Crisis intervention in psychiatry

Crisis Management In Psychiatry
By
Dr Sunil Suthar Under guidance of
Prof. Dr. Pradeep
Sharma

Contents
 Definition
 Characteristics Of Crisis Events
 Examples Of Crises
 Symptoms of Distress During Crisis
 Stages of a Crisis Reaction
 Types of Crisis
 Principles of Crisis Intervention
 Crisis Assessment and Intervention
 Crisis Intervention In Specific Situations

Definition
• Caplan (1964) initially defined a crisis as occurring when individuals
are confronted with problems that cannot be solved. These
irresolvable issues result in an increase in tension, signs of anxiety, a
subsequent state of emotional unrest, and an inability to function
for extended periods.
• James and Gilliland (2005) define crises as events or situations
perceived as intolerably difficult that exceed an individual’s
available resources and coping mechanisms.
• The Chinese translation of the word “crisis” consists of two separate
characters, which paradoxically mean danger and opportunity
(Greene, Lee, Trask, & Rheinscheld, 2000).
• Crisis intervention thus provides opportunities for clients to learn
new coping skills while identifying, mobilizing, and enhancing those
they already possess.

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.

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

Symptoms of Distress During Crisis
• Physical Symptoms
 Sleep disturbances; jaw, shoulder, back or neck pain.
 Tension headache, cramps, heartburn, constipation, diarrhea,
eating disturbances.
 Muscle tension, fatigue, sweaty palms, cold hands or feet
 Shortness of breath, chest pain, skin problems
 Increased vulnerability to cold, flu and infections.
• Psychological Symptoms
 Anxiety, fear, irritability, hopelessness, helplessness, impatience,
feeling of doom and gloom, nervousness

Symptoms of Distress During Crisis
• Interpersonal Symptoms
 Increased arguments, isolation from social activities.
 Job instability, conflict with co-workers and employers.
 Road rage, domestic or workplace violence, overreactions.

Stages of a Crisis Reaction
• Caplan (1961) describes the four stages of a crisis reaction as
follows:
1. An initial rise in tension occurs in response to an event.
2. Increased tension disrupts daily living.
3. Unresolved tension results in depression.
4. Failure to resolve the crisis may result in a psychological breakdown.
• Researchers have identified three primary phases of crisis reactions
(Herman, 1997; Horowitz, 1986; Yassen & Harvey, 1998). These
phases are outlined below.
1. Acute Phase
2. Outward Adjustment Phase
3. Integration Phase

Types of Crisis
1. Accidental Crises
2. Developmental Crises

Types of Crisis
1. Accidental Crises-
• Traumatic events which might or might not happen at a given time.
• These could either be major catastrophes such as earthquakes,
floods, etc., which could affect a whole section of society or
individual ( like a child losing its mother at an early age, even the
loss of a job or a broken relationship, or any other sudden tragic
event ).

Types of Crisis
2. Developmental Crises-
• Erikson calls these: ‘developmental crises’ as distinct from
‘accidental crises’ associated with various life hazards.
• Events such as birth, which is a crisis both for the mother and the
infant, the onset of puberty and adolescence, marriage, the
menopause, and so on as we progress through the biological stages
of life.
• These differ from “accidental crisis” in that they necessarily occur
at a given point in development and everyone has to pass through
them.

Principles of Crisis
Intervention
In general effective crisis should lead to-
• Stabilizing symptoms of distress
• Mitigation of symptoms
• Restoring adaptive level functioning
• Facilitating access to further support.

Crisis Assessment and Intervention
• There are three primary methods of assessing clients in crisis:
standardized inventories, general personality tests interpreted in
the light of the crisis, and client interviews. The interview is the
most commonly used method.
• Different Models of crisis assessment and intervention-
1. Triage Assessment System
2. Gilliland’s Six-Step Model
3. Seven-Stage Model of Crisis Intervention
4. ABC model of Crisis intervention

Triage Assessment System
• Triage Assessment System was developed by Myer (2001), who
posits that it is necessary to assess crisis reactions in three
domains: affective(emotional), cognitive (thinking), and
behavioral (actions).
 Affective reactions include anger, hostility, anxiety, fear, sadness,
and melancholy.
 Cognitive reactions include transgression, threat, and loss.
 Behavioral reactions include approach/avoidance and immobility,
and can be constructive or maladaptive.

Gilliland’s Six-Step Model
• Gilliland’s Six-Step Model, which includes three listening and three
action steps, is a useful crisis intervention model-
1. Listening
defining the problem
ensuring client safety
providing support
2. Action
examining alternatives
making plans
obtaining commitment

Gilliland’s Six-Step Model
• Attending, observing, understanding, and responding with empathy,
genuineness, respect, acceptance, non-judgment, and caring are
important elements of listening.
• Action steps are carried out in a nondirective and collaborative
manner, which attends to the assessed needs of clients as well as
the environmental supports available to them (James & Gilliland,
2005).

