crises, its types, phases and management of crises.

1. Ms. Sonali katoch

2. CRISIS
• A sudden event in one’s life that disturbs
homeostasis, during which usual coping
mechanisms cannot resolve the problem
(Lagerquist, 2006).

3. INTRODUCTION
• Urgent need for assistance
• Therapist becomes a part of the individual’s
life situation
• Unable to solve problems
• Requires guidance and support to help
mobilize the resources needed to resolve the
crisis.

4. CHARACTERISTICS
• Crisis occurs in all individuals at one time or another
and is not necessarily equated with psychopathology.
• Crises are precipitated by specific identifiable events.
• Crises are personal by nature. What may be considered
a crisis situation by one individual may not be so for
another.
• Crises are acute, not chronic, and will be resolved in
one way or another within a brief period.
• A crisis situation contains the potential for
psychological growth or deterioration.

5. CHARACTERISTICS OF A CRISIS
• Disorganised biological, cognitive, emotional and behavioural experiences
• The person in crisis becomes less able to perform problem solving and
interpret the circumstances of crisis event
• There will be as precipitating event of actual or perceived loss, threats of
losses or challenges
• There is a presence of both danger and opportunity. Crisis events bring
about complicated symptomology that defy cause and effect descriptions
and may not always be logical and cohesive
• Crisis carries seeds of both growth and change
• Crisis is universal and idiosyncratic: something is going to happen to
everyone, and it can be a matter of pure luck
• Crises are time-limited, and involve a precipitating event. They can be
situational as well as developmental
• Crisis brings about vulnerability and reduced defensiveness, as well as a
heightened state of suggestibility
• Crisis is not mental illness, and it should not be confused as such.

6. STAGES OF CRISIS DEVELOPMENT (TYHURST)
1. Period of impact: The individual realizes the actuality of the event.
2. Period of recoil: Distress resulting from the event becomes overwhelming and
the individual struggle to cope.
3. Posttraumatic period: The individual experience disruptions in normal
functioning. Kaplan describes a four phase’s paradigm to understand the
development of crisis:
– First phase: A traumatic event causes an initial rise in the individual’s level of anxiety.
The individual responds with familiar problem solving mechanics in an attempt to
reduce the stress and discomfort. If coping mechanisms are effective the crisis is
averted.
– Second phase: When the individuals usual problem solving abilities fail he enters the
second phase and the stimulus that caused the initial rise in the tension continues.
– Third phase: The individual’s anxiety continues to rise and the increased tension moves
the individual to reach out for assistance and use every available resource to solve the
problem and reduce the increasingly painful state of anxiety.
– Fourth stage: The state of active crisis results when integral strengths and social
supports are insufficient, the problem remains unresolved and tension and anxiety rise
to an unbearable level. The individual experiences the continuation of the crisis and
severe anxiety or panic predisposes him to psychological disorganization.

7. PHASES IN THE DEVELOPMENT
OF A CRISIS, Caplan (1964)
• Phase 1. The individual is exposed to a
precipitating stressor. Anxiety increases; previous
problem-solving techniques are employed.
• Phase 2. When previous problem-solving
techniques do not relieve the stressor, anxiety
increases further. The individual begins to feel a
great deal of discomfort at this point. Coping
techniques that have worked in the past are
attempted, only to create feelings of helplessness
when they are not successful. Feelings of
confusion and disorganization prevail.

8. PHASES IN THE DEVELOPMENT
OF A CRISIS, Caplan (1964)
• Phase 3. All possible resources, both internal and
external, are called on to resolve the problem and relieve
the discomfort. The individual may try to view the problem
from a different perspective, or even to overlook certain
aspects of it. New problem-solving techniques may be
used, and, if effectual, resolution may occur at this phase,
with the individual returning to a higher, a lower, or the
previous level of premorbid functioning.
• Phase 4. If resolution does not occur in previous phases,
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.” Anxiety may reach panic levels. Cognitive functions
are disordered, emotions are labile, and behavior may
reflect the presence of psychotic thinking.

9. PHASES IN THE DEVELOPMENT
OF A CRISIS, Caplan (1964)
• 1. The individual’s perception of the event. If the
event is perceived realistically, the individual is more
likely to draw on adequate resources to restore
equilibrium. If the perception of the event is distorted,
attempts at problem-solving are likely to be ineffective
and restoration of equilibrium goes unresolved.
• 2. The availability of situational supports. Situational
supports are those persons who are available in the
environment and who can be depended on to help
solve the problem. Without adequate situational
supports during a stressful situation, an individual is
most likely to feel overwhelmed and alone.

