crisis intervention

CRISIS
 Introduction:
Crisis intervention is a technique used to help an individual or family to understand and cope with the intense feelings that typical of a crisis.
In a crisis the individual or a family experiences such strong emotions that make them incapable of approaching the situation in a rational or logical way.
 Definition:
A crisis is defined as “a state disequilibrium resulting from the interaction of an event with the individuals or families coping mechanisms which are inadequate to meet the demands of the situations, combined with the individuals or families perception of the meaning of the event – Taylar 1982
 Types of crisis:
According to the nature and the types of events, Crisis may labeled as two types
 Developmental crisis:
Human beings go through different stages of development the transition between these stages can be an emotionally disturbing period. A nurse who anticipates these stages can give necessary guidance in advance.
 Situational Crisis:
These are the Crisis precipitated by the some of the majpr catastrophes that can happen in life.
E.g.: Sudden unexpected death of a family member can cause chaos in the family system.
The event that precipitate a crisis need not always big. Anything that requires a sudden change can be a threat to the psychological equilibrium
 Maturational crisis:
Maturational crisis are developmental events. The nature and extent of the maturational crisis can be influenced by role models, interpersonal relations, and the ease of others accepting the new role.
E.g. successfully moving from childhood to middle childhood requires the child to become socially involved with people outside the family. With the move from the adolescence to adulthood, financial responsibility is expected. Both biological and social pressures to change can precipitate crisis
 Signs and symptoms of Crisis state:
The major feeling ion a Crisis is anxiety. The individual experience a heavy burden of freeflating anxiety, the anxiety may be manifested through depression, anger and guilt feelings. Normally it will take about 4-6 weeks to resolve a Crisis.
 Phases of Crisis:
Experts in Crisis theory have explained various stages of Crisis for theoretical purposes, there need not to be any specific demarcation between the stages.
Different stages can develop each other
• Phase of denial: This is the phase that occurs soon after the incident or immediately after the individual receives the message of the incidents. Here the victim shows disbelief unacceptance and the incident change. So the individual act as though nothing had happen.
• Phase of increased tension: As the reality is being acknowledge the victim experience anxiety. He tries to function but may depression or over activity. Most often the increased tension acts as the motivation factor.
• Phase of dis-organization: This is a stage when individual experiences real anxiety and feels that he can not go on any longer this due to the flood of anxiety the individual may fall apart because the realities acknowledged and the individual really experienced the loss.
• Attempt to recognize: The affected individual tries to recognize his life in spite of loss. He resumes his duties and gradually progress into adjustment.
• Phase attempt to escape the problem: As the victim trying to recognize he may make an attempt to escape the reality in this attempt to escape he blames others for what had happen. The individual use a great deal of projection.
• Phase of local re organization: The individual realizes that others or not to be blamed and actually there is nobody to be blamed and start to look at the situation realistically.
• Phase general re organization: At this phase individual learns to adapt to the new situation. The victim life is organized according to the loss in consolidation and the new circumstances.
 Resolution of crisis:
There are 3 ways by which the individual may resolve the crisis.
• Pseudo Isolation: In pseudo isolation the individual uses repression and pushes out of consciousness. The incidence emotions associated with it. There will not be any change the level functioning of the individual but in future when crisis occurs the repressed feelings may come to surface and influence the feeling aroused by the new crisis.
• Unsuccessful Resolution: In this case the victim uses the pathological adoption at any phases of crisis resulting in a lower level of functioning. The victim rather than accepting the loss and recognizing the life keep reminding over the loss.
• Successful Resolution: In this case the victim may go through the various stages of crisis but reaches the reorganization. The individual develops better skills and problem ability.















