Recognising a Crisis


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Delivered in 2011

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  • Now we all recognise these scenes, we have of our own personal recollections and memories as some of these unfolded here in the UK and across the world and our emotions were all affected in different ways I am sure. These are sometimes called "Humanitarian emergency", "man-made disaster", and "complex emergency" which call for action and intervention to prevent future situations escalating again….now in a way that is no different in a sense of how we would work with individual crisis situations I am guessing, at least that would be our underlying fundamental principles. Shocking as these situations and for those involved indirectly, directly there is probably post traumatic issues in abundance today we are going to look much more focused at what we mean by crisis, so here are the objectives…..
  • First thing first – what is a crisis? – lets do this slightly differently, in pairs, take turns to explain to each other what you think ‘crisis’ means. Within mental health debate is big about what is a mental health crisis, theories of what a crisis is are pretty inconsistent. Crisis was first used as a specific term in psychiatry by Gerald Caplan, after considering earlier evidence that survivors of severe trauma of a nightclub fire in Boston in 1942, had much better outcomes from immediate psychiatric help. He said in these situations people were upset, provoked and a person’s likelihood of making life decisions were impaired. Apparently from the Greek meaning turning point or judgement, but also from the Latin meaning decision, to decide.
  • Tricky, its not all the same thing, but it does blend in and inform each thing, for example, a crisis situation could well turn into a more serious problem, depression, anxiety and what some call ‘adjustment disorder ’ - significant emotional or behavioural symptoms in response to an identifiable psychological stress, generally, it shouldn’t cause significant or lasting problems socially for example. Stress - Stress and crisis do have a relationship, we all face stress as part of our human condition. Not all stressful experiences produce crises but at the same time stress may be linked to crises, or even more complex problems.
  • Developmental – Life changes and transitions Situational – Cultural maybe, social and specific Complex – Not part of our everyday experience, much harder to overcome
  • What I would like you to do is to list as many situations under these headings that may lead someone to be in a crisis situation…. PAIRS
  • These are transitions, stages of life that we all go through, marked by clearly defined moments etc. They are crises because they can be periods of severe and prolonged stress at these junctions. In some cultures there is a further element whereby people believe strongly that they have a role in the after life spirtually and this is also considered to be a tranistion or development stage in life. Any others?
  • Psychologists often refer to these as accidental crises, they are usually cultural and rely on specific situations. Any others?
  • Trauma - Violent assualt or abuse, and man made or natrual disasters Mental Illness- If someone has an exisiting mental health condition a decline in a persons health and coping can precipiate a state of crisis, that’s obvious isnt it, its complex as there are a number of mental health realted problems that can place people in a state of crisis, severe anxiety, depression, psychoses, eating distress etc. Important to note that these crises are not singular events insolation, they are often inter linked and related and can inform one another, a mental illness crisis point can affect development, development such as transition into adulthood can increase stress upon someone who may already have a signioficant mental illness.
  • Midlife crisis is a term coined in 1965 by Elliott Jaques and used in Western societies to describe a period of dramatic self-doubt that is felt by some individuals in the "middle years" or middle age of life, as a result of sensing the passing of their own youth and the imminence of their old age. Now we might chuckle about this and in some ways it is amusing, hence the picture,however common triggers such as the death of parents or other causes of grief , unemployment or underemployment, realizing that a job or career is hated but not knowing how else to earn an equivalent living, or children leaving home can have an have a dramatic effect upon a person Has anyone heard of what is called an existential crisis ??... Where an individual questions the very foundations of his or her life, similar in my opinion to a mid life crisis but perhaps with more philosophical questions surrounding mortality, purpose and meaning of life, aspects of freedom, a lot of the situational factors we dicussed can give rise to this. but lets look more globally at the types of crisis.
