CRISIS INTERVENTION

INTRODUCTION

A crisis situation is, by definition, both short-term and overwhelming. As a result, crisis situations
require assessment and treatment methods that differ in a number of ways from methods used in
non-crisis situations. For example, crisis interventions are ordinarily characterized by a "here-and-
now" orientation, a time-limited course of intervention (typically 1-6 sessions), a view of the client's
behavior as an understandable reaction to stress, and the assumption that an active directive role
is needed by therapists and others trained in crisis intervention methods.

DEFINITION OF CRISIS

A "crisis" involves a disruption of an individual's normal or stable state. More specifically, a crisis
occurs "when a person faces an obstacle to important life goals that is, for a time, insurmountable
through the utilization of his customary methods of problem solving"
(Caplan, 1961).

risis is a state of disequilibrium resulting from the interaction of an event with the individual's or
family's coping mechanisms, which are inadequate to meet the demands of the situation,
combined with the individual's or family's perception of the meaning of the event.
(Taylor, 1982)

A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms
cannot resolve the problem
(Lagerquist,2012)

CHARACTERSTICS OF CRISIS

The following are characteristics of crisis events:

• 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 state of crisis.

The following are examples of crises:

• An accident (automobile or in home)
• Death/loss of a loved one
• Natural disaster
• Physical illness (self or significant other)
• Divorce/separation
• Unemployment
• Unexpected pregnancy
• Financial difficulties

As per Aguilera, 1998; Caplan 1964. Crisis has following characterstics

1. Crisis Occurs in all individuals at one time or another and is not necessarily equated with
psychopathology
2. Crisis are precipitated by specific identifiable events
3. Crisis are personal in nature
4. Crisis are acute, not chronic and will be resolved in one way or another within a brief period
5. A crisis situation contain the potential for psychological growth or deterioration
CRISIS PRONENESS CHARACTERSTICS

Hendricks (1985) suggests that certain individuals are more prone to crisis than others.

1. Dissatisfaction with employment or lack of employement

2. History of Unresolved Crisis
3. History of Substance abuse
4. Poor Self Esteem, Unworhtiness
5. Superficial relationship with others
6. Difficulty in coping with everyday situations
7. Under Utilisation of resources and support systems
8. Aloofness
9. Lack of caring

TYPES OF CRISES

We often think of a crisis as a sudden unexpected disaster, such as a car accident, natural
disaster, or another cataclysmic event.However, crises can range substantially in type and severity

1. Developmental crises/ Maturational Crisis

A maturational crisis is a stagein a peron’s life where adjustment amd adpataiton to new
responsibilities and life patterns are necessary. These occur as part of the process of growing and
developing through various periods of life. Sometimes a crisis is a predictable part of the life cycle,
such as the crises described in Erikson’s stages of psychosocial development.
Example - Adolescence, marriage, parenthood, midlife and retirement

2. Situational crises:
A situational crisis is one that is precipitated by an unanticipated stressful event that creates
disequilibrium y threatening one’s sense of biological, social or psychological integrity.
Example - Premature birth, Status and role changes, death of a loved one, physical or
mental illness, divorce, change in geographic location and poor performance in school

3. Social Crisis
These sudden and unexpected crises include accidents and natural disasters., resulting in
multiple losses and radical environmental changes. It different form the maturational and
situational crisis because it doesn’t occur in the lives of all people

Example - Getting in a car accident, experiencing a flood or earthquake, or being the

victim of a crime are just a few types of situational crises.

4. Others types
a) Existential crises: Inner conflicts are related to things such as life purpose, direction, and
spirituality. A midlife crisis is one example of a crisis that is often rooted in existential
anxiety
b) Crisis reflecting Psychopathology - a crisis that is influenced or triggered by pre existing
psychopathology. Example - personality disorders, anxiety disorders, Bipolar disorders
c) Psychiatric Emergencies - Crisis Situation when general functioning is severely imparied
and the individual rendered incompetent or unabke to assume personal resonsibility of hi
or her behavior. Example - acute suicide risk. Reaction to hallucinogenic drugs, acute
psychosis, uncontrollable anger, and alcohol intoxication.

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
appropiate 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.

COMPONENTS OF A CRISIS

SIFNEOS (1960) has identified 4 components of an emotional crisis:

1) The hazardous event that starts the chain of reactions that lead to the crisis. Sometimes it is a
sudden unexpected event, while other times it can be a developmental change.

2) A vulnerable state of the individual which is essential for the crisis to develop.