10. PHASES IN THE DEVELOPMENT
OF A CRISIS, Caplan (1964)
• 3. The availability of adequate coping mechanisms. When
a stressful situation occurs, individuals draw on behavioral
strategies that have been successful for them in the past. If
these coping strategies work, a crisis may be diverted. If
not, disequilibrium may continue and tension and anxiety
may increase. As previously set forth, it is assumed that
crises are acute, not chronic, situations that will be resolved
in one way or another within a brief period. Kaplan and
Sadock (1998) state, “A crisis is self-limited and can last
from a few hours to weeks. It is characterized by an initial
phase in which anxiety and tension rise, followed by a
phase in which problem-solving mechanisms are set in
motion.” Crises can become growth opportunities when
individuals learn new methods of coping that can be
preserved and used when similar stressors reoccur.

11. CRISIS INTERVENTION
• It is a time for doing what is needed to help the
individual get relief and for calling into action all the
people and other resources required to do so.
• Aguilera (1998) states: The goal of crisis intervention is
the resolution of an immediate crisis.
• Its focus is on the supportive, with the restoration of
the individual to his pre-crisis level of functioning or
possibly to a higher level of functioning.
• The therapist’s role is direct, supportive, and that of an
active participant.

12. CRISIS INTERVENTION
• Crisis intervention takes place in both inpatient and
outpatient settings.
• An orderly problem-solving techniques and structured
activities that are focused on change.
• Through adaptive change, crises are resolved, and
growth occurs.
• Crisis intervention, is not aimed at major personality
change or reconstruction (as may be the case in long-
term psychotherapy); its goal is using a given crisis
situation to, at the very least, restore functioning and,
at most, to enhance personal growth.

13. PHASES OF CRISIS INTERVENTION:
THE ROLE OF THE NURSE
Aguilera (1998) describes four specific phases
in the technique of crisis intervention. These
phases are clearly comparable to the steps of
the nursing process.

14. PHASE 1: ASSESSMENT
In this phase, the crisis helper gathers
information regarding the precipitating
stressor and the resulting crisis that prompted
the individual to seek professional help. A
nurse in crisis intervention might perform
some of the following assessments:

15. Cont…
• Ask the individual to describe the event that
precipitated this crisis.
• Determine when it occurred.
• Assess the individual’s physical and mental
status.
• Determine if the individual has experienced
this stressor before. If so, what methods of
coping were used? Have these methods been
tried this time?

16. Cont…
• If previous coping methods were tried, what was the
result?
• If new coping methods were tried, what was the result?
• Assess suicide or homicide potential, plan and means.
• Assess the adequacy of support systems.
• Determine level of pre-crisis functioning. Assess the usual
coping methods, available support systems, and ability to
solve problems.
• Assess the individual’s perception of personal strengths and
limitations.
• Assess the individual’s use of substances.

17. Cont…
Information from the comprehensive assessment is
then analyzed, and appropriate nursing diagnoses
reflecting the immediacy of the crisis are identified.
Some nursing diagnoses that may be relevant include:
 Ineffective
 Anxiety (severe to panic)
 Disturbed thought processes
 Risk for self-or-other-directed violence
 Rape-trauma syndrome
 Post-trauma response
 Fear

18. PHASE 2: PLANNING OF THERAPEUTIC
INTERVENTION
In the planning of the nursing process, the
nurse selects the appropriate nursing actions
for the identified nursing diagnoses. In
planning the interventions, the type of crisis
(as well as the individual’s strengths and
available resources for support) is taken into
consideration. Goals are established for crisis
resolution and a return to or increase in the
pre-crisis level of functioning.

19. PHASE 3: INTERVENTION
During phase 3, the actions that were
identified in phase 2 are implemented. The
following interventions are the focus of nursing in
crisis intervention:
 Uses a reality-oriented approach. The focus of the
problem is on the here and now.
 Remain with the individual who is experiencing panic
anxiety.
 Establish a rapid working relationship by showing
unconditional acceptance, by active listening, and by
attending to immediate needs.

20. Cont….
 Discourage lengthy explanations or
rationalizations of the situation; promote an
atmosphere for verbalization of true feelings.
 Set firm limits on aggressive, destructive
behaviors. At high levels of anxiety, behavior is
likely to be impulsive and regressive. Establish
at the outset what is acceptable and what is
not, and maintain consistency.