  • High and Low Level Crises Acute – sudden detertiation, possibly leading to self injury, suicidal intent, danger to self and maybe to others, likely to have a major mental illness, schizophrenia, bi polar, severe depression, extreme anxiety and usually in connection with secondary mh services and may at some point have had a period of inpatient admission. Early on set psychosis and other problems may be catergorised as acute crisis situations. What do we mean??? - FLIPCHART Non acute – period, episode of mental distress, painful, out of control, unmangeable, may not require any specialist help, instead a person turns primarily to something such as a support line, GP, friends and family to gain support until the crisis point is passed, that doesn’t mean to say that people who are acutely unwell might not also do this too. This is just an exercise in producing 2 definitions.
  • There are typically three phases in a person's response to a crisis: The Impact phase : the initial response to the crisis consists of an alarm phase, classic stress stuff, the basic purpose of this stage is to prepare the body for immediate action: energy is mobilized to cope with the emergency, real or imagined, and your physical capabilities are heightened for speed or power. a mobilization phase, interpretation of stressors affects our ability to cope with stress. Our beliefs, attitudes, and values determine how we interpret and react to potentially stressful situations. If we tend to see those situations as threats, pressures, demands, or catastrophes, we compromise our ability to cope. , and an action phase. The Aftermath (or Let Down) phase : the aftermath of any event can last for days or months deending on the nature of the event, occurrence and on the impact on the individual which will differ greatly. The Recovery phase : this is the transition back to normality, re-engaging with roles and activities in our work and social lives etc.
  • This steady state might also be described as ‘euthymic’, can anyone remember what that is?, symptomless period.
  • Think about a time you had a crisis or a very stressful situation, what happened to you physically during each of the phases three phases and also what happened to you emotionally and how did you behave. Do individually but then speak to the person next to you and share your experiences then we will ask a handful of people to talk to the group if people are comfortable with that. IMPACT AFTERMATH RECOVERY
  • Typical physical reactions include: The Impact Phase Rapid heart rate, difficulty breathing, sweating, nausea, diarrhea. Typical emotional and cognitive responses include: The Impact Phase Excitement, anxiety, fear, irritability, denial, raring thoughts, confusion, hyper-alertness, sense of helplessness, euphoria, feeling high and excited The Impact Phase hyperactivity, immobilization, angry outbursts, shock and disbelief,injustice, why??, why me?
  • The Aftermath Phase Fatigue, lack of energy, sleep disturbance, aches and pains The Aftermath Phase Depression, sadness, guilt, anger, mood swings, shame – for the reaction, for being helpless and needy of others, grief, recurrent thoughts, flashbacks, poor concentration – at this stage there maybe overuse of alcohol or drugs, caffeine intake to cope with tension but in reality will prolong recovery. The Aftermath Phase avoidance, random activity, work inefficiency
  • The Recovery Phase Return of energy, normalization of sleep and appetite The Recovery Phase Stabilization of moods, ability to feel pleasure and joy, increased interest in other things, improved thinking. The Recovery Phase increased socialization, more goal-directed activity
  • Lets just be clear, a crisis can be a terribly upsetting experience for someone which if not supported correctly they will run the risk of further mental health problems. But, it can be positive too, in what way???. some say cathartic,from the Greek, meaning cleansing the emotions, benefits, accepting the past, going forward with new enthusiasm, access to some treatment, e.g. counselling. Crisis as a crisis point can often mean a change in direction…..
  • Case Studies For one day only, today!, lets just pretend we are manning a crisis line!,ok, you are all support workers working for KY MH Line, so we work with 18 – 65 year olds, the wide brief is that we take calls from anyone with a mental health problem or anyone that is having a personal crisis, off we go!! Box, pull a case study out and in twos dicuss your response.
