THEORIES OF CRISIS, CRISIS INTERVENTION

DEFINITIONS OF CRISIS

• Caplan (1960) defines crisis: brief episode of psychological unbalance which occurs when the subject is faced with a problem that cannot be solved or avoided.

• Triggers of a crisis:- traumatic events- life changes entailed by the life cycle

CRISIS Stressful event or perceived threat + lack of

efficient coping skills, resulting in emotional unbalance

Limited in time: 1-6 weeks During the crisis, the subject asks for help During the crisis, the subject is more compliant

to external intervention The evolution in crisis depends on the timing of

the intervention

COPING AND CRISIS

• Stages of coping in crisis:Stage I. Immediate response: astonishment,

denialStage II. Emotional reactions: anxiety, anger,

guilt, regression, depressionStage III. Resolution: acceptance, planning the

future

Model of crisis (G. Caplan, 1961)

EMOTIONAL BALANCE

INCREASE OF PSYCHOLOGICAL TENSION

(brief, unnoticed)

FURTHER INCREASE OF PSYCHOLOGICAL TENSION

(acknowledged)

PSYCHOLOGICAL DISTRESS(anxiety, discomfort)

SEVERE PSYCHOLOGICAL TENSION, DISORGANISATION,

SYMPTOMS, UNBALANCE, CRISIS

THREAT

STAGE 1

STAGE 2

STAGE 3

STAGE 4

Automatic resolution of the problem-situation

Problem-solving strategies

New problem-solving strategies

TYPES OF CRISIS1. MATURATIONAL CRISIS

– Periods in life which entail changes in social roles, biological and social pressures;

– Adolescence, marriage, birth of a child, retirement;

– Adolescence: maturational crisis – originality, hormonal and psychological unbalance

TYPES OF CRISIS2. SITUATIONAL CRISIS

– A specific external event disrupts the internal psychological balance of the individual;

– Holmes & Rahe Scale:Death of spouse, divorceIllness, accidentsPregnancy, childbirthSexual dysfunction …

SITUATIONAL CRISIS1. The experience of loss (of a loved one, of self-

esteem, of normal functioning, of status, of job…)

2. Issues concerning change (transition in Romania, marriage, birth of a child, moving, change of job…)

3. Interpersonal issues (family conflicts)4. Environmental factors (polution, work

environment…)

TYPES OF CRISIS

3. CATASTROFIC CRISIS (SOCIAL)– accidental, unusual, unexpected: fire,

earthquake, flood, kidnapping, nuclear accidents…

– They do not occur in any subject’s life– Severe stress, requiring maximal coping

strategies and abilities

CATASTROFIC CRISIS - STAGES

• Impact• Heroic stage• “Honeymoon” stage• Disillusionment stage• Reconstruction, reorganisation

CATASTROFIC CRISIS - STAGESImpact: shock, extreme fear; poor/ distorted

assessment of reality, and self-destructive behaviourHeroic stage: Cooperative spirit between friends,

neighbours, and emergency teams; constructive activity at this time may help overcome anxiety and depression but excessive activity can lead to "burnout"

Honeymoon: 1 week-several months after the disaster; the need to help others is sustained; psychological problems may be overlooked

Disillusionment: 2 months to 1 year; disappointment, resentment, frustration, anger; victims often begin to show hostility toward others

Reconstruction: Individuals admit that they must come to grips with their own problems; they begin to behave in a constructive manner

THE CONSEQUENCE OF UNRESOLVED

CRISIS→SUICIDE!!!!

