CRISIS INTERVENTION

INTRODUCTION
 A crisis occurs when a stressful life
event overwhelm an individual’s
ability to cope effectively in the face
of a perceived challenge or threat.
 A crisis may be thought of as
response:
1. Psychological homeostasis has been
disrupted.
2. One’s usual coping mechanisms have
failed to reestablish homeostasis.
3. The distress engendered by the crisis
has yielded some evidence of
functional impairment.
CRISIS ? ? ?
 Upset in a person’s steady state
provoked when an individual finds an
obstacle to important life goal.
(Caplan 1962)
 Crisis is not similar to emergency …
but emergency is always a crisis.
crisis
 Situation/event
 Usual coping methods inadequate
 Powerless/hopelessness/paralysis
 Severe anxiety
 Personality disorganization
 crisis
crisis
 Situation/event
 Usual coping methods inadequate
 Development of new coping
skills/help
 Anxiety reduced
 Return to pre crisis functioning
 Crisis resolved
DEVELOPMENT OF CRISIS
INTERVENTION
 Caplan’s theory
“ People’s traditional patterns of coping
breakdown in a crisis. He hypothesised that
in their response to an adverse event there
is a critical period during which people are
extremely responsive to therapeutic
intervention, the disequilibrium of the crisis
providing an opportunity for more adaptive
coping skills to emerge”.
 Development of community care and
steady reduction in inpatient beds
that accompanied this policy which
has stimulated interest in the
management of people with acute
psychiatric illness at home.
 Crisis intervention teams respond to
urgent calls for assistance (Waldron,
1983)
*
 RATNA. L(1976)-A two matched
populations of 150,000 each, one
with a crisis service and one without.
The crisis population had 60% fewer
first admissions, 45% fewer
readmissions, less chronicity and a
fall in the parasuicide rate.
*
 A number of follow-up studies on
victims of disaster all consistently
show that crisis support reduces the
risk of developing post traumatic
stress disorder, depression and other
psychiatric sequelae in the aftermath
of major adverse events
(Joseph,Williams & Andrews 1993, Yule et al
1990, Raphael 1986).
  *

