CRISIS INTERVENTION

INTRODUCTION

Stressful situations are the part of everyday life. Any stressful situation can precipitate a crisis.
Crisis result in a disequilibrium from which many individuals require assistance to recover. A
crisis is a severely stressful experience for which coping mechanisms fail to provide any
adaptation, whether the experience is positive or negative. Usually, a crisis occurs when the
precipitating event is unusual or rare. E.g. one woman coped with chronic physical abuse by her
husband, who abused by her husband, who abuse both drugs and alcohol.

Crisis intervention requires problem- solving skills that are often diminished by the level
of anxiety accompanying disequilibrium. Assistance with problem solving during the crisis
period preserves self- esteem and promotes growth with resolution. The priority of crisis
intervention/counseling is to increase stabilization. Crisis interventions occur at the spur of the moment
and in a variety of settings, as trauma can arise instantaneously. Crisis counselors must keep in mind that
crises are temporary, no longer than a month, although the effects may become long-lasting

DEFINITION

Crisis is defined by Lagerquist, “A sudden event in one’s life that disturbs homoeostasis,
during which usual coping mechanisms cannot resolve the problem.”

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.”

“A crisis is a turning point, resulting from a stressful or threat to one’s well being. It occurs
where a conflict, problem or situation is perceived as threatening and not readily solvable
by past methods.” Anxiety increases, effective cognitive functioning decreases and behavior
becomes disorganized. Te person urgently seeks help because old problem solving methods do
notwork.

Crisis Intervention can be defined as emergency psychological care aimed to assist individuals in
returning to normal levels of functioning and to prevent or alleviate potential negative psychological
trauma

There are some ASSUMPTIONS on which the concept of crisis is based (Caplan1964, Kaplan
& Sadock 1998)

1. Crisis occurs in all individuals at one time or another and is not necessarily equated with
psychopathology.

2. Crisis is precipitated by specific identifiable events.

3. Crisis is personal by nature. What may be considered a crisis situation by one individual
may not be so for other.
 4. Crisis is acute, not chronic and will be resolved in one way or another within a brief
period.

5. A crisis situation contains the potential for psychological growth or deterioration.

PHASES IN THE DEVELOPMENT OF CRISIS

The development of a crisis situation follows a relatively predictable course. Caplan (1964)
outlined 4 specific phases through which individuals’ progress in response to a precipitating
stressor and which culminate in the state of acute crisis.

Phase 1: The individual is exposed to a precipitator stressor. Anxiety increases; previous

problem-solving techniques are used

Phase 2: When previous problem solving techniques do not relieve the stressor, anxiety
increase 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 stressful. Feelings of confusion and disorganization prevail.

Phase 3: All possible recourses, 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, 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.” Anxiety may reach
panic levels. Cognitive functions are disordered, emotions are labile and behavior may reflect the
presence of psychotic thinking.

Universal Principles of Crisis Intervention

While dealing with crisis, both personal and societal, there are five basic principles outlined for
intervention. Victims are initially at high risk for maladaptive coping or immobilization.
Intervening as quickly as possible is imperative. Resource mobilization should be immediately
enacted in order to provide victims with the tools they need to return to some sort of order and
normalcy, in addition to enable eventual independent functioning. The next step is to facilitate
understanding of the event by processing the situation or trauma. This is done in order to help the
victim gain a better understanding of what has occurred and allowing him or her to express
feeling about the experience. Additionally, the counselor shoule assist the victim(s) in problem
solving within the context of their situation and feelings. This is necessary for developing self-
efficacy and self-reliance. Helping the victim get back to being able to function independently by
actively facilitating problem solving, assisting in developing appropriate strategies for addressing
those concerns, and in helping putting those strategies into action. This is done in hopes of
assisting the victim to become self-reliant
General Approach to Crisis Intervention
ACT Model of Crisis Intervention developed by Roberts as a response to the September 11, 2001
tragedy outlines a three stage framework:Assessment Crisis Intervention Trauma Treatment
(ACT) This theory of crisis intervention integrates numerous assessment tools and triage
procedures; Roberts’ seven stage crisis intervention model and the ten step acute traumatic stress
management protocol creates one comprehensive model for responding to crisis that can be
utilized in most all crisis situations. It is important to note that this should be followed as a guide
not to be followed rigidly.