21. Cont….
 Clarify the problem the individual is facing. The
nurse does this by describing his or her
perception of the problem and comparing it with
the individual’s perception of the problem.
 Help the individual determine what he or she
believes precipitated the crisis.
 Acknowledge feelings of anger, guilt,
helplessness, and powerlessness, taking care to
avoid providing positive feedback for these
feelings.

22. Cont….
 Guide the individual through a problem-
solving process by which he or she may move
in the direction of positive life change:

23. Cont….
Help the individual confront the source of the
problem that is creating the crisis response.
Encourage the individual to discuss changes he or
she would like to make. Jointly determine whether
desired changes are realistic.
Encourage exploration of feelings about aspects
that cannot be changed, and explore alternative
ways of coping more adaptively in these
situations.

24. Cont…
Discuss alternative strategies for creating
changes that are realistically possible.
Weigh benefits and consequences of each
alternative.
Assist the individual to select alternative
coping strategies that will help alleviate future
crises.
 Identify external support systems and new
social networks from which the individual may
seek assistance in times of stress.

25. PHASE 4: EVALUATION OF CRISIS
RESOLUTION AND ANTICIPATORY
PLANNING
To evaluate the outcome of crisis intervention,
a reassessment is made to determine if the
stated objective was achieved:
• Have positive behavioral changes occurred?
• Has the individual developed more adaptive
coping strategies? Have they been effective?
• Has the individual grown from the experience
by gaining insight into his or her responses to
crises?

26. Cont….
• Does the individual believe that he or she
could respond with healthy adaptation in
future stressful situations to prevent crisis
development?
• Can the individual describe a plan of action for
dealing with stressors similar to the one that
precipitated this crisis?

27. Cont…
During the evaluation period, the nurse and
client summarize what has occurred during
the intervention.
They review what the individual has learned
and “anticipate” how he or she will respond in
the future.
A determination is made regarding follow-up
therapy; if needed, the nurse provides referral
information.

28. ROBERTS’ SEVEN-STAGE CRISIS
INTERVENTION MODEL
Stage I. Psychosocial and Lethality Assessment
• Conduct a rapid but thorough biopsychosocial
assessment.
Stage II. Rapidly Establish Rapport
• The counselor uses genuineness, respect, and
unconditional acceptance to establish rapport
with the client.
• Skills such as good eye contact, a nonjudgmental
attitude, flexibility, and maintaining a positive
mental attitude are important.

29. ROBERTS’ SEVEN-STAGE CRISIS
INTERVENTION MODEL
Stage III. Identify the Major Problems or Crisis Precipitants-
• Identify the precipitating event that has led the client to seek help at the
present time.
• Identify other situations that led up to the precipitating event.
• Prioritize major problems with which the client needs help.
• Discuss the client’s current style of coping, and offer assistance in areas
where modification would be helpful in resolving the present crisis and
preventing future crises.
Stage IV. Deal with Feelings and Emotions
• Encourage the client to vent feelings. Provide validation.
• Use therapeutic communication techniques to help the client explain his
or her story about the current crisis situation.
• Eventually, and cautiously, begin to challenge maladaptive beliefs and
behaviors, and help client adopt more rational and adaptive options.

30. ROBERTS’ SEVEN-STAGE CRISIS
INTERVENTION MODEL
Stage V. Generate and Explore Alternatives
• Collaboratively explore options with the client.
• Identify coping strategies that have been successful for the client in the past.
• Help the client problem-solve strategies for confronting the current crisis
adaptively.
Stage VI. Implement an Action Plan
• There is a shift at this stage from crisis to resolution.
• Develop a concrete plan of action to deal directly with the current crisis.
• Having a concrete plan restores the client’s equilibrium and psychological balance.
• Work through the meaning of the event that precipitated the crisis. How could it
have been prevented? What responses may have aggravated the situation?
Stage VII. Follow-Up
• Plan a follow-up visit with the client to evaluate the post-crisis status of the client.
• Beneficial scheduling of follow-up visits include 1-month and 1-year anniversaries
of the crisis event.

