crisis & its intervention

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 SEMINAR ON CRISIS & ITS INTERVENTION SUBMITTED TO SUBMITTED BY ANNIE MADAM ANCY VARKEY LECTURER  M.Sc NSG 1 st YEAR  K.N.C K.N.C SEWAGRAM SEWAGRAM 

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Page 1: Crisis & Its Intervention

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SEMINAR

ON

CRISIS & ITS

INTERVENTION

SUBMITTED TO SUBMITTED BY

ANNIE MADAM ANCY VARKEY

LECTURER M.Sc NSG 1 st YEAR

K.N.C K.N.C

SEWAGRAM SEWAGRAM

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INTRODUCTIONStressful events or crisis are a common part of life. Any

stressful situation can precipitate a crisis. Crisis results in a disequilibrium from which manyindividuals require assistance to recover. Crisis intervention requires problem solving skills that are often diminished by the level of anxiety accompanying disequilibrium. Knowledge of CrisisIntervention techniques is an important skill of all nurses, regardless of clinical settling orpractice specialty.

Here we will examine the phases in the development of a crisis and the types of crisis that occurs in people s lives. The methodology of crisis intervention, including the role of the nursesis exploded here.

DEFINITIONS

According to Largerquist , 2001

Crisis is a sudden event in one¶s life that disturbs Homeostasis, during which usual copingmechanisms cannot resolve the problem´.

OR

³Crisis is a struggle for equilibrium when problems seen insolvable. A crisis can be a turning point in one¶s life´.

According to Taylor, 1982

Crisis is a state of disequilibrium resulting from the interaction of an event with the individual¶sor family¶s coping mechanisms, which are inadequate to meet the demands of the situation,combined with the individual¶s or familyµs perception of the meaning of the event.´

OR

³A crisis is an acute, time-limited reaction to an overwhelming emotional experience, which canresult in a state of state of disequilibrium or imbalance´.

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CHARACTERISTICS

Crisis occurs in all the individuals at one time or other. 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. It is self limiting, lasts for 4-6 weeks Universal experience Almost all crises will develop in a predictable fashion.

Developmental Ph ases of Crisis

Crisis results from certain distinct bio-psychological phases. It followsrelatively predictable course.

Caplan in 1964 described four specific phases through which individual progress into crisis inresponse to a precipitating stressor.

PHASE 1:

Whenever the individual is exposed to a precipitating stressor, it results into anxiety to overcome it. If individuals uses effective problem solving techniques andsituational support is provided then the problem will be resolved and no crisis occurs.

PHASE 2:

When previous problem-solving techniques do not relieve thestressor or when coping mechanisms are ineffective, anxiety, discomfort, helplessness furtherincreases hence person s ability to overcome the stressor will decrease. Feeling of confusion,personal disorganization prevails.

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PHASE 3:

Individual feels more pressure, unable to respond, anxiety

still increases; In this phase all external and internal resources will be tried to resolve the crisisand to relieve discomfort. Individuals use every means like cognitive emotional andphysiological means, counseling etc. as a last resort. If it fails the premorbid functioning willresults.

PHASE 4:

If resolution does not occur in previous phases, Caplanstates that The tension reaches to its peak. As time passes, burden increases to a breakingpoint. Major disorganization of the individual with drastic results often occurs . Anxiety mayreach panic levels. Cognitive functions are disordered, emotions are labile and behavior mayreflect the presence of psychotic thinking.

TYPES:

1. Situational Crisis/ External Crisis/ Coincidental CrisisD evelops from an external event such as an accident, loss of job,

death of very close person, illness, financial troubles etc. It is sudden, unexpected, onset.An acute response occurs due to an external situational stressor i.e. dispositional crisis.The life events can become situational crisis, depending on a person¶s emotional status,ability to cope and the support received.