THE EFFECTS OF BALANCING FACTORS IN A STRESSFUL EVENT

Human organism

Stressful events State of equilibrium Successful events


State of disequilibrium


Need to restore equilibrium


Balancing factors are Balancing factors are
present absent


Realistic perception disorted perception of the
of the event event
+ /
Adequate situational No adequate situational
Support support



Adequate coping mechanism no adequate coping mechanism



Resolution of the problem unresolution of the problem


Equilibrium regained Dis-equilibrium continued


No crisis Crisis




CRISIS INTERVENTION
PRINCIPLES OF CRISIS INTERVENTIONS:
 Begin the counseling immediately.
 Be concerned and competent.
 Listen to the facts of the situation.
 Help to realize that the crisis event has occurred.
 Do not encourage or support blaming.
 Do not give false reassurance.
 Recognize the primacy of taking action.

 ASSESSMENT
The first step of crisis intervention is assessment. At this time data about the nature of the crisis and its effect on the patient must be collected from the data on intervention plan will develop.
People in crisis experience many symptoms including
Anger-apathy
Back ache - boredom
Crying spells - diminished sexual drive
Fear flash - flash balls
Disbelief - fatigue
Forgetfulness - headache
Helplessness - hopelessness
Insomnia - intrusive thoughts
Irritability - labiality
Night mares - numbness
Over eating / under eating - poor concentration
Sadness - school problems
Self thought - show
School withdrawal - substance abuse
Suicidal thoughts - survivor guilt
Work difficulties - survivor guilt

Sometimes these symptoms can cause further problems
E.g. 1. Problems at work may lead loss of job, financial stress or lowered self esteem, crisis can be complicated by old conflicts that as a result of current problem, making crisis resolution more difficult.
2. A woman who wads orphaned at early age may have more difficulty in resolving a crisis precipitated by the work injury of her husband than a woman who had not suffered an earlier loss.
During this phase the nurse begins to establish a positive working relation with the patient. A number of balanced factors are important in the development of resolution of a crisis, and should be assessed
 Precipitating events / stressors.
 Patient’s perception of the client events.
 Nature and strength of the patient’s support system and coping resources.
 Patient’s previous strength and coping mechanism.
Precipitating events:
To help, identify the precipitating event the nurse should explore the patient needs the events that threaten those needs and the time at which symptoms appear.
Four kinds of needs that have been identified are related to,
 Self esteem: Is achieved when the person attains successful role experience.
 Role mastery: Is achieved when the person attains work, sexual and family role successes.
 Dependency: Is achieved when the person satisfying interdependent relationship with others attained.
 Biological function: Is achieved when a person is safe and life is not threatened.
Perception of the event:
The patient’s perceptions are appraisal of the precipitating event is very important. Themes and surfacing members of the patient give further clues to precipitate event. Current issues of concern are often connected to the past issues..
e.g.: a female patient who talks about the death of heer father which occurred tree years ago may, on questioning reveal a recent loss of relationship with her mate.
Support system and coping recourses:
The patient living situation and support system in the environment must be assessed. Assessing the patient’s support system is important in determining who should come for the crisis therapy sessions. Assessing the patient’s coping resources is vital in determining whether hospitalization is more important than out patient crisis therapy.
Coping mechanism:
Here the nurse assesses the patient’s strength and previous coping mechanism. Besides exploring coping mechanisms, the nurse who should note the absence of other possible successful mechanisms.
 PLANNING AND IMPLEMENTATION:
The next step of crisis intervention is planning the previously collected data are analyzed and specific interventions are proposed. Dynamics underlying the present crisis are formulated from the information about the precipitating event. Levels of crisis intervention or planning are given below.


Indi
vidual
Approach
General
Approach


General support

Environmental
Manipulation

Levels of crisis intervention


Environmental manipulation:
 It includes interventions that directs change the patient’s physical or interpersonal situation.
 Interventions provide situational support over move stress .
 Important elements of these interventions are mobilizing the patient’s supporting and social system agencies.
General support:
It includes interventions that convey the feeling that the nurse is on the patient’s side and will be a helping person; the nurse uses warmth acceptance, empathy caring and reassurance to provide this type of support.
General approach:
 It is designed to reach high risk individuals as quickly as possible.
 Interventions consist of ventilation of feelings within a context of group support. Normalization of responses and education about psychological reaction to traumatic events.
Individual approach:
It is type of crisis intervention similar to the diagnosis and treatment of a specific problem in a specific patient. The nurse must understand the specific characteristics that lead to the present crisis and education and must use the interventions that lead to the present crisis and must the intervention that is likely to help the patient to develop an adaptive response to the crisis.

