CRISIS AND CRISIS INTERVENTION
Katherine R. Casale
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Discuss how the body responds to stress
2. Define crisis
3. Identify the characteristics of crisis
4. Explain the factors that impact an individual’s response to stress and development of crisis
5. Differentiate among the types and magnitudes of crisis
6. Describe crisis intervention
7. Trace the historical and current role of the psychiatric-mental health nurse in crisis intervention and stress management
8. Apply the nursing process for crisis intervention to develop a plan of care for a person experiencing crisis
9. Explain the methods used to assist psychiatric-mental health nurses to deal with effects of providing crisis care
Nurses have many opportunities to interact with patients while engaged in the interpersonal relationship for delivering psychiatric-mental health nursing care. It is inevitable that many of these interactions will occur during moments of crisis. Crisis in mental health may range from violent out-of-control behavior to withdrawal and suicidal ideation, affecting individuals, families, communities, and the world. Understanding the nature of crisis and how to best intervene are crucial to a nurse’s skill set. Nurses have the ability and moral obligation to prepare for and respond to these critical moments of human need. With knowledge in crisis intervention, nurses are thus empowered to make a difference during these pivotal moments.
This chapter briefly reviews the stress response and how it relates to crisis. It discusses the characteristics and types of crises and the factors that can affect an individual’s response to a crisis. Integrating the interpersonal relationship and therapeutic use of self, the nurse’s role in crisis intervention is explored by applying the nursing process.
STRESS is an increase in an individual’s level of arousal created by a stimulus. Initially, as stress levels increase, a person’s performance and ability to focus may actually improve. Attention to detail sharpens and the person is in a heightened state of readiness to take in the world around him. Immediately, the body physiologically responds to stress via the brain, which alerts the adrenal glands to produce adrenaline (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011). This classic “fight or flight” reaction can ensure one’s safety. However, once a stress threshold is crossed, these benefits are lost and performance and health deteriorate. A sustained stress response can cause damage to the cardiovascular, immune, and nervous systems, causing chronic illness and maladaptation (U.S. Department of Health and Human Services [DHHS], 2005). Evidence-Based Practice 6-1 provides information of the potential effects of stress.
Stress is a stimulus that increases an individual’s level of arousal.
General Adaptation Syndrome
Hans Selye first identified the body’s reaction to physiological stress through research he performed in 1956 on laboratory animals. Termed the general adaptation syndrome, he identified three stages of a person’s reaction to stress and the accompanying responses experienced. Since his initial research, additional studies have shown that this response occurs not only when a person is subjected to physiological stress but also when subjected to psychological or emotional stress.
In this stage, the body is stimulated by a stressor. This causes the hypothalamus, in turn, to stimulate the sympathetic nervous system, which leads to innervation of the glands, such as the pituitary and adrenal glands and various body systems to prepare the body to defend itself against the stressor. Table 6-1 summarizes the major events that occur in the body during the alarm stage.
Resistance and Recovery Stage
In the resistance and recovery stage, the body continues to maintain its preparedness against the stressor and adapt to the situation. If the person is able to adapt, the stressor abates and the body recovers, returning to its normal state. However, if the stress continues, the person progresses to the next stage.
The exhaustion stage occurs when the person is no longer able to adapt to the continued stress. The defense mechanisms and reserves of the body are depleted. If intervention does not occur, exhaustion continues, which can lead to death.
The three stages of stress response are alarm, resistance and recovery, and exhaustion.
CRISIS is a time-limited event, usually lasting no more than 4 to 6 weeks, that results from extended periods of stress unrelieved by adaptive coping mechanisms. Many different types of stress can lead to crisis. Modern science recognizes the biopsychosocial components of crisis from its examination of the reaction of people to global natural disasters such as the devastating tsunami in Phuket, Thailand, during the holiday season of 2004, followed by Hurricane Katrina the following summer in New Orleans. Man-made disasters, such as the attacks on the World Trade Center and the U.S. Pentagon in 2001 and the 2004 train bombing in Madrid, the Boston Marathon bombing in 2013, and multiple school shootings such as Columbine and Newtown, also created crisis responses in citizens around the world. It is estimated that a man-made or a natural disaster occurs somewhere in the world almost daily (Sederer, 2012; Wilkinson & Matzo, 2015). These catastrophes, whether caused by suicide bombers, mass murderers, Ebola outbreaks, or any other disaster, require that health care personnel respond quickly and effectively.
EVIDENCE-BASED PRACTICE 6-1:
EFFECTS OF STRESS
Can prolonged stress affect whether breast cancer returns? NIH MedlinePlus, the Magazine, 3(1), 6. Winter 2008.