The first step is the assessment stage; this is done by determining the needs of victims, other
involved persons, survivors, their families, and grieving family members of possible victim(s)
and making appropriate referrals when needed. Three types of assessments need to be conducted.
The first is triage assessment, which is an immediate assessment to determine lethality and
determine appropriate referral to one of the following: emergency inpatient hospitalization,
outpatient treatment facility or private therapist, or if no referral is needed. A crisis assessment
also needs to be completed which consists of gathering information regarding the individual’s
crisis state, environment, and interpersonal relationships in order to work towards resolving the
current crisis. This step helps facilitate development of an effective and appropriate treatment
plan. The last area of assessment includes a biosocial and cultural assessment. This would be
completed by using systematic assessment tools to ascertain the client’s current level of stress,
situation, present problem, and severe crisis episode .

The goal of the crisis intervention stage of Robert’s ACT model is to resolve the client’s
presenting problems, stress, psychological trauma, and emotional conflicts. This is to be done
with a minimum number of contacts, as crisis intervention is intended to be time limited and goal
directed.Stage one of the seven step approach focuses on assessing lethality. The clinician is to
plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment; this
should be done promptly at the time of arrival. Once lethality is determined one should establish
rapport with the victim(s) whom the clinician will be working with. The next phase is to identify
major problem(s), including what in their life has lead to the crisis at hand. During this stage is it
is important that the client is given the control and power to discuss their story in his or her own
words. While he or she is describing the situation the intervention specialist should develop a
conceptualization of the clients “modal coping style”, which will most likely need adjusting as
more information unfolds, this is referred to as stage three. As a transition is made to stage four
feelings will become prevalent at this time thus deal with those feelings will be an important
aspect of the intervention. While managing the feelings the counselor must allow the client(s) to
express his or her story, and explore feelings and emotions through active listening and
validation. Eventually, the counselor will have to work carefully to respond to the client using
challenging responses in order to help him or her work past maladaptive beliefs and thoughts,
and to think about other options. At step five, the victim and counselor should begin to
collaboratively generate and explore alternatives for coping. Although this situation will be
unlike any other experience before the counselor should assist the individual in looking at what
has worked in the past for other situations; this is typically the most difficult to achieve in crisis
counseling. Once a list has been generated a shift can be made to step six, development of a
treatment plan that serves to empower the client. The goal at this stage it to make the treatment
plan as concrete as possible as an attempt to make meaning out of the crisis event. Having
meaning in the situation is an important part of this stage because it allows for gaining mastery.
Finally, step seven, the intervention specialist is to arrange for follow-up contact with the client
to evaluate his or her post crisis condition in order to make certain resolution towards
progressing. The follow up plan may include “booster” sessions to explore treatment gains and
potential problems.

After the situation has been assessed and crisis interventions have been applied the aim is at
eliminating PTSD symptoms, thus treating the traumatic experience. A comprehensive view of
how to treat the trauma consists of ten stages outlined by Lerner and Shelton (2001). These steps
relate similarly to the crisis intervention steps. The first step is to assess for danger/safety for self
and others, this means for the victim, counselor, and others who may have been effected by the
trauma. Then the counselor should consider the physical and perceptual mechanisms of injury.
Once injury is assessed the victim’s level of responsiveness should be evaluated and any medical
needs should be addressed. Each individual who witnessed or is experiencing a crisis should be
observed to identify his or her sign’s of traumatic stress. After the assessment of the situation is
completed the interventionist should introduce his or her self, state their title and role, and begin
building rapport. Building this relationship allows for a more fluid approach to grounding the
individual, this can be done by allowing him or her to tell his or her story. Again, the counselor is
encouraged to provide support through active and empathetic listening, normalize, validate, and
educate. Finally, the intervention specialist is to bring the person to the present, describe future
events, and provide referrals as needed.
The relationship between transactional model of stress/ adaptation and Caplan’s phases in
the development of crisis.

