Crises, types ,management

crises, its types, phases and management of crises.

1. Ms. Sonali katoch

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

3. INTRODUCTION Urgent need for assistance Therapist becomes a part of the individual’s life situation Unable to solve problems Requires guidance and support to help mobilize the resources needed to resolve the crisis.

4. CHARACTERISTICS Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology. Crises are precipitated by specific identifiable events. Crises are personal by nature. What may be considered a crisis situation by one individual may not be so for another. Crises are acute, not chronic, and will be resolved in one way or another within a brief period. A crisis situation contains the potential for psychological growth or deterioration.

5. CHARACTERISTICS OF A CRISIS Disorganised biological, cognitive, emotional and behavioural experiences The person in crisis becomes less able to perform problem solving and interpret the circumstances of crisis event There will be as precipitating event of actual or perceived loss, threats of losses or challenges There is a presence of both danger and opportunity. Crisis events bring about complicated symptomology that defy cause and effect descriptions and may not always be logical and cohesive Crisis carries seeds of both growth and change Crisis is universal and idiosyncratic: something is going to happen to everyone, and it can be a matter of pure luck Crises are time-limited, and involve a precipitating event. They can be situational as well as developmental Crisis brings about vulnerability and reduced defensiveness, as well as a heightened state of suggestibility Crisis is not mental illness, and it should not be confused as such.

6. STAGES OF CRISIS DEVELOPMENT (TYHURST) Period of impact: The individual realizes the actuality of the event. Period of recoil: Distress resulting from the event becomes overwhelming and the individual struggle to cope. Posttraumatic period: The individual experience disruptions in normal functioning. Kaplan describes a four phase’s paradigm to understand the development of crisis: First phase: A traumatic event causes an initial rise in the individual’s level of anxiety. The individual responds with familiar problem solving mechanics in an attempt to reduce the stress and discomfort. If coping mechanisms are effective the crisis is averted. Second phase: When the individuals usual problem solving abilities fail he enters the second phase and the stimulus that caused the initial rise in the tension continues. Third phase : The individual’s anxiety continues to rise and the increased tension moves the individual to reach out for assistance and use every available resource to solve the problem and reduce the increasingly painful state of anxiety. Fourth stage: The state of active crisis results when integral strengths and social supports are insufficient, the problem remains unresolved and tension and anxiety rise to an unbearable level. The individual experiences the continuation of the crisis and severe anxiety or panic predisposes him to psychological disorganization.

7. PHASES IN THE DEVELOPMENT OF A CRISIS, Caplan (1964) Phase 1. The individual is exposed to a precipitating stressor. Anxiety increases; previous problem-solving techniques are employed. Phase 2. When previous problem-solving techniques do not relieve the stressor, anxiety increases further. The individual begins to feel a great deal of discomfort at this point. Coping techniques that have worked in the past are attempted, only to create feelings of helplessness when they are not successful. Feelings of confusion and disorganization prevail.

8. PHASES IN THE DEVELOPMENT OF A CRISIS, Caplan (1964) Phase 3. All possible resources, both internal and external, are called on to resolve the problem and relieve the discomfort. The individual may try to view the problem from a different perspective, or even to overlook certain aspects of it. New problem-solving techniques may be used, and, if effectual, resolution may occur at this phase, with the individual returning to a higher, a lower, or the previous level of premorbid functioning. Phase 4. If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs.” Anxiety may reach panic levels. Cognitive functions are disordered, emotions are labile, and behavior may reflect the presence of psychotic thinking.

9. PHASES IN THE DEVELOPMENT OF A CRISIS, Caplan (1964) 1. The individual’s perception of the event. If the event is perceived realistically, the individual is more likely to draw on 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. Situational supports are those persons who are available in the environment and who can be depended on to help solve the problem. Without adequate situational supports during a stressful situation, an individual is most likely to feel overwhelmed and alone.

