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CHAPTER 13 Crisis and Disaster Intervention Gail W. Stuart He knows not his own strength that hath not met adversity. Francis Bacon, Of Fortunehttp://evolve.elsevier.com/Stuart LEARNING OBJECTIVES1. Describe a crisis and its characteristics, including crisis 4. Develop a patient education plan to cope with crisis. responses, types of crises, characteristics of disasters, 5. Evaluate nursing care for patients related to their crisis and crisis intervention. and disaster responses.2. Analyze aspects of the nursing assessment related to crisis 6. Describe the settings in which crisis and disaster and disaster responses. intervention may be practiced.3. Plan and implement nursing interventions for patients 7. Discuss modalities of crisis intervention. related to their crisis and disaster responses.Stressful events, or crises, are a common part of life. They occurred weeks or days before the crisis, and it may or maymay be social, psychological, or biological in nature, and not be linked in the individual’s mind to the crisis state thethere is often little that a person can do to prevent them. As individual is experiencing. Precipitating events can be actualthe largest group of health care providers, nurses are in an or perceived losses, threats of losses, or challenges.excellent position to help promote healthy outcomes for peo-ple in times of crisis and disaster (Happell et al, 2009). Crisis Responses Crisis intervention is a brief, focused, and time-limited After the precipitating event, the person’s anxiety begins totreatment strategy that is effective in helping people adap- rise, and three phases of a crisis response emerge:tively cope with stressful events. Knowledge of crisis and 1. The anxiety activates the person’s usual methods of cop-disaster intervention techniques is an important clinical ing. If these do not bring relief, anxiety increases becauseskill for all nurses, regardless of clinical setting or practice coping mechanisms have failed.specialty. 2. New coping mechanisms are tried or the threat is rede- ﬁned so that old ones can work. Resolution of the problem can occur in this phase. However, if resolution does notCRISIS CHARACTERISTICS occur, the person goes on to the last phase.A crisis is a disturbance caused by a stressful event or a per- 3. The continuation of severe or panic levels of anxiety mayceived threat. The person’s usual way of coping becomes inef- lead to psychological disorganization.fective in dealing with the threat, causing anxiety. The threat, In describing the phases of a crisis, it is important toor precipitating event, usually can be identiﬁed. It may have consider the balancing factors shown in Figure 13-1. These 181
182 UNIT II Continuum of Care Human organism Stressful event State of equilibrium Stressful event State of disequilibrium Need to restore equilibrium A. Balancing factors present B. One or more balancing factors absent Realistic perception of the event Distorted perception of the event PLUS AND/OR Adequate situational support No adequate situational support PLUS AND/OR Adequate coping mechanisms No adequate coping mechanisms RESULT IN RESULT IN Resolution of the problem Problem unresolved Equilibrium regained Disequilibrium continues No crisis Crisis FIG 13-1 Paradigm: the effect of balancing factors in a stressful event. (From Aguilera DC: Crisis intervention: theory and methodology, ed 8, St Louis, 1998, Mosby.)include the individual’s perception of the event, situational The phases of a crisis and the impact of balancing fac-supports, and coping mechanisms. Successful resolution tors are similar to the elements of the Stuart Stress Adapta-of the crisis is more likely if the person has a realistic view tion Model used in this textbook and described in Chapter 3.of the event; if situational supports are available to help However crises are self-limiting. People in crisis are too upsetsolve the problem; and if effective coping mechanisms are to function at such a high level of anxiety indeﬁnitely. Thepresent (Aguilera, 1998). time needed to resolve the crisis, whether it is a positive
CHAPTER 13 Crisis and Disaster Intervention 183solution or a state of disorganization, may be 6 weeks baby. The patient’s boyfriend, who was the baby’s father,or longer. had promised to marry her, but he had recently decided It also is important to recognize that periods of intense he was too young to handle the responsibility of a wifeconﬂict ultimately can result in increased growth. It is how and child. In summary, the young woman who had unmet dependency needs of her own was now a parent and hadthe crisis is handled that determines whether growth or dis- to meet the dependency needs of her infant. This precipi-organization will result. Growth comes from learning in new tated a crisis for her.situations. People in crisis feel uncomfortable, often reach Selected Nursing Diagnosesout for help, and accept help until they feel that their lives • Ineffective coping related to birth of a child, as evi-are back to normal. The fact that crises can lead to personal denced by feelings of depressiongrowth is important to remember when working with • Interrupted family processes related to birth of a grand-patients in crisis. child, as evidenced by lack of family support • Impaired parenting related to being a single mother, as Critical Reasoning Think of a crisis you have experienced. evidenced by difﬁculty caring for her baby Do you feel that the way you handled it made you a better person in some way? If so, how? CLINICAL EXAMPLE Mr. R was a 67-year-old white, married pharmacist who came to the mental health clinic complaining of anxiety,Types of Crises. The two types of crises are maturational depression, and insomnia. His symptoms had begunand situational. Sometimes these crises can occur simultane- 2 weeks ago when his wife decided that they shouldously. For example, an adolescent who is having difﬁculty move to a retirement community in Florida. He describedadjusting to a change in role and body image (maturational his wife as a strong, determined woman who was outgo-crisis) may at the same time undergo the stress related to the ing and charming and made friends easily. He considereddeath of a parent (situational crisis). himself a quiet, nervous person who was comfortable only with old friends and his two sons and their families. Mr. R, although at retirement age, had continued to work as aMaturational Crises. Maturational crises are develop- pharmacist, doing relief work for a drugstore chain whenmental events requiring role changes. Transitional periods the regular pharmacists were absent. In moving to Florida,during adolescence, parenthood, marriage, midlife, and he would lose his pharmacist’s license, which was validretirement are key times for the onset of maturational cri- only in his state of residence. He expressed difﬁculty inses. For example, successfully moving from early childhood making the transition from work to retirement. He hadto middle childhood requires the child to become socially fears of becoming directionless and useless. He was anx-involved with people outside the family. With the move from ious about leaving his sons and his friends. The prospectadolescence to adulthood, ﬁnancial responsibility is expected. of complete retirement and moving to another state pre-Both social and biological pressures to change can precipitate cipitated his distress.a crisis. Selected Nursing Diagnoses • Relocation stress syndrome related to pending retire- The nature and extent of the maturational crisis can be ment, as evidenced by feelings of anxietyinﬂuenced by role models, interpersonal resources, and the • Interrupted family processes related to conﬂict aboutresponse of others. Positive role models show the person how lifestyle changes, as evidenced by inability to plan futureto act in the new role. Interpersonal resources encourage thetrying out of new behaviors to achieve role changes. Other people’s acceptance of the new role is also impor- Situational Crises. Situational crises occur when a lifetant. The greater the resistance of others, the more stress the event upsets an individual’s or group’s psychological equilib-person faces in making the changes. Some conﬂicts related rium. Examples of situational crises include loss of a job, lossto maturational crises are seen in the clinical examples that of a loved one, unwanted pregnancy, onset or worsening offollow. a medical illness, divorce, school problems, and witnessing a crime. CLINICAL EXAMPLE The loss of a job can result in ﬁnancial stress, feelings of Ms. J was a 19-year-old African-American, single, unem- inadequacy, and marital conﬂict caused by a family mem- ployed woman who came to the mental health clinic ber’s anger over the lost job. The loss of a loved one results 1 month after the birth of her ﬁrst child. Ms. J complained in bereavement and also can cause ﬁnancial stress, change of feeling depressed. Her symptoms included difﬁculty fall- in roles of family members, and loss of emotional support. ing asleep, early-morning awakening, crying spells, a poor Homelessness is another possible outcome of the loss of a job appetite, and difﬁculty in caring for the baby because of fatigue and apathy. The patient lived with her parents and or a loved one. The onset or worsening of a medical illness siblings and had never lived on her own. She had always causes anticipatory grief and fear of the loss of a loved one. depended on her mother to take care of her. Her mother Again, ﬁnancial stress and change in roles of family members worked, however, and the patient was totally responsible often occur. Divorce is similar to the stress of losing a loved for her daughter’s care each day. Also, Ms. J’s mother was one, except that the crisis can recur with the stress of dealing angry that she had a child and often refused to care for the with the ex-spouse.
