cadre of consultants who know the family from firsthand experience.
Some authors find that "the literature clearly indicates that multimodal interventions
tailored to the subjects' deficits should be implemented rather than [provision of one
type of program (e.g., parent education)] that emphasizes one or two factors for all
abusers." They add that family, community, and social supports are part of adequate
interventions.
Cognitive Behavioral Approach
Clients' belief systems and their thought processes can contribute to their abusive or
victimized behaviors. Cognitive behavioral therapy assumes that clients have
irrational, maladaptive beliefs that require cognitive restructuring. Behavior therapy is
effective in child management, parenting, and parent training and, more recently, in
shaping adult behavior. Many authors have outlined specifics of behavioral assessment
and treatment.
Briefly, cognitive behavioral therapy is designed to identify specific, undesirable target
behaviors through listening to the opinions of individual family members and the
family as a group. The listener attempts to identify the antecedents to undesirable
behavior (what set it off). New instructions, or new behavior by other family members
or a certain family member, replace the antecedents. Desirable responses are agreed

upon through a contract with family members. Reinforcements are provided when
family members exhibit a desirable response, and consequences are provided if
behavior is undesirable. Consistency is critical in both the approval (reinforcements)
and disapproval (consequences) of behavior. Positive results, or bonus reinforcements
such as family outings or free meals, can be given when behavioral objectives are
achieved. Consistency and follow through are essential to success.
Task-Centered Approach
Task-centered methods of treatment seem to merge well with crisis intervention theory
and practice, with research indicating that these methods are effective with a broad
range of clients. Uncontrolled studies on the effectiveness have been conducted in
medical, family, child guidance, psychiatric, school, corrections, and public-welfare
settings. Controlled studies in a school system and a psychiatric clinic in southside
Chicago rendered very positive results, as did a suicide prevention study and group
treatment of delinquent youth. Contracting, task planning, incentives, and homework
assignments, which keep families practicing communication and problem-solving
tasks between meetings with the crisis worker, are effective in moving the family
toward independence and nonabusive behaviors.
The Family Treatment Approach
In conventional family treatment, therapists permit situations to develop which
demonstrate how the family interacts and functions. The therapist then tries to engage
the most influential members to assure their active involvement in ongoing treatment.
Just as in crisis intervention, active listening comes first.
As with crisis intervention the major focus is on the family system rather than one
individual. In no way, however, does this prevent the therapist from being aware of
assigned family roles ("he is the mentally ill one"), scapegoating ("he is the cause of
our problems"), or triangulation ("detouring" of parental problems through the child)
within the family.
Family secrets, myths, enmeshment, dyads, triads, and schisms give clues to why the
family has become so dysfunctional and what was brewing underneath the surface
before the crisis-precipitating event.
Family treatment is inseparable from crisis intervention, and, in addition to being more
cost effective for most children and families, family preservation is more desirable
than separation.

The Eclectic Team Approach


In an eclectic team approach, team members use their varied knowledge and expertise
to assess and manage the presenting crisis. Using their different perspectives, team
members work with the family during the initial crisis response, developing a brief
treatment plan with specific strategies to foster crisis resolution and healthy family
functioning. If only one team member establishes direct contact with the family in
crisis, that member consults with other members to ensure that assessment, treatment
planning, and treatment techniques incorporate the full team's knowledge and
experience.
Interdisciplinary teams, composed of individuals who are eclectic in their training and
perspectives, bring a plethora of possible resources and resolutions to any crisis
situation. The team's varied perspectives, in conjunction with the clients' innate
resources or strengths, are powerful forces that support the clients in steadily lifting
themselves out of the crisis. Note that the intervention team strives to not do the work
"for" the clients. Instead, the eclectic knowledge is shared with the clients, enabling
them to choose problem-solving strategies that restore their sense of well-being and
ability to cope.
Eclecticism allows crisis workers to determine which theoretical approach, or
combination of approaches, fits the crisis situation best. For instance, the task-centered
approach draws from behavioral, communications, problem-solving, and familytherapy models, and assigns "homework" to clients. On the other hand, the cognitive
behavioral approach is particularly effective in changing behavior of children and is
one of the major theories for work with adults as well. Cognitive theory encourages
clients to think through problems and to plan solutions thoughtfully, believing that
"emotions, motives, goals, and behavior are conscious phenomena that are usually the
consequences of thought."
Other approaches are considered, as well, by the eclectic team. For example, the
family-treatment approach focuses on failures of role performance as a parent or
spouse, and considers role confusion and role reversal to be present in sexual and
physical child abuse cases.
Transactional analysis was founded on the belief that people have the power to think,
act, and make positive changes, allowing them to feel OK about themselves and
others. Systems theory is akin to ecological and family-centered approaches in that it
is concerned about the individual and family in the social environment. Existentialism

emphasizes the uniqueness of each client and each situation and allows for openness,
empathy, and honest-but-respectful feedback to clients. Existentialists use
"provocative contact" in assertively provoking "hard-to-reach" clients toward wanting
change in their lives. This offers clients an opportunity to at least consider the use of
behavior modification in making specific behavior or symptom changes.
Gestalt theory does not hypothesize about unobservable systems in the client's life, but
may ask the client to reenact his or her perceptions of them. Gestaltists look for
patterns or descriptions of interactions, which are not working, as opposed to
diagnoses or labels. Similarly, client-centered theory is opposed to diagnosing and
labeling, believing that families are capable of knowing and shaping what is best for
them.
TECHNIQUES
Special treatment techniques such as humor, generalization, self-disclosure,
storytelling, limit-setting, and instillation of hope are effective in crisis intervention.
By understanding client resistance, treatment outcomes are further enhanced.
Use of Humor
It is imperative for crisis workers to set aside time for client social activities and fun.
Many clients have never had fun. Good professional role models demonstrate a fun
loving sense of humour from time to time.
It is also helpful for crisis workers to respond to their own mistakes with humour.
When a verbal or tactical error is made in front of clients, crisis workers need to
demonstrate their comfort in laughing at themselves. This helps clients relax and
realize that professionals are not perfect and that they may be able to laugh at their
own mistakes someday, too. Words of caution are warranted here, however. Some
clients are prone to concrete interpretation of humour. In other words, if professionals
laugh at themselves or encourage clients to, these clients may feel emotionally
degraded. Some clients are ultrasensitive to teasing and require months of addressing
past trauma or verbal abuse before they can understand the subtleties of humour.
Generalization
Generalization is another good technique to use with clients in crisis. Saying "we all
get angry and don't know how to express it sometimes" is more effective than
implying that clients get angry and professionals never do.

Self-Disclosure and Storytelling


Clients need positive role models, but they are relieved to know that professionals are
human and sometimes struggle with emotions. The caution here is for the crisis worker
to focus on the clients' needs, rather than to vent personal frustrations. To tell a story or
two on how the crisis worker or someone else overcame similar problems, however,
may be helpful to clients. Crisis workers can test whether self-disclosure is appropriate
by honestly questioning, "am I doing this for my benefit or is it for the clients'
benefit?"
Setting Limits
All models of crisis intervention emphasize respect for the clients' culture and value
systems. Every model also emphasizes the importance of listening closely (for hours)
to what the clients are saying. This helps establish rapport but, more importantly,
determines what the family is motivated to do. It respects the family's wishes rather
than imposing the crisis worker's wishes or needs on the family.
In respecting and being accepting of clients, but not their inappropriate behavior, it
may be necessary to say specifically that child abuse and neglect are never acceptable.
Many clients need that directive because proper family values were not instilled during
their childhoods. Certain clients misinterpret crisis worker acceptance of them as full
agreement with their abusive actions. It may be necessary to state frequently that child
maltreatment is never an acceptable behavior. If not clarified, clients may assume that
the crisis worker approves of such behavior. When encouraging clients to discontinue
corporal punishment, for example, it is best to give specific instructions on use of
"timeout" for young children, choices and natural consequences for older children, and
the need for parents to learn active parenting skills.
Instilling Hope
A crisis worker's belief in self, personal enthusiasm, and ability to instill hope are
critical variables in crisis work. If the family senses that a crisis worker believes
positive resolution to the crisis is possible, then family members begin to feel
confident in their ability to bring about change.
Imparting hope requires crisis workers and clients to search for times in the past when
the clients almost succeeded, or did succeed, in finding solutions to similar crises.
Likewise, when clients are encouraged to try a new approach, rather than being
blamed for failure, hope springs forth. Words such as "when" and "will" should be
used rather than "if" or "maybe" when discussing plans.

