Crisis Intervention Adaptation and coping are a natural part of life. If children are protected from experiencing negative events and developing coping skills, they may be unable to cope and adapt to crisis situations in later life. Crisis occurs when there is a perceived challenge or threat that overwhelms the capacity of the individual to cope effectively with the event. A crisis disrupts the life of the individual experiencing the event. In a crisis, the person’s habits and coping patterns are suspended. Often, unexpected emotional (e.g., depression) and biologic (e.g., nausea, vomiting, diarrhea, headaches) responses occur. Although a person may become extremely anxious, depressed, or elated, feeling states do not determine whether a person is in a crisis. If functioning is severely impaired, a crisis is occurring (Yeager & Roberts, 2003). Crisis A crisis is generally regarded as time limited, lasting no more than 4 to 6 weeks. At the end of that time, the person in crisis should have begun to come to grips with the event and to harness resources to cope with its long-term consequences. By definition, there is no such thing as a chronic crisis. People who live in constant turmoil are not in crisis but in chaos. A crisis can also represent a turning point in a person’s life, with either positive or negative outcomes. It can be an opportunity for growth and change because new ways of coping are learned. Either internal or external demands that are perceived as threats to a person’s physical or emotional functioning can initiate a crisis. The precipitating event is not only stressful, but unusual or rare. Many life events can evoke a crisis, such as pandemics, natural disasters (e.g., floods, tornadoes, earthquakes) and manmade disasters (e.g., wars, bombings, airplane crashes) as well as traumatic experiences (e.g., rape, sexual abuse, assault). In addition, interpersonal events (divorce, marriage, birth of a child) may create a crisis event in the life of any person. A crisis is not the same as a psychiatric emergency that requires immediate intervention. A person in crisis may not need an immediate intervention and should not be viewed as having a mental disorder (Roberts, 2005). However, if the person is significantly distressed or social functioning impaired, an Axis I diagnosis of acute stress disorder should be considered (American Psychiatric Association [APA], 2000). The person with an acute stress disorder has dissociative symptoms and persistently re-experiences the event (APA). A. Historical Perspectives of Crisis The basis of our understanding of the biopsychosocial implications of a crisis began in the 1940s when Eric Lindemann (l944) studied bereavement reactions among the friends and relatives of the victims of the Coconut Grove nightclub fire in Boston in 1942. That fire, in which 493 people died, was the worst single building fire in the country’s history at that time. Lindemann’s goal was to develop prevention approa ...

1. Crisis Intervention
Adaptation and coping are a natural part of life. If children are
protected from experiencing negative events and developing
coping skills, they may be unable to cope and adapt to crisis
situations in later life. Crisis occurs when there is a perceived
challenge or threat that overwhelms the capacity of the
individual to cope effectively with the event. A crisis disrupts
the life of the individual experiencing the event.
In a crisis, the person’s habits and coping patterns are
suspended. Often, unexpected emotional (e.g., depression) and
biologic (e.g., nausea, vomiting, diarrhea, headaches) responses
occur. Although a person may become extremely anxious,
depressed, or elated, feeling states do not determine whether a
person is in a crisis. If functioning is severely impaired, a crisis
is occurring (Yeager & Roberts, 2003).
Crisis
A crisis is generally regarded as time limited, lasting no more
than 4 to 6 weeks. At the end of that time, the person in crisis
should have begun to come to grips with the event and to
harness resources to cope with its long-term consequences. By
definition, there is no such thing as a chronic crisis. People who
live in constant turmoil are not in crisis but in chaos. A crisis
can also represent a turning point in a person’s life, with either
positive or negative outcomes. It can be an opportunity for
growth and change because new ways of coping are learned.
Either internal or external demands that are perceived as threats
to a person’s physical or emotional functioning can initiate a
crisis. The precipitating event is not only stressful, but unusual
or rare. Many life events can evoke a crisis, such as pandemics,
natural disasters (e.g., floods, tornadoes, earthquakes) and