184 UNIT II Continuum of Care An unwanted pregnancy is stressful because it requires BOX 13-1 CHARACTERISTICSdecisions to be made about whether to complete the preg- OF DISASTERSnancy or to abort it and whether to keep the baby or placethe baby for adoption. If the pregnancy is aborted or adop- • Intensity of the impact: Disasters that result in intense destruction within a short period of time are more likelytion occurs, the mother may need to deal with feelings of to cause emotional distress among survivors than aregrief or anger. If the baby is to be kept, changes in lifestyle disasters that spread their impact over a longer period ofare required. Finally, being the victim of or witnessing a time.crime can cause feelings of helplessness, distrust of others, • Impact ratio (i.e., the proportion of the communityfear, nightmares, and guilt about causing or not stopping the sustaining personal losses): When a disaster affects acrime. signiﬁcant proportion of a community’s population, few Situational crises can be accidental, uncommon, and individuals may be available to provide material and emo-unexpected events including natural and man-made disas- tional support to survivors.ters such as ﬁres, tornadoes, earthquakes, hurricanes, or • Potential for recurrence of other hazards: The real orﬂoods. These disrupt entire communities and cause wide- perceived threat of recurrence of the disaster or of associ-spread damage. Disasters, such as killings in the workplace ated hazards can lead to anxiety and heightened stress among survivors.or in schools, airplane crashes, suicide bombings, and acts of • Cultural and symbolic aspects: Changes in survivors’terrorism, also can precipitate situational crises. social and cultural lives and routine activities can be pro- The terrorist attacks of September 11, 2001, in which air- foundly disturbing. Both natural and human-caused disas-planes were hijacked and ﬂown into the World Trade Center ters can have symbolic implications.in New York City, presented unprecedented trauma and cri- • Extent and types of loss sustained by survivors: Prop-sis to people throughout the United States. Entire communi- erty damage or loss, deaths of loved ones, injury, and job lossties, especially people living in New York City, experienced a all affect emotional recovery.sudden and unexpected violent act that resulted in multiplelosses and extensive community disruption. In addition, the safety felt by all people across the UnitedStates was affected. One study found that more than half of CRISIS INTERVENTIONthe people who lived or worked in New York had some emo- Crisis intervention is a short-term therapy focused on solv-tional sequelae 3 to 6 months after September 11; however, ing the immediate problem. It is usually limited to 6 weeks.only a small portion of those with severe responses were seek- The goal of crisis intervention is for the individual toing treatment (DeLisi et al, 2003). return to a precrisis level of functioning. Often the person Disaster-precipitated emotional problems can surface advances to a level of growth that is higher than the pre-immediately, or weeks or even months after the disaster. crisis level because new ways of problem solving have beenAfter the September 11 attack, individuals who lost family learned.members accounted for 40% of mental health visits in the It is important for the nurse to remember that cultureﬁrst month but dropped to 5% by 5 months. Uniformed per- strongly inﬂuences the crisis intervention process, includ-sonnel used many more mental health services after the ﬁrst ing the communication and response style of the crisisyear (Covell et al, 2006). worker. Cultural attitudes are deeply ingrained in the pro- Researchers have identiﬁed several common character- cesses of asking for, giving, and receiving help. They alsoistics of disasters that are particularly important when dis- affect the victimization experience, as seen in Box 13-2, so itcussing emotional distress and recovery. These are listed in is essential to understand and respect the sociocultural con-Box 13-1. text of crisis care. Speciﬁc cultural factors to be considered in Disaster responses usually occur in seven phases. These are crisis intervention include the following:described in Table 13-1. Individuals and communities prog- • Migration and citizenship statusress through these phases at different rates depending on the • Gender and family rolestype of disaster and the degree and nature of disaster expo- • Religious belief systemssure. This progression may not be sequential, because each • Child-rearing practicesperson and each community is unique in the recovery pro- • Use of extended family and support systemscess. Individual variables such as psychological resilience, • Housing and living conditionssocial support, and ﬁnancial resources inﬂuence a survi- • Socioeconomic statusvor’s capacity to move through the phases. The age of the survivors is also important for the nurse to consider when providing crisis intervention. Responses to stressful events differ across the life span. Therefore age- Critical Reasoning Some crises, such as obtaining a appropriate interventions are most effective in helping divorce, develop over time and are of longer duration. Other survivors return to their previous level of functioning. For crises, such as an earthquake, are sudden and unexpected. example, 4-year-old children may best express themselves How do you think the element of time affects the response through play, whereas adolescents may best work through to crisis? crisis issues in peer group discussions.
CHAPTER 13 Crisis and Disaster Intervention 185 TABLE 13-1 PHASES OF DISASTER RESPONSE PHASE RESPONSE Warning or threat phase Disasters vary in the amount of warning communities receive before they occur from little or no warning to hours or even days of warning. When no warning is given, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies. Impact phase The impact period of a disaster can vary from the slow, low-threat build-up associated with some types of ﬂoods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects. Rescue or heroic phase In the immediate aftermath, survival, rescuing others, and promoting safety are priorities. For some, postimpact disorientation gives way to adrenaline-induced rescue behavior to save lives and protect property. Although activity level may be high, actual productivity is often low. Altru- ism is prominent among both survivors and emergency responders. Remedy or honeymoon During the week to months following a disaster, formal governmental and volunteer assistance phase may be readily available. Community bonding occurs as a result of sharing the catastrophic experi- ence and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more read- ily accepted and have a foundation from which to provide assistance in the difﬁcult phases ahead. Inventory phase Over time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted because of enormous multiple demands, ﬁnancial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue. Disillusionment phase As disaster assistance agencies and volunteer groups begin to pull out, survivors may feel aban- doned and resentful. The reality of losses and the limits and terms of the available assistance be- come apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle. Stressors abound—family discord, ﬁnancial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of preexisting condi- tions emerge because of ongoing, unrelenting stress and fatigue. Reconstruction or The reconstruction of physical property and recovery of emotional well-being may continue for recovery phase years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and gradually assume the responsibility for doing so. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin. When people come to see meaning, personal growth, and opportunity from their disaster experi- ence despite their losses and pain, they are well on the road to recovery. Although disasters may cause profound life-changing losses, they also bring the opportunity to recognize personal strengths and to reexamine life priorities.From U.S. Department of Health and Human Services: Training manual for mental health and human service workers in major disasters, ed 2,Washington, DC, 2000, U.S. Government Printing Ofﬁce. BOX 13-2 SOCIOCULTURAL CONTEXT OF CARE Survivors of Katrina of Hurricane Katrina highlighted the social inequities in U.S. Many of the African-American survivors of Hurricane Katrina in society and the need to directly address the issues of race, New Orleans were at high risk for physical and mental health class, and gender inequality in disaster preparation, postdisas- problems because of their residence in high-poverty areas, the ter rescue, and recovery mission and rebuilding efforts. residential segregation that existed before the storm, and the Another study examined the use of mental health services enormous dislocation that resulted from the hurricane. A study among adult survivors of Hurricane Katrina to evaluate the of this population found that survivors who lacked ﬁnancial impact of disasters on persons with existing mental illness resources faced higher risks for general mental health prob- who were living in the community. As a result of the storm, lems and that racial discrimination increased the health-related entire mental health delivery systems were destroyed, and few risk for Katrina survivors. Further, female African-American Katrina survivors with mental disorders received adequate care survivors reported more posttraumatic stress disorder (PTSD) (Wang et al, 2007, 2008). The sociocultural, ﬁnancial, structural, symptoms and worse mental health (Chen et al, 2007). In con- and attitudinal barriers that prevented those with mental illness trast, support provided by network members enhanced physi- from obtaining needed treatment also will need to be over- cal and mental health. This study of African-American survivors come in future disasters.
