CRISIS INTERVENTION

I. INTRODUCTION

Crisis can be viewed as an integral component of everyday life situations.

A crisis may influence people’s lives in different ways. As a consequence of a crisis
experience, the individual may go down to a lower or less healthy level of functioning
than what was before the crisis, or he may resume the same level of functioning by
repressing the crisis and the related emotions. On the other hand, he may function at a
healthier level than prior to the crisis, because the challenge of a crisis can bring out
new strengths, skills and coping mechanisms.

Intervention at a crisis is extremely important to prevent mental illness,

because longstanding problems make the person totally incapable of handling the
situation. If proper guidance is provided at the correct time, the victim will come out
of it and be better equipped to handle future problems in life.

II. DEFINITION OF CRISIS

Crisis is a state of disequilibrium resulting from the interaction of an event

with the individual's or family’s coping mechanisms, which are inadequate to meet the
demands of the situation, combined with the individual's or family’s perception of the
meaning of the event (Taylor 19112).

A sudden event in one’s life that disturbs homeostasis, during which usual
coping mechanisms cannot resolve the problem (Lagerquist, 2006,)

A crisis is a situation in which something or someone is affected by one or

more very serious problem.

III. CHARACTERISTICS OF A CRISIS

A number of characteristics have been identified that can be viewed as

assumptions upon which the concept of crisis is based (Aguilera, 1998; Caplan, 1964;
Winston, 2008). They include the following:

1. Crisis occurs in all individuals at one time or another and is not necessarily

1
 equated with psychopathology.

2. Crises are precipitated by specific identifiable events.

3. Crises are personal by nature. What may be considered a crisis situation by one
individual may not be so for another.

4. Crises are acute, not chronic, and will he resolved in one way or another within
a brief period,

5. A crisis situation contains the potential for psychological growth or

deterioration.

Individuals who are in crisis feel helpless to change. They do not believe
they have the resources to deal with the precipitating stressor. Levels of anxiety rise to
the point that the individual becomes non functional, thoughts become obsessional,
and all behavior is aimed at relief of the anxiety being experienced. The feeling is
overwhelming and may affect the individual physically as well as psychologically.

Bateman and Peternelj-Taylor (1998) stated:

Outside Western culture, a crisis is often viewed as a time for movement

and growth. The Chinese symbol for crisis consists of the characters for danger and
opportunity. When a crisis is viewed as an opportunity for growth, those involved are
much more capable of resolving related issues and more able to move toward positive
changes. When the crisis experience is overwhelming because of its scope and nature
or when there has not been adequate preparation for the necessary changes, the
dangers seem paramount and overshadow any potential growth.

IV. SOURCES OF CRISIS

The range of potential issues and crises that face the modern organization can
seem impossibly daunting when taken as a whole.  This can lead management to
decide, explicitly or implicitly, that there are simply too many potential threats to
effectively prepare for, and thus they end up preparing for none.

2
While it is true there are a vast number of potential crises threatening any given
organization, not all of them have the same probabilities for all organization types. 
Further, organizations themselves are not uniform in terms of risk exposure,
reputational capital, executive experience and a host of other factors that determine
their overall risk profile.

It is thus important for the relevant management actors to review the range of potential
issues and crises based on the company’s own risk profile and environmental
situation.  The most effective way to do this is to segment these potential threats into
logical categories.  This also helps make it easier to divide up the review process
among team members as well as make the whole task much more ‘doable’.

One approach to categorization of issue and crisis sources is to look at internal

sources, external sources and overlapping sources.

Internal Sources

Some issues and crises are directly attributable to factors or actions within the
organization.  Because they are within the organization’s control, mitigation should be
easier than would be the case for external sources.  When a crisis is traced to an
internal source the organization is often subject to harsher treatment because

3
stakeholders feel that it was clearly within the organization’s power to prevent it.  A
good example of this is the recent Volkswagen emissions cheating crisis.  There is no
way the organization can blame some external factor for the crisis, it was 100% within
the company.

Internal sub-categories include:

 People – the actions of management and/or staff

 Culture – the nature of the organization’s corporate culture (e.g. the hyper
competitive cultures found in many large financial institutions prior to the 2008
sub-prime crisis)
 Product/Service – the specific items produced by the organization or the
services it provides
 Process – the processes / ways of work within the organization
 Operations – the sourcing, manufacturing, distribution systems employed by
the organization
 Financial – the organization’s financial systems and/or status

External Sources

The potential sources of issues and crisis found outside of the organization such as the
political, economic, cultural and demographic environments in which the organization
operates.  These tend to be macro risks that can manifest themselves as a crisis for the
organization depending on its relationship with its external stakeholders.

External sub-categories include:

 Regulatory – the nature of the regulatory environment in which the

organization operates
 Legal – the legal system(s) and potential for hostile litigation that the
organization is exposed to
 Environmental – the potential impact the organization has on the natural
environment and the level public awareness regarding environmental protection

4
  Market – the market(s) in which the organization operates including stability of
demand, competitive systems, and overall health of the economy
 Societal – cultural, religious, national, ethnic and demographic factors that can
impact the organization’s relationship with its stakeholders

Overlapping Sources

Increasingly organizations are exposed to sources of risk that span the internal and
external categories.  This is especially true for larger organizations that offer a range
of products or services and use an array of suppliers and service providers.

