Crisis Intervention- psychiatric nursing

Nursing students in all format
psychiatric and mental health studies

1. Crisis Intervention Mr. D.Elakkuvana..

2. Introduction Crisis is an initial disturbance that results from a stressful event or a perceived threat to self. A crisis may influence people’s life in different ways. A crisis is an internal disturbance that an result from a stressful event or a perceived threat to self precipitators events of crisis include perceived losses, threats of losses or challenges.

3. In the Chinese language, two symbols communicate crisis: “danger” and “opportunity”.

4. Crisis definition A crisis is defined by the mental health authorities as “A state of disequilibrium resulting from the interaction of an event with the individual’s or family’s coping mechanisms, which are inadequate to meet the demands of the situation, combined with the individual’s or family’s perception of the meaning of the event”. (Taylor, 1982)  

5. Characteristics of crisis Crisis is a sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problems. Crisis are precipitated by specific identifiable events. Crisis are personal by nature. Crisis are acute, not chronic and will be solved on one way or another within a brief period. Crisis is self-limiting acute and last one to six weeks. A crisis situation is dangerous to the person, he or she may harm self or others.

6. Phases in the development of a crisis Caplan (1964) – four specific phases through which individuals progress in response to a precipitating stressor ;; Phase 1: The individual is exposed to a precipitating stressor. Phase 2: When previous problem solving techniques do not relieve the stressor, anxiety increases further. Phase 3: All possible resources, both internal and external are called on to resolve the problem and relieve the discomfort.

7. Phases 4: If resolution does not occur in previous phases, caplan states that “ 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”.

8. Types of Crisis Maturational Crisis: It is otherwise called as developmental crisis. Human beings go through different stages of development. The transition between these stages can be an emotionally disturbing period. Ex: Child’s first real separation from home to attend school, a girl who attains puberty, attending college, staying away from home for the first time, getting married etc.

9. 2. Situational Crisis: Crisis are unanticipated or sudden events that threaten the individual’s integrity such as the death of a loved one, loss of a job, and physical or emotional illness in the individual of family members. 3. Adventitious Crisis: Accidental uncommon or unexpected crisis. For ex: both the parents die and the child is left alone.

10. Types of crisis- baldwin (1978) He has identified six classes of emotional crises, which progress by degree of severity. Class 1: Dispositional crises Class 2: Crises of Anticipated Life Class 3: crises Resulting from Traumatic Stress Class 4: Maturation / Development crises Class 5: Crises Reflecting Psychopathology Class 6: Psychiatric Emergencies

11. Class 1: Dispositional crises An acute response to an external situational stressor.

12. Class 2: Crises of Anticipated Life Normal life cycle transitions that may be anticipated but over which the individual may feel a lack of control.

13. Class 3: crises Resulting from Traumatic Stress Crises precipitated by unexpected external stressors over which the individual has little or no control and from which he or she feels emotionally overwhelmed and defeated.

14. Class 4: Maturation / Development crises Crises that occur in response to situations that trigger emotions related to unresolved conflicts in one’s life. These crises are of internal origin and reflect underlying developmental issues that involve dependency, value conflicts, sexual identity, control, and capacity for emotional intimacy.

15. Class 5: Crises Reflecting Psychopathology Emotional crises in which preexisting psychopathology has been instrumental precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution.

16. Class 6: Psychiatric Emergencies Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility.

17. Signs & symptoms of crisis The major feeding in a crisis is anxiety. The individual experiences a heavy burden of free – floating anxiety. The anxiety may be manifested through depression, anger and guilt feelings. Normally crisis will take about 4 – 6 weeks to resolve a crisis. The individual could be irrational. He may get angry and blame others for what happened to him. He may even neglect his responsibilities.

18. Stages of Crisis Caplan (1964) outlined four specific phases through which individuals progress in response to a precipitating stressor. Phase I: Threat to the individual resulting in anxiety. Anxiety increases when individual is exposed to a precipitating stressors.   Phase II: Increased tension and anxiety. When coping mechanisms failed in the Phase I, anxiety continuously increase and individual coping ability decrease. So, the individual begins to feel a great deal of discomfort at this point.