2. manmade disasters (e.g., wars, bombings, airplane crashes) as
well as traumatic experiences (e.g., rape, sexual abuse, assault).
In addition, interpersonal events (divorce, marriage, birth of a
child) may create a crisis event in the life of any person.
A crisis is not the same as a psychiatric emergency that requires
immediate intervention. A person in crisis may not need an
immediate intervention and should not be viewed as having a
mental disorder (Roberts, 2005). However, if the person is
significantly distressed or social functioning impaired, an Axis
I diagnosis of acute stress disorder should be considered
(American Psychiatric Association [APA], 2000). The person
with an acute stress disorder has dissociative symptoms and
persistently re-experiences the event (APA).
A. Historical Perspectives of Crisis
The basis of our understanding of the biopsychosocial
implications of a crisis began in the 1940s when Eric
Lindemann (l944) studied bereavement reactions among the
friends and relatives of the victims of the Coconut Grove
nightclub fire in Boston in 1942. That fire, in which 493 people
died, was the worst single building fire in the country’s history
at that time. Lindemann’s goal was to develop prevention
approaches at the community level that would maintain good
health and prevent emotional disorganization. He described both
grief and prolonged reactions as a result of loss of a significant
person. From those results, he hypothesized that during the
course of one’s life, some situations, such as the birth of a
child, marriage, and death, evoke adaptive mechanisms that lead
either to mastery of a new situation (psychological growth) or
impaired functioning.
In 1961, psychiatrist Gerald Caplan defined a crisis as occurring
when a person faces a problem that cannot be solved by
customary problem-solving methods. When the usual problem-
solving methods no longer work, a person’s life balance or

3. equilibrium is upset. During period of disequilibrium, there is a
rise in inner tension and anxiety, followed by emotional upset
and an inability to function. This conceptualization of phases of
a crisis is used today. According to Caplan, during a crisis, a
person is open to learning new ways of coping to survive. The
outcome of a crisis is governed by the kind of interaction that
occurs between the person and available key social support
systems.
Gerald Caplan’s Four Phases of Crisis
Phase 1: A problem arises that contributes to increase in anxiety
levels. The anxiety stimulates the implementation of usual
problem-solving techniques of the person.
Phase 2: The usual problem-solving techniques are ineffective.
Anxiety levels continue to rise. Trial-and-error attempts are
made to restore balance.
Phase 3: The trial-and-error attempts fail. The anxiety escalates
to severe or panic levels. The person adopts automatic relief
behaviors.
Phase 4: When these measures do not reduce anxiety, anxiety
can overwhelm the person and lead to serious personality
disorganization, which signals the person is in crisis.
B.Types of Crises
Recent research has focused on categorizing types of crisis
events, understanding biopsychosocial responses to crisis, and
developing intervention models that support people through
crisis (Stone & Conley, 2004).
Maturational Crisis – While Lindemann and Caplan were
creating their crisis model, Erik Erikson was formulating his
ideas about crisis and development. He proposed that
maturational crises are a normal part of growth and

4. development, and that successfully resolving a crisis at one
stage allows the child to move to the next. According to this
model, the child develops positive characteristics after
experiencing a crisis. If he or she develops less desirable traits,
the crisis is not resolved. This concept of maturational crisis
assumes that psychosocial development progresses by an easily
identifiable, orderly process.
The concept of developmental crisis continues to be used today
to describe unfavorable person-environment relationships that
relate to maturational events, such as leaving home for the first
time, completing school, or accepting the responsibility of
adulthood. The accomplishment of developmental tasks
throughout the life cycle will impact the interpretation of crisis
events during the transition of an individual from one stage of
life to another.
Situational Crisis – A situational crisis occurs whenever a
specific stressful event threatens a person’s biopsychosocial
integrity and results in some degree of psychological
disequilibrium. The event can be an internal one, such as a
disease process or any number of external threats. A move to
another city, a job promotion, or graduation from high school
can initiate a crisis even though they are positive events. For
example, graduation from high school marks the end of an
established routine of going to school, participating in school
activities, and doing homework assignments. When starting a
new job after graduation, the former student must learn an
entirely different routine and acquire new knowledge and skills.
If a person enters a new situation without adequate coping
skills, a crisis may develop, resulting in dissonance
(inconsistency between attitude and behavior).
Situational Crises
Death of spouse
Divorce