3) The precipitating factor that is the final event or circumstance that makes the hazardous event
unbearable and results in the crisis, and

4) The state of active crisis.

A different approach has been taken by JACOBSON (1968) who refers to social, intrapsychic and
somatic components of a crisis.

1) The social aspects of the crisis include any role changes or other alterations in the interpersonal
behavior that occur during a crisis,
2) The intrapsychic factors of the crisis emphasize the changes in conscious and unconscious
processes brought about by the crisis,
3) The somatic aspects of the crisis refer to somatic illnesses that might develop as a result of the
crisis.

SHULBERG & SHELDON (1968) have developed a probability formula 126 QUADERNS DE
PSICOLOGIA for a crisis:
the probability of a crisis situation occurring because of a hazardous event is a function of the
interaction between the hazardous event, the exposure of the individual to the event and the
vulnerability of the individual:
P Crisis = f (hazardous event exposure vulnerability)

STAGES IN DEVELOPMENT OF A CRISIS

Caplan was the first to describe the main stages of a crisis reaction. The contributions of later
theorists have been based on Caplan's work and have basically consisted on a restatement of his
phases. According to CAPLAN (1964) most crisis reactions follow 4 distinct phases:
1. In the initial phase the individual is confronted by a problem that poses a threat to his
homeostatic state: the person responds to feelings of increased tension by calling forth the
habitual problem-solving measures in an effort to restore his emotional equilibrium.
2. There is a rise in tension due to the failure of habitual problem-solving measures and the
persistence of the threat and problem. The person's functioning becames disorganized and the
individual senses feelings of upset and ineffectuality.

3. With the continued failure of the individual's efforts, a further rise in tension acts as a stimuli for
the mobilization of emergency and novel problem-solving measures. At this stage, the problem
may be redefined, the individual may resign himself to the problem or he may find a solution to it.

4. If the problem continues, the tension mounts beyond a further threshold or its burden increases
over time to a breaking point. The result may be a major breakdown in the individual's mental and
social functioning.
A crisis situation involves a sequence of events that leads individuals from "equilibrium to
disequilibrium and back again" (Golan, 1978). This sequence generally involves five components:
1. The Hazardous Event: The hazardous event is a stressful circumstance that disrupts an
individual's equilibrium and initiates a series of actions and reactions. The hazardous event may
be anticipated (e.g., divorce, retirement) or unanticipated (e.g., the sudden loss of a family
member).
2. The Vulnerable State: An individual's reaction to the hazardous event is ordinarily linked to
his/her subjective interpretation of the event. Most commonly, a hazardous event is perceived
either as a threat, a loss, or a challenge. The vulnerable state is characterized by an increase in
tension which the individual attempts to alleviate by using one or more of his/her usual coping
strategies. If these strategies are unsuccessful, the individual's tension continues to increase and,
as a result, he/she eventually becomes unable to function effectively.
3. The Precipitating Factor: The precipitating factor is the event that converts a vulnerable state
into a crisis state. In some situations, the hazardous event and precipitating factor are identical; in
other situations, the precipitating factor follows the hazardous event (i.e., the precipitating factor
acts as the "last straw"). The precipitating factor may produce a variety of responses including, for
example, a suicide attempt or, more constructively, a desire to seek help.
4. Active Crisis State: The active crisis state is characterized by disequilibrium and normally
involves the following: physical and psychological agitation (e.g., disturbed appetite and/or sleep,
impaired concentration and problem-solving ability, anxiety, or depression), preoccupation with the
events that led to the crisis, and, finally, a gradual return to a state of equilibrium. The individual
ordinarily recognizes during the active crisis stage that his/her usual coping mechanisms are
inadequate and, thus, is usually highly motivated to seek and accept outside help.
5. Reintegration: Successful reintegration (restoration of equilibrium) is dependent on a number of
factors including the individual's ability to objectively evaluate the crisis situation and to develop
and utilize effective coping strategies.

EFFECT OF BALANCING FACTORS

Individuals respond to a crisis in their own unique ways. There are certain factors that determine
the manner in which they respond, referred to as balancing factors. They include:

1. Perception of the event. The perception one has of an event determines the reaction to the
situation. If the person has a realistic perception and has access to adequate resources,
restoration of homeostasis will occur, and there will be no crisis. A realistic perception occurs
when a person is able to distinguish the relationship between an event and feelings of stress.

