CRISIS CRISIS INTERVENTIONINTERVENTION

Components of crisis interventionComponents of crisis interventionGuidelinesGuidelinesCrisis at various stages of lifeCrisis at various stages of lifeSpecial challengesSpecial challenges

DefinitionDefinition

““the helping response of a crisis worker the helping response of a crisis worker to a victim in crisis”. (to a victim in crisis”. (Mitchell, ResnikMitchell, Resnik))

An active but temporary entry into the An active but temporary entry into the life situation of a person, family or life situation of a person, family or group during a period of stressgroup during a period of stress

Paramedic needs to be alert, flexible, Paramedic needs to be alert, flexible, resourceful and willing to get involvedresourceful and willing to get involved

Intervention targets the response – Intervention targets the response – NOT the event per se.NOT the event per se.

Goals of crisis interventionGoals of crisis intervention

Earmarked by narrow goals of short durationEarmarked by narrow goals of short duration

1. Shield the person from additional stress1. Shield the person from additional stress

2. Assist the person in organizing and 2. Assist the person in organizing and mobilizing their resourcesmobilizing their resources

3. Return the person, a much as possible, to 3. Return the person, a much as possible, to a pre-crisis level of functioninga pre-crisis level of functioning

Five major components of crisis Five major components of crisis interventionintervention

Intervention is flexible but structured – not Intervention is flexible but structured – not haphazard or sloppyhaphazard or sloppy

Consider the stages the individual is going Consider the stages the individual is going through during your interventionthrough during your intervention

Assist you [the paramedic] to decide what to Assist you [the paramedic] to decide what to dodo

1. Assessment1. Assessment

First priority is safety – is there any danger to First priority is safety – is there any danger to you or othersyou or others

What has happened?What has happened? Who is involved?Who is involved? What was the cause?What was the cause? How serious is the problem?How serious is the problem?

2. The plan2. The plan

Preliminary plan of action based on Preliminary plan of action based on assessmentassessment

Does not need to be detailed; the crisis will Does not need to be detailed; the crisis will not wait!not wait!

Doing something positive is better than doing Doing something positive is better than doing nothingnothing

3. Implementation of the plan3. Implementation of the plan

Act, interveneAct, intervene What ever the plan, get going!What ever the plan, get going!

4. Reassessment4. Reassessment

Once a plan has been implemented, it needs Once a plan has been implemented, it needs to be monitored for successto be monitored for success

If the plan is working, keep going!If the plan is working, keep going! If not, formulate a new planIf not, formulate a new plan

5. Recapping5. Recapping

Victims of crisis have a difficult time following Victims of crisis have a difficult time following what is going on around themwhat is going on around them

The person may need someone to tell them The person may need someone to tell them what is happeningwhat is happening

This may need to be done repeatedlyThis may need to be done repeatedly

RememberRemember

Most important tools are verbal and Most important tools are verbal and non verbal communication. Careful non verbal communication. Careful use of these skills will:use of these skills will:

Help the person reduce emotional Help the person reduce emotional reactionsreactions

Make sense out of what is happeningMake sense out of what is happening Find short term solutions to the Find short term solutions to the

problemproblem

GuidelinesGuidelines

The DO’s and DON’T’s of The DO’s and DON’T’s of InterventionIntervention

ApplicationApplicationCrisis ptCrisis ptMost incidentsMost incidents

1. Provide a reality base1. Provide a reality base

Be calmBe calm Identify yourself and your positionIdentify yourself and your position Explain the presence of others such as Explain the presence of others such as

police and fire fighterspolice and fire fighters Use the person’s nameUse the person’s name Reassure the person of confidentialityReassure the person of confidentiality Give supportive and truthful Give supportive and truthful

informationinformation

Let the person know what you expect of Let the person know what you expect of them and what they can expect of youthem and what they can expect of you

Explain why you are doing or not doing Explain why you are doing or not doing somethingsomething

Explain unusual equipment or proceduresExplain unusual equipment or procedures Anticipate the concerns of the person and Anticipate the concerns of the person and

familyfamily Be non judgmental Be non judgmental Be aware of your reactionsBe aware of your reactions