Overlapping sub-categories include:

 Supply-chain – increasingly, major corporations and brands are being held

responsible for the actions of organizations throughout their supply chain, even
if these organization have no formal/legal relationship beyond the selling and
buying of goods or services
 Organized labor – the potential impact of local, national and international labor
organizations and/or organizations advocating for the rights of labor on an
organization – in terms of its relationship with its own employees as well as its
overall reputation

The above segmentations should be considered as a potential starting point and

certainly not a comprehensive listing.  Further, each organization will need to review
the various sub-categories to see if they are relevant and then to determine the
probability that they will be the source of an issue or crisis.  The crisis management
team must be brutally honest with themselves in this process.  For example, an
organization that is highly leveraged or utilizes complex derivative instruments,
probably has a greater financial risk exposure than a more conservative company –
regardless of how smart or successful management is.

By breaking down the potential sources of issues and crisis and then reviewing them
in light of the organization’s own unique situation the crisis management team can

5
begin to define an overall picture of the risk environment.  With this information,
management can make more informed decisions regarding the allocation of resources
to be tasked for risk mitigation.

V. TYPES OF CRISIS

Baldwin (1978) identified six classes of emotional crises, which progress by

degree of severity. As the measure of psychopathology increases, the source of the
stressor changes from external to internal. The type of crisis determines (he
method of intervention selected.

Class 1: Dispositional
Crises

Definition An acute response to an external situational stressor.

EXAMPLE

Nancy and Ted have been married for 3 years and have a 1-year-old
daughter. Ted has been having difficulty with his boss at work. Twice during the

6
past 6 months he has exploded in anger at home and become abusive with Nancy.
Last night he became angry that dinner was not ready when he expected. He
giabbed the baby from Nancy and tossed her, screaming, into her crib. He hit ahd
punched Nancy until she feared for her life. This morning when he left for work,
she took the baby and went to the emergency department of the city hospital, not
having anywhere else to go.

Intervention Nancy’s physical wounds were cared for in the emergency

department. The mental health counselor provided support and guidance in terms
of presenting alternatives to her. Needs and issues were clarified, and referrals for
agency assistance were made.

Class 2: Crises of Anticipated Life Transitions

Definition : Normal life-cycle transitions that may be anticipated but over which
the individual may feel a lack of control.

EXAMPLE

College student J.T. is placed on probationary status because of low grades

this semester. His wife had a baby and had to quit her job. He increased his
working hours from part time to full time to compensate, and therefore had little
time for studios. He presents himself to the student-health nurse practitioner
complaining of numerous vague physical complaints.

Intervention Physical; examination should be performed (physical symptoms could

be caused by depression) and ventilation of feelings encouraged. Reassurance and
support should be provided as needed. J.T. should be referred to services that can
provide financial and other types of needed assistance. Problematic areas should be
identified and approaches to change discussed.

Class 3: Crises Resulting From Traumatic Stress

Definition : Crisis precipitated by an unexpected external stressor over which the

individual has little or no control and as a result of which he or she feels
emotionally overwhelmed and defeated,

7
EXAMPLE

Sally is a waitperson whose shift ended at midnight. Two weeks ago, while
walking to her car in the deserted parking lot, she was abducted by two men with
guns, taken to an abandoned building, and raped and beaten. Since that time, her
physical wounds have nearly healed. However, Sally cannot be alone, is constantly
fearful, relives the experience in : flashbacks and dreams, and is unable to eat,
sleep, or work : at her job in the restaurant. Her friend offers to accompany her to
the mental health clinic.

Intervention The nurse should encourage Sally to talk about the experience and to
express her feelings associated with it. The nurse should offer reassurance and
support; discuss stages of grief and how rape causes a loss of self-worth, triggering
the grief response; identify support systems that can help Sally to resume her
normal activities; and explore new methods of coping with emotions arising from a
situation with which she has had no previous experience.

Class 4: Maturational/Developmental Crises

Definition : Crises that occur in response to situations that trigger emotions related
to unresolved conflicts in one’s life. These crises are of internal origin and reflect
underlying developmental issues that involve dependency, value conflicts, sexual
identity, control, and capacity for emotional intimacy.

EXAMPLE

Bob is 40 years old. He has-just been passed over for a job promotion for
the third time. He has moved many times within the large company for which he
works, usually after angering and alienating himself from the supervisor. His
father was domineering and became abusive when Bob did not comply with his
every command. Over the years, Bob's behavioral response became one of passive-
aggressiveness-first with his father, then with his supervisors. This third rejection
has created feelings of depression and intense anxiety in Bob. At his wife's
insistence, he has sought help at the mental health clinic.

Intervention The primary intervention is to help Bob identify the unresolved

8
developmental issue that is creating the conflict. Support and guidance are offered
during the initial crisis period, then assistance is given to help Bob work through
the underlying conflict in an effort to change response patterns that are creating
problems in his current life situation.

Class 5: Crises Reflecting Psychopathology

Definition: Emotional crises in which preexisting psychopathology has been

instrumental in precipitating the crisis or in which psychopathology significantly
impairs or complicates adaptive resolution. Examples of psychopathology that may
precipitate crises include personality disorders, anxiety disorders, bipolar disorder,
and schizophrenia.

EXAMPLE

Sonja, age 29, was diagnosed with borderline personality disorder at age
18. She has been in therapy on a weekly basis for 10 years, with several
hospitalizations for suicide attempts during that time. She has had the same
therapist for the past 6 years. This therapist told Sonja today that she is to be mar-
ried in 1 month and will be moving across the country with her new husband.
Sonja is distraught and experiencing intense feelings of abandonment. She is found
wandering in and out of traffic on a busy expressway, oblivious to her
surroundings. Police bring her to the emergency department of the hospital.

