Definition of Crisis:-
Any serious interruption in the steady state or equilibrium of a person, family, or group is considered a crisis. A crisis is a state of emotional turmoil. It is also considered an emotionally significant event which acts as a turning point for better or worse in a person’s life.
-: According to Mitchell &Resnik, 1981
Most people exist in a state of equilibrium, despite the occurrence of crisis situations. That is, their everyday lives contain some degree of harmony in their thoughts, wishes, feelings, and physical needs. This existence generally remains intact unless there is a serious interruption or disturbance of one’s biologic, psychological, spiritual, or social integrity. As undue stress occurs, one’s equilibrium can be affected and one may lose control of feelings and thoughts, thus experiencing an extreme state of emotional turmoil. When this occurs, one may be experiencing a crisis. Individuals respond to crisis in different ways. Table summarizes two types of common responses to a crisis, high anxiety emotional shock or stunned inactive response.
|Two Common Responses to a Crisis
Types of Crises
A crisis can be situational or maturational. A situational crisis refers to an extraordinarily stressful event such as the terrorist attacks or incidents that affects an individual or a family regardless of age group, socioeconomic status, or socio-cultural status. Examples of other events that can precipitate a situational crisis include economic difficulty, medical or psychiatric illness, rape, workplace or school violence, marital discord, divorce, or death of a loved one due to a terminal illness.
A maturational crisis, on the other hand, is an experience such as puberty, adolescence, young adulthood, marriage, or the aging process in which one’s lifestyle is continually subject to change. These are the normal processes of growth and development that evolve over an extended period and require the person to make some type of change. Another example of a maturational crisis is retirement, in which a person faces the loss of a peer group as well as loss of a status identity.
Classification According to Severity
Situational and maturational crises also can be classified based on the severity of the crises. A classification system developed by Burgess and Baldwin (1981) systematically describes six types of crises based on the severity of the situation. Each classification is briefly summarized below:-
- Class 1: Dispositional or situational crisis in which a problem is presented with a need for immediate action, such as finding housing for the homeless during subzero temperatures
- Class 2: Life transitional or maturational crisis that occurs during normal growth and development, such as going away to college or experiencing a planned pregnancy
- Class 3: Situational crisis due to a sudden, unexpected, traumatic external stress, such as the loss of a home during a hurricane or earthquake
- Class 4: Maturational or developmental crisis involving an internal stress and psychosocial issues, such as questioning one’s sexual identity or lacking the ability to achieve emotional independence
- Class 5: Situational crisis due to a preexisting psychopathology, such as depression or anxiety, that interferes with activities of daily living (ADL) or various areas of functioning
- Class 6: Psychiatric situational crisis or emergency, such as attempted suicide, drug overdose, or extreme agitation, resulting in unpredictable behavior or the onset of an acute psychotic disorder
Characteristics of a Crisis
A crisis usually occurs suddenly, when a person, family, or group is inadequately prepared to handle the event or situation. Normal coping methods fail, tension rises, and feelings of anxiety, fear, guilt, anger, shame, and helplessness may occur. Most crises are generally short in duration, lasting 24 to 36 hours. Crises rarely last longer than 4 to 6 weeks. They can cause increased psychological vulnerability, resulting in potentially dangerous, self-destructive, or socially unacceptable behavior, or they can provide an opportunity for personal growth. The outcome of a crisis depends on, among other factors, the availability of appropriate help (Mitchell &Resnik, 1981).