Seven-Stage Model of Crisis
Intervention
• This model, developed by Roberts (1990), contains seven stages:
1. Plan and conduct a thorough biopsychosocial and crisis assessment.
This also includes assessing suicidal and homicidal risk, need for
medical attention, drug and alcohol use, and negative coping
strategies. Assessing resilience and protective factors as well as
family and other support networks is helpful.
2. Make psychological contact and establish rapport. By conveying
respect and acceptance, the responder develops a solid therapeutic
relationship with the client. Displaying a nonjudgmental attitude
and neutrality are important in crisis work.
3. Examine and define the dimensions of the problem or crisis.

Seven-Stage Model of Crisis
Intervention
4. Encourage an exploration of feelings and emotions. This can be
achieved by actively listening to the client and responding with
encouraging statements.
5. Explore past positive coping strategies and alternatives. Viewing the
individual as a resourceful and resilient person with an array of
potential resources and alternatives can help this process (Roberts,
2000). Crisis workers should be creative and flexible in resolving
crisis situations.
6. Implement the action plan. At this stage, identify supportive
individuals and contact referral sources. The client should be able to
implement some coping strategies.
7. Establish a follow-up plan.

ABC model of Crisis intervention
• ABC model of Crisis intervention is problem
focused method of intervening in a brief time
period. It begins with identifying the person’s
perception of the event that triggered the
crisis.
• Stages of ABC model are-
A. Achieving Rapport
B. Beginning of Problem Identification
C. Coping

A) Achieving Rapport
 Clinician creates a safe environment in which talking about
perception and meaning of crisis is encouraged.
 Listening, eye contact and appropriate questioning facilitates the
development of rapport.
 Open ended questions that begin with “what” and “how” can help
persons in crisis freely express their personal views and feelings.
 Closed ended questions are not effective in crisis interview.

B) Beginning of Problem Identification
 Precipitating event- exploration of the event that triggered the
crisis from person’s point of view.
 Perception- meaning of the event as perceived by person in crisis,
perception of stressful situation and loss of ability to cope
effectively.
 Subjective distress- the emotions that resulted from crisis.
 Level of functioning- the degree of impairment in occupational,
social, academic, interpersonal, and family areas as a result of crisis.

C) Coping
• This step focus on the past, present, and future coping behaviors.
The clinician may use certain techniques to encourage and motivate
the improvement of coping abilities.
• POSITIVE COPING METHODS:
 Talking to another person for support
 Relaxation methods
 Breathing exercise
 Exercise in moderation
 Self-defense (training in martial arts)
 Positive distracting activities(Positive recreational or work activities)
 Support group participation
 Positive self-talk when facing a stressor
 Self-statements

• NEGATIVE COPING METHODS-
 Use of alcohol or drugs
 Social isolation
 Anger
 Avoidance
 Self-destructive behaviors (for example- cutting, burning)

Crisis Intervention In Specific
Situations
1. Death and Dying
2. Children and Adolescents
3. Suicide
4. Rape

Death and Dying
• Certain individual may present to Emergency Department due to
crisis related to death of loved one or anticipation of one’s own
death.
• Elisabeth Kubler-Ross described five stages related to death and
dying.
1. Denial
2. Anger
3. Bargaining (attempt to negotiate with physician or God.)
4. Depression
5. Acceptance

Children and Adolescents
• While the emotional effects of a crisis can significantly affect
children and adolescents, most victims in this age range make a full
recovery. The following crisis responses are likely to manifest in
younger children-
 Regressive behaviors are likely to occur among toddlers, preschool,
and elementary school children. Thumb-sucking, bed-wetting, fear
of the dark, and other past problematic behaviors can recur.
 Fears and anxiety are likely to be exhibited in separation anxiety
and clinging behaviors. Children may have difficulty leaving a
parent’s side.
 Although school phobia and anxiety may develop, parents are
encouraged to continue sending children to school to maintain
routine.
 Children who lose a parent to suicide persistently reminisce about
the loss, engage in self-destructive behavior, and are more likely to
display behavioral and academic problems (Saarinen, Hintikka, Viinamäki, Lehtonen,
&Lönnqvist, 2000).

• Adolescents display generalized anxiety rather than the specific
fears observed in younger children.
 As adolescents’ anxiety increases, a decrease in academic
performance and poor concentration may become evident.
 An increase in aggressive and oppositional behavior is possible.
 Controlling anger and frustration becomes a challenge for
adolescents in crisis.
 Risk taking behaviors may be increased. Antisocial behaviors of
substance abuse and alcoholism may become prominent in this
group.
 Adolescents are likely to display moodiness and social withdrawal.
 Adolescents may continue to use denial as a coping mechanism. It
may be necessary to confront them in a sensitive but direct manner.

 Teachers and caregivers become critical resources to help children
cope with a crisis.
 school mental health program is an effective vehicle for engaging
children and adolescents in treatment
 School counselors are expected to serve students and school
personnel during times of crisis by providing individual and group
counseling.