Intervention The initial intervention is to help bring down the level of anxiety in
Sonja that has created feelings of unreality in her. She requires that someone stay
with her and reassure her of her safety and security. After the feelings of panic
anxiety have subsided, she should be encouraged to verbalize her feelings of
abandonment. Regressive behaviors should he discouraged, Positive reinforcement
should he given for independent activities and accomplishments. The primary
therapist will need to pursue this issue of termination with Sonja at length. Referral
to a long-term care facility may be required.

9
Class 6: Psychiatric Emergencies

Definition: Crisis situations in which general functioning has been severely

impaired and the individual rendered incompetent or unable to assume personal
responsibility. Examples include acutely suicidal individuals, drug overdoses,
reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and
alcohol intoxication.

EXAMPLE

Jennifer, age 16, had been dating Joe, the star high school football player,
for 6 months, After the game on Friday night, Jennifer and Joe went to Jackie's
house, where a number of high school students had gathered for an after-game
party. No adults were present. About midnight, Joe told Jennifer that he did not
want to date her anymore. Jennifer became hysterical, and Jackie was frightened
by her behavior. She took Jennifer to her parent’s bedroom and gave her a Valium
from a bottle in her mother’s medicine cabinet. She left Jennifer lying on her
parent’s her bed and returned to the party downstairs. About an hour later, she
returned to her parent's bedroom and found that Jennifer had removed the bottle of
Valium from the cabinet and swallowed all of the tablets. Jennifer was
unconscious and Jackie could not awaken her. An ambulance was called and
Jennifer was transported to the local hospital.

Intervention The crisis team monitored vital signs, ensured maintenance oh

adequate airway, initiated gastric lavage, and administered activated charcoal to
minimize absorption, Jennifer's parents were notified and rushed to the hospital.
The situation was explained to them, and they were encouraged to stay by her side.
When the physical crisis was resolved, Jennifer' was transferred to the psychiatric
unit. In therapy, she was encouraged to ventilate her feelings regarding the
rejection and subsequent overdose. Family therapy sessions were conducted in an
effort to clarify interpersonal issues and identify areas for change. On an individual
level Jennifer’s therapist worked with her to establish more adaptive methods of
coping with stressful situations.

10
 VI. SIGNS AND SYMPTOMS OF CRISIS

 The major feeling in a crisis situation is anxiety. The individual experiences a

heavy burden of free-floating anxiety.

 The anxiety may be manifested through depression, anger and guilt. The victim
will attempt to get rid of the anxiety using various coping mechanisms, healthy
or unhealthy.

 The individual may become incapable of even taking care of his daily needs
and may neglect his responsibilities.

 The individual may become irrational and blame others for what has happened
to him.

VII. PROCESS OF CRISIS (RESOLUTION OF CRISIS)

Healthy resolution of a crisis depends upon the following three factors:

1. Realistic appraisal of the precipitating event, i.e. recognition of the relationship

between the event and feelings of anxiety is necessary for effective problem
solving to occur.

2. Availability of support systems.

3. Availability of coping measures over a lifetime: A person develops a repertoire

of successful coping strategies that enable him to identify and resolve stressful
situations. There are three ways by which the individual may resolve the crisis:

Pseudo-resolution

In this, the individual uses repression and pushes out of consciousness the
incident and the intense emotions associated with it, resulting in the individual
functioning at the same earlier level. But in future, if and when a crisis occurs, the
repressed feelings may surface and influence the feelings aroused by the new crisis. In
such a situation, the particular crisis may he more difficult to resolve because the
feelings associated with the earlier crisis are neither expressed nor handled at that
11
time.

Unsuccessful Resolution

In this, the victim uses pathological adaptation at any phase of crisis,

resulting in a lower level of functioning. The victim, rather than accepting the loss and
reorganizing his life, keeps ruminating over the loss. An example is prolonged grief
reaction, which results in depression.

Successful Resolution

In this, the victim may go through the various phases of crisis, hut reaches
Phase III where various coping measures are utilized to resolve the crisis situation,
The individual develops better skills and problem solving ability, which can be and
will be used in various crisis situations in future.

VIII. PHASES IN THE DEVELOPMENT OF A CRISIS

Caplan (I964) has described four phases of crisis as described below:

Phase I

Perceived threat acts as a precipitant that generates increased anxiety.

Normal coping strategies are activated, and if unsuccessful, the individual moves
into phase II.

Phase II

The ineffectiveness of the Phase I coping mechanisms leads to further

disorganization, 'Ihe individual experiences a sense of vulnerability. 'Ihe individual
may attempt to cope with the situation in a random fashion. If the anxiety
continues and there is no reduction, the individual enters phase III

Phase III

Redefinition of the crisis is attempted and the individual is most amenable

to assistance in this phase. New problem solving measures may also affect a
solution. Return to pre- crisis level of functioning may occur. If problem solving is
unsuccessful, further disorganization occurs and the individual is said to have

12
 entered phase IV.

Phase IV

Severe to panic levels of anxiety with profound cognitive, emotional and

physiological changes may occur. Similarly, Aguilera (1998) spoke of “balancing
factors" that affect the way in which an individual perceives and responds to a
precipitating stressor. A schematic of these balancing factors is illustrated

13
 Aguilera suggests that whether or not an individual experiences a crisis in
response to a stressful situation depends upon the following three factors:

1. The individual’s perception of the event. If the event is perceived

realistically, the individual 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.

2. 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" (p. 37), without adequate situational
supports during a stressful situation, an individual is most likely to feel
overwhelmed and alone.

3. The availability of adequate coping mechanisms. When a stressful situation

occurs, individuals draw upon behavioral strategies that have been successful
for them in the past. If these coping strategies work, a crisis may he diverted, If
not, disequilibrium may continue and tension and anxiety increase.