19. Phase III: Reorganization phase. When the individual experiences real anxiety and feels that he cannot go on any longer, its due to the flood of anxiety. The affected individual tries to reorganize his life inspire of the loss. He may make an attempt to escape the reality.   Phase IV: Resolution phase. At this phase the individual learns to adapt to new situation. The victims life is organized according to the loss in consideration and the new circumstances.

20. According to Mary Verghese (1994) , Phase of crisis explained following ways Phase of denial Phase of increased tension Phase of disorganization Attempt to reorganize Phase of attempt to escape the problem Phase of local reorganization Phase of general reorganization

21. Resolution of Crisis There are 3 ways. Pseudo resolution: The individual uses repression and pushes out of consciousness the incident and the intense emotions associated it. But in future, if and when a crisis occurs, the repressed feeling may come to surface and influence the feelings aroused by the new crisis.

22. Successful resolution: The individual may go through the various stages of crisis but reaches the phase of general reorganization. Unsuccessful resolution: The individual uses pathological adaptation at any phases of crisis resulting in a lower level of functioning.  

23. Crisis Intervention Crisis intervention is a technique used to help an individual or family to understand and cope with the intense feelings that are typical of a crisis. Aims of crisis intervention: To provide a correct cognitive perception of the situation. To assist the individual in managing the feelings.  

24. Procedure for the crisis intervention: To provide a correct cognitive perceptions: 1. Assessment of the situation Purpose of identification of the problem. To identify the support system available. To identify the strength and limitation. 2. Define the event / situation: To identify the event. To bring the precipitating event to the awareness of the victim.

25. 3. Plan of action: Victim and people should have active involvement in developing the plan of action. Guidance of the victim. Instruction and supportive care to provide for victim by the therapist.

26. Three Approaches Affective: Expression and management of feelings involving techniques of ventilation; psychological support; emotional catharsis. Cognitive: Helping the client understand the connections between the stressor event and their response. Techniques include clarifying the problem; identifying and isolating the factors involved; helping the client gain an intellectual understanding of the crisis Also involves giving information; discussing alternative coping strategies and changing perceptions.

27. Environmental modification: Pulling together needed external, environmental resources (either familial or formal helping agencies) Any and all three approaches may be used at any time depending where the client is, emotionally and cognitively. The goal is to help the client restore pre-crisis levels of functioning.

28. To assist the individual in managing the feeling   Help the individual to be aware of the feelings. Help the individual to attain mastery over the feelings.

29. Crisis Intervention: “Models” Pre-crisis level shows normal level of equilibrium between body and functions – crisis levels shows it is disturbed. If crisis intervention is adequate and successful the person come Normal activity and functioning. If it is failed, the person will develop mental illness.

30. CRISIS INTERVENTION: METHODS 1. Based on Caplan – 3 levels of crisis intervention. 1. Primary Level: Assess the crisis, define the crisis, assess the problem, and promote and support coping mechanism. 2. Secondary Level: Hot lines services link, walk-in-clinic, and counseling can use. 3. Tertiary Level: Treatment and following Rehabilitation and self-help groups

31. Generic Approach General Approach Environmental manipulation Based on Stuart Model Environmental manipulation – Change the environment from the crisis situation. General approach – Those are affected provide care and set the relief from the crisis. Generic approach / Individual approach.

32. Role of the nurse in crisis intervention Crisis intervention can be provided through general hospital, the home setting, the community health care setting, schools, offices and private practice. There are 4 phases in the techniques of crisis intervention.

33. Phase I: Assessment Here, helper gathers information regarding crisis event and assess the professional help. A nurse in crisis intervention might perform some of the following assessments:

34. To describe the even Determine when it occurred. Assess physical and mental status of the victim. Assess coping mechanism skills. Assess suicide / Homicide plan. Assess the adequacy of support system. Assess the individual strengths & limitations.

35. Phase II: Planning Here, the nurse selects the appropriate nursing actions for the identified nursing needs / problem. Goals are, resolution for the crisis and to increase in precrisis level of functioning.

36. Phase III: Implementation During this phase, the actions that were identified in phase two are implemented. The implementation are, Use a reality oriented approach. Establish a rapport with victim. Clarify the problem that individual is facing. Guide the individual through a problem solving process. Identify external support system and new social networks.

