Crisis

crisis and its intervention

1. crisis Mrs.Alka kapri m.Sc nursing State college of nursing

2. Barry Kidd 2010 2 DEFINITION A crisis is an overwhelming reaction to a threatening situation in which a person’s usual problem solving strategies fail to resolve the situation resulting in a state of disequilibrium.

3. Internal disturbances that result from a stressful event or a perceived threat to self. .Greek--word "crisis" is derived from the word " krinen "--to decide. .Chinese--2 characters used to denote crisis; one is character for danger, the other character for opportunity. .Crises are an inevitable part of human existence. .Any stressful event can trigger a crisis, depending on the individual's perception of the event, coping skills and support system. .A crisis is a period of increased vulnerability that may lead to growth of an individual. DEFINITION OF CRISIS

4. . All crises are experienced as "sudden" to the individual or family. They were unaware of warning signals and unprepared for the event. The crises is often experienced as ultimately life-threatening, whether hat perception is realistic or not . Communication with significant others is often decreased or cut off . There may be perceived or real displacement from familiar surroundings or significant loved ones . All crises have an aspect of loss, whether actual or perceived. CHARACTERISTICS OF CRISES

5. Transitional (maturational and anticipated) crisis .Precipitated by the normal stress created during social, psychological, and behavioral changes associated with transitions. These crises are anticipated and can be prepared for. . Universal transition states: .Normal transitions of human development. .Predictable and occurs gradually. .Each stage is characterized by unique stressors and tasks to accomplish. .Failure at one stage compromises the next stage of development . TYPES OF CRISIS

6. Non-universal transition states: .Includes changes such as marriage, retirement, student to worker. .Crises occur when the individual cannot adapt to functioning at the new level. . Crisis may occur if the individua l : .Is not able to visualize a new role. .Experiences two or more life changes or events suddenly. .Lacks interpersonal resources to make necessary changes. .Has significant persons refusing to acknowledge the individual's new role.

7. . Can originate from material or environmental sources (disaster), personal or physical sources (illness ), and interpersonal or social sources (divorce, death). .Occurs in response to a traumatic event that is usually sudden and unavoidable. .Can produce threat of loss or loss of a role necessary to maintain one's self image. .May challenge every coping mechanism, especially if it is an uncommon or unexpected event involving multiple losses or gross environmental changes . Situational crisis

8. .Phases of human disaster responses: .Impact phase .Includes the event itself. .Characterized by shock, panic, or extreme fear. .Judgment and assessmenot f reality are poor. .Heroic phase .Cooperative spirit between friends, neighbors and emergency teams. .Constructive activity can help overcome feelings of anxiety and depression. .Over-activity can lead to burn-out. .Honeymoon phase .Appears one to several months after disaster. .Money, resources and support received cause daily life to begin again. .Psychological and behavioral problems may be overlooked.

9. Disillusionment phase .Lasts two months to one year. .A time of disappointment, resentment, frustration and anger. .Victims compare others to their own plights; may experience resentment and show hostility toward others. Reconstruction and reorganization phase .May last for years. .Individuals begin to come to grip with their own problems. .They begin to re-build their lives, homes, businesses

10. . Can originate from cultural and social sources (loss of a job due to discrimination, being a victim of deviant acts of others or behaviors that violate social norms). .Often are less amenable to control by individuals. .Community or government action may be a component of identification and resolution of the Crisis. Cultural/Social crisis

11. . Precrisis Stage --individual maintains equilibrium through use of coping skills during minor stressors . .Crisis Stage .Individual perceives an event as threatening to life goals and unmanageable based on current coping mechanisms. .Leads to increased anxiety, tension, and disorganization. .Lasts no longer than six weeks since much energy is expended. . Postcrisis Stage --may result in positive or negative state. . Positive state --develops new equilibrium and functioning (a better social network,nproblem solving abilities, improved self-image). . Negative state -loses skills, regresses or develops socially unacceptable behaviors. CRISIS SEQUENCE

12. 12 CRISIS INTERVENTION BALANCING FACTORS Crisis- good outcome Perception of event realistic Situational support adequate Coping mechanism adequate No crisis Crisis- development Perception of event distorted Situational support inadequate Coping mechanisms inadequate Crisis

13. Barry Kidd 2010 13 PHASES OF CRISIS STRESS ANXIETY USUAL COPING MECHANISMS INEFFECTIVE TRIAL & ERROR SOLUTIONS SEVERE ANXIETY PERSONALITY DISORGANIZATION (CRISIS) OR NEW PROBLEM- SOLVING SOLUTIONS AND SUPPORT ANXIETY PRE-CRISIS LEVEL OF FUNCTIONING

14. Anxiety .Depression .Confusion .Anger .Helplessness .Withdrawal .Somatic symptoms .Inefficiency .Hopelessness SYMPTOMS EXPERIENCED IN CRISIS

15. Crisis intervention is an action-oriented model that is present-focused, with the objective for the intervention being specific to the hazardous event, situation, or problem that precipitated the state of crisis Crisis intervention focus on the Here and now and only addresses past issues when needed. Crisis intervention

16. Dr. Eric Lindemann was one of the pioneers of crisis intervention. Dr Lindemanns pioneering study on the loss and bereavement with 101 survivors and family members of the victims of the Coconut Grove nightclub fire in Boston was one of the first efforts to develop a more systematic way of helping people in crisis. Through his research, theories of grief process and typical reactions to crisis were developed.