As previously set forth, it is assumed that crises are acute, not chronic,
situations that will be resolved in one way or another within a brief period. Winston
(2008) stated, “Crises tend to be time limited, generally lasting no more than a lew
months; the duration depends on the stressor and on the individual’s perception of and
response to the stressor" (p, 1270). Crises can become growth opportunities when
individuals learn new methods of coping that can be preserved and used when similar
stressors recur.necessary.

14
 IX. CRISIS INTERVENTION
i. Introduction

Crisis intervention is a technique used to help an individual or family to

understand and cope with the intense feelings that are typical of a crisis. Nurses
function as part of the inter-disciplinary team in the use of crisis intervention as a
therapeutic modality. Nurses may employ crisis techniques in their work with high-
risk groups such as patients with chronic diseases, new parents and bereaved persons.
Nurses may also use crisis intervention in dealing with intra-group staff issues and
patient management issues

Individuals experiencing crises have an urgent need for assistance. In crisis

intervention the therapist, or oilier intervener’, becomes a part of the individual’s life
situation. Because of the individual’s emotional suite, he or she is unable to problem-
solve, so requires guidance and support from another' to help mobilize the resources
needed to resolve the crisis.

Lengthy psychological interpretations are not appropriate for crisis

intervention. It. is a time for doing what is needed to help the individual get relief and
for calling into action all the people and other resources required to do so. Aguilera
(1998) stated:

The goal of crisis intervention is the resolution of an immediate crisis. Its

focus is on the supportive with the restoration of the individual to Ids precrisis level of
functioning or possibly to a higher level of functioning. The therapist’s role is direct,
supportive, and that of an active participant.

Crisis intervention takes place in both inpatient and outpatient: settings.

The basic methodology relies heavily on orderly problem-solving techniques and
structured activities that are focused on change. Through adaptive change, crises are
resolved and growth occurs. Because of the time limitation of crisis intervention, the
individual must experience some degree of relief almost from the first interaction.
Crisis intervention, then, is not aimed at major personality change or reconstruction
(as may be the case in long-term psychotherapy), but rather at using a given crisis

15
situation, at the very least, to restore functioning and, at most, to enhance personal
growth.

ii. Definition of crisis intervention

Crisis intervention refers to the methods used to offer immediate, short-term

help to individuals who experience an event that produces emotional, mental,
physical, and behavioral distress or problems.

A crisis can refer to any situation in which the individual perceives a sudden
loss of his or her ability to use effective problem-solving and coping skills. A number
of events or circumstances can be considered a crisis: life-threatening situations, such
as natural disasters (such as an earthquake or tornado), sexual assault or other criminal
victimization; medical illness; mental illness; thoughts of suicide or homicide; and
loss or drastic changes in relationships (death of a loved one or divorce, for example).

iii. Goals of crisis intervention

The goal of crisis intervention is the resolution of an immediate crisis. Its focus
is on the supportive with the restoration of the individual to Ids precrisis level of
functioning or possibly to a higher level of functioning. The therapist’s role is direct,
supportive, and that of an active participant.

iv. Aims of crisis intervention

• To provide a correct cognitive perception of the situation

• To assist the individual in managing the intense and overwhelming feelings

associated with the crisis.

Intervention

Steps to Provide a Correct Cognitive Perception

Assessment of the situation

• This may be achieved by direct questioning with the purpose of identification

of the problem and the people involved.

16
 • It is necessary to identify the support systems available and to know the depth
in which the individual's feelings are affected.

• Assessment should also be done to identify the strengths and limitations of the
victim.

Defining the event

• The victim at times may not be able to identify the precipitating event because
of possible denial, or due to reluctance to talk about it.

• It may be necessary for the therapist to review the details of the incidents in the
past 2 to 4 weeks in order to identify the event that precipitated the crisis. Such
a review will help the victim becoming aware of the precipitating event.

Develop a plan of action

• The victim and the people closely associated with him should have active
involvement in developing the plan of action.

• The therapist must be aware that the victim may not be in a condition to
mentally comprehend complicated information due to the overwhelming
anxiety experienced by him. The instructions given by the therapist must be
simple and clear, and too much information should not be given at a time. The
instructions may have to be written down, as the victim may not be able to
retain all the information.

Steps to Assist the Victim in managing the Intense Feelings

Helping the individual to be aware of the feelings

• The victim needs help in identifying his own feelings, which is the first step in
handling them.

• The therapist should use appropriate communication technique so that the

victim will be comfortable expressing his feelings without the fear of being
judged or criticized.

• The therapist should also be efficient in observing verba! and non-verbal

17
 behavior of the victim, so that he will be able to make a careful assessment of
his feelings.

Help the individual to attain mastery over the feeling

The individual should be given adequate support and guidance through

therapeutic process in order to handle feelings associated with crisis but special care
should be taken not to give any false reassurance.

• He should not in any way be encouraged to blame others, as this will only let
him escape from taking any responsibility.

• Care must be taken to ensure that the individual does not develop too much
dependence on the therapist, which is unhealthy.

• After the victim and the support groups prepare the plan of action under the
guidance it should he discussed with the victim and the concerned others, so
that they will have a clear understanding of the methods of implementation of
the plan.

• To improve coping with the situation necessary environmental manipulation

must be done in physical or interpersonal areas.

• It is advisable to have another appointment for the victim to visit the therapist
within a week, in order to assess how the plan is working out, and if needed, to
revi.se and modify the plan.

v. Principles of crisis intervention

 Be specific, use concise statements, and avoid over whelming the patient with
irrelevant questions or excessive detail.