Precipitating event

Predisposing factors
Genetic influences
Family history
Past experiences Phase 1
Previously used prob-
-lem solving techni. Cognitive appraisal
Existing conditions Primary
Coping mechanisms Stress appraisals
Support systems
Harm/loss Threat Challenge

Secondary

Availability of coping strategies Phase 2

Perceived effectiveness of coping strategies

Perceived ability to use coping strategies effectively Phase 3

Quality of response

Adaptive (No crisis) Maladaptive (Crisis)

Phase 4

CONTINUM OF CRISIS RESPONSES

In describing the phases of a crisis, it is important to consider the balancing factors shown as
follow. These include the individual’s perception of the event, situational supports and coping
mechanisms. Successful resolution of the crisis is more likely if the person has a realistic view of
event, if situational supports are available to help solve the problem and if effective coping
mechanisms are present (Aguilera 1998).
CONTINUM OF CRISIS RESPONSES

Adaptive responses Maladaptive responses

Growth Precrisis functioning Disorganization

THEORETICAL PERSPECTIVES:

Erik Lindemann

In 1944, Lindemann develop a classic paper on bereavement that later evolved as a model for
considering the nature and resolution of crisis in broader teams. He studied 101 patients who
were in crisis as a result of personal loss. Included in this group were bereaved disaster victims
and their relatives who had lost someone in the famous coconut Grove fire and those of patients
who had lost a relative during therapy. Other participants in the study were the relatives of armed
service men either killed or lost in World War 2 and relatives of patients who had died in the
hospital. His study of their behavior provided Lindemann with the observations of normal and
morbid grief, which he later formulates into a stage theory concerning grief resolution. He noted
that individuals experiencing a normal grief reaction suffered from physical complaints,
preoccupation with memories of the decreased, anger, grief, guilt, changes in pattern of activity
and imitating characteristics of the decreased. Some people had more difficulty accepting the
reality of the lose and other appeared to have a delayed reaction to the loss of a loved one.
Distorted reactions included development of physical illness or clinical depression. Unable to
integrate the experience, the individual fail to ascribe a meaning to the loss that allowed life to
continue. Prolonged intense grief represented the unresolved part of the relationship.

Lindemann believe that crisis intervention should have a community focus; he worked with
Caplan to establish the first mental health clinic devoted to preventive psychiatry.

Gerald Caplan

Caplan (1964; 1974) a colleague of Lindemann, receive credit for describing the sequence of the
crisis state and for defining crisis intervention as a distinct form of preventive psychiatric
therapy. The crisis intervention technique developed through his research studies with the
Harvard family health clinic serve as a model for modern community mental health systems.
Caplan believe that crisis represent a transitional period in a person’s life characterized by
emotional and cognitive disequilibrium forcing a reappraisal of previously held value and
beliefs. It occurs when a person is faced with a potentially insoluble problem that has meaning
for the person. The crisis state is self limiting and usually lasting 4-6 weeks. An inability to
resolve a crisis successfully makes a person more vulnerable to difficulties in resolving other life
crisis.

According to Caplan, a crisis state dose not develops spontaneously, nor does it unfold apart
from the person in crisis. To understand fully the nature of the crisis, it is necessary to assess the
context in which the crisis arises. This assessment includes information about the nature of
family bond, work affiliation and other significant relationships. The patient can avoid more
serious dysfunction by altering the unhealthy environmental conditions that create a stress
quickly. Caplan’s work is particularly relevant for understanding interpersonal and
developmental crisis states.

Caplan (1974) recognized the important role nurses health professionals’ nurses play in crisis
intervention. He states “I felt that among health professional nurses were particularly well suited
to stimulate such support and to act as bridges of communication and as mediator between their
patients and professional and non- professional agencies.”

