Crisis and Disaster Intervention



Crisis and Disaster Intervention


Gail W. Stuart




Learning Objectives



1. Describe a crisis and its characteristics, including crisis responses, types of crises, characteristics of disasters, and crisis intervention.


2. Analyze aspects of the nursing assessment related to crisis and disaster responses.


3. Plan and implement nursing interventions for patients related to their crisis and disaster responses.


4. Develop a patient education plan to cope with crisis.


5. Evaluate nursing care for patients related to their crisis and disaster responses.


6. Describe the settings in which crisis and disaster intervention may be practiced.


7. Discuss modalities of crisis intervention.



Stressful events, or crises, are a common part of life. They may be social, psychological, or biological in nature, and there is often little that a person can do to prevent them. As the largest group of health care providers, nurses are in an excellent position to help promote healthy outcomes for people in times of crisis and disaster (Happell et al, 2009).


Crisis intervention is a brief, focused, and time-limited treatment strategy that is effective in helping people adaptively cope with stressful events. Knowledge of crisis and disaster intervention techniques is an important clinical skill for all nurses, regardless of clinical setting or practice specialty.



Crisis Characteristics


A crisis is a disturbance caused by a stressful event or a perceived threat. The person’s usual way of coping becomes ineffective in dealing with the threat, causing anxiety. The threat, or precipitating event, usually can be identified. It may have occurred weeks or days before the crisis, and it may or may not be linked in the individual’s mind to the crisis state the individual is experiencing. Precipitating events can be actual or perceived losses, threats of losses, or challenges.



Crisis Responses


After the precipitating event, the person’s anxiety begins to rise, and three phases of a crisis response emerge:



In describing the phases of a crisis, it is important to consider the balancing factors shown in Figure 13-1. These include the individual’s perception of the event, situational supports, and coping mechanisms. Successful resolution of the crisis is more likely if the person has a realistic view of the event; if situational supports are available to help solve the problem; and if effective coping mechanisms are present (Aguilera, 1998).


image
FIG 13-1 Paradigm: the effect of balancing factors in a stressful event. (From Aguilera DC: Crisis intervention: theory and methodology, ed 8, St Louis, 1998, Mosby.)

The phases of a crisis and the impact of balancing factors are similar to the elements of the Stuart Stress Adaptation Model used in this textbook and described in Chapter 3. However crises are self-limiting. People in crisis are too upset to function at such a high level of anxiety indefinitely. The time needed to resolve the crisis, whether it is a positive solution or a state of disorganization, may be 6 weeks or longer.


It also is important to recognize that periods of intense conflict ultimately can result in increased growth. It is how the crisis is handled that determines whether growth or disorganization will result. Growth comes from learning in new situations. People in crisis feel uncomfortable, often reach out for help, and accept help until they feel that their lives are back to normal. The fact that crises can lead to personal growth is important to remember when working with patients in crisis.



Critical Reasoning


Think of a crisis you have experienced. Do you feel that the way you handled it made you a better person in some way? If so, how?




Maturational Crises


Maturational crises are developmental events requiring role changes. Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are key times for the onset of maturational crises. For example, successfully moving from early childhood to middle childhood requires the child to become socially involved with people outside the family. With the move from adolescence to adulthood, financial responsibility is expected. Both social and biological pressures to change can precipitate a crisis.


The nature and extent of the maturational crisis can be influenced by role models, interpersonal resources, and the response of others. Positive role models show the person how to act in the new role. Interpersonal resources encourage the trying out of new behaviors to achieve role changes.


Other people’s acceptance of the new role is also important. The greater the resistance of others, the more stress the person faces in making the changes. Some conflicts related to maturational crises are seen in the clinical examples that follow.



CLINICAL EXAMPLE


Ms. J was a 19-year-old African-American, single, unemployed woman who came to the mental health clinic 1 month after the birth of her first child. Ms. J complained of feeling depressed. Her symptoms included difficulty falling asleep, early-morning awakening, crying spells, a poor appetite, and difficulty in caring for the baby because of fatigue and apathy. The patient lived with her parents and siblings and had never lived on her own. She had always depended on her mother to take care of her. Her mother worked, however, and the patient was totally responsible for her daughter’s care each day. Also, Ms. J’s mother was angry that she had a child and often refused to care for the baby. The patient’s boyfriend, who was the baby’s father, had promised to marry her, but he had recently decided he was too young to handle the responsibility of a wife and child. In summary, the young woman who had unmet dependency needs of her own was now a parent and had to meet the dependency needs of her infant. This precipitated a crisis for her.




