INTRODUCTIONThe term crisis derives from the Greek word «krisis» which means decision or

turning point. This definition of the word as a decisive stage that has important consequences in the future of an individual or a system, has been preserved up to our days and has provided the frameworkfor the development of the theory and practice of crisis intervention. Crisis intervention is a relatively new field in community psychology. Its origins are usually dated in the 1940's and 1950's with Lindemann 'spioneering work on grief and bereavement after the Coconut Grove Club fire in Boston and with the work of Caplan at Harvard University. The 1960's and 1970's were periods of further elaboration of crisis theory and intervention with the development of suicide prevention centres, «hot lines)), crisis centres and other agencies. New conceptualizations of services and important innovations in the intervention area were developed during this period (McGEE, 1974). In the last few years, efforts have concentrated on the evaluation crisis intervention programs and on further developing crisis intervention practice.

DEFINITIONCaplan (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.

Roberts (2000) defines a crisis as “a period of psychological disequilibrium, experienced as a result of a hazardous event or situation that constitutes a significant problem that cannot be remedied by using familiar coping strategies”

CHARACTERISTICS OF A CRISIS The following are characteristics of crisis event

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 stateof crisis. There may be physical danger, which should be your first priority You and your staff may suffer from confusion, friction, pressure and stress Key staff may be unavailable It may be difficult or impossible to carry out your usual daily activities External support may be needed (e.g. from emergency services or neighbouring

businesses) There may be a lack of clear information about what is happening

There may be limited time in which to make decisions about what to do Attention from your stakeholders, customers and the media may be intense

news may travel fast, shaping the public perception of the crisis and how it is being handled.

CRISIS STAGESCaplan was the first to describe the main stages of a crisis reaction.The contributions of later theorists have been based on Caplan's workand have basically consisted on a restatement of his phases. Accordingto CAPLAN(1 964) most crisis reactions follow 4 distinct phases:

1. In the initial phase - The individual is confronted by a problem thatposes a threat to his homeostatic state: the person responds to feelingsTHEORY AND PRACTICE OF CRISIS INTERVENTION 127of increased tension by calling forth the habitual problem-solving measuresin an effort to restore his emotional equilibrium.2. Escalation-There is a rise in tension due to the failure of habitual problem- Solving measures and the persistence of the threat and problem. The person'sfunctioning becames disorganized and the individual senses feelingsof upset and ineffectuality.3. Crisis With the continued failure of the individual's efforts, a furtherrise in tension acts as a stimuli for the mobilization of emergency andnovel problem-solving measures. At this stage, the problem may beredefined, the individual may resign himself to the problem or he mayfind a solution to it.4. Personality disorganizationIf the problem continues, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. The result may be a major breakdown in the individual's mental and social.

BALANCING FACTORS

In her seminal work on crisis, Donna Aguilera (1998) noted that the equilibrium of people in crisis is significantly affected by three balancing factors: their perception of an event, their support system, and their coping mechanisms.

Perception of an event refers to the importance of a problem to the individual in crisis and includes such things as health, career, financial status, and reputation.

system refers to the resources possessed by the person in crisis, such as other people the individual trusts who can provide support and assistance during a time of need.

Coping mechanisms are skills or methods people use to reduce anxiety and solve problems, such as reasoning, meditation, physical exercise, sleep, and denial.

CRISIS IN RESPONSE TO A STRESSFUL SITUATION DEPENDS UP ON THE FOLLOWING THREE FACTORS

The individual’s perception of the event- if the event is perceived realistically, the individually is more likely to draw upon adequate resources to restore equilibrium. If the perception of the event is distorted, attempts at problem solving are likely to be ineffective, and restoration of equilibrium goes unresolved

The availability of situational supports-Aguilera stated “situational supports are those persons who are available in the environment and who can be depended on to help solve the problem” without adequate situational support during a stressful situation, an individual is most likely to feel overwhelmed and alone.

The availability of adequate coping mechanisms-when a stressful situation occurs, individuals draw up on behavioural strategies that have been successful for them in the past. If these coping strategies work, a crisis may be diverted. If not, disequilibrium may continue and tension and anxiety increase .

PARADIGM: THE EFFECT OF BALANCING FACTORS IN A STRESSFUL EVENT:

TYPES OF CRISESAlthough crises arise from many different sources, most healthcare professionals agree there are at least three causal categories of crises: maturational, situational, and adventitious (rare/unexpected/disastrous).MATURATIONAL CRISES

Maturational crises have to do with the predictable transitions individuals experience as they move from one stage of human development to another. In his classic text, Erik Erikson (1963) identified eight stages of maturity delineated by developmental tasks:

Infancy Early childhood Preschool School age

Adolescent Young adult Mature adult Late adulthood

He declared that each of these stages constitutes a crisis in personal growth and development. For example, toddlers are developing autonomy and self-esteem and may have a temper tantrum when they do not get what they want. Having a child and retiring from the workforce are also situations that will cause major changes in what an individual and/or family have previously considered “normal.” Taking a “wait and see” approach has the potential to exaggerate the impact of the event.

Maturational crises are predictable and can be prepared for and prevented. Proactively identifying actual or possible changes that the event will cause and then taking steps to become more prepared for those changes can minimize the disruption. For example, a young couple can take parenting classes to help prevent pediatric head trauma that could result from shaking their infant out of frustration during a period of uncontrollable crying.

SITUATIONAL CRISES

Situational crises arise from an external source and are events or circumstances that threaten the physical, social, and psychological integrity of individuals. These events may originate in the physical body as a result of disease or injury or in social or emotional situations, such as the loss of a job or death of a child. Sometimes maturational and situational crises occur at the same time, and occasionally, one crisis triggers another, compounding the problem.

For example, a teenage boy and girl are attracted to one another and experiment with sexual intimacy. When the menstrual period of the girl is late, both adolescents are thrust into a state of emotional disequilibrium as they experience both the maturational crisis of adolescence and the situational crisis of a potential pregnancy. The actions they take to resolve the crisis may thrust them into even greater confusion and tumult.

