Professional Documents
Culture Documents
The term crisis derives from the Greek word krisis which means decision or
turning point. This definition of the word as a decisive stage that has important
consequences in the future of an individual or a system, has been preserved up to our
days and has provided the frameworkfor the development of the theory and practice of
crisis intervention. Crisis intervention is a relatively new field in community
psychology. Its origins are usually dated in the 1940's and 1950's with Lindemann
'spioneering work on grief and bereavement after the Coconut Grove Club fire in
Boston and with the work of Caplan at Harvard University. The 1960's and 1970's
were periods of further elaboration of crisis theory and intervention with the
development of suicide prevention centres, hot lines)), crisis centres and other
agencies. New conceptualizations of services and important innovations in the
intervention area were developed during this period (McGEE, 1974). In the last few
years, efforts have concentrated on the evaluation crisis intervention programs and on
further developing crisis intervention practice.
DEFINITION
Caplan (1964) initially defined a crisis as occurring when individuals are confronted
with problems that cannot be solved. These irresolvable issues result in an increase in
tension, signs of anxiety, a subsequent state of emotional unrest, and an inability to
function for extended periods.
James and Gilliland(2005) define crises as events or situations perceived as intolerably
difficult that exceed an individuals available resources and coping mechanisms.
Roberts (2000) defines a crisis as a period of psychological disequilibrium,
experienced as a result of a hazardous event or situation that constitutes a significant
problem that cannot be remedied by using familiar coping strategies
CHARACTERISTICS OF A CRISIS
The following are characteristics of crisis event
The event precipitating the crisis is perceived as threatening.
There is an apparent inability to modify or reduce the impact of stressful events.
There is increased fear, tension, and/or confusion.
There is a high level of subjective discomfort.
A state of disequilibrium is followed by rapid transition to an active stateof crisis.
There may be physical danger, which should be your first priority
You and your staff may suffer from confusion, friction, pressure and stress
Key staff may be unavailable
It may be difficult or impossible to carry out your usual daily activities
External support may be needed (e.g. from emergency services or neighbouring
businesses)
Coping mechanisms are skills or methods people use to reduce anxiety and solve
problems, such as reasoning, meditation, physical exercise, sleep, and denial.
CRISIS IN RESPONSE TO A STRESSFUL SITUATION DEPENDS UP ON
THE FOLLOWING THREE FACTORS
The individuals perception of the event- if the event is perceived realistically, the
individually is more likely to draw upon 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
The availability of situational supports-Aguilera stated 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 support during a stressful
situation, an individual is most likely to feel overwhelmed and alone.
The availability of adequate coping mechanisms-when a stressful situation occurs,
individuals draw up on behavioural 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 increase .
PARADIGM: THE EFFECT OF BALANCING FACTORS IN A STRESSFUL
EVENT:
TYPES OF CRISES
Although crises arise from many different sources, most healthcare professionals agree
there are at least three causal categories of crises: maturational, situational, and
adventitious (rare/unexpected/disastrous).
MATURATIONAL CRISES
Maturational crises have to do with the predictable transitions individuals
experience as they move from one stage of human development to another. In his
classic text, Erik Erikson (1963) identified eight stages of maturity delineated by
developmental tasks:
Infancy
Early childhood
Preschool
School age
Adolescent
Young adult
Mature adult
Late adulthood
He declared that each of these stages constitutes a crisis in personal growth and
development. For example, toddlers are developing autonomy and self-esteem and
may have a temper tantrum when they do not get what they want. Having a child and
retiring from the workforce are also situations that will cause major changes in what
an individual and/or family have previously considered normal. Taking a wait and
see approach has the potential to exaggerate the impact of the event.
Maturational crises are predictable and can be prepared for and prevented.
Proactively identifying actual or possible changes that the event will cause and then
taking steps to become more prepared for those changes can minimize the disruption.
For example, a young couple can take parenting classes to help prevent pediatric
head trauma that could result from shaking their infant out of frustration during a
period of uncontrollable crying.
SITUATIONAL CRISES
Situational crises arise from an external source and are events or circumstances
that threaten the physical, social, and psychological integrity of individuals. These
events may originate in the physical body as a result of disease or injury or in social
or emotional situations, such as the loss of a job or death of a child. Sometimes
maturational and situational crises occur at the same time, and occasionally, one
crisis triggers another, compounding the problem.
For example, a teenage boy and girl are attracted to one another and experiment
with sexual intimacy. When the menstrual period of the girl is late, both adolescents
are thrust into a state of emotional disequilibrium as they experience both the
maturational crisis of adolescence and the situational crisis of a potential pregnancy.
The actions they take to resolve the crisis may thrust them into even greater
confusion and tumult.
ADVENTITIOUS CRISES
Adventitious crises have been called events of disaster. They are rare,
unexpected happenings that are not part of everyday life and may result from 1)
natural disasters, such as floods, fires, and earthquakes; 2) national disasters, such as
airplane crashes, riots, and wars; 3) interpersonal disasters, such as assault and rape;
and 4) acts of terrorism.
The National Incident Management System (NIMS) provides a systematic
approach to the work necessary during such disaster situations (FEMA, 2013).