CLINICAL EXAMPLE


Mr. R was a 67-year-old white, married pharmacist who came to the mental health clinic complaining of anxiety, depression, and insomnia. His symptoms had begun 2 weeks ago when his wife decided that they should move to a retirement community in Florida. He described his wife as a strong, determined woman who was outgoing and charming and made friends easily. He considered himself a quiet, nervous person who was comfortable only with old friends and his two sons and their families. Mr. R, although at retirement age, had continued to work as a pharmacist, doing relief work for a drugstore chain when the regular pharmacists were absent. In moving to Florida, he would lose his pharmacist’s license, which was valid only in his state of residence. He expressed difficulty in making the transition from work to retirement. He had fears of becoming directionless and useless. He was anxious about leaving his sons and his friends. The prospect of complete retirement and moving to another state precipitated his distress.




Situational Crises


Situational crises occur when a life event upsets an individual’s or group’s psychological equilibrium. Examples of situational crises include loss of a job, loss of a loved one, unwanted pregnancy, onset or worsening of a medical illness, divorce, school problems, and witnessing a crime.


The loss of a job can result in financial stress, feelings of inadequacy, and marital conflict caused by a family member’s anger over the lost job. The loss of a loved one results in bereavement and also can cause financial stress, change in roles of family members, and loss of emotional support. Homelessness is another possible outcome of the loss of a job or a loved one. The onset or worsening of a medical illness causes anticipatory grief and fear of the loss of a loved one. Again, financial stress and change in roles of family members often occur. Divorce is similar to the stress of losing a loved one, except that the crisis can recur with the stress of dealing with the ex-spouse.


An unwanted pregnancy is stressful because it requires decisions to be made about whether to complete the pregnancy or to abort it and whether to keep the baby or place the baby for adoption. If the pregnancy is aborted or adoption occurs, the mother may need to deal with feelings of grief or anger. If the baby is to be kept, changes in lifestyle are required. Finally, being the victim of or witnessing a crime can cause feelings of helplessness, distrust of others, fear, nightmares, and guilt about causing or not stopping the crime.


Situational crises can be accidental, uncommon, and unexpected events including natural and man-made disasters such as fires, tornadoes, earthquakes, hurricanes, or floods. These disrupt entire communities and cause widespread damage. Disasters, such as killings in the workplace or in schools, airplane crashes, suicide bombings, and acts of terrorism, also can precipitate situational crises.


The terrorist attacks of September 11, 2001, in which airplanes were hijacked and flown into the World Trade Center in New York City, presented unprecedented trauma and crisis to people throughout the United States. Entire communities, especially people living in New York City, experienced a sudden and unexpected violent act that resulted in multiple losses and extensive community disruption.


In addition, the safety felt by all people across the United States was affected. One study found that more than half of the people who lived or worked in New York had some emotional sequelae 3 to 6 months after September 11; however, only a small portion of those with severe responses were seeking treatment (DeLisi et al, 2003).


Disaster-precipitated emotional problems can surface immediately, or weeks or even months after the disaster. After the September 11 attack, individuals who lost family members accounted for 40% of mental health visits in the first month but dropped to 5% by 5 months. Uniformed personnel used many more mental health services after the first year (Covell et al, 2006).


Researchers have identified several common characteristics of disasters that are particularly important when discussing emotional distress and recovery. These are listed in Box 13-1.



BOX 13-1   CHARACTERISTICS OF DISASTERS




• Intensity of the impact: Disasters that result in intense destruction within a short period of time are more likely to cause emotional distress among survivors than are disasters that spread their impact over a longer period of time.


• Impact ratio (i.e., the proportion of the community sustaining personal losses): When a disaster affects a significant proportion of a community’s population, few individuals may be available to provide material and emotional support to survivors.


• Potential for recurrence of other hazards: The real or perceived threat of recurrence of the disaster or of associated hazards can lead to anxiety and heightened stress among survivors.


• Cultural and symbolic aspects: Changes in survivors’ social and cultural lives and routine activities can be profoundly disturbing. Both natural and human-caused disasters can have symbolic implications.


• Extent and types of loss sustained by survivors: Property damage or loss, deaths of loved ones, injury, and job loss all affect emotional recovery.


Disaster responses usually occur in seven phases. These are described in Table 13-1. Individuals and communities progress through these phases at different rates depending on the type of disaster and the degree and nature of disaster exposure. This progression may not be sequential, because each person and each community is unique in the recovery process. Individual variables such as psychological resilience, social support, and financial resources influence a survivor’s capacity to move through the phases.