ADVENTITIOUS CRISES

Adventitious crises have been called events of disaster. They are rare, unexpected happenings that are not part of everyday life and may result from 1)

natural disasters, such as floods, fires, and earthquakes; 2) national disasters, such as airplane crashes, riots, and wars; 3) interpersonal disasters, such as assault and rape; and 4) acts of terrorism.

The National Incident Management System (NIMS) provides a systematic approach to the work necessary during such disaster situations (FEMA, 2013). Training material for Community Emergency Response Teams (CERT) can be found on their website (see “Resources” at the end of this course)

crisis are periods of psychological and behavioural upset precipitated by life hazards that usually inflict significant losses on the individual (e.g. accident). Caplan has used Erikson's classification in his theoretical development of crisis reactions. He has emphasized that developmental and accidental crises are transitional periods that present the individual. with both an opportunity for personal growth as well as for deterioration.

BALDWIN (1978) has developed a classification of emotional crisesthat includes six types of crisis situations:1. Dispositional crises produced by problematic situations that canbe remediated through an appropriate management such as making areferral, providing information and/or education, making administrative

changes, etc.2. Crises of anticipated life transitions, that reflect normal life transitionsover which the person may have little control.3. Crises resulting from traumating stress, which are precipitated byexterna1 stressors or situations that are unexpected, uncontrolled and

emotionally overwhelming.4. Maturational/developmental crises, that result from attempts todeal with interpersonal situations that reflect interna1 unresolved problems.5; Crises reflecting psychopathology, in which pre-existing or currentpsychopathology complicates their resolution.6. Psychiatric emergencies, in which general functioning is severely

impaired.

Potential Crisis Situations

Common Crisis Situations

On a daily basis, situations arise that have the potential to adversely affect Special Olympics’ business and reputation. When such situations develop, it is important for the staff or volunteer who first learns of the situation to immediately inform his/her

supervisor. It is also important that volunteers are aware of what is considered to be a potential crisis situation.

It is recommended that key volunteers receive the listing of potential crisis situations so they may determine when to contact the appropriate Special Olympics contact.

Possible Crisis Situations and Levels of Impact

In the event of a crisis situation at any level, it is critical that the appropriate Special Olympics Program staff or volunteers are contacted. It is also critical that the Crisis Communications Manager is also contacted to determine how to communicate the appropriate message to key publics and Special Olympics constituents.

Level 1

A minor incident or accident

Delayed event (but to be held the same day) Sick participant not requiring hospitalization Injured participant/spectator/volunteer – treated on-site or taken to the

emergency room but released Minor venue property damage Severe weather watch

Level 2

A serious incident, accident or situation

Canceled event Postponed event Moved event/change of venue Injured or ill participant/spectator/volunteer – requiring hospitalization Food poisoning/contamination Allegations of wrongdoing by or arrest of a participant Allegations of wrongdoing by or arrest of a spectator/volunteer/staff/guest or

celebrity (if financial, see level 3) Missing participant Illegal use of drugs/alcohol Major venue property damage Transportation accident Severe weather warning

Honored Guest concerns, e.g.: crowds, protection, threats à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Protests/Demonstrations à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Allegations or actions against an organization that impacts Special Olympics (i.e., Paralympics, INAS) à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Attack by the media against Special Olympics or constituents à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Negative campaigning against Special Olympics or Special Olympics-involved party à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Alleged discrimination against Special Olympics participant within or outside of Special Olympics à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

Level 3

A critical incident or situation

All situations considered Level 3 should follow these channels of communications: Special Olympics Program office à Contact Special Olympics Regional Office à Regional Office contacts Special Olympics headquarters

National/State or Provincial declared emergency (e.g., natural disaster, power outage, terrorist attack).

Actual impact of severe weather (e.g., hurricane, tornado) Flood (if it shuts down office operations) Bomb threat Contagious health threat or outbreak Missing participant or volunteer under suspicious circumstances Death of a participant Death of spectator or volunteer Fire Criminal activity Financial fraud or fundraising scandal Sexual abuse

SUDDEN CRISIS

We define a sudden crisis as a disruption in the company's business that occurs without warning, including fires, explosions, natural disasters and workplace violence and may adversely impact:

Employees, investors, customers, suppliers or other publics Offices, plants, franchises or other business assets Revenues, net income, stock price, etc. Reputation

Here are some examples of a sudden crisis: A business-related accident resulting in significant property damage that will disrupt

normal business operations The death or serious illness or injury of a manager, employee, contractor, customer,

visitor, etc. as the result of a business-related accident The sudden death or incapacitation of a key executive

OPERATIOAL CRISISRogue employees may cause companies’ share prices to dip sharply in the short term but it is the slow-drip of bad news caused by operational crises such as environmental disasters that do most damage to company value.Scandals that can be characterised as behavioural, such as illegal price-fixing or rogue trading, can cause share prices to lose as much as half their value on the day news breaks. But most companies can recover this loss within six months, new research shows, highlighting the importance of how bad news is managed. By contrast, events that go to the core of a company’s operations, such as an oil spill or product recall, may not have such a dramatic short-term effect but may be more insidious in the longer term, according to an analysis of 78 major crises suffered by publicly listed companies around the world since 2007.

NATURAL DISATER

A natural disaster is a major adverse event resulting from natural processes of the Earth; examples include floods, volcanic eruptions,earthquakes, tsunamis, and other geologic processes. A natural disaster can cause loss of life or property damage, and typically leaves some economic damage in its wake, the severity of which depends on the affected population's resilience, or ability to recover.

An adverse event will not rise to the level of a disaster if it occurs in an area without vulnerable population. In a vulnerable area, however, such as San Francisco, an earthquake can have disastrous consequences and leave lasting damage, requiring years to repair.