31. Suicide
• Crisis lines – Suicide (04424640050;
04427546669), child (1098), Sexual abuse (181),
HIV/AIDS (1098; 18001802008), Anti poison
(1066); cancer (9910516562); medical (104),
mental health (18602662345)
• Interpersonal violence
• Substance abuse and drug addiction
• Posttraumatic stress disorder
• The mentally ill on the streets

32. CRISIS LINES
• Suicide (04424640050; 04427546669)
• Child (1098)
• Sexual abuse (181)
• HIV/AIDS (1097; 18001802008)
• Anti poison (1066)
• Cancer (9910516562)
• Medical (104)
• Mental health (18602662345)

33. TYPES OF CRISIS
There are four types of crisis explained from the crisis
theory:
1. Situational crisis: This results from an external
environment or event influence that upsets the
individual or his bio-psycho-social environment. It is
characterized by a sudden, unexpected onset and
generally has a singular origin. Examples are
accidents, diagnosis of terminal illness etc.
2. Maturational crisis: This develops’ as a result of
developmental events, or life transitions requiring
significant rile changes. It can occur at unpredictable
stages of growth and development like infancy and
early childhood, preschool, puberty, adolescence,
adulthood and old age.

34. TYPES OF CRISIS
3. Adventitious crisis: It is described as accidental, uncommon and
expected tragedies that disrupt entire communities, often natural
disasters such as hurricanes earth quakes, floods, tsunami and fires.
Shock and generalized anxiety strike the entire community. Left
untreated the effects of theses crisis may lead to acute or post traumatic
stress disorder.
4. Socio Cultural Crisis: It is described as one rising from the cultural values
that are embedded in the social structure. The loss of a job or loss of
class is examples. Other incidents like rape, robbery and incest are also
socio cultural crisis.

35. MATURATIONAL CRISIS
• It is found that increased crisis potential
during development period is:
• Adolescent
• Marriage
• Parenthood
• Midlife
• Retirement

36. MATURATIONAL CRISIS-Adolescence
• Adolescence is a transition in to young
adulthood. An often definition of an adolescent
by an anonymous author is, ‘a toddler with
hormones and wheels’. Adolescents have many
issues to deal with and many choices to make.
Some of these issues that relate to self-esteem,
body image, peer relationship, educators, career
selection, establishing a set of values and ideals,
sexuality and sexual experimentation, drug and
alcohol abuse and physical appearance.

37. MATURATIONAL CRISIS-Adolescence
Nursing interventions:
• Focus on providing adolescent with support and
accurate information; ease the difficult transition
they are undergoing.
• Educational program that inform about and
validate bodily changes and emotional feelings
about which there may be some concerns.
• Educational program that inform about sexuality,
pregnancy, conception, sexually transmitted
disease.

38. MATURATIONAL CRISIS-Marriage
• Marriage is considered under risk population because
additional conflicts sometimes arise when the marriage is
influenced by crossover in religion, ethnicity, social status,
race, although these type of differences have become more
individually and socially acceptable than they were once.
• Nursing interventions:
• Education regarding what to expect at various stages in
marriage through rol-play about family situations in the
schools
• Encouraging honest communications in married couple
• Determining what each person expects the relationships
• Ascertaining whether each individual can accept
compromise

39. MATURATIONAL CRISIS-Parenthood
• It is unfortunate that parenting is one of the most
important positions an individual will hold in life
and one for which he/she is least prepared, and
coming of the child is a crisis and turning point in
couple’s life.
• Nursing interventions:
• Prepared child birth classes: What most likely will
happen but with additional information about
possible variations from what is expected.
• Information about what to expect after the baby
arrives
• Parent-infant bonding

40. MATURATIONAL CRISIS-Parenthood
• Parent-infant bonding
• Changing husband wife relationship
• Clothing and equipment
• Feeding – e.g. advantages/ disadvantages of breast
feeding, formula feeding etc.,
• Other expectations i.e. important for expectant parents
to receive anticipatory guidance about the infant’s
sleeping and crying pattern, bathing the infant, care of
cord etc…
• Explain the expected behaviour in each stage of growth
and development of the child.
• Educational programmes that inform about the use
and abuse of alcohol and other drugs.

41. MATURATIONAL CRISIS-Middle life
• Midlife crisis has been identified with three broad
categories.
1. An alteration in perception of self: One’s perception of
self may occur slowly. One may suddenly become aware
of being old, middle aged e.g. menopausal period.
2. An alteration in the perception of others: A change in the
relationship with adult children requires a sensitive shift
in caring.
3. An alteration in the perception of time: Middle age has
been defined as the end of youth and the beginning of the
old age. Individuals often experience a sense that time is
running out. Depression and sense of loss may occur as
individuals realize that some of the goals established in
their youth go unmet.