186 UNIT II Continuum of Care BOX 13-3 BEHAVIORS COMMONLY QUALITY AND SAFETY ALERT EXHIBITED AFTER A CRISIS • As a helper, do not sacriﬁce one’s personal safety to estab- Anger Irritability lish a relationship. Apathy Lability • Trust your instincts and exit a situation too soon rather than Backaches Nightmares too late. Boredom Numbness • Don’t run from danger; rather have an exit plan and run to Crying spells Overeating or undereating safety. Diminished sexual drive Poor concentration Disbelief Sadness Although the crisis situation is the focus of the assessment, Fatigue School problems the nurse may identify more signiﬁcant and long-standing Fear Self-doubt problems. Those individuals with preexisting psychological Flashbacks Shock problems may have more postdisaster health problems. For Forgetfulness Social withdrawal example, those with serious mental illness will need help in Headaches Substance abuse ensuring access to their medications and caregiver stability Helplessness Suicidal thoughts (Milligan and McGuinness, 2009). Hopelessness Survivor guilt It is important, therefore, to identify which areas can be Insomnia Work difﬁculties helped by crisis intervention and which problems must be Intrusive thoughts referred to other sources for further treatment. During this phase the nurse begins to establish a positive working relationship with the patient. A number of balancing factors are important in the development and resolution of a crisis and should be assessed: Critical Reasoning Describe how sociocultural factors • Precipitating event or stressor might affect a woman’s decision to seek help after being raped. • Patient’s perception of the event or stressor • Nature and strength of the patient’s support systems and coping resources • Patient’s previous strengths and coping mechanisms ASSESSMENTThe ﬁrst step of crisis intervention is assessment. At this time, Precipitating Eventdata about the nature of the crisis or disaster and its effect on To help identify the precipitating event, the nurse shouldthe patient must be collected. From these data an interven- explore the patient’s needs, the events that threaten thosetion plan will be developed. People in crisis experience many needs, and the time at which symptoms appear. Four kindssymptoms, including those listed in Box 13-3. Sometimes of needs that have been identiﬁed are as follows:these symptoms can cause further problems. For example, 1. Self-esteem needs are achieved when the person attainsproblems at work may lead to loss of a job, ﬁnancial stress, successful social role experience.and lowered self-esteem. 2. Role mastery needs are achieved when the person attains Crises also can be complicated by old conﬂicts that resur- work, sexual, and family role successes.face as a result of the current problem, making crisis resolu- 3. Dependency needs are achieved when a satisfying interde-tion more difﬁcult. For example, a woman who was orphaned pendent relationship with others is attained.at an early age may have more difﬁculty resolving a crisis pre- 4. Biological function needs are achieved when a person iscipitated by the work injury of her husband than a woman safe and life is not threatened.who had not experienced an earlier loss. The nurse determines which needs are not being met and Anger is one of the most understandable responses to a looks for obstacles that might interfere with meeting thecrisis or disaster but it also may be the most difﬁcult one patient’s needs.to manage. Anger can be productive if it is channeled in the Coping patterns become ineffective and symptoms appearright way but also can become a serious obstacle to recov- usually after the stressful incident. When did the patientery, creating problems for one’s physical and mental health, begin to feel anxious? When did sleep disturbances begin? Atas well as family and community cohesion. Questions that what point in time did suicidal thoughts start? If symptomsshould be considered are as follows: began last Tuesday, ask what took place in the patient’s life on • Is the anger justiﬁed? Tuesday or Monday. As the patient connects life events with • Is the anger purposeful? the breakdown in coping mechanisms, an understanding of • Can the anger be used in a positive way? the precipitating event can emerge. • Does the anger pose an immediate threat or danger? Anger is most common in the “disillusionment phase” QUALITY AND SAFETY ALERTnoted in Table 13-1. In some cases, it can even pose a dangerto the health care responders who have come to assist survi- • The safety of the patient is the ﬁrst priority. • Only when biological needs of food, shelter and physicalvors. Thus, safety issues should be a priority for the nurse in integrity are met can other needs be addressed.working with patients in crisis.
CHAPTER 13 Crisis and Disaster Intervention 187Perception of the Event problems? Did the patient leave the usual surroundings forThe patient’s perception or appraisal of the precipitating a period of time to think things through from another per-event is very important. In times of disaster, perceptions of spective? Was physical activity used to relieve tension? Didthe event may be very similar. With other events it may not be the patient ﬁnd relief in crying? Besides exploring previousso clear. What may seem trivial to the nurse may have great coping mechanisms, the nurse also should note the absencemeaning to the patient. of other possible successful mechanisms. For example, an overweight adolescent girl may have been theonly girl in the class not invited to a dance. This may have threat-ened her self-esteem. A man with two unsuccessful marriages PLANNING AND IMPLEMENTATIONmay have just been told by a girlfriend that she wants to end their The next step of crisis intervention is planning; the previ-relationship; this may have threatened his need for sexual role ously collected data are analyzed, and speciﬁc interventionsmastery. An emotionally isolated, friendless woman may have are proposed. Dynamics underlying the present crisis are for-had car trouble and been unable to ﬁnd someone to give her a mulated from the information about the precipitating event.ride to work. This may have threatened her dependency needs. Alternative solutions to the problem are explored, and stepsA chronically ill man who has had a recent relapse of his illness for achieving the solutions are identiﬁed. The nurse decidesmay have had his need for biological functioning threatened. which environmental supports to engage or strengthen and Themes and surfacing memories of the patient give fur- how best to do this, as well as deciding which of the patient’sther clues to the precipitating event. Current issues of con- coping mechanisms to develop and which to strengthen.cern are often connected to past issues. For example, a This process is outlined in the Patient Education Plan forfemale patient who talks about the death of her father, which coping with crisis in Table 13-2. The expected outcome ofoccurred 3 years ago, may, on discussion, reveal a recent loss nursing care is that the patient will recover from the crisisof a relationship with a male. A patient who talks about feel- event and return to a precrisis level of functioning. A moreings of inadequacy he had as a child because of poor school ambitious expected outcome would be for the patient toperformance may, on discussion, reveal a recent experience recover from the crisis event and attain a higher than precrisisin which his feelings of adequacy on his job were threatened. level of functioning and improved quality of life. Because most crises involve losses or threats of losses, Nursing interventions can take place on many levels usingthe theme of loss is a common one. In assessment, the nurse a variety of techniques. The four levels of crisis intervention—looks for a recent event that may be connected to an underly- environmental manipulation, general support, generic approach,ing theme. and individual approach—represent a hierarchy from the most basic to the most complex (Shields, 1975) (Figure 13-2).Support Systems and Coping Resources Each level includes the interventions of the previous level,The patient’s living situation and supports in the environ- and the progressive order indicates that the nurse needs addi-ment must be assessed. Does the patient live alone or with tional knowledge and skill for implementing high-level inter-family or friends? With whom is the patient close, and who ventions. It is often helpful to consult others when