 The service deal with all forms of

psychiatric crisis or focus on
particular patient groups- in an acute
psychological crisis.
Classification
 Crisis events have been classified into
accidental/situational and
developmental/maturational.
 Accidental/situational causes are
chance events, ‘the slings and arrows
of outrageous fortune’,
 such as car accidents, illnesses,
bereavement and disasters like floods or
fire.
Classification
 Developmental/maturational crises
are related to the stage in the
individual’s or family’s life cycle.
These are psycho-social transitions
engendering tasks, which if not
completed ,store up problems for a
later stage.
 Examples leaving home, getting married,
having a baby, retirement etc.
VULNERABILITY
PSYCHOSOCIAL
 Life events - redundancy,
bereavement, disasters
 Life changes - Leaving home,
childbirth, divorce, retirement
 Carers of elderly, chronic sick, single
parents
 Physical illness
 Victims of abuse/rape - sexual,
emotional, physical
 Individuals with poor coping skills,
low self esteem.
 Lack of social or family support.
Isolated individuals.
 High stressed individuals, overloaded
workaholics
 PSYCHIATRIC
 Previous suicidal attempt
 Chronic mentally ill - schizophrenia,
manic depressive, depression
 Addicts - alcohol, drugs
 Learning disorder, Brain injury
 SOCIAL
 Single, widowed, divorced
 Housing problems , living alone,
homeless
 Unemployment, Social class IV and V.
 Oppressed groups - Immigrants, ethnic
minorities, elderly, the disabled
 Disability - Deafness, Blindness,
Paralyses, Disfigurement
WHY CRISIS DEVELOPS?
 Loss problems
 Bereavement/separation/loss of body part or
function of an organ
 Role changes
 Entering marriage/parenthood/a new job with
added responsibilities
 Problems in relationship
 Between sexual partners/ between parent and
child
 Conflict problems
 Difficulties in choosing between two equally
undesirables alternatives
 PSYCHOSOCIAL
 Adverse events :
 Those with a previously healthy
personality
 Those with previous problems
 Accidental crises: - Bereavement,
Rape, Disasters, Post Traumatic
Syndromes.
 Social crises :
 Marital Breakdown, Family conflict,
Unemployment, Redundancy,
Homelessness.
 Abandonment, Breakdown in care
systems
 Abuse :- Physical, Sexual, Emotional
 Reaction to physical illness
 BEHAVIOURAL
 The Suicidal
 The Dangerous
 Acting out
 PSYCHIATRIC
 Acute psychiatric episode -
Psychoses, Mania, Depression,
Confusion
 Acute on chronic mental illness
 Relapse
 Psychosocial difficulties
HOW????
 Expressive behavior, on the other hand,
is designed to communicate the
subject's frustration, outrage, passion,
despair, anger, or other feelings. The
actions of a subject who is in crisis often
appear illogical and highly emotional,
given the lack of substantive or goal-
oriented demands.
 Expressive behavior stems from the
subject's need to ventilate.
 They are more concerned with
expressing their anger, hurt, despair,
or beliefs of being treated unfairly
than they are in bargaining in a
rational manner. They have lost their
equilibrium and are experiencing
heightened levels of arousal that
interfere with their ability to function
normally.
THE NATURE OF CRISIS
 As people grow and develop, they
continually meet new demands.
These demands could be intellectual,
employment-related, economic, or
rooted in relationships with other
people.
 Occasionally, individuals confront
situations they have seldom or never
encountered in the past.
 A crisis overrides an individual's
normal psychological and biological
coping mechanisms .
 These crises leave individuals feeling
overwhelmed and powerless. For
many people, these crises cause their
heightened emotions to impair their
ability to think rationally.
 As a consequence of feeling powerless
and helpless, individuals may experience
extreme levels of physiological arousal in
the form of anxiety--the natural human
response to threat and danger. This
anxiety serves to disrupt further their
ability to think clearly.
 When individuals face a crisis, their
increased levels of arousal interfere with
attempts to cope with an already
incomprehensible circumstance.
 During situations of crisis, people
spontaneously turn to others for
comfort, support, understanding, and
protection. Some research suggests
that people possess a biological need
for attachment.
 The absence of support during a crisis
represents the loss of the primary
human coping resource
 Without the sense of security provided
by others, the troubled individual's
extreme state of physiological arousal is
exacerbated further.
 As a growing feeling of despair sets in,
the person feels unable to escape the
crisis.
 When all roads back to equilibrium seem
blocked, the individual's ability to cope
becomes overwhelmed.
 As every attempt to deal with the
perceived threat seemingly meets
with failure, the individual learns to
do nothing-"learned helplessness."
 This shift in thinking only complicates
the individual's situation, serving to
undermine the sense of personal
competence and effectiveness while
increasing anxiety even more.
 Individuals whose heightened state of
anxiety and reduced self-esteem
cause them to react recklessly to
crisis situations.
 EXPRESSIVE SUBJECTS ARE IN A STATE OF
CRISIS THAT BLOCKS THEIR NORMAL
COPING MECHANISMS FOR HANDLING
STRESS.
 THEIR THINKING BECOMES HIGHLY
CONSTRICTED AND DISORGANIZED,
MAKING IT DIFFICULT FOR THEM TO DEAL
LOGICALLY WITH THEIR PROBLEMS AND
EXERCISE GOOD JUDGMENT.
RESPONSE TO CRISIS
1. Emotional efforts to solve the problems; if
these fails;
2. Greater emotional arousal and distress
accompanied by disorganization of
behaviour;
3. Trials of alternative ways of dealing with
problem;
4. If there is still no solution, exhaustion and
abnormal behaviour -“decompensation”.
CAPLAN’S STAGES OF CRISIS
 Stage 1: mounting tension
 Habitual problem solving responses, in
attempts to maintain a person’s steady
state
 Stage 2: Plateau of
disorganisation
 Feeling anxious
 Repeated attempts at problem solving
 Stereotyped (frustating) responses
 Increased dependence and needs
ventilation
 Stage 3: Mobilisation of all
internal and external resources
 Maximum arousal
 Hightened suggestibility
 Emergency methods or creative solutions
- attempted
 Stage 4: Adapation or
maladaptation
 Crisis resolution – adaptation to new
circumstances. Steady state restored.
Most common outcome
 Maladaptation – superficial ‘closure’ of
crisis or reactivation of past crisis
 Major disorganisation – may precipitate
psychotic episode or affective disorder
STAGES OF CRISIS