In 2012, there were 905 natural disasters worldwide, 93% of which were weather-related disasters. Overall costs were US$170 billion and insured losses $70 billion. 2012 was a moderate year. 45% were meteorological (storms), 36% were hydrological

(floods), 12% were climatological (heat waves, cold waves, droughts, wildfires) and 7% were geophysical events (earthquakes and volcanic eruptions). Between 1980 and 2011 geophysical events accounted for 14% of all

FINANCIAL CRISIS

The term financial crisis is applied broadly to a variety of situations in which some financial assets suddenly lose a large part of their nominal value. In the 19th and early 20th centuries, many financial crises were associated with banking panics, and many recessions coincided with these panics. Other situations that are often called financial crises include stock market crashes and the bursting of other financial bubbles, currency crises, and sovereign defaults. Financial crises directly result in a loss of paper wealth but do not necessarily result in changes in the real economy.

Many economists have offered theories about how financial crises develop and how they could be prevented. There is no consensus, however, and financial crises continue to occur from time to time.

CRISIS INTERVENTION

Crisis Intervention is emergency psychological care aimed at assisting individuals in a crisis situation to restore equilibrium to their bio psychosocial functioning and to minimise the potential for psychological trauma.

The priority of crisis intervention and counselling is to increase stabilization. Crisis interventions occur at the spur of the moment and in a variety of settings, as trauma can arise instantaneously. Crises are temporary, usually with short span, no longer than a month, although the effects may become long-lasting.

Crisis Intervention is the emergency and temporary care given an individual who, because of unusual stress in his or her life that renders them unable to function as they normally would, in order to interrupt the downward spiral of maladaptive behavior and return the individual to their usual level of pre-crisis functioning.

DEFINITION

Crisis can be defined as one’s perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms.

PRINCIPLES OF CRISIS INTERVENTION

Establish a Relationship

The counsellor must establish rapport and trust with the addicted client and his support system to begin the process from crisis to recovery. The client will trust the counsellor who offers him respect and hope for change, provided the client is willing to admit there is a problem and he desires the change. Even if the client desires change, he will resist help if a trusting relationship is not established first. The counsellor may help the family to schedule an intervention, which may help open the door for the counsellor to establish a working relationship with the client.

Assess and Define

The client and the counselor work together to assess the situation and define the problem. The counselor may employ questionnaires, assessment processes and direct counseling with the client. The counselor may also discuss any previous methods the client has tried to make changes in her life and addictive behavior.

Process the Trauma Cycle

Next, the client and counselor discuss any precipitating events that pushed the client to choose addictive coping mechanisms. The counselor will employ active and compassionate listening as the client expresses her emotional response to life events. This process must occur in a nonjudgmental environment where the client feels safe and free to share.

Problem Solving

The client and the counselor may discuss a variety of options the client can use to move from the current situation toward recovery. The counselor will often know options the client and support system are unaware of. The client and the support system may explore each alternative and determine which alternative is most in line with the resources and needs of the client.

Mobilizing Resources

Once a plan is formulated, the counselor works with the client and support system to begin implementation. The counselor may help the client move directly to treatment by helping to arrange for in-house care and transportation. If the choice is to use out-patient treatment, the counselor may continue to work with the client.

Termination of Agreement

Once the client moves into a treatment program, the counselor can terminate the client-counselor relationship so the treatment program can work with the client. The

counselor may continue to work the support system to help them recover and avoid enabling the client into further addictive behavior.

CRISIS INTERVENTION GUIDELINESEvery crisis is different, but all crises require immediate intervention tointerrupt and reduce crisis reactions and restore affected individuals to precrisisfunctioning. Crisis interventions provide victims with emotional firstaid targeted to the particular circumstances of the crisis (Rosenbluh, 1981).Several guiding principles are involved in crisis intervention; some key principlesare outlined below (Shapiro & Koocher, 1996).

Making an accurate assessment is the most critical aspect of a crisis response because it guides the intervention. A wrong decision in response to a crisis can be potentially lethal. Although situations may be similar, each person is unique; therefore, care must be exercised to avoid overgeneralizing.

The ability to think quickly and creatively is crucial. People under crisis sometimes develop tunnel vision or are unable to see options and possibilities. The crisis responder must maintain an open mind in order to help explore options and solve problems in an empowering manner with those affected. People in crisis already feel out of control; when opportunities to restore control present themselves, they should be grasped quickly.

The responder must be able to stay calm and collected. Crisis work is not suitable for everyone. It requires the ability to maintain empathy while simultaneously avoiding subjective involvement in the crisis.

Crisis intervention is always short term and involves establishing specific goals regarding specific behaviors that can be achieved within a short time frame. For example, in response to a suicidal client, a therapist may increase the frequency of therapy sessions until the client’s ideation subsides. Management, rather than resolution, is the objective of crisis interventions.

Crisis intervention is not process-oriented. It is action-oriented and situationfocused Crisis interventions prepare clients to

manage the sequelae of a specific event. Therapists help clients recognize an event’s impact and anticipate its emotional and behavioral consequences. Furthermore, clients learn to identify coping skills, resources, and support available to them. They learn to formulate a safety plan in an effort to cope with the current and anticipated challenges the event presents.

A crisis is characterized by loss of control and safety. This loss makes it incumbent on the helper to focus on restoring power and control in the client’s internal and external environment (Yassen & Harvey, 1998).

The goal is not to ask exploratory questions, but rather to focus on the present (“here and now”). The crisis responder merely acts as an emotional support at a time when self-direction may be impossible (Greenstone & Leviton, 2002). Therapists do not attempt to change clients, but serve as catalysts for clients’

discovery of their own resources, which they can then use to accomplish their goals (Saleebey, 1997).

Since crisis intervention is the first intervention that a client may encounter after a calamity, the goal is always to reestablish immediate coping skills, provide support, and restore pre-crisis functioning.

Crisis intervention requires responders to possess familiarity with the work setting.The ability to direct people to local shelters and other safe places and to

offer help in locating loved ones is crucial in this work. Viewing the client holistically, rather than isolating the individual’s emotional

and cognitive functioning, will provide insight into the resources and support available to the victim.