2. Availability of situational supports. If the person utilizes support from available persons in the
environment and receives assistance in solving the problem, a crisis can be averted. These
individuals reflect appraisal of the person’s values. When this is not available, the person is more
likely to define the event as more overwhelming, thus increasing vulnerability to crisis.

3. Availability of adequate coping skills. Coping skills or mechanisms are those methods

usually used by an individual to deal with anxiety or stress in order to reduce tension in difficult
situations. People may have positive or negative coping mechanisms, and many people
instinctively opt for a maladaptive coping mechanism. These may include denial, rationalization,
repression, regression, dissociation, or avoidance. However, if the person is able to successfully
use positive strategies from the past, a crisis can be averted. The inability to use strategies from
previous experiences or unsuccessful attempts to use strategies that were successful in the past
can lead to continued disequilibrium, tension, and anxiety.

Developmental factors can also impact a person’s response to stress and the development of a
crisis. For adults, a crisis can be hard to accept and impossible to understand, which can erode
feelings of personal and community safety. Adolescents and children may be even more deeply
affected. The effects of crisis on a child may interfere with normal growth and development,
leading to negative long-term physical and psychological health outcomes (Casale, 2017).
 CRISIS INTERVENTION
INTRODUCTION

BUTCHER, STELMACHERS & MAUDAL (1983) have discussed the historical origins of crisis
intervention. The high incidence of traumatic neuroses in World War 11 created a great need for
expanded psychological services: as a result of it, new treatment approaches were developed to
meet the needs of the soldiers who experienced stress related neuroses. The treatment was given
to them in the Unit as soon as possible after the breakdown and its aim was mainly to relieve the
symptoms. Lindemann's grief work and the development of early crisis clinics are cited by Butcher
et al. as other important historical origins of crisis intervention, as well the suicide prevention
movement. As they point out, the successful management of suicide related crises was made
possible by some innovative movement; these included the development of the telephone as a
means of communicating with people who needed help, the initiation of 24 hours service, and the
introduction of non professional personal into the role of helpers. Butcher et al., also cite the free
clinic movement as being influential in the development of crisis intervention.

DEFINITION

1. Crisis intervention is a technique used to help an individual or family to understand and cope
with the intense feelings that are typical of a crisis

2. Crisis intervention also refers to the methods used to offer immediate, short-term help to
individuals who experience an event that produces emotional, mental, physical, and behavioral
distress or problems

3. Crisis intervention is the informed and planful application of techniques derived from the
established principles of crisis theory, by persons qualified through training and experience to
understand these principles, with the intention of assisting individuals or families to modify
personal characteristics such as feelings, attitudes and behaviors that are judged to be
maladaptive or maladjustive.
EWING (1978)

4. Crisis intervention refers to the kind of psychological first aid that enables to help an 130
QUADERNS DE PSICOLOGIA individual or group experiencing a temporary loss of ability to cope
with a problem or situation.
HAFER and PETERSON (1982)

5. Crisis intervention programs originated as an attempt to serve unmet treatment needs of

individuals, but now they have come into their own as an important treatment alternative
(BUTCHER et al.; 1983)

CRISIS INTERVENTION GOALS

The precise goals of a crisis intervention depend, of course, on the specific nature of the crisis.
However, crisis-oriented treatments do share a number of common goals

The general goals of crisis intervention are:

1. Relieving the client's symptoms;
2. Restoring the client to his/her previous level of functioning;
3. Identifying the factors that led to the crisis state;
4. Identifying and applying remedial measures;
5. Helping the client connect current stresses with past life experiences; and
6. Helping the client develop adaptive coping strategies that can be used in the current situation as
well as in any future situation
Many consider the last two goals "optional" (i.e., feasible only in certain situations), while most
agree that the first four are the minimal goals for all types of crisis intervention.

PRINCIPLES OF CRISIS INTERVENTION

According to Puryear, crisis intervention is based on the following eight principles:

 Immediate Intervention: People are unable to endure crises for long periods of time; thus,
crisis interventions must be immediate. If the therapist cannot see a client requesting help
immediately, the client should be referred to someone who can. It is when clients request help
and are at the peak of their crisis that they are most amenable to treatment; i.e., when they are
least defensive and most introspective.
 Action: The therapist actively participates in and directs those activities that help the client
resolve the crisis.
 Limited Goals: While long-term forms of therapy may address a number of goals, crisis
intervention focuses on goals that are clearly related to the crisis situation.

 Hope and Expectations: Because people in crisis usually feel hopeless, a primary task for
the therapist is to instill the expectation that the crisis will be resolved.

