-Universal, occurs in all individuals
-Not necessarily associated with psychopathology
-Acute limited to a brief period, 4 to 6 weeks, except in the event of death
-Crisis' are personal
-Crisis presents both danger to: Personality organization & Opportunity for growth or deterioration, can either make or break us
• A crisis is self-limiting and is usually resolved within 4 to 6 weeks.
• The goal of crisis intervention is to return the individual to the pre-crisis level of functioning. Resolution of a crisis may result in return to pre-crisis functioning, or to a higher or lower level.
• How a crisis is resolved is unique to the specific crisis, as well as how the individual responds and the interventions of others.
• During a crisis people are often more open to outside intervention than they are at times of stablee* functioning. When their normal coping methods have failed, the opportunity exists to learn different adaptive means of problem solving.
• A person in a crisis situation is assumed to be mentally healthy and to have functioned well in the past, but is presently in a state of disequilibrium.
• Crisis intervention deals with the person's present problem and resolution of the immediate crisis only, the "here and now." Addressing issues or needs not directly related to the crisis can take place at a later time,,* and referrals can be provided.
• A nurse must be willing to take a more directive role in intervention, especially initially,,* which is contrary to the usual therapeutic approach. As anxiety decreases, the patient can assist more in problem solving and planning.
• Early intervention increases the chances for a good prognosis.
• A patient is encouraged to set realistic goals and plan an intervention with the nurse that is focused on the current situation.
Maturational: Erikson's identified eight stages of growth and development in which specific tasks must be mastered to effectively reach maturity, each stage has it's own crisis. When a person arrives at a new stage, previous coping styles are no longer appropriate, and new coping mechanisms have yet to be developed. For a time, the person is in transition. This often leads to increased anxiety, which may manifest as variations in the person's normal behavior until he or she establishes a new equilibrium. (A person's equilibrium may be affected adversely by one or more of the following: an unrealistic perception of the precipitating event, inadequate situational supports, and inadequate coping mechanisms). Marriage, the birth of a child, and retirement are examples of maturational crises. Alcohol and drug addiction will interrupt an individual's progression through the maturational stages. As the patient escapes from stressors through the use of substances, he or she is not practicing communication and coping skills that contribute to maturity. When the individual gets clean and sober, he or she will discover that maturation has been halted at about the age that drugs or alcohol began to be used. The good news
is that the developmental process can resume and progress through supportive treatment. The way in which each developmental crisis is resolved becomes a foundation for the next stage, and thus affects the ability to pass through subsequent stages. If a person lacks adequate parenting, support systems, and role models, successful resolution of developmental tasks and emotional learning may be difficult or not occur.
A situational crisis arises from an external rather than an internal source and is frequently unanticipated. Examples of external situations that can precipitate a crisis include loss of a job, death of a loved one, unwanted pregnancy (not maturational), a move, change of job, change in financial status, divorce, and severe physical or mental illness. Situational crises are somewhat common, and at least some of them will be experienced by all individuals during their lifetime. Response to the situation depends in part on the degree of support available from caring friends, family members, and groups; previous success in navigating life events (resiliency); and the overall physical and emotional health of the individual. The stressful events that precipitate or constitute the crisis involve a loss or change that threatens a person's self-concept and self-esteem. Successful resolution of a crisis also depends on resolving the grief surrounding the loss. Phase 1: Person confronted by conflict that threatens self-concept responds with increased anxiety. Activates those defense responses. The increase in anxiety stimulates the use of problem-solving techniques and defense mechanisms in an effort to solve the problem and lower anxiety. The nurse should assist the client to identify past coping skills. It helps the client to develop problem-solving and decision-making skills
Phase 2: If the usual defensive response fails and if threat persists, then anxiety escalates. Individual functioning becomes disorganized. Trial-and-error begins.
Phase 3: If the trial-and-error attempts fail, then anxiety can escalate to severe and panic levels. (using all resources & still not working, can have symptoms of panic such as not breathing you can either resolve the conflict or continue to escalate): If the trial-and-error attempts fail, anxiety can escalate to severe and panic levels, and the person mobilizes automatic relief behaviors such as withdrawal and flight. Some form of compromise such as redefining the situation or reevaluating needs may occur in this stage, in order to come to some sort of resolution. An example might be giving in on child visitation in order to end ongoing divorce
Phase 4: If the problem is not solved and new coping skills are ineffective, then anxiety can overwhelm the person and lead to serious illness; assess for suicidal thoughts. (potential for reachin breaking point, become overwhelmed apprehensive, depression & confusion may creep in, may be in acting out phase, can be self violent, self harm, assess for suicide): If the problem is not solved after considerable time and efforts, and coping skills have been ineffective and exhausted, anxiety can overwhelm the person. In this final phase of crisis, serious personality disorganization, depression, confusion, violence against others, or suicidal behavior can develop.