A solid training in crisis intervention (with a focus on identifying suicidal and homicidal ideation) as well as experience in counseling is indispensable. Finally, although crises are universal and affect people from all cultures, culture mediates how individuals and communities express crisis reactions and how they ask for and accept help (Dykeman, 2005). Since culture defines individuals’ pathways to healthy adjustment and how they reconstruct their lives after a crisis, the crisis responder has to be multiculturally competent.

Approaches

Integration of various approaches is required to help families accomplish their goals. These approaches, as described below, include: community system and use of community resources; multiple impact or multimodal; cognitive-behavioral or rational-emotive; task-centered; family treatment; and eclectic.

A "Community Systems" and "Use of Community Resources" Approach

Total family involvement is of paramount importance to crisis intervention. Similarly, successful crisis workers find that coordination and involvement of all available community agencies and resources are of paramount importance to successful resolution of most crises. System-centered or person-in-situation perspectives place less emphasis on pathology and more on the interaction of the client with environmental systems.

When addressing the needs of families in crisis, close cooperation between community services assures the maximum benefit from utilization of resources. Poor communication and lack of coordinated efforts between health, legal, social service, education, volunteer, and church-related resources can create extreme frustration for families who are in crisis. For instance, many clients have grown to distrust agencies that promise cooperation from other organizations. Often, they have been told that an agency would help, only to learn that they are ineligible, must go on a waiting list, must subscribe to the helper's value system, or must accept a substitute service. Even

worse, some clients have been criticized and humiliated for not understanding agency eligibility requirements.

To provide stability and consistent support for families, crisis workers can guide them to appropriate organizations and services, but it helps when crisis workers give the name of a specific person rather than simply a telephone number. During the initial crisis, crisis workers may even need to accompany the clients to appointments. As the family begins to stabilize, members can be expected to take more individual initiative. As a support system, the crisis worker should always be available by phone or beeper. Advocacy for clients, helping them access and use resources, dramatically enhances the therapeutic relationship.

Abusive families' diverse needs require services from a plethora of organizations, since no one agency controls and delivers investigation, crisis intervention, concrete services, long-term treatment, and the variety of health, social, legal, housing, education, employment, mental health, spiritual, welfare maintenance, and other necessary service components for successful crisis resolution. So-called "wrap-around" services provide whatever the family thinks it needs in order to stabilize. Obviously, this requires strong, collaborative efforts among community resources. As Fandetti states in Issues in the Organization of Services for Child Abuse and Neglect, "Children at risk of placement because of abuse and neglect require tight rather than confused and loosely organized networks of service, interlocked rather than fragmented services and agency policies."

Respite child care from a parent aide, day-care placement, a baby sitter, or recreational agency placement may give the parents the free time needed for relief of tension and time to focus on them selves. Medical attention, Alcoholics Anonymous or Narcotics Anonymous meetings, or a contact regarding better housing may reduce day-to-day stress. Development of a joint service treatment plan with the family, CPS, and other crisis workers demonstrates how various resources can cooperate to everyone's satisfaction.

Throughout crisis intervention, the crisis worker must make repeated contacts with other providers. Division or disagreement between agencies will feel like rejection to clients who experience chaos and disorganization not only as emotionally hurtful but also as irreversible.

The crisis-intervention team, a child and family advocacy organization, or a social service agency needs to assume leadership in bringing community organizations together to develop trust and exchange information on missions and programs. If possible, a community committee should be developed to study gaps in services and coordinate existing services. This is more a responsibility for administrative personnel, but every person who is concerned about families in crisis needs to advocate for

coordination and collaboration and participate in both formal and informal coordinating committees.

The Multiple Impact or Multimodal Approach

The value of the multiple-impact approach, using many crisis workers, has been recognized for well over a decade, as has the efficacy of a generalist-specialist team for dealing with family and community-wide dysfunction. The generalist-specialist team model incorporates professionals with specialized training, such as child development, sexual abuse assessment, or behavioral management, along with team members who are broadly trained so that consultation is maximized for all team members. Ultimately, to be effective, the team needs to maintain strong relationships with public and community service systems which address additional child and family needs.

Several programs have demonstrated that multiple impact and multimodal interventions are effective with even the most chaotic families.

Multiple Impact Therapy (MIT) assigns therapists, students, or volunteers to each family member for an hour or so of assessment and on-going treatment. The initial session may be with the entire family and with the many therapists assigned to each member, and there may be some individual time spent with specific family members. Ultimately, all family members and all therapists come together. Family members may be asked to observe while each therapist role plays a family member, who sits by the therapist, saying what the family member feels and wants from other family members. If a family member feels misrepresented, a timeout may be called for consultation with the therapist who is representing him or her. The therapist uses "I" messages to express how things in the family look from his or her perspective as a family member. This process takes several hours since family members are encouraged to say how they feel, what else they want to clarify, and what they want to work on in the future.

For crisis treatment beyond the first day or two, only one crisis worker may be assigned or, if it seems necessary, more than one. This is when well-trained students or volunteers can be an extremely cost-effective part of the continuing process. Even if only one crisis worker is assigned for ongoing treatment with the family, there is now a cadre of consultants who know the family from firsthand experience.

Some authors find that "the literature clearly indicates that multimodal interventions tailored to the subjects' deficits should be implemented rather than [provision of one type of program (e.g., parent education)] that emphasizes one or two factors for all abusers." They add that family, community, and social supports are part of adequate interventions.

Cognitive Behavioral Approach

Clients' belief systems and their thought processes can contribute to their abusive or victimized behaviors. Cognitive behavioral therapy assumes that clients have irrational, maladaptive beliefs that require cognitive restructuring. Behavior therapy is effective in child management, parenting, and parent training and, more recently, in shaping adult behavior. Many authors have outlined specifics of behavioral assessment and treatment.