Phases of a Crisis
Research involving crisis has led to the identification of specific stages or phases associated with it. Most individuals consider Eric Lindemann (1965) to be the father of crisis theory. His theory evolved from the study of grief responses in families of victims of the Coconut Grove nightclub fire in Boston in 1943. After World War II, Gerald Caplan (1964) contributed to the concept of crisis theory while working with immigrant mothers and children. Each described stages or phases of a crisis. Generally, theorists describe five stages or phases of a crisis:
The general state of equilibrium in which a person is able to cope with everyday stress is called the pre-crisis phase. When a stressful event occurs, the person is said to be experiencing the impact phase. This phase occurs when, for example, a pediatrician tells a young couple that their 5-year-old son has inoperable cancer. After the shock is over, the young parents become acutely aware of their son’s critical illness and poor prognosis. This is an extraordinarily stressful event, threatening their child’s life and their integrity as a family. With this realization, they are now in the crisis phase. They may experience continuing confusion, anxiety, and disorganization because they feel helpless and are unable to cope with their son’s physical condition. When the young parents are able to regain control of their emotions, handle the situation, and work toward a solution concerning their son’s illness with or without intervention from others, they are in the resolution phase of a crisis. If they are able to resume normal activities while living through their son’s hospitalization and illness, they are in the post-crisis phase. The experience of a crisis and passage through the phases may result in permanent emotional injury or it may make the young parents feel a stronger bond with each other and their son, depending on their ability to cope. These phases are described further in Table :-
|Phases of a Crisis|
Paradigm of Balancing Factors
Various factors can influence an individual’s ability to resolve a crisis. Aguilera (1997) describes a paradigm of balancing factors that determines the resolution of a crisis.
These factors, which can affect an individual’s return to equilibrium, are:-
(1) Realistic perception of an event
(2) Adequate situational support
(3) Adequate defense or coping mechanisms to help resolve a problem.
Additional factors may influence the development of a crisis. These factors include the person’s physical and emotional status, previous experience with similar situations, and cultural influences.
Defense or coping mechanisms are those methods usually used by the individual, when dealing with anxiety or stress, to reduce tension in difficult situations. These mechanisms may be conscious or unconscious, revealing themselves in behavioral responses such as denial, intellectualization, productive worrying, grieving, crying, aggression, regression, withdrawal, or repression. Coping mechanisms are used during early developmental stages and, if found effective in maintaining emotional stability, will become a part of a person’s lifestyle in dealing with daily stress. The person who has met developmental tasks and achieved a level of personal maturity usually adapts more readily in a crisis. Recall the example of the executive. She may cope by burying herself in her work, calling an emergency meeting of the board of trustees to discuss the situation, or withdrawing from the situation.
A realistic perception occurs when a person is able to distinguish the relationship between an event and feelings of stress. For example, a 45-year-old executive recognizes the fact that her company is on the verge of bankruptcy because of inefficient projected financial planning by the board of trustees. Although she realizes the seriousness of the situation and feels stress, she does not place the blame on herself and view herself as a failure. Her perception, rather than the actual event, determines her reaction to the situation.
A situational support refers to the resources available in the person’s environment. Consider the example of the 45-year-old executive. The executive may discuss the situation with a financial consultant, a lawyer, or the firm’s accountant. Such persons available in the environment are considered to be situational supports because they reflect appraisals of one’s intrinsic and extrinsic values. Support by these people may prevent a state of disequilibrium and crisis from occurring. When emotional or environmental support systems such as family or friends are not as readily available, the person is more likely to define the event as more overwhelming or hazardous, thus increasing his or her vulnerability to crisis.
Crisis intervention is an active but temporary entry into the life situation of an individual, a family, or a group during a period of stress (Mitchell &Resnik, 1981). It is an attempt to resolve an immediate crisis when a person’s life goals are obstructed and usual problem-solving methods fail. The client is called on to be active in all steps of the crisis intervention process, including clarifying the problem, verbalizing feelings, identifying goals and options for reaching goals, and deciding on a plan.