In a study funded by the National Institute on Aging (NIA) and the National Cancer Institute (NCI), a group of 94 women in whom breast cancer had spread (metastatic) or returned (recurrent) were asked to determine if they ever experienced stressful or traumatic life events. The categories ranged from traumatic stress to some stress to no significant stress. Responses to the questions were markedly different. A comparison of the data revealed a significantly longer disease-free interval among women reporting no traumatic or stressful life events. Results also showed that a history of traumatic events early in life can have many physical and emotional effects, including changing the hormonal stress response system. The research also demonstrated that individuals function better after exposure to traumatic stress if they deal with it directly, facing it rather than avoiding or fleeing from it.
APPLICATION TO PRACTICE
These findings support the need for nurses working in all areas, especially in psychiatric-mental health, to implement interventions to assist patients in dealing with stress rather than avoiding it. Such interventions could help prevent an individual from crossing over his or her stress threshold, thereby minimizing the effects of stress on the person’s health status.
QUESTIONS TO PONDER
1. What types of interventions might be appropriate to institute for this group?
2. How would the interventions proposed be different and/or similar for different populations?
These disasters, whether created by man or nature, affect many thousands of individuals simultaneously. They are abrupt interruptions in the usual way of life, creating disequilibrium and a sense of helplessness. On many of these occasions, the need for assistance significantly exceeds the local resources, necessitating help from prepared responders from other communities (Lateef, 2011; Sederer, 2012).
Feelings of vulnerability result. Nurses have a unique opportunity to plan for and intervene to support individuals, groups, and communities during times of crisis. The frequent need for disaster response has led to a relatively new area of health care that focuses on providing mental health services to disaster response. The value of nurse intervention and coordination of community-based response following natural or man-made disasters is validated in the literature (Knebel, Toomey, & Libby, 2012). Mental health nurses play a vital role in this response during the days and weeks following a disaster, as psychological victims often exceed the number of victims with physical injuries (Stanley, Bulecza, & Gopalani, 2012).
SYSTEM OR ORGAN INVOLVEMENT
Posterior pituitary gland
↑ Secretion of antidiuretic hormone (ADH) ↑ water reabsorption and ↓ urine output
Anterior pituitary gland adrenal cortex
↑ Secretion of adrenocorticotropic hormone (ACTH) ↑ cortisol and aldosterone secretion
↑ Aldosterone secretion to ↑ sodium reabsorption, ↑ water reabsorption, ↑ potassium excretion, and ↓ urine output
↑ Cortisol secretion ↑ gluconeogenesis, ↑ protein catabolism, ↑ fat catabolism
Adrenal cortex and sympathetic nervous system stimulation
Release of norepinephrine and epinephrine
Epinephrine ↑ heart rate, ↑ oxygen consumption, ↑ blood glucose, and ↑ mental acuity
Norepinephrine ↑ blood flow to skeletal muscles, ↑ arterial blood pressure
↑ Respiratory rate
↑ Myocardial contractility
↑ Cardiac output and heart rate
↑ Blood pressure
↑ Sphincter contraction
↓ Glycogen synthesis
↑ Motility of ureters
Crisis is a time-limited event that usually lasts no longer than 4 to 6 weeks in which the person is unable to relieve prolonged stress through adaptive coping mechanisms.
Characteristics of a Crisis
For many individuals, modern everyday life is a series of events strung together with stress and anxiety. A crisis occurs when there is a real or perceived threat to a person’s physical, social, or psychological self. Additionally, witnessing a trauma of another individual or of an entire community can also lead to crisis (Everly & Lating, 1995; Figure 6-1).
In crisis, an individual confronts a stressor and his or her coping mechanisms fail to resolve the perceived stress. Crisis is a time-limited state of disequilibrium accompanied by increased anxiety that can trigger adaptive or nonadaptive biopsychosocial responses to maturational, situational, or interpersonal experiences (Boyd, 2008). Typically, a crisis interrupts psychological balance or homeostasis. Subsequently, this disruption overwhelms a person’s ability to deal with the challenge or threat at hand (Fortinash & Holoday Worret, 2007). Regardless of whether the stressor is internal or external, the change in the environment causes disequilibrium, interrupting the individual’s coping patterns and usual behaviors.