  • Most of us will find ourselves working with someone who is in a state of emotional crisis. They are all different circumstances, and they are all challenging in different ways. Let's face it, we all have baggage.  Some of us just carry it in more public place is all. Observable Behaviour – Is it ok to ask what's going on?, esp when we see clearly something is wrong, show concern, say what you see, esp if you see a build up which may reach crisis point. Assess for suicide or self harm - When helping a person going through a mental health crisis, it is important look for signs of suicidal thoughts and behaviors and/or non-suicidal self-injury, e.g. Threatening to hurt or kill oneself, Appearing agitated or angry, Seeking access to means to hurt or kill oneself – what do we do in these circumstances??, is there a protocol?, what duties do you have as staff supporting people here? Non Judgmental - It may seem simple, but the ability to listen and have a meaningful conversation with an individual requires skill and patience.  It is important to make an individual feel respected, accepted, and understood and validated, sometimes that’s what people are after, validation that they are suffering, that they are at crisis point, the answers may well not be there. Give reassurance and information - It is important for individuals to recognize that mental illnesses are real, treatable illnesses from which people can and do recover.  When having a conversation with someone whom you believe may be experiencing symptoms of a mental illness, it is important to approach the conversation with respect and dignity for that individual and to not blame the individual for his or her symptoms. Encourage self support and help – exercise, relaxation, self help books and information, anxiety techniques, breathing, cognitive thought exercises, engaging with friends and family, not everyone will be responsive in the same way, so for people you work with and know you will know the distractions and techniques that work for them, for others that you know less well it will be a process of discovery, trial and error. Allow tension – Sometimes allowing or even encouraging a tolerable degree of arousal, tension or dependence for a limited time is sometimes functional in promoting crisis resolution, this maybe easier to do if you know the person. Example – swearing on the phone…allowed it…. Personal Strengths – Sometimes it is useful to affirm what strengths a person has to see things in a more positive light, that often needs facilitated, often a person in crisis can find it difficult if not impossible to do this is on their own, guidance is needed. Example – Affirmations. Goals for intervention – Help someone create a list of the most important specific goals for the crisis intervention which are realistic and achievable within a limited time frame, may need discussion with other services that maybe involved and part of a consistent care plan etc.
  • Some of these things are more about what you might look at doing to help someone manage and avoid a future crisis. Spend more time – Increase contact, offer extra time to talk and support, talking about experiences can help, being listened to can help. Encourage someone to be open to the support. Promote ownership – That is encourage and motivate someone to take control of their own decisions during a crisis and to own this essentially. The aim here is to promote communication skills and coping skills, so in the future the person is better at coping without the need to ask for help. Important Goals -A small list of the most important specific goals for the crisis intervention which are realistic and achievable could be agreed with the person and with others involved. Would need to be reviewed. Doing things – Encouragement to engage in something meaningful can help, exercise, proper diet, some recreational activity, this will help people physically aswell as mentally. Privacy – Its important for someone to find some reflective space in which to be alone with their thoughts and feelings and work things out without the pressure from someone else, blend of this and support. Help facing reality – Encouraging someone to look realistically at their situation, coming to terms, for example if it is grief, returning to the scene, going to the funeral, consolidating the loss and planning to move forward. Or if its stress at work, might be realistic to consider that changes may not be in the persons control and therefore decisions need to be reached about the future, i.e. find another job, redeployment etc.
  • What is available to someone….in your area, what do you know of…?? May include… GP – Could be gateway to psychiatric help, medication, counselling. There are 24 hrs out of hours GP’s, some GPs are very knowledgable when it comes to mental health crises others are less aware and therein lies a problem!. CMHT – CPN’s, for example can assist with people who are known to services etc. Psychiatrists and psychology services and talking treatments are also available in many teams. Crisis Resolution – crisis resolution and home treatment is the full name, what do they do?? – the good news is the service is for people known to services and those who are not, the teams should work hard to prevent admission to hospital but they do provide access to it too. GP or Psychiatrist can refer, but also relative / carer and the person expericing difficulties themselves. Also there should be a crisis line?. A and E / Casualty – Sometimes staff can refer on to other services from there. Can be lenghty wait and a and e can be very busy and chaotic which might increase a person’s stress and anxiety. NHS Direct – They could ring the GP and request a home visit, in some areas can also talk with specialist mental health services. Crisis Lines – Differ from place to place, our area – crisis call, the samaritans, others are run by organisations such as MIND, and Sane, sane line for example. Internet – Good and bad, the incident in wales and facebook is a bad example but there are a number of specific blogs, support groups and services on line and since this is the way we seem to communicate these days then it may well be a viable option for some. Anything else to your knowledge in your area???