decidingoffers understanding and strength? Is there a supportive which approach to use.clergy member or friend? Assessing the patient’s support system is important in QUALITY AND SAFETY ALERTdetermining who should come for the crisis therapy sessions.It may be decided that certain family members should come • Individuals who have experienced a crisis can grow from it and function at a higher level afterwards based on thewith the patient so that the family members’ support can be coping skills they learned in dealing with the situation.strengthened. If the patient has few supports, participation ina crisis therapy group may be recommended. Assessing the patient’s coping resources also is vital in Environmental Manipulationdetermining whether hospitalization would be more appro- Environmental manipulation includes interventions thatpriate than outpatient crisis therapy. If there is a high degree of directly change the patient’s physical or interpersonal situa-suicidal or homicidal risk along with weak outside resources, tion. These interventions provide situational support or removehospitalization may be a safer and more effective treatment. stress and include mobilizing the patient’s supporting social sys- tems and serving as a liaison between the patient and social sup- Critical Reasoning Identify people in your social system that port agencies. After a disaster, agencies such as the American you would turn to in a time of crisis. Compare your list with Red Cross often provide temporary shelter, food, and clothing. that of a friend. At other times, unaffected family members may be help- ful. For example, a patient who is having trouble coping with her six children may temporarily send several of the childrenCoping Mechanisms to their grandparents’ house. In this situation some stress isNext, the nurse assesses the patient’s strengths and previ- reduced. Similarly, a patient having difﬁculty on the job mayous coping mechanisms. How has the patient handled other take 1 week of sick leave to be removed temporarily fromcrises? How were anxieties relieved? Did the patient talk out that stress. A patient who lives alone may move in with his
188 UNIT II Continuum of Care TABLE 13-2 PATIENT EDUCATION PLAN Coping with Crisis CONTENT INSTRUCTIONAL ACTIVITIES EVALUATION Describe the crisis event. Ask about the details of the crisis, including the following: Patient describes the crisis event • A timeline of the crisis in detail. • Who was affected • The events of the crisis • Any precipitating events Explore feelings, thoughts, Determine precrisis level of functioning. Patient discusses precrisis level and behaviors related to Discuss patient’s perception of the crisis event. of functioning and perceptions the crisis event. Determine acute and long-term needs, threats, of the crisis event. and challenges. Patient’s needs are identiﬁed. Identify coping mechanisms. Ask how stressful events have been handled in the past. Patient identiﬁes adaptive coping Analyze whether these are adaptive or maladaptive for the mechanisms for the current current crisis event. crisis event. Suggest additional coping strategies. Develop a plan for coping Reinforce adaptive coping mechanisms and healthy Patient develops a plan for cop- adaptively with the crisis defenses. ing with the crisis event. event. With the patient, construct a coping plan for the aftermath of the crisis event. Assign the patient activities Review implementation of the coping plan. Patient reports satisfaction with from coping plan. Help patient generalize coping strategies for use in future coping abilities and level of crisis events. functioning. and mapped out. The intervention is then set up to ensure that the course of the crisis results in an adaptive response. Grief is an example of a crisis with a known pattern that Individual can be treated by the generic approach. Helping the patient approach to overcome ties to the deceased and ﬁnd new patterns of rewarding interaction may effectively resolve the grief. Apply- ing this intervention to people experiencing grief, especially Generic approach with a high-risk group such as families of disaster victims, is an example of the generic approach. Interventions following an acute stress are sometimes referred to as debrieﬁng. Originally a military concept, General support debrieﬁng has been used as a therapeutic intervention to help people recall events and clarify traumatic experiences. Inter- Environmental manipulation ventions consist of ventilation of feelings within a context of group support, normalization of responses, and education about psychological reactions to traumatic events. FIG 13-2 Levels of crisis intervention. Although debrieﬁng may be effective for some indi- viduals, research evidence does not support the usefulnessclosest sibling for several days. Likewise, involving the patient of psychological debrieﬁng in reducing symptoms afterin family or group crisis therapy provides environmental psychological trauma and suggests that it may be harmfulmanipulation for the purpose of providing support. (Sijbrandij et al, 2006).General Support QUALITY AND SAFETY ALERTGeneral support includes interventions that convey thefeeling that the nurse is on the patient’s side and will be a • Debrieﬁng is not an evidence-based practice. • It has not been shown to be an effective psychologicalhelping person. The nurse uses warmth, acceptance, empa- intervention.thy, caring, and reassurance to provide this type of support. • Some studies suggest that it actually worsens the trauma symptoms.Generic ApproachThe generic approach is designed to reach high-risk individu-als and large groups as quickly as possible. It applies a speciﬁc Individual Approachmethod to all people faced with a similar type of crisis or disas- The individual approach is a type of crisis interventionter. The expected course of the particular type of crisis is studied similar to the diagnosis and treatment of a speciﬁc problem
CHAPTER 13 Crisis and Disaster Intervention 189in a speciﬁc patient. The nurse must understand the speciﬁc For example, helping a patient see that it was after beingpatient characteristics that led to the present crisis and must passed over for a promotion that the patient felt too sick touse the intervention that is most likely to help the patient go to work is clariﬁcation. Clariﬁcation helps the patient gaindevelop an adaptive response to the crisis. a better understanding of feelings and how they lead to the This type of crisis intervention can be effective with all types development of a crisis.of crises. It is particularly useful in combined situational and Suggestion is inﬂuencing a person to accept an idea ormaturational crises. The individual approach is also helpful belief. In crisis intervention the patient is inﬂuenced to seewhen symptoms include homicidal and suicidal risk. In addi- the nurse as a conﬁdent, calm, hopeful, empathic person whotion, the individual approach should be applied if the course can help. By believing the nurse can help, the patient may feelof the patient’s crisis cannot be determined and if resolution more optimistic and less anxious.of the crisis has not occurred using the generic approach. It is a technique in which the nurse engages patients’ Interventions are aimed at facilitating cognitive and emo- emotions, wishes, or values to their beneﬁt in the therapeu-tional processing of the traumatic event and at improving tic process. Suggestion is a way of inﬂuencing the patient bycoping. Five core interventions to assist survivors of acute pointing out alternatives or new ways of looking at things.stress are as follows: Reinforcement of behavior occurs when healthy, adaptive • Restore psychological safety. behavior of the patient is reinforced by the nurse, who strength- • Provide information. ens positive responses made by the patient by agreeing with or • Correct misattributions. positively acknowledging those responses. For example, when • Restore and support effective coping. a patient who has passively allowed himself to be criticized by • Ensure social support. the boss later reports being assertive in a discussion with the boss, the nurse can commend the patient on this assertiveness. Critical Reasoning How might each level of crisis interven- Support of defenses occurs when the nurse encourages the tion be used in a high school after a star player of the football use of healthy defenses and discourages those that are mal- team commits suicide? adaptive. Defense mechanisms are used to cope with