Training material for Community Emergency Response Teams (CERT) can be found
on their website (see Resources at the end of this course)
crisis are periods of psychological and behavioural upset precipitated by life
hazards that usually inflict significant losses on the individual (e.g. accident). Caplan
has used Erikson's classification in his theoretical development of crisis reactions. He
has emphasized that developmental and accidental crises are transitional periods that
present the individual. with both an opportunity for personal growth as well as for
deterioration.
BALDWIN (1978) has developed a classification of emotional crises
that includes six types of crisis situations:
1. Dispositional crises produced by problematic situations that can
be remediated through an appropriate management such as making a
referral, providing information and/or education, making administrative
changes, etc.
2. Crises of anticipated life transitions, that reflect normal life transitions
over which the person may have little control.
3. Crises resulting from traumating stress, which are precipitated by
externa1 stressors or situations that are unexpected, uncontrolled and
emotionally overwhelming.
4. Maturational/developmental crises, that result from attempts to
deal with interpersonal situations that reflect interna1 unresolved problems.
5; Crises reflecting psychopathology, in which pre-existing or current
psychopathology complicates their resolution.
6. Psychiatric emergencies, in which general functioning is severely
impaired.
Potential Crisis Situations
Common Crisis Situations
On a daily basis, situations arise that have the potential to adversely affect Special
Olympics business and reputation. When such situations develop, it is important for
the staff or volunteer who first learns of the situation to immediately inform his/her
supervisor. It is also important that volunteers are aware of what is considered to be a
potential crisis situation.
It is recommended that key volunteers receive the listing of potential crisis situations
so they may determine when to contact the appropriate Special Olympics contact.
Possible Crisis Situations and Levels of Impact
In the event of a crisis situation at any level, it is critical that the appropriate Special
Olympics Program staff or volunteers are contacted. It is also critical that the Crisis
Communications Manager is also contacted to determine how to communicate the
appropriate message to key publics and Special Olympics constituents.
Level 1
A minor incident or accident
Delayed event (but to be held the same day)
Sick participant not requiring hospitalization
Injured participant/spectator/volunteer treated on-site or taken to the
emergency room but released
Minor venue property damage
Severe weather watch
Level 2
A serious incident, accident or situation
Canceled event
Postponed event
Moved event/change of venue
Injured or ill participant/spectator/volunteer requiring hospitalization
Food poisoning/contamination
Allegations of wrongdoing by or arrest of a participant
Allegations of wrongdoing by or arrest of a spectator/volunteer/staff/guest or
celebrity (if financial, see level 3)
Missing participant
Illegal use of drugs/alcohol
Level 3
A critical incident or situation
All situations considered Level 3 should follow these channels of communications:
Special Olympics Program office Contact Special Olympics Regional Office
Regional Office contacts Special Olympics headquarters
National/State or Provincial declared emergency (e.g., natural disaster, power
outage, terrorist attack).
Actual impact of severe weather (e.g., hurricane, tornado)
Flood (if it shuts down office operations)
Bomb threat
Contagious health threat or outbreak
Missing participant or volunteer under suspicious circumstances
Death of a participant
Death of spectator or volunteer
Fire
Criminal activity
earthquake can have disastrous consequences and leave lasting damage, requiring
years to repair.
In 2012, there were 905 natural disasters worldwide, 93% of which were weatherrelated disasters. Overall costs were US$170 billion and insured losses $70 billion.
2012 was a moderate year. 45% were meteorological (storms), 36% were hydrological
(floods), 12% were climatological (heat waves, cold waves, droughts, wildfires) and
7% were geophysical events (earthquakes and volcanic eruptions). Between 1980 and
2011 geophysical events accounted for 14% of all
FINANCIAL CRISIS
The term financial crisis is applied broadly to a variety of situations in which some
financial assets suddenly lose a large part of their nominal value. In the 19th and early
20th centuries, many financial crises were associated with banking panics, and many
recessions coincided with these panics. Other situations that are often called financial
crises include stock market crashes and the bursting of other
financial bubbles, currency crises, and sovereign defaults. Financial crises directly
result in a loss of paper wealth but do not necessarily result in changes in the real
economy.
Many economists have offered theories about how financial crises develop and how
they could be prevented. There is no consensus, however, and financial crises continue
to occur from time to time.
CRISIS INTERVENTION
Crisis Intervention is emergency psychological care aimed at assisting individuals in
a crisis situation to restore equilibrium to their bio psychosocial functioning and to
minimise the potential for psychological trauma.
The priority of crisis intervention and counselling is to increase stabilization. Crisis
interventions occur at the spur of the moment and in a variety of settings, as trauma
can arise instantaneously. Crises are temporary, usually with short span, no longer than
a month, although the effects may become long-lasting.
Crisis Intervention is the emergency and temporary care given an individual who,
because of unusual stress in his or her life that renders them unable to function as they
normally would, in order to interrupt the downward spiral of maladaptive behavior and
return the individual to their usual level of pre-crisis functioning.
DEFINITION
Mobilizing Resources
Once a plan is formulated, the counselor works with the client and support system to
begin implementation. The counselor may help the client move directly to treatment
by helping to arrange for in-house care and transportation. If the choice is to use outpatient treatment, the counselor may continue to work with the client.
Termination of Agreement
Once the client moves into a treatment program, the counselor can terminate the
client-counselor relationship so the treatment program can work with the client. The
counselor may continue to work the support system to help them recover and avoid
enabling the client into further addictive behavior.