5. Marital Separation from mate
Detention in jail or other institution
Death of a close family member
Major personal injury or illness
COVID-19
Marriage
Being fired at work
Marital reconciliation with mate
Retirement from work
Major change health/behavior of a family member
Pregnancy/Abortion
Adventitious Crisis – An adventitious crisis is initiated by
unexpected unusual events that can affect an individual or a
multitude of people. In such situations, people face
overwhelmingly hazardous events that may entail injury,
trauma, destruction, or sacrifice. Such an event involves a
physically aggressive and forced act by a person, a group, or an
environment. National disasters (e.g., racial persecutions,
kidnappings, riots, war); violent crimes (e.g., rape, murder, and
assault and battery); and natural disasters (e.g., earthquakes,
floods, forest fires, hurricanes) are examples of events that
precipitate this type of crisis (Hazelwood & Burgess, 2001).
9/11 is an example of an adventitious crisis.
C. Advanced Practice Psychiatric/Mental Health Nursing
Management of Crisis
The goal for people experiencing a crisis is to return to the pre-
crisis level of functioning. The role of the PMH-APRN is to
provide a framework of support systems that guide the client
through the crisis and facilitate the development and use of
positive coping skills. The PMH-APRN must be acutely aware
that a person in crisis may be at high risk for suicide or
homicide. To determine the level of effectiveness of coping
capabilities of the person, the PMH-APRN should complete a

6. careful assessment for suicidal or homicidal risk. If a person is
at high risk for either, the PMH-APRN should consider the
possible need for the person to be referred for admission to the
hospital. When assessing the coping mechanisms and ability of
the client to use those mechanisms for adaptation, the PMH-
APRN should assess for unusual behaviors and determine the
level of involvement of the person with the crisis. In addition,
assess for evidence of self-mutilation activities that may
indicate the use of self-preservation measures to avoid suicide.
It is critical to assess the client’s perception of the problem and
the availability of support mechanisms (emotional and
financial) for use by the person (Litz, Gray, Bryant, & Adler,
2002).
During an adventitious crisis (e.g., flood, hurricane, forest fire)
that affects the well-being of many people, the interventions of
the PMH-APRNwill be a part of the community’s efforts to
respond to the event. On the other hand, when a personal crisis
occurs, the person in crisis may have only the PMH-APRN to
respond to his or her needs. After the assessment, the PMH-
APRN must decide whether to provide the care needed or to
refer the person to a psychiatrist.
Biologic Domain/Assessment – Biologic assessment focuses on
areas that usually undergo initial changes. Eliciting information
about changes in health practices provide important data that
the PMH-APRN can use to determine the severity of the
disruption in functioning. Biologic functioning is important
because a crisis can be physically exhausting. Disturbances in
sleep and eating patterns and the reappearance of physical or
psychiatric symptoms are common. Changes in body function
may include tachycardia, tachypnea, profuse perspiration,
nausea, vomiting, dilated pupils, and extreme shakiness. Some
victims may exhibit loss of control and have total disregard for
their personal safety. The victims are at high risk for injury,
which may include infection, trauma, and head injuries (France,