When crisis workers keep their promises, clients begin to trust and to believe in
change. When clients and professionals form a positive "team" that builds on client
strengths, change occurs.
Working Through Resistance
By objectively, nonjudgmentally, and respectfully focusing on family strengths and the
immediate crisis, crisis workers can minimize client resistance during early
intervention. For example, the crisis worker should state the allegations of child
maltreatment and ask the family to clarify any discrepancies. Conveying hope that the
allegations can be worked through if the family cooperates is effective in moving the
family toward desired change. Family members need to know what they are expected
to do, what consequences they are facing, and what services they will receive if they
cooperate.
Crisis workers must be careful how they use their professional authority. If authority is
misused, parents may experience a double message: Parents should not misuse power
with their children, but professionals may misuse power with parents. Such double
messages create confusion and resentment. If crisis workers expect clients to be
effective parents, then they need to be role models of behavior for the parents.
Anything less is likely to create new crises, further weakening the family's level of
functioning.
In periods of crisis or disorganization, people may feel more inadequate, alienated, or
needy, thereby causing them to take on facades of adequacy, arrogance, or
dependency. They may withdraw or they may attack, according to what they perceive
as necessary for survival. They may act as if they need no help, even when they need it
desperately. Whatever the clients' facade, crisis workers must remember that families
in crisis crave respect, care, and compassion. They want to regain some semblance of
security and stability.
Often, CPS crisis workers complain that the "nonoffending parent" in sexual abuse
cases is passive or defensive and refuses to become involved in family treatment.
Instead, crisis workers need to evaluate whether the nonoffending parent has always
been defensive or passive. If it is new behavior, then the nonoffending parent is merely
frightened and afraid the family will be destroyed. Such fears can be honestly
recognized by the crisis worker. If the defensiveness is typical behavior, the
nonoffending parent will need to observe positive role modeling, have total honesty
from crisis workers, and receive training on how to respond more openly. In the

meantime, crisis workers need to realize that an accusation of abuse, the consequent
investigation, and an influx of various strangers into the home would make anyone
defensive.
By assessing the reasons for clients' recalcitrant behavior, crisis workers can then
address the clients' needs for answers or information. They may have many remaining
questions about the intervention. For example:
What further consequences may they expect?
What happens next?
What is expected of the family and its members?
Is the crisis worker a nonjudgmental, credible, honest, and respectful
professional?
What resources can the crisis worker and community offer that can help the
family?
Will the crisis worker listen to and respond to family needs?
Does the crisis worker see any strengths in the family?
Is the crisis worker implying that solutions to the crisis are available?
Is there hope for the future?
Rather than believing that clients are resistant, do not want to change, are denying
their problems, or are being deceitful, crisis workers need to believe clients when they
express a desire to reach a solution.75 When clients seem "resistant," it is best to
assume that they are merely frightened and hesitant about trying new behaviors or the
unfamiliar. They need crisis workers to be patient and listen to how they are feeling
and what they suggest for relieving the crisis. If crisis workers convey that clients are
the experts on what they want, and if professionals are honest with themselves about
what they are feeling, then they will give clients room to make the changes that they
need.
For instance, a nonoffending parent in a child sexual abuse case may be fearful of
losing her identity as a member of an intact family; her identity as wife of a certain
man; her identity as part of a neighborhood or a church; her identity as a member of a

respected family; her identity as part of a household which had a good income but
must now accept welfare benefits. A skillful crisis worker must be prepared to explore
all of these possibilities with the parent, rather than proposing "quick" solutions, such
as divorce.
If there is such a thing as resistance to change, some of the causes or sources may be:
uncertainty about change or fear of failure;
fear of loss of the familiar;
lack of confidence in the crisis worker;
lack of participation in developing crisis resolution goals;
inability to see change as a viable alternative;
inappropriate timing on the part of the crisis worker;
disruption of important, existing family or social relationships; and
belief that change equals criticism.76
Some interviewing techniques which can be used to work through client
resistance include:
active listening and reflection;
universalizing (normalizing);
partialization (breaking into several smaller issues) of problems, when the client
presents numerous issues;
ventilation of feelings (with closure before the interview ends);
summarization of client feelings after extended listening;
acceptance of the client, but not the client's abusive or neglectful behaviors;
logical, not rambling and disorganized, discussion;
education or information about crisis intervention, forthcoming events,
community resources, etc.;

setting boundaries and limits on behaviors and contracting on acceptable


alternatives;
concrete services such as housing, homemaker services, and respite care;
firm, but kind, confrontation regarding inconsistencies in the clients' statements
or behaviors;
reframing client statements or behaviors to find the positive aspects; and
joining client resistance by saying "why should you change?" The crisis worker
should not say this regarding acts of abuse or neglect or any criminal
behaviors.77
Crisis workers that maintain nonjudgmental attitudes, family involvement, and no
preconceived notions about a family's motivation have found that almost all families
are open to change for the better. A well-timed, quick response reinforces solutions to
a crisis in a limited period of time.
Solution-focused crisis workers are optimistic about substance-abusing, ghettoresiding, chronically disorganized, and even criminally involved families. This means
that they do not box families in; they do not categorize or reject them based on their
past behavior. Instead, a new, more-effective beginning is sought. Many of these
families welcome the opportunity to adapt in more socially acceptable ways. They
thought no one would ever give them the hope that they could change.
This is not to say that crisis workers should naively proceed as if they see no drug
dealing, prostitution, theft, sexual abuse, child abuse or neglect, or spouse abuse in
these families. It is rather a matter of being honest but not condescending, being a role
model but not acting superior, being a bearer of hope but not bringing false hope, and
being a trustworthy person even if family members are not.
Power struggles accomplish nothing of value in crisis intervention. The least
cooperative families may become the most receptive to positive change within a few
days, particularly if professionals accept them and help them find their strengths and
their solutions to the crisis. Professional commitment and positive attitude toward
short-term resolution of a crisis are sensed and appreciated by clients. They have a
sense of self-worth when crisis workers ask: "What do you want to happen?" "What do
you want to change?" "What do you want to do?" and similar questions that respect
clients' competence.

If crisis workers are respectful of culture and empathetic with the predicament in
which families find themselves, new horizons may start to open up. For many families,
crisis workers will only have time to help them stabilize, but can help them contact
other therapists and agencies where client culture is honored.78 Ultimately, crisis
workers who are effective listeners are so responsive to clients' needs that there is no
reason for clients to resist. This, however, takes great patience and a willingness to
meet clients' needs rather than crisis workers' needs.

MEDICAL/NURSING CARE PROCESS AND MENTAL HEALTH CRISES


The medical/nursing process is a five-part, systematic decision-making method
used to identify and treat responses of persons with alterations in mental or physical
health. Assessment, diagnosis, planning, intervention, and evaluation are the steps
used in the process of providing appropriate care for a person in crisis. This process
requires collaboration by many individuals working as members of a team to
improve the patients quality and enjoyment of life. Below is listed a range of
professionals who may comprise the team:
Patients are the most important members of any healthcare team.
Psychiatrists are physicians responsible for the diagnosis and treatment of
mental disorders. They prescribe medications and function as the leader of the
mental health team.
Medical doctors, physicians assistants, and nurse practitioners provide
ongoing management of physical healthcare concerns and assess for underlying
physical causes of symptoms.
Psychologists conduct psychological testing, interpret and evaluate their
outcomes, and implement programs of behavior modification.
Inpatient nurses (RNs, LPNs) provide holistic care by assessing patients mental,
social, physical, psychological, and spiritual needs; making nursing diagnoses;
formulating nursing care plans; providing nursing interventions; and evaluating
the outcomes.
Caregivers are nurse aides or psychiatric technicians who maintain the therapeutic
milieu, provide care under supervision, and contribute to the ongoing assessment
of patients.