42. MATURATIONAL CRISIS-Middle life
• Nursing interventions:
• Nutritional classes to inform individuals in this age
group about the essentials of diet and exercise.
Educational materials on how to avoid obesity to
reduce weight can be included, along with important of
good nutrition.
• Assistance with ways to improve health e.g. quit
smoking, cease/reduce alcohol consumption and
reduce fat intake.
• Discussions on the important of having regular physical
examination including pap and breast examination for
women and prostate examination for men, monthly
breast self examination should be taught and early
mammograms encouraged.

43. MATURATIONAL CRISIS-Middle life
Nursing interventions:
• Classes on menopause should be given, provide
information about what to expect. Myths that
bound regarding this topic should be expelled.
Support groups for women undergoing the
menopausal experiences should be formed.
• Support and information related to care of aging
parents should be given. Individuals should be
referred to community resources for respite and
assistance before strain of the caregiver role
threatens to disrupt the family system.

44. MATURATIONAL CRISIS-Retirement
• Retirement which is often anticipated as an
achievement in principle may meet a great
deal of ambivalence when it actually occurs.
Our society places a great deal of importance
on productivity and on earning as much
money as possible at young age as possible.
These types of values contribute to the
ambivalence associated with retirement.
Adjustment to this life cycle event becomes
more difficult in the face of societal values
that are in direct conflict with new life style.

45. SITUATIONAL CRISIS
• Situational crisis are acute responses that
occur as a result of an external circumstantial
stressor.
• The number and type of situational stressors
are limitless and may be real/ exist only in the
perception of the individual.
• Some type of situational crisis that put
individuals at risk for mental illness includes
the following:

46. SITUATIONAL CRISIS
1. Poverty:
• A number of studies have identified as a direct co-relation to emotional
illness. This may have to do with the direct consequences of poverty such
as inadequate and crowded living conditions, nutritional deficiencies,
medical neglect, and unemployment/being homeless.
2. High rate of life change events:
• Miller and Retie found that frequent changes in life patterns due to large
number of significant events occurring in close proximity tend to decrease
person’s ability to deal with stress, and physical/emotional illness may be
result. These includes life change events such as death of loved one,
divorce, fired from job, change in living conditions, change in place or
employment/residence, physical illness or change in body image as a
result of loss of body part or functions.

47. SITUATIONAL CRISIS
3. Environmental conditions:
• Environmental conditions can create
situational crisis. Tsunami, floods, hurricanes
and earthquakes have wrecked devastation on
thousands of individuals and families in recent
years.

48. SITUATIONAL CRISIS
4. Trauma: Individuals who have experienced traumatic experiences must be
considered at risk for emotional illness. Guide the individuals through a problem
solving process by which he/she may move in the direction of positive life
changes.
• Help the individual the sources of the problem that is creating the crisis response.
• Encourage the individual to discuss changes he/she would like to make. Jointly
determine whether desired changes are realistic.
• Encourage exploration of feelings about aspects that cannot be changed, and
explore alternative ways of coping more adaptively in this situations.

49. SITUATIONAL CRISIS
• Encourage exploration of feelings about aspects that cannot
be changed, and explore alternative ways of coping more
adaptively in this situations.
• Discuss alternative strategies for creating changes that are
realistically possible.
• Weigh benefits and consequences of each alternative.
• Assist the individual to select alternative coping strategies
that will help alleviate future crisis.
• Identify external support systems and social networks from
which the individual may seek the assistance in times of crisis.

50. SITUATIONAL CRISIS
4. Trauma: Individuals who have experienced traumatic
experiences must be considered at risk for emotional illness.
Guide the individuals through a problem solving process by
which he/she may move in the direction of positive life
changes.
• Help the individual the sources of the problem that is creating
the crisis response.
• Encourage the individual to discuss changes he/she would like
to make. Jointly determine whether desired changes are
realistic.
• Encourage exploration of feelings about aspects that cannot
be changed, and explore alternative ways of coping more
adaptively in this situations.

51. SITUATIONAL CRISIS
4. Trauma:
Discuss alternative strategies for creating changes that
are realistically possible.
• Weigh benefits and consequences of each
alternative.
• Assist the individual to select alternative coping
strategies that will help alleviate future crisis.
• Identify external support systems and social
networks from which the individual may seek the
assistance in times of crisis.

52. THANKYOU
52