7. 2002). If the victim’s sleep patterns are disturbed or nutrition is
inadequate, the victim will not have the physical resources to
deal with the crisis.
Any negative physiological responses should be treated
immediately. Triage the victims according to the level of care
needed. If the crisis involves a life-threatening physical injury,
those types of injuries should be treated immediately.
Throughout the triage process, the victims should be reassured
that the caregiver is concerned and committed to providing
quality nursing care. Be careful not to give unrealistic or false
reassurances of positive outcomes over which you have no
control. Make referrals as appropriate. Ideally, a PMH-APRN
would be an integral part of the triage team. Pharmacologic
interventions may be needed to help maintain a high level of
psychophysical functioning. While medication cannot resolve a
crisis, the judicious use of psychopharmacologic agents can
help reduce its emotional intensity.
Psychological Domain/Assessment – Psychological assessment
focuses on the victim’s emotions and coping strengths. In the
beginning of the crisis, the victim may report the feeling of
numbness and shock. Responses to psychological distress
should be differentiated from symptoms of psychiatric illnesses
of the victim. Later, as the reality of the crisis sinks in, the
victim will be able to recognize and describe the felt emotions.
The PMH-APRN should expect those emotions to be intense and
will need to provide some support during their expression by
that victim. At the beginning of a crisis, assess the victim for
behaviors that indicate a depressed state, the presence of
confusion, uncontrolled weeping or screaming, disorientation,
or aggression. The victim may be suffering from loss of feelings
of well-being and safety. In addition, panic responses, anxiety,
and fear may be present (Hall, Norwood, Ursano, & Fullerton,
2003). The ability to cope by problem-solving may be disrupted.
By assessing the victim’s ability to solve problems, the PMH-

8. APRN can evaluate whether the victim can cognitively cope
with the crisis situation and determine the kind and amount of
support needed. The survivor of a disaster may experience
traumatic bereavement because of feelings of guilt for survival
of the crisis.
Safety interventions to protect the person in crisis from harm
should include preventing the person from committing suicide
or homicide, arranging for food and shelter (if needed), and
mobilizing social support. Once the person’s safety needs are
met, the PMH-APRN can address the psychosocial aspects of
the crisis. Prepare the victims for recovery. Victims should be
encouraged to report any depression, anxiety, or interpersonal
difficulties during the recovery period. There may be a need for
support groups to be established to help victims and their
families deal with the psychological effects of the phenomenon
(Dattilio & Freeman, 2007).
Counseling reinforces healthy coping behaviors and interaction
patterns. Counseling focuses on identifying the victim’s
emotions and positive coping strategies. Responses to crisis
differ with individuals. Some victims may present w ith
behaviors that indicate transient disruptions in their ability to
cope. Others may be totally devastated (Bonanno, 2004). At
times, telephone counseling may provide the victim with enough
help that face-to-face counseling is not necessary. If counseling
strategies do not work, other stress reduction and coping
enhancement interventions can be used. For anyone who cannot
cope with a crisis, the PMH-APRN should make referral to
short-term psychiatric inpatient treatment.
Social Domain/Assessment – Assessment of the impact of the
crisis on the victim’s social functioning is essential because a
crisis usually severely disrupts social proficiencies. The PMH-
APRN should assess the severity of the crisis to determine the
capability of the individual or the community to respond in a

9. supportive way. Assist the victims to maintain a calm demeanor,
obtain and distribute information about the crisis and the
victims of the crisis. Initiate attempts to reunite victims and
their families. Shelter, food, and other resources may not be
available. In a crisis, the first priority is to meet the basic
human needs of the victims.
The nursing interventions for the social domain include the
individual, the family, and the community. A crisis often
disrupts a victim’s social network leading to changes in
available social support. Development of a new social support
network may help the victim cope more effectively with the
crisis. Supporting the development of new support contacts
within the context of available social networks can be done by
contacting available local and state agencies for assistance as
well as specific private support groups and religious groups.
Disaster Management
A disaster is a sudden ecological or man-made phenomenon that
is of sufficient magnitude to require external help to address the
psychosocial needs as well as the physical needs of the victims.
Acts of terrorism present situations that mimic disasters;
terrorism can be categorized as a type of disaster.
Although crises and disasters are usually viewed as survivors of
disasters draw on resources that they never survivors of
disasters draw on resources that they never realized they had
and grow from those experiences (Walter & Berkovitz, 2005).
However, the survivors of disasters may present with severe
psychological problems that begin with expressed feelings of
fear, anger, and distress that elevate to severe anxiety at the
panic level with deterioration to more severe mental illnesses
(Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002).
Unresolved crisis and/or disastrous events can lead to
disorganized thinking and responses that are inappropriate and
traumatic for the person experiencing the situation (Flynn &
Norwood, 2004). In addition, the victims may experience the