 Support: Lack of support is ordinarily an important contributing factor to the development of a

crisis; thus, provision of support is a crucial factor in crisis
intervention.
 Focused problem-solving: Crisis interventions are problem oriented; i.e., their emphasis is
on resolution of the problem(s) underlying the crisis.

 Self-Image: The client experiencing a crisis typically sees him/herself as inadequate.

Therefore, the therapist must assume an approach that both protects and raises the client's
self-esteem.

 Self-Reliance: From the onset of the crisis intervention, the therapist must maintain a balance
between providing support and fostering the client's self-reliance and independence.

STAGES OF CRISIS INTERVENTION

A number of crisis intervention models have been developed. The model proposed by Golan
(1978) involves three stages:

Assessment (Session 1)
The assessment stage of crisis intervention entails:

1. Identifying the precipitating factor ("what happened?");

2. Determining the client's subjective reactions to the precipitating factor ("how did you respond?");

3. Defining the context of the crisis situation including the hazardous event ("can you remember
what started this?");

4. Assessing the client's present state ("what is happening now?"); and

5. Precisely defining, in conjunction with the client, the current problem ("we agree that the most
important problem is your anxiety about getting along without your husband").

Note that, depending on the nature of the crisis, assessment of the client may or maynot include
obtaining a recent medical and psychiatric history, assessing the client's current mental status,
determining if drugs or alcohol are involved, and/or assessing the client's potential for suicide. At
the end of the assessment stage, the therapist and client reach an explicit agreement regarding
the goals of the intervention.

Implementation (sessions 1-4)

The implementation phase involves obtaining relevant background information (e.g.,information on
the client's pre-crisis functioning, previously used coping strategies, the client's strengths and
weaknesses, and available resources and support systems), setting immediate goals, and
identifying tasks that allow the client to achieve those goals.

Termination (sessions 5-6)

During the termination phase, the client and therapist review the client's progress in terms of the
goals of the intervention, arrive at a decision to terminate, and discuss the client's plans for the
future.

Samuel Dixon (1987) presents a somewhat different model for crisis intervention. Although
different than Golan's, you will notice that both models integrate elements of the overall principles
of crisis intervention discussed earlier in this section. Dixon lists nine, more specific steps for
helping people in crisis. The first six steps generally occur during the first session with a client. As
necessary, steps 7 and 8 may take up to five weeks.

1. Establish a positive relationship early in the relationship: The therapist should appear to
the client as a "helpful person"; i.e., the therapist should communicate acceptance, be supportive
and show respect for the client and an eagerness to help. Essential in this step is a consideration
of the client's feelings with regard to seeking help (e.g., is he or she reluctant, embarrassed,
etc.), his or her feelings of helplessness and the degree of the client's debilitation.

2. Elicit and encourage expression of painful feelings and emotions: Clients in crisis should
be given the opportunity to ventilate painful feelings and emotions before discussing the specific
events surrounding the crisis. If the client is visibly distraught, the therapist should encourage such
expression before attempting to discuss the reasons for the crisis. In other situations, the client
may seem immediately prepared to discuss the crisis event itself and feelings will surface later.

3. Discuss the precipitating event: Next, the therapist can move on to an exploration of the
event that precipitated the crisis. Various aspects of the event should be explored, including when
it occurred, the circumstances surrounding it, how the client has tried to resolve the crisis, how the
client has coped thus far and what finally made the client seek help. Also helpful is the gathering of
information about the client's history and current life circumstances.

4. Assess and evaluate: At this point, the therapist uses the information gathered in the earlier
steps to assess the cause of the client's crisis, the degree of debilitation and potential for recovery.
Note that the gathering of information necessary for an assessment and evaluation should begin
as soon as the therapist and client meet each other. This assessment, along with the following
step, forms the basis for treatment planning and implementation.

5. Formulate a dynamic explanation: This step forms the basis for the client's cognitive
restoration; i.e., it is the basis of client insight and understanding of the crisis itself and his or her
reaction to it. Such understanding is essential for change to occur. The dynamic explanation
assesses why the client reacted to the crisis as he or she did (as opposed to what he or she has
responded to). In this step, the therapist evaluates both the internal (psychic) and external (social)
factors that precipitated the crisis and that prevented the client from resolving it without assistance.
An assessment of these factors allows the therapist to plan an appropriate intervention.

6. Restore cognitive functioning: This step is both empathic and intellectual. It permits the client
to move beyond the avoidance and defensiveness that characterize the peak of a crisis situation.
By providing an explanation for the crisis and an interpretation of the client's response to it, the
therapist helps the client regain both emotional and cognitive control.