 Encourage the expression of feelings.

 A calm, controlled presence reassures the person that the nurse can help.

 Listen for facts and feelings: seeking clarification, paraphrasing and reflection
are effective strategies.

 Allow sufficient time for the individuals involved to process information and

18
 ask questions.

 Help patients legitimize feelings by letting them know that others in similar
situations have experienced comparable emotions.

 Clarify distortions by getting persons to look at the situation realistically, focus

on what can be changed versus what cannot

 Empower person by allowing them to make informed choices

 Assist the person in confronting reality

 Encourage the person to focus on one implication at a time.

vi. Techniques of crisis intervention

1. Catharsis: The release of feelings that takes place as the patient talks about
emotionally charged areas.

2. Clarification: Encouraging the patient to express more clearly the relationship

between certain events.

3. Manipulation: Using the patient's emotions, wishes or values to benefit the

patient in the therapeutic process.

4. Reinforcement of behavior: Giving the patient positive reinforcement to

adaptive behavior.

5. Support of defenses: Encouraging the use of healthy, adaptive defenses and

discouraging those that are unhealthy or maladaptive.

6. Increasing self-esteem: Helping the patient to regain feelings of self worth.

7. Exploration of solutions: Examining alternative ways of solving the

immediate problem. Help patients legitimize feelings by letting.

vii. Crisis intervention strategies

Myer and James (2005) have outlined nine strategies used in crisis intervention. The
listening and responding skills outlined previously are the foundation of these strategies. The
use of the strategies depends on the context of the events, the assessment of the client and

19
within what step of the six-step model you are operating. The nine strategies useful in crisis
intervention include:

•Creating awareness.

In creating awareness you are attempting to bring to the client’s awareness the denied
and repressed feelings, thoughts and behaviours that have immobilized her. Creating
awareness is especially important in step one – defining the problem.

•Allowing catharsis.

Allowing clients to vent feelings and thoughts may be one of the most therapeutic
strategies you can use. In order to do this you need to provide a safe and accepting
environment. In doing so you are saying that you accept the client’s feelings and thoughts.
This strategy is most often used with individuals who have struggled to get in touch with their
feelings or thoughts. This strategy is useful in step 1 and step 3. A cautionary note – allowing
angry feelings to build and escalate may not be the best strategy.

•Providing support.

Sometimes you may be the sole support available to the client. It can be helpful for you
to validate the client’s responses as being reasonable given her situation. At times clients
believe they must be crazy and it is helpful to share that many others would act in a similar
way given the crisis situation. While validating the client it is essential not to give the
impression that you are supporting injurious or lethal behaviours. Providing support is
essential throughout the six step model but is particularly important in Steps 1, 3, 4, 5, and 6.
It is sometimes necessary when intervening in a crisis for a client to be dependent for a short
time with the longer term goal being to empower the client.

•Increasing expansion

Means engaging the client in activities to expand her view of the situation. Individuals
are often unable to see other perceptions and possibilities and tend to focus on one
perspective only. By presenting another view of the situation, clients are able to step back,
reframe their problems and gain new perspectives. This is particularly useful when clients
appear to be stuck cognitively in any of the steps of the six-step model. For example “You
say that there is nothing that can be done but I am going to ask you to think about the
possibility of getting an emergency protection order. Are you open to learning more about
this possibility?”

20
•Emphasizing focus:

Sometimes clients are unfocused and talk about numerous issues in their lives that are
not working. At times some may appear to be out of control. It can be helpful for you to
attempt to focus the client’s often overwhelming interpretation of the crisis event to more
specific, realistic and manageable options. This strategy is useful acrossall six steps. For
example “You’ve talked about the struggles with finances, lack of housing as well as the
strained relationship with your mother. What is one thing that you can do now to bring you
some relief?” It can be helpful to write down all of the issues that the client expresses and
then ask her to focus on the one that she is able to take some action steps to bring about some
change.

•Providing guidance.

When clients are in crisis they often may need guidance and direction. They may not
have the knowledge or the resources needed to make good decisions. When you provide
information, referrals and direction in regards to the client receiving assistance from specific
external resources and support systems you empower the client by providing information that
they did not have previously. For example “You talked about feeling lonely and isolated and
not having any supports in your community. Were you aware that there is a Parent Link
Centre in your area where you could meet other moms as well as gain valuable information
about parenting and other resources in the community? Are you interested in learning more?”
This strategy is used primarily in steps 4 and 5 but is also utilized in steps 2 and 3 when
clients are not able to access support systems or are engaging in unsafe behaviour.

•Promoting mobilization

Means that you attempt to activate and organize the client’s internal resources and to
find and use external support systems to assist in generating coping skills and problem
solving abilities. For example “You seem pretty confident that you want to leave your
relationship. You have some good ideas about how you are going to manage on your own.
There is a support group for women who have experienced domestic abuse that meets here
every Wednesday. This may be helpful for you to gain additional support”.

•Implementing order:

There may be times where you need to assist a client to classify and categorize problems
in order to prioritize and systematically deal with the crisis in a logical and linear manner. For

21
example “You seem overwhelmed with all that is going on in your life right not. Let’s make a
list of all of the issues. Which one would you like to deal with first?”

•Providing protection.