Erik Erikson

Ericson (1963; 1968) is important for his description of crisis as a natural part of personal
maturation. He viewed developmental crisis point as critical to normal healthy personality
development. Erikson used an 8 stage model of human ego development and proposed that
personality growth could be divided into distinctive psychosocial developmental periods or life
stages. Each psychosocial crisis marks the transition to the next life stage to stage; they are
relatively similar for all members of a given society. The precise timing, however and behavioral
expression of a stage reflect an individual’s culture, physical development and life circumstances
such as illness or family norms. That culture plays a role is seen in the fact that societal
expectation in eastern culture is quite different than they are in the West. E.g. a women’s identity
in many Eastern cultures are clearly tied to family and spouse, whereas in the West, women have
more freedom to express their identity with ever- expanding career and life choices. The
behavior of women in each culture reflects societal expectations.

Although developmental crisis are directly related to social expectation, they also are age
related. Psychosocial development emerges from a ground plan that uniquely defines each
person’s personality. In the beginning, the ground plan is not within the individual’s conscious
awareness but develops with greater clarity as the result of interactions with others and signicant
life experiences. A crisis point occurs when the self understandings previously used by an
individual to negotiate life on longer are sufficient to meet its social demands.

Each developmental crisis is systematically related to all other and each has its own time
of special focus or ascendancy. The task necessary for maturation exists in its purest form during
the assigned stage but may also reappear during a later phase in a modified form. To move to the
next stage of development, a person must successfully resolve each maturation crisis, the threats
of which are incorporated into the higher level of psychosocial development.
 Solutions of the task contained within each phase of development are established as a
formative seed in previous phase, worked on in the previous phase and refined in subsequent
ones. E.g. the adolescent’s focus on identity actually begins much earlier as the child engaged in
social role behaviors during play and later developed fundamental skills in peer relationship with
schoolmates. In old age, mature adults reflect back on the meaning of their lives and share their
insights with the younger generation.

The environment plays an important role in the development of a psychosocial crisis

because it presents an individual with new defining characteristics about expected modes of
behavior for each time period that is qualitatively different from the social expectations that
preceded it rather than describing a psychosocial crisis as a purely situational response, Erikson
(1963) viewed its development as an internal psychological process, “ a necessary turning point,
a crucial moment, when development must move one way or another, marshaling resources of
growth, recovery and further differentiation.

TYPES OF CRISIS

Mainly there are 2 types of crisis:

1. Situational

2. Maturational

1) Situational: It refers to an extraordinarily stressful event such as the terrorist attacks or

“beltway sniper” incidents that affects an individual or family regardless of age group,
socioeconomic status or sociocultural status. E.g. economic difficulties, medical or psychiatric
illness, rape, workplace or school violence, divorce etc.

2) Maturational Crisis: On the other hand, is an experience such as puberty, adolescence,

young adulthood, marriage or the aging process- in which one’s lifestyle is continually subject to
change. These are the normal process of growth and development that evolve over an extended
period and require the person to make some type of change.

A process of maturation occurs throughout the life cycle. Erikson identified

eight stages of growth and development in which specific maturational tasks must
be mastered. Each of this stage constitutes a crisis in personal growth and
development. The eight stages and their tasks as defined by Erikson are:

Beldwin (1978) has identified six classes of emotional crisis, which progress by degree of
severity. As the measure of psychopathology increases, the sources of the stressor changes from
external to internal. The type of crisis determines the method of intervention selected.

Class 1: Dispositional crisis

Definition: An acute response to an external situational stressor.

Intervention: Nancy’s physical wounds were cared for in the emergency department. The
mental health counselor provided support and guidance in terms of presenting alternatives to her.
Needs and issues were clarified and referrals for agency assistance were made.

Class 2: Crisis of anticipated life transitions

Definition: Normal life cycle transitions that may be anticipated but over which the individual
may feel a lack of control.

Intervention: physical examination should be performed (physical symptoms could be caused

by depression) and ventilation of feelings encouraged. Reassurance and support should be
provided as needed. The client should be referred to services that can provide financial and other
types of needed assistance. Problematic areas should be identified and approaches to change
discussed.

Class: 3 Crisis resulting from traumatic stress

Definition: Crisis precipitated by unexpected external stresses over which the individual has
little or no control and from which he or she feels emotionally overwhelmed and defeated.