2. Provide verbal and non 2. Provide verbal and non verbal supportverbal support

Maintain a relaxed postureMaintain a relaxed posture Be near and at their level, if appropriateBe near and at their level, if appropriate Touch is important, if appropriateTouch is important, if appropriate Encourage communicationEncourage communication Realistic reassurance with reasonable Realistic reassurance with reasonable

expectationsexpectations Stay with them if possibleStay with them if possible

3. Listen and respond3. Listen and respond

Effective listeningEffective listening AttendingAttending ParaphrasingParaphrasing Reflection of feelingsReflection of feelings SummarizingSummarizing ProbingProbing Helper self disclosureHelper self disclosure

4. Ask clear, simple questions 4. Ask clear, simple questions

Ask open ended questionsAsk open ended questions Questions should be understandable and Questions should be understandable and

focusedfocused One at a timeOne at a time A definite plan of questioning is helpfulA definite plan of questioning is helpful

Remember the GoalRemember the Goal Get the person to talk freely and Get the person to talk freely and

frankly about the present situationfrankly about the present situation Obtain background info about the Obtain background info about the

problem - detailproblem - detail Help the person understand about Help the person understand about

the situationthe situation Consider if time permits alternative Consider if time permits alternative

to resolve problems...usually more to resolve problems...usually more the crisis Interventionalistthe crisis Interventionalist

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Precautionary Precautionary Measures Measures (the don’ts )(the don’ts )

1. Don’t deny the possibility of violence 1. Don’t deny the possibility of violence when the early signs of agitation are first when the early signs of agitation are first noticed.noticed.

2. Don’t dismiss warnings from records, 2. Don’t dismiss warnings from records, family authorities or fellow workers family authorities or fellow workers (dispatch).(dispatch).

3. Don’t become isolated with potentially 3. Don’t become isolated with potentially violent patientsviolent patients

4. Don’t engage in certain behaviors that 4. Don’t engage in certain behaviors that may be interpreted as aggressive. may be interpreted as aggressive.

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Precautionary Precautionary Measures Measures (don’ts) (don’ts) continuedcontinued

5. Don’t allow a number of emergency 5. Don’t allow a number of emergency personnel to interact simultaneously with the personnel to interact simultaneously with the pt.pt.

6. Don’t make promises that can’t be kept !!6. Don’t make promises that can’t be kept !! 7. Don’t argue, give orders, or disagree unless 7. Don’t argue, give orders, or disagree unless

absolutely necessary.absolutely necessary. 8. Don’t become condescending by using 8. Don’t become condescending by using

cynical, satirical or otherwise confrontational cynical, satirical or otherwise confrontational mannerisms.mannerisms.

9. Don’t attempt to reason with pts who are 9. Don’t attempt to reason with pts who are under the influence of a mind altering under the influence of a mind altering substance.substance.

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Precautionary Precautionary Measures Measures (don’ts) (don’ts) continuedcontinued

10. Don’t attempt to gain compliance based 10. Don’t attempt to gain compliance based upon the assumption that the patient is as upon the assumption that the patient is as reasonable about things as you are.reasonable about things as you are.

11. Don’t keep the pt waiting or leave a 11. Don’t keep the pt waiting or leave a potentially violent pt alone with freedom to potentially violent pt alone with freedom to move about.move about.

12. Don’t allow a crowd to congregate as 12. Don’t allow a crowd to congregate as spectators to an altercation.spectators to an altercation.

13. Don’t use why and what questions that 13. Don’t use why and what questions that put the pt on the defensive.put the pt on the defensive.

Danger signs to watch out forDanger signs to watch out for

Living in a fantasy world, has difficulty Living in a fantasy world, has difficulty separating fact from fictionseparating fact from fiction

Won’t accept or ask for helpWon’t accept or ask for help Uses extreme withdrawal, retreat, Uses extreme withdrawal, retreat,

avoidanceavoidance Turns to drugs/alcoholTurns to drugs/alcohol Consumed with rageConsumed with rage Acts on impulse after the stage of Acts on impulse after the stage of

emotional shock has passedemotional shock has passed

Danger continued…Danger continued…

Becomes hopeless and gives upBecomes hopeless and gives up Very dependent on othersVery dependent on others Comes across as ‘a rock’ – may be denying Comes across as ‘a rock’ – may be denying

or suppressing emotionsor suppressing emotions Usual patterns are disrupted to the extremeUsual patterns are disrupted to the extreme