In crisis situations it is important to evaluate the person's level of anxiety. Common coping mechanisms may be overeating, drinking, smoking, withdrawing, seeking out someone to talk to, crying, yelling, sleeping too much, praying, or engaging in other physical activity. The potential for suicide or homicide must be assessed. If the patient is thinking of harming self or someone else or is unable to take care of personal needs, hospitalization should be considered.
• Have you thought of harming yourself?
• Have you been thinking that you don't want to be around or want to die? If yes, what have you been thinking about doing?
• Have you thought of hurting someone else? If yes, who do you want to harm? How would you do it?
• Do you have access to weapons?
• What do you usually do to feel better?
• Have you tried any of those coping mechanisms this time?
• What have you been doing to deal with the stress? How has it been working?
Initial goal: patient safety & decrease anxiety
-Use problem solving approach.
-Identify needed social supports (with patient's input) and assemble them first.
-Identify and work to increase needed coping skills (problem solving, relaxation, self-care, housing).
-Schedule regular follow-up to assess progress.
Identify the individual's needs and strengths. Listen make sure we observe. Tell them what resources are there. Outside agencies. Medications: long-term SSRI's would be bezodiazepines for acute.
During the initial interview, the person in crisis first needs to gain a feeling of safety and security. Providing genuine support and hope will begin to decrease the patient's anxiety. The nurse assures the patient in crisis that help is available, and solutions will be found together. The patient's anxiety must be decreased to a level where the patient can hear and absorb potential ideas, before he or she will be able to actively problem solve with the nurse. False reassurance that everything will be all right damages trust and rapport. The nurse will need to be creative and flexible in helping the patient to solve his or her problems. Although the nurse helps guide the patient, it is important to remember that the patient is ultimately in charge of his or her own life and decision making.
1) Assess for suicidal or homicidal thoughts or plans
2) Take initial steps to make patient feel safe and to lower anxiety, such as providing a quiet environment, biolding rapport, and acknowledging the crisis experience
3) Listen carefully using eye contact and supportive body language, and provide feedback/summarization to ensure understanding
4) Crisis intervention calls for directive and creative approaches. Initially the nurse may make phone calls to help with tasks such as arranging babysittersand finding shelter
5) Assess patient's support systems. Rally existing supports (with patient's permission) if patient is overwhelmed
6)Identify and mobilize needed social supports
7) Identify needed coping skills such as problem solving, relaxation or job training
8) Collaborate with patient to plan interventions, as much as he or she is able at given time
9) Plan regular follow-up to assess patient's progress through clinic appointments, phone calls, or home visits (patient is evaluated to see what works and what needs adjustment)
Tertiary care provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state. Social and community facilities that offer tertiary intervention include rehabilitation centers, sheltered workshops, day hospitals, and outpatient clinics. Primary goals are to facilitate optimal levels of functioning and prevent further emotional disruptions. People with severe and persistent mental problems are often extremely susceptible to crisis, and community outpatient and inpatient facilities provide the structured environment needed for recovery.
Critical Incident Stress Debriefing (CISD) is an example of a tertiary intervention directed toward a group that has experienced a crisis such as a school shooting or natural disaster. A seven-phase group meeting offers individuals the opportunity to share their thoughts and feelings in a safe and controlled environment.
1. Introductory phase—The purpose and overview of the debriefing process is presented. Confidentiality is assured, team members are identified, and questions are answered.
2. Fact phase—Participants are assisted in discussing the facts of the incident from their perspectives.
3. Thought phase—All participants are asked to discuss their initial thoughts about the incident.
4. Reaction phase—Participants engage in freewheeling discussion about the worst, most painful parts of the incident.
5. Symptom phase—Participants describe cognitive, physical, emotional, or behavioral experiences at the time of the incident and ongoing.
6. Teaching phase—The feelings of the participants are affirmed. Guidance is provided regarding future symptoms and stress management techniques.
7. Reentry phase—The debriefing process thus far is reviewed, and any new topics are discussed. Team members provide encouragement and resources for additional help, and summarize the experience.
CISD is used to debrief:
-Staff members on an inpatient unit after the suicide of a patient
-Staff members after incidents of patient violence
-Crisis hotline volunteers
-Schoolchildren and school personnel after shootings have occurred in a school
-Rescue and health care workers who have responded to a natural disaster or terrorist attack