TABLE 13-1


PHASES OF DISASTER RESPONSE




























PHASE RESPONSE
Warning or threat phase Disasters vary in the amount of warning communities receive before they occur from little or no warning to hours or even days of warning. When no warning is given, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies.
Impact phase The impact period of a disaster can vary from the slow, low-threat build-up associated with some types of floods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects.
Rescue or heroic phase In the immediate aftermath, survival, rescuing others, and promoting safety are priorities. For some, postimpact disorientation gives way to adrenaline-induced rescue behavior to save lives and protect property. Although activity level may be high, actual productivity is often low. Altruism is prominent among both survivors and emergency responders.
Remedy or honeymoon phase During the week to months following a disaster, formal governmental and volunteer assistance may be readily available. Community bonding occurs as a result of sharing the catastrophic experience and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more readily accepted and have a foundation from which to provide assistance in the difficult phases ahead.
Inventory phase Over time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted because of enormous multiple demands, financial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue.
Disillusionment phase As disaster assistance agencies and volunteer groups begin to pull out, survivors may feel abandoned and resentful. The reality of losses and the limits and terms of the available assistance become apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle. Stressors abound—family discord, financial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of preexisting conditions emerge because of ongoing, unrelenting stress and fatigue.
Reconstruction or recovery phase The reconstruction of physical property and recovery of emotional well-being may continue for years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and gradually assume the responsibility for doing so. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin.
When people come to see meaning, personal growth, and opportunity from their disaster experience despite their losses and pain, they are well on the road to recovery. Although disasters may cause profound life-changing losses,
they also bring the opportunity to recognize personal strengths and to
reexamine life priorities.

From U.S. Department of Health and Human Services: Training manual for mental health and human service workers in major disasters, ed 2, Washington, DC, 2000, U.S. Government Printing Office.



Critical Reasoning


Some crises, such as obtaining a divorce, develop over time and are of longer duration. Other crises, such as an earthquake, are sudden and unexpected. How do you think the element of time affects the response to crisis?



Crisis Intervention


Crisis intervention is a short-term therapy focused on solving the immediate problem. It is usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. Often the person advances to a level of growth that is higher than the precrisis level because new ways of problem solving have been learned.


It is important for the nurse to remember that culture strongly influences the crisis intervention process, including the communication and response style of the crisis worker. Cultural attitudes are deeply ingrained in the processes of asking for, giving, and receiving help. They also affect the victimization experience, as seen in Box 13-2, so it is essential to understand and respect the sociocultural context of crisis care. Specific cultural factors to be considered in crisis intervention include the following:



BOX 13-2   SOCIOCULTURAL CONTEXT OF CARE


Survivors of Katrina


Many of the African-American survivors of Hurricane Katrina in New Orleans were at high risk for physical and mental health problems because of their residence in high-poverty areas, the residential segregation that existed before the storm, and the enormous dislocation that resulted from the hurricane. A study of this population found that survivors who lacked financial resources faced higher risks for general mental health problems and that racial discrimination increased the health-related risk for Katrina survivors. Further, female African-American survivors reported more posttraumatic stress disorder (PTSD) symptoms and worse mental health (Chen et al, 2007). In contrast, support provided by network members enhanced physical and mental health. This study of African-American survivors of Hurricane Katrina highlighted the social inequities in U.S. society and the need to directly address the issues of race, class, and gender inequality in disaster preparation, postdisaster rescue, and recovery mission and rebuilding efforts.


Another study examined the use of mental health services among adult survivors of Hurricane Katrina to evaluate the impact of disasters on persons with existing mental illness who were living in the community. As a result of the storm, entire mental health delivery systems were destroyed, and few Katrina survivors with mental disorders received adequate care (Wang et al, 2007, 2008). The sociocultural, financial, structural, and attitudinal barriers that prevented those with mental illness from obtaining needed treatment also will need to be overcome in future disasters.



The age of the survivors is also important for the nurse to consider when providing crisis intervention. Responses to stressful events differ across the life span. Therefore age-appropriate interventions are most effective in helping survivors return to their previous level of functioning. For example, 4-year-old children may best express themselves through play, whereas adolescents may best work through crisis issues in peer group discussions.



Critical Reasoning


Describe how sociocultural factors might affect a woman’s decision to seek help after being raped.



Assessment


The first step of crisis intervention is assessment. At this time, data about the nature of the crisis or disaster and its effect on the patient must be collected. From these data an intervention plan will be developed. People in crisis experience many symptoms, including those listed in Box 13-3. Sometimes these symptoms can cause further problems. For example, problems at work may lead to loss of a job, financial stress, and lowered self-esteem.



BOX 13-3   BEHAVIORS COMMONLY EXHIBITED AFTER A CRISIS


Anger


Apathy


Backaches


Boredom


Crying spells


Diminished sexual drive


Disbelief


Fatigue


Fear


Flashbacks


Forgetfulness


Headaches


Helplessness


Hopelessness


Insomnia


Intrusive thoughts


Irritability


Lability


Nightmares


Numbness


Overeating or undereating


Poor concentration


Sadness


School problems


Self-doubt


Shock


Social withdrawal


Substance abuse


Suicidal thoughts


Survivor guilt


Work difficulties


Crises also can be complicated by old conflicts that resurface as a result of the current problem, making crisis resolution more difficult. For example, a woman who was orphaned at an early age may have more difficulty resolving a crisis precipitated by the work injury of her husband than a woman who had not experienced an earlier loss.