Briefly, cognitive behavioral therapy is designed to identify specific, undesirable target behaviors through listening to the opinions of individual family members and the family as a group. The listener attempts to identify the antecedents to undesirable behavior (what set it off). New instructions, or new behavior by other family members or a certain family member, replace the antecedents. Desirable responses are agreed upon through a contract with family members. Reinforcements are provided when family members exhibit a desirable response, and consequences are provided if behavior is undesirable. Consistency is critical in both the approval (reinforcements) and disapproval (consequences) of behavior. Positive results, or bonus reinforcements such as family outings or free meals, can be given when behavioral objectives are achieved. Consistency and follow through are essential to success.

Task-Centered Approach

Task-centered methods of treatment seem to merge well with crisis intervention theory and practice, with research indicating that these methods are effective with a broad range of clients. Uncontrolled studies on the effectiveness have been conducted in medical, family, child guidance, psychiatric, school, corrections, and public-welfare settings. Controlled studies in a school system and a psychiatric clinic in southside Chicago rendered very positive results, as did a suicide prevention study and group treatment of delinquent youth. Contracting, task planning, incentives, and homework assignments, which keep families practicing communication and problem-solving tasks between meetings with the crisis worker, are effective in moving the family toward independence and nonabusive behaviors.

The Family Treatment Approach

In conventional family treatment, therapists permit situations to develop which demonstrate how the family interacts and functions. The therapist then tries to engage the most influential members to assure their active involvement in ongoing treatment. Just as in crisis intervention, active listening comes first.

As with crisis intervention the major focus is on the family system rather than one individual. In no way, however, does this prevent the therapist from being aware of

assigned family roles ("he is the mentally ill one"), scapegoating ("he is the cause of our problems"), or triangulation ("detouring" of parental problems through the child) within the family.

Family secrets, myths, enmeshment, dyads, triads, and schisms give clues to why the family has become so dysfunctional and what was brewing underneath the surface before the crisis-precipitating event.

Family treatment is inseparable from crisis intervention, and, in addition to being more cost effective for most children and families, family preservation is more desirable than separation.

The Eclectic Team Approach

In an eclectic team approach, team members use their varied knowledge and expertise to assess and manage the presenting crisis. Using their different perspectives, team members work with the family during the initial crisis response, developing a brief treatment plan with specific strategies to foster crisis resolution and healthy family functioning. If only one team member establishes direct contact with the family in crisis, that member consults with other members to ensure that assessment, treatment planning, and treatment techniques incorporate the full team's knowledge and experience.

Interdisciplinary teams, composed of individuals who are eclectic in their training and perspectives, bring a plethora of possible resources and resolutions to any crisis situation. The team's varied perspectives, in conjunction with the clients' innate resources or strengths, are powerful forces that support the clients in steadily lifting themselves out of the crisis. Note that the intervention team strives to not do the work "for" the clients. Instead, the eclectic knowledge is shared with the clients, enabling them to choose problem-solving strategies that restore their sense of well-being and ability to cope.

Eclecticism allows crisis workers to determine which theoretical approach, or combination of approaches, fits the crisis situation best. For instance, the task-centered approach draws from behavioral, communications, problem-solving, and family-therapy models, and assigns "homework" to clients. On the other hand, the cognitive behavioral approach is particularly effective in changing behavior of children and is one of the major theories for work with adults as well. Cognitive theory encourages clients to think through problems and to plan solutions thoughtfully, believing that "emotions, motives, goals, and behavior are conscious phenomena that are usually the consequences of thought."

Other approaches are considered, as well, by the eclectic team. For example, the family-treatment approach focuses on failures of role performance as a parent or

spouse, and considers role confusion and role reversal to be present in sexual and physical child abuse cases.

Transactional analysis was founded on the belief that people have the power to think, act, and make positive changes, allowing them to feel OK about themselves and others. Systems theory is akin to ecological and family-centered approaches in that it is concerned about the individual and family in the social environment. Existentialism emphasizes the uniqueness of each client and each situation and allows for openness, empathy, and honest-but-respectful feedback to clients. Existentialists use "provocative contact" in assertively provoking "hard-to-reach" clients toward wanting change in their lives. This offers clients an opportunity to at least consider the use of behavior modification in making specific behavior or symptom changes.

Gestalt theory does not hypothesize about unobservable systems in the client's life, but may ask the client to reenact his or her perceptions of them. Gestaltists look for patterns or descriptions of interactions, which are not working, as opposed to diagnoses or labels. Similarly, client-centered theory is opposed to diagnosing and labeling, believing that families are capable of knowing and shaping what is best for them.

TECHNIQUES

Special treatment techniques such as humor, generalization, self-disclosure, storytelling, limit-setting, and instillation of hope are effective in crisis intervention. By understanding client resistance, treatment outcomes are further enhanced.

Use of Humor

It is imperative for crisis workers to set aside time for client social activities and fun. Many clients have never had fun. Good professional role models demonstrate a fun loving sense of humour from time to time.

It is also helpful for crisis workers to respond to their own mistakes with humour. When a verbal or tactical error is made in front of clients, crisis workers need to demonstrate their comfort in laughing at themselves. This helps clients relax and realize that professionals are not perfect and that they may be able to laugh at their own mistakes someday, too. Words of caution are warranted here, however. Some clients are prone to concrete interpretation of humour. In other words, if professionals laugh at themselves or encourage clients to, these clients may feel emotionally degraded. Some clients are ultrasensitive to teasing and require months of addressing past trauma or verbal abuse before they can understand the subtleties of humour.

Generalization

Generalization is another good technique to use with clients in crisis. Saying "we all get angry and don't know how to express it sometimes" is more effective than implying that clients get angry and professionals never do.