CRISIS INTERVENTION GUIDELINES
Every crisis is different, but all crises require immediate intervention to
interrupt and reduce crisis reactions and restore affected individuals to precrisis
functioning. Crisis interventions provide victims with emotional first
aid targeted to the particular circumstances of the crisis (Rosenbluh, 1981).
Several guiding principles are involved in crisis intervention; some key principles
are outlined below (Shapiro & Koocher, 1996).
Making an accurate assessment is the most critical aspect of a crisis response
because it guides the intervention. A wrong decision in response to a crisis can
be potentially lethal. Although situations may be similar, each person is unique;
therefore, care must be exercised to avoid overgeneralizing.
The ability to think quickly and creatively is crucial. People under crisis
sometimes develop tunnel vision or are unable to see options and possibilities.
The crisis responder must maintain an open mind in order to help explore
options and solve problems in an empowering manner with those affected.
People in crisis already feel out of control; when opportunities to restore control
present themselves, they should be grasped quickly.
The responder must be able to stay calm and collected. Crisis work is not
suitable for everyone. It requires the ability to maintain empathy while
simultaneously avoiding subjective involvement in the crisis.
Crisis intervention is always short term and involves establishing specific
goals regarding specific behaviors that can be achieved within a short
time frame. For example, in response to a suicidal client, a therapist
may increase the frequency of therapy sessions until the clients ideation
subsides. Management, rather than resolution, is the objective of crisis
interventions.
upon through a contract with family members. Reinforcements are provided when
family members exhibit a desirable response, and consequences are provided if
behavior is undesirable. Consistency is critical in both the approval (reinforcements)
and disapproval (consequences) of behavior. Positive results, or bonus reinforcements
such as family outings or free meals, can be given when behavioral objectives are
achieved. Consistency and follow through are essential to success.
Task-Centered Approach
Task-centered methods of treatment seem to merge well with crisis intervention theory
and practice, with research indicating that these methods are effective with a broad
range of clients. Uncontrolled studies on the effectiveness have been conducted in
medical, family, child guidance, psychiatric, school, corrections, and public-welfare
settings. Controlled studies in a school system and a psychiatric clinic in southside
Chicago rendered very positive results, as did a suicide prevention study and group
treatment of delinquent youth. Contracting, task planning, incentives, and homework
assignments, which keep families practicing communication and problem-solving
tasks between meetings with the crisis worker, are effective in moving the family
toward independence and nonabusive behaviors.
The Family Treatment Approach
In conventional family treatment, therapists permit situations to develop which
demonstrate how the family interacts and functions. The therapist then tries to engage
the most influential members to assure their active involvement in ongoing treatment.
Just as in crisis intervention, active listening comes first.
As with crisis intervention the major focus is on the family system rather than one
individual. In no way, however, does this prevent the therapist from being aware of
assigned family roles ("he is the mentally ill one"), scapegoating ("he is the cause of
our problems"), or triangulation ("detouring" of parental problems through the child)
within the family.
Family secrets, myths, enmeshment, dyads, triads, and schisms give clues to why the
family has become so dysfunctional and what was brewing underneath the surface
before the crisis-precipitating event.
Family treatment is inseparable from crisis intervention, and, in addition to being more
cost effective for most children and families, family preservation is more desirable
than separation.
emphasizes the uniqueness of each client and each situation and allows for openness,
empathy, and honest-but-respectful feedback to clients. Existentialists use
"provocative contact" in assertively provoking "hard-to-reach" clients toward wanting
change in their lives. This offers clients an opportunity to at least consider the use of
behavior modification in making specific behavior or symptom changes.
Gestalt theory does not hypothesize about unobservable systems in the client's life, but
may ask the client to reenact his or her perceptions of them. Gestaltists look for
patterns or descriptions of interactions, which are not working, as opposed to
diagnoses or labels. Similarly, client-centered theory is opposed to diagnosing and
labeling, believing that families are capable of knowing and shaping what is best for
them.
TECHNIQUES
Special treatment techniques such as humor, generalization, self-disclosure,
storytelling, limit-setting, and instillation of hope are effective in crisis intervention.
By understanding client resistance, treatment outcomes are further enhanced.
Use of Humor
It is imperative for crisis workers to set aside time for client social activities and fun.
Many clients have never had fun. Good professional role models demonstrate a fun
loving sense of humour from time to time.
It is also helpful for crisis workers to respond to their own mistakes with humour.
When a verbal or tactical error is made in front of clients, crisis workers need to
demonstrate their comfort in laughing at themselves. This helps clients relax and
realize that professionals are not perfect and that they may be able to laugh at their
own mistakes someday, too. Words of caution are warranted here, however. Some
clients are prone to concrete interpretation of humour. In other words, if professionals
laugh at themselves or encourage clients to, these clients may feel emotionally
degraded. Some clients are ultrasensitive to teasing and require months of addressing
past trauma or verbal abuse before they can understand the subtleties of humour.
Generalization
Generalization is another good technique to use with clients in crisis. Saying "we all
get angry and don't know how to express it sometimes" is more effective than
implying that clients get angry and professionals never do.
When crisis workers keep their promises, clients begin to trust and to believe in
change. When clients and professionals form a positive "team" that builds on client
strengths, change occurs.
