Crisis and Disaster Intervention
Any serious interruption in the steady state or equilibrium of a person, family, or group is considered a crisis. A crisis is a state of emotional turmoil. It is also considered an emotionally significant event which acts as a turning point for better or worse in a person’s life.
Learning objectives
After studying this chapter, you should be able to:
Define the terms crisis and disaster.
Distinguish the six classifications of a crisis according to severity.
Describe the characteristics of a crisis.
Recognize the phases of a crisis.
Articulate the five periods of the disaster recovery process.
Explain how the following balancing factors can influence the development of a crisis: realistic perception of the event, adequate situational support, and adequate defense and/or coping mechanisms.
Compare and contrast crisis intervention and disaster mental health nursing.
Interpret the goals of crisis intervention.
Verbalize the role of the psychiatric–mental health nurse in crisis intervention and disaster nursing.
Use the steps of crisis intervention.
Discuss the issue of legal immunity for the crisis worker.
Key Terms
Crisis
Crisis forensics
Crisis intervention
Crisis response team
Crisis situations
Disaster
Disaster intervention
Disaster mental health nursing
Disaster response team
Maturational crisis
Paradigm of balancing factors
Situational crisis
On December 26, 2004, the world’s most powerful earthquake in more than 40 years struck deep under the Indian Ocean in South Asia, triggering massive tsunamis that obliterated seaside communities and holiday resorts, killing tens of thousands of people in a dozen countries. The psychological effects of this natural disaster included feelings of despair, anxiety, and fear for safety and security.
In October 2002, the “beltway sniper” killed several individuals in Maryland, Virginia, and Washington, DC. Residents of these areas responded to this stressful situation by discontinuing their daily routines such as grocery shopping, going to gas stations, eating at restaurants, attending outdoor activities, and taking their children to school. Numerous outdoor events were cancelled. Public schools maintained a lock-down mode and later cancelled classes.
On September 11, 2001, the hijacking of commercial airplanes and subsequent terrorist attacks on the World Trade Center and Pentagon left many Americans feeling numb, frightened, angry, and profoundly sad. The number of individuals classified as missing or dead was high, businesses were destroyed, and many individuals stated that they would never fly again.
The news media refer to such events as disasters, or traumatic events that occur suddenly, often without warning; cause great damage; deprive people of their homes and possessions; and generally precipitate crisis situations, conditions or periods of emotional instability that can result in a psychiatric disorder. A crisis situation can also threaten the safety, integrity, or reputation of an individual or members of the community. Among those most influenced are survivors or witnesses of the events and those whose friends, family, and acquaintances were survivors or victims. To promote recovery from such situations, it is extremely important to provide crisis or disaster intervention. This chapter focuses on the different aspects of crisis, including examples of precipitating events, and the major interventions used to control or resolve a crisis situation. Information regarding disaster intervention and nursing care is included where appropriate. The legal implications associated with crisis situation and crisis intervention for children/adolescents also are highlighted.
Crises
Most people exist in a state of equilibrium, despite the occurrence of crisis situations. That is, their everyday lives contain some degree of harmony in their thoughts, wishes, feelings, and physical needs. This existence generally remains intact unless there is a serious interruption or disturbance of one’s biologic, psychological, spiritual, or social integrity. As undue stress occurs, one’s equilibrium can be affected, and one may lose control of feelings and thoughts, thus experiencing an extreme state of emotional turmoil. When this occurs, one may be experiencing a crisis. Individuals respond to crisis in different ways. Table 13-1 summarizes two types of common responses to a crisis, high anxiety–emotional shock or stunned–inactive response.
Types of Crises
A crisis can be situational or maturational. A situational crisis refers to an extraordinarily stressful event such as domestic violence or “beltway sniper” incidents that affects an individual, or family regardless of age, socioeconomic status, or sociocultural status. A situational crisis can be personal or public (ie, affect an entire community). Examples of events that can precipitate a personal situational crisis include economic
difficulty, medical or psychiatric illness, rape, child abuse or neglect, divorce, or death of a loved one due to a terminal illness. Examples of disasters that can precipitate a public situational crisis include workplace violence, school violence, hurricane, tornado, or tsunami.
difficulty, medical or psychiatric illness, rape, child abuse or neglect, divorce, or death of a loved one due to a terminal illness. Examples of disasters that can precipitate a public situational crisis include workplace violence, school violence, hurricane, tornado, or tsunami.
