Chapter 26: Crisis Intervention

Nursing assessment in crisis intervention: situational support

Does the patient recognize situational supports available questions: (a) "Who do you live with?" (b) "Who is available to help you?" (c) "Who can you trust?" (d) "How important is spirituality in your life?"

Nursing assessment in crisis intervention: Precipitating event

Does the patient recognize the event: questions: (a) "Has anything happened recently that has been particularly upsetting?" (b) "What leads you to seek help now?" (c) "Describe how you are feeling and how you see the situation."

Function of Critical Incident Stress Debriefing (CISD)

-Used to debrief: -staff on an inpatient unit following a pt. suicide or an incident of violence -crisis hotline volunteer -schoolchildren and school personnel after multiple school shootings -rescue and health care workers who have responded to a natural disaster or a terrorist attack such as that on the World Trade Center -Phases (attached): introductory, fact, thought, reaction, symptom, teaching, re-entry

Nurse's role in psychotherapeutic crisis Intervention: Primary Care

-Work with a pt. to recognize potential problems by evaluating the pt. experience of stressful life events -teach specific coping skills (i.e decision making, problem solving, assertiveness skills, meditation, and relaxation skills) -assist pt. in evaluating the timing or reduction of life changes to decrease negative effects of stress as much as possible

Crisis Care Model: Psychiatric advance directive plan

-a proactive method of addressing a crisis situation before it occurs -document developed by the pt. to be used in crisis when pt. unable to make decisions -stipulates treatment choice, treatment facilities, providers, and designated support person who can be involved in decision making

Psychotherapeutic Crisis Intervention: Secondary Care

-establishes intervention during an acute crisis to prevent prolonged anxiety from diminishing personal effectiveness and personality organization -lessens the time pt. is mentally disabled during a crisis -occurs in hospital units, emergency departments, clinics or mental health centers, usually during day time hours

Phase 2 of crisis

-if the usual defensive response fails, and the threat persists, anxiety continues to rise and produce rising levels of discomfort -individual functioning becomes disorganized -Trial & error attempts to solve problem & restore balance

Phase 1 of crisis

-increased anxiety when confronted by a conflict or problem that threatens his/her self concept -increased anxiety stimulates use of problem-solving techniques and defense mechanisms in an effort to address the problem & lower anxiety

Maturational Crisis

-internal: developmental stages (Erikson's 8 stages of ego growth & development) -results in either psychosocial growth or regression -when a person reaches a new stage (i.e. moving out of parents home/going to college/marriage), coping styles are no longer effective, and new coping mechanisms have yet to be developed. -unresolved problems in the past and inadequate coping mechanism adversely affect what is learned in each developmental stage

Mental Illness interaction with Law Enforcement

-many states have crisis intervention team (CIT) training programs to prepare police officer to react appropriately to situation involving mental illness

Nurse's role in psychotherapeutic crisis Intervention: Secondary Care

-priority is patient safety -Then, work with pt. to assess the pt's problems, support systems, and coping styles -Desired goals are explores and interventions are planned

Psychotherapeutic Crisis Intervention: Primary Care

-promotes mental health and reduces mental illness to decrease the incidence of crisis

Crisis Care Model: Mobile crisis service

-provide acute crisis stabilization and psychiatric assessment services to people within their own home and in other sites outside the clinical setting. -Staff include variety of mental health professionals: counselors, social workers, and registered nurses (RN) -Typically, a psychiatrist or advanced practice psychiatric mental health RN is on call -Goal: to provide a rapid response, resolve crisis situations, and prevent hospitalizations

Crisis Care Model: Warm lines

-provide confidential telephone support -NOT designed for crisis situations -Goal: prevent escalation of distress -support services provided by trained consumers, people who have experience using mental health services

Crisis Care Model: Short-term crisis residential services

-provide continuous 24-hour observation and supervision for people who do not require inpatient services -Goal: eliminate or reduce acute symptoms of psychiatric disorders -pt. provided w/ a range of community-based resources and safe environment for care & recovery

Crisis Care Model: Peer crisis services

-provided by people who have had experience with living with a psychiatric disorder -peers provide calming environment, support, and links to psychiatric support. -services are intended to last less than 24 hours, but may be continued for several day

Psychotherapeutic Crisis Intervention: Tertiary Care

-provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state -facilities include rehab. centers, sheltered workshops, day hospitals, and outpatient clinics

Crisis Care Model: 24/7 crisis hotline

-telephone call: first line intervention for those in acute crisis -provide immediate responses from a variety of people (i.e. professional or trained volunteer) -confidential -does not require insurance and can link person with other community services

Phase 3 of crisis

-trial and error failed -anxiety can escalate to severe & panic levels -automatic relief behavior (i.e. withdrawal & flight) -may make some form of resolution (i.e. compromising needs or redefining the situation)

Crisis Evaluation Questions

1. "Has anything upsetting occurred in the past few days?" 2. "What led you to seek help at this time?" 3. "Are you thinking of hurting yourself or someone else?" 4. "Who can be helpful to you during this time?" 5."How are you coping with this now?" 6."What goal would you like to set?"