Counselors and therapists identify problems a person is facing in various aspects


of life and help discover effective ways of dealing with them.
Social workers assess the patient, the family, and his/her community support
system. They help with discharge planning, counsel for job placement, and
advocate for the patients rights. They are skilled in interview techniques and
group dynamics.
Occupational therapists assess the interpersonal responses of patients and help
them adapt to their environment, cope with daily life, and integrate back into life
outside the healthcare setting. They supervise and assess peoples abilities to care
for themselves and may use different types of therapy on an individual or group
basis.
Community psychiatric nurses see people living in the community, provide
support, monitor medications, help with goal setting and getting patients involved
in finding work, and assist family and caregivers.
Each member of the team employs a variety of assessments, and together they
set goals and plan treatment.
ASSESSMENT
When the safety of a person in crisis is secured, the formal data-gathering process
begins. It is conducted in person or by telecommunications and starts with an
assessment interview. Of course, the interview is modified to match the
circumstances, age, and cognitive ability of the person in crisis.
INTERVIEW
The purpose is to assess the mental and physical status of the person and the
problem. Data collection is enhanced by information gathered from family members,
other healthcare providers, and authorities such as police officers. Professionals may
find the influencing (balancing) factors of crises a useful framework for an
assessment interview, specifically the persons perception of the event, situational
supports, and coping skills.
Perception of the event. Something has happened to create a crisis in a
persons life, motivating the person to seek help from a crisis hotline or emergency
department. By gaining information about the precipitating event, both healthcare

professionals and patients gain a better understanding of the problem. Questions


clinicians might ask about a precipitating event are:
What happened to make you so upset?
How are you feeling right now?
How does this event affect your life?
How will this event affect your future?
What needs to be done to fix the problem?
Situational supports. The support system of a patient includes the resources
available to the person in crisis. Family and friends, social clubs, church groups, and
networks of professional associates are all sources of support. When these resources
are not available, caregivers act as a temporary support system for the patient. The
plan of care should include the identification of a support system. Some questions a
clinician might ask about a support system are:
With whom do you live?
When you feel lonely and overwhelmed by life, whom do you talk to?
Is there someone in your life whom you trust?
In the past, during difficult times, whom did you want to help you?
Where do you go to school (to worship, to have fun)?
Coping skills. In crisis situations, it is important to evaluate the patients level
of anxiety and their usual coping methods. Some people drink, some eat, some sleep,
and some gamble. Others engage in physical activity, work harder, pick fights, or talk
to friends. Some questions clinicians may ask about coping methods are:
What do you do to make yourself feel better?
Did you try doing that this time?
If you did, what was different this time?

Have you thought of killing yourself or someone else?


How would you go about doing this?
MENTAL STATUS EXAMINATION
The mental status examination (MSE) is used to evaluate critical areas of
cognition and emotion. In psychiatry, the MSE is analogous to the physical
examination in general medicine (Varcarolis, 2013). Caregivers use their findings to
diagnose unmet needs, identify desired goals, and create a plan of care. In an
emergency, clinicians may need to modify the examination, however a complete
mental status examination includes the following.
ELEMENTS OF A MENTAL STATUS EXAM
Personal Information

Appearance

Behaviour

Speech

Affect and Mood

Thought

Perceptual Disturbances

Cognition

PHYSICAL STATUS EXAMINATION


A basic physical examination is essential at the initial in-person interview with
persons in crisis because medical conditions sometimes mimic psychiatric ones.
Furthermore, people with psychiatric disorders are more likely to have medical or
drug-related conditions. When an interview is conducted by telephone, the caregiver
should urge the caller to obtain a physical examination by a qualified clinician and
should provide a referral list for such services.
In an emergency situation, healthcare professional use what is called a focused
physical examination rather than a general examination, and if this suggests a need
for a general examination, then that is performed. The elements of a physical
examination are as follows:
ELEMENTS OF A PHYSICAL EXAMINATION

Measurements

Review of body systems

Medications

Last physical examination

Laboratory tests

DIAGNOSIS
After assessing the person in crisis, clinicians make a tentative diagnosis using
one of three major diagnostic classification systems, all of which identify the
problem or unmet need, the probable cause, signs and symptoms, and other
supporting data. These systems include:
International Statistical Classification of Diseases (ICD-10)
Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
Nursing Diagnoses: Definitions and Classifications (NANDA)
All caregivers need to be familiar with ICD codes and DSM-5 codes because
healthcare organizations and government agencies use these codes to pay clinicians
for their professional services.
ICD-10
The International Statistical Classification of Diseases, 9th Revision (ICD-9)
was adopted in the United States in 1979, and in 1988 Medicare required physicians
to report conditions using this code. In 1990 the International Statistical
Classification of Diseases, 10th Revision (ICD-10), was published by the World
Health Organization (WHO) and adopted worldwide in 1994. The United States was

ready at that time also to adopt ICD-10 to align with WHO and other countries, but
this was put on hold following the enactment of HIPAA (Health Insurance Portability
and Accountability Act) in 1996. Since then, legislative steps have been ongoing, and
in October 2014 ICD-10 becomes effective in the United States.
ICD-10 is not a revision of ICD-9 but rather a replacement that is more
clinically accurate and offers more available codes and a less-restrictive coding
structure (CDC, 2013). The ICD-10 classifies both psychiatric and medical
syndromes (clusters of symptoms) using a number and a word or phrase, such as
295.30 Schizophrenia, paranoid, or 577.1 Pancreatitis, chronic. The code
number facilitates research studies, demographic data collection, and the
reimbursement of providers.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) was
published by the American Psychiatric Association in 2013. DSM-5 is a standard
classification of mental disorders used by mental health professions and contains a
listing of diagnostic criteria for every psychiatric disorder recognized by the U.S.
healthcare system. It is used in both clinical settings as well as with community
populations. In addition to supplying detailed descriptions of diagnostic criteria,
DSM-5 is also used for collecting and communicating accurate public health
statistics about the diagnosis of psychiatric disorders (APA, 2014).
NANDA
A complete nursing diagnosis states a response to a health problem related to a
medical or psychiatric disorder, as evidenced by signs and symptoms exhibited by
the patient. For example, risk for suicide, related to depressed mood, as evidenced
by statements of patient and reckless behavior such as drinking and driving.
PLANNING
When clinicians assess a person in a mental health crisis and diagnose the
disorder, they and the patient decide what goals and outcomes are desirable and
feasible. They then determine the process by which each outcome can be achieved.
Naturally, outcomes depend on the setting and condition of the person in crisis.

For example, for a patient who hears voices telling him to hurt himself, a
NANDA diagnosis might be disturbed thought processes related to schizophrenia,
paranoid type, as evidenced by persecutory hallucination. The outcome criteria
might be to consistently refrain from doing what the voices command.
INTERVENTION
Interventions are the actions healthcare professionals take to achieve identified
outcomes. Such actions are based on the clinical knowledge, judgment, and skill of
the professional; how acceptable the intervention is to the person in crisis; and
whether the action is feasible given the circumstances of the individual.
When a patient is a danger to self or others, as with the patient who hears voices
telling him to hurt himself, it may be necessary to call the authorities for emergency
involuntary commitment, whereby the individual is restrained and taken to a locked
facility for evaluation and treatment. Emergency departments and telephone crisis
centers often develop standardized procedures called clinical protocols to assist
caregivers in giving more appropriate and effective emergency care to people in
crisis. For example, when a victim of sexual assault comes to an emergency
department, clinicians implement what is called a rape protocol. As well as
physical and forensic interventions, this type of protocol will include mental health
interventions such as:
Providing emotional support and privacy
Staying with the patient
Referring the person to a rape advocacy program
EVALUATION
The effectiveness of an intervention is judged by its outcome. When outcome
goals are met, the crisis is resolved, and the person in crisis is returned to a prior
level of functioning, then the healthcare professional can rightfully say the
intervention was successful. Ideally, as a result of the intervention and anticipatory
guidance, individuals who have been in a crisis also learn new coping skills, increase
their social support network, and are better equipped to cope with future disruptive
events in their lives.