Anger is one of the most understandable responses to a crisis or disaster but it also may be the most difficult one to manage. Anger can be productive if it is channeled in the right way but also can become a serious obstacle to recovery, creating problems for one’s physical and mental health, as well as family and community cohesion. Questions that should be considered are as follows:



Anger is most common in the “disillusionment phase” noted in Table 13-1. In some cases, it can even pose a danger to the health care responders who have come to assist survivors. Thus, safety issues should be a priority for the nurse in working with patients in crisis.



imageQUALITY AND SAFETY ALERT




Although the crisis situation is the focus of the assessment, the nurse may identify more significant and long-standing problems. Those individuals with preexisting psychological problems may have more postdisaster health problems. For example, those with serious mental illness will need help in ensuring access to their medications and caregiver stability (Milligan and McGuinness, 2009).


It is important, therefore, to identify which areas can be helped by crisis intervention and which problems must be referred to other sources for further treatment. During this phase the nurse begins to establish a positive working relationship with the patient. A number of balancing factors are important in the development and resolution of a crisis and should be assessed:




Precipitating Event


To help identify the precipitating event, the nurse should explore the patient’s needs, the events that threaten those needs, and the time at which symptoms appear. Four kinds of needs that have been identified are as follows:



The nurse determines which needs are not being met and looks for obstacles that might interfere with meeting the patient’s needs.


Coping patterns become ineffective and symptoms appear usually after the stressful incident. When did the patient begin to feel anxious? When did sleep disturbances begin? At what point in time did suicidal thoughts start? If symptoms began last Tuesday, ask what took place in the patient’s life on Tuesday or Monday. As the patient connects life events with the breakdown in coping mechanisms, an understanding of the precipitating event can emerge.



imageQUALITY AND SAFETY ALERT





Perception of the Event


The patient’s perception or appraisal of the precipitating event is very important. In times of disaster, perceptions of the event may be very similar. With other events it may not be so clear. What may seem trivial to the nurse may have great meaning to the patient.


For example, an overweight adolescent girl may have been the only girl in the class not invited to a dance. This may have threatened her self-esteem. A man with two unsuccessful marriages may have just been told by a girlfriend that she wants to end their relationship; this may have threatened his need for sexual role mastery. An emotionally isolated, friendless woman may have had car trouble and been unable to find someone to give her a ride to work. This may have threatened her dependency needs. A chronically ill man who has had a recent relapse of his illness may have had his need for biological functioning threatened.


Themes and surfacing memories of the patient give further clues to the precipitating event. Current issues of concern are often connected to past issues. For example, a female patient who talks about the death of her father, which occurred 3 years ago, may, on discussion, reveal a recent loss of a relationship with a male. A patient who talks about feelings of inadequacy he had as a child because of poor school performance may, on discussion, reveal a recent experience in which his feelings of adequacy on his job were threatened.


Because most crises involve losses or threats of losses, the theme of loss is a common one. In assessment, the nurse looks for a recent event that may be connected to an underlying theme.



Support Systems and Coping Resources


The patient’s living situation and supports in the environment must be assessed. Does the patient live alone or with family or friends? With whom is the patient close, and who offers understanding and strength? Is there a supportive clergy member or friend?


Assessing the patient’s support system is important in determining who should come for the crisis therapy sessions. It may be decided that certain family members should come with the patient so that the family members’ support can be strengthened. If the patient has few supports, participation in a crisis therapy group may be recommended.


Assessing the patient’s coping resources also is vital in determining whether hospitalization would be more appropriate than outpatient crisis therapy. If there is a high degree of suicidal or homicidal risk along with weak outside resources, hospitalization may be a safer and more effective treatment.



Critical Reasoning


Identify people in your social system that you would turn to in a time of crisis. Compare your list with that of a friend.




Planning And Implementation


The next step of crisis intervention is planning; the previously collected data are analyzed, and specific interventions are proposed. Dynamics underlying the present crisis are formulated from the information about the precipitating event.


Alternative solutions to the problem are explored, and steps for achieving the solutions are identified. The nurse decides which environmental supports to engage or strengthen and how best to do this, as well as deciding which of the patient’s coping mechanisms to develop and which to strengthen.


This process is outlined in the Patient Education Plan for coping with crisis in Table 13-2. The expected outcome of nursing care is that the patient will recover from the crisis event and return to a precrisis level of functioning. A more ambitious expected outcome would be for the patient to recover from the crisis event and attain a higher than precrisis level of functioning and improved quality of life.



TABLE 13-2


PATIENT EDUCATION PLAN
Coping with Crisis












CONTENT INSTRUCTIONAL ACTIVITIES EVALUATION
Describe the crisis event. Ask about the details of the crisis, including the following:

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