crisis and its intervention

1. Mrs.Alka kapri
m.Sc nursing
State college of nursing

2. Barry Kidd 2010 2
DEFINITION
A crisis is an overwhelming reaction to a
threatening situation in which a person’s usual
problem solving strategies fail to resolve the
situation resulting in a state of disequilibrium.

3.  Internal disturbances that result from a stressful
event or a perceived threat to self.
 .Greek--word "crisis" is derived from the word
"krinen"--to decide.
 .Chinese--2 characters used to denote crisis; one is
character for danger, the other character
 for opportunity.
 .Crises are an inevitable part of human existence.
 .Any stressful event can trigger a crisis, depending on
the individual's perception of the event,
 coping skills and support system.
 .A crisis is a period of increased vulnerability that
may lead to growth of an individual.

4.  .All crises are experienced as "sudden" to the
individual or family. They were unaware of
warning signals and unprepared for the event.
 The crises is often experienced as ultimately life-
threatening, whether hat perception is realistic or
not.
 Communication with significant others is often
decreased or cut off.
 There may be perceived or real displacement
from familiar surroundings or significant loved
ones.
 All crises have an aspect of loss, whether actual
or perceived.

5. Transitional (maturational
and anticipated) crisis
 .Precipitated by the normal stress created during social,
psychological, and behavioral changes
 associated with transitions. These crises are anticipated
and can be prepared for.
 .Universal transition states:
 .Normal transitions of human development.
 .Predictable and occurs gradually.
 .Each stage is characterized by unique stressors and tasks
to accomplish.
 .Failure at one stage compromises the next stage of
development.

6.  Non-universal transition states:
 .Includes changes such as marriage, retirement,
student to worker.
 .Crises occur when the individual cannot adapt to
functioning at the new level.
 .Crisis may occur if the individual:
 .Is not able to visualize a new role.
 .Experiences two or more life changes or events
suddenly.
 .Lacks interpersonal resources to make necessary
changes.
 .Has significant persons refusing to acknowledge the
individual's new role.

7.  .Can originate from material or environmental
sources (disaster), personal or physical sources
(illness), and interpersonal or social sources
(divorce, death).
 .Occurs in response to a traumatic event that is
usually sudden and unavoidable.
 .Can produce threat of loss or loss of a role
necessary to maintain one's self image.
 .May challenge every coping mechanism,
especially if it is an uncommon or unexpected
event
 involving multiple losses or gross environmental
changes.

8.  .Phases of human disaster responses:
 .Impact phase
 .Includes the event itself.
 .Characterized by shock, panic, or extreme fear.
 .Judgment and assessmenot f reality are poor.
 .Heroic phase
 .Cooperative spirit between friends, neighbors and emergency teams.
 .Constructive activity can help overcome feelings of anxiety and
depression.
 .Over-activity can lead to burn-out.
 .Honeymoon phase
 .Appears one to several months after disaster.
 .Money, resources and support received cause daily life to begin again.
 .Psychological and behavioral problems may be overlooked.

9.  Disillusionment phase
 .Lasts two months to one year.
 .A time of disappointment, resentment,
frustration and anger.
 .Victims compare others to their own plights;
may experience resentment and show
 hostility toward others.
 Reconstruction and reorganization phase
 .May last for years.
 .Individuals begin to come to grip with their own
problems.
 .They begin to re-build their lives, homes,
businesses

10.  .Can originate from cultural and social
sources (loss of a job due to discrimination,
being a victim of deviant acts of others or
behaviors that violate social norms).
 .Often are less amenable to control by
individuals.
 .Community or government action may be a
component of identification and resolution of
the Crisis.

11.  .Precrisis Stage--individual maintains equilibrium through
use of coping skills during minor stressors.
 .Crisis Stage
 .Individual perceives an event as threatening to life goals
and unmanageable based on current coping mechanisms.
 .Leads to increased anxiety, tension, and disorganization.
 .Lasts no longer than six weeks since much energy is
expended.
 .Postcrisis Stage--may result in positive or negative state.
 .Positive state--develops new equilibrium and functioning
(a better social network,nproblem solving abilities,
improved self-image).
 .Negative state-loses skills, regresses or develops socially
unacceptable behaviors.