EMERGENCY-PRODUCING CRISES
Emergency-producing crises can be grouped into five categories: 1) moodrelated (mania, depression, and suicide), 2) anxiety-related, 3) anger-generated, 4)
substance use, and 5) major mental illness. All of the conditions require immediate
assessment and knowledgeable interventions from caring professionals.
Mood-Related Crises
All people experience a range of moods, from great joy to profound sadness.
They express these moods in an array of behaviors, from laughing and smiling to
weeping and withdrawing. When moods become exaggerated at either end of the
emotional spectrum, they become disorders, limiting the ability of the person to
function socially or occupationally.
In their extremes, mood disorders produce the frenzy of mania, the melancholy
of depression, and suicide. When people experience mood disorders and seek help in
emergency departments or on crisis hotlines, clinicians need to recognize typical
symptoms, identify their cause, plan a course of action, implement the plan, and
evaluate its effectiveness.
MANIA
Manic episodes are periods of extreme elevation of mood when people feel
expansive, energetic, grandiose, and, sometimes, irritable and short-tempered.
Typical manic behaviors are:
Inflated self-esteem or grandiosity
Decreased need for sleep (feel rested after only 3 hours of sleep)
More talkative than usual or pressured to keep talking
Subjective experience that thoughts are racing or flight of ideas
Distractible, attention easily drawn to unimportant or irrelevant external stimuli
Intense, goal-directed activity either socially, sexually, or occupationally
Hyperactive behaviors and symptoms occurring in episodes of a week or more

Excessive involvement in pleasurable activities with a high potential for painful


consequences, such as unrestrained buying sprees, gambling, foolish business
investments, and sexual indiscretions
(APA, 2013)
Hypomanic episodes last less than a week and are more moderate than manic
episodes. The symptoms, though noticeable, are not severe enough to keep the
person from functioning. During these times many individuals are exceptionally
creative, productive, and focused, often becoming successful standup comedians,
performers, inventors, teachers, and artists.
Assessment: Caregivers assess patients who suffer mood
disorders for a potential danger to themselves and to others and
the need for hospitalization. Patients who are experiencing a manic
episode may not eat or sleep for several days, may harm
themselves or others because of their poor impulse control, and
may become exhausted to the point of death. Thus, emergency
assessment includes:
Medical status, by means of a physical examination to determine if mania is
primary or secondary to a medical condition or to a substance disorder
Behaviors that indicate a psychiatric condition, such as bipolar disorder and
schizoaffective disorder, using diagnostic criteria identified in ICD-10 and DSM-5
Level of understanding by patients and their family about the disorder, prescribed
medications, support groups, and medical care
Diagnosis
Medical Diagnoses. DSM-5 identifies mania as a symptom in all of the
following medical diagnoses:
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Substance/medication-induced bipolar and related disorder

Bipolar and related disorder due to another medical condition


Other specified bipolar and related disorder
Unspecified bipolar and related disorder
Caregiver/Nursing Diagnoses. Because patients exhibit constant and excessive
motor activity, poor judgment, difficulty evaluating reality, probable dehydration,
and lack of impulse control, the following NANDA diagnoses may be appropriate:
Risk for other-directed violence
Risk for self-directed violence
Risk for suicide
Ineffective coping
Defensive coping
Disturbed thought processes (delusions)
Disturbed sensory perception (hallucinations)
Impaired verbal communication
Impaired social interaction
Imbalanced nutrition
Deficient fluid volume
Self-care deficit
Disturbed sleep pattern
Planning
The goal of care for patients in an acute manic episode is to prevent injury and
instill hope for the future. Therefore, outcome criteria for the patient are as follows:

Be well hydrated within 24 hours, as evidenced by good skin turgor and normal
urinary output and concentration
Maintain or obtain stable cardiac status as evidenced by stable vital signs within
normal limits
Maintain or obtain tissue integrity as evidenced by absence of infection or wounds
Get sufficient sleep and rest as evidenced by 46 hours of sleep at night
Demonstrate self-control with the help of staff or medications as evidenced by
absence of harm to others
Make no attempt at self harm with the help of staff or medications as evidenced by
safety checks during acute mania
(Varcarolis, 2013)
Intervention
To meet outcome criteria and ensure safety, medical stabilization, and external
control, people in crisis manifesting manic symptoms need hospitalization. If they
are not cooperative and are a danger to themselves or others, emergency involuntary
commitment may be necessary (see Legal Issues above). To gain their cooperation
and communicate more effectively, clinicians:
Use short and concise statements and explanations
Use a calm but firm approach
Remain neutral, avoiding power struggles
Coordinate care with other staff members to avoid manipulation
Medications prescribed for acute manic episodes include:
Mood stabilizers and anticonvulsants: lithium and valproic acid
Atypical antipsychotics: olanzapine, risperidone, quetiapine
Typical antipsychotics: chlorpromazine, haloperidol

Benzodiazepines (anxiolytics): diazepam, lorazepam, clonazepam


The most successful treatment is with a combination of medications such as
lithium and quetiapine. Lithium and valproic acid are the drugs of choice for
maintenance therapy for persons with bipolar disorders (Preston et al., 2013).
Evaluation
The mental healthcare team achieves treatment goals when outcome criteria are
met, the person is safe, and families are informed of resources for ongoing
assistance. If these goals are not met, the team needs to begin the steps of the
medical/nursing process over again, adjusting the plan to make changes for the
future.
DEPRESSION AND SUICIDE
Depression is a dis-ease in a true sense of the word. Those who experience
depression feel sad, joyless, and empty. They believe that life is not worth living.
According to the World Health Organization (2012), depression is the leading cause
of disability worldwide. Depression is twice as common in women as it is in men
and is not related to education, income, ethnicity, or marital status. Many of those
who suffer from the disorder also suffer from anxiety. Typical symptoms of major
depression are:
Depressed mood most of the time
Lack of interest or pleasure in almost everything, most of the time
Significant weight gain or weight loss when not dieting
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue and loss of energy
Feelings of worthlessness and inappropriate guilt
Diminished concentration
Indecisiveness

Recurrent thoughts of suicide and death, but without a specific plan


Symptoms that are not attributable to the effects of a substance or to another
medical condition
Morbid preoccupation with worthlessness and guilt
Symptoms are not better accounted for by the normal grieving process
Clinically significant distress or impairment in social, occupation, and other areas
of functioning
(APA, 2013)
Adolescents with depression have most of those same symptoms, with the
addition of the following:
Anger or irritability, rather than sadness, as the predominant mood
Frequent unexplained aches and pains, such as stomachaches or headaches
Extreme sensitivity to criticism
Unlike adults who isolate from everyone, withdrawal from some, but not all,
people
(Smith et al., 2014)
Sufferers of persistent depressive disorder (dysthymia) have less severe
symptoms than those who suffer major depression. Nonetheless, the symptoms occur
over two or more years and cause significant distress in every area of life (APA,
2013).
Assessment
Guidelines for assessing depressed patients include the following:
Evaluate the persons risk of harm to self or others.
Perform a thorough medical and neurologic examination to determine if
depression is secondary to another disorder or to drugs.

Evaluate whether the person is psychotic, has taken drugs or alcohol, has medical
conditions, or has a history of psychiatric syndromes.
Ask if the person has a history of depression.
Assess support systems, family, significant others, and the need for referral.
In crisis situations, there may not be time to complete an assessment according
to these guidelines. Assessing a person in these circumstances requires observing for:
Verbal clues
o Expressing strong feelings of hopelessness
o Making covert statements such as Things will never work out
o Making overt statements such as I wish I were dead
Delusional thinking
o God wants me dead.
Cognitive function
o Slowed speech and understanding
o Difficulty concentrating or making up ones mind
Behavioral clues
o Psychomotor agitation
o Giving away prized possessions
o Acting recklessly
Affect
o Flat, without expression

o Exhibiting a sudden and unexpected improvement in affect after being


depressed or withdrawn
(Varcarolis, 2013)
The risk for suicide in people with major depressive disorder is higher than that
of the general public. It is the tenth leading cause of death in the United States and
third leading cause of death for ages 1524 years (NAMI, 2013a).
Guidelines for assessing suicidal patients include the following:
Assess risk factors, including history of suicide, degree of hopelessness and
helplessness, and lethality of plan (gun, poison, hanging).
If there is a history of suicide attempts, assess intent, lethality, and injury.
Determine whether the patients age, medical condition, or psychiatric diagnosis
puts the person at higher risk.
Note whether a patients mood changes suddenly from sadness to a happier state.
Often a decision to commit suicide gives a feeling of relief and calm.
If the patient is to be managed on an outpatient basis, assess social supports and
knowledge of potential suicide signs.
ASSESSMENT QUESTIONS FOR THOSE AT RISK OF SUICIDE
Are you feeling hopeless about the present or future?
Have you had thoughts about taking your life?
When did you have these thoughts?
Have you ever attempted suicide?
Do you have a plan to take your life?
Have you ever had a suicide attempt?
Source: U.S. Dept. of Veterans Affairs, 2011.
CASE