Self-Disclosure and Storytelling

Clients need positive role models, but they are relieved to know that professionals are human and sometimes struggle with emotions. The caution here is for the crisis worker to focus on the clients' needs, rather than to vent personal frustrations. To tell a story or two on how the crisis worker or someone else overcame similar problems, however, may be helpful to clients. Crisis workers can test whether self-disclosure is appropriate by honestly questioning, "am I doing this for my benefit or is it for the clients' benefit?"

Setting Limits

All models of crisis intervention emphasize respect for the clients' culture and value systems. Every model also emphasizes the importance of listening closely (for hours) to what the clients are saying. This helps establish rapport but, more importantly, determines what the family is motivated to do. It respects the family's wishes rather than imposing the crisis worker's wishes or needs on the family.

In respecting and being accepting of clients, but not their inappropriate behavior, it may be necessary to say specifically that child abuse and neglect are never acceptable. Many clients need that directive because proper family values were not instilled during their childhoods. Certain clients misinterpret crisis worker acceptance of them as full agreement with their abusive actions. It may be necessary to state frequently that child maltreatment is never an acceptable behavior. If not clarified, clients may assume that the crisis worker approves of such behavior. When encouraging clients to discontinue corporal punishment, for example, it is best to give specific instructions on use of "timeout" for young children, choices and natural consequences for older children, and the need for parents to learn active parenting skills.

Instilling Hope

A crisis worker's belief in self, personal enthusiasm, and ability to instill hope are critical variables in crisis work. If the family senses that a crisis worker believes positive resolution to the crisis is possible, then family members begin to feel confident in their ability to bring about change.

Imparting hope requires crisis workers and clients to search for times in the past when the clients almost succeeded, or did succeed, in finding solutions to similar crises. Likewise, when clients are encouraged to try a new approach, rather than being blamed for failure, hope springs forth. Words such as "when" and "will" should be used rather than "if" or "maybe" when discussing plans.

When crisis workers keep their promises, clients begin to trust and to believe in change. When clients and professionals form a positive "team" that builds on client strengths, change occurs.

Working Through Resistance

By objectively, nonjudgmentally, and respectfully focusing on family strengths and the immediate crisis, crisis workers can minimize client resistance during early intervention. For example, the crisis worker should state the allegations of child maltreatment and ask the family to clarify any discrepancies. Conveying hope that the allegations can be worked through if the family cooperates is effective in moving the family toward desired change. Family members need to know what they are expected to do, what consequences they are facing, and what services they will receive if they cooperate.

Crisis workers must be careful how they use their professional authority. If authority is misused, parents may experience a double message: Parents should not misuse power with their children, but professionals may misuse power with parents. Such double messages create confusion and resentment. If crisis workers expect clients to be effective parents, then they need to be role models of behavior for the parents. Anything less is likely to create new crises, further weakening the family's level of functioning.

In periods of crisis or disorganization, people may feel more inadequate, alienated, or needy, thereby causing them to take on facades of adequacy, arrogance, or dependency. They may withdraw or they may attack, according to what they perceive as necessary for survival. They may act as if they need no help, even when they need it desperately. Whatever the clients' facade, crisis workers must remember that families in crisis crave respect, care, and compassion. They want to regain some semblance of security and stability.

Often, CPS crisis workers complain that the "nonoffending parent" in sexual abuse cases is passive or defensive and refuses to become involved in family treatment. Instead, crisis workers need to evaluate whether the nonoffending parent has always been defensive or passive. If it is new behavior, then the nonoffending parent is merely frightened and afraid the family will be destroyed. Such fears can be honestly recognized by the crisis worker. If the defensiveness is typical behavior, the

nonoffending parent will need to observe positive role modeling, have total honesty from crisis workers, and receive training on how to respond more openly. In the meantime, crisis workers need to realize that an accusation of abuse, the consequent investigation, and an influx of various strangers into the home would make anyone defensive.

By assessing the reasons for clients' recalcitrant behavior, crisis workers can then address the clients' needs for answers or information. They may have many remaining questions about the intervention. For example:

What further consequences may they expect? What happens next? What is expected of the family and its members? Is the crisis worker a nonjudgmental, credible, honest, and respectful

professional? What resources can the crisis worker and community offer that can help the

family? Will the crisis worker listen to and respond to family needs? Does the crisis worker see any strengths in the family? Is the crisis worker implying that solutions to the crisis are available? Is there hope for the future?

Rather than believing that clients are resistant, do not want to change, are denying their problems, or are being deceitful, crisis workers need to believe clients when they express a desire to reach a solution.75 When clients seem "resistant," it is best to assume that they are merely frightened and hesitant about trying new behaviors or the unfamiliar. They need crisis workers to be patient and listen to how they are feeling and what they suggest for relieving the crisis. If crisis workers convey that clients are the experts on what they want, and if professionals are honest with themselves about what they are feeling, then they will give clients room to make the changes that they need.

For instance, a nonoffending parent in a child sexual abuse case may be fearful of losing her identity as a member of an intact family; her identity as wife of a certain man; her identity as part of a neighborhood or a church; her identity as a member of a respected family; her identity as part of a household which had a good income but must now accept welfare benefits. A skillful crisis worker must be prepared to explore all of these possibilities with the parent, rather than proposing "quick" solutions, such as divorce.

If there is such a thing as resistance to change, some of the causes or sources may be:

uncertainty about change or fear of failure; fear of loss of the familiar;

lack of confidence in the crisis worker; lack of participation in developing crisis resolution goals; inability to see change as a viable alternative; inappropriate timing on the part of the crisis worker; disruption of important, existing family or social relationships; and belief that change equals criticism.76

Some interviewing techniques which can be used to work through client resistance include:

active listening and reflection; universalizing (normalizing); partialization (breaking into several smaller issues) of problems, when the client

presents numerous issues; ventilation of feelings (with closure before the interview ends); summarization of client feelings after extended listening; acceptance of the client, but not the client's abusive or neglectful behaviors; logical, not rambling and disorganized, discussion; education or information about crisis intervention, forthcoming events,

community resources, etc.; setting boundaries and limits on behaviors and contracting on acceptable

alternatives; concrete services such as housing, homemaker services, and respite care; firm, but kind, confrontation regarding inconsistencies in the clients' statements

or behaviors; reframing client statements or behaviors to find the positive aspects; and joining client resistance by saying "why should you change?" The crisis worker

should not say this regarding acts of abuse or neglect or any criminal behaviors.77

Crisis workers that maintain nonjudgmental attitudes, family involvement, and no preconceived notions about a family's motivation have found that almost all families are open to change for the better. A well-timed, quick response reinforces solutions to a crisis in a limited period of time.