Working Through Resistance
By objectively, nonjudgmentally, and respectfully focusing on family strengths and the
immediate crisis, crisis workers can minimize client resistance during early
intervention. For example, the crisis worker should state the allegations of child
maltreatment and ask the family to clarify any discrepancies. Conveying hope that the
allegations can be worked through if the family cooperates is effective in moving the
family toward desired change. Family members need to know what they are expected
to do, what consequences they are facing, and what services they will receive if they
cooperate.
Crisis workers must be careful how they use their professional authority. If authority is
misused, parents may experience a double message: Parents should not misuse power
with their children, but professionals may misuse power with parents. Such double
messages create confusion and resentment. If crisis workers expect clients to be
effective parents, then they need to be role models of behavior for the parents.
Anything less is likely to create new crises, further weakening the family's level of
functioning.
In periods of crisis or disorganization, people may feel more inadequate, alienated, or
needy, thereby causing them to take on facades of adequacy, arrogance, or
dependency. They may withdraw or they may attack, according to what they perceive
as necessary for survival. They may act as if they need no help, even when they need it
desperately. Whatever the clients' facade, crisis workers must remember that families
in crisis crave respect, care, and compassion. They want to regain some semblance of
security and stability.
Often, CPS crisis workers complain that the "nonoffending parent" in sexual abuse
cases is passive or defensive and refuses to become involved in family treatment.
Instead, crisis workers need to evaluate whether the nonoffending parent has always
been defensive or passive. If it is new behavior, then the nonoffending parent is merely
frightened and afraid the family will be destroyed. Such fears can be honestly
recognized by the crisis worker. If the defensiveness is typical behavior, the
nonoffending parent will need to observe positive role modeling, have total honesty
from crisis workers, and receive training on how to respond more openly. In the
meantime, crisis workers need to realize that an accusation of abuse, the consequent
investigation, and an influx of various strangers into the home would make anyone
defensive.
By assessing the reasons for clients' recalcitrant behavior, crisis workers can then
address the clients' needs for answers or information. They may have many remaining
questions about the intervention. For example:
What further consequences may they expect?
What happens next?
What is expected of the family and its members?
Is the crisis worker a nonjudgmental, credible, honest, and respectful
professional?
What resources can the crisis worker and community offer that can help the
family?
Will the crisis worker listen to and respond to family needs?
Does the crisis worker see any strengths in the family?
Is the crisis worker implying that solutions to the crisis are available?
Is there hope for the future?
Rather than believing that clients are resistant, do not want to change, are denying
their problems, or are being deceitful, crisis workers need to believe clients when they
express a desire to reach a solution.75 When clients seem "resistant," it is best to
assume that they are merely frightened and hesitant about trying new behaviors or the
unfamiliar. They need crisis workers to be patient and listen to how they are feeling
and what they suggest for relieving the crisis. If crisis workers convey that clients are
the experts on what they want, and if professionals are honest with themselves about
what they are feeling, then they will give clients room to make the changes that they
need.
For instance, a nonoffending parent in a child sexual abuse case may be fearful of
losing her identity as a member of an intact family; her identity as wife of a certain
man; her identity as part of a neighborhood or a church; her identity as a member of a
respected family; her identity as part of a household which had a good income but
must now accept welfare benefits. A skillful crisis worker must be prepared to explore
all of these possibilities with the parent, rather than proposing "quick" solutions, such
as divorce.
If there is such a thing as resistance to change, some of the causes or sources may be:
uncertainty about change or fear of failure;
fear of loss of the familiar;
lack of confidence in the crisis worker;
lack of participation in developing crisis resolution goals;
inability to see change as a viable alternative;
inappropriate timing on the part of the crisis worker;
disruption of important, existing family or social relationships; and
belief that change equals criticism.76
Some interviewing techniques which can be used to work through client
resistance include:
active listening and reflection;
universalizing (normalizing);
partialization (breaking into several smaller issues) of problems, when the client
presents numerous issues;
ventilation of feelings (with closure before the interview ends);
summarization of client feelings after extended listening;
acceptance of the client, but not the client's abusive or neglectful behaviors;
logical, not rambling and disorganized, discussion;
education or information about crisis intervention, forthcoming events,
community resources, etc.;
If crisis workers are respectful of culture and empathetic with the predicament in
which families find themselves, new horizons may start to open up. For many families,
crisis workers will only have time to help them stabilize, but can help them contact
other therapists and agencies where client culture is honored.78 Ultimately, crisis
workers who are effective listeners are so responsive to clients' needs that there is no
reason for clients to resist. This, however, takes great patience and a willingness to
meet clients' needs rather than crisis workers' needs.
Appearance
Behaviour
Speech
Thought
Perceptual Disturbances
Cognition
Measurements
Medications
Laboratory tests
DIAGNOSIS
After assessing the person in crisis, clinicians make a tentative diagnosis using
one of three major diagnostic classification systems, all of which identify the
problem or unmet need, the probable cause, signs and symptoms, and other
supporting data. These systems include:
International Statistical Classification of Diseases (ICD-10)
Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
Nursing Diagnoses: Definitions and Classifications (NANDA)
All caregivers need to be familiar with ICD codes and DSM-5 codes because
healthcare organizations and government agencies use these codes to pay clinicians
for their professional services.