SHEILA
Sheila came to the community counseling center for help. She told Mary, the
counselor, that the man she had been dating had left her and returned to Mexico to
marry a girl from his home village. Sheila burst into tears: I dont think I can live
without him.
Mary listened attentively and asked, Have you been thinking about not living?
Sheila nodded and whispered, Yes, and began to sob. The counselor said, And
what have you thought about doing? After a long pause, Sheila said, I just want to
go to sleep and never wake up.
Mary hypothesized that Sheila did not have a specific plan to end her life but
was at risk of overdosing on alcohol or drugs, the most common means women use
to commit suicide. She told Sheila to refrain from taking alcohol in any form until
she felt better; asked if Sheila had a friend or relative who could stay with her for a
few days, just to be there for her; gave Sheila her card and the crisis hotline number
to call if she felt like harming herself; and referred Sheila to a support group of
others who had suffered loss.
(continues)
Diagnosis
Medical Diagnoses. The APA (2013) recognizes eight types of depressive
disorders that do not have manic features. The eight types of depressive disorders
are:
Disruptive mood dysregulation disorder in children
Major depressive disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
Substance/medication-induced depressive disorder
Depressive disorder due to another medical condition
Other specified depressive disorder

Unspecified depressive disorder


Caregiver/Nursing Diagnoses. Because depressed individuals have many
needs and may suffer from other psychological and physical disorders, numerous
nursing diagnoses may be appropriate. However, risk for suicide is a constant. Other
diagnoses may be:
Hopelessness
Ineffective coping
Social isolation
Spiritual distress
Self-care deficit
Powerlessness
Chronic low self-esteem
Imbalanced nutrition
Sexual dysfunction
(NANDA, 2014)
Planning
The planning of care for depressed individuals in crisis is based on the
circumstances that bring them to emergency care. For example, the outcome criteria
for the nursing diagnosis of risk for suicide might be: Patient will 1) value and
nurture himself/herself and 2) refrain from hurting himself/herself.
When depressed persons are judged to be a danger to themselves or others,
clinicians must consider the need for emergency hospitalization (see also Legal
Issues above).
Intervention
There are three phases in the treatment and recovery of persons with major
depression:

Acute phase (612 weeks). The goal of treatment is to reduce depressive


symptoms and restore psychosocial and work function. Hospitalization during this
phase may be necessary.
Continuation phase (49 months). The goal of treatment is to prevent relapse
with pharmacotherapy, education, and depression-specific psychotherapy.
Maintenance phase (1 or more years). The goal of treatment is to prevent further
episodes of depression.
Antidepressant interventions are classified as first line (preferred) and second
line (back-up, used when a preferred intervention cannot be used).
First-line interventions include:
Selective serotonin reuptake inhibitor (SSRI) drugs
Serotonin/norepinephrine reuptake inhibitor (SNRI) drugs
Atypical, newer antidepressant drugs
Cyclic antidepressants, such as tricyclic drugs
Second-line interventions include:
Monoamine oxidase inhibitor (MAOI) drugs
Electroconvulsive therapy (ECT)
For children and adolescents, SSRI drugs are the preferred pharmacological
treatment for depressive disorders (Halverson, 2014). The FDA warns, however, that
antidepressants can increase the risk of suicidal thoughts and behavior in children,
adolescents, and young adults ages 1824 during initial treatment (FDA, 2013).
The most common psychosocial interventions for depression include:
Psychotherapy
Cognitive-behavioral therapy
Interpersonal therapy

Problem-solving therapy
Supportive therapy
Psychosocial intervention
Bereavement groups
Family counseling
Participation in social events
Psychoeducation
Exercise
Nursing interventions for severely depressed patients include providing food
and fluids, suicide precautions, personal hygiene, supportive communication, and
psychotherapy using cognitive-behavioral, psychodynamic, and interpersonal
approaches. If a person is hospitalized because they are deemed at risk for suicide,
suicide risk precautions are implemented.
Suicide risk precautions include:
Search patient and belongings for harmful objects.
Make sure visitors do not leave potentially harmful objects or gifts in patients
room.
Keep electric cords to minimal length.
Hang-proof and jump-proof bathrooms.
Provide plastic eating utensils.
Do not assign patient to a private room.
Lock utility rooms, kitchens, stairwells, windows, and offices.
Conduct one-to-one nursing observations and interaction 24 hours a day.

Occupational therapists most often work in hospital settings and provide


interventions to help patients with depression examine how to balance leisure, work,
and relationships so they are able to meet the responsibilities of the roles that are
meaningful to them.
Evaluation
Treatment of depressed persons is considered successful if, after treatment, they
are able to think clearly, behave appropriately, and express greater hope and selfesteem.
CASE
SHEILA (continued)
Eight days following her visit to the community counseling center, Sheila was taken
to the emergency department by a coworker, Liz, who stopped by to see why Sheila
had been absent from work for the past week. Liz said that she found Sheila lying on
the sofa, tearful, and saying she wanted to die.
When Sheila arrived at the hospital emergency department, she was interviewed
by a nurse, who obtained her history. Sheila indicated she had not attended the
recommended support group and had forgotten about the hotline number the
counselor had given her. The nurse noted that Sheila had a very flat affect, her
speech and movements were slow, and she had problems understanding some of the
questions asked. She was unkempt and admitted that she had not been eating or
drinking much over the past week. She denied using any medications or alcohol
during this time. Sheila told the nurse, I dont want to live anymore. Im so tired.
The nurse asked Sheila if she was thinking of harming herself, and Sheila
replied that she was. She admitted that she was planning to lay in a tub of hot water
and slit her wrists, but I havent gotten the energy to do it so far. The nurse
assigned an ER tech to stay with Sheila until the emergency department physician
could see her.
The ED physician interviewed Sheila, performed physical and neurological
examinations to rule out medical conditions, and recommended she be hospitalized
for treatment of major depression with the need for suicide precautions. Sheila
agreed to voluntarily enter the hospital.

Nursing diagnoses for Sheila on admission included:


Risk for suicide, related to depressed mood, as evidenced by statements of patient
Hopelessness, related to depressed mood, as evidenced by statements of patient
Self-care deficit, related to depressed mood, as evidenced by statements of patient
and patient appearance
Imbalanced fluids and nutrition, related to depressed mood, as evidenced by
statements of patient
Her care plan included:
Appropriate medications
Serial laboratory tests to accurately determine her fluid and electrolyte status
A nutritional assessment leading to a meal plan including preferred foods, small
frequent meals and snacks, and documentation of food intake
Individual and group therapy
Assistance with and reinforcement of personal care practices
Suicide precautions
Early start of discharge planning to allow adequate time to develop an outpatient
support plan
Anxiety-Related Crises
Anxiety is a feeling of apprehension, uneasiness, uncertainty, or dread resulting
from real or imagined threats whose actual source is unknown or unrecognized.
Unlike fear, which is a reaction to a specific danger, anxiety affects us at a deeper
level. Anxiety invades the central core of the personality. It erodes the individuals
feeling of self-esteem and personal worth (Varcarolis, 2013). Anxiety disorders
develop from a complex set of risk factors, including genetic, brain chemistry,
personality, and life events (ADAA, 2011).