10. PHASES IN THE DEVELOPMENT OF A CRISIS, Caplan (1964) 3. The availability of adequate coping mechanisms. When a stressful situation occurs, individuals draw on behavioral strategies that have been successful for them in the past. If these coping strategies work, a crisis may be diverted. If not, disequilibrium may continue and tension and anxiety may 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 . Kaplan and Sadock (1998) state , “A crisis is self-limited and can last from a few hours to weeks. It is characterized by an initial phase in which anxiety and tension rise, followed by a phase in which problem-solving mechanisms are set in motion.” Crises can become growth opportunities when individuals learn new methods of coping that can be preserved and used when similar stressors reoccur.

11. 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) states: 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 his pre-crisis level of functioning or possibly to a higher level of functioning. The therapist’s role is direct, supportive, and that of an active participant.

12. CRISIS INTERVENTION Crisis intervention takes place in both inpatient and outpatient settings. An orderly problem-solving techniques and structured activities that are focused on change. Through adaptive change, crises are resolved, and growth occurs. Crisis intervention, is not aimed at major personality change or reconstruction (as may be the case in long-term psychotherapy); its goal is using a given crisis situation to, at the very least, restore functioning and, at most, to enhance personal growth.

13. PHASES OF CRISIS INTERVENTION: THE ROLE OF THE NURSE Aguilera (1998) describes four specific phases in the technique of crisis intervention. These phases are clearly comparable to the steps of the nursing process.

14. PHASE 1: ASSESSMENT In this phase, the crisis helper gathers information regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. A nurse in crisis intervention might perform some of the following assessments:

15. Cont… 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 methods of coping were used? Have these methods been tried this time?

16. Cont… 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 pre-crisis functioning. Assess the usual coping methods, available support systems, and ability to solve problems. Assess the individual’s perception of personal strengths and limitations. Assess the individual’s use of substances.

17. Cont… Information from the comprehensive assessment is then analyzed, and appropriate nursing diagnoses reflecting the immediacy of the crisis are identified. Some nursing diagnoses that may be relevant include: Ineffective Anxiety (severe to panic) Disturbed thought processes Risk for self-or-other-directed violence Rape-trauma syndrome Post-trauma response Fear

18. PHASE 2: PLANNING OF THERAPEUTIC INTERVENTION In the planning of the nursing process, 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) is taken into consideration. Goals are established for crisis resolution and a return to or increase in the pre-crisis level of functioning.

19. PHASE 3: INTERVENTION During phase 3, the actions that were identified in phase 2 are implemented. The following interventions are the focus of nursing in crisis intervention: Uses a reality-oriented approach. The focus of the problem is on the here and now. 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.

20. Cont…. 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.

21. Cont…. Clarify the problem 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, taking care to avoid providing positive feedback for these feelings.

22. Cont…. Guide the individual through a problem-solving process by which he or she may move in the direction of positive life change:

23. Cont…. Help the individual confront the source of the problem that is creating the crisis response. Encourage the individual to discuss changes he or she would like to make. Jointly determine whether 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.

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

25. 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 crises?

26. Cont…. 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?

27. Cont… 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.

28. ROBERTS’ SEVEN-STAGE CRISIS INTERVENTION MODEL Stage I. Psychosocial and Lethality Assessment Conduct a rapid but thorough biopsychosocial assessment. Stage II. Rapidly Establish Rapport The counselor uses genuineness, respect, and unconditional acceptance to establish rapport with the client. Skills such as good eye contact, a nonjudgmental attitude, flexibility, and maintaining a positive mental attitude are important.

29. ROBERTS’ SEVEN-STAGE CRISIS INTERVENTION MODEL Stage III. Identify the Major Problems or Crisis Precipitants- Identify the precipitating event that has led the client to seek help at the present time. Identify other situations that led up to the precipitating event. Prioritize major problems with which the client needs help. Discuss the client’s current style of coping, and offer assistance in areas where modification would be helpful in resolving the present crisis and preventing future crises. Stage IV. Deal with Feelings and Emotions Encourage the client to vent feelings. 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 client adopt more rational and adaptive options.

30. ROBERTS’ SEVEN-STAGE CRISIS INTERVENTION MODEL Stage V. Generate and Explore Alternatives Collaboratively explore options with the client. Identify coping strategies that have been successful for the client in the past. Help the client problem-solve strategies for confronting the current crisis adaptively. Stage VI. Implement an Action Plan There is a shift at this stage from crisis to resolution. Develop a concrete plan of action to deal directly with the current crisis. Having a concrete plan restores the client’s equilibrium and psychological balance. Work through the meaning of the event that precipitated the crisis. How could it have been prevented? What responses may have aggravated the situation? Stage VII. Follow-Up 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.