 PLATAEU OF DISORGANIZATION MALADAPTATION

 RESOLUTION/ADAPTATION

 TENSIONS MOUNTS
 Crises are a part of life. All services
psychiatric, social, nursing and
medical have to deal with a variety of
psychiatric emergencies every day.
There are many models of
intervention : medical, social, psycho-
social.
CRISIS INTERVENTION
 DEFINITION
“the provision of emergency
psychological care to victims as to
assist those victim’s in returning to
an adaptive level of functioning and
to prevent or mitigate the potential
negative impact of psychological
trauma”
(Everly & Mitchell, 1999).
 THE HALLMARKS:
1. Immediacy
2. Proximity
3. Expectancy
4. Brevity (Brief and exact)
GOALS
 STABILIZATION(cessation of
escalating distress).
 “What can I do now that will keep the
victim’s distress from escalating?”
 MITIGATION of acute signs and
symptoms of distress.
 “What can I do now that will assist in
reducing the victim’s distress?”
GOALS
 RESTORATION of adaptive
independent functioning, if possible.
 “Is this person capable of returning, in
an assisted manner to home, work etc?”
if NO
 FACILITATION/(REFERRAL
TO)?FOLLOW UP by someone
representing some higher level of
care/support.
BASIC PRINCIPLES
 INTERVENE IMMEDIATELY
 STABILIZE
 FACILITATE UNDERSTANDING
 FOCUS ON PROBLEM SOLVING
 ENCOURAGE SELF-RELIANCE
STRATEGIES
 ALLOWING EMOTION TO BE
RELEASED
 Show that it is all right if the patient
wants to cry or shout.
 Crying can be a relief from suffering.
 Encourage the patient to tell his
problems.
Crisis : assessment - 1
 Assess the Crisis
 Type, severity and duration
 Psychiatric or physical symptoms
 Predisposing and precipitating factors
 Risk of harm to self or others
 Complication (unwanted outcome ! )
Crisis: intervention - 2
 Identify resources available
 Personal – past experience
 Social – family, friend and colleagues
 Professional – doctor, counsellor or
community leaders
OUTCOME
 Well motivated people with stable
personalities who are facing major
but transitory difficulties will have
good prognosis.
7 STAGES CRISIS INTERVENTION
(ROBERT’S MODEL)

 Plan and conduct crisis assessment

(including lethality measures).

 Establish rapport and rapidly

establish relationship.

 Identify major problems (including

the "last straw" or crisis precipitants).
 Deal with feelings and emotions
(including active listening and
validation).

 Generate and explore alternatives.

 Develop and formulate and action

plan.

 Follow-up and agreement

 TAKING CONTROL OF THE
INTERVIEW
 Do not let the patient leave the
interview without ensuring that he is
safe and calm. Patient can get too
distressed and overwhelmed by their
problems and decide to leave while
still distressed and suicidal.
 Distract the patient-ask more positive
aspects.
ADDRESSING IMMEDIATE PROBLEMS
Assessment (CLARIFY???)

 What exactly happened?

 What would be acceptable to the
patient?
 What is the discrepancy between
these two?
 Does the patient’s view of the
problem sound accurate and
plausible?
 Would the patient accept some form
of compromise?
 Does the patient need more
information to check out the
practicalities of his viewpoint or
goal?
 What practical problems
prevent his goal or a suitable
compromise from being
achieved?
 Who else need to be involved?