Solution-focused crisis workers are optimistic about substance-abusing, ghetto-residing, chronically disorganized, and even criminally involved families. This means that they do not box families in; they do not categorize or reject them based on their past behavior. Instead, a new, more-effective beginning is sought. Many of these families welcome the opportunity to adapt in more socially acceptable ways. They thought no one would ever give them the hope that they could change.

This is not to say that crisis workers should naively proceed as if they see no drug dealing, prostitution, theft, sexual abuse, child abuse or neglect, or spouse abuse in

these families. It is rather a matter of being honest but not condescending, being a role model but not acting superior, being a bearer of hope but not bringing false hope, and being a trustworthy person even if family members are not.

Power struggles accomplish nothing of value in crisis intervention. The least cooperative families may become the most receptive to positive change within a few days, particularly if professionals accept them and help them find their strengths and their solutions to the crisis. Professional commitment and positive attitude toward short-term resolution of a crisis are sensed and appreciated by clients. They have a sense of self-worth when crisis workers ask: "What do you want to happen?" "What do you want to change?" "What do you want to do?" and similar questions that respect clients' competence.

If crisis workers are respectful of culture and empathetic with the predicament in which families find themselves, new horizons may start to open up. For many families, crisis workers will only have time to help them stabilize, but can help them contact other therapists and agencies where client culture is honored.78 Ultimately, crisis workers who are effective listeners are so responsive to clients' needs that there is no reason for clients to resist. This, however, takes great patience and a willingness to meet clients' needs rather than crisis workers' needs.

MEDICAL/NURSING CARE PROCESS AND MENTAL HEALTH CRISES

The medical/nursing process is a five-part, systematic decision-making method used to identify and treat responses of persons with alterations in mental or physical health. Assessment, diagnosis, planning, intervention, and evaluation are the steps used in the process of providing appropriate care for a person in crisis. This process requires collaboration by many individuals working as members of a team to improve the patient’s quality and enjoyment of life. Below is listed a range of professionals who may comprise the team:

Patients are the most important members of any healthcare team. Psychiatrists are physicians responsible for the diagnosis and treatment of

mental disorders. They prescribe medications and function as the leader of the mental health team.

Medical doctors, physicians’ assistants, and nurse practitioners provide ongoing management of physical healthcare concerns and assess for underlying physical causes of symptoms.

Psychologists conduct psychological testing, interpret and evaluate their outcomes, and implement programs of behavior modification.

Inpatient nurses (RNs, LPNs) provide holistic care by assessing patients’ mental, social, physical, psychological, and spiritual needs; making nursing diagnoses; formulating nursing care plans; providing nursing interventions; and evaluating the outcomes.

Caregivers are nurse aides or psychiatric technicians who maintain the therapeutic milieu, provide care under supervision, and contribute to the ongoing assessment of patients.

Counselors and therapists identify problems a person is facing in various aspects of life and help discover effective ways of dealing with them.

Social workers assess the patient, the family, and his/her community support system. They help with discharge planning, counsel for job placement, and advocate for the patient’s rights. They are skilled in interview techniques and group dynamics.

Occupational therapists assess the interpersonal responses of patients and help them adapt to their environment, cope with daily life, and integrate back into life outside the healthcare setting. They supervise and assess people’s abilities to care for themselves and may use different types of therapy on an individual or group basis.

Community psychiatric nurses see people living in the community, provide support, monitor medications, help with goal setting and getting patients involved in finding work, and assist family and caregivers.

Each member of the team employs a variety of assessments, and together they set goals and plan treatment.

ASSESSMENT

When the safety of a person in crisis is secured, the formal data-gathering process begins. It is conducted in person or by telecommunications and starts with an assessment interview. Of course, the interview is modified to match the circumstances, age, and cognitive ability of the person in crisis.

INTERVIEW

The purpose is to assess the mental and physical status of the person and the problem. Data collection is enhanced by information gathered from family members, other healthcare providers, and authorities such as police officers. Professionals may find the influencing (balancing) factors of crises a useful framework for an

assessment interview, specifically the person’s perception of the event, situational supports, and coping skills.

Perception of the event. Something has happened to create a crisis in a person’s life, motivating the person to seek help from a crisis hotline or emergency department. By gaining information about the precipitating event, both healthcare professionals and patients gain a better understanding of the problem. Questions clinicians might ask about a precipitating event are:

What happened to make you so upset? How are you feeling right now? How does this event affect your life? How will this event affect your future? What needs to be done to fix the problem?

Situational supports. The support system of a patient includes the resources available to the person in crisis. Family and friends, social clubs, church groups, and networks of professional associates are all sources of support. When these resources are not available, caregivers act as a temporary support system for the patient. The plan of care should include the identification of a support system. Some questions a clinician might ask about a support system are:

With whom do you live? When you feel lonely and overwhelmed by life, whom do you talk to? Is there someone in your life whom you trust? In the past, during difficult times, whom did you want to help you? Where do you go to school (to worship, to have fun)?

Coping skills. In crisis situations, it is important to evaluate the patient’s level of anxiety and their usual coping methods. Some people drink, some eat, some sleep, and some gamble. Others engage in physical activity, work harder, pick fights, or talk to friends. Some questions clinicians may ask about coping methods are:

What do you do to make yourself feel better? Did you try doing that this time? If you did, what was different this time? Have you thought of killing yourself or someone else? How would you go about doing this?