31. Suicide Crisis lines – Suicide (04424640050; 04427546669), child (1098), Sexual abuse (181), HIV/AIDS (1098; 18001802008), Anti poison (1066); cancer (9910516562); medical (104), mental health (18602662345) Interpersonal violence Substance abuse and drug addiction Posttraumatic stress disorder The mentally ill on the streets

32. CRISIS LINES Suicide (04424640050; 04427546669) Child (1098) Sexual abuse (181) HIV/AIDS (1097; 18001802008) Anti poison (1066) Cancer (9910516562) Medical (104) Mental health (18602662345)

33. TYPES OF CRISIS There are four types of crisis explained from the crisis theory: Situational crisis: This results from an external environment or event influence that upsets the individual or his bio-psycho-social environment. It is characterized by a sudden, unexpected onset and generally has a singular origin. Examples are accidents, diagnosis of terminal illness etc. Maturational crisis: This develops’ as a result of developmental events, or life transitions requiring significant rile changes. It can occur at unpredictable stages of growth and development like infancy and early childhood, preschool, puberty, adolescence, adulthood and old age.

34. TYPES OF CRISIS Adventitious crisis: It is described as accidental, uncommon and expected tragedies that disrupt entire communities, often natural disasters such as hurricanes earth quakes, floods, tsunami and fires. Shock and generalized anxiety strike the entire community. Left untreated the effects of theses crisis may lead to acute or post traumatic stress disorder. Socio Cultural Crisis: It is described as one rising from the cultural values that are embedded in the social structure. The loss of a job or loss of class is examples. Other incidents like rape, robbery and incest are also socio cultural crisis.

35. MATURATIONAL CRISIS It is found that increased crisis potential during development period is: Adolescent Marriage Parenthood Midlife Retirement

36. MATURATIONAL CRISIS- Adolescence Adolescence is a transition in to young adulthood. An often definition of an adolescent by an anonymous author is, ‘a toddler with hormones and wheels’. Adolescents have many issues to deal with and many choices to make. Some of these issues that relate to self-esteem, body image, peer relationship, educators, career selection, establishing a set of values and ideals, sexuality and sexual experimentation, drug and alcohol abuse and physical appearance.

37. MATURATIONAL CRISIS- Adolescence Nursing interventions: Focus on providing adolescent with support and accurate information; ease the difficult transition they are undergoing. Educational program that inform about and validate bodily changes and emotional feelings about which there may be some concerns. Educational program that inform about sexuality, pregnancy, conception, sexually transmitted disease.

38. MATURATIONAL CRISIS- Marriage Marriage is considered under risk population because additional conflicts sometimes arise when the marriage is influenced by crossover in religion, ethnicity, social status, race, although these type of differences have become more individually and socially acceptable than they were once. Nursing interventions: Education regarding what to expect at various stages in marriage through rol -play about family situations in the schools Encouraging honest communications in married couple Determining what each person expects the relationships Ascertaining whether each individual can accept compromise

39. MATURATIONAL CRISIS- Parenthood It is unfortunate that parenting is one of the most important positions an individual will hold in life and one for which he/she is least prepared, and coming of the child is a crisis and turning point in couple’s life. Nursing interventions: Prepared child birth classes: What most likely will happen but with additional information about possible variations from what is expected. Information about what to expect after the baby arrives Parent-infant bonding

40. MATURATIONAL CRISIS- Parenthood Parent-infant bonding Changing husband wife relationship Clothing and equipment Feeding – e.g. advantages/ disadvantages of breast feeding, formula feeding etc., Other expectations i.e. important for expectant parents to receive anticipatory guidance about the infant’s sleeping and crying pattern, bathing the infant, care of cord etc… Explain the expected behaviour in each stage of growth and development of the child. Educational programmes that inform about the use and abuse of alcohol and other drugs.