2. Maturational Crisis/ Developmental Crisis/ Internal CrisisMaturational crisis are developmental events requiring role

changes, including the many issues that arise in progressing from one stage of development to the next. During each stage of development there are undesirablebehaviors. These behaviors may lead to crisis if development outcomes are not achieved. It will be dependent on previous experiences, availability of situationalsupport, and motivation from significant people, acceptability and performance of newrole by others. For eg:- adolescence, marriage, antenatal period, parenthood,retirement, death of spouse or loved ones, loss of job etc. Maturational crisis involveshow an individual will perceive themselves, their role and their status.

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3. Socio-Cultural CrisisIt arises from the cultural values that are embedded in the social structure. For

eg:- Discrimination between race and robbery.

4. Crisis resulting from Traumatic StressCrisis results when unexpected external stress over which the individual has

little or no control. For eg:- Rape, robbery, terrorism.

5. Crisis resulting from PsychopathologyEmotional crisis in which pre-existing psychopathology has been instrumental

in precipitating the crisis or in which psychopathology significantly impairs orcomplicates. For eg:- Border line personality disorder, severe neurosis, schizophrenia etc

6. Adventitious Crisis/ Community CrisisIt is accidental, uncommon, anticipated results in multiple losses may be

because of environmental changes. For eg:- natural disasters like flood, earth quake,tidal waves, famine, contamination of large areas by toxic waste products, nuclear wasteetc. People believe that the event may occur due to God s anger or fate. Thepsychological disturbances will occur eg:- fear, confusion ets.

7. Psychiatric EmergenciesCrisis situation in which general functioning is impaired and the individual is

incompetent to assume personal responsibility. For eg:- Suicide, addictions, drug overdoses, uncontrollable anger and alcohol intoxication

SIGN AN D SYMPTOMS Depression or Agitated Anger, guilt, tension, fear H elplessness, hopelessness, uselessness P anic

Low self-esteem Irrational and blaming others Uncontrollable crying F rustration, confused, depressed Lack of self control Altered sensorium

Impaired judgment Lack of confidence, discouragement P hysical illness Irritable

Change in life style Withdrawal behavior H allucinations Shortness of breath Inappropriate relationships Disorganized thinking

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CRISIS INTERVENTIONIn crisis intervention, the therapist becomes a part of the

individual s life situation. Because of the individual s emotional state, he or she is unable tosolve the problem, so requires guidance and support from another to help mobilizes theresources needed to resolve the crisis.

Definition: Crisis intervention is a short term therapy focused on solving the

immediate problem. The goal of crisis intervention is for the individual to return to a pre-crisis

level of functioning. It usually limited to 6 weeks.

I ndications for Crisis intervention

Abstinence Pediatric Geriatric Maturational Crisis Adolescent People who attempted suicide Psychosomatic patients Violent behavior eg: Crime Accident victims Family crisis High risk families eg. Ill members recent death, bereavement, H/o difficulty coping

chronic illness Severe depression Severe anxiety Marital conflicts Suicidal thoughts Illicit drug abuse; alcohol abuse Traumatic events/ experiences Inter group staff issues Client management issues

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Settings for Crisis I ntervention Hospitals outpatient unit, Inwards, Emergency room settings Mental Health Care Centre Community settlings

Home visits Outreach Centers

Telephonic counseling and hotline Crisis calls Ventilation calls Information calls

Suicide prevention and Crisis Intervention centers Schools, offices, private practice

Tec h niques of Crisis I ntervention

The nurse should be creative and flexible, trying many different techniques. These should be active, focused and explorative techniques that can facilitateachieving the targeted interventions. It must be aimed at achieving quick resolution.

Some of these include:-

1) Cat h arsis The release of feelings that takes place as the patient takes about emotionally chargedareas. As feelings about the events are realized, tension is reduced. Catharsis is otenused in crisis intervention. The nurse asks open-ended questions and repeats thepatient s word so that more feelings are expressed.Only when feelings seem out of control, such as in cases the nurse should discourageCatharsis and help the patient to concentrate on thinking rather than feeling.

For eg:- If a patient angrily talks of wanting to kill a specific person.