ICD-10
The International Statistical Classification of Diseases, 9th Revision (ICD-9)
was adopted in the United States in 1979, and in 1988 Medicare required physicians
to report conditions using this code. In 1990 the International Statistical
Classification of Diseases, 10th Revision (ICD-10), was published by the World
Health Organization (WHO) and adopted worldwide in 1994. The United States was
ready at that time also to adopt ICD-10 to align with WHO and other countries, but
this was put on hold following the enactment of HIPAA (Health Insurance Portability
and Accountability Act) in 1996. Since then, legislative steps have been ongoing, and
in October 2014 ICD-10 becomes effective in the United States.
ICD-10 is not a revision of ICD-9 but rather a replacement that is more
clinically accurate and offers more available codes and a less-restrictive coding
structure (CDC, 2013). The ICD-10 classifies both psychiatric and medical
syndromes (clusters of symptoms) using a number and a word or phrase, such as
295.30 Schizophrenia, paranoid, or 577.1 Pancreatitis, chronic. The code
number facilitates research studies, demographic data collection, and the
reimbursement of providers.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) was
published by the American Psychiatric Association in 2013. DSM-5 is a standard
classification of mental disorders used by mental health professions and contains a
listing of diagnostic criteria for every psychiatric disorder recognized by the U.S.
healthcare system. It is used in both clinical settings as well as with community
populations. In addition to supplying detailed descriptions of diagnostic criteria,
DSM-5 is also used for collecting and communicating accurate public health
statistics about the diagnosis of psychiatric disorders (APA, 2014).
NANDA
A complete nursing diagnosis states a response to a health problem related to a
medical or psychiatric disorder, as evidenced by signs and symptoms exhibited by
the patient. For example, risk for suicide, related to depressed mood, as evidenced
by statements of patient and reckless behavior such as drinking and driving.
PLANNING
When clinicians assess a person in a mental health crisis and diagnose the
disorder, they and the patient decide what goals and outcomes are desirable and
feasible. They then determine the process by which each outcome can be achieved.
Naturally, outcomes depend on the setting and condition of the person in crisis.
For example, for a patient who hears voices telling him to hurt himself, a
NANDA diagnosis might be disturbed thought processes related to schizophrenia,
paranoid type, as evidenced by persecutory hallucination. The outcome criteria
might be to consistently refrain from doing what the voices command.
INTERVENTION
Interventions are the actions healthcare professionals take to achieve identified
outcomes. Such actions are based on the clinical knowledge, judgment, and skill of
the professional; how acceptable the intervention is to the person in crisis; and
whether the action is feasible given the circumstances of the individual.
When a patient is a danger to self or others, as with the patient who hears voices
telling him to hurt himself, it may be necessary to call the authorities for emergency
involuntary commitment, whereby the individual is restrained and taken to a locked
facility for evaluation and treatment. Emergency departments and telephone crisis
centers often develop standardized procedures called clinical protocols to assist
caregivers in giving more appropriate and effective emergency care to people in
crisis. For example, when a victim of sexual assault comes to an emergency
department, clinicians implement what is called a rape protocol. As well as
physical and forensic interventions, this type of protocol will include mental health
interventions such as:
Providing emotional support and privacy
Staying with the patient
Referring the person to a rape advocacy program
EVALUATION
The effectiveness of an intervention is judged by its outcome. When outcome
goals are met, the crisis is resolved, and the person in crisis is returned to a prior
level of functioning, then the healthcare professional can rightfully say the
intervention was successful. Ideally, as a result of the intervention and anticipatory
guidance, individuals who have been in a crisis also learn new coping skills, increase
their social support network, and are better equipped to cope with future disruptive
events in their lives.
EMERGENCY-PRODUCING CRISES
Emergency-producing crises can be grouped into five categories: 1) moodrelated (mania, depression, and suicide), 2) anxiety-related, 3) anger-generated, 4)
substance use, and 5) major mental illness. All of the conditions require immediate
assessment and knowledgeable interventions from caring professionals.
Mood-Related Crises
All people experience a range of moods, from great joy to profound sadness.
They express these moods in an array of behaviors, from laughing and smiling to
weeping and withdrawing. When moods become exaggerated at either end of the
emotional spectrum, they become disorders, limiting the ability of the person to
function socially or occupationally.
In their extremes, mood disorders produce the frenzy of mania, the melancholy
of depression, and suicide. When people experience mood disorders and seek help in
emergency departments or on crisis hotlines, clinicians need to recognize typical
symptoms, identify their cause, plan a course of action, implement the plan, and
evaluate its effectiveness.
MANIA
Manic episodes are periods of extreme elevation of mood when people feel
expansive, energetic, grandiose, and, sometimes, irritable and short-tempered.