41. MATURATIONAL CRISIS- Middle life Midlife crisis has been identified with three broad categories. An alteration in perception of self: One’s perception of self may occur slowly. One may suddenly become aware of being old, middle aged e.g. menopausal period. An alteration in the perception of others: A change in the relationship with adult children requires a sensitive shift in caring. An alteration in the perception of time: Middle age has been defined as the end of youth and the beginning of the old age. Individuals often experience a sense that time is running out. Depression and sense of loss may occur as individuals realize that some of the goals established in their youth go unmet.

42. MATURATIONAL CRISIS- Middle life Nursing interventions: Nutritional classes to inform individuals in this age group about the essentials of diet and exercise. Educational materials on how to avoid obesity to reduce weight can be included, along with important of good nutrition. Assistance with ways to improve health e.g. quit smoking, cease/reduce alcohol consumption and reduce fat intake. Discussions on the important of having regular physical examination including pap and breast examination for women and prostate examination for men, monthly breast self examination should be taught and early mammograms encouraged.

43. MATURATIONAL CRISIS- Middle life Nursing interventions: Classes on menopause should be given, provide information about what to expect. Myths that bound regarding this topic should be expelled. Support groups for women undergoing the menopausal experiences should be formed. Support and information related to care of aging parents should be given. Individuals should be referred to community resources for respite and assistance before strain of the caregiver role threatens to disrupt the family system.

44. MATURATIONAL CRISIS- Retirement Retirement which is often anticipated as an achievement in principle may meet a great deal of ambivalence when it actually occurs. Our society places a great deal of importance on productivity and on earning as much money as possible at young age as possible. These types of values contribute to the ambivalence associated with retirement. Adjustment to this life cycle event becomes more difficult in the face of societal values that are in direct conflict with new life style.

45. SITUATIONAL CRISIS Situational crisis are acute responses that occur as a result of an external circumstantial stressor. The number and type of situational stressors are limitless and may be real/ exist only in the perception of the individual. Some type of situational crisis that put individuals at risk for mental illness includes the following:

46. SITUATIONAL CRISIS Poverty: A number of studies have identified as a direct co-relation to emotional illness. This may have to do with the direct consequences of poverty such as inadequate and crowded living conditions, nutritional deficiencies, medical neglect, and unemployment/being homeless. High rate of life change events: Miller and Retie found that frequent changes in life patterns due to large number of significant events occurring in close proximity tend to decrease person’s ability to deal with stress, and physical/emotional illness may be result. These includes life change events such as death of loved one, divorce, fired from job, change in living conditions, change in place or employment/residence, physical illness or change in body image as a result of loss of body part or functions.

47. SITUATIONAL CRISIS Environmental conditions: Environmental conditions can create situational crisis. Tsunami, floods, hurricanes and earthquakes have wrecked devastation on thousands of individuals and families in recent years.

48. SITUATIONAL CRISIS Trauma: Individuals who have experienced traumatic experiences must be considered at risk for emotional illness. Guide the individuals through a problem solving process by which he/she may move in the direction of positive life changes. Help the individual the sources of the problem that is creating the crisis response. Encourage the individual to discuss changes he/she would like to make. Jointly determine whether desired changes are realistic. Encourage exploration of feelings about aspects that cannot be changed, and explore alternative ways of coping more adaptively in this situations.

49. SITUATIONAL CRISIS Encourage exploration of feelings about aspects that cannot be changed, and explore alternative ways of coping more adaptively in this 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. Identify external support systems and social networks from which the individual may seek the assistance in times of crisis.

50. SITUATIONAL CRISIS Trauma: Individuals who have experienced traumatic experiences must be considered at risk for emotional illness. Guide the individuals through a problem solving process by which he/she may move in the direction of positive life changes. Help the individual the sources of the problem that is creating the crisis response. Encourage the individual to discuss changes he/she would like to make. Jointly determine whether desired changes are realistic. Encourage exploration of feelings about aspects that cannot be changed, and explore alternative ways of coping more adaptively in this situations.

51. SITUATIONAL CRISIS Trauma: 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. Identify external support systems and social networks from which the individual may seek the assistance in times of crisis.

52. THANKYOU 52