TECHNIQUES
The nurse should be creative and flexible trying many techniques, there should be active focused and explorative techniques that can facilitate achieving the targeted intervention.
 Catharsis: The release of feelings that takes place as the patient takes about emotionally charged areas.
E.g. tell me about how you have been feeling since you lost your job.
 Clarification: Encourages the patient to express more clearly the relationship between certain events.
E.g. I have noticed that after you have an argument with your husband you become sick and can not leave your bed.
 Suggestion: Influencing the person to accept an idea or belief, particularly the belief that nurse can help and that the person in time will feel better.
E.g. many other people have found it helpful to talk about this and I think you will too.
 Support of defense: Encouraging the use of healthy, adaptive defenses and discouraging these, that are unhealthy or mal adaptive.
E.g. going for a bicycle ride when you were so angry was very helpful because when you and your wife able to take things through.
 Rising of self esteem: Helping the patient regain the feeling of self worth.
E.g. you have very strong person to be able to manage the family, all the time, I think you will be able to handle this situation too.
 Exploration of solution: Examining alternative ways of solving immediate problem.
E.g. you seem to know many people in the computer field, could you contact some of them to see whether they might know of available jobs.
 EVALUATION:
the last phase of crisis intervention is evaluation. When the nurses and patient evaluate whether the interventions in a positive resolution of crisis.
Modalities of crisis intervention:
Nurses work in many settings in which they see people in crisis. Crisis intervention modalities are based on the philosophy that the health care team must be aggressive and go out to the patient rather than wait for the patient to come to them.
 Mobile crisis programme:
Mobile crisis team provides frontline interdisciplinary crisis intervention to individuals, families and communities. By diffusing the immediate crisis situation can be saved, in certain people it can be stabilized, they are usually able to provide onset assessment, crisis management, treatment, referral and educational to the patient and families.
 Group work:
Crisis group follow the same steps that individual interventions follows. The nurse and group help the patient to solve the problem and resolving behavior. The nurses role in the group is acts as a support system for the patient and is therefore of particular benefit to the socially isolated people.
 Telephone contacts:
Crisis intervention is some times practiced by telephone or internet communication rather than through face to face contacts. Nurses working for these types of hotlines or those who answer emergency telephone calls or e-mails may find themselves practicing crisis intervention without having visual cues to relay on.
 Disaster response:
As a part of community nurses are called on when situational crisis strikes the community. Natural and unnatural disasters precipitate large number of crisis. It is important that the nurse in the immediate post disaster period go to places where victims are likely together such as hospitals, shelters and areas surrounding the disaster site.
 Victim out search programme:
Although crisis intervention is not considered the appropriate treatment for serious concerns of victimization such as PTSD or depression. It is very useful as as a community support for victims in the immediate aftermath of crime and may provide an important link for the referral to more comprehensive services needed.
 Health education:
Although health education can take place during the entire crisis intervention process, it is emphasized during the evaluation phase. At this time the patient’s anxiety has decreased, so better use can be made of cognitive abilities.
GRIEF REACTION:
Grief is subjective state that that follows loss. It is one of the most powerful emotional states that affect all aspect of person life. It forces the person to atop the normal activities and focuses on present feelings and needs.
Grief involves stress, pain, suffering and an impairment of function that can last days, weeks or months.
Adaptive Responses Mal Adaptive Responses




Emotional uncomplicated suppression delayed grief depression
Responsiveness grief of emotion reaction or mania
Reaction