Typical manic behaviors are:
Inflated self-esteem or grandiosity
Decreased need for sleep (feel rested after only 3 hours of sleep)
More talkative than usual or pressured to keep talking
Subjective experience that thoughts are racing or flight of ideas
Distractible, attention easily drawn to unimportant or irrelevant external stimuli
Intense, goal-directed activity either socially, sexually, or occupationally
Hyperactive behaviors and symptoms occurring in episodes of a week or more
Be well hydrated within 24 hours, as evidenced by good skin turgor and normal
urinary output and concentration
Maintain or obtain stable cardiac status as evidenced by stable vital signs within
normal limits
Maintain or obtain tissue integrity as evidenced by absence of infection or wounds
Get sufficient sleep and rest as evidenced by 46 hours of sleep at night
Demonstrate self-control with the help of staff or medications as evidenced by
absence of harm to others
Make no attempt at self harm with the help of staff or medications as evidenced by
safety checks during acute mania
(Varcarolis, 2013)
Intervention
To meet outcome criteria and ensure safety, medical stabilization, and external
control, people in crisis manifesting manic symptoms need hospitalization. If they
are not cooperative and are a danger to themselves or others, emergency involuntary
commitment may be necessary (see Legal Issues above). To gain their cooperation
and communicate more effectively, clinicians:
Use short and concise statements and explanations
Use a calm but firm approach
Remain neutral, avoiding power struggles
Coordinate care with other staff members to avoid manipulation
Medications prescribed for acute manic episodes include:
Mood stabilizers and anticonvulsants: lithium and valproic acid
Atypical antipsychotics: olanzapine, risperidone, quetiapine
Typical antipsychotics: chlorpromazine, haloperidol
Evaluate whether the person is psychotic, has taken drugs or alcohol, has medical
conditions, or has a history of psychiatric syndromes.
Ask if the person has a history of depression.
Assess support systems, family, significant others, and the need for referral.
In crisis situations, there may not be time to complete an assessment according
to these guidelines. Assessing a person in these circumstances requires observing for:
Verbal clues
o Expressing strong feelings of hopelessness
o Making covert statements such as Things will never work out
o Making overt statements such as I wish I were dead
Delusional thinking
o God wants me dead.
Cognitive function
o Slowed speech and understanding
o Difficulty concentrating or making up ones mind
Behavioral clues
o Psychomotor agitation
o Giving away prized possessions
o Acting recklessly
Affect
o Flat, without expression
SHEILA
Sheila came to the community counseling center for help. She told Mary, the
counselor, that the man she had been dating had left her and returned to Mexico to
marry a girl from his home village. Sheila burst into tears: I dont think I can live
without him.
Mary listened attentively and asked, Have you been thinking about not living?
Sheila nodded and whispered, Yes, and began to sob. The counselor said, And
what have you thought about doing? After a long pause, Sheila said, I just want to
go to sleep and never wake up.
Mary hypothesized that Sheila did not have a specific plan to end her life but
was at risk of overdosing on alcohol or drugs, the most common means women use
to commit suicide. She told Sheila to refrain from taking alcohol in any form until
she felt better; asked if Sheila had a friend or relative who could stay with her for a
few days, just to be there for her; gave Sheila her card and the crisis hotline number
to call if she felt like harming herself; and referred Sheila to a support group of
others who had suffered loss.
(continues)
Diagnosis
Medical Diagnoses. The APA (2013) recognizes eight types of depressive
disorders that do not have manic features. The eight types of depressive disorders
are:
Disruptive mood dysregulation disorder in children
Major depressive disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
Substance/medication-induced depressive disorder
Depressive disorder due to another medical condition
Other specified depressive disorder
Problem-solving therapy
Supportive therapy
Psychosocial intervention
Bereavement groups
Family counseling
Participation in social events
Psychoeducation
Exercise
Nursing interventions for severely depressed patients include providing food
and fluids, suicide precautions, personal hygiene, supportive communication, and
psychotherapy using cognitive-behavioral, psychodynamic, and interpersonal
approaches. If a person is hospitalized because they are deemed at risk for suicide,
suicide risk precautions are implemented.
Suicide risk precautions include:
Search patient and belongings for harmful objects.
Make sure visitors do not leave potentially harmful objects or gifts in patients
room.
Keep electric cords to minimal length.
Hang-proof and jump-proof bathrooms.
Provide plastic eating utensils.
Do not assign patient to a private room.
Lock utility rooms, kitchens, stairwells, windows, and offices.
Conduct one-to-one nursing observations and interaction 24 hours a day.
ASSESSMENT
As with everyone who comes to an emergency facility for help, a physical
examination and at least a modified mental status examination should be performed.
Although all anxiety disorders are fear-based, the symptoms they display differ
greatly.
Assessment guidelines for anxious individuals in crisis include the following:
Assess for potential self-harm, because people with high anxiety are more likely to
become desperate and suicidal.
Conduct a physical and neurologic examination to determine whether the anxiety
is the cause or the result of substance use or a medical or psychiatric disorder.
Assess for psychosocial and environmental problems that may be affecting the
person, such as stressful relationships, recent loss of job, and economic pressures.
Consider cultural differences that may affect the way people exhibit anxiety.
ANXIETY VERSUS CARDIAC CONDITIONS
Persons experiencing acute anxiety or panic may appear in the emergency
department with symptoms that closely resemble cardiac conditions, including:
Palpitations, heart pounding
Diaphoresis
Shakiness, unsteadiness
Sensation of choking
Chest pain
Nausea
Dizziness
Feeling of impending doom
Caregiver Interventions
Teaching interventions include:
Medication management
Behavioral therapy techniques to reduce anxiety
Relaxation exercises
Cognitive reframing (changing negative thoughts to positive ones)
Lifestyle personal care, such as nutrition, exercise, and sleep
Referral interventions include:
Community resources, such as an obsessive-compulsive disorder (OCD) support
group
Personal psychotherapy to gain self-knowledge
EVALUATION
The treatment of anxiety disorders is considered successful if symptoms of
anxiety in patients are reduced and they are able to live a happier, less fearful life.