 Table 13.1 Two Common Responses to a Crisis | ||||||
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A 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 processes of growth and development that evolve over an extended period and require a person to make some type of change. Another example of a maturational crisis is retirement, in which a person faces the loss of a peer group as well as loss of a status identity.
Classification According to Severity
Situational and maturational crises also can be classified based on the severity of the precipitating events. A classification system developed by Burgess and Baldwin (1981) systematically describes six types of crises based on the severity of the situation. Each classification is briefly summarized below.
Class 1: Dispositional or situational crisis in which a problem is presented with a need for immediate action, such as finding housing for the homeless during subzero temperatures
Class 2: Life transitional or maturational crisis that occurs during normal growth and development, such as going away to college or experiencing a planned pregnancy
Class 3: Situational crisis due to a sudden, unexpected, traumatic event or disaster, such as the loss of a home during a hurricane or earthquake
Class 4: Maturational or developmental crisis involving an internal stress and psychosocial issues, such as questioning one’s sexual identity or lacking the ability to achieve emotional independence
Class 5: Situational crisis due to a preexisting psychopathology, such as depression or anxiety, that interferes with activities of daily living (ADL) or various areas of functioning
Class 6: Psychiatric situational crisis or emergency, such as attempted suicide, drug overdose, or extreme agitation, resulting in unpredictable behavior or the onset of an acute psychotic disorder
Characteristics of a Crisis
A crisis usually occurs suddenly, when a person, family, or group is inadequately prepared to handle the event or situation. Normal coping methods fail, tension rises, and feelings of anxiety, fear, guilt, anger, shame, and helplessness may occur. Most crises, unless the result of a natural or manmade disaster, are generally short in duration, lasting 24 to 36 hours. Crises rarely last longer than 4 to 6 weeks, whereas the period of recovery from a disaster such as a hurricane may involve several years. A crisis situation can cause increased psychological vulnerability, resulting in potentially dangerous, self-destructive, or socially unacceptable behavior, or it can provide an opportunity for personal growth. The outcome of a crisis situation depends on, among other factors, the availability of appropriate help (Mitchell & Resnik, 1981).
Phases of a Crisis
Research involving crisis has led to the identification of specific stages or phases associated with it. Most individuals consider Eric Lindemann (1965) to be the father of crisis theory. His theory evolved from the study of grief responses in families of victims of the Coconut Grove nightclub fire in Boston in 1943. After World War II, Gerald Caplan (1964) contributed to the concept of crisis theory while working with immigrant mothers and children. Each described stages or phases of a crisis. Generally, theorists describe five stages or phases of a crisis:
Precrisis
Impact
Crisis
Resolution
Postcrisis
The general state of equilibrium in which a person is able to cope with everyday stress is called the precrisis phase. When a stressful event occurs, the person is said to be experiencing the impact phase. This phase occurs when, for example, a pediatrician tells a young couple that their 5-year-old son has inoperable cancer. After the shock is over, the young parents become acutely aware of their son’s critical illness and poor prognosis. This is an extraordinarily stressful event, threatening their child’s life and their integrity as a family. With this realization, they are now in the crisis phase. They may experience continuing confusion, anxiety, and disorganization because they feel helpless and are unable to cope with their son’s physical
condition. When the young parents are able to regain control of their emotions, handle the situation, and work toward a solution concerning their son’s illness with or without intervention from others, they are in the resolution phase of a crisis. If they are able to resume normal activities while living through their son’s hospitalization and illness, they are in the postcrisis phase. The experience of a crisis and passage through the phases may result in permanent emotional injury or it may make the young parents feel a stronger bond with each other and their son, depending on their ability to cope. These phases are described further in Table 13-2.
condition. When the young parents are able to regain control of their emotions, handle the situation, and work toward a solution concerning their son’s illness with or without intervention from others, they are in the resolution phase of a crisis. If they are able to resume normal activities while living through their son’s hospitalization and illness, they are in the postcrisis phase. The experience of a crisis and passage through the phases may result in permanent emotional injury or it may make the young parents feel a stronger bond with each other and their son, depending on their ability to cope. These phases are described further in Table 13-2.