12. 12
Crisis- good
outcome
1. Perception of
event realistic
2. Situational
support adequate
3. Coping
mechanism
adequate
No crisis
Crisis- development
1. Perception of event
distorted
2. Situational support
inadequate
3. Coping
mechanisms
inadequate
Crisis

13. Barry Kidd 2010 13
STRESS ANXIETY
USUAL COPING
MECHANISMS
INEFFECTIVE
TRIAL & ERROR
SOLUTIONS
SEVERE
ANXIETY
PERSONALITY
DISORGANIZATION
(CRISIS)
OR
NEW PROBLEM- SOLVING
SOLUTIONS AND SUPPORT
ANXIETY
PRE-CRISIS LEVEL OF
FUNCTIONING

14.  Anxiety
 .Depression
 .Confusion
 .Anger
 .Helplessness
 .Withdrawal
 .Somatic symptoms
 .Inefficiency
 .Hopelessness

15. Crisis intervention is an action-oriented model
that is present-focused, with the objective for
the intervention being specific to the
hazardous event, situation, or problem that
precipitated the state of crisis
Crisis intervention focus on the Here and
now and only addresses past issues when
needed.

16. Dr. Eric Lindemann was one of the pioneers of
crisis intervention.
Dr Lindemanns pioneering study on the loss and
bereavement with 101 survivors and family
members of the victims of the Coconut Grove
nightclub fire in Boston was one of the first
efforts to develop a more systematic way of
helping people in crisis.
Through his research, theories of grief process and
typical reactions to crisis were developed.

17.  Crisis intervention derived from ego
psychology and ecological systems theory.
Below are the ideas that were derived from
these two systems.
Ego:
Life
Development
stages
Psychosocial
crisis
Coping
skills
Defense
mechanism
Ecological:
Homeostasi
s
Disequilibriu
m
Interdep
endence

18.  Two important concepts in crisis intervention
include:
Levels of crisis & Stages of Crisis
 Level of crisis include: Somatic Distress,
Transitional Stress Crisis, Traumatic Stress Crisis,
Family Crisis, Serious Mental Illness, Psychiatric
Emergencies, and Catastrophic Crisis
 Stages of Crisis include: Outcry, Denial or
Intrusiveness, Working Through, and Completion
or Resolution

19. • Ann Wolbert Burgess and Albert R. Roberts
developed the model for assessing emotional
stress and acute crisis using seven main
levels of crisis along a stress-crisis
continuum.
 Although each crisis is unique, this stress-
crisis continuum can be used in assessment
and intervention planning to determine the
level of care that is needed, as well as the
most effective treatment modality.

20.  Level 1: Somatic Distress- Biomedical causes, situational
problems, health problems, relationship conflicts, work-related
stressors, chemical dependency issue
 Level 2: Transitional Stress Crisis- Stressful events
that are expected in part of one’s lifespan development.
Examples include premature birth, bankruptcy, divorce,
relocation
 Level 3: Traumatic Stress Crisis- Unexpected and/or
accidental situations outside the individuals locus of control.
Crisis can be life threatening. Examples include disasters, crime
victimization, family violence, child abuse, sexual assault
 Level 4: Family Crisis- Issues related with interpersonal
and family relationships that are unresolved and harmful
psychologically, emotionally, and physically. Examples include
child abuse, family violence, homelessness, and parental
kidnapping

21.  Level 5: Serious Mental Illness- relates from
preexisting psychopathology. Examples include
schizophrenia, dementia, and major depression
 Level 6: Psychiatric Emergencies-When situations
in which general functioning have been severely impaired.
Examples include a drug overdose, suicide attempts, or the
acute onset of a major mental illness
 Level 7- Catastrophic Crisis- This level involves 2
or more level 3 traumatic crisis in combination with level 4,5,
or 6 stressors. Examples include loosing all family members
in a disaster or multiple homicides

22. The stages of crisis resemble the stages of the
grief process. Individuals can skip a stage,
can get stuck in a stage, or can even move
back and forth throughout the stages.
The four stages of crisis include: outcry, denial
or intrusiveness, working trough, and
completion or resolution.

