In a crisis usual methods of problem solving are not effective or not available.
The person becomes more willing to try new ways of problem solving (including professional help) à
and this results in growth.
Development of Crisis Theory
Caplan defines crisis as a threat to homeostasis.
In a crisis an imbalance occurs that results in confusion & disorganization.
An active crisis state may last 4-6 weeks.
Crisis theory was developed out of studies on crisis in bereavement.
Crisis theory is derived from psychoanalytic theory & ego psychology (which stresses that people have the ability to learn & grow)
What happens in a crisis?
A person is confronted with an overwhelming threat & cannot cope.
This creates a crisis – which can last 4-6 weeks.
The person will either adapt at this point & develop new coping skills OR decompensate (not adapt) to a lower level of functioning.
How a person handles a crisis depends on:
Their previous problem-solving experience (experience with coping & available coping mechanisms)
The way they view the problem (how they perceive the event)
And the amount of help (people who can be supportive to the person) OR hindrance from significant others.
What are the phases of a crisis?
Phase I - The person has an increase in anxiety in response to a traumatic event à
if the coping mechanisms work, there’s no crisis à
if coping mechanisms do not work (are ineffective) a crisis occurs.
Phase II – In the second phase anxiety continues to increase.
Phase III – Anxiety continues to increase & the person asks for help. (If the person has been emotionally isolated before the trauma they probably will not have adequate support & a crisis will surely occur).
Phase IV – Is the active crisis – here the persons inner resources & supports are inadequate. The person has a short attention span, ruminates (goes on about it), & wonders what they did or how they could have avoided the trauma. Their behavior is impulsive & unproductive. Relationships with others suffer à
they view others in terms of how can they help to solve the problem. The person feels like they are losing their mind à
this is frightening – Be sure to teach them that when the anxiety decreases that thinking will be clearer.
Types of crisis
What refers to a crisis precipitated by the normal stress of development?
A maturational crisis
What refers to a crisis precipitated by a sudden traumatic event?
A situational crisis
What can you tell me about maturational crisis?
Well… Erikson found that there were specific times in normal development when anxiety or stress increases & could precipitate a maturational crisis. (Remember those teenage years? Crisis or what?).
Examples include being born, mastering control of body functions, starting school, experiencing puberty, leaving home, getting married, becoming a parent, losing physical youthfulness & entering retirement.
Why are these times considered a crisis for some & not for other? It is thought that some people are unable to make the role changes necessary for the new maturational level. A good example might be the birth of a first child – One couple is able to adapt & make the role change while another couple cannot readily adapt to the new role of being parents.
There are three reasons why people may not be able to prevent a maturational crisis.
They can’t see themselves in the new role.
They lack the interpersonal resources to make the role change (i.e. they are not flexible enough to change).
Other people may refuse to recognize the role change.
In each stage of development a person needs nurturance from others.
Maturational crisis are predictable & occur gradually à
they can be prepared for and prevented with for example, marriage counseling, parenting classes, retirement planning.
What can you tell me about situational crisis?
A situational crisis is a response to a traumatic event that is usually sudden & unavoidable.
It usually follows the loss of an established support or role.
The threat or loss of a role viewed as necessary to maintain self-image usually will lead to a crisis state.
Situations that affect the way people perceive themselves include loss of a job, failure in school, loss of a spouse, birth of a retarded child, or diagnosis of a terminal or chronic illness.
The goal is to assist the person in distress to resolve the immediate problem & regain emotional equilibrium.
Your role as the nurse, or intervener is one of active participation à
however you do not take over & make decisions unless the person is suicidal or homicidal. Intervention is a partnership & the belief is that with help people can help themselves.
What does the nurse do? – Helps the person analyze the event, encourages expression of feelings, affirms the right to those feelings no matter what they are, reinforces strengths & abilities, explore other ways to deal with the stressors & encourages support from family, friends & other resources.
What is Critical Incident Stress Debriefing?
A type of crisis intervention.
Critical incidents are any situation that occurs suddenly & unexpectedly, disrupts values & beliefs, & challenges basic assumptions of how the world operates.
Examples of critical incidents include witnessing a violent act, sudden infant death, physical or psychological threats or losses, unusual media events, fires, volcanic eruptions, earthquakes, hurricanes & typhoons.
Intervention focuses on the here & now & is completed in one session. Debriefing usually takes place about 24-72 hours after the incident à
it may act to prevent the development of post-traumatic stress disorder.
What are the characteristics of a crisis intervener?
They must demonstrate calmness & empathy, be able to identify facts in a situation & think clearly to plan solutions to the problem. They must possess courage, make the commitment to work with the person until the problem is resolved & be able to tolerate the uncomfortableness, sadness & anger associated with crisis. It is also important to be nonjudgmental & aware of different cultural values, and not to impose a different lifestyle or value system on the client.
Application of the Nursing Process
Determine if the person is really in crisis (tears, anger & being upset don’t always mean crisis) What is their perception of the stressful event? How threatened are they? Is the perception realistic or distorted?
If there is great anxiety, the person cannot think clearly or identify solutions – is helpful to have them talk about what immediately preceded the distress à
it frequently calms people to talk.
Focus on the immediate problem not the history à
people will reach out for help even if the event occurred in the last 14 days, sometime within 24 hours.
Ask the person to describe their feelings & frustrations (accept them without judgement & it helps the client to accept them). Experiencing pain is also beneficial to the person – although it may be difficult for the nurse to see someone crying.
It is important that you know that nurses are not suppose to have all the answers for patient à
we provide the support & feedback while the patients solve their own problem and in this way they grow…
Assess the availability of support systems – which can provide continued support. Who do they trust? Who is your best friend? Who are you close to? (Children cope better if they are with their parents) Do they have a religious beliefs & support?
Assess coping skills. Are they adaptive or maladaptive? Are they still functioning in life (i.e. with a job, school or family)?
Assess the potential for self-harm. Are they having thoughts of hurting themselves? Most patients will not volunteer this information – but will readily talk about suicidal thoughts when asked. If there is a history or specific plan of suicide the patient must be watched closely.
Possible Nursing Diagnosis
Anxiety, Altered Thought Processes, Ineffective Individual Coping Impaired Social Interaction, Social Isolation & Self Esteem Disturbance.
See page 797 or any Nursing Diagnosis book for more.
The major goal of crisis intervention is to assist the patient in reestablishing equilibrium.
The goals of crisis intervention are different form the goals of other therapies.
Assist the patient to reexamine any feelings that might block adaptive coping & realize the potential for growth.
Teach the patient that it is alright to ask for help, people who place high value on independence may have difficulty.
Encourage adaptive coping methods such as expression of feelings, progressive relaxation, and physical exercise, as well as drinking warm milk or herbal tea to aid in relaxation & sleep.
Assist the patient to focus on the problem & specific goals leading to its resolution.
Another approach to care includes a crisis team – possibly consisting of a psychiatrist, nurse, psychologist, social worker, aide, minister & students. The disadvantage of this approach is a possible loss in continuity of care – which should be monitored closely.
Crisis Groups are an option to one-on-one crisis intervention.
Groups may work best for people who have difficulty with interpersonal relationships (feel more comfortable in a group), and those who have difficulty accepting information from psychiatric professionals or people in positions of authority.
Advantages are - people feel less isolated, make social contact, see others have similar problems - which helps them to open up about their problems.
Disadvantages are - an inability to focus on one patient’s problems & suggestions of maladaptive or destructive coping methods by group members.
Groups are usually 5-7 people that meet 1 ˝ to 2 hours once a week for 6 weeks.
A closed group does not accept new members after it is formed & continues for a specified time.