Crisis intervention can occur in many settings the home, emergency department, industrial dispensary, classroom, surgical intensive care unit, or psychiatric sunit. The generic approach focuses on a particular kind of crisis by directly encouraging adaptive behavior and providing general support, environmental manipulation, and anticipatory guidance. The individual approach focuses on the present, shows little or no concern for the developmental past, and places an emphasis on the immediate causes of disequilibrium. It can be used as secondary or tertiary prevention and can be effective in preventing future crises.
goals of crisis intervention:-
The goals of crisis intervention are:-
- To decrease emotional stress and protect the client from additional stress
- To assist the client in organizing and mobilizing resources or support systems to meet unique needs and reach a solution for the particular situation or circumstance that precipitated the crisis, ultimately enabling the individual to understand the relationship of past life experiences to current stress; prevent hospitalization; reduce the risk of chronic mal-adaptation; and promote adaptive family dynamics
- To return the client to a pre-crisis or higher level of functioning
Steps in Crisis Intervention
Crisis intervention is not to be confused with traditional psychotherapy. Clients may need to address issues quickly, but may not tolerate frequent sessions. They may not respond to interventions, and may require an extended amount of time to resolve issues. A multidisciplinary approach may facilitate resolution because it provides support and a learning opportunity for both client and nurse.
The process of crisis intervention contains four steps: assessment; planning of therapeutic intervention; implementation of therapeutic intervention; and resolution of the crisis with anticipatory planning and evaluation (Aguilera, 1997). When working with a maturational crisis (also referred to as a developmental or internal crisis) or a situational crisis (also referred to as an accidental or external crisis), the crisis worker should be aware of the following usual occurrences (Lego, 1984):
- Most crises occur suddenly, without warning; therefore, there is inadequate prior preparation to handle such a situation.
- The client in crisis perceives it to be life threatening.
- There is a decrease or loss of communication with significant others.
- Some displacement from familiar surroundings or significant others occurs.
- All crises have an aspect of an actual or perceived loss involving a person, object, idea, or hope.
Assessment of a client during crisis intervention depends on several factors, such as the severity of the crisis, the client’s perception of the crisis, and the accurate interpretation of data to formulate a nursing diagnosis.
Determining Crisis Severity
The first factor in the assessment process is to determine the severity of the crisis and to identify the degree of disruption the client is experiencing. Is the individual anxious, depressed, fearful, confused, disoriented, suicidal, or homicidal? Is the crisis due to an interpersonal or intrapersonal issue? Does the crisis involve one person, several people, or a community? Is this a criminal situation with actual or potential harm or lethality? Individuals who are isolated, are dependent, were previously traumatized, and have physical or mental disorders are considered to be at risk for a high degree of disruption. In addition, the effects of a crisis on children can be compounded if adults express great fear and anger around them, thus being insensitive to children’s insecurities or needs. Recognizing the magnitude of physical, emotional, social, and spiritual components of a crisis is essential to helping clients, as well as to intervening such that additional complications do not develop (Davidhizar& Shearer, 2002).
When the nurse assesses the dangerousness of a client’s behavior toward self or others, the term crisis forensics is used. The word forensics is used because the nurse has a responsibility toward society, the liberty interest of the client, and the legal regulation of psychiatry, all of which are operating in a crisis mode (Saunders, 2000).
Assessing Client’s Perception.
The second factor involves assessing the client’s perception of the event. Two major approaches may be used: symptom-focused and constructivist self-development theory (CSDT). The symptom-focused approach focuses on the emotions of the client, whereas the CSDT focuses on one’s relationship with oneself and one’s relationship with others.
Rosenbloom (1999) compares the symptom-focused approach of crisis intervention to the CSDT of McCann and Pearlman (1990). According to McCann and Pearlman, a symptom-focused approach concentrating on the emotions of the client does not adequately explore root causes of trauma. That is, some individuals are unaware of the significance of the event in their lives. Are the client’s perceptions realistic or distorted? Does the client see the situation as a threat to self-esteem, well-being, intimacy, self-control, or ability to trust? As a result of any misperceptions about the severity of the crisis event, the client in crisis may be misdiagnosed and receive inappropriate treatment. With CSDT, identifying a threat can help clients connect to their experiences on an emotional level and make sense of their feelings. Examining symptoms does not necessarily help clients understand what is particularly distressing or destabilizing them. Also using CSDT, attention is given to present coping skills and the availability of support systems on whom the individual can rely for continued support.