This is essential through out the six-step model. Your role is to protect clients from
engaging in harmful, destructive, detrimental and unsafe feelings, behaviours and thoughts
that may be harmful to themselves or others. For example “I am concerned about your safety
if you do choose to go to your home on your own to get your belongings. Would you
consider calling the police for a police stand-by?” When these nine strategies are used with
the basic verbal crisis intervention skills outlined previously, they form the backbone of crisis
intervention techniques.

viii. Management of the nurse in crisis intervention

Nurses respond to crisis situations on a daily basis. Crises can occur on

every unit in the general hospital, in the home setting, in the community health care
setting, in schools and offices, and in private practice. Indeed, nurses may he called on
to function as crisis helpers in virtually any setting committed to the practice of
nursing.

Roberts and Otto ns (2005) provided a seven-stage model of crisis

intervention. This model is summarized in Table 13-1. Aguilera (1998) described four
specific phases in the technique of crisis intervention that are clearly comparable to
the steps of the nursing process. These phases are discussed in the following
paragraphs.

TABLE ROBERT'S SEVEN STAGE CRISIS INTERVENTION MODEL-

CONT'D

STATE INTERVENTIONS
STATE I; Identify the Major  Identify the precipitating even that has led the client to
problems or crisis precipitants seek help at the present time
 Identify other situations that led up to the precipitating
event
 Prioritize major problems with which the client needs

22

State II Deal with feelings and
Etmotions
State III. Generate and Exlore
Alternatives
Stage IV Implement an Action Plan
Stage V. Follow-up
Phase 1. Assessment
In this phase, the crisis helper gathers information regarding the
precipitating stressor and the resulting crisis that prompted die individual to seek
help
 Discuss client's current style of coping, and offer
assistance in areas where modification would be
helpful in resolving the present cirsis and preventing
future crises.
 Encourage the client to vent feeling, provide
validation
 Use therapeutic communication techniques to help the
client explain his or her story about the current crisis
situation
 Eventually, and cautiously, begin to challenge
maladaptive beliefs and behaviors, and help the client
adopt more rational and adaptive options
 Collaboratively explore options with the cleint.
 identify coping strategies that have been successful for
the client in the past
 Help the client problem-solve strategies for
confronting current crisis adaptively
 There is a shift at this stage from crisis to resolution
 Develop a concrete plant of action to deal directly
with the current crisis
 Having concrete plan restores the client's equilibrium
and psychological balance
 Work through the meaning of the even that
precipitated the crisis. How could it have been
prevented? what responses may have aggravated the
situation?
 Plan a follow-up visit with the client to evaluate the
post-crisis status of the client
 Beneficial scheduling of follow-up visits include 1
month and 1 year anniversaries of the crisis event.
23
professional help, A nurse in crisis intervention might perform some of the following
assessments:

 Ask the individual to describe the event that precipitated this crisis.

 Determine when it occurred.

 Assess the individual’s physical and mental status.

 Determine if' the individual has experienced this stressor before. If so, what
method of coping was used? Have these methods been tried this time?

 If previous coping methods were tried, what, was the result?

 If new coping methods were tried, what was the result?

 Assess suicide or homicide potential, plan, and means.

 Assess the adequacy of support systems.

 Determine level of precrisis functioning. Assess the usual coping methods,

available support systems, and ability to problem-solve. Assess the individual’s
perception of personal strengths and limitations.

 Assess the individual’s use of substances.

Information from the comprehensive assessment is then analyzed, and

appropriate nursing diagnoses reflecting the immediacy of the crisis situation are
identified. Some nursing diagnoses that may be relevant include:

 Ineffective coping

 Anxiety severe to panic

 Disturbed thought processes (has been removed from the NANDA-I list of
approved diagnoses, but is used for purposes of this textbook)

 Risk for self- or other-directed violence

 Rape-trauma syndrome

 Post-trauma syndrome S Fear

24
Phase 2. Planning of Therapeutic Intervention

In the planning phase of crisis intervention, the nurse selects the

appropriate nursing actions for the identified nursing diagnoses. In planning the
interventions, the type of crisis, as well as the individual’s strengths and available
resources for support, are taken into consideration. Goals are established for crisis
resolution and a return to, or increase in, the precrisis level of functioning.

Phase 3. Intervention

During phase 3, the actions that were identified in phase 2 are implemented. The
following intervention are the focus of nursing in crisis intervention.

 Use a reality-oriented approach. The focus of the problem is on the here and
now. u Remain with the individual who is experiencing panic anxiety.

 Establish a rapid working relationship by showing unconditional acceptance,

by active listening, and by attending to immediate needs.

 Discourage lengthy explanations or rationalizations of the situation; promote

an atmosphere for verbalization of true feelings.

 Set firm limits on aggressive, destructive behaviors. At high levels of anxiety,

behavior is likely to be impulsive and regressive. Establish at the outset what is
acceptable and what is not, and maintain consistency.

 Clarify the problem that the individual is facing. The nurse does this by
describing his or her perception of the problem and comparing it with the
individual’s perception of the problem.

 Help the individual determine what he or she believes precipitated the crisis.

 Acknowledge feelings of anger, guilt, helplessness, and powerlessness, while

taking care not to provide positive feedback for these feelings.

 Guide the individual through a problem-solving process by which he or she

may move in the direction of positive life change:

 Help the individual confront the source of the problem that is creating the crisis

25
 response.

 Encourage the individual to discuss changes he or she would like to make.

Jointly determine whether or not desired changes are realistic.

 Encourage exploration of feelings about aspects that cannot be changed, and

explore alternative ways of coping more adaptively in these situations.

 Discuss alternative strategies for creating changes that are realistically possible.

 Weigh benefits and consequences of each alternative.

 Assist the individual to select alternative coping strategies that will help
alleviate future crisis situations.

 Identify external support systems and new social networks from which the
individual may seek assistance in times of stress.