6. Plan and implement treatment: Once the therapist has provided the client with some
understanding of the causes and reasons for the crisis condition, specific interventions can be
recommended. These can include referrals, environmental modification and/or additional crisis
therapy. The therapist should discuss these treatment goals with the client.

8. Terminate: Termination is indicated when the client has returned to the pre-crisis level of
functioning. In addition to resolving the crisis itself, crisis therapy should have helped the client
develop overall coping skills that can be applied to later events.

9. Follow-up: This step is optional. At the end of the last session, the therapist may let the client
know that he or she will contact the client some time in the future to see how he or she is doing.
Some therapists believe this fosters dependency; however, clients generally appreciate this show
of interest and such follow-up allows the therapist to evaluate therapy outcome.

MODELS OF CRISIS INTERVENTION

LANGSLEY & KAPLAN (1968) have classified crisis intervention models according to their main
focus:

a) Recompensation Model. It is a patient-oriented model, that is, it focuses on the patient

exclusively. The main goal of the treatment intervention is to stop the decompensation, get the
symptoms under control and return the patient to his pre-crisis leve1 of functioning. The model
does not aim at explaining the failure to cope nor at understanding the past dynamics of the
person that led him to the crisis. Moreover, there is not much concern about the person's future
adjustment. The military treatment of the traumatic neuroses is a typical example of the
recompensation approach to treatment.

b) Stress-Oriented Model. It takes into account the stress event. The goal of the intervention is to
achieve successful resolution of the specific tasks posed by the stress event. It emphasizes the
development of problem-solving strategies and coping skills and it is concerned with the future
adjustment of the individual to other stressful situations. This model has been developed to great
extent by Lindemann and Caplan.

c) System-Oriented Model. It is the one advocated by Langsley and Kaplan; it takes into account
the social field in which the person deals with the crisis. It is based on the belief that not only the
development but also the outcome of the crisis depend in part on the social field of the person in
crisis, and therefore emphasizes the systems approach to intervention. Family-Oriented crisis
treatment is an important development of this model, which is based on the assumption that the
symptoms of the family member who seeks treatment are usually an expression of family conflicts.

These are the three basic models on which most of the crisis intervention strategies are based.
While all of them seek a resolution of the crisis state, they focus on different aspects, namely the
individual, the stress event and the system, in their attempt to deal with the crisis situation.
 This three-stage intervention model integrates assessment and triage protocols
with Robert’s Seven-Stage Crisis Intervention Model (R-SSCIM) and is useful with persons calling
or walking into an outpatient psychiatric clinic, psychiatric screening center, community mental
health center, counseling center, or crisis intervention setting. The R-SSCIM model identifies
seven critical stages a clinician goes through to help the individual reach stabilization, resolution,
and mastery. The stages are sequential but may overlap in the process:

 Assessment
 Rapidly establish rapport
 Identify major problems
 Explore feelings and emotions
 Generate and explore alternatives
 Develop and formulate an action plan
 Plan follow-up

STAGE 1: ASSESSMENT

The first step in the assessment of an individual experiencing a mental health crisis is to begin a
fast but thorough biopsychosocial assessment, which includes inquiring about the major physical,
psychological, and social issues of the person. This assessment should provide a brief medical
history, medications being taken, current and past history of alcohol or drug use, environmental
resources and supports available to the person, mental health problems and symptoms, as well as
cultural considerations.
Assessment should inquire about the support system and resources available to the person in
crisis. Family and friends, social clubs, church groups, and networks of professional associates
are all sources of support. When these resources are not available, caregivers act as a temporary
support system for the patient. Some questions a clinician might ask about a support system are:
 “With whom do you live?”
“When you feel lonely and overwhelmed by life, whom do you talk to?”
“Is there someone in your life whom you trust?”
“In the past, during difficult times, whom did you want to help you?”
“Where do you go to school (to worship, to have fun)?”

Assessment of the level of anxiety the person is experiencing is conducted as well as the person’s
usual coping methods. Some people drink, some eat, some sleep, and some gamble. Others
engage in physical activity, work harder, pick fights, or talk to friends. Some questions clinicians
may ask about coping methods are:
“What do you do to make yourself feel better?”
“Did you try doing that this time?”
“If you did, what was different this time?”