stressful situations and to maintain self-esteem and ego integrity. When defenses deny, falsify, or distort reality to the point that the per-Techniques son cannot deal effectively with reality, they are maladaptive.The nurse should be creative and ﬂexible, trying many differ- The nurse should encourage the patient to use adap-ent techniques. These should be active, focused, and explor- tive defenses and discourage those that are maladaptive. Forative techniques that can achieve the targeted interventions. example, when a patient denies that her husband wants a sep-Some of these include catharsis, clariﬁcation, suggestion, aration despite the fact that he has told her so, the nurse canreinforcement of behavior, support of defenses, raising self- point out that she is not facing facts and dealing realisticallyesteem, and exploration of solutions. with the problem. This is an example of discouraging the mal- The intervention must be aimed at achieving quick res- adaptive use of the defense mechanism of denial. If a patientolution. The nurse also must be active in guiding the crisis who is furious with his boss writes a letter to his boss’s super-intervention through its various steps. A passive approach is visor rather than assaulting his boss, the nurse should encour-not appropriate because of the time limitations of the crisis age the adaptive use of the defense mechanism of sublimation.situation. A brief description of these techniques follows. In crisis intervention, defenses are not attacked but rather Catharsis is the release of feelings that takes place as the are more gently encouraged or discouraged. When defensespatient talks about emotionally charged areas. As feelings are attacked, the patient cannot maintain self-esteem and egoabout the events are discussed, tension is reduced. Cathar- integrity. Also, the immediacy of crisis intervention does notsis is often used in crisis intervention. The nurse explores the allow enough time to replace the attacked defenses with newpatient’s feelings about the speciﬁc situation, recent events, ones. Returning the patient to a prior level of functioning is theand signiﬁcant people involved in the particular crisis. goal of crisis intervention, not the restructuring of defenses. The nurse asks open-ended questions and repeats the Raising self-esteem is a particularly important technique.patient’s words so that more feelings are expressed. The nurse The patient in a crisis feels helpless and may be overwhelmeddoes not discourage crying or angry outbursts but rather sees with feelings of inadequacy. The fact that the patient hasthem as a positive release of feelings. found it necessary to seek outside help may further increase Only when feelings seem out of control, such as in cases feelings of inadequacy.of extreme rage or despondency, should the nurse discourage The nurse should help the patient regain feelings of self-catharsis and help the patient concentrate on thinking rather worth by communicating conﬁdence that the patient can ﬁndthan feeling. For example, if a patient angrily talks of want- solutions to problems. The nurse also should convey that theing to kill a speciﬁc person, it is better to shift the focus to a patient is a worthwhile person by listening to and acceptingdiscussion of the consequences of carrying out the act rather the patient’s feelings, being respectful, and praising help-than to encourage free expression of the angry feelings. seeking efforts. Clariﬁcation is used when the nurse helps the patient iden- Exploration of solutions is essential because crisis interven-tify the relationship among events, behaviors, and feelings. tion is geared toward solving the immediate crisis. The nurse
190 UNIT II Continuum of Care BOX 13-4 TECHNIQUES OF CRISIS INTERVENTION Technique: Catharsis Example: “That’s the ﬁrst time you were able to defend your- Deﬁnition: The release of feelings that takes place as the self with your boss, and it went very well. I’m so pleased that patient talks about emotionally charged areas you were able to do it.” Example: “Tell me about how you have been feeling since you Technique: Support of defenses lost your job.” Deﬁnition: Encouraging the use of healthy, adaptive defenses Technique: Clariﬁcation and discouraging those that are unhealthy or maladaptive Deﬁnition: Encouraging the patient to express more clearly the Example: “Going for a bicycle ride when you were so angry relationship among certain events was very helpful because when you returned you and your Example: “I’ve noticed that after you have an argument wife were able to talk things through.” with your husband you become sick and can’t leave your Technique: Raising self-esteem bed.” Deﬁnition: Helping the patient regain feelings of self-worth Technique: Suggestion Example: “You are a very strong person to be able to manage Deﬁnition: Inﬂuencing a person to accept an idea or belief, par- the family all this time. I think you will be able to handle this ticularly the belief that the nurse can help and that the person situation, too.” will in time feel better Technique: Exploration of solutions Example: “Many other people have found it helpful to talk Deﬁnition: Examining alternative ways of solving the immedi- about this and I think you will, too.” ate problem Technique: Reinforcement of behavior Example: “You seem to know many people in the computer Deﬁnition: Giving the patient positive responses to adaptive ﬁeld. Could you contact some of them to see whether they behavior might know of available jobs?”and patient actively explore solutions to the crisis. Answers that TABLE 13-3 NURSING INTERVENTIONSthe patient had not thought of before may become apparent FOR CRISIS AND DISASTERduring conversations with the nurse as anxiety decreases. For EVENTSexample, a patient who has lost his job and has not been ableto ﬁnd a new one may become aware of the fact that he knows TARGET AREAS NURSING INTERVENTIONSmany people in his ﬁeld of work whom he could contact to get Basic Needs Provide liaison to social agencies.information regarding the job market and possible openings. Physical Deﬁcits Attend to physical emergencies. These crisis intervention techniques are summarized in Refer to other health care providers asBox 13-4. In addition to using these techniques, the crisis necessary.worker should have some other particular attitudes towardthe care being given in order to be effective. Psychological Effects The crisis worker should see this work as the treatment of Shock Attentively listen to telling of the crisischoice for people in crisis rather than as a second-best treatment. details.Assessment of the present problem should be viewed as necessary Confusion Give nurturing support; permitfor treatment, whereas a complete diagnostic assessment should regression. Denial Permit intermittent denial; identifybe recognized as being unnecessary. The goal and time limita- patient’s primary concern.tions of crisis intervention should be kept in mind constantly, Anxiety Provide structure; enact antianxietyand material unrelated to the crisis should not be explored. interventions. The crisis worker must take an active directive role and Lethargy/heroics Encourage sublimation and construc-maintain ﬂexibility of approach. If more complex problems tive activity.are identiﬁed that are not suitable for crisis intervention, thepatient should be referred for further treatment. Table 13-3 Protective Factorsdescribes interventions for helping individuals and families Coping Encourage patient’s favored, adaptivecope with stress resulting from crisis. coping mechanisms; emphasize ratio- nalization, humor, sublimation. Self-efﬁcacy Support patient’s previous successes EVALUATION and belief in own abilities; dilute ir- rational self-doubts; emphasize powerThe last phase of crisis intervention is evaluation, when the of expectations to produce results.nurse and patient evaluate whether the intervention resulted Support Add social supports to the patient’sin a positive resolution of the crisis. Speciﬁc questions the world; provide professional support; re-nurse might ask include the following: fer for counseling when necessary; help • Has the expected outcome been achieved, and has the patient develop new coping strategies. patient returned to the precrisis level of functioning? Modiﬁed from Hardin SB: Catastrophic stress. In McBride AB, • Have the needs of the patient that were threatened by Austin JK, editors: Psychiatric–mental health nursing, Philadelphia, the event been met? 1996, Saunders.