Resolution of crisis depends on:

1. Action of client AND 2. Helpful intervention of others

Expected functional level after crisis

1. Higher than before crisis 2. Same as before crisis 3. Lower than before crisis

a successful outcome for a crisis depends on:

1. a realistic perception of the event 2. adequate situational support 3. adequate coping mechanism

After assessing for safety identify:

1. person's perception of precipitating event 2. person's situational supports 3. person's personal coping skills

Crisis intervention

designed for persons: -in good mental health -who functions adequately, but became OVERWHELMED and UNABLE to cope well -therapy is brief (4-6 weeks) -The focus is ONLY on resolution of immediate / present problem "here & now"

Adventitious Crisis

external events: crimes, illegal activity, violence, war, natural disasters (fires, floods, earthquakes) -not a part of every day life -The person has little or no control; feels overwhelmed and defeated -serious post-trauma responses include acute stress disorder, PTSD, and major depressive disorder

Situational Crisis

external: unanticipated -example: loss of job, the death of a loved one, divorce -whether or not these events precipitate a crisis depends on factors such as the degree of support available from caring friends, family members, and others

Complex Crisis

**Adjust crisis model** -Impaired coping related to mental health or medical illness diagnosis ANOTHER stressful event -"The last straw" of multiple stressors. -Presence of "unresolved" or multiple losses = losses are cumulative -Excessive fatigue or pain

Crisis

-A major disturbance caused by a stressful event or threat, which disrupts homeostasis/equilibrium -SUDDEN EVENT result in psychological disequilibrium -OVERWHELMS usual coping methods and problem solving do not work. -Causes Extreme distress/anxiety occurs -Person UNABLE to function

Nurse's Role in Crisis Intervention

-Active & direct: elicit crisis, feelings and meanings from the person; -Allow patient autonomy: as possible do not make decisions for the person; however, may need to take an active, direct role in planning and goal setting. -Assess for violence: DTS (self) or DTO (others) or psychotic?Is hospitalization needed?

Elements of Crisis

-Acute (not chronic) -Time-limited occurrence (lasts 4-6-8 weeks and resolves or lessens) -Overwhelming emotional reaction to event -Crises are universal across cultures. -Culture plays a strong role in how event is perceived and interpreted.

Nursing diagnosis: Crisis

-Anxiety related to inadequate coping skills as evidenced by _____(confusion, suicidal thoughts, etc.). -Ineffective coping related to inadequate coping methods as evidenced by ______(anger, withdrawal, violence). -Powerlessness related to lack of control over environment as evidenced by______ (anger, lack of support system).

Crisis Care Model: 23-hour crisis stabilization

-Goal: quickly deescalate crisis situations and avoid unnecessary and costly hospitalizations -pt. provided with specific referrals for outpatient care (i.e. residential substance treatment or partial hospitalization)

Nurse's role in psychotherapeutic crisis Intervention: Tertiary Care

-Goals are to facilitate optimal levels of functioning and prevent further emotional disruptions -community facilities provide structured environment that can help prevent problem situation

Phase 4 of crisis

-If the problems is not solved and new coping skills are ineffective, anxiety can overwhelm the person and lead to serious: -personality disorganization -depression -confusion -violence against others -suicidal behavior

Crisis Intervention: Early Intervention

-Increases good prognosis -Psychosocial interventions: BUILD RAPPORT, patient safety, anxiety reduction -Client works with nurse to set realistic goals and plan interventions (ways to deal with crisis)

Nursing assessment in crisis intervention: Specific Goals

-Patient sets specific goals: questions: (a) "What might you do now?" -Help client set specific goals that can be achieved: Call someone, talk with someone...

Goal of crisis intervention:

-Reduce anxiety, feel safe, think, and return to previous level of functioning before crisis occurred

Nursing assessment in crisis intervention: Basic needs met

Has patient eaten? Feed first—talk later

Nursing assessment in crisis intervention: Coping skills

Is the person able to assess personal coping skills? questions: (a) "What do you usually do to feel better?" (b) "Did you try it this time? If so, what happened? "What was different?" (c) "What has helped you through difficult times in the past?" (d) " What do you thing might happen now?"

Nursing assessment in crisis intervention: Patient safety

Safety is always the first area to assess: 1. Does client need external controls, i.e. hospitalization/51-50? 2. Suicidal or homicidal ideation or gestures? 3. Psychotic thinking? Violent behavior?