23.  Outcry: The earliest reactions after the crisis event, which
are reflexive, emotional, and behavioral. The reactions can
very depending on the person. Some examples include panic,
screaming, shock, anger, defensiveness, moaning, flat affect,
crying, and hyperventilation.
 Denial or Intrusiveness: Outcry can lead to denial,
which eliminates the impacts of the crisis through emotional
numbing, dissociation, cognitive distortion, or minimizing.
Outcry can also lead to intrusiveness , which includes the
involuntary flooding of feelings about the crisis, such as
flashbacks, nightmares, and automatic thoughts.

24.  Working Through: This is the stage of recovery or
healing in which thoughts, feelings, and images of the crisis
are expressed, acknowledged, explored, and reprocessed
through adaptive and healthy coping skills.
 Completion or Resolution: This stage can take
months or even years to complete. Some individuals may
never even complete this process. This process allows the
individual to reorganize their life, and use the resolution of
the trauma in positive meanings of growth or change. Many
crisis survivors reach out through volunteer work to help
others who suffer similar traumas.

25. The ACT model is a conceptual three-stage
framework and intervention model.
This model amalgamates various assessment
and triage protocols with three primary crisis
intervention strategies: the seven stage crisis
intervention model, critical incident stress
management, and the 10-step acute
traumatic stress management protocol.

26. A: Assessment/appraisal of immediate medical needs, threats to
public safety and property damage
-Triage assessment, crisis assessment, trauma assessment,
and the biopsychosocial and cultural assessment protocols
C: Connecting to support groups, the delivery of disaster relief
and social services, and critical incident stress debriefing
-Crisis intervention implemented through a strengths
perspective and coping skills bolstered
T: Traumatic stress reactions and posttraumatic stress disorders
-Ten step acute trauma and stress management protocol,
trauma treatment plans, and recovery strategies implemented

27. Seven-stage crisis intervention model is
effective when dealing with a diverse
population, and when dealing with traumatic
situations.
This model adapts easily to different level of
crisis and to different timeframes for
intervention.
All of these stages can be completed within
one contact if necessary.

28. (7) Establish Follow-Up Plan and Agreement
(6) Develop and Formulate an Action Plan
(5) Generate and Explore Alternatives
(4) Deal with Feelings and Emotions
(3) Identify Major Problems
(2) Establish Rapport and Rapidly Establish
Relationship
(1) Plan and Conduct a Crisis Assessment

29.  Stage 1: Plan and Conduct a Crisis Assessment: When
conducting an assessment the crisis worker needs to evaluate
how severe the crisis is, the emotional state of the client, the
clients immediate psychosocial needs, and the level of the
client’s current coping skills and resources.
 Stage 2: Establish Rapport: This can be done in stage 1.
This stage involves the initial contact between the client and the
crisis worker. The main goal is to establish rapport with the
client by being genuine. Active listening and empathetic
communication are important to be successful at establishing
rapport. Crisis workers must be conscious of their own body
language and facial expressions because trauma survivors may
be sensitive to physical space and body movements. Being
observant of the survivors physical and facial reactions can give
insight to the workers level of engagement with the client.

30.  Stage 3: Identify the Major Problem: The crisis worker
should help the survivor arrange the most important
problems by identifying the problems by how they affect the
survivors current status. The crisis worker must make sure
not to overwhelm the survivor while focusing on the most
important problems needing intervention.
 Stage 4: Deal with Feelings and Emotions: During this
stage the clients primary task is ventilation and exploration of
his or her feelings about the crisis. The crisis worker should
be actively listening to the survivor. It is necessary for the
crisis worker to demonstrate empathy when with the survivor.
The crisis worker must also be aware of his or her own
emotions and levels of comfort when helping clients. Crisis
workers should also attend to their own self-care to prevent
burn out.