Anger-Generated Crises
Anger-generated crises that involve assault and battery are well known to
clinicians in emergency departments and on crisis hotlines. In recent times, violence
has become a serious public health issue, affecting individuals, families, entire
communities, and healthcare providers. For this reason it is essential that clinicians
understand anger and aggression, recognize its signs and symptoms, plan appropriate
interventions, and evaluate those interventions. The goal of such care is to ensure
safety for everyone concerned.
In his classic study of human emotions, Robert Plutchik (1991) identified anger
as one of the primary emotions, an inborn response to the frustration of desire. The
purpose of anger is to remove whatever is blocking a desire or need.
Conduct disorder
Antisocial personality disorder
Pyromania
Kleptomania
Other specified disruptive, impulse-control, and conduct disorder
Unspecified disruptive, impulse-control, and conduct disorder
Caregiver/Nursing Diagnoses
Diagnoses for patients who display aggressive behavior include
Risk for self-directed violence
Risk for other-directed violence
Aggression self-control
Ineffective coping
(NANDA, 2014)
PLANNING
Without question, de-escalation of anger and prevention of violence is the
primary outcome criteria for interventions with angry patients. Such planning takes
into account resource availability and situations in which violence may occur, is
occurring, or has occurred.
In planning interventions, it is important to consider the stages of violence.
These are the:
Pre-assaultive stage: tension increases and person becomes increasingly agitated
Assaultive stage: person loses control and becomes violent
Post-assaultive stage: person is calm and incident is reviewed
INTERVENTION
Pre-assaultive stage interventions focus on de-escalation of anger. Clinicians
follow these practices:
1. Assess patients and their situation and reassure them of your concern and expectation
that they will stay in control of themselves.
2. Place patient in a quiet and secure area and inform staff of what is happening. When
possible, interact with patients in a quiet place that is in plain view of other
caregivers.
3. Never turn your back on or walk ahead of the individual.
4. Ensure you have a safe escape route.
5. Demonstrate respect for personal space, thus decreasing the threat. If the person is
sitting, sit. If the person is standing, stand.
6. Remain calm and nonconfrontational in words and actions.
7. Interact with patients respectfully in a slow, low, and nonthreatening voice.
8. Verbalize options. Encourage patients to assume responsibility for the choices they
make and acknowledge the difficulties they have in making choices.
9. Use time wisely. Give adequate time for depressed or suicidal patients to consider
options. Set limits with manipulative patients.
10.Provide continuous observation and record behavior changes in patient notes.
11.Secure personal safety:
Avoid dangling jewelry.
Alert other caregivers.
Eliminate hazards caused by furniture or other objects.
Stand to the side of patients, not directly in front of them in a threatening way.
If patients begin to escalate, provide feedback, assure them that they will be safe.
stressors, and teaching alternative coping behavior. When it is available, patients are
referred to longer-term counseling and anger management group therapy.
EVALUATION
After an assault by a patient, clinicians need time to regroup and regain a sense
of personal safety, control, and security. It is important to take time to debrief and to
discuss what happened, what went right, what went wrong, and what they will do in
future situations. All incidents of violence are reported and documented according to
agency protocol.
CASE
Curt and his nine-year-old son were tossing a football back and forth when the
son fell backward onto a sharp rock, which cut a deep gash in his scalp. Curt rushed
the boy to the emergency department (ED) at the local hospital and stood by
anxiously as the triage nurse examined his injury. She said the doctor would come to
see the boy soon and left, closing the cubicle curtain behind her.
Curt waited as minutes went by. Getting anxious, he went to the curtain, pushed
it aside, and gazed out at the busy unit. Workers rushed this way and that, but no one
came to see his son. Curt went to the desk and asked the clerk when the doctor would
come to see his son. The clerk said the doctor was seeing other patients and would be
there shortly. Curt returned to his sons cubicle and waited, leaving the curtain open.
After some time, Curt went back to the clerk. How much longer is it going to be?
The clerk barely looked up and said, It wont be much longer.
More minutes crawled by, and Curt became more and more agitated. His
perception of the event was that this was a life-and-death situation. He had no
support system except the ED staff, and they were too busy to help. His usual coping
mechanism was actionoften aggressivenot passivity. His son groaned in pain,
and Curt became angrier by the minute. He set his jaw and went to the clerk,
clenched his fist, pounded on the counter, and shouted, You said the doctor would
come and take care of my son! That was ages ago! Where is he? Wheres the f**king
doctor?!
A nurse overhearing this exchange immediately approached Curt and quietly and
calmly asked if she could be of assistance. She listened to Curt, asking open-ended
questions and acknowledging his anger. She empathized with his concern and
Opiates
Hallucinogens
Phencyclidine piperidine (PCP)
Inhalants
Nitrates
Anesthetics
CNS depressants
Alcohol withdrawal
Complicated alcohol withdrawal with delirium tremens (DTs)
DIAGNOSIS
Medical Diagnoses
In the DSM-5, the APA (2013) lists a large number of substance-related
disorders: 6 alcohol, 4 caffeine, 6 cannabis, 9 hallucinogen, 4 inhalant, 5 opioid, 5
sedative/hypnotic/anxiolytic, 5 stimulant, 4 tobacco, and 6 other substance disorders.