Phase 4. Evaluation of Crisis Resolution and Anticipatory Planning

To evaluate the outcome of crisis intervention, a reassessment is made to

determine if the stated objective was achieved:

 Have positive behavioral changes occurred?

 Has the individual developed more adaptive coping strategies? Have they been
effective?

 Has the individual grown from the experience by gaining insight into his or her
responses to crisis situations?

 Does the individual believe that he or she could respond with healthy
adaptation in future stressful situations to prevent crisis development?

 Can the individual describe a plan of action for dealing with stressors similar to
the one that precipitated this crisis?

During the evaluation period, the nurse and client summarize what, has
occurred during the intervention. They review what the individual has learned and
"anticipate'’ how he or she will respond in the future. A determination is made
regarding follow-up therapy; if needed, the nurse provides referral information.
26
 ix. Modalities of crisis intervention

Community-based crisis intervention modalities have recently been

developed. They are based on the philosophy that the health, care team must be active
and go out to the patients rather than wait for the patients to come to them. Nurses
working in these modalities intervene in a variety of community settings, ranging
from patient's home to street corners.

Mobile Crisis Programs

Mobile crisis teams provide front-line interdisciplinary crisis intervention

to individuals, families and communities. The nurse, who is a member of a mobile
crisis team, should be able to provide on-site assessment, crisis management,
treatment, referral and educational services to patients, families and the community at
large. Nurses are, thus, able to ensure mental healthcare for even the most underserved
populations efficiently and cost effectively.

Telephone Contacts

Crisis intervention is sometimes practiced over telephone rather than

through face-to- face contacts. The nurse should have effective listening skills to
provide crisis intervention to victims.

Group Work

People who have common traits on stressors will form a group. The group
provides an opportunity for members to express common concerns and experiences,
foster hope and build mutual support. The nurse's role in the group is active, focal and
focused on the present. The nurse and the group help the patient solve the problem and
reinforce new problem solving behavior.

Disaster Response

As part of the community, nurses are called on when an adventitious or

social crisis strikes the community. Floods, earthquakes, airplane crashes, fires,
nuclear accidents, etc, precipitate large number of crises. The nurse has an important
role in dealing with psychosocial problems of disaster victims. The nurse participates

27
in crisis operations and acts as a case-finder for persons suffering from psychosocial
stress. It is important that nurses in the immediate post disaster period go to places
where victims are likely to gather, such as hospitals, shelters, morgues. During this
period, nurses use die generic approach of crisis intervention so that as many people
as possible can receive help in a short duration of time.

Victim Outreach Programs

Victim outreach programs use crisis intervention techniques to identify

the needs of victims and then to connect them with appropriate referrals and other
resources.

Nurses often work in victim outreach programs, where victims are often
seen immediately after the crisis. These victims need thorough evaluation, empathic
support, and information and help with the large system and social networking system.

Crisis Intervention Centers

Crisis intervention centers provide emergency psychiatric care and

counseling to victims, experiencing extreme stress or conflict, often involving suicide
attempts or drug or alcohol abuse. These centers, which are usually self-contained
units within a hospital or community healthcare center, provide services 24 hours a
day. The services may be delivered directly on the premises, or counseling may be
provided over the telephone. The primary objective of crisis intervention centers is to
help the person cope with immediate problem and to offer guidance and support for
long term therapy.

Health Education

Nurses are involved in identifying people who are at high-risk for

developing crisis and in teaching coping strategies to avoid the development of crisis.
The public also needs education so that they can identify those needing crisis services,
be aware of available services, change their attitude so that people will feel free to
seek services, and obtain information about how others deal will) potential crisis
producing problems.

28
 x. Crisis Prevention Planning

Primary prevention
The CPP focuses on preventing future crises (not responding to crises once they
occur).
-Crises may include danger to self (suicide attempts) or to others (e.g., aggression,
property destruction).
-It can be helpful to have kids and parents work on this activity separately at first, but
it is important to get everyone’s input when creatinga final version.
Secondary prevention
Focus on triggers that are specific to the crisis or crises being addressed (do not
include triggers for irritation or minor difficulties)
-Clarify triggers, get specific.(“Being told ‘no’” -> “Being told I can’t go out with my
friends when there is an important event”; “Homework” -> “A major long-term
project is due, I am way behind and at risk of not passing.”)
-When kids/parents are having difficulty identifying triggers/warning signs, you can
help them by exploring exactly what led up to the most recent crisis/crises.
Tertiary prevention
Draw as much as possible from past/recent crisis situations.-Ask: “How will you
know when the safety plan should be used?” -Ask: “What do you experience when
you start to think about suicide or feel extremely depressed?”
-List warning signs (thoughts, images, thinking processes, mood, and/or behaviors)
using the patient’s/family’ sown words.
Rehabilitation
For many kids, this will include giving them space until emotions cool off;
parents may need to exercise their own coping strategies to stay calm or walk away to
avoid escalating the situation further. (It is recommended that problem-solving not
occur during a state of heightened emotion/escalation, but that parties return to discuss
how things could be resolved/go better next time after emotions return to baseline, and
within about 6 hours.)

