The degree of stress experienced in coping with the unexpected crisis will interact with the life cycle

stage and the social situation to influence the individual's coping ability.

Typical responses to crisis These behaviors may alert you to the fact that someone is experiencing a crisis (Hansel, 1976). The person shows a preoccupation with the crisis situation and talks about the event, not attending to other issues. She feels isolated, alone and distant and may be cut off from friends and relative.. This occurs because the person in crisis is fearful that she cannot live up to the rules and expectations about behavior in asocial interaction at this time. She is likely to cry at work or when out with friends or to withdraw or to be unable to think clearly. Nonetheless, the need for closeness is shown by the way the person uses touch and eye contact, standing near, disclosing deep information and using intimate language. She is looking for warmth and comfort from someone, particularly those she thinks might be able to help resolve the crisis. There is a loss of confidence, with a less sure feeling about herself and a heightened sensitivity to the judgments of others. It is important to help this person find the positive in herself and work with the person's strengths rather than reinforce her perception of weakness and lack of self, experienced at this time. A crisis often shows in random and unexpected behaviors that do not conform to role expectations. A person in crisis is open to trying. out new roles due to the disruption of clear identity. People in this crisis environment need to be very aware of this. This willingness to try new roles can be helpful and allow for change and growth as a result of crisis. It can be unhelpful if the roles suggested and taken on are restricting or even dysfunctional. Becoming mentally or physically ill, taking on the sick role, may or may not prove constructive. The significant people in the person's life may help or hinder the person in crisis. The resolution of the crisis will be affected by these close networks of people. They may be accepting and tolerant of distress, yet reinforce

effective behavior. If the person distances too far from them they may be hurt and reject the person in crisis. If the crisis continues and new behavior becomes entrenched which the significant other people disapprove of they may withdraw from the individual. Change is not necessarily encouraged. People in crisis feel uncertain and confused and find that memories of the past swirl about at random, interfering with attention to that moment. When it comes to decision-making trial and error is used, with random stabs in the dark. It is difficult to choose from different solutions let alone to formulate those solutions. You cannot see the wood for the trees. Signals of distress are sent out to others, clinging and embracing behavior occurs. The person wants to change but does not know how. Initially, significant other people will act as buffers and protect the person in crisis and may significantly influence the selection of solutions. If they are not able to cope with the distress, or disapprove of the way the person in crisis is acting they may withdraw. There are three major ways of understanding crisis (Bancroft, 1979).

The individual model (based on psychoanalytic theory) This model looks at why this particular person is overwhelmed. It is of interest to know what degree of self identity the person has and to what degree she can tolerate frustration. Have there been past crisis experiences and if so how were these handled? One factor which correlates with an ineffective response in crisis is parental over protection. A young person who is deprived of any opportunity to experience coping with frustration and failure has no basis on which to build crisis handling behaviour.

The behavioural model (based on normative understanding) Crisis experience is viewed as normal. The interest centers on what problemsolving skills the person has and on what actions she has taken which indicate success or failure in resolving the crisis. It is also of interest to know if the thoughts and actions which would normally be expected in the situation are occurring. If you have experienced a crisis you will know that it is comforting to

find, that while feeling out of control and acting that way in your view, others appear to cope with this and see it as normal under the circumstances.

The interactional model (based on systems theory) This view is interested to monitor the responses of significant others in the person'? life, Do they encourage the person to deal with and resolve the crisis or is the person encouraged to become helpless and dependent. The *mad' or 'bad' role may be encouraged, or the 'sick' role. Sometimes the family unit (the system) needs the person in a particular role known as the 'identified patient' so as to protect the other family members from chaos. The social network can inhibit change and growth. Within a system like the family the person is encouraged to remain her usual self, for better or worse, because that is what the family knows and that old 'self has a function for that family. The same idea can be transferred to the workplace. Does someone function as the scapegoat, the problem, the person in crisis who 'can't', thereby allowing everyone else to function? When understanding a person in crisis and the coping mechanisms they employ it is of value to look at all these aspects: the intrapersonal, the interpersonal and the social context - a systemic interactional perspective.