  • The MH Act gives the nearest relative of someone who suffering from a mental illness the right to request an approved SW to assess the person to see if they need further treatment or assessment. An approved SW and 2 doctors do have the right to section someone under the act, last resort stuff, and obviously this action could have a negative effect on the person’s relationship with his or her carer or friend etc ( Section 13, paragraph 4 ) Also, it might be worth reading more about the Mental Capacity Act 2005, It makes it clear who can make decisions for people who are unable to themselves and in what situations decisions can be made. It also allows people to plan ahead in case of a time where they may lose capacity. Really we are talking about people with severe symptoms during an episode of mental illness, for example delusions, very high or very low mood.
  • Recognising a Crisis

    1. 1. Kaleidoscope YorkshireRecognising a Crisis
    2. 2. Objectives• Defining what we mean by ‘crisis’• Recognise different types of crises• Examine what we mean by ‘mental health crisis’ in more detail• Explore the typical stages of a crisis• Consider a personal crisis of our own with regard to the above• Examine some case studies• Consider aspects of supporting someone in crisis• Examine what services might be available
    3. 3. What is a crisis?• A brief psychological response to severe stress (Rosen, 1998)• A situation in which you are confronted with circumstances outside your usual life experience and outside of your control• An emotional state where someone requires urgent help (MIND )
    4. 4. Is there a difference between a crisis and an emergency?• EMERGENCY – A life- threatening situation demanding an immediate response.• CRISIS - Often not immediately life- threatening
    5. 5. Crisis, stress, mentalhealth, they are the same things, right?• Adjustment Disorder• Stress
    6. 6. Types of Crisis DevelopmentalSituational Complex
    7. 7. • Developmental – Life changes and transitions.• Situational – Cultural maybe, social and specific• Complex – Not part of our our everyday experience, much harder to overcome.
    8. 8. Developmental• Becoming an adult• Starting, forming, keeping relationships• Becoming old• Dying
    9. 9. Situational• Loss job, unemployment• Loss of income or home• Accident• Burglary• Grief and loss• Loss of relationship (e.g. divorce)
    10. 10. Complex• Trauma• Mental Illness
    11. 11. Mental Health Crisis• Acute• Non acute
    12. 12. Crisis Phases• 3 Typical Phases Impact Aftermath Recovery
    13. 13. Rosen, 1998
    14. 14. What about you?
    15. 15. Some Typical Responses• IMPACT• Physical – Heart rate, breathing, sweating, nausea• Emotional – Excitement, fear, confusion, denial, shock, euphoria• Behavioural – Hyperactivity, immobility, anger
    16. 16. Cont….• AFTERMATH• Physical – Fatigue, no energy, sleep, pain• Emotional - Depression, guilt, anger, mood, shame• Behavioural – Avoidance, inefficiency, random activity
    17. 17. Cont…..• RECOVERY• Physical – Energy, sleep, appetite• Emotional – Stability, pleasure, interest, improved thinking• Behavioural – Socialising, goal directed activity, hope
    18. 18. Can experiencing a crisis be positive?• Yes or No?
    19. 19. Kaleidoscope YorkshireMental Health Crisis Line
    20. 20. How would you deal with someone having a crisis• Talk about observable behaviour• Assess for suicide or self harm• Non judgmental• Give reassurance and information• Encourage self support and help• Allowing the tension• Personal strengths• Goals for intervention
    21. 21. Other supportive ideas• Spend more time• Promote ownership• Doing things• Privacy• Help facing reality
    22. 22. Support Services• Professional services• GP• CMHT• Crisis Resolution• A & E / Casualty• NHS Direct• Crisis lines• Internet resources
    23. 23. The Mental Health Act