Can apply to the patient, family member or the paramedic – watch out for them

Do’s and Don’ts use Do’s and Don’ts use thethe

Dual Action ApproachDual Action Approach

In approaching the situationIn approaching the situation

A – AssessA – Assess

C – controlC – control

T – treatT – treat

I – InformI – Inform

O – OkayO – Okay

N - NotateN - Notate

Check personal ActionCheck personal Action

A – AttitudesA – Attitudes

C – ConcernC – Concern

T – Thinking abilityT – Thinking ability

I – InteractionsI – Interactions

O – ObjectivityO – Objectivity

N - NeedsN - Needs

Crisis at various stages of lifeCrisis at various stages of life

Beyond the expected…Beyond the expected…

Consider a “Normal” cycle of Consider a “Normal” cycle of eventsevents

ChildrenChildren

Children in various age groups Children in various age groups have specific needs and respond have specific needs and respond to crisis in different waysto crisis in different ways

May regress or return to May regress or return to behaviour of another agebehaviour of another age

Assessment and InterventionAssessment and Intervention

Consider the child’s age, past Consider the child’s age, past experience with injury, what they were experience with injury, what they were doing when the event occurred and doing when the event occurred and their developmental leveltheir developmental level

Look at the child’s relationship with Look at the child’s relationship with adults – if his physical, social and adults – if his physical, social and emotional needs are being met, his emotional needs are being met, his response to you will be different than if response to you will be different than if they are not being metthey are not being met

Children under six years oldChildren under six years old

Greatest anxiety is separation from a Greatest anxiety is separation from a parent or caregiver – include the parent or caregiver – include the parent in care providedparent in care provided

Fear pain and disapprovalFear pain and disapproval Allow them to keep a favorite toy or Allow them to keep a favorite toy or

blanketblanket

Children between 6 and 12Children between 6 and 12

Often fear retaliation or punishment Often fear retaliation or punishment from a parentfrom a parent

Let the parent know that although they Let the parent know that although they may be angry, they need to give may be angry, they need to give support and comfortsupport and comfort

All childrenAll children

Remember; children listen to Remember; children listen to everything that is saideverything that is said

Escort away from the sceneEscort away from the scene Give brief explanation of what is Give brief explanation of what is

happeninghappening Always tell the child if you will be Always tell the child if you will be

doing something painful before hand doing something painful before hand and tell them when you are finishedand tell them when you are finished

Don’tDon’t

Leave a child aloneLeave a child alone Threaten a child with punishment if Threaten a child with punishment if

they are unco-operativethey are unco-operative Lie or frighten Lie or frighten Talk about the child’s family or living Talk about the child’s family or living

conditions conditions Criticize the parents Criticize the parents

Student [17-?]Student [17-?]

Not doing well at schoolNot doing well at school Lost scholarshipLost scholarship $$$$ School complete NOW WHATSchool complete NOW WHAT Job searchJob search Interview...Interview...

Adult [beyond school]Adult [beyond school]

Job lossJob loss 22ndnd career – forced on them career – forced on them MarriageMarriage

– May have more conflictMay have more conflict– Sexual difficulties often increase due Sexual difficulties often increase due

to health problems or fear of health to health problems or fear of health problemsproblems

Retirement – the mature adultRetirement – the mature adult

May have a sense of worthlessnessMay have a sense of worthlessness Possibly forced to retire due to agePossibly forced to retire due to age Some become depressedSome become depressed

Sensory loss – not age Sensory loss – not age dependentdependent

Decrease in sight, hearing and smellDecrease in sight, hearing and smell May increase anxiety May increase anxiety Does not mean they are Does not mean they are

intellectually inferiorintellectually inferior

Physical appearance Physical appearance

Accept the changes of agingAccept the changes of aging Never joke about or unnecessarily discuss Never joke about or unnecessarily discuss

these changesthese changes

Emotional changesEmotional changes

Slowed thinking, forgetfulness, rigid Slowed thinking, forgetfulness, rigid thought patterns, irritabilitythought patterns, irritability

May be anxious about securityMay be anxious about security Depressed and feel a loss of social Depressed and feel a loss of social

statusstatus Grief is common due to loss of loved Grief is common due to loss of loved

ones, friends, health status and ones, friends, health status and activity levelactivity level