10. development of acute stress disorder (that has a strong emphasis
on dissociative symptoms), and posttraumatic stress disorder
(PTSD; Harvey & Pauwels, 2000).A. Historical Perspectives of
Disasters in the United States
Throughout history, disasters have been portrayed from a
fatalistic perspective that humans have little control over
catastrophic events. Some cultures contend that natural disasters
are an act of God. Other cultures express their belief that
natural disaster events can be attributed to gods dwelling within
such places as volcanoes, with eruptions being an expression of
the gods’ anger (van Griensven, et al., 2006). Although often
caused by nature, disasters can have human origins. Wars and
civil disturbances that destroy homelands and displace people
are included among the causes of disasters. Other causes can be
a building collapse, blizzard, drought, earthquake, epidemic,
explosion, famine, fire, flood, hazardous material or
transportation incident (such as a chemical spill), hurricane,
nuclear incident, terrorist attack, tornado, or volcano eruptions.
Often, it is the unpredictability of such disasters that causes
fear, confusion, and stress that can have lasting effects on the
health of affected communities and their sense of well -being.
In recent history, we have experienced several attacks of
violence and terrorism that are unprecedented in North America.
The bombing of the federal office building in Oklahoma City on
April 19, 1995; the shooting massacre of Columbine High
School students on April 20, 1999; the destruction of the World
Trade Center in New York and the attack on the Pentagon in
Washington, DC, on September 11, 2001; and later, the
dispersal of anthrax spores in the United States mail shattered
North Americans’ sense of safety and security (Miller, 2002;
North et al., 2002).
Since September 11, 2001, the emergency response planning of
federal, state, and local agencies has focused on possible
terrorist attacks with chemical, biological, radiological, nuclear,
or high-yield explosive weapons. Before September 11,
government agencies and public health leaders had not

11. incorporated mental health into their overall response plans to
bioterrorism. In the aftermath of the mass destruction of human
life and property in 2001, government and health care leaders
have recognized the need for monumental mental health efforts
to be implemented during episodes of terrorism and disaster.
The psychological and behavioral consequences of a terrorist
attack are now included in most disaster plans (Hall, Norwood,
Ursano, & Fullerton, 2003).
The hurricane Katrina disaster 2005 highlighted the importance
of government preparedness for natural disasters as well as
terrorism. The lack of government response and breakdown in
communication resulted in thousands of hurricane victims being
displaced and injured. Consequences of Hurricane Katrina are
still being felt today.B. Phases of Disaster
Natural and man-made disaster can be conceptualized in three
phases:
1. Pre-warning of the disaster. This phase entails preparing
victims for possible evacuation of the environment,
mobilization of resources, and review of community disaster
plans.
2. Disaster event occurs. Here the rescuers provide resources,
assistance, and support as needed to preserve the
biopsychosocial functioning and survival of the victims.
3. Recuperative effort. The focus here is to implement strategies
for healing the sick and injured, preventing complications of
health problems, repairing damages, and reconstructing the
community (Flynn & Norwood, 2004).C. Advanced Practice
Psychiatric/Mental Health Nursing Management of Disasters
PMH-APRNs encounter three different types of disaster victims.
The first category is the victims who may or may not survive. If
they survive, the victims often suffer severe physical injuries.
The more serious the physical injury, the more likely the victim
will experience a mental health problem such as PTSD, depress
ion, anxiety, or other mental health problems (North et al.,
2002; Pfefferbaum et al., 2001). Victims and families will need
ongoing health care to prevent complications related to both