17. Central Constructs Crisis intervention derived from ego psychology and ecological systems theory. Below are the ideas that were derived from these two systems. Ego: Life Development stages Psychosocial crisis Coping skills Defense mechanism Ecological: Homeostasis Disequilibrium Interdependence

18. Crisis Intervention Two important concepts in crisis intervention include: Levels of crisis & Stages of Crisis Level of crisis include: Somatic Distress, Transitional Stress Crisis, Traumatic Stress Crisis, Family Crisis, Serious Mental Illness, Psychiatric Emergencies, and Catastrophic Crisis Stages of Crisis include: Outcry, Denial or Intrusiveness, Working Through, and Completion or Resolution

19. Levels of Crisis in detail Ann Wolbert Burgess and Albert R. Roberts developed the model for assessing emotional stress and acute crisis using seven main levels of crisis along a stress-crisis continuum. Although each crisis is unique, this stress-crisis continuum can be used in assessment and intervention planning to determine the level of care that is needed, as well as the most effective treatment modality.

20. Levels of Crisis Continued Level 1: Somatic Distress - Biomedical causes, situational problems, health problems, relationship conflicts, work-related stressors, chemical dependency issue Level 2: Transitional Stress Crisis- Stressful events that are expected in part of one’s lifespan development. Examples include premature birth, bankruptcy, divorce, relocation Level 3: Traumatic Stress Crisis - Unexpected and/or accidental situations outside the individuals locus of control. Crisis can be life threatening. Examples include disasters, crime victimization, family violence, child abuse, sexual assault Level 4: Family Crisis- Issues related with interpersonal and family relationships that are unresolved and harmful psychologically, emotionally, and physically. Examples include child abuse, family violence, homelessness, and parental kidnapping

21. Levels of Crisis Continued Level 5: Serious Mental Illness- relates from preexisting psychopathology. Examples include schizophrenia, dementia, and major depression Level 6: Psychiatric Emergencies- When situations in which general functioning have been severely impaired. Examples include a drug overdose, suicide attempts, or the acute onset of a major mental illness Level 7- Catastrophic Crisis- This level involves 2 or more level 3 traumatic crisis in combination with level 4,5, or 6 stressors. Examples include loosing all family members in a disaster or multiple homicides

22. Stages of Crisis The stages of crisis resemble the stages of the grief process. Individuals can skip a stage, can get stuck in a stage, or can even move back and forth throughout the stages. The four stages of crisis include: outcry, denial or intrusiveness, working trough, and completion or resolution.

23. Stages of Crisis Outcry: The earliest reactions after the crisis event, which are reflexive, emotional, and behavioral. The reactions can very depending on the person. Some examples include panic, screaming, shock, anger, defensiveness, moaning, flat affect, crying, and hyperventilation. Denial or Intrusiveness: Outcry can lead to denial, which eliminates the impacts of the crisis through emotional numbing, dissociation, cognitive distortion, or minimizing. Outcry can also lead to intrusiveness , which includes the involuntary flooding of feelings about the crisis, such as flashbacks, nightmares, and automatic thoughts.

24. Stages of Crisis Continued Working Through: This is the stage of recovery or healing in which thoughts, feelings, and images of the crisis are expressed, acknowledged, explored, and reprocessed through adaptive and healthy coping skills . Completion or Resolution: This stage can take months or even years to complete. Some individuals may never even complete this process. This process allows the individual to reorganize their life, and use the resolution of the trauma in positive meanings of growth or change. Many crisis survivors reach out through volunteer work to help others who suffer similar traumas.

25. ACT Model (Assessment, Crisis Intervention, and Trauma Treatment Service) The ACT model is a conceptual three-stage framework and intervention model. This model amalgamates various assessment and triage protocols with three primary crisis intervention strategies: the seven stage crisis intervention model, critical incident stress management, and the 10-step acute traumatic stress management protocol.

26. ACT Model A : Assessment/appraisal of immediate medical needs, threats to public safety and property damage -Triage assessment, crisis assessment, trauma assessment, and the biopsychosocial and cultural assessment protocols C: Connecting to support groups, the delivery of disaster relief and social services, and critical incident stress debriefing -Crisis intervention implemented through a strengths perspective and coping skills bolstered T: Traumatic stress reactions and posttraumatic stress disorders -Ten step acute trauma and stress management protocol, trauma treatment plans, and recovery strategies implemented

27. Seven-Stage Crisis Intervention Model Seven-stage crisis intervention model is effective when dealing with a diverse population, and when dealing with traumatic situations. This model adapts easily to different level of crisis and to different timeframes for intervention. All of these stages can be completed within one contact if necessary.