Formulating Nursing Diagnoses:-
Formulating nursing diagnoses is the third factor in the assessment of a client in crisis. Examples of nursing diagnoses for clients experiencing a crisis may include the following:
- Ineffective Coping
- Impaired Verbal Communication
- Risk for Injury
- Dysfunctional Grieving
- Disabled Family Coping
- Planning of Therapeutic Intervention
With information gained through the assessment process and the formulation of one or more nursing diagnoses, several specific interventions are proposed. Connoly and Chandler (1997) state that individuals must learn to ask for help and realize the potential for growth during a crisis. They should be involved in the choice of alternate coping methods and encouraged to make as many arrangements as possible by themselves. If significant others are involved, their needs and reactions must also be considered. The nurse should identify strengths and resources of all persons providing support.
- Implementation of Therapeutic Interventions
Therapeutic intervention depends on preexisting skills, the creativity and flexibility of the nurse, and the rapidity of the person’s response. The nurse helps the person establish an intellectual understanding of the crisis by noting the relationship between the precipitating factor and the crisis. He or she also helps the client explore coping mechanisms, remember or recreate successful coping devices used in the past, or devise new coping skills. Reducing immobility caused by anxiety and encouraging verbalization of feelings is an immediate goal of the nurse. An attempt is also made to establish new supportive and meaningful relationships and experiences, reopening the person’s social world. The therapeutic techniques commonly used by nurses performing crisis intervention are listed:-
Commonly Used Therapeutic Techniques in Crisis Intervention
- Displaying acceptance and concern and attempting to establish a positive relationship
- Encouraging the client to discuss present feelings, such as denial, guilt, grief, or anger
- Helping the client to confront the reality of the crisis by gaining an intellectual as well as emotional understanding of the situation; not encouraging the person to focus on all the implications of the crisis at once
- Explaining that the client’s emotions are a normal reaction to the crisis
- Avoiding false reassurance
- Clarifying fantasies; contrasting them with facts
- Not encouraging the client to place the blame for the crisis on others because such encouragement prevents the client from facing the truth, reduces the client’s motivation to take responsibility for behavior, and impedes or discourages adaptation during the crisis
- Setting limits on destructive behavior
- Emphasizing the client’s responsibility for behavior and decisions
- Assisting the client in seeking help with the activities of daily living until resolution occurs
- Evaluating and modifying nursing interventions as necessary
During resolution, anticipatory planning and evaluation occur. Reassessment is crucial to ascertain that the intervention is reducing tension and anxiety successfully rather than producing negative effects. Reinforcement is provided whenever necessary while the crisis work is reviewed and accomplishments of the client are emphasized. Assistance is given to formulate realistic plans for the future, and the client is given the opportunity to discuss how present experiences may help in coping with future crises.
Crisis Intervention Modes
The steps in crisis intervention just presented usually are evident during individual crisis counseling. Clients also may elect to participate in a crisis group that resolves various crises through use of the group process. Such groups generally meet for four to six sessions. They provide support and encouragement to persons who depend on others for much of their sense of personal fulfillment and achievement. Family crisis counseling includes the entire family during sessions lasting approximately 6 weeks. This type of counseling is considered the preferred method of crisis intervention for children and adolescents.
Suicide prevention and crisis intervention counseling centers provide telephone hotlines on a 24-hour basis. Volunteers who have had intensive training in telephone interviewing and counseling, and can give the person in crisis immediate help, usually staff such hotlines.