Assessment of the person’s strengths and needs also begins in this stage and continues
throughout the crisis intervention. It is also important to determine whether the patient is unable to
take care of personal needs such as eating, sleeping, and tending to personal hygiene and safety.
Assessment of lethality is conducted to determine whether the person is suicidal or homicidal by
asking:
“Have you thought of killing yourself or someone else?”
“How would you go about doing this?”

If there is any concern about suicidality, it is essential to find out what the person’s thoughts are, if
there is intent and the strength of the intent, whether there is a plan and the lethality of the plan,
any past history of suicide attempts, and other specific risk factors for suicide such as substance
abuse, social isolation, or recent losses. In cases of imminent danger, emergency medical or
police intervention is often necessary. (See also “Assessing for Risk of Harm to Self or Others”
below.)

STAGE 2: RAPIDLY ESTABLISH RAPPORT

Stage 1 and stage 2 most often occur simultaneously. Establishing rapport and a collaborative
therapeutic relationship begins with the initial contact between the crisis clinician and the person.
The main task for the clinician at this point is to establish rapport by conveying genuine respect for
and acceptance of the person’s feeling and circumstances. The person may need reassurance
that they can be helped and that this is the appropriate place to receive such help.

The clinician demonstrates an understanding of the person’s situation and feelings by showing
patience and empathy, engaging in active listening, and concentrating on what the person is
communicating verbally and nonverbally. It is also important to reinforce any evidence of the
person’s resiliency.

Other ways in which rapport can be made is through eye contact, being nonjudgmental, mirroring
physical posture and movement to indicate listening intently, and the cautious use of touch to
convey understanding.

STAGE 3: IDENTIFY MAJOR PROBLEMS

This stage involves identifying the major problem(s) the person is having, including the chain of
events leading up to the crisis and the “last straw” that brought things to a head. The clinician
encourages the person to examine when and how the crisis occurred, the contributing
circumstances, and how the person attempted to deal with it. Questions clinicians might ask about
a precipitating event are:
“What happened to make you so upset?”
“How are you feeling right now?”
“How does this event affect your life?”
 “How will this event affect your future?”
“What needs to be done to fix the problem?”

Exploration of other problems the patient is concerned about is also accomplished during this
stage. It can be useful to prioritize the problems in terms of which problems the person wants to
work on first, recognizing that the focus of crisis intervention is the current problem rather than
issues from the past.

STAGE 4: EXPLORE FEELINGS AND EMOTIONS

It is extremely important to allow the person to vent feelings and emotions and to validate them by
accepting them and recognizing them as understandable. This is best accomplished by using
active listening skills, such as paraphrasing, reflective listening, and probing questions.
With caution, the clinician may also challenge maladaptive thinking and behavior. Challenging
responses can include giving the person information, reframing and interpreting thoughts and
behaviors, and playing “devil’s advocate.”
“How many times in the past have you had this kind of thought? Have you ever been
wrong?”
“What could you do to determine if this thought is true?”
“Even if that’s true, tell me if you can think of more positive behaviors you might engage
in?”

When used appropriately, these challenging responses help the person take a second look at
thoughts and behaviors and to consider other options.

STAGE 5: GENERATE AND EXPLORE ALTERNATIVES

This process may be the most difficult to accomplish in crisis intervention, People in crisis often
lack the ability to see the big picture and hold on to familiar ways of coping even when they are not
working.
The clinician draws conclusions about the patient’s strengths and needs related to the current
crisis and evaluates the potential for recovery. The person’s strengths are tapped to improve self-
esteem, which also provides the energy and skills for problem-solving.
During this stage of intervention, the clinician and the individual collaborate and negotiate to come
up with options that will improve the current situation. It is important that such collaboration occur
in order to ensure that the options selected are “owned” by the person. Brainstorming about
possibilities or asking about what has been helpful in the past can elicit the person’s input

STAGE 6: DEVELOP AND FORMULATE AN ACTION PLAN

At this point there is a shift from crisis to resolution. The person and the clinician begin to take the
steps negotiated in stage 5, and the person begins to make meaning of the crisis event by
exploring why it happened. It is important for the person to obtain a realistic picture and
understanding of what happened and what led to the crisis. It is also important for the person to
understand the specific meaning of the event and how it conflicts with expectations, life goals, and
belief system. Working through the meaning of an event is important in order to gain mastery over
the situation and for being able to cope with similar situations in the future.
During this stage, the person begins to restructure, rebuild, or replace irrational beliefs and
erroneous thinking with rational beliefs and new thinking. Action plans may also involve options
such as entering a 12-step treatment program, joining a support group, or entering a women’s
shelter. These are often critical options for restoration of the person’s equilibrium and
psychological balance.