CAPLAN'S CRISIS CIRCLE To understand further what happens in a crisis, Caplan's circle (see Fig. 7.1) will now be explored, based on the definition presented earlier. The person is faced with an obstacle and the coping mechanisms normally used do not work effectively. Consequently an increase further reduction in anxiety and tension is experienced. The more the anxiety and tension increase the more difficult it is to see the wood for the trees. Consequently, loss of insight occurs. It becomes harder and harder to think of possible solutions; ways out of this chaotic experience. Problem-solving ability is reduced leaving the person feeling helpless, not knowing which way to go and where to turn; immobilized. A further increase in anxiety and tension may then occur with further loss of insight, reduction in

problem-solving and an even deeper helplessness and immobility. This vicious circle can go round and round until a threshold level is reached (sec Fig. 7.2); a level where the person draws on latent or new resources which can be physical, psychosocial, spiritual or all of these. Otherwise major disorganization will occur (including perhaps a psychotic episode).

Phases of the crisis circle There are four phases in this process towards resolution or major disorganization (Brandon, 1970). Phase 1 Phase one occurs as a result of the threat being perceived. Old memories are revived accompanied by emotional reaction. The impact of the crisis will be influenced by such factors as bodily state, influence of infection or exhaustion, and the availability of support systems and other external resources. Past experience and previously developed coping mechanisms will also influence behavior. As tension and anxiety increase usual problem-solving methods are tried. When unsuccessful the crisis state develops.

Phase 2 As the tension rises disorganization begins. Usual functioning is interfered with. The person is upset, anxious and feels insecure and helpless. Trial and error problem-solving occurs and feelings are discharged.

Phase3 Tension rises and there is a threshold level reached with a draining of internal and external resources. New problem-solving techniques are employed and solutions attempted. Often at this stage the problem is defined in a new way. The solution may resolve the crisis. Resolution normally occurs within 4-6 weeks when new coping mechanisms are found.

Phase 4 This occurs when the solution applied does not really solve the crisis. It may stop the discomfort and distress but in the longer term prove maladaptive. Major disorganization ensues including sometimes psychosis. However, it is important to realize that the majority of people reach threshold level and do find the necessary resources to adapt to the crisis and overcome the obstacle. Sometimes you can see a person struggling with an issue, going round in circles and making poor and unfruitful attempts to solve the problem. While the person does not want to recognize her need for help, all you can do is offer support and wait. When threshold level (Fig. 7.2) is reached the person will be willing to use the resources available. It can be very frustrating watching someone go round in circles but if you rush in and fix it for them they will not learn from experience and develop new coping mechanisms. Even when asked for help it is important to act as a supporter and confidante who can help the person in crisis gain some equilibrium and problem-solve, but wherever possible the most effective help still leaves the person in charge of her own decisions and life.

Where to intervene in a crisis Taking over responsibility Here you are helping at the 'inability to act' part of the circle. Sometimes the person is so overwhelmed or so ill that she becomes a' 'patient' to be taken care of. This means that the person's current responsibilities will have to be dealt with by others. The person is usually then removed from the environment provoking the stress. She may stay with friends or relatives or be admitted to a hospital. The person needs time spent with her and permission to talk, with acceptance and concern offered by the care givers. The person may be quite exhausted and require sleep. Medication has a place for helping sleep if really necessary and also to dampen high and distressing psychological arousal. If used, medication is viewed as a short term treatment only!

Taking over of responsibility is not usually necessary in the majority of crisis reactions and is the choice made only when the person is considerably swamped.