Often, crisis is viewed as a negative occurrence. However, the experience of a crisis does not mean that a psychopathology exists. Crisis can also provide an opportunity for personal growth and positive change (North & Pfefferbaum, 2013). For example, adaptation by the person during crisis allows the person to act and resolve the situation. The person can be supported to consider the incident from a fresh perspective and can develop new coping skills for use during future periods of stress. Mounting an adaptive response allows individuals to seek and implement solutions, thus restoring homeostasis and promoting personal growth. When an individual’s responses are maladaptive, he or she feels a sense of helplessness, unable to harness the internal or external resources needed to resolve the all-encompassing anxiety and stress. This individual needs support from health care professionals to work through the crisis and restore homeostasis.
Individuals and families experience crises every day. Across the life span, from infancy to death, many situations in an individual’s life can lead to stress and precipitate a crisis. For some, a single event, such as the unexpected death of a child, can cause a person to lose complete control and become unable to follow through with the simplest daily functions. For others, a series of stressors, such as loss of a job followed by illness of a parent and then death of a loved one, can compound the anxiety. This series of events leads to feelings of loss of control, becoming more than the individual can handle.
Crisis can have positive or negative results for a person.
During a period of crisis, new emotional and physiological symptoms, such as nausea and/or emesis, head and body aches, and bowel changes, may emerge. These symptoms, in combination with extreme impairment in daily functioning, signal crisis and need for professional intervention (Boyd, 2008). The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5, American Psychiatric Association, 2013), associates crisis with several different psychiatric diagnoses and disorders including depression, anxiety, and posttraumatic stress disorder. However, it does not categorize crisis as a distinct diagnosis (Fortinash & Holoday Worret, 2007).
Crisis is not an established psychiatric diagnosis. It is, however, associated with numerous psychiatric disorders.
Factors Impacting an Individual’s Response to Crisis
Each individual’s response to crisis is unique. Not every person experiencing stress will go on to experience crisis. Additionally, individuals exposed to the same crisis will exhibit completely different responses. As noted by Watson and Fulambarker (2012), individuals develop balancing factors that determine the manner in which they will respond to crisis. These balancing factors include the individual’s perception of the event, availability of situational supports, and availability of adequate coping strategies. Table 6-2 describes these balancing factors and how they impact the development of crisis.
Developmental factors can also impact a person’s response to stress and development of crisis. For adults, a crisis can be difficult to accept and impossible to understand, eroding feelings of personal and community safety. Adolescents and children may be even more deeply affected (Davidhizar & Shearer, 2002). The effects of disaster and crisis on a child may interfere with normal growth and development, leading to negative long-term physical and psychological health outcomes (Crane & Clements, 2005). Therefore, both physical and psychological emergency interventions must be addressed promptly in crisis, including natural and man-made disasters.
Development of Crisis
When examining the ways in which crisis unfolds, it is helpful to separate the phenomenon into four distinct phases. These phases, depicted in Figure 6-2, were first identified by Gerald Caplan in 1964.
Phase 1 begins with exposure to a significant precipitating stressor. This stressor can be large or small in scale (affecting a single individual or many persons), a natural or human-initiated disaster, or an accident or an intentional affront.
DEVELOPMENT OF CRISIS
Perception of event
Distorted perception ineffective problem solving failure to restore homeostasis
Realistic perception use of adequate resources restoration of homeostasis
Availability of situational supports
Inadequate supports feelings of being overwhelmed and isolated
Use of available persons in environment assistance in solving problem
Availability of adequate coping skills
Inability to use strategies from previous experiences or strategies used unsuccessfully continued disequilibrium, tension, and anxiety
Use of strategies from the past successfully diversion of crisis
Large-scale stressors such as disasters affect millions of people annually. Some of the more publicly recognized events include such natural disasters as earthquakes, tornadoes, hurricanes, and floods. However, equally stressful are man-made disasters such as acts of terrorism and school shootings. For days and weeks after these events, the video tapes are repeated over and over again in the media. People are repeatedly exposed to the horror and stress that these depictions evoke. Small-scale stressors or individual stressors, such as a murdered family member or the terminal illness of a spouse, can also affect the lives of individuals in overwhelming ways (Stanley et al., 2012).
During this phase, the individual experiences anxiety and begins to use previous problem-solving strategies used for coping. For some individuals with strong coping skills, the crisis ends at this point. When the stress level is manageable, the brain may initiate actions to restore internal balance and resolve the threat or stress. How is this possible for some? The brain does a computer-like search: “Have I encountered this problem before? How did I deal with it then? Do I possess internal resources that I can use to deal with this problem? Do I have friends or family to count on?” Most people are resilient and can rebound from a transient stressor. This stress response becomes problematic, however, when it cannot be resolved by the individual and the crisis begins to interrupt daily functioning (DHHS, 2005).