Suicide
• Working with a suicidal client in crisis is a scenario many counselors
face.
The first step in preventing suicide is to identify risk factors:
 Previous suicide attempt(s)
 History of mental disorders, particularly depression
 History of alcohol and substance abuse
 Family history of suicide
 Family history of child maltreatment
 Feelings of hopelessness
 Impulsive or aggressive tendencies
 Barriers to accessing mental health treatment
 Loss (relational, social, work, or financial)

Suicide
 Physical illness
 Easy access to lethal methods
 Unwillingness to seek help because of the stigma attached to
mental health, substance abuse disorders, or suicidal thoughts
 Cultural and religious beliefs, for instance, the belief that suicide is
a noble resolution of a personal dilemma
 Local epidemics of suicide
 Isolation or a feeling of being disconnected from other people.

Suicide
• Determining Suicidal Intent
 Assessing the persistence of suicidal thoughts and the client’s ability
to control them and differentiating between active, passive, or
compulsive suicidal thoughts are important first steps for
determining intent.
 Understanding a clients reasons for living or dying, establishing
specific motivating forces and their bases (i.e.,feeling worthless),
and determining the contributing psychosocial factors can shed
more light on a clients’ level of intentionality.
 Assessing the degree of planning involved, the method
contemplated for use, its lethality, and the individual’s access to
weapons or other means can help a therapist determine the
likelihood that the client will carry out the suicidal act.

Suicide
• How to Help
 Effective clinical care for mental, physical, and substance
abuse disorders.
 Easy access to a variety of clinical interventions and
support.
 Family and community support.
 Support from ongoing medical and mental health services.
 Skills in problem solving, conflict resolution, and nonviolent
handling of disputes.
 Cultural and religious beliefs that discourage suicide and
support self-preservation.

Rape
 Typical reactions in both rape and sexual abuse victims include
shame, humiliation, anxiety, confusion, and outrage.
 Many victims wonder whether they are partly responsible and
somehow invited the assault.
 Clinicians should be reassuring, supportive, and nonjudgmental.
 Inform the patient about the availability of medical and legal
services and about rape crisis centers that provide multidisciplinary
services.
 If possible, a female clinician should evaluate the patient in private
place/room.
 In an emergency psychiatric intervention, all attempts are made to
help patients' self-esteem.
 Empathy is critical to healing in a psychiatric emergency.

Rape
 Education about common reactions to rape such as irritability, problems
with hypervigilance, and problems with sexual intimacy are important to
share with the patient once a therapeutic relationship has been
established.
 Discussing sleep problems, intrusive thoughts, nightmares, avoidance,
and numbing help to restore psychological competence and allay fears
that he or she is crazy or has lost control.
• Some helpful suggestions for partners and family members-
 Allow partners and family members to vent their feelings.
 Use the same crisis intervention techniques you would use with a
survivor. Evaluate the problem, assess safety , provide support, generate
coping options, make a plan, and obtain a commitment.

Conclusion
 During a crisis, normal ways of dealing with the world are suddenly
interrupted.
 Although reactions and responses to crises are time-limited, they may
persist as symptoms of post-traumatic stress.
 Crises are universal and can affect people from all cultures; however,
culture plays a strong role in how an individual interprets and reacts to a
crisis.
 Crisis intervention strategies should be structured and considerate of a
culturally diverse and dynamically changing world.
 Crisis interventions are usually brief, and counselors can expect to have
only a single session to work with a client.
 Although this time may appear to be limited, an effective counselor
conveys an expectation that change will occur, that small changes can be
sufficient to solve problems.
 In crisis intervention counter transference can block the therapeutic
process.

References
 Handbook of emergency psychiatry; Khouzam, Tan and Gill;2008.
 Dynamic Considerations in Psychiatric Crisis Intervention; Keith
Cheng, M.D.
 Views of service users and providers on joint crisis plans: single
blind randomized controlled trial.Henderson C, Flood C, Leese
M, Thornicroft G, Sutherby K, Szmukler G. Soc Psychiatry Psychiatr
Epidemiol. 2009 May;44(5):369-76. Epub 2008 Oct 4.
 Kaplan & Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 10th Edition
 Techniques of Crisis Intervention; ANNABEL PRINS AND JOSEF
RUZEK
 B. E. Gilliland and R. K. James, Crisis Intervention Strategies (Pacific
Grove, CA: Brooks/Cole, 1997), 28–32.
 Adapted from Connecticut Sexual Assault Crisis Services,
Standardized Training Curriculum for Sexual Assault Crisis Counselor
Certification (1998).

References
 L. A. Hoff, People in Crisis: Understanding and Helping, 3rd ed.
(Menlo Park, CA: Addison-Wesley Publishing, 1989), 179.
 Adapted from Connecticut Sexual Assault Crisis Services,
Standardized Training Curriculum for Sexual Assault Crisis Counselor
Certification (STCSACC), module 6, (1998), 5–6. Also Hoff, People in
Crisis, 222–223.
 R. Young, “Helpful Behaviors in the Crisis Center Call,” Journal of
Community Psychology 17 (1989): 70–77.
 Joy CB, Adams CE, Rice K; Crisis intervention for people with severe
mental illnesses. Cochrane Database Syst Rev. 2006 Oct
8;(4):CD001087. [abstract]
 Treatment of Rape Victims; Gillian C. Mezey, APT 1997, 3:197-203

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