Normal anxiety is a natural response to the demands of life. It provides energy


to achieve goals and carry out the activities of daily living. It energizes people and
helps them manage the usual demands of life, including such things as arriving for
work on time, fulfilling commitments, and pursuing worthwhile goals.
Acute anxiety is a sudden, intense feeling of fear caused by an imminent threat
to ones sense of security. It is the feeling new graduates may experience as they sit
for a licensing examination, singers may experience as they walk to center-stage to
audition for a leading role, and patients may feel as they climb into a dentists chair.
Like other emotions, the intensity of anxiety varies with the situation, ranging from
mild to panic.
Mild anxiety can improve performance, sharpen focus, increase attention, and
help people grasp information. Even so, as anxiety increases, the perceptual field
narrows and people are less able to see, hear, and grasp information. Their ability to
think lessens, and their bodies respond with profuse perspiration and rapid pulse and
respirations.
As anxiety intensifies to severe, people feel dazed and confused, unable to solve
problems or focus on more than one thing at a time. They may feel dizzy and
experience a sense of impending doom.
Panic is the most extreme level of anxiety. Persons experiencing panic have a
sudden, overwhelming fear, with or without cause, which produces hysterical or
irrational behavior. They may behave automatically, lose touch with reality, and
experience false sensory perceptions.
Chronic anxiety is a long-lasting, fear-based condition that persists over many
years. Children with this condition appear apprehensive and high-strung. Adults with
the disorder experience unrelenting angst and often develop physical and emotional
disorders such as insomnia or chronic fatigue syndrome.
Self-harm is the most severe complication of acute anxiety and panic. The
majority of persons experiencing acute anxiety or panic do not really want to die, but
they genuinely want to break free from suffering. They may see suicide as a way to
escape from oneself, rather than from daily life.

ASSESSMENT
As with everyone who comes to an emergency facility for help, a physical
examination and at least a modified mental status examination should be performed.
Although all anxiety disorders are fear-based, the symptoms they display differ
greatly.
Assessment guidelines for anxious individuals in crisis include the following:
Assess for potential self-harm, because people with high anxiety are more likely to
become desperate and suicidal.
Conduct a physical and neurologic examination to determine whether the anxiety
is the cause or the result of substance use or a medical or psychiatric disorder.
Assess for psychosocial and environmental problems that may be affecting the
person, such as stressful relationships, recent loss of job, and economic pressures.
Consider cultural differences that may affect the way people exhibit anxiety.
ANXIETY VERSUS CARDIAC CONDITIONS
Persons experiencing acute anxiety or panic may appear in the emergency
department with symptoms that closely resemble cardiac conditions, including:
Palpitations, heart pounding
Diaphoresis
Shakiness, unsteadiness
Sensation of choking
Chest pain
Nausea
Dizziness
Feeling of impending doom

Evaluation must ensure that there is no underlying medical condition to explain


these symptoms.
DIAGNOSIS
Medical Diagnoses
DSM-5 identifies anxiety as a symptom in all of the following medical
diagnoses:
Anxiety Disorders
Separation anxiety disorder
Selective mutism
Specific phobia
Social anxiety disorder (social phobia)
Panic disorder
Panic attack (specifier)
Agoraphobia
Generalized anxiety disorder
Substance/medication-induced anxiety disorder
Anxiety disorder due to another medical condition
Other specific anxiety disorder
Unspecified disorder
Obsessive-Compulsive and Related Disorders
Obsessive-compulsive disorder
Body dysmorphic disorder
Hoarding disorder

Trichotillomania (hair-pulling disorder)


Excoriation (skin-picking) disorder
Substance/medication-induced obsessive-compulsive and related disorder
Obsessive-compulsive and related disorder due to another medical condition
Other specified obsessive-compulsive and related disorder
Unspecified obsessive-compulsive and related disorder
Trauma- and Stressor-Related Disorders
Reactive and attachment disorder
Disinhibited social engagement disorder
Posttraumatic stress disorder
Acute stress disorder
Adjustment disorders
Other specified trauma- and stressor-related disorder
Unspecified trauma- and stressor-related disorder
Caregiver/Nursing Diagnoses
Although many anxiety disorders described by the APA differ markedly from
one another, certain NANDA diagnoses may appear in all of the anxiety conditions.
For example:
Ineffective coping
Fatigue
Anxiety
Disturbed sleep pattern

Chronic low self-esteem


Hopelessness
Self-care deficit
Powerlessness
(NANDA, 2014)
PLANNING
Patients in crisis with anxiety disorders usually do not require hospitalization.
However, clinicians encounter these people in homes, clinics, and acute and skilled
nursing facilities. Healthcare professionals encourage people with symptoms of
anxiety to participate in planning their treatment. For example, if the nursing
diagnosis is self-control of anxiety, the outcome criteria might be patient will
monitor the intensity of anxiety and use relaxation and regular exercise to decrease
anxiety.
INTERVENTION
Medical Interventions
Both psychotherapy and pharmacotherapy are used to treat anxiety disorders.
Psychotherapy of various types has proved useful, especially cognitive therapy
in which patients learn to recognize behaviors and take action to change them.
Therapists teach cognitive restructuring or reframing (replacing irrational negative
statements and beliefs with positive statements), relaxation to help reduce anxiety,
systemic desensitization to overcome phobias, and thought-stopping to reduce
obsessions.
Pharmacotherapy includes:
Antidepressants: selective serotonin reuptake inhibitors
Antiseizure medications that replace the use of anxiolytics
Anxiolytics (benzodiazepines) only for short-term treatment of acute anxiety
(Bystritsky et al., 2013)

Caregiver Interventions
Teaching interventions include:
Medication management
Behavioral therapy techniques to reduce anxiety
Relaxation exercises
Cognitive reframing (changing negative thoughts to positive ones)
Lifestyle personal care, such as nutrition, exercise, and sleep
Referral interventions include:
Community resources, such as an obsessive-compulsive disorder (OCD) support
group
Personal psychotherapy to gain self-knowledge
EVALUATION
The treatment of anxiety disorders is considered successful if symptoms of
anxiety in patients are reduced and they are able to live a happier, less fearful life.
Anger-Generated Crises
Anger-generated crises that involve assault and battery are well known to
clinicians in emergency departments and on crisis hotlines. In recent times, violence
has become a serious public health issue, affecting individuals, families, entire
communities, and healthcare providers. For this reason it is essential that clinicians
understand anger and aggression, recognize its signs and symptoms, plan appropriate
interventions, and evaluate those interventions. The goal of such care is to ensure
safety for everyone concerned.
In his classic study of human emotions, Robert Plutchik (1991) identified anger
as one of the primary emotions, an inborn response to the frustration of desire. The
purpose of anger is to remove whatever is blocking a desire or need.

Aggression is the physical or verbal action people take to overcome obstacles


that block their desires. As with other emotions, a stimulus event evokes a feeling
and the feeling motivates a response. The decision to express anger aggressively
depends on many factors, including cultural influences, genetic predisposition, low
serotonin levels, and brain abnormalities, especially in the limbic system.
As with other crises, anger and aggression are mediated by three balancing
factors: 1) the perception of an event, 2) the availability of a support system, and 3)
coping mechanisms. On feeling angry, some people use aggression as their primary
coping mechanism. Such a response is common in disorders like substance abuse,
mania, antisocial personality, and cognitive deficit.
ASSESSMENT
Because of the danger to themselves and others in aggressive patients, it is
important for clinicians to recognize common predictors of violence. These include:
A history of recent acts of violence
Intoxication with alcohol or drugs
Possession of a potential weapon
Situations that lead to violence: overcrowding, arbitrary rules, apparent favoritism
Signs and symptoms of violence: hyperactivity, restlessness, clenched jaw, fierce
facial expression, increasing tension, mumbling to self, clenched fist, profanity,
loud voice, soft voice, argumentative, avoidance of eye contact, and intense eye
contact
Guidelines caregivers can use to assess anger and violence in patients include:
Hyperactive, irritable, impulsive behavior
Risk factors: wish or intent, plan to harm, means to carry out plan
Demographic factors: male aged 1424, low socioeconomic status, lack of support
system, limited coping skills, frequent use of intimidation to meet needs
Intolerance of limit-setting by authorities

AGGRESSION AND MEDICAL CONDITIONS


Assessment must include ruling out medical conditions that can lead to
aggression, such as:
Head injury
Substance use and intoxication
Underlying mental illness
Metabolic disturbances (hypoglycemia)
Hypoxia
Infection (sepsis, encephalitis, meningitis)
Seizures
Vascular stroke
Subarachnoid hemorrhage
Guidelines caregivers can use to assess their own anger:
Personal triggers, such as physical characteristics of patients or situations
Sense of personal competence in a situation of potential danger
Ability to ask for assistance
DIAGNOSIS
Medical Diagnoses
DSM-5 identifies loss of self-control of emotions and behaviors leading to
aggressive acts in all of the following medical diagnoses:
Disruptive, Impulse-Control and Conduct Disorders
Oppositional defiant disorder
Intermittent explosive disorder