E.g. Rape

Intervention: The nurse should encourage the patient to talk about the experience and to express
the feelings associated with it. The nurse should offer reassurance and support; discuss stages of
grief and how rape causes a loss of self- worth, triggering the grief response; identify support
systems that can help the patient to resume her normal activities and explore new methods of
coping with emotions arising from a situation with which the patient has had no previous
experience

Class: 4 Maturational/ developmental crisis

Class: 5 Crisis reflecting psychopathology

Definition: Emotional crisis in which preexisting psychopathology has been instrumental in

precipitating the crisis or in which psychopathology significantly impairs or complicates
adaptive resolution. Examples of psychopathology that may precipitate crisis include borderline
personality, severe neuroses, characterological disorders or schizophrenia.

Intervention: Someone stay with her and reassure her for safety and security. After the feelings
of panic have subsided, she should be encouraged to verbalize her feelings of abandonment.
Regressive behaviors should be discouraged. Positive reinforcement should be gives for
independent activities and accomplishments.

Class: 6 psychiatric emergencies

Definition: crisis situation in which general functioning has been severely impaired and
individual rendered incompetent or unable to assume personal responsibility. E.g. acutely
suicidal individuals, drug overdoses, reaction to hallucinogenic drugs, acute psychosis and
alcohol intoxication.

Intervention: the crisis team monitored vital signs, ensure maintenance of adequate airway,
initiated gastric lavage and administered activated charcoal to minimize absorption. The situation
was explained to relatives and they were encouraged to stay with their patients.

CRISIS PARADIGM

The paradigm set by Aguilera (1994) suggests that whether or not an individual experiences in
the past. If a crisis in response to a stressful situation to a stressful situation depends on the
following 3 factors:

1. The individual’s perception of the event: If the event is perceived realistically, the
individual is more likely to draw on adequate recourses 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: Aguilera states, “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.

3. The availability of adequate coping mechanisms: When a stressful situation occurs,

individual draw on behavioral strategies that have been successful for these coping
strategies work, a crisis may be diverted. If not, disequilibrium may continue and tension
and anxiety may increase.

State of equilibrium

Description of crisis
Stressful event: A young couple is told that their son has inoperable cancer
State of disequilibrium occurs: the impact of their son’s illness results in feeling of increased
anxiety, tension and helplessness. They experienced a threatened loss: their son’s life.
Need to restore equilibrium: parents recognize the need to decrease feelings of anxiety,
tension and helplessness so that they can handle their own feelings and their son’s illness.

BALANCING FACTORS DISTURBANCE IN ONE OR MORE

PRESENT BALANCING FACTOR

Realistic perception of the event: Distorted perception of the events

Prognosis of illness is poor because Question seriousness of illness.

the cancer is inoperable.

Adequate situational support: Inadequate situational support: No

Receive support of pastor, parent’s religious affiliation: decline help from

the hospital chaplain; poor IPR with

And close friends. Both sets of parents; no close friends to

Turn to for help.

Adequate defense and/or coping skills: Inadequate defense and/or coping skills:

Able to discuss their feelings and unable to communicate openly with

thoughts with each other, family each other; each blames the other for

members and friends. Not recognizing signs of their son’s

illness earlier.

Resolution of problem: able to apply Problem unresolved: uncertain what to

Problem solving process. Do about son’s illness; confusion, anxiety

Decide to: 1. Stay with their son and make & feelings of helplessness persist. Usual

The most of their time together as a coping mechanisms do not alleviate the

Family. Fear of a threatened loss. They avoid

2. Provide the best medical care possible reality with over activity.

to keep their son comfortable.

Anxiety lessens after the problem

Solving process applied.

Crisis resolving: Crisis not resolving: experiencing severe or

Achieving equilibrium extraordinary stress that is precipitated

by son’s illness.

Crisis situation paradigm

COMMONLY USED THERAPEUTIC TECHNIQUES IN CRISIS INTERVENTION

1. Displaying acceptance and concern and attempting to establish a positive relationship.

2. Encouraging the client to discuss present feelings, such as denial, guilt, grief or anger.

3. Helping the client to confront the reality of the crisis by gaining and intellectual- as well
as emotional- understanding of the situation; not encouraging the person to focus on all
the implications of the crisis at once.