CHAPTER 13 Crisis and Disaster Intervention 191 • Have the patient’s symptoms decreased or been family crises. The child who refuses to go to school, the man resolved? who resists learning how to give himself an insulin injection, • Does the patient have adequate support systems and and the family with a member dying at home are possible coping resources on which to rely? candidates for crisis intervention. Community health nurses • Is the patient using constructive coping mechanisms? are also in an ideal position to evaluate high-risk families, • Is the patient demonstrating adaptive crisis responses? such as those with new babies, ill members, recent deaths, • Does the patient need to be referred for additional and a history of difﬁculty coping. treatment? Finally, nurses in primary care, community health centers, The nurse and patient also should review the changes that managed care clinics, schools, occupational health centers,have occurred. The nurse should give patients credit for suc- long-term care facilities, and home health agencies also maycessful changes so that they can realize their effectiveness and see patients in crisis, such as those experiencing depression,understand that what they learned from a crisis may help in anxiety, marital conﬂict, suicidal thoughts, illicit drug use,coping with future crises. If the goals have not been met, the and traumatic responses. Crisis intervention can be imple-patient and nurse can return to the ﬁrst step, assessment, and mented in any setting and should be a competency skill ofprogress through the phases again. all nurses, regardless of specialty area. At the end of the evaluation process, if the nurse andpatient believe referral for additional professional help wouldbe useful, the referral should be made as quickly as possible. MODALITIES OF CRISIS INTERVENTIONAll phases of crisis intervention are presented in the Case Crisis intervention modalities are based on the philosophyStudy in Box 13-5. that the health care team must be aggressive and go out to the patients rather than wait for the patients to come to them. Critical Reasoning Given that stress is experienced by all Nurses working in these modalities intervene in a variety of people, why aren’t all nurses required to be competent in community settings, ranging from patients’ homes to street crisis intervention skills, just as they are in cardiopulmonary corners, with great success. resuscitation (CPR) skills? Disaster Responses As part of the community, nurses are called upon when situ-SETTINGS FOR CRISIS AND DISASTER ational crises and disasters strike the community. Floods, earthquakes, airplane crashes, ﬁres, nuclear accidents, and otherINTERVENTION natural and unnatural disasters precipitate large numbers of cri-Disasters can occur anytime and anywhere. Nurses live and ses. Key concepts that should be understood by all disaster men-work in settings in which they often see people in crisis. Hos- tal health providers are presented in Box 13-6 (DHHS, 2003).pitalizations of any type are stressful for patients and their It is important that nurses in the immediate postdisasterfamilies and are precipitating causes of crises. period go to places where victims are likely to gather, such as The patient who becomes demanding or withdrawn or morgues, hospitals, shelters, and areas surrounding the disas-the spouse who becomes bothersome to the nursing staff is a ter site. Rather than waiting for people to publicly identifypossible candidate for crisis intervention. The diagnosis of an themselves as being unable to cope with stress, it is suggestedillness, the limitations imposed on activities, and the changes that nurses work with the American Red Cross, talk to peoplein body image because of surgery can all be viewed as losses waiting in lines to apply for assistance, go door-to-door, or,or threats that may precipitate a situational crisis. Simply the at a relocation site, ask people how they are managing theirstress of being dependent on nurses for care can precipitate a affairs and explore their reactions to stress (Weeks, 2007).crisis for the hospitalized patient. Common psychiatric responses to disaster should be con- Nurses who work in obstetric, pediatric, adolescent, or sidered when developing plans. These are listed in Box 13-7.geriatric settings often observe patients or family members Experts in the ﬁeld of disaster response suggest that orga-undergoing maturational crises. The anxious new mother, nized plans for crisis response be developed and practicedthe acting-out adolescent, and the newly retired depressed during nondisaster times (Sederer et al, 2011).patient are all possible candidates for crisis therapy. If physi- A study of World Trade Center rescue and recovery workerscal illness is an added stress during maturational turning indicated that disaster preparedness training and shift rotations,points, the patient is at an even greater risk. which allowed for shorter time worked, may have reduced post- Emergency department and critical care settings also are traumatic stress disorder (PTSD) among workers and volun-ﬂooded with crisis cases. People who attempt suicide, psy- teers. Furthermore, PTSD was signiﬁcantly higher among thosechosomatic patients, survivors of sudden cardiac arrest, and who did not have disaster training and who performed taskscrime and accident victims are all possible candidates for cri- not common for their occupation (Perrin et al, 2007).sis intervention. If the nurse is not in a position to work with Disaster plans are needed for large and small communi-the patient on an ongoing basis, a referral should be made. ties so that multiple complex needs can be met and effective Community and home health nurses work with patients in triage implemented (Beach, 2010; Culley and Effken, 2010).their own environments and can often spot and intervene in Speciﬁcally, disaster plans need to have a way of identifying
192 UNIT II Continuum of CareBOX 13-5 CASE STUDY Assessment Diagnosis Mr. A is a 39-year-old, medium-build, casually dressed, African- Mr. A was in a situational crisis. The threat or precipitating American man who was referred to the mental health clinic by stress was his job transfer and supervision by a former boss, his primary care provider. The patient came to the center alone. whom he felt was harassing him. The patient’s need for role The nurse working with Mr. A collected the following data. mastery was not being met because he was not feeling suc- The patient worked in a large naval shipyard that was recently cessful at his job. Soon after the transfer, Mr. A’s usual means scheduled for closing. It was laying off many workers and reas- of coping became ineffective and he experienced increased signing others. One month earlier Mr. A was assigned to an anxiety. His nursing diagnosis was ineffective coping related to area where he had difﬁculty 2 years ago. The patient believed changes at work, as evidenced by physical complaints of diz- that the foreman was harassing him as he had done previously. ziness and tension. His DSM-IV-TR diagnosis was adjustment Two weeks ago the patient had become angry with the disorder with mixed anxiety and depressed mood. foreman and had thoughts of killing him. Instead of acting on these thoughts, Mr. A became dizzy, and his head ached. He Outcomes Identiﬁcation and Planning requested medical attention but was refused. He then passed The expected outcome of treatment was for Mr. A to return out and was taken by ambulance to the dispensary. Since that to his precrisis level of functioning. If possible, he could reach a time Mr. A had a comprehensive physical examination and was higher level, having learned new methods of problem solving. found to be in excellent health. He was prescribed diazepam The patient showed good potential for growth, and the nurse (Valium) on an as-needed basis, which was only slightly helpful. made a contract with him for crisis intervention. Mutually iden- He returned to work for 2 days this week but again felt sick. tiﬁed short-term goals included the following: Mr. A complained of being depressed, nervous, and tense. • Mr. A will explore his thoughts and feelings about recent He was not sleeping well, was irritable with his wife and chil- work events. dren, and was preoccupied with angry feelings toward his fore- • Mr. A will not harm his boss. man. He denied suicidal thoughts but admitted that he felt like • Mr. A will describe coping mechanisms that have been killing the foreman. He quickly added that he would really never successful for him in the past. do anything like that. • Mr. A will identify three new ways of coping with work He appeared to have good comprehension, above-average stress. intelligence, adequate memory, and some paranoid ideation • Mr. A will implement two of the new coping strategies. related to the foreman at work. His thought processes were • Mr. A will be free of symptoms and function well at work. organized, and there was no evidence of a perceptual disorder. Ego boundary disturbance was evident in the patient’s paranoid Implementation thoughts. It seemed that the foreman was a difﬁcult man to get The level of intervention used by the nurse was the individual along with, but the description of personal harassment was not approach, which includes the generic approach, general sup- based on any speciﬁcs. port, and environmental manipulation. Mr. A was raised by his parents. His father beat him and his Environmental manipulation involved having the patient siblings often. His mother was quiet and always agreed with remain home from work temporarily. Letters were written by his father. The patient had a younger brother and sister and an the nurse to his employer explaining Mr. A’s absence in general older sister. The patient and his brother had always been close. terms. Mr. A was encouraged to talk to his wife about his dif- The two of them had stopped their father’s beatings by gang- ﬁculties so that she could understand his anxiety and provide ing up on him and “psyching him out.” As a child, Mr. A hung emotional support. around with a tough crowd and fought frequently. He believed General support was given by the nurse, who provided an that he could physically overpower others but tried to keep out atmosphere of reassurance, nonjudgmental caring, warmth, of trouble by talking to people rather than ﬁghting. empathy, and optimism. Mr. A was encouraged to talk freely Mr. A had no psychiatric history. His physical health was about the problem, and the nurse assured him that his problem excellent, and he was taking no medication other than the pre- could be solved and that he would be feeling better soon. scribed Valium. He had a tenth-grade education, and his work The generic approach was used to decrease the patient’s record up to this time was good. His interests included bowling anxiety and guide him through the steps of problem solving. Lev- and other sports. He had been married for 17 years and had els of anxiety were assessed and ways of reducing anxiety and three daughters, ages 16, 13, and 9 years. Mr. A stated that he helping the patient tolerate moderate anxiety were identiﬁed. had a good relationship with his wife and daughters and that The patient was encouraged to use his anxiety constructively to both his wife and his brother were strong supports for him. solve his problem and develop new coping mechanisms. His usual means of coping were talking calmly with the The individual approach was used in assessing and treating threatening party and working hard on his job, at home, and in the speciﬁc problems of Mr. A, who was strongly sensitive to leisure activities. These coping mechanisms failed to work for mistreatment as a result of early childhood experiences. His him at this time, but they had been successful in the past. He emotional response was to strike out physically, as his father had no arrest record and was able to think through his actions had struck out at him. Intellectually, Mr. A knew this would rather than act impulsively. Mr. A showed strong motivation for not be good, and his conﬂict was solved by becoming sick working on his problem. He was reaching out for help and was and passing out so that he could not assault his boss. Mr. A’s able to form a therapeutic relationship with the nurse. Although intense anger was recognized, and a high priority was placed his wife and brother were supportive, he felt a need for outside on channeling the anger in a positive direction. He stated that support because his previous coping skills were not working. he had no intentions of hurting his boss.