Look at past solutions the patient

has employed in solving similar
problems.
Could these be used again?
 PROVIDING IMMEDIATE SUPPORT
 Try and establish who can be
available to support the patient.
 BOLSTERING SELF-ESTEEM
 Share painful feelings with therapist
as this can help to bolster self-esteem
and confidence.
 INCREASING HOPEFULNESS
 Is there anything he can look forward
to?
 ENSURING SAFETY
 Attempt to ensure safety.
 May or may not involve admissions.
 USE OF FAMILIES/FRIENDS/OTHER
PROFESSIONALS
 Inform families/friends of the risks
and what should be done if the
situation gets out of hands.
 Offer access to other professionals
WHEN TO INTERVENE?
 Primary Prevention
 To prevent development of psychiatric
illness
 Secondary Prevention
 To reduce severity and duration
 To reduce risk of relapse
 Tertiary Prevention
 To reduce disability of chronic illness
Interventions: situation
 People with early or acute mental
disorder
 Preventing suicide, reducing depression
and suicide
 People with severe and prolonged
mental disorder
 Acute exacerbation of chronic illness
 ‘behavior’ problems
 others
COPING WITH THE LOSS
 Someone close to you, your brother or
good friend has died. As you struggle to
accept this difficult loss, you may find
yourself consumed by pain, fear, and
grief.
 Grief is a natural response to losing
someone who was important to you.
Grief hurts, but it is necessary. When a
death tears your world apart, grieving is
the process that helps to put it back
together.
COPING WITH THE LOSS
 Grief runs through stages, and even if
you do not experience all of them,
chances are you will experience some of
them. This is why it is important to
understand the stages of grief.
 1. Denial – This response is
nature’s way of protecting you and of
insulating you from what happened.
 2. Anger – You may feel angry
toward the doctors or nurses who
couldn’t save your brother. You may
even be mad at the deceased for leaving
you. These feelings of anger may lead
you to feel guilty.
 3. Guilt – You may feel guilty for
simply being alive when someone else
has died. You might feel guilty for
not saying good-bye, or you may
remember a fight or argument you
had with the deceased.
 4. Depression – Even if you are
normally a committed, caring person,
you may find that you don’t care
about anything or anyone. This is a
common feeling as are the others.
 5. Acceptance – Hopefully, the
grieving will accept the death
eventually. That does not mean you
have to forget the deceased. It just
means it is time to go on living.
 One of the best ways to begin
working through the grief is to attend
the funeral. A funeral confirms the
reality of death and serves as a focus
for expressing feelings of loss. You
begin to help the family of the
deceased, and yourself, by attending
the funeral.
 Being there demonstrates that although
someone has died, friends like you remain,
and it demonstrates you care. Both before
and after the funeral, it is important you
express your feelings.
 Crying is both normal and healthy.
 Arrange a group or individual discussion for
assistance with grief and loss.
CRISIS INTERVENTION vs
PSYCHOTHERAPY
 Prevention  Reparation
 Immediate, close  Delayed,distant
temporal from stressor or
relationship to acute
stressor or acute decompensation
decompensation
 Anywhere, close  Safe, secure
proximity to environment
stressor
CRISIS INTERVENTION vs
PSYCHOTHERAPY
 1-3 contacts  As long as needed
 Active, directive  Guiding,
collaborative,
consultative
 Conscious process  Conscious and
and environmental unconscious
stressors/factors sources of
pathogenesis

 Here and now

 Present and past
 CRISIS INTERVENTION vs
PSYCHOTHERAPY
 Directive, symptoms  Guidance. Symptoms
reduction, reduction in reduction, reduction in
impairment. impairment, personal
growth.
 Stabilize, reduce  Symptoms reduction,
impairment, return to reduction of
function, or move to impairment, correction
next level of care. of pathogenesis,
personal growth,
personal
reconstruction.
THANK YOU