Helping people in crisis help themselves Here you are helping at the anxiety and tension, insight and problem-solving areas. This is the preferred choice. People are aware of the crisis and turmoil they are experiencing and ask for help. Often the first step is to define the actual problem. Towards this end it is useful to encourage the person to express emotion; anger, frustration, guilt, sadness; whatever the emotions are which have been elicited as a result of the crisis. It is usually of benefit to release and express these feelings. The person requires acceptance; the showing of warmth and empathy which will build trust. Emphasizing the positive aspects of the person and using and eliciting her strengths will build self-esteem and prevent the helper from also being overcome by the problem. Most importantly the person is encouraged and helped to problem-solve. Choices are presented. If there is only one choice there is really no choice at all. If there are two choices, they are often polarized; good or bad; right or wrong; black or white. The availability of two choices only, may leave a person stuck on the horns of a dilemma with no way of finding shades of grey and room to move. Wherever possible try to find at least three possible choices before deciding on a potential solution. As part of this process you may need to give information, make statements of reality, let a person know about incongruent messages, employ reflective listening, not provide answers and be comfortable with silence or with strong emotion. It is sometimes appropriate to give advice particularly of an expert kind such as medical, legal, monetary or contraceptive advice. Avoid advice-giving unless it is really necessary. The patient is best helped by finding her own solution which is right for her.

There are times when psychotropic drugs may be valuable such as to lower intense feeling, to make way for problem-solving behaviour, to help with sleep, or to improve mood in depression so that problem-solving behaviour can be initiated. Drugs are best kept until last and not used unless really necessary. Distressed behaviour with experience of emotion and feelings of chaos are normal during crisis. Out of chaos comes change. A crisis is certainly one for the person experiencing it, but as that person becomes very stressed those around her may also experience severe stress to the point of crisis. This is often the case in nursing when the stress load carried may be very great if dealing with many very ill people, death, and distressed and bereaved relatives. Many times health professionals also have a sense of grief sharpened by a tense of failure. It is a trap to emphasize curing sometimes to the detriment of caring. Dying is the final stage of living. To care and make comfortable while a person negotiates this final life stage is really what is needed. Curing is no longer relevant.

THE KUBLER-ROSS CRISIS MODEL The dying process is often avoided and not talked about partly because of the fear of death and the uncertainty about a future life; partly because the possible loss of someone dear is not faced early, and in hospitals partly because of the 'cure' injunction which contributes to the health professional's sense of failure when someone dies. Although people have often not been told their diagnosis or their prognosis they nonetheless know, and will be able to tell you this when they realize you are willing to let them talk about their realization, and the feelings and thoughts they are experiencing.

Stages in the dying process Denial This functions as a buffer while the person becomes ready to accept the diagnosis which heralds her death. It is a useful mechanism which allows time to adjust. The patient will let it go when ready as long as the staff are not giving non-verbal

messages which imply that the illness and feelings are not to be talked about. Some people die denying their illness; that is their right. Partial denial is also useful from time to time. The person may accept the diagnosis but will sometimes talk of a future which is clearly not possible. This can help the person continue to face life, when death becomes difficult to look at too closely.

Anger People often wonder why this should happen to them! 'Why me?' they will ask. There is no answer to this question. An answer is not being looked for, it is just a way of expressing frustration at the limits now placed on life plans. If the person is allowed to express her anger and it is realized there is no need to respond defensively or to prevent the expression of this emotion, in most people this anger will pass. Anger0 is often expressed towards the very people we love and trust the most. Somehow we believe they will still care and be there for us. Patients can be co-operative and friendly from a nurse's perspective and give particular relatives an awful time. The important thing is to recognize the anger for what it is: the person's expression of frustration and not a personal attack. Support needs to be provided for the person to whom the anger is addressed. The majority of people will lose their angry feelings eventually, particularly if accepted and supported. That means you acknowledge their anger, do not defend yourself, and treat them as people, not someone to be handled with kid gloves, or avoided. Confrontation, Imessages, reality statements and information will not do any harm accompanied by your listening skills where appropriate.

Bargaining People make bargains between themselves and their God. These are private and not usually shared. They sometimes make bargains like 'If I don't cat, I'll feel better.' A bargain is really trying to gain more time. Many patients will bargain for time 'Just to be at my daughter's