Mental health crisis intervention services are often hospital based or tied to community mental health centers. Mobile crisis units are now used, especially to provide services to the homebound, older adult clients, or individuals who live in rural areas. Outreach programs in rural communities have been known to reduce psychiatric hospitalizations by approximately 60% (Crisis Intervention Network, 2001). Examples of Centers That Provide Crisis Intervention
Children’s Protective Services
Domestic Violence Crisis Center
Life Crisis Center
Rape Crisis Center
Sexual Assault Crisis Center
Suicide Crisis Center
Youth Crisis Center
Workplace Crisis Center
Role of the Nurse During a Crisis:-
The most essential element of a crisis intervention is the ability of the nurse to provide emotional support while assessing the individual’s emotional and physical needs and enlisting his or her cooperation. Whittlesey, Vinekar, and Tucker (1999) discuss the role of the Nurse or practitioner in crisis situations, emphasizing the educational preparation of the nurse, because most practitioners have little experience dealing with individual or community crises. The nurse must understand the effects of severe stress on the average person. Indeed, clients, as well as clinicians, are vulnerable to permanent damage as a result of exposure to continued stress.
Preparation for intervening during crisis situations takes on various forms. Role-play exercises, focusing on the possible emotional responses of both client and nurse during a specific crisis situation or disaster, are one example. Preparation also includes attending educational seminars to develop crisis intervention techniques to assist victims experiencing denial, anger, remorse, or grief, and guide the victim toward the resolution phase of the crisis. The nurse’s attitude may affect the outcome of the client’s response. For example, the nurse may give the impression that a particular situation is not a crisis, while the client thinks that it is the worst thing that could happen. Here, the nurse’s attitude blocks good communication and effective crisis intervention.
Crisis Intervention for Children
When children are in crisis, the entire family is affected. Trauma can change the way.
Children view their world. Assumptions about safety and security are challenged. Their reactions will depend upon the severity of the trauma, their personality, the way they cope with stress, and the availability of support. It is not uncommon for children to regress both behaviorally and academically following a trauma.
Assessment of the Child in Crisis
To assess a child in crisis, the nurse needs to have a working knowledge of the theories of personality growth and development. Assessment of a child in crisis focuses on the child’s psychosocial abilities, specifically his or her intellectual, emotional, and social development (Mitchell &Resnik, 1981).
Common Reactions of a Child in Crisis
A child in crisis presents a complex challenge. Depending upon the age of a child, individual needs and responses may differ with the same crisis events. Among the many events that produce a crisis state in a child or adolescent’s life, injury, illness, and death are considered to be the most disruptive (Mitchell &Resnik, 1981).
It is natural for a child to first experience denial that the crisis situation really happened. When the child does respond, clinical symptoms commonly exhibited include:
- Excessive fears, worries, self-blame, or guilt
- Irritability, anger, or sadness
- Sleep disturbances or nightmares
- Loss of appetite or weight problems
- Agitation or restlessness
- Somatic complaints such as headaches or stomachaches
- Behavioral regression or aggression
- Poor concentration and loss of interest in school or activities
These symptoms may range from mild to severe. A child who is in crisis should be encouraged to process emotions or reactions within 24 to 36 hours following the traumatic event to prevent the development of post-traumatic stress disorder.
Interventions for a Child in Crisis
The major functions of crisis intervention for a child in crisis are to:
- Provide safety and security including freedom from fears and terrors associated with the crisis event
- Provide an opportunity for bonding with a professional who displays an atmosphere of open acceptance, encourages verbalization of feelings and emotions, and assists the child in practicing coping and communication skills
- Provide stabilization services that will assist a child in the return to a precrisis level of functioning
- Assist the child and family members in resolving issues or situations that may have precipitated the crisis
- Provide linkages with community services to facilitate aftercare to process trauma and prevent the development of post-traumatic stress disorder
Resolution of a Child’s Crisis
Resolution of a crisis may occur in a child’s home or school, or in the community. Crisis response teams, also referred to as mobile acute crisis teams, are available 24-hours-per-day, 7-days-per-week and provide crisis counseling in homes and schools. Family members, teachers, and other concerned adults are encouraged toactively participate in the resolution of a crisis. Emergency shelters or safe houses are provided at confidential locations to provide for basic needs of a child who is the victim of domestic violence. Outreach programs provide individual support and crisis counseling to a child experiencing difficulty at home and school due to domestic violence issues (Crossroads, 2003; Life Skills, 2003; Mitchell &Resnik, 1981; Wheeler Clinic, 2003).