The ability to experience grief is gradually formed in course of normal development and is closely related to the capacity for developing meaningful relationships. Grief response s may either uncomplicated and adaptive and pathological. Uncomplicated grief runs a consistent course that is modified by the abruptness of the loss. The person’s perception of the events and the significance of the last object. It makes real fact of loss.
Types of grief reaction:
• The delayed grief reaction: persistent of any emotion may signal an undue delay the work of mourning or a delayed grief reaction. The delay may occur in the beginning of mourning process or slow the process once it has begun.
• The distorted grief reaction: depressions the type of the distorted grief reaction. The person who does not mourn can experience the pathological grief reaction known as depression / melancholia.
Theories of grief:
Aggression turned inward theory:
The aggression turned inward theory of FREUD views depression as the inward turning of the aggressive instinct, which for some reason is not directed at the appropriate object and accompanied by feelings of guilt. The process is initiated by the loss of an ambivalently loved object. The person feels angry and loving at the same time and is unable to express anger because it is considered in appropriate or irrational. Also the person may have developed a pattern throughout the life of containing feelings, especially those that are viewed negatively. Angry feelings are then directed inward.
Object loss theory:
The object loss theory of depression refers to traumatic separation of the person from significant object of attachments. Two issues are important to this theory. Loss during childhood as a predisposing stress. The connection between early object loss and adult depression is complex.
Another perspective on this theory focuses on the negative impart of maternal depression on infants and children. This expressed by the infant as flat effect, over activity, disengagement and difficulty in being consoled. Among older children it is seen as sadness, submissive, helplessness and social withdrawal.
Personality organization theory:
The personality organization view of depression focuses on the major psychosocial variable of low self esteem. The patient’s self concept is an underlying issues, whether expressed as dejection and depression or as over compensation eith supreme competence as displayed in manic and hypo manic episodes threats to self esteem arise from poor role performance, previewed loe level everyday and the absence of clear identity.
Cognitive model:
It proposes that people experiences depression because their thinking is disturbed. Depression is seen as a cognitive problem dominated by a person’s negative evaluation of self, the world and the future. It suggests that in the course of development certain experiences sensitize the people and make them vulnerable to depression such people also acquire a tendency to make extreme absolute judgment.
Learned helplessness – hopelessness theory:
Helplessness is belief that no one will do ant thing to aid you and hopelessness is a belief that neither you nor May one else can do anything, this thing propose that it is not trauma that produces depression, but the belief that one has no control over important outcomes in life and therefore refrains from adaptive responses. Learned helplessness is both a behavioral state and a personality trait of one who believes that control over the reinforce in the environment has been lost. These negative expectation lead to hopelessness and passiving and as inability to assert oneself.
Behavioral model:
The behavioral model views people as being capable of exercising control over their own behavior, they do not merely react to external influences. They select organize and transform incoming stimuli. Thus people are not viewed as powerless objects controlled by their environment.
Biological model:
The biological model explores chemical changes in the body during the depressed state. Whether these chemical changes cause depression or are a result of depression not yet understood
E.g. changes in the endocrine can cause decreased appetite, weightless, insomnia can cause depression.
NURSES RESPONSIBILITY IN CRISIS INTERVENTIONS:
 Provide liaison to social agencies.
 Attend the physical emergencies.
 Attentively listen to telling of crisis details.
 Give nurturing support.
 Identify patient’s primary concern.
 Support the patient’s previous successes.
 Add social support to the patient’s world.
CONCLUSION:
Crisis is a state of disequilibrium, the major sign is anxiety. Crisis situation is some times dangerous to life, it is all on the nurses hand to save a person, now a days so many programmes like mobile crisis programme, victim out search programme etc are available.
BIBLIOGRAPHY:
 Stuart W Gail and Loraia T Michele; Principles And Practice Of Psychiatric Nursing; Eighth Edition; Mosby Publishers; Page Number.234-250, 334
 Frish cavan nareen and Frisch E Lawrence; Psychiatric mental Health Nursing; First Edition’ Delmor Publishers; Page Number:
 Kishore J; National Programmes Of India; 4th Edition; Century Publications, New Delhi; Page Number: 200