12. physical and mental health.
The second category of victims includes the professional
rescuers. These are persons who are less likely to suffer
physical injury but who often suffer psychological stress. The
professional rescuers, such as policemen, firefighters, nurses,
and so on, have more effective coping skills than do volunteer
rescuers who are not prepared for the emotional impact of a
disaster (North et al., 2002). However, many professional
responders have reported experiencing PTSD for many months
following the traumatic event in which they were involved (Puig
& Glynn, 2003).
The third category includes everyone else involved in the
disaster. Psychological effects may be experienced worldwide
by millions of people as they experience terrorism or disaster
vicariously or as direct victims of the terrorism/disaster event
(Hall et al., 2003). After an act of terrorism, most people will
experience some psychological stress, including an altered
sense of safety, hypervigilance, sadness, anger, fear, decreased
concentration, and difficulty sleeping. Others may alter their
behavior by traveling less, staying at home, avoiding public
events, keeping children out of school, or increasing smoking
and alcohol use. In a nationwide interview of 560 adults after
September 11, 2001, 90% reported at least one stress symptom
and 44% had several symptoms of stress (Schuster et al., 2001).
In New York state, almost half a million people reported
symptoms that would meet the criteria for acute PTSD. In
Manhattan, the estimated prevalence of acute PTSD was 11.2%,
increasing to 20% in people living close to the World Trade
Center (Galea et al., 2002: Schlenger et al., 2002).
The interventions developed by the PMH-APRN in collaboration
with the victim should address individual outcomes specific to
that victim. Victims experiencing head injuries or psychic
trauma after a disaster may have to be hospitalized. During a
disaster, a victim with a mental illness may experience
regression to his or her pretreatment condition and may require
short-term inpatient hospitalization.

13. Biologic Domain/Assessment – The PMH-APRN should assess
physical reactions that may involve many changes in body
functions, such as tachycardia, tachypnea, profuse perspiration,
nausea, vomiting, dilated pupils, and extreme shakiness.
Virtually any organ may be involved. Some victims may exhibit
panic reactions and loss of control and have a total disregard for
their personal safety. The victims may be suicidal or homicidal
and are at high risk for injuries that may include infection,
trauma, and head injuries (France, 2002).
Any physiological problems or injuries should be treated
quickly. During the emergency response, individuals will be
triaged to the appropriate level of care (see Table – Triage
Categories During a Mass Casualty Incident (MCI) below).
Victims who are primarily distressed and may have somatic
symptoms will be treated after those suffering from exposure
with critical injuries. All patients need to be reassured of the
caring and commitment of the PMH-APRN to their safety,
comfort, and well-being throughout the triage process. The
PMH-APRN is an integral member of the triage team. Many of
the same interventions used for persons experiencing stress or
crisis will be used for these victims.Triage Categories During a
Mass Casualty Incident (MCI)
Triage Category
Priority
Color
Typical Conditions
Immediate: Injuries are life-threatening but survivable with
minimal intervention. Individuals in this group can progress
rapidly to expectant if treatment is delayed.
1
Red
Sucking chest wound, airway obstruction secondary to
mechanical cause, shock, hemothorax, tension pneumothorax,
asphyxia, unstable chest and abdominal wounds, incomplete
amputations, open fractures of long bones, and 2nd/3rd degree
burns of 15%–40% total body surface area.

14. Delayed: Injuries are significant and require medical care, but
can wait hours without threat to life or limb. Individuals in this
group receive treatment only after immediate casualties are
treated.
2
Yellow
Stable abdominal wounds without evidence of significant
hemorrhage; soft tissue injuries; maxillofacial wounds without
airway compromise; vascular injuries with adequate collateral
circulation; genitourinary tract disruption; fractures requiring
open reduction, débridement, and external fixation; most eye
and CNS injuries.
Minimal: Injuries are minor and treatment can be delayed hours
to days. Individuals in this group should be moved away from
the main triage area.
3
Green
Upper extremity fractures, minor burns, sprains, small
lacerations without significant bleeding, behavioral disorders or
psychological disturbances.
Expectant: Injuries are extensive and chances of survival are
unlikely even with definitive care. Persons in this group should
be separated from other casualties, but not abandoned. Comfort
measures should be provided when possible
4
Black
Unresponsive patients with penetrating head wounds, high
spinal cord injuries, wounds involving multiple anatomical sites
and organs, 2nd/3rd degree burns in excess of 60% of body
surface area, seizures or vomiting within 24 hr after radiation
exposure, profound shock with multiple injuries, agonal
respirations; no pulse, no BP, pupils fixed and dilated.
Table is provided with permission by the United States military
Psychological Domain/Assessment – Therapeutic
communication is key to understanding the extent of the
psychological responses to a disaster and to establishing a

