Nursing students in all format psychiatric and mental health studies

1. Crisis Intervention
Mr. D.Elakkuvana..

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

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

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

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

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

7. • Phases 4: If resolution does not occur in
previous phases, caplan states that “ the
tension mounts beyond a further threshold
or its burden increases over time to a
breaking point. Major disorganization of the
individual with drastic results often occurs”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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