CHAPTER 13 Crisis and Disaster Intervention 193BOX 13-5 CASE STUDY—cont’d The ﬁrst two meetings were used for data gathering and Mr. A’s defenses were not attacked, but his use of projectionestablishing a positive therapeutic relationship. Through the was discouraged.use of catharsis the patient vented angry feelings but did not In the ﬁfth session the patient reported that a car tried to runconcentrate on wanting to kill his boss. The nurse used clariﬁ- him off the road. At a red trafﬁc light the patient spoke calmlycation to help the patient begin to understand the precipitating to the offending driver and the driver apologized. The nurseevent and its effect on him. Suggestion was used to allow reinforced this behavior and supported his use of sublima-the patient to see the nurse as one who could help. The nurse tion as a defense. Discussion of termination of the therapytold the patient the problem could be worked out by the two of was begun.them and that he would soon be feeling better. Mr. A decided In the sixth session Mr. A said that things were going wellto contact several people at work to obtain information about at work and that he would soon be going to a different depart-transferring to another department and ﬁling a formal complaint ment. He also talked about a course he had begun at a com-against the foreman. The patient and nurse therefore were munity college. He showed no evidence of anxiety, depression,exploring solutions. The nurse reinforced the patient’s use or paranoia and thought he didn’t need to come back to theof problem solving by telling him that his ideas about alterna- mental health clinic.tive solutions were good ones. Throughout these and othersessions the nurse raised his self-esteem by communicating Evaluationher conﬁdence that he could ﬁnd solutions to his problems. The interventions resulted in an adaptive resolution of the cri-She listened to and accepted his feelings and treated him with sis. The patient’s need for role mastery was being met. He wasrespect. By contacting others at work, the patient also found once again comfortable and successful at work. His symptomssome supportive people. of anxiety, paranoia, dizziness, headaches, passing out, and During the third session the patient described an incident in homicidal thoughts had ended. He no longer felt harassed. Hiswhich he became furious at a worker in an automobile repair original coping mechanisms were again effective. He was talk-shop. The repairs on the patient’s car were repeatedly done ing calmly to people with whom he was having difﬁculty, andincorrectly, and the patient had to keep returning the car. The he was again working hard in a goal-oriented way (his collegepatient shoved the worker but limited his physical assault to course).just that. He then felt nervous and jittery. The patient had previ- He had learned new methods of coping, which includedously expressed pride in his ability to control his angry feelings talking about his feelings to signiﬁcant others, followingand not physically strike out at others. Suggestion was used administrative or ofﬁcial avenues of protest, and seekingby telling the patient that he showed control in stopping the support. The patient and nurse discussed how Mr. A couldassault before it had become a full-blown ﬁght and he could use the methods of problem solving he had learned from thecontinue to do so. During this session the patient spoke of experience to help cope with future problems. The expectedold, angry feelings toward his father. Some of this venting was outcome, return to the precrisis level of functioning, hadallowed, but soon thereafter the focus was guided back to the been attained.present crisis. It was also recommended to the patient that he engage in In the fourth session the patient reported no episodes of psychotherapy so that he could deal with the old angers thatuncontrollable anger. However, he still put much empha- continued to interfere with his life. Mr. A rejected the recom-sis on being harassed by others. The nurse questioned the mendation and said he would contact the clinic if he changednotion that others were out to intentionally harass the patient. his mind.BOX 13-6 KEY CONCEPTS OF DISASTER—MENTAL HEALTH• No one who sees a disaster is untouched by it. • Most people do not see themselves as needing mental health• There are two types of disaster trauma—individual and services following a disaster and will not seek such services. community. • Survivors may reject disaster assistance of all types.• Most people pull together and function adequately during • Disaster mental health assistance is often more practical and after a disaster, but they are less effective due to the than psychological in nature. effects of the event. • Disaster mental health services must be tailored to the cul-• Stress and grief in disasters are normal reactions to abnor- ture of communities where they are provided. mal situations. • Mental health workers should set aside traditional meth-• Many emotional reactions of disaster survivors stem from ods, avoid mental health labels, and use an active outreach problems of daily living brought about by the disaster. approach to intervene successfully in disaster.• Disaster relief assistance may be confusing to some survi- • Survivors respond to active, genuine interest, and concern. vors. They may experience frustration, anger, and feelings • Interventions must be appropriate to the phase of the of helplessness related to federal, state, and private-sector disaster. disaster assistance programs. • Social support systems are crucial to recovery.