15. bridge of trust that communicates respect, commitment, and
acceptance. By developing rapport with the victim or victims,
the PMH-APRN communicates reassurance and support (Flynn
& Norwood, 2004).
The PMH-APRN should assess the victim for behaviors that
indicate a depressed state, presence of confusion, uncontrolled
weeping or screaming, disorientation, or aggressive behavior.
Ideally, thePMH-APRN should assess the coping strategies the
victim uses to normally manage stressful situations. The victims
may suffer from loss of feelings of well-being and various
psychological problems, including panic responses, anxiety, and
fear (Hall et al., 2003). In addition, the victims may
demonstrate behaviors indicative of acute stress disorder and
PTSD. The survivors of the disaster may experience traumatic
bereavement because of their feelings of guilt that they survived
the disaster (Ozer, Best, Lipsey, & Weiss, 2003). Responses to
psychological distress need to be differentiated from any
psychiatric illness that the person may be experiencing. A
response to a disaster may leave the person feeling
overwhelmed, incapacitated, and disoriented.
The ABCs of psychological first aid include focusing on A
(arousal), B (behavior), and C (cognition). When arousal is
present, the intervention goal is to decrease excitement by
providing safety, comfort, and consolation. When abnormal or
irrational behavior is present, survivors should be assisted to
function more effectively in the disaster and when cognitive
disorientation occurs, reality testing and clear information
should be provided. In the initial phases, the PMH-APRN
should assist the victim in focusing on the reality of problems
that are immediate, with specific goals that are consistent with
available resources, as well as the culture and lifestyle of the
victim.
After the initial interventions, the PMH-APRN should support
the development of resilience, coping, and recovery while
providing technical assistance, training, and consultation.
During the treatment process, it may become necessary to

16. administer an antianxiety medication or sedative, especially in
the early phases of recovery (Centers for Disease Control
[CDC], 2005; Dochterman, Butcher, & McCloskey-Bulechek,
2007). The goals of care include helping the victims prioritize
and match available resources with their needs, and preventing
further complications, monitoring the environment,
disseminating information, and implementing disease control
strategies (CDC, 2005; Noji, 2000).
Debriefing (the reconstruction of the traumatic events by the
victim) may be helpful for some. Long ago a common practice,
debriefing was believed to be necessary in order for the person
to develop a healthy perspective of the event and ultimately
prevent PTSD. However, current research does not support
debriefing as a useful treatment for the prevention of PTSD
after traumatic incidents; compulsory debriefing is not
recommended (Rose, Bisson, Churchill, & Wessely, 2006). If
the victim has symptoms of PTSD, referral to a mental health
clinic for additional evaluation and treatment is important.
The PMH-APRN should prepare the victim for recovery by
teaching about the effects of stress and helping the victim
identify personal strengths and coping skills. Positive coping
skills should be supported. The victims should be encouraged to
report any depression, anxiety, or interpersonal difficulty
during the recovery period. After most disasters, support groups
are established that help victims and their families deal with the
psychological effects of the disaster (Dochterman et al., 2007).
Women exhibit higher levels of distress than men after a
disaster, especially older women (Norris et al., 2002). Assess
the ages of the female victims, their capability to participate in
problem-solving activities related to the devastation left by the
disaster, and their level of self-confidence/self-esteem that
would allow each to participate as a team member or a team
leader in addressing the needs of others. This includes
encouraging the victims to do necessary chores and participate
in decision-making, and to take advantage of the opportunity to
serve as a leader or team member, as dictated by their abilities.