 Table 13.2 Phases of a Crisis | ||||||||||||||
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Paradigm of Balancing Factors
Various factors can influence an individual’s ability to resolve a crisis. Aguilera (1997) describes a paradigm of balancing factors that determines the resolution of a crisis. These factors, which can affect an individual’s return to equilibrium, are (1) realistic perception of an event; (2) adequate situational support; and (3) adequate
defense or coping mechanisms to help resolve a problem. Figure 13-1 incorporates Aguilera’s paradigm, depicting a comparison of what could happen in the presence or absence of adequate balancing factors during a stressful situation, specifically, that of the young parents whose son has cancer.
defense or coping mechanisms to help resolve a problem. Figure 13-1 incorporates Aguilera’s paradigm, depicting a comparison of what could happen in the presence or absence of adequate balancing factors during a stressful situation, specifically, that of the young parents whose son has cancer.
Additional factors may influence the development of a crisis. These factors include the person’s physical and emotional status, previous experience with similar situations, and cultural influences.
Realistic Perception
A realistic perception occurs when a person is able to distinguish the relationship between an event and feelings of stress. For example, a 45-year-old executive recognizes the fact that her company is on the verge of bankruptcy because of inefficient projected financial planning by the board of trustees. Although she realizes the seriousness of the situation and feels stress, she does not place the blame on herself and view herself as a failure. Her perception, rather than the actual event, determines her reaction to the situation.
Situational Supports
Situational supports refers to the resources available in the person’s environment. Consider the example of the 45-year-old executive. The executive may discuss the situation with a financial consultant, a lawyer, or the firm’s accountant. Such persons available in the environment are considered to be situational supports because they reflect appraisals of one’s intrinsic and extrinsic values. Support by these people may prevent a state of disequilibrium and crisis from occurring. When emotional or environmental support systems such as family or friends are not as readily available, a person is more likely to define the event as more overwhelming or hazardous, thus increasing his or her vulnerability to crisis.
Defense Mechanisms
Defense or coping mechanisms are those methods usually used by the individual, when dealing with anxiety or stress, to reduce tension in difficult situations (see Chapter 2). Common defense mechanisms utilized during a crisis generally include denial, rationalization, identification, regression, or repression. Behavioral responses such as refusal to face reality, intellectualization about why the situation occurred, productive worrying about how to deal with the crisis, grieving over perceived losses, social withdrawal, or agitation may be exhibited by victims during a crisis. Coping mechanisms are used during early developmental stages and, if found effective in maintaining emotional stability, will become a part of a person’s lifestyle in dealing with daily stress. The person who has met developmental tasks and achieved a level of personal maturity usually adapts more readily in a crisis. Recall the example of the executive. She may cope by burying herself in her work, calling an emergency meeting of the board of trustees to discuss the situation, or withdrawing from the situation.
Crisis and Disaster Intervention
Crisis intervention is an active but temporary entry into the life situation of an individual, a family, or a group during a period of stress (eg, divorce, rape, or natural disaster; Mitchell & Resnik, 1981). It is an attempt to resolve an immediate crisis when a person’s life goals are obstructed and usual problem-solving methods fail. The client is called on to be active in all steps of the crisis intervention process, including clarifying the problem, verbalizing feelings, identifying goals and options for reaching goals, and deciding on a plan. Crisis intervention can occur in many settings: the home, emergency department, industrial dispensary, classroom, surgical intensive care unit, or psychiatric unit. The generic approach focuses on a particular kind of crisis by directly encouraging adaptive behavior and providing general support, environmental manipulation, and anticipatory guidance. The individual approach focuses on the present, shows little or no concern for the developmental past, and places an emphasis on the immediate causes of disequilibrium. It can be used as secondary or tertiary prevention and can be effective in preventing future crises.
The goals of crisis intervention are:
To decrease emotional stress and protect the client from additional stress
To assist the client in organizing and mobilizing resources or support systems to meet unique needs and reach a solution for the particular situation or circumstance that precipitated the crisis, ultimately enabling the individual to understand the relationship of past life experiences to current stress; prevent hospitalization; reduce the risk of chronic maladaptation; and promote adaptive family dynamics
Figure 13.1 Crisis situation paradigm.
To return the client to a precrisis or higher level of functioning
Disaster intervention involves the provision of postdisaster support services during the early phase of a disaster. Disaster mental health nursing includes the application of the nursing process to meet the biopsychosocial needs of victims and communities as they experience different periods of the recovery process. A brief summary of the transitional periods and nursing interventions provided follows:
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