28. Seven Stage Crisis Intervention Model

29. Seven- Stage Crisis Intervention Model Stage 1: Plan and Conduct a Crisis Assessment : When conducting an assessment the crisis worker needs to evaluate how severe the crisis is, the emotional state of the client, the clients immediate psychosocial needs, and the level of the client’s current coping skills and resources. Stage 2: Establish Rapport: This can be done in stage 1. This stage involves the initial contact between the client and the crisis worker. The main goal is to establish rapport with the client by being genuine. Active listening and empathetic communication are important to be successful at establishing rapport. Crisis workers must be conscious of their own body language and facial expressions because trauma survivors may be sensitive to physical space and body movements. Being observant of the survivors physical and facial reactions can give insight to the workers level of engagement with the client.

30. Seven-Stage Crisis Intervention Model Stage 3: Identify the Major Problem: The crisis worker should help the survivor arrange the most important problems by identifying the problems by how they affect the survivors current status. The crisis worker must make sure not to overwhelm the survivor while focusing on the most important problems needing intervention. Stage 4: Deal with Feelings and Emotions: During this stage the clients primary task is ventilation and exploration of his or her feelings about the crisis. The crisis worker should be actively listening to the survivor. It is necessary for the crisis worker to demonstrate empathy when with the survivor. The crisis worker must also be aware of his or her own emotions and levels of comfort when helping clients. Crisis workers should also attend to their own self-care to prevent burn out.

31. Seven-Stage Crisis Intervention Model Stage 5: Generate and Explore Alternatives: In this stage the crisis worker will work with survivor to explore alternatives for restoring a precise level of functioning. Some alternatives would include using support systems, developing coping skills, and increasing positive thinking to reduce the survivors anxiety and stress. Stage 6: Develop and Formulate an Action Plan: The main goals are to help the survivor achieve an appropriate level of functioning and maintain adaptive coping skills and resources. The survivor must feel ownership in the treatment plan. Termination should begin when the client has met their goals of their action plan or has been referred for additional services. Stage 7: Establish Follow-Up Plan and Agreement: This stage helps determine if the desired results were maintained, or if further work is needed. This is typically done 4-6 weeks after termination.

32. Critical Incident Stress Debriefing and Management Critical Incident stress debriefing is used for frontline crisis workers who are exposed to gruesome and life-threatening situations. Examples: suicides, homicides, natural disasters, terrorist attacks, hostage situations. This allows the worker to discuss the traumatic event, promote group cohesion, and educate first responders on stress reactions and coping techniques.

33. Critical Incident Stress Debriefing and Management This typically occurs 24 to 72 hours after the traumatic accident. This can be done individually or with a group. These debriefing meetings should encourage the first responders to be supportive and to not be critical of each other.

34. 10-step Acute Traumatic Stress Management Protocol A guideline for critical incident stress debriefing for first responders Assess for danger/safety for self and others Consider the physical and perceptual mechanism of injury Evaluate the level of responsiveness Address medical needs Observe and identify each individual’s sign of traumatic stress Introduce yourself, state your role, and begin to develop a relationship Ground the individual by allowing him/her to tell his or her story Provide support trough active and empathic listening Normalize, validate, and educate Bring the person to the present, describe future events, and provide referrals

35. Barry Kidd 2010 35 CRISIS INTERVENTION ASSESSMENT Perception of event: What happened that prompted you to seek help?; How are you feeling now?; etc. Coping mechanisms: Suicidal?; Plans?; What helps you feel better?; etc. Support systems: With whom do you live with?; Who is available to help you?; Who is most helpful?; etc Mental status, previous history Identify client’s strengths Self-assessment: EMR’s feelings

36. Barry Kidd 2010 36 CRISIS INTERVENTION EMR Diagnosis: 1. Risk self directed violence 2. Chronic low self esteem 3. Hopelessness 4. Powerlessness 5. Severe/Panic levels of anxiety 6. Disturbed thought process 7. Sleep deprivation

37. Barry Kidd 2010 37 CRISIS INTERVENTION Planning and outcome identification 1. Assist the patient in setting realistic goals to return to the pre-crisis level of functioning 2. Establish desired outcome criteria for the patient using the problem solving approach.

38. Barry Kidd 2010 38 CRISIS INTERVENTION Implementation Assess for any suicidal/ homicidal thoughts or plans. Take initial steps to make the patient feel safe and lower anxiety. Safety- intervene to prevent violence- suicide/ angry, aggressive patient. Listen attentively and encourage the patient to discuss the crisis situation. Facilitate the verbalization of thoughts and feelings. Creative and directive approach needed. Initially the EMR/or other health care persons may make phone calls (arrange baby-sitters, find shelters, contact social workers, etc.)

39. Barry Kidd 2010 39 CRISIS INTERVENTION Con’t Use problem solving approach. Identify needed social support (with patient’s input) and mobilize the most needed first. Identify and work to increase needed coping skills (problem solving, relaxation, assertiveness, job training, newborn care, self-esteem). Plan with patient interventions that are acceptable to both. Evaluate plan and instruct patient with alternative plan if needed.