Legal Aspects of Crisis Intervention
Since 1980, the National Crisis Prevention Institute (NCPI) has trained over 100,000 human service providers in the technique of nonviolent crisis intervention. Participants are trained to recognize an individual in crisis and prevent an emotionally or physically threatening situation from escalating out of control. Crisis intervention training helps eliminate staff confusion, develops self-confidence among staff, and promotes teamwork.
Most people are not required by law to help a person in crisis. However, certain individuals such as police officers, firefighters, and emergency medical personnel are legally responsible to provide help. In certain states, doctors and nurses are also expected to intervene during an emergency or crisis situation. Generally, these individuals are legally protected as long as they provide reasonable and prudent care according to a set of previously established criteria, and thus do not hesitate to aid people who need their help.
The criteria or standards of care for a person providing crisis intervention state that the person who begins to intervene in a crisis is obligated to continue the intervention unless a more qualified person relieves him or her. Discontinuing care constitutes abandonment, and the caregiver is liable for any damages suffered as a result of the abandonment. Any unauthorized or unnecessary discussion of the crisis incident by the person intervening is considered a breach of confidentiality. Touching a crisis victim without the client’s permission could result in a charge of battery. However, permission can be obtained verbally or by nonverbal actions that express a desire for help. Consent also can be implied. Implied consent is permission to care for an unconscious crisis victim to preserve life or prevent further injury. Therefore, failure to act in a crisis carries a greater legal liability than acting in favor of the treatment.
In cases where a client is injured by the actions of a crisis worker, negligence may be charged. However, the client must prove that the worker acted with a blatant disregard for the standard of care. Usually, the charge is dropped if the caregiver can prove he or she acted in a prudent and reasonable manner.
- A crisis situation can interrupt or disturb one’s biologic, psychological, spiritual, or social integrity and may affect an individual, family, or community.
- There are two types of crises: a situational crisis, which refers to an extraordinary stressful event, and a maturational crisis, which can occur as one’s lifestyle is continually subject to change.
- The onset of a crisis usually occurs suddenly when normal coping methods fail, tensions rise, and emotional feelings such as fear, anxiety, or helplessness occur.
- The individual in crisis generally experiences five phases: precrisis, impact, crisis, resolution, and postcrisis.
- Crises are classified depending on the degree of disruption or severity of the situation. Class 6, the most severe type, includes psychiatric emergencies, such as suicide or a drug overdose.
- Aguilera has described a paradigm of balancing factors. Balancing factors include realistic perception of an event, adequate situational support, and adequate defense or coping mechanisms to help resolve a problem. Assessment of these factors is important during crisis intervention.
- The nurse clinician or practitioner who assists in crisis interventions should not confuse crisis intervention with traditional psychotherapy. A multidisciplinary approach may facilitate resolution of crisis.
- Crisis intervention consists of assessment, planning therapeutic intervention, implementation of intervention techniques, and resolution of crisis with anticipatory planning for the future.
- Crisis intervention modes include counseling of individuals, groups, or families; telephone hotlines; mental health crisis intervention services; mobile crisis units; and outreach programs in rural communities.
- Legal aspects of crisis intervention focus on which personnel are expected to assist in crisis situations; when legal immunity is granted; when the obligation to continue crisis intervention is expected; and when negligence may be charged.
- The focus of assessment of a child in crisis centers is on the child’s psychosocial abilities, specifically his or her intellectual, emotional, and social development. Reactions to interventions depend upon the severity of the trauma, the child’s personality and ability to cope with stress, and the availability of support.