Suicide risk increases in the elderlySuicide risk increases in the elderly

Illness or death of a spouseIllness or death of a spouse

Linked to decline in the health and Linked to decline in the health and functioning of the survivor functioning of the survivor

Often the most serious loss the person Often the most serious loss the person facedfaced

Crisis intervention with the Crisis intervention with the elderlyelderly

Often find it difficult to ask for help Often find it difficult to ask for help because of sense of privacy and pridebecause of sense of privacy and pride

May have a sense of immediacy – may May have a sense of immediacy – may become demandingbecome demanding

Reassurance is important Reassurance is important Use touch – if appropriateUse touch – if appropriate Be patientBe patient

Sudden Infant Death SyndromeSudden Infant Death Syndrome

Make every attempt to resuscitate the babyMake every attempt to resuscitate the baby Do not give false hopeDo not give false hope Do not be overly silentDo not be overly silent Do not accuse the parentDo not accuse the parent Gather information from the parentsGather information from the parents ListenListen Provide supportive care to the familyProvide supportive care to the family Only provide the information you canOnly provide the information you can

The silent patientThe silent patient

Depression, organic brain condition, Depression, organic brain condition, muscular impairment, stroke, lack of muscular impairment, stroke, lack of trust, quiet persontrust, quiet person

Observe for non verbal cluesObserve for non verbal clues Encourage speechEncourage speech Are your actions contributing to the Are your actions contributing to the

silence – talking too fast, have you silence – talking too fast, have you frightened or offendedfrightened or offended

Always keep safety in mind - yoursAlways keep safety in mind - yours

Language barriersLanguage barriers

Try to locate an interpreter (verbal)Try to locate an interpreter (verbal) The interpreter may paraphrase what The interpreter may paraphrase what

is being said. The true meaning may is being said. The true meaning may not be conveyednot be conveyed

Don’t try to interpret yourself unless Don’t try to interpret yourself unless you are fluentyou are fluent

Most Common Interpreter Most Common Interpreter ErrorsErrorsGlenn Flores, MD, FAAP, Medical College of WisconsinGlenn Flores, MD, FAAP, Medical College of Wisconsin

Omission (52%), in which the interpreter left Omission (52%), in which the interpreter left out an important piece of information. out an important piece of information.

False fluency (16%), in which the interpreter False fluency (16%), in which the interpreter used words or phrases that didn’t exist in a used words or phrases that didn’t exist in a specific language. specific language.

Substitution (13%), in which a word or phrase Substitution (13%), in which a word or phrase is replaced with another word or phrase of a is replaced with another word or phrase of a different meaning. different meaning.

Editorialization (10%), in which the Editorialization (10%), in which the interpreter’s opinion is added to the interpreter’s opinion is added to the interpretation. interpretation.

Addition (8%), in which a word or phrase is Addition (8%), in which a word or phrase is added by the interpreter.added by the interpreter.

BlindnessBlindness

Identify yourself Identify yourself Explain who you are and what you are doingExplain who you are and what you are doing Touch is importantTouch is important Remember; your voice is your only means of Remember; your voice is your only means of

communicationcommunication Guide dogs are working dogs. Do not touch Guide dogs are working dogs. Do not touch

or feed themor feed them

Cultural differencesCultural differences

Both you and the patient bring cultural Both you and the patient bring cultural stereotypes to the situationstereotypes to the situation

Some are more comfortable with different Some are more comfortable with different distances and may or may not be receptive distances and may or may not be receptive to touchto touch

It is important to be aware of various culturesIt is important to be aware of various cultures

Recap…Recap…Remember you may encounter the Remember you may encounter the

pt at any point during their critical pt at any point during their critical eventevent

Emotional shockEmotional shock DenialDenial AngerAnger RemorseRemorse GriefGrief ReconciliationReconciliation

Crisis InterventionCrisis Intervention

A short term helping processA short term helping process Acute intervention designed Acute intervention designed

to mitigate the crisis to mitigate the crisis responseresponse

Not psychotherapyNot psychotherapy

Crisis InterventionCrisis Intervention

Goal: To foster natural resiliency Goal: To foster natural resiliency through...through...

1.1. StabilizationStabilization

2.2. Symptom reductionSymptom reduction

3.3. Return to adaptive function orReturn to adaptive function or

4.4. Facilitation of access to continued careFacilitation of access to continued care