17. Educating the public and emphasizing the natural recovery
process is important. There are information gaps and rumors
that add to the anxiety and stress of the situation. By giving
information and direction, it will help the public and victims to
use the coping skills they already possess. Initially, the event
may leave individuals and families in a stage of ambiguity with
frantic disorganized behavior. In addition, individuals and
family members are concerned about their own physical and
psychological responses to the disastrous event. Children are
especially vulnerable to disasters and respond according to their
age and family experiences (Davidhizar & Shearer, 2005;
Hoven, Duarte, & Mandell, 2003). Traumatized children and
adolescents are high risk victims of a wide range of behavioral,
psychological, and neurological problems after experiencing
various traumatic events (Caffo, Forresi, & Lievers, 2005;
Davidhizar & Shearer, 2005).
When the PMH-APRN explains anticipated reactions and
behaviors, this helps the victims gain control and improve
coping. For example, after a major disaster, there may be
excessive worry, preoccupation with the event, and changes in
eating and sleeping patterns. With time, counseling, and group
work, these symptoms will lessen. Active coping strategies can
be presented in multiple media forums, such as television and
radio (Hall et al., 2003). After the initial shock, victims react by
trying to do something to resolve the situation. When victims
begin working to appropriately remedy the disaster situation,
their physical responses become less exaggerated and they are
more able to work with less tension and fear.
Social Domain/Assessment – The PMH-APRN should assess the
kind and severity of a natural or man-made disaster or terrorist
act to determine the capability of individuals and communities
to respond in a supportive way. The PMH-APRN should
maintain a calm demeanor, obtain and distribute information
about the disaster and the victims, and reunite victims and their
families. In addition, there is a need to monitor the news
media’s impact on the mental health of the victims of the crisis.

18. Sometimes, the persistence of the news media diminishes the
ability of the survivors to achieve closure to the crisis (Majer et
al., 2002). Constant rehearsal of the disaster in the newspapers
and on television can increase and prolong the severity or
initiate feelings of anxiety and depression.
In a disaster, the victims may experience economic distress
because of job loss and loss of other resources. This may
ultimately lead to psychological distress. In addition, acts of
aggression and other mental health problems may emerge
(Dooley, Prause, & Ham-Rowbottom, 2000; Bonanno, 2004).
Again, shelter, money, and food may not be available. The
absence of basic human needs such as food, a place to live, or
immediate transportation quickly becomes a priority that may
precipitate acts of violence.
The nursing interventions for the social domain include the
individual, family, and community. The individual should learn
about the community resources that can be made available.
Family support systems may need to be re-established. The
health care community should actively reach out to the media
and keep the press engaged. Direct attention to stories that
inform and help the public respond should be encouraged. There
are federal agencies that assist victims of disaster. This
assistance is available for individual, families, and
communities. One of those agencies is the Federal Emergency
Management Agency (FEMA). When a disaster occurs, FEMA
sends a team of specialists who review the devastation of
disaster. They provide counseling and mental health services ,
and arrange for many of the victims to access other services
needed for survival, including training programs. In addition,
the Substance Abuse and Mental Health Services Administration
(SAMHSA) of the Department of Health and Human Services
(DHHS) are available to assist both victims of and responders to
the disaster. When a disaster disrupts the victim’s social
network, other resources must be made available for social
support. The social support system provides an environment in
which the victims experience respect and caring from the

19. caregivers, the opportunity to ventilate and examine personal
feelings regarding the tragedy, as well as the opportunity to
begin the healing and recovery process (Everly, 2000).
Supporting the development of more contacts within the social
network can be done by organizing support groups within the
area of the disaster that address grief and loss, trauma,
psychoeducational needs, and substance abuse. In addition, the
PMH-APRN may refer the victims to nearby support groups or
religious groups that are appropriate to meet their needs
(Herman, Kaplan, & LeMelle, 2002).
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Figures
1. Figure 1: Crisis. Retrieved March 9, 2011 from http://www.e-
missions.net/ssa/teacher/webimages/logoBIG_CRISIS.gif
2. Figure 2: The World Trade Center on 9/11. Retrieved March
9, 2011 from http://www.dailymail.co.uk/tvshowbiz/article-
523729/9-11-attacks--says-French-best-actress-Oscar-
winner.html