4. Explaining that the client’s emotions are normal reaction to the crisis.

5. Avoiding false reassurance.

6. Clarifying fantasies; contrasting them with facts.

7. Not encouraging the client to place the blame for the crisis on others because such
encouragement prevents the client from facing the truth, reduces the client’s motivation
to take responsibility for behavior and impedes or discourages adaptation during the
crisis.

8. Setting limits on destructive behavior.

9. Emphasizing the client’s responsibility for behavior and decision.

10. Assisting the client in seeking help with the activities of daily living until resolution
occurs.

11.Evaluating and modifying nursing interventions as necessary.

Application of the Nursing Process

Assessment

• Determine if the person is really in crisis (tears, anger & being upset don’t always mean
crisis) What is their perception of the stressful event? How threatened are they? Is the
perception realistic or distorted?
• If there is great anxiety, the person cannot think clearly or identify solutions – is helpful
to have them talk about what immediately preceded the distress à it frequently calms
people to talk.
• Focus on the immediate problem not the history à people will reach out for help even if
the event occurred in the last 14 days, sometime within 24 hours.
• Ask the person to describe their feelings & frustrations (accept them without judgement
& it helps the client to accept them). Experiencing pain is also beneficial to the person –
although it may be difficult for the nurse to see someone crying.
• It is important that you know that nurses are not suppose to have all the answers for
patient à we provide the support & feedback while the patients solve their own problem
and in this way they grow…
 • Assess the availability of support systems – which can provide continued support. Who
do they trust? Who is your best friend? Who are you close to? (Children cope better if
they are with their parents) Do they have a religious beliefs & support?
• Assess coping skills. Are they adaptive or maladaptive? Are they still functioning in life
(i.e. with a job, school or family)?
• Assess the potential for self-harm. Are they having thoughts of hurting themselves? Most
patients will not volunteer this information – but will readily talk about suicidal thoughts
when asked. If there is a history or specific plan of suicide the patient must be watched
closely.

Possible Nursing Diagnosis

• Anxiety, Altered Thought Processes,

• Ineffective Individual Coping
• Impaired Social Interaction,
• Social Isolation
• Self Esteem Disturbance.

Planning

• The major goal of crisis intervention is to assist the patient in reestablishing

equilibrium.
• The goals of crisis intervention are different form the goals of other therapies.

Interventions

• Assist the patient to reexamine any feelings that might block adaptive coping & realize
the potential for growth.
• Teach the patient that it is alright to ask for help, people who place high value on
independence may have difficulty.
• Encourage adaptive coping methods such as expression of feelings, progressive
relaxation, and physical exercise, as well as drinking warm milk or herbal tea to aid in
relaxation & sleep.
• Assist the patient to focus on the problem & specific goals leading to its resolution.
• Another approach to care includes a crisis team – possibly consisting of a psychiatrist,
nurse, psychologist, social worker, aide, minister & students. The disadvantage of this
approach is a possible loss in continuity of care – which should be monitored closely.

Crisis Groups

• Crisis Groups are an option to one-on-one crisis intervention.

• Groups may work best for people who have difficulty with interpersonal relationships
(feel more comfortable in a group), and those who have difficulty accepting information
from psychiatric professionals or people in positions of authority.
• Advantages are - people feel less isolated, make social contact, see others have similar
problems - which help them to open up about their problems.
• Disadvantages are - an inability to focus on one patient’s problems & suggestions of
maladaptive or destructive coping methods by group members.
• Groups are usually 5-7 people that meet 1 ½ to 2 hours once a week for 6 weeks.
• A closed group does not accept new members after it is formed & continues for a
specified time.

Summary: Crisis means a turning point. In the crisis intervention the goal is to assist the
person in distress to resolve the immediate problem & regain emotional equilibrium. Your
role as the nurse or intervener is one of active participation. Intervention is a partnership &
the belief is that with help people can help themselves. Nurse helps the person analyze the
event, encourages expression of feelings, affirms the right to those feelings no matter what
they are, reinforces strengths & abilities, explore other ways to deal with the stressors &
encourages support from family, friends & other resources.