194 UNIT II Continuum of Care BOX 13-7 COMMON PSYCHIATRIC BOX 13-8 GUIDING PRINCIPLES FOR RESPONSES TO DISASTER CULTURAL COMPETENCE IN Psychiatric Diagnoses DISASTER MENTAL HEALTH • Organic mental disorders secondary to head injury, toxic • Recognize the importance of culture and respect diversity. exposure, illness, and dehydration • Maintain a current proﬁle of the cultural composition of the • Acute stress disorder community. • Adjustment disorder • Recruit disaster workers who are representative of the • Substance use disorders community or service area. • Major depression • Provide ongoing cultural competence training to disaster • Posttraumatic stress disorder mental health staff. • Generalized anxiety disorder • Ensure that services are accessible, appropriate, and equitable. Psychological/Behavioral Responses • Recognize the role of help-seeking behaviors, customs and • Grief reactions and other normal responses to an traditions, and natural support networks. abnormal event • Involve as “cultural brokers” community leaders and orga- • Family violence nizations representing diverse cultural groups. • Self-directed violence • Ensure that services and information are culturally and lin- • Other-directed violence guistically competent. • Assess and evaluate the program’s level of cultural competence.those individuals who are at greatest risk for developing orworsening psychiatric illnesses. Finally, attention also has been focused on offering support Examples of agencies, organizations, and individuals to be and help to the helpers involved in disasters. Health and men-included in disaster planning include hospitals, mental health tal health professionals who are victims of disasters as wellprograms, substance abuse agencies, departments of health, as providers of care during disasters often feel overwhelmedemployee assistance programs, housing programs, univer- with stress (Adams, 2007; Chaffee, 2006). These care provid-sity-afﬁliated nurses, and school district nurses. The Ameri- ers describe feelings of concern for their patients and theircan Nurses Association has guidance for professionals during own families, as well as themselves. Thus crisis interventiondisasters, pandemics, and other extreme emergencies that strategies for the caregivers in times of disaster are essential.includes ethical principles, emergency preparedness compe-tencies, and speciﬁc emergency event care (ANA, 2008). Critical Reasoning Nurses are often called on to help out in Nurses providing crisis therapy during large disasters use times of disaster. What special needs might nurses have inthe generic approach to crisis intervention so that as many situations where they are both victims and caregivers?people as possible can receive help in a short amount of time.Tragedies such as workplace violence and school shootingsmay affect fewer people and may at times require the indi- Mobile Crisis Programsvidual approach. The nurse may choose to work with families Mobile crisis teams provide frontline interdisciplinary crisisor groups rather than individuals during situational crises so intervention to individuals, families, and communities. Thethat people can gain support from others in their family or nurse who is a member of a mobile crisis team may respondcommunity who are undergoing stresses similar to theirs. to a desperate person threatening to jump off a bridge in a sui- It is important to prioritize those in need of crisis inter- cide attempt, an angry person who is becoming violent towardvention. At the top of the list are those who have themselves family members at home, or a frightened person who has bar-been physically attacked or injured. This is followed by those ricaded himself in an ofﬁce building. By defusing the imme-who suffer immediate and direct loss, such as the families and diate crisis situation, lives can be saved, incarcerations andneighbors of victims. Below that are people who have been hospitalizations can be avoided, and people can be stabilized.less directly affected but have still experienced some signiﬁ- Mobile crisis programs throughout the United States varycant changes in their lives, such as friends and co-workers of in the services they provide and the procedures they use. How-the injured person and rescue workers. Next are those who ever, they are usually able to provide on-site assessment, crisishave not been directly affected but who are particularly sen- management, treatment, referral, and educational services tositive to environmental uncertainty, such as those who are patients, families, law enforcement ofﬁcers, and the communityphysically and mentally ill. And ﬁnally, at the bottom, are the at large. Studies of mobile crisis services show favorable out-masses of people who have experienced some changes in their comes for patients and families, lower hospitalization rates andlives and feel fear as a result of the disaster. fewer arrests (Compton et al, 2006; Skeem and Bibeau, 2008). Providing culturally competent care requires a concertedeffort by disaster mental health planners and frontline work- Critical Reasoning Ask if you can shadow a mobile crisisers. Successful programs share common practices that are team in your community for a day. Observe the work they dodeﬁned by nine guiding principles listed in Box 13-8. and share your experience with your peers.
CHAPTER 13 Crisis and Disaster Intervention 195Telephone Contacts identify the needs of victims and then to connect them withCrisis intervention is sometimes practiced by telephone appropriate referrals and other resources. Patient concernsor Internet communication rather than through face-to- such as the personal meaning of the crime, who to tell, andface contacts. When individuals in crisis use the telephone the reaction of others should be discussed. A victim advocateor Internet, it is usually at the peak of their distress. Nurses can contact employers regarding the need for temporary timeworking for these types of hotlines or those who answer emer- off, can mobilize community resources for food and sheltergency telephone calls or electronic mail may ﬁnd themselves if necessary, and can arrange for grace periods with debtorspracticing crisis intervention without having visual cues to to delay payment of bills without penalty until the victimrely on. Referrals for face-to-face contact should be made, recovers.but often, because of the patient’s unwillingness or inability Crisis intervention is successful in the immediate after-to cooperate, the telephone or Internet remains the only con- math of rape. It uses an integrated framework of outreach,tact. A variety of listening skills must therefore be emphasized emergency care, and advocacy assistance. Nurses often workin the nurse’s role. in rape crisis centers, where victims commonly are seen Most emergency telephone and Internet services have immediately after the rape. These victims need thoroughextensive training programs to teach this specialized type evaluation, empathic support, information, and help withof crisis intervention. Manuals written for the crisis worker the legal system.include content such as suicide-potential rating scales, com- Another important issue is that of abusive relationships.munity resources, drug information, guidelines for helping Whether the victim is a spouse, a child, a date, an elderly per-the caller or crisis worker discuss concerns, and advice on son, or a caregiver, abusive relationships are experienced byunderstanding the limitations of the crisis worker’s role. people of both genders and of all racial, ethnic, economic, educational, and religious backgrounds. Chapter 38 presentsGroup Work more information regarding care of survivors of violence.Crisis groups follow the same steps that individual inter-vention follows. The nurse and group help the patient solve Health Educationthe problem and reinforce the patient’s new problem-solving Although health education can take place during thebehavior. The nurse’s role in the group is active, focal, and entire crisis intervention process, it is emphasized duringpresent oriented. The group follows the nurse’s example and the evaluation phase. At this time the patient’s anxiety hasuses similar therapeutic techniques. The group acts as a sup- decreased, so better use can be made of cognitive abilities.port system for the patient and is therefore of particular ben- The nurse and patient summarize the course of the crisis, andeﬁt to socially isolated people. the intervention is to teach the patient how to avoid other Often the way the patient functions in the group suggests similar crises.the faulty coping pattern that is responsible for the patient’s For example, the nurse helps the patient identify thecurrent problem. For example, a patient’s interaction with feelings, thoughts, and behaviors experienced followinggroup members may show that he does not appear to listen to the stressful event. The nurse explains that if these feelings,anything said by others. This same patient may be in a crisis thoughts, and behaviors are again experienced, the patientbecause his girlfriend left him because she thought he did not should immediately become aware of being stressed and takecare about her thoughts and feelings. The nurse can comment steps to prevent the anxiety from increasing. The nurse thenon the faulty coping behavior seen in the group and encour- teaches the patient ways to use these newly learned copingage group discussion about it. mechanisms in future situations. Nurses practicing on acute psychiatric units also can use Nurses also are involved in identifying people who are atcrisis intervention in working with patients and families to high risk for developing crises and in teaching coping strate-prepare for discharge and prevent rehospitalization. With gies to help them avoid the development of the crises. Forthe shortened lengths of hospital stays, crisis intervention is example, coping strategies that can be taught include how tooften the treatment of choice. The hospitalization itself may request information, access resources, and obtain support.be viewed as an environmental manipulation and part of thecrisis intervention. Critical Reasoning Explain how conducting a group on stress management for critical care nurses is an example ofVictim Outreach Programs health education as crisis intervention.Crisis intervention is not considered the appropriate treat-ment for serious consequences of victimization, such as Finally, members of the public also need education so thatPTSD or depression. However, it is very useful as a com- they can identify those requiring crisis services, be aware ofmunity support for victims in the immediate aftermath of available services, change their attitudes so that people willcrime and may provide an important link for referral to feel free to seek services, and obtain information about howmore comprehensive services when needed. others deal with potential crisis-producing problems. Nurses, Violent crime has become a global issue, concerning as health care professionals, have a great opportunity to pro-people in every walk of life and in every country. Many vic- vide health education and crisis intervention, thus preventingtim outreach programs use crisis intervention techniques to mental illness and promoting mental health.