STAGE 7: PLAN FOLLOW-UP

A plan for follow-up with the person after initial intervention should be done to make certain the
crisis is being resolved and to evaluate the postcrisis status of the person. Such an evaluation may
include current functioning and assessment of progress as well as satisfaction with treatment. It is
recommended for those individuals who are grieving that a follow-up session be scheduled around
the one-month and one-year anniversary of a death. This is also recommended for individuals who
are victims of violent crimes (Black & Flynn, 2021; Yeager & Roberts, 2015).

TECHNIQUES OF CRISIS INTERVENTION

1. Catharsis -Release of Feelings that takes place as the patient talks about emotionally charged
areas

2. Clarification - Encouraging the patient to express more clearly the relationship between certain
events

3. Reinforcement of Behaviour - Giving patient Positive Reinforcement to Adaptive Behaviour

4. Support of Defenses - encouraging the use of healthy, adaptive defenses and discouraging
those that are unhealthy or maladaptive

5. Increasing Self Esteem - Helping the patient to regain feelings of self worth

6. Exploration of solutions - Examining alternative ways of solving the immediate problem

7. Manipulation - Using the patient’s emotions, wishes or values to benefit the patient in the
therapeutic process

MODALITIES OF CRISIS INTERVENTION

1. Mobile Crisis Programs

Teams provide front-line interdisciplinary crisis intervention to individuals, families and
communities. Nurse should be able to provide onsite assessment, crisis management, treatment,
referral and educational services to patients, families and the community at large

2. Telephone contacts
Crisis intervention by telephone rather than face to face contact.
TELE - MANAS 14416
KIRAN - 1800-599-0019

3. Group work
 People who have common traits on stressors will form a group. The group provides an
opportunity for members to express common concerns and experiences, foster hope and build
mututal support. The nurses role in the group is active, focal and focussed on the present.

4. Disaster Response
Nurses have an important role in dealing with psychosocial problems of the disaster victims.
The nurse participates in crisis operations and acts as a case-finder for persons suffering from
psychosocial stress. Nurses in the post diaster phase must go to the places where victims are
likely to gather, such as Hospitals, shelters, morgues. During theis period, the nurse use the
generic approach of crisis intervention so that as many people as possible can receive help in a
short duration of time.

5. Victim Outreach Program

Victim outreach Programs use crisis intervention techniques to identify the needs of victims
and then to connect them with appropriate referrals and resources. The Victims need throrough
evaluation, empathetic support and information and helo with the large system and social
networking system.

6. Crisis Intervention Centres

They provide emergency psychiatric care and counseling to victims, experiencing extreme
stress or conflict, often involving suicide attempts or drug or alcohol abuse. Self contained units
within hospital or community health centre and provide services 24 hours a day.

7. Health Education
Nurses are responsible for identifying people at a high risk of developing crisis and in
teaching coping strategies to avoid the development of crisis.
Health education on
Identification of crisis prone people
Aware of the Available resources
Change of attitude
 ROLE OF A NURSE IN CRISIS INTERVENTION

BUTCHER et al. (1983) have developed a comprehensive list of tactics of crisis intervention that
cover many important functions of the crisis therapist.
Some of these functions are:
- Offering emotional support.
- Providing opportunities for catharsis.
- Listening selectively for workable material.
- Providing factual information and clearing up misconceptions when necessary.
- Formulating the problem situation.
- Being empathic and to the point.
- Predicting future consequences if the patient follows his present course of action.
- Clarifying and reinforcing adaptive mechanisms.
- Working out a contract with the client.
- Follow-up of the client's progress after termination of treatment .

PHASES OF CRISIS INTERVENTION: THE ROLE OF THE NURSE

Nurses respond to crisis situations on a daily basis. Crises can occur on every unit in the
general hospital, in the home setting, the community healthcare setting, schools, offices, and in
private practice. Indeed, nurses may be called on to function as crisis helpers in virtually any
setting committed to the practice of nursing. Roberts and Ottens (2005) provide a seven-stage
model of crisis intervention.

Aguilera (1998) describes four specific phases in the technique of crisis intervention that
are clearly comparable to the steps of the nursing process. These phases are discussed in the
following paragraphs.