31.  Stage 5: Generate and Explore Alternatives: In this stage
the crisis worker will work with survivor to explore alternatives
for restoring a precise level of functioning. Some alternatives
would include using support systems, developing coping skills,
and increasing positive thinking to reduce the survivors anxiety
and stress.
 Stage 6: Develop and Formulate an Action Plan: The main
goals are to help the survivor achieve an appropriate level of
functioning and maintain adaptive coping skills and resources.
The survivor must feel ownership in the treatment plan.
Termination should begin when the client has met their goals of
their action plan or has been referred for additional services.
 Stage 7: Establish Follow-Up Plan and Agreement: This
stage helps determine if the desired results were maintained, or
if further work is needed. This is typically done 4-6 weeks after
termination.

32. • Critical Incident stress debriefing is used for
frontline crisis workers who are exposed to
gruesome and life-threatening situations.
Examples: suicides, homicides, natural disasters, terrorist
attacks, hostage situations.
• This allows the worker to discuss the
traumatic event, promote group cohesion,
and educate first responders on stress
reactions and coping techniques.

33.  This typically occurs 24 to 72 hours after the
traumatic accident.
 This can be done individually or with a group.
 These debriefing meetings should encourage
the first responders to be supportive and to
not be critical of each other.

34. A guideline for critical incident stress debriefing for first
responders
1. Assess for danger/safety for self and others
2. Consider the physical and perceptual mechanism of injury
3. Evaluate the level of responsiveness
4. Address medical needs
5. Observe and identify each individual’s sign of traumatic stress
6. Introduce yourself, state your role, and begin to develop a
relationship
7. Ground the individual by allowing him/her to tell his or her
story
8. Provide support trough active and empathic listening
9. Normalize, validate, and educate
10. Bring the person to the present, describe future events, and
provide referrals

35. Barry Kidd 2010 35
ASSESSMENT
a. Perception of event: What happened that
prompted you to seek help?; How are you
feeling now?; etc.
b. Coping mechanisms: Suicidal?; Plans?; What
helps you feel better?; etc.
c. Support systems: With whom do you live with?;
Who is available to help you?; Who is most
helpful?; etc
d. Mental status, previous history
e. Identify client’s strengths
f. Self-assessment: EMR’s feelings

36. Barry Kidd 2010 36
EMR Diagnosis:
1. Risk self directed violence
2. Chronic low self esteem
3. Hopelessness
4. Powerlessness
5. Severe/Panic levels of anxiety
6. Disturbed thought process
7. Sleep deprivation

37. Barry Kidd 2010 37
Planning and outcome identification
1. Assist the patient in setting realistic
goals to return to the pre-crisis level of
functioning
2. Establish desired outcome criteria for
the patient using the problem solving
approach.

38. Barry Kidd 2010 38
Implementation
1. Assess for any suicidal/ homicidal thoughts or
plans.
2. Take initial steps to make the patient feel safe
and lower anxiety.
3. Safety- intervene to prevent violence- suicide/
angry, aggressive patient.
4. Listen attentively and encourage the patient to
discuss the crisis situation. Facilitate the
verbalization of thoughts and feelings.
5. Creative and directive approach needed. Initially
the EMR/or other health care persons may make
phone calls (arrange baby-sitters, find shelters,
contact social workers, etc.)

39. Barry Kidd 2010 39
6. Use problem solving approach.
7. Identify needed social support (with patient’s
input) and mobilize the most needed first.
8. Identify and work to increase needed coping skills
(problem solving, relaxation, assertiveness, job
training, newborn care, self-esteem).
9. Plan with patient interventions that are acceptable
to both.
10. Evaluate plan and instruct patient with alternative
plan if needed.