Studies have suggested that almost one third of persons with a mental illness
and about one half of persons with severe mental illness also experience substance
abuse. Likewise, more than one third of all alcohol abusers and one half of all drug
abusers have mental illness. When more than one disorder presents, patients are
described as suffering from dual diagnoses or co-morbid conditions (NAMI, 2013b).
Caregiver/Nursing Diagnoses
Many caregiver/nursing diagnoses are appropriate to substance abusers,
indicating just how dysfunctional their lives may be. Some common diagnoses
include:
Disturbed sleep pattern
Ineffective health maintenance
Imbalanced nutrition
Deficient fluid volume
Risk for electrolyte imbalance
Ineffective impulse control
Impaired environmental interpretation
Disturbed thought processes
Hopelessness
Nonadherence to healthcare regimen
Anxiety
Self-care deficit
Ineffective coping
Dysfunctional family processes
Risk for suicide or violence to others
(NANDA, 2014)
PLANNING
The goal of emergency care of substance-using individuals is to provide
immediate, life-saving measures, identify the drug or drugs the individual has taken,
and give supportive emotional care. The goal of long-term care is to encourage
abstinence from substance abuse, meet physical and emotional needs, restore selfrespect, and assist patients to establish a support system.
INTERVENTIONS
In the emergency department, interventions for a substance-abusing individual
include identifying the specific drug or drugs he or she has taken, giving immediate
life-saving care, providing food and fluid, and transporting the patient to inpatient
care or referring to outpatient care.
Sadly, many substance abusers are homeless and friendless and afflicted with
serious co-morbid conditions. Some communities provide shelter and drug treatment
facilities, but persons must agree to the rules and regulations of such facilities. Many
refuse, preferring to live on the street until another crisis sends them back to the
emergency department.
EVALUATION
Clinicians in emergency departments evaluate how well they have met the
immediate needs of patients, though they may find it difficult to empathize with
those who return over and over again. Nevertheless, it is important to determine the
success of interventions by evaluating whether the principles of ethics were involved
in providing care to each individual patient.
CASE
The owner of a small downtown caf called the police. One of those homeless
drunks is out cold on my doorstep. Yep, I know the man names Ken. He hangs
around all the time, bothering customers and begging for leftovers sells cheap
newspapers and uses the money for booze.
The owner hung up and went back to the entrance of his caf. Ken had vomited
all over himself. When the owner nudged him with his foot, Ken groaned but didnt
move. When the police arrived, they called an ambulance.
The emergency department (ED) staff knew Ken well. He had a long history of
coming to the ED, responding to care, being discharged, and then repeating the
cycle. This time the staff was determined to do things differently. They gave
emergency care, admitted Ken to a medical unit, and referred him to social services.
When Ken was sober and his condition stable, social workers devised a long-term
plan that included housing and alcohol rehabilitation.
Major Mental Illness Crises
When precipitating events occur in the lives of people with major mental
illnesses, they may become so distressed that they seek help in an emergency
department or by means of a crisis hotline. This is not surprising, since the coping
skills and support systems of these individuals often are limited. Clinicians need to
assess the signs and symptoms of such individuals, diagnose their disorders, plan
their care, intervene, make appropriate referrals, and evaluate the effectiveness of
interventions. Some of the more common major mental illnesses seen in emergency
departments are:
Delirium (acute confusional state): Individual experiences a disturbance of
consciousness and change in ability to think that develops within a few hours or
days. Delirium is a syndrome and is always secondary to another condition, such
as a general medical condition, medications, or substance use.
Dissociative disorders: Individual experiences a disturbance of memory
(amnesia), depersonalization (disconnected or detached), or confusion about
personal identity. A dissociative identity disorder is present when the individual
exhibits two or more distinct personalities.
Mania: Individual exhibits a period of expansive or irritable mood, lasting at least
a week. The person is talkative, grandiose, sleeps very little and experiences a
INTERVENTIONS
Immediate interventions for individuals suffering from the disorders listed
above are carried out in the emergency department in consultation with their personal
physician. Ongoing interventions are provided by either a facility to which they are
sent or to their family or other responsible caregivers. Discharge planning and
referral to social service agencies is essential.
EVALUATION
As discussed earlier, clinicians evaluate the care they give patients, especially
the care they give vulnerable persons who arrive alone, without family or friends. In
a way, the arrival of a patient in an emergency department constitutes a precipitating
event of a potential crisis for the staff. Clinicians use their coping skills (experience,
knowledge, and reasoning) and support system (professional colleagues) to meet the
needs of each patient. Thus, a potential crisis is resolved.
CONCLUSION
Individuals experiencing an emergency-producing mental health crisis need
immediate, appropriate, and sensitive care, whether the crisis is caused by a mood
disorder, anxiety, anger, substance use, or a major mental illness. Although clinicians
who work in emergency departments and on crisis hotlines encounter these
individuals every day, all healthcare professionals meet people in crisis who are
overwhelmed by mental and emotional distress. It is important that all caregivers be
educated to rapidly assess, diagnose, plan, and intervene in such situations.
Mental health crises have a high risk for poor outcomes, and it is imperative
that healthcare professionals respond appropriately. Evaluation of responses requires
the determination that ethical principles be followed and that these individuals
receive compassionate care.