2 ) Clarification Encourage the client to express more clearly the relationship between certain events,behaviors and feelings. It helps the client to understand his feelings and the pattern of developing these feelings into crisis.

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For eg:- After having an argument, discussion about future with spouse, the client became sick.

3 ) Suggestion

It influences a person to accept an idea or belief. In crisis intervention the patient is

influenced to see the nurse as a confident, calm, hopeful, empathic person who canhelp. By believing the nurse can help, the patient may feel more optimistic and lessanxious. Suggestion is a way of influencing the patient by pointing out alternatives ornew ways of looking at things.

4 ) Reinforcement of Be h avior It occurs when healthy, adaptive behaviors of the patient give positive response andappreciate the patient.For eg:- I observed you have done it, you can do it

5 ) Support of Defenses Encourage the client to use healthy and adaptive behavior to cope up stressful situationto maintain ego and integrity, at the same time discourage the maladaptive, unhealthybehavior.For eg:- Ask the client, when he is angry, over the other, divert it by drinking half glassof cool water and doing other works.

6 ) Raising Self- Esteem It is a particularly important technique. The patient in crisis feels helpless and may beoverwhelmed with feelings of inadequacy. Help the client to regain the feelings of self-worth, active participation, communicates effectively, good listening skills, accepts hisfeelings with respect.For eg:- you have done so many tasks in your life up to now. I feel you can be able todo this task also.

7 ) Ex ploration of Solutions It is essential because crisis intervention is geared towards solving the immediate crisis.The nurse and patient actively explore solutions to the crisis.For eg:- A client who has lost her job, is aware of the fact that there are people who canhelp her out for getting a new job.

Some other Techniques are:-

Family Work:-

Identify the individual and family affected with crisis. Involving the familyin client care is essential. A nurse has to have knowledge related to family dynamics.

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Provide calm and conducive, comfortable environment to the client, help to establishgood rapport and IPR between client and his family.

Identify the stressor and suggest possible attacking of the problem, utilize the best suiting approach to resolve the crisis.

Family interventions consist of educational supportive, cognitive and behavioral

strategies.

Group Work:-

Nurses and group help the patient to solve the problem and develop new copingstrategies. The group and the client follow the nurse as a role model and ideal example usessimilar therapeutic techniques. Group acts as a support system for the client.

For eg:- Hospitalization of the client.

Patient Education:-

The therapeutic team members will educate and counsel the client andfamily about problem resolving techniques, alternative adoptive coping strategies; importanceof having balance mind and emotional maturity. Educate the public to identify the crisissituations and victims.

Role of Nurse

Phases and techniques of crisis intervention are similar to the steps of nursing process.

Ph ase I : Assessment

The first step of crisis intervention is Assessment. At this phase data about the nature of thecrisis and its effect on the patient must be collected. Assess the following.

Identification of precipitating event or stressor and when it occurred. Explore the needs of the client like

( 1) Self- Esteem- Achieved when the person attains successful social roleexperience.

(2 ) Role Mastery- Achieved when the person attains work, sexual and family rolesuccesses.

(3 ) Dependency- Achieved when a satisfying interdependent relationship withothers is attained.

(4 ) Biological function- Achieved when a person is safe and life is not threatened.

Ability for the perception of the event.

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Client s abilities and limitations in dealing with the problem. Nature and strength or adequacy of clients supporting systems and coping resources. Nature of crisis and its effects on the individual and family. Associated behavioral problems. Physical and mental status of an individual

History of previous exposure and adapted strategies Exploration of problematic situation

Ph ase II : Nursing Diagnosis

After analyzing the information gathered through assessment, appropriate nursing diagnosiscan be formulated to solve the crisis situation. Nursing diagnosis may be related to any aspect of the client s life which can reflect the variety of nursing problems.