29
-When there is suicidal risk, you may need to negotiate strategies parents can use to
non-intrusively keep an eye on the youth (e.g., teen agrees to leave bedroom door
open a crack so parents don’t have to disturb him in order to verify safety; teen agrees
to respond to texts within a certain time frame indicating he is safe, otherwise the
parent will check on them).
-You may explore what forms of support or checking in are best received by the teen
(e.g., a supportive text vs. repeated verbal questioning).
Try not to encourage parent behavior that clearly reinforces the teen’s crisis behavior
(e.g., withdrawing limits in response to aggression); in these situations it may be
important to promote desired alternative behaviors (e.g., by setting clear expectations,
decide on meaningful rewards for compliance with expectations).
Draw on existing coping strategies/healthy activities, and/or suggest new ones.-Assess
how likely they are to actually use these when needed. Identify potential obstacles,
problem-solve.
Typically helpful to include a crisis support line (teens may feel more comfortable
calling a line staffed by teens).
-Include mental health providers if involved and appropriate.
-Include several supportive adults or friends, in case some are not reachable.
-Evaluate the likelihood the youth would actually call these contacts in a time of
crisis. Consider role-play/rehearsal to increase chances of follow through.
-Make a plan for these numbers to be available/accessible when needed (e.g., enter in
phone; keep numbers in places they might be needed).
Learn about any suicide plans and remove lethal means.-Secure/remove
dangerous/lethal materials (firearms, knives, sharps, cleaners, OTC and prescription
medications) in the home to reduce the likelihood that passing, impulsive thoughts
would lead to lethal outcomes.

xi. Crisis intervention mode

30
 1. MTCrisis Roster Model

Post Crisis Level

Post Crisis Level

Crisis Intervention success)

Pre-crisis
Mental illness(CI

Crisis

Pre-crisis level shows normal level of equilibrium between body and functions -
crisis levels-shows it is disturbed . If crisis intervention is adequate and successful the
person come Normal activity and functioning. If it is failed, the person will develop
mental illness.
Human organism

state of equilibrium

state of disequilibrium

Need to restore equilibrium

Balancing factors present

One or more balancing factor absent
Realistic
Balancingperception
factors present
of the event
Destored perception of events

Adequate situation support and /or No adequate situational

support
Adequate coping mechanism and/or no coping mechanism Result
Result in in

Resolution of the problem Problem unresolved

Equilibrium resign Disequilibrium continues

No crisis crisis

2. Caplan Model
31
Basod on Caplan - 3 levels of crisis intervention.

1. Primary Level:

Assess the crisis, define the crisis, assess the problem, and promote and support
coping mechanism.

2. Secondary Level:

Hot lines services link, walk-in-clinic, and counseling can use.

3. Tertiary Level:

Treatment and following Rehabilitation and self-help groups

4. Based on Stuart Model

1. Environmental manipulation - Change the environment from the crisis situation.

2. General approach - Those are affected provide care and set the relief from the
crisis.

3. Generic approach / Individual approach

4. Stuart Model

Predisposing factor (Biological, Chemical, Natural, etc)

32
 Precipitating Factor Stress)

Stress/Anxiety

Use Coping Mechanism/Defence

Mechanism

Constructive Behaviour Un constructive Behaviour

Normal Mental Health Abnormal Mental Health

X. SUMMARY

Crisis can be viewed as an integral component of everyday life situations.

A crisis may influence people’s lives in different ways. As a consequence of a crisis
experience, the individual may go down to a lower or less healthy level of functioning
than what was before the crisis, or he may resume the same level of functioning by
repressing the crisis and the related emotions. On the other hand, he may function at a
healthier level than prior to the crisis, because the challenge of a crisis can bring out
new strengths, skills and coping mechanisms. Intervention at a crisis is extremely
important to prevent mental illness, because longstanding problems make the person
totally incapable of handling the situation. If proper guidance is provided at the correct
time, the victim will come out of it and be better equipped to handle future problems
in life.

XI. CONCLUSION

Stressful situations arc a part of everyday life. Any stressful situation can

33
precipitate a crisis. Crises result in a disequilibrium from which many individuals
require assistance to recover. Crisis intervention requires problem-solving skills that
are often diminished by the level of anxiety accompanying disequilibrium. Assistance
with problem solving during the crisis period preserves self-esteem and promotes
growth with resolution.

In recent years, individuals in the United States have been faced with a
number of catastrophic events, including natural disasters such as tornados, earth-
quakes, hurricanes, and floods. Also, man-made disasters, such as the Oklahoma City
and Boston Marathon bombings and the attacks on the World Trade Center and the
Pentagon, have created psychological stress of astronomical proportions in
populations around the world.

This chapter examines the phases in tire development of a crisis and the
types of crises that occur in people’s lives. The methodology of crisis intervention,
including the role of the nurse, is explored. A discussion of disaster nursing is also
presented.

Crisis is a state of disequilibrium resulting from the interaction of an event

with the individual's or family’s coping mechanisms, which are inadequate to meet the
demands of the situation, combined with the individual's or family’s perception of the
meaning of the event (Taylor 19112).

XII. BIBLIOGRAPHY

34
 1. Elakkuvana bhaskara raj (2014),text book of mental health nursing, first edition,
emmess publication. page no; 298-301

2. Neeraja K P, Essentials of mental health and psychiatric nursing, volume one, jaypee
publications, page no; 318-339

3. Shija, Text book of foundation of psychiatric mental health nursing, 1st edition, Jaypee
publication, page no; 5

4. Sreevani, Text book of mental health & psychiatric nursing, 4th edition, Jaypee
publication, page no; 331-338

5. Subash Indra Kumar C.L, Text book of Psychiatry and mental health nursing, emmess
publivations, pp; 600-604

6. Townsend Mary C, Text book of Psychiatric mental health nursing,8 th edition, Jaypee
publication, Page no; 217-224

Internet sourses

http://www.cmha.ca

http://www.mentalhelp.net

http://helpguide.org.

http://www.oprah.com

35
36