SPECIFIC GOALS OF CRISIS INTERVENTION (Korchin)

a) Releasing the psychological tension and distress (anxiety, despair, confusion, agitation)

b) Restoring the level of functioning and activity that the subject had prior to the crisis

c) Reassuring the subject that the coping resources (internal, external) and support are available

TECNIQUES OF CRISIS INTERVENTION

1. Abreaction – remembering the highly emotionally charged events decreases the tension: "ventilation of emotions";

2. Clarifying – encouraging the subject to rationalize the relationship between previous life events and current situation;

3. Suggestion – persuasive discourse in order to improve personal and overall situation;

4. Manipulation – employing patient’s emotions and desires in the therapeutic process;

TECHNIQUES OF CRISIS INTERVENTION

5. Positive reinvestment - positive answers to patient’s successful adaptive behaviors;

6. Supporting effective defense mechanisms that maintain integrity of the ego;

7. Encouraging the increase of self-esteem – regaining the purpose of living, reassuring the subject of his/her value and meaning;

8. Exploring solutions – finding specific alternative solutions and problem-solving through teamwork;

PROBLEM-SOLVING SEQUENCE IN CRISIS INTERVENTION

Step-by-step sequence: a) Assessment of severity of crisisb) Planning the actions according to available

resourcesc) Interventiond) Reassessment of the situation and planning of

future actions If the specific goal has not been attained after

these 4 steps, the crisis team has to start over and retrace the 4 actions.

a) ASSESSMENT The first action in crisis intervention:

assessment of the subject and of triggers The therapist gathers specific information

concerning the triggering event The current risk for suicide and violence are

assessed If the assessment indicates that

hospitalization is not required, the therapist may proceed with the intervention

b) INTERVENTION PLANNING The decisive factor in planning: the time passed from

the outbreak of crisis (commonly: the event occurs 1-2 weeks prior to the subject’s “cry for help”)

The impact of the event on subject’s life The impact on people close to the subject Coping styles previously (but not currently)

employed by the subject in difficult situations Time required for intervention Size and structure of the intervention team First specific actions Estimated time until the first signs of improvement

c) INTERVENTION1. First contact with the person in crisis2. Employing a set of specific questions in order

to find out specific information about the case3. Involving the family, facilitating communication4. Accurate assessment of the situation, drawing

up a “therapeutic contract” between all parties involved

5. Inventory of the problems and establishing priorities

FIRST CONTACT

Establishing a “normal” environment The subject, other people present and their

relationship with the subject are identified The triggering event is debated The therapist informs all parties involved that

they will all be required to take part in the resolution of crisis

SPECIFIC QUESTIONS About the triggering event of the crisis About symptoms generated by the impact with

the event About the subject’s coping resources in front of

psychological aggression Practical issues: clinical and gynecological

assessment, nutritional status… Events/changes within the previous 2-3 weeks Brief psychiatric assessment – possible

symptoms (anxiety, depression) prior to the crisis

FAMILY, COMMUNICATION Crisis (acute psychological unbalance) in a subject:

sign of disturbed family system, will also affect other family members

Roles in the family system will have to change in order to accommodate the needs of the patient

A list of problems for each family member to solve is drawn up – this enhances the feeling of cohesion and involvement in therapy

Optimal communication in the family – listening to all parties, excluding critiques, objective and sensible assessment of alternatives to proposed solutions

Active listening and unconditional support of the subject by all parties involved is needed

THERAPEUTIC CONTRACT The therapist expresses his viewpoint The connection between symptoms of subject and traumatic

events The necessity of admittance is assessed, according to severity

of symptoms Benefits and disadvantages of admittance Subjects without psychiatric disorders are kept in their home

environment A contract is drawn up with family members – responsibilities

of each party involved is detailed (family, friends, neighbors, volunteers in NGO’s, physicians, psychologists, social worker, nurse)

If the situation progressively improves, regular follow-up at-home visits continue for a predetermined period (3 – 6 weeks)

PRIORITIES OF ACTION The specific problem of the subject in crisis is

avoided, if it cannot be solved in a short time If the problem can be solved, the specific

actions to eliminate the consequences of “disaster” will be the focus of intervention

The family is involved in action planning Multiple solutions are explored Tasks are divided All support resources are identified, mobilized Support resources for the therapist are

identified

d) REASSESSMENT The last stage: the subject and intervention

team evaluate the degree of positive outcomes and resolution of crisis

The best assessment tool: level of functioning – the extent to which the subject has returned to the level of functioning prior to the crisis

Inventory of specific activities, daily routine Coping abilities in family and professional

situations