Conduct disorder
Antisocial personality disorder
Pyromania
Kleptomania
Other specified disruptive, impulse-control, and conduct disorder
Unspecified disruptive, impulse-control, and conduct disorder
Caregiver/Nursing Diagnoses
Diagnoses for patients who display aggressive behavior include
Risk for self-directed violence
Risk for other-directed violence
Aggression self-control
Ineffective coping
(NANDA, 2014)
PLANNING
Without question, de-escalation of anger and prevention of violence is the
primary outcome criteria for interventions with angry patients. Such planning takes
into account resource availability and situations in which violence may occur, is
occurring, or has occurred.
In planning interventions, it is important to consider the stages of violence.
These are the:
Pre-assaultive stage: tension increases and person becomes increasingly agitated
Assaultive stage: person loses control and becomes violent
Post-assaultive stage: person is calm and incident is reviewed

INTERVENTION
Pre-assaultive stage interventions focus on de-escalation of anger. Clinicians
follow these practices:
1. Assess patients and their situation and reassure them of your concern and expectation
that they will stay in control of themselves.
2. Place patient in a quiet and secure area and inform staff of what is happening. When
possible, interact with patients in a quiet place that is in plain view of other
caregivers.
3. Never turn your back on or walk ahead of the individual.
4. Ensure you have a safe escape route.
5. Demonstrate respect for personal space, thus decreasing the threat. If the person is
sitting, sit. If the person is standing, stand.
6. Remain calm and nonconfrontational in words and actions.
7. Interact with patients respectfully in a slow, low, and nonthreatening voice.
8. Verbalize options. Encourage patients to assume responsibility for the choices they
make and acknowledge the difficulties they have in making choices.
9. Use time wisely. Give adequate time for depressed or suicidal patients to consider
options. Set limits with manipulative patients.
10.Provide continuous observation and record behavior changes in patient notes.
11.Secure personal safety:
Avoid dangling jewelry.
Alert other caregivers.
Eliminate hazards caused by furniture or other objects.
Stand to the side of patients, not directly in front of them in a threatening way.
If patients begin to escalate, provide feedback, assure them that they will be safe.

Avoid confrontation and show of force by security guards.


Wear an alarm if available.
12.Use LEAPS:
Listen
Empathize
Ask questions
Paraphrase
Summarize
(Butler, 2011)
Assaultive stage interventions include application of restraints, administration
of medication, and seclusion. These measures should be used only after alternative
interventions have been tried (verbal intervention, decreased sensory stimulation).
Restraints, medications, and seclusion are used only when patients present a clear
and present danger to themselves or others and have been legally detained for
involuntary treatment, or when they request seclusion.
When physical restraint is necessary, a team of at least five staff members
trained in the techniques of management of assaultive behavior (MAB) subdues the
patient. Guidelines for MAB allow for one member (the leader) to speak to the
patient and instruct other members of the team. Only the leader communicates with
the patient. When the patient is restrained, caregivers administer physicianprescribed sedatives and the patient is placed in a quiet, secluded area.
MAB certification requires that staff receive training and demonstrate current
competency in all aspects of dealing with behavioral emergencies, including
seclusion and restraint. All healthcare workers should be familiar with the techniques
of MAB and be prepared to become trained as a member of a team if that should be
necessary. MAB training courses are available through the Internet or provided by
healthcare facilities.
Post-assaultive stage interventions begin when the patient has become calm.
These measures include establishing rapport, engaging in a therapeutic discussion of

stressors, and teaching alternative coping behavior. When it is available, patients are
referred to longer-term counseling and anger management group therapy.
EVALUATION
After an assault by a patient, clinicians need time to regroup and regain a sense
of personal safety, control, and security. It is important to take time to debrief and to
discuss what happened, what went right, what went wrong, and what they will do in
future situations. All incidents of violence are reported and documented according to
agency protocol.
CASE
Curt and his nine-year-old son were tossing a football back and forth when the
son fell backward onto a sharp rock, which cut a deep gash in his scalp. Curt rushed
the boy to the emergency department (ED) at the local hospital and stood by
anxiously as the triage nurse examined his injury. She said the doctor would come to
see the boy soon and left, closing the cubicle curtain behind her.
Curt waited as minutes went by. Getting anxious, he went to the curtain, pushed
it aside, and gazed out at the busy unit. Workers rushed this way and that, but no one
came to see his son. Curt went to the desk and asked the clerk when the doctor would
come to see his son. The clerk said the doctor was seeing other patients and would be
there shortly. Curt returned to his sons cubicle and waited, leaving the curtain open.
After some time, Curt went back to the clerk. How much longer is it going to be?
The clerk barely looked up and said, It wont be much longer.
More minutes crawled by, and Curt became more and more agitated. His
perception of the event was that this was a life-and-death situation. He had no
support system except the ED staff, and they were too busy to help. His usual coping
mechanism was actionoften aggressivenot passivity. His son groaned in pain,
and Curt became angrier by the minute. He set his jaw and went to the clerk,
clenched his fist, pounded on the counter, and shouted, You said the doctor would
come and take care of my son! That was ages ago! Where is he? Wheres the f**king
doctor?!
A nurse overhearing this exchange immediately approached Curt and quietly and
calmly asked if she could be of assistance. She listened to Curt, asking open-ended
questions and acknowledging his anger. She empathized with his concern and

frustration, paraphrasingCurts frustration about how hard it is to have a child hurting


and not be able to help him right away. She guided Curt back to the cubicle,
while asking him what happened to his son. She carefully examined the boy and
offered reassurance to Curt that he was not in imminent danger. She spoke to the boy,
who told her his head hurt but that he was okay. By this time, Curts anger had
subsided and he was speaking calmly. The nurse summarized the event and
acknowledged that emergency rooms are busy places in which someone else might
need attention sooner than his son.
At this point, the nurse told Curt she would return to check on them both in a
few minutes. Shortly thereafter the physician entered, apologized for the delay,
closed the wound, and discussed the boys care with Curt.
The nurse's use of the mnemonic LEAPS was effective in reducing Curt's anger
and avoided an incidence of violence in the ED.
Substance Use Emergencies
We are a drug-oriented society. We use drugs to reduce pain, lessen anxiety,
induce sleep, increase energy, restore health, create feelings of euphoria, and enhance
alertness. At least two thirds of the U.S. adult population consume alcohol regularly,
and more than half of those with mental illnesses use or have used mind-altering
substances (Smith-Dijulio, 2011).
Because of the widespread use of substances, clinicians in emergency
departments and on crisis hotlines must assess, diagnose, plan, intervene, and
evaluate not only physical but also psychiatric disorders, including substance use
disorders.
SUBSTANCE USERELATED TERMINOLOGY
Term
Physical dependence
Psychological dependence (addiction)
Polysubstance abuse

SUBSTANCE USERELATED TERMINOLOGY


Term
Substance abuse
Substance use
Tolerance
Withdrawal syndrome
ASSESSMENT
People in crisis often resort to mind-altering substances to dull their senses, lift
their spirits, or in some way relieve their discomfort. Usually, they appear in
emergency departments because they have been brought there by someone else for
some other reason than abuse of a substance. In any case, clinicians routinely assess
patients for substance use, especially when they exhibit bizarre behavior typical of
mind-altering substances.
Specifically, caregivers inquire about:
History of substance abuse: What substance have you taken, how long ago, what
symptoms? Have you had blackouts, overdoses, complications, recent accidents,
head trauma? Do you have a family history of substance abuse? Have you been
treated previously for substance abuse?
Medical history: What medical disorders do you have? What medicines do you
take?
Psychiatric history: Have you been diagnosed with any psychiatric disorder?
Have you undergone treatment for a specific disorder? Do you have a history of
physical or sexual abuse or family violence?
Suicide attempt history: Have you ever thought about ending your life or hurting
yourself? Have you tried to end your life? When, and under what circumstances?
Are you currently having suicidal thoughts?