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:
1. Ask the individual to describe the event that precipitated this crisis.
2. Determine when it occurred.
3. Assess the individual’s physical and mental status.
 4. Determine if the individual has experienced this stressor before. If so, what method of
coping was used? Have these methods been tried this time?
5. If previous coping methods were tried, what was the result?
6. If new coping methods were tried, what was the result?
7. Assess suicide or homicide potential, plan, and means.
8. Assess the adequacy of support systems.
9. Determine level of precrisis functioning. Assess the usual coping methods, available
support systems, and ability to problem solve.
10. Assess the individual’s perception of personal strengths and limitations.
11. Assess the individual’s use of substances.

Information from the comprehensive assessment is then analyzed, and appropriate nursing
diagnoses reflecting the immediacy of the crisis situation are identified. Some nursing diagnoses
that may be relevant include
1. Ineffective coping
2. Anxiety (severe to panic)
3. Disturbed thought processes
4. Risk for self- or other-directed violence
5. Rape-trauma syndrome
6. Post-trauma syndrome
7. Fear Phase

PHASE 2 : PLANNING OF THERAPEUTIC INTERVENTION

In the planning phase of the nursing process, the nurse selects the appropriate nursing
actions for the identified nursing diagnoses. In planning the interventions, the type of crisis, as well
as the individual’s strengths and available resources for support, are taken into consideration.
Goals are established for crisis resolution and a return to, or increase in, the precrisis level of
functioning.

PHASE 3. INTERVENTION
During phase 3, the actions that were identified in phase 2 are implemented. The following
interventions are the focus of nursing in crisis intervention:

1. Use a reality-oriented approach. The focus of the problem is on the here and now.
2. Remain with the individual who is experiencing panic anxiety.
3. Establish a rapid working relationship by showing unconditional acceptance, by active
listening, and by attending to immediate needs.
4. Discourage lengthy exp lanations or rationalizations of the situation; promote an
atmosphere for verbalization of true feelings.
5. Set firm limits on aggressive, destructive behaviors. At high levels of anxiety, behavior is
likely to be impulsive and regressive. Establish at the outset what is acceptable and what is not,
and maintain consistency.
6. Clarify the problem that the individual is facing. The nurse does this by describing his or
her perception of the problem and comparing it with the individual’s perception of the problem.
7. Help the individual determine what he or she believes precipitated the crisis.
8. Acknowledge feelings of anger, guilt, helplessness, and powerlessness, while taking care
not to provide positive feedback for these feelings.
9. Guide the individual through a problem-solving process by which he or she may move in
the direction of positive life change:
a. Help the individual confront the source of the problem that is creating the crisis
response.
b. Encourage the individual to discuss changes he or she would like to make. Jointly
determine whether or not desired changes are realistic.
 c. Encourage exploration of feelings about aspects that cannot be changed, and
explore alternative ways of coping more adaptively in these situations.
d. Discuss alternative strategies for creating changes that are realistically possible.
e. Weigh benefits and consequences of each alternative.
f. Assist the individual to select alternative coping strategies that will help alleviate
future crisis situations.
10. Identify external support systems and new social networks from whom the individual
may seek assistance in times of stress.

Another approach to Nursing Implementation is :

a) Environmental manipulation. In this case the helper serves as a referral source, getting the
client in touch with a resource person or facility.

b) General support. It consists basically of active listening in a non threatening manner, allowing
the person to speak in some detail about his problem without challenging him.

C) Generic manipulation. It is helping the person resolve a crisis by accomplishing certain

psychological tasks that are the same for al1 the people experiencing the same crisis regardless
of individual differences.

D) Individual approach. It focuses on the specific needs of the person in crisis and emphasizes the
assessment of the psychological and psychosocial processes that are influencing the client. It
looks at the specific psychoIogica1 tasks and problem solving activities that each person must
accomplish in resolving a particular crisis.

PHASE 4. EVALUATION OF CRISIS RESOLUTION AND ANTICIPATORY

PLANNING
To evaluate the outcome of crisis intervention, a reassessment is made to determine if the
stated objective was achieved:
1. Have positive behavioral changes occurred?
2. Has the individual developed more adaptive coping strategies? Have they been
effective? 3. Has the individual grown from the experience by gaining insight into his or her
responses to crisis situations?
3. Does the individual believe that he or she could respond with healthy adaptation in future
stressful situations to prevent crisis development?
4. Can the individual describe a plan of action for dealing with stressors similar to the one
that precipitated this crisis?

During the evaluation period, the nurse and client summarize what has occurred during the
intervention. They review what the individual has learned and “anticipate” how he or she will
respond in the future. A determination is made regarding follow-up therapy; if needed, the nurse
provides referral information.