Notes: Crisis

Crisis

            A sudden event in ones life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem ( Largerquist,2001)
  Phases in the development of crisis
 Caplan has outlined 4 specific steps through which individual progress in response to a precipitating stressor and which culminate in the state of acute stress
  Phase 1:

• The individual is exposed to a precipitating stressor.
• Anxiety increases
• previous problem solving techniques are employed.

Phase 2:

• When the previous problem solving techniques do not relieve the stressor, anxiety increases further.
• The individual begins to feel a great deal of discomfort at this point.
• Coping techniques that have worked in the past are attempted and found not successful.
• Feelings of confusion and disorganization prevail.

Phase 3

• All possible resources , both internal and external are called 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

Phase 4

• If resolution does not occur in the previous state, 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, behavior may reflect the presence of psychotic thinking

Characteristics of crisis

• Occurs in all individuals at one time or another and is not necessarily equated with psychopathology
• Are precipitated by specific identifiable events
• Are personal by nature
• 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

Types of crisis

• Maturational crisis- These are the predicted times of stress in everyones life which occurs in response to a transition from one stage to another in the life cycle. The transition points where individuals move into successive stage often generate disequilibrium. Individuals are required to make cognitive and behavioral changes and to integrate those physical changes that accompany development. The transitional periods or events that are most commonly identified as having increased crisis potential are adolescence, marriage, parenthood, midlife and retirement.
• Situational crisis- occurs in response to a sudden unexpected event in a persons life. The critical life events revolve around experiences of grief and loss. A situational crisis is one that is precipitated by an unanticipated stressful event that creates disequilibrium by threatening ones sense of biological, social or psychological integrity.

Eg: loss of a job, divorce, abortion, death of a love one, severe physical or mental illness, premature birth, status and role changes,  change in geographic location and poor performance in school.

• Social crisis-Social crisis is accidental, uncommon, unplanned and unanticipated and results in multiple losses and radial environment changes.

Eg: Natural disasters, hurricanes, flood, fire, earthquake, war, riots, Crime of violence.

• Dispositional crisis- An acute response to an external situational stressor.

Eg: A person who got scolding from boss showing that anger at home to wife.
  Crisis intervention
 It is a technique used to help an individual or family to understand and cope with the intense feelings that are typical of a crisis.
  Principles

• Be specific, use concise statements, and avoid over whelming the patient with irrelevant questions or excessive detail.
• Encourage the expression of feelings.
• A calm, controlled presence reassures the person that the nurse can help.
• Listen for facts and feelings, seeking clarification, paraphrasing and reflection are effective strategies.
• Allow sufficient time for the individuals involved to process information and ask questions.
• Help patients legitimize feelings by letting them know that others in similar situations have experienced comparable emotions.
• Clarify distortions by getting persons to look at the situation realistically, focus on what can be changed versus what cannot.
• Empower person by allowing them to make informed choices.
• Assist the person in confronting reality.
• Encourage the person to focus on one implication at a time.

Techniques

• Catharsis: the release of feelings that takes place as the patient talks emotionally charged areas
• Clarification: encouraging the patient to express more clearly the relationship between certain events.
• Manipulation: using the patients emotions, wishes or values to benefit the patient in the therapeutic process.
• Reinforcement of behavior: giving the patient positive reinforcement to adaptive behavior.
• Support of defenses: encouraging the use of healthy, adaptive defenses and discouraging those that are unhealthy or maladaptive.
• Increasing self- esteem: helping the patient to regain feelings of self worth.
• Exploration of solution: examining alternative ways of solving the immediate problem.

Process of crisis (resolution of crisis)

• Pseudo resolution

   In this the client uses repression and pushes out of consciousness the incident and the intense emotions associated with it, resulting in the individual functioning at the same earlier level. But in future, if and when a crisis occurs, the repressed feelings may surface on, but influence the feelings aroused by the new crisis.

• Unsuccessful resolution

         The victim uses pathological adaptation at any phase of crisis, resulting in a lower level of functioning. The victim, rather than accepting the loss and re cognizing his life, keeps ruminating over the loss. An example is prolonged grief reaction, which results in depression.

• Successful resolution

         The victim may go through the various phases of crisis, but reaches phase III where various coping measures are utilized to resolve the crisis situation. The victim develops better skills and problem solving ability, which can be and will be used in various crisis situations in future.
  Role of nurse Phase 
1. Assessment                   In this phase, the crisis helper gathers information regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. A nurse in crisis intervention might perform some of the following assessments:

• Precipitating event or stressor
• Patients perception of the event
• Nature and strength of support system available
• Level of psychological stress client is experiencing
• Patient previous strengths and coping mechanisms.

Phase 2: Nursing diagnoses Primary nursing diagnoses are

• Ineffective individual coping
• Anxiety
• Risk for self- or other- directed violence
• Post trauma syndrome
• Fear
• Chronic low self esteem
• Hopelessness
• Disturbed Sleep pattern

Phase 3: Planning of therapeutic intervention and outcome identification

• Causes for present crisis are identified
• Alternative solutions are explored with the patient
• Strategic plan for achieving this solution is created.
• Necessary environmental support is being facilitated.

Phase 4: Implementation Interventions are

• Environmental manipulation- This involves modification of individuals physical and interpersonal environment which may predispose to crisis.
• General support- It is the general support provided by the nurse by showing empathy, warmth and reassurance.
• Generic approach- This approach is used for a large group who are at high risk. Debriefing and group support enables recovery from the traumatic event.
• Individual approach- It is one to one approach in identifying and providing support in resolution of crisis.

Phase 5: Evaluation             During this phase the nurse and the patient evaluate the changes have occurred. If goals are not met, the patient and the nurse will return to first phase.  
  Modalities of crisis intervention

• Mobile crisis programs
• Telephone contacts
• Disaster response
• Group work
• Victim outreach programme
• Crisis intervention centers
• Health Education