Psychosocial issues: Do you have a family or friends? What do you do for a


living? What do you do to feel happy? Have you had a crisis in your life recently?
How has substance use affected your ability to meet usual role expectations? Do
you have a police or criminal record or legal problems related to substance use?
When people do not know or will not tell caregivers what substance they have
taken, clinicians look for typical signs of stimulants, depressants, inhalants,
hallucinogens, intoxicants, opiates, and other drugs. Signs and symptoms of the most
common types of drugs are described in the following table.
SIGNS AND SYMPTOMS OF SUBSTANCE USE
Type of Intoxication
Source: Webb et al., 2000.
Central nervous system (CNS) stimulants

Opiates
Hallucinogens
Phencyclidine piperidine (PCP)
Inhalants
Nitrates
Anesthetics
CNS depressants
Alcohol withdrawal
Complicated alcohol withdrawal with delirium tremens (DTs)

DIAGNOSIS
Medical Diagnoses
In the DSM-5, the APA (2013) lists a large number of substance-related
disorders: 6 alcohol, 4 caffeine, 6 cannabis, 9 hallucinogen, 4 inhalant, 5 opioid, 5
sedative/hypnotic/anxiolytic, 5 stimulant, 4 tobacco, and 6 other substance disorders.
Studies have suggested that almost one third of persons with a mental illness
and about one half of persons with severe mental illness also experience substance
abuse. Likewise, more than one third of all alcohol abusers and one half of all drug
abusers have mental illness. When more than one disorder presents, patients are
described as suffering from dual diagnoses or co-morbid conditions (NAMI, 2013b).
Caregiver/Nursing Diagnoses
Many caregiver/nursing diagnoses are appropriate to substance abusers,
indicating just how dysfunctional their lives may be. Some common diagnoses
include:
Disturbed sleep pattern
Ineffective health maintenance
Imbalanced nutrition
Deficient fluid volume
Risk for electrolyte imbalance
Ineffective impulse control
Impaired environmental interpretation
Disturbed thought processes
Hopelessness
Nonadherence to healthcare regimen
Anxiety

Self-care deficit
Ineffective coping
Dysfunctional family processes
Risk for suicide or violence to others
(NANDA, 2014)
PLANNING
The goal of emergency care of substance-using individuals is to provide
immediate, life-saving measures, identify the drug or drugs the individual has taken,
and give supportive emotional care. The goal of long-term care is to encourage
abstinence from substance abuse, meet physical and emotional needs, restore selfrespect, and assist patients to establish a support system.
INTERVENTIONS
In the emergency department, interventions for a substance-abusing individual
include identifying the specific drug or drugs he or she has taken, giving immediate
life-saving care, providing food and fluid, and transporting the patient to inpatient
care or referring to outpatient care.
Sadly, many substance abusers are homeless and friendless and afflicted with
serious co-morbid conditions. Some communities provide shelter and drug treatment
facilities, but persons must agree to the rules and regulations of such facilities. Many
refuse, preferring to live on the street until another crisis sends them back to the
emergency department.
EVALUATION
Clinicians in emergency departments evaluate how well they have met the
immediate needs of patients, though they may find it difficult to empathize with
those who return over and over again. Nevertheless, it is important to determine the
success of interventions by evaluating whether the principles of ethics were involved
in providing care to each individual patient.
CASE

The owner of a small downtown caf called the police. One of those homeless
drunks is out cold on my doorstep. Yep, I know the man names Ken. He hangs
around all the time, bothering customers and begging for leftovers sells cheap
newspapers and uses the money for booze.
The owner hung up and went back to the entrance of his caf. Ken had vomited
all over himself. When the owner nudged him with his foot, Ken groaned but didnt
move. When the police arrived, they called an ambulance.
The emergency department (ED) staff knew Ken well. He had a long history of
coming to the ED, responding to care, being discharged, and then repeating the
cycle. This time the staff was determined to do things differently. They gave
emergency care, admitted Ken to a medical unit, and referred him to social services.
When Ken was sober and his condition stable, social workers devised a long-term
plan that included housing and alcohol rehabilitation.
Major Mental Illness Crises
When precipitating events occur in the lives of people with major mental
illnesses, they may become so distressed that they seek help in an emergency
department or by means of a crisis hotline. This is not surprising, since the coping
skills and support systems of these individuals often are limited. Clinicians need to
assess the signs and symptoms of such individuals, diagnose their disorders, plan
their care, intervene, make appropriate referrals, and evaluate the effectiveness of
interventions. Some of the more common major mental illnesses seen in emergency
departments are:
Delirium (acute confusional state): Individual experiences a disturbance of
consciousness and change in ability to think that develops within a few hours or
days. Delirium is a syndrome and is always secondary to another condition, such
as a general medical condition, medications, or substance use.
Dissociative disorders: Individual experiences a disturbance of memory
(amnesia), depersonalization (disconnected or detached), or confusion about
personal identity. A dissociative identity disorder is present when the individual
exhibits two or more distinct personalities.
Mania: Individual exhibits a period of expansive or irritable mood, lasting at least
a week. The person is talkative, grandiose, sleeps very little and experiences a

flight of ideas, psychomotor agitation, distractibility and excessive involvement in


pleasurable activities that have a high potential for painful consequences.
Panic disorder: Individual experiences intense fear that develops suddenly,
reaching a peak within minutes, with rapid heart rate, palpitations, sweating,
tremor, shortness of breath, feelings of being smothered or choked, fear of going
crazy or dying, and dizziness. Symptoms gradually subside.
Posttraumatic stress disorder: Individual repeatedly experiences memories or
dreams of an overwhelming traumatic event, causing intense fear, helplessness,
horror, dissociative reactions, and avoidance of stimuli associated with the trauma.
Schizophrenia: Individual may experience delusions (false ideas), hallucinations
(false perceptions),disorganized thinking, grossly disorganized or abnormal motor
behavior, and negative symptoms such as flattened affect, diminished motivation,
and disturbed work and social functioning.
(APA, 2013)
ASSESSMENT
When individuals come to the emergency department with psychotic symptoms,
caregivers interview them and, when possible, interview relatives and associates.
Initial information may suggest the need for laboratory or other diagnostic studies. If
patients have been hospitalized recently, their records may be available. If they are
agitated and assaultive, it may be necessary to restrain or seclude them for a period
of time, as described above under Legal Issues.
DIAGNOSIS
Clinicians consider carefully the signs, symptoms, history, medical record, and
laboratory test of each patient. Medical and nursing diagnoses are made using the
standard medical references: ICD-9-CM, DSM-5, and NANDA.
PLANNING
Individuals must have an individualized plan of care that includes their
immediate needs as well as ongoing ones. Many patients require medication, some
need hospitalization, and most will need referral to outpatient care. The goal of all
care is stabilization and appropriate ongoing interventions.

INTERVENTIONS
Immediate interventions for individuals suffering from the disorders listed
above are carried out in the emergency department in consultation with their personal
physician. Ongoing interventions are provided by either a facility to which they are
sent or to their family or other responsible caregivers. Discharge planning and
referral to social service agencies is essential.
EVALUATION
As discussed earlier, clinicians evaluate the care they give patients, especially
the care they give vulnerable persons who arrive alone, without family or friends. In
a way, the arrival of a patient in an emergency department constitutes a precipitating
event of a potential crisis for the staff. Clinicians use their coping skills (experience,
knowledge, and reasoning) and support system (professional colleagues) to meet the
needs of each patient. Thus, a potential crisis is resolved.

CONCLUSION
Individuals experiencing an emergency-producing mental health crisis need
immediate, appropriate, and sensitive care, whether the crisis is caused by a mood
disorder, anxiety, anger, substance use, or a major mental illness. Although clinicians
who work in emergency departments and on crisis hotlines encounter these
individuals every day, all healthcare professionals meet people in crisis who are
overwhelmed by mental and emotional distress. It is important that all caregivers be
educated to rapidly assess, diagnose, plan, and intervene in such situations.
Mental health crises have a high risk for poor outcomes, and it is imperative
that healthcare professionals respond appropriately. Evaluation of responses requires
the determination that ethical principles be followed and that these individuals
receive compassionate care.