37. Phase IV: Evaluation To evaluate the outcome of crisis intervention, a reassessment is made to determine if the stated objective was achieved.

38. GRIEF A nurse works with many people who experience different types of loss. Coping mechanisms determine the person’s ability to face and accept loss. Grief is a natural response to loss. The nurse assists patients / clients in understanding and accepting loss so that life can continue.

39. Grief Grief is a form of sorrow that follows the perception or anticipation of a loss of one or more of valued or significant objects. These responses often include helplessness, loneliness, hopelessness, sadness, guilt and anger.

40. Grief involves thoughts, feelings and behaviours . Its purpose is to enable adjustment to a new way of life, which takes time. The grieving person will try a variety of strategies in order to cope.

41. Worden (1991) describes the following tasks of grief that facilitate healthy adjustment to loss. Accepting the reality of the loss Experiencing the pain of grief Adjusting to an environment Re-investing emotional energy

42. Theories of the grieving process Grief is a normal response to any loss. Behaviours ad feelings associated with the grieving process occurs in individuals suffering from losses such as a physical deformity or the death of a close friend.

43. Theories: (1) Engel’s Theory: Engel (1964) proposed that the grieving process has 3 phases that can be applied to grieving and dying people.   Phases: Shock and disbelief Developing awareness Reorganization and restitution  

44. Shock and disbelief: During the first phase, the individuals denies the reality of the loss and may withdraw, sit motionless or wander aimlessly.   Physical reactions may include fainting, nausea, diarrhoea , rapid heart rate, restlessness, insomnia and fatigue.

45. Developing awareness: In the second phase the individual begins to feel the loss acutely and may experience desperation. Suddenly anger, guilt, frustration, depression and emptiness occur.   Reorganization and restitution: During the third phase, inevitability of the loss is acknowledged. The loss is clear to the individual, who begins to reorganize life. New self awareness is also developed.

46.   (2) Kubler – Ross stages of dying: The framework provided by Kubler – Ross (1969) is behaviour oriented and includes 5 stages. 1) Denial 2) Anger 3) Bargaining 4) Depression 5) Acceptance     Denial: The individual acts as though nothing has happened and may refuse to believe that a loss has occurred.   Anger: The individual resists the loss and may feel frustrated and angry or may experience a sense of helplessness and loss of control.   Bargaining: Postponement of the reality of the loss. The individual may attempt to make a deal in a subtle or overt way to prevent the loss. The person frequently seeks the opinions of others during this stage.  

47. Depression: Occurs when the loss is realized and the full impact of its significance is apparent. This stage may be accompanied by overwhelming loneliness and withdrawal.   Acceptance: Physiological reactions cease, and social interactions resume

48. (3) Martocchio’s Phases – 1985: Martocchio (1985) describes 5 phases of grief that have overlapping boundaries and no expected order. Intense reactions of grief usually subside within 6 to 12 months and active mourning may continue for 3 to 5 yrs. Phases are 1) Shock & disbelief, 2) Yearning & protest, 3) Anguish, disorganization & despair, 4) Identification in bereavement, 5) Reorganization & restitution.

49. Complicated Grief: Some individuals find it more difficult to give than do others. A normal, healthy movement through their bereavement does not occur. So indicators of unresolved or complicated grief includes: Over activity without a sense of loss. Alteration in relationships with friends and family. Hostilities against specific people. Agitated depression with tension, agitation, insomnia, feelings or worthlessness, extreme guilt and even suicidal tendencies. Inability to discuss the loss without crying. False euphoria. Often, individuals with prolonged grief require long-term support, referral to psychiatric help or counselling .  

50. Nursing Care and Grief: Goals for a person dealing with loss are to resolve grief, accept the reality of the loss, regain a sense to self-esteem, renew normal activities and relationships. Physiological needs must also be met. During planning, the nurse has several resources, including family members, significant others, other team members and community support groups.

51. Promoting Comfort: Personal hygiene – basic needs – pain control – sleep, appetite, mobility & psychological function. Maintaining Independence Preventing loneliness and isolation Promoting spiritual comfort Supporting the grieving family – supportive relationship with family