For eg:-

y Disturbed thought processesy Risk for emergency situation like suicide or violencey Altered family processesy Maladaptive crisis responses

Ph ase III : P lanning

Based on the assessment, diagnosis the short term and long term goals will be formulated witha specific and appropriate plan of activities. In planning the interventions the type of crisis, aswell as the individual s strength and available resources for support are taken intoconsideration. Goals are established for crisis resolution and a return to or increase in, the pre-crisis level of functioning.

Ph ase IV : I mplementation of I ntervention

During phase I V, the actions that identified in phase 3 areimplemented. The following interventions are the focus of nursing in crisis intervention:

1. Use a reality- oriented approach2. Remain with the individual who is experiencing panic anxiety3. Establish a rapid, positive working relationship by

Showing unconditional acceptance Active listening

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Attending to immediate needs Appropriate communication technique to make the client to feel more comfortable

4. Discourage length explanation by rationalizing the situation5. Provide adequate situational support and guidance6. Handle the feelings gently, don t give false reassurance7. Maintain consistency8. Clarify the problem that the individual is facing9. Guide the individual in problem solving process and to alleviate future crisis10. Identify external support system and new social network for the individual to scale

assistance and advice for follow up visit.

Nursing intervention can take place on many levels using a variety of techniques. There are four levels of crisis intervention that represent a hierarchy from the most

basic to the most complex (shields, 1975)

Individual

Approach

Generic Approach

General Support

Environmental Manipulation

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Levels of Crisis I ntervention

1. Environmental ManipulationEnvironmental manipulation includes interventions that directly change

the patient s physical or interpersonal situation. These interventions provide situationalsupport or remove stress. Important elements of this intervention are mobilizing thepatient s supporting social system and serving as a liaison between the patient and socialsupport agencies.For eg:- if an individual is facing problem in working environment to avoid stress, she/hemay change another job.

2. General Support General support includes interventions that convey the feeling that the

nurse is on the patient s side and will be a helping person. The nurse uses warmth, support,

acceptance, empathy, caring, concern and reassurance has to be providing general support.

3. Generic ApproachThe generic approach is designed to reach high-risk individuals and large

groups as quickly as possible. A specific method will be used to the persons who havesimilar problems. The intervention is then setup to ensure that the course of the crisisresults in an adaptive response.For eg:- Grief , disastersDebriefing- an acute stress is a therapeutic intervention will be used to recall the traumaticevents and to clarify painful experiences and to prevent maladaptive responses.

4. Individual ApproachThe individual approach is a type of crisis intervention, similar to the

diagnosis and treatment of a specific problem in a specific patient. The nurse must understand the specific patient characteristics that led to the present crisis and must use theintervention that is most likely, to help the patient to develop an adaptive response to thecrisis.

Ph ase V: Evaluation

The last phase of crisis intervention is evaluation. When the nurse andpatient evaluate whether the intervention resulted in

A positive resolution of the crisis or Behavioral change has been achieved or not Whether the client returned to the normative level of functioning

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Does the patient have adequate support systemsFor eg:- additional treatment have to be planned to resolve crisis

SUMMARY :- All individuals experiences crisis at one time or another. Crisis is

precipitated by specific identifiable events and is determined by an individual¶s personal perception of the situation. Crisis occurs when an individual is exposed to a stressor and previous problem solving techniques are ineffective. Crisis intervention is designed to provide rapidassistance for individuals who have an urgent need. Nurses regularly respond to the individualsin crisis, in all types of setting. Nursing process is the vehicle by which nurses assist individualsin crisis with a short term problem solving approach to change. Nurses have many importantskills that can assist individuals and communities in the wake of traumatic events.

BIBLIOGRA PH Y

Gail W. S tuart ;M ic h ele T. Laraia P rinciples & P ractice of P syc h iatric Nursing ; E lsevier P ublication ; 8 t h edition

Mary C. T ownsend ; P syc h iatric Mental Healt h N ursing ;J aypee P ublication ; 5 t h edition

KP N eeraja ; E ssentials of Mental Healt h & P syc h iatric Nursing ; vol- 1 J aypee publication ; 1 st edition

BT B asvant h apa P syc h ology for Nursing Jaypee Publication