The individual moves into the second phase of crisis when anxiety exacerbates to a level where problem-solving ability is arrested or becomes unsuccessful. Stress interferes with daily activities and the person becomes increasingly uncomfortable. The person struggles to find a previously used coping strategy. The lack of success with its use or the inability to find an appropriate coping strategy leads to a sense of restlessness, confusion, and helplessness.
On moving into the third phase, the individual expands the search for helpful resources in an effort to relieve the psychological discomfort caused by the stressor. He or she draws on all available resources, internal and external, in an attempt to relieve the stress and discomfort. For example, the person may try to look at the situation from a different perspective or possibly ignore certain aspects of the situation in an attempt to cope. At this juncture, the individual searches for possible new methods for solutions, and may seek the assistance of professionals such as services of a nurse, psychologist, crisis worker, or some other external source for possible answers and resolution. If the new methods are effective, the crisis will resolve, allowing the individual to return to a functional level, which may be the same, higher, or lower than the person’s previous level of functioning.
If individuals cannot find resolution in the second or third phases, their anxiety levels continue to build. Either they build “beyond a further threshold” or the “burden increases to a breaking point” (Caplan, 1964). Here, the level of anxiety can approach panic or despair, the hallmark of this phase. Emotions are fragile and labile; thought processes are disrupted, possibly even with psychotic thinking; and external supports are necessary.
A crisis develops over four phases. If the crisis is not resolved during the second or third phase, panic or despair can occur in the fourth phase.
Classification of Crises
Over the past 30 years, many experts have categorized acute emotional crises in several different ways. Some organize them by type, while others categorize them by increasing severity. At the low end of the continuum are crises that develop because of external interruptions or problems. Crises induced by psychopathology and psychiatric emergencies are at the most intense and complex end of the crisis continuum. Many psychiatric diagnoses prevent individuals from resolving internal conflicts, leaving them panicked, dysfunctional, and unable to safely live in an unsupervised community setting. These individuals, regardless of age, lack the ability to maintain their own personal safety during the crisis and must rely on others to help them make responsible decisions and choices. Developing an association with a mental health nurse promotes a psychotherapeutic relationship that will be vital to healing (Wheeler, 2011).
Regardless of the severity, a simple way to categorize crises that occur in reaction to life events is by considering their point of origin. Using this method, three categories of emotional crisis are identified as maturational, situational, and social (also called adventitious).
A MATURATIONAL CRISIS occurs during an individual’s normal growth and development at any point of change. Examples of maturational crises include leaving home for college (for either the child who is leaving or the parent who is left behind), getting married, having children, or retirement. These normal events occur in everyone’s life, but can be identified as an actual or perceived threat that could lead to crisis. When the response to these life transitions is negative or overwhelming and the individual feels a lack of control, crisis occurs and professional intervention may become necessary. In this instance, an internal arrest of development stalls the person’s journey through Maslow’s (1968) hierarchy of needs, which progress from the most basic level (physiological needs) to the highest level of actualization (see also Chapter 10 for a more in-depth discussion of Maslow; Gorman & Sultan, 2008). The priority is to assist the individuals to recognize the specific point of conflict and readjust their capacity to resolve the conflict and move along life’s path. Providing support, helping to define the problem and develop an action plan, and connecting the person to appropriate community resources are important interventions.
A SITUATIONAL CRISIS stems from an unanticipated life event that threatens one’s sense of self or security. The threat can be internal such as a disease, or it can be external such as family illness, the unexpected death of a loved one, foreclosure on a home, death of a pet, and being fired from a job. Any of these examples could lead to an individual’s inability to cope. A person’s ability to resolve this type of crisis depends on his or her unique perception of the event, adequacy of a support system, and his or her repertoire of coping mechanisms (Downey, Andress, & Schultz, 2013). The loss of personal control associated with situational crises may leave the person unable to complete tasks of everyday living. In this instance, the use of past coping skills along with new alternative coping strategies, support, active listening, and connection to community resources are helpful.
A SOCIAL CRISIS, also called an adventitious crisis, results from an unexpected and unusual social or environmental catastrophe that can either be a natural or man-made disaster. The crisis can affect an individual, families, communities, a specific geographic area, and millions of people. Earthquakes, tsunamis, and hurricanes are all natural disasters that have left thousands, perhaps millions, of people facing crisis. Man-made crises include crimes of rape and murder, city-wide riots, terrorist attacks, and global wars. In these instances, the individuals are overwhelmed by the events that typically involve trauma, injury, destruction, or sacrifice (Boyd, 2008). The widespread media coverage of various disasters can result in crisis for persons who are far removed from the area but subsequently are exposed to the repeated depictions of the injuries and devastation.