MENTAL STATUS EXAMINATION

The mental status examination (MSE) is used to evaluate critical areas of cognition and emotion. In psychiatry, the MSE is “analogous to the physical examination in general medicine” (Varcarolis, 2013). Caregivers use their findings to diagnose unmet needs, identify desired goals, and create a plan of care. In an emergency, clinicians may need to modify the examination, however a complete mental status examination includes the following.

ELEMENTS OF A MENTAL STATUS EXAM

Personal Information

Age Sex Marital status Religious preference Ethnic background Employment Living arrangements

Appearance Grooming and dress Hygiene Facial expression Height, weight, nutritional status Unique body markings: scars, tattoos, piercings Age related to appearance

Behaviour Body movement: excessive or reduced Peculiar movement: scanning, gesturing, balance, gait Abnormal movement: tremors, teeth chattering Eye contact

Speech Rate: slow, rapid, normal Volume: loud, soft, normal Disorganized, rapid

Affect and Affect: flat, bland, animated, angry, withdrawn,

Mood appropriate to context Mood: sad, labile, euphoric

Thought Process: coherent, flight of ideas, neologism, thought blocking, circumstantiality

Content: delusions, obsessions, suicidal ideations

Perceptual Disturbances

Hallucinations: auditory, visual Illusions: perceptual misinterpretations

Cognition Orientation as to time, place, person Level of consciousness: alert, confused, clouded,

stuporous, unconscious, comatose Memory: remote, recent, immediate Fund of knowledge (historically accumulated and

culturally developed knowledge essential for functioning and well-being)

Abstractions: performance on tests involving similarities, proverbs

Insight into problems Judgment

PHYSICAL STATUS EXAMINATION

A basic physical examination is essential at the initial in-person interview with persons in crisis because medical conditions sometimes mimic psychiatric ones. Furthermore, people with psychiatric disorders are more likely to have medical or drug-related conditions. When an interview is conducted by telephone, the caregiver should urge the caller to obtain a physical examination by a qualified clinician and should provide a referral list for such services.

In an emergency situation, healthcare professional use what is called a “focused physical examination” rather than a general examination, and if this suggests a need for a general examination, then that is performed. The elements of a physical examination are as follows:

ELEMENTS OF A PHYSICAL EXAMINATION

Measurements Temperature Pulse Respirations Blood pressure

(Abnormal vital signs suggest an underlying medical or drug-related condition.)

Review of body systems

Cardiovascular Gastrointestinal Pulmonary Genitourinary Musculoskeletal Integumentary Endocrine Neurosensory

Medications Names and dosages Prescribed and nonprescribed

Last physical examination

Date and provider

Laboratory tests Complete blood count Alcohol and sugar levels Thyroid panel Urinalysis Hematocrit Hemoglobin Chemistry profile Folate and thiamine levels STDs Hepatitis Electrocardiogram Liver and renal function

Drug toxicology screen Pregnancy (as appropriate)

DIAGNOSIS

After assessing the person in crisis, clinicians make a tentative diagnosis using one of three major diagnostic classification systems, all of which identify the problem or unmet need, the probable cause, signs and symptoms, and other supporting data. These systems include:

International Statistical Classification of Diseases (ICD-10) Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) Nursing Diagnoses: Definitions and Classifications (NANDA)

All caregivers need to be familiar with ICD codes and DSM-5 codes because healthcare organizations and government agencies use these codes to pay clinicians for their professional services.

ICD-10

The International Statistical Classification of Diseases, 9th Revision (ICD-9) was adopted in the United States in 1979, and in 1988 Medicare required physicians to report conditions using this code. In 1990 the International Statistical Classification of Diseases, 10th Revision (ICD-10), was published by the World Health Organization (WHO) and adopted worldwide in 1994. The United States was ready at that time also to adopt ICD-10 to align with WHO and other countries, but this was put on hold following the enactment of HIPAA (Health Insurance Portability and Accountability Act) in 1996. Since then, legislative steps have been ongoing, and in October 2014 ICD-10 becomes effective in the United States.

ICD-10 is not a revision of ICD-9 but rather a replacement that is more clinically accurate and offers more available codes and a less-restrictive coding structure (CDC, 2013). The ICD-10 classifies both psychiatric and medical syndromes (clusters of symptoms) using a number and a word or phrase, such as “295.30 Schizophrenia, paranoid,” or “577.1 Pancreatitis, chronic.” The code number facilitates research studies, demographic data collection, and the reimbursement of providers.

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) was published by the American Psychiatric Association in 2013. DSM-5 is a standard classification of mental disorders used by mental health professions and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system. It is used in both clinical settings as well as with community populations. In addition to supplying detailed descriptions of diagnostic criteria, DSM-5 is also used for collecting and communicating accurate public health statistics about the diagnosis of psychiatric disorders (APA, 2014).

NANDA

A complete nursing diagnosis states a response to a health problem related to a medical or psychiatric disorder, as evidenced by signs and symptoms exhibited by the patient. For example, “risk for suicide, related to depressed mood, as evidenced by statements of patient and reckless behavior such as drinking and driving.”

PLANNING

When clinicians assess a person in a mental health crisis and diagnose the disorder, they and the patient decide what goals and outcomes are desirable and feasible. They then determine the process by which each outcome can be achieved. Naturally, outcomes depend on the setting and condition of the person in crisis.

For example, for a patient who hears voices telling him to hurt himself, a NANDA diagnosis might be “disturbed thought processes related to schizophrenia, paranoid type, as evidenced by persecutory hallucination.” The outcome criteria might be “to consistently refrain from doing what the voices command.”

INTERVENTION

Interventions are the actions healthcare professionals take to achieve identified outcomes. Such actions are based on the clinical knowledge, judgment, and skill of the professional; how acceptable the intervention is to the person in crisis; and whether the action is feasible given the circumstances of the individual.

When a patient is a danger to self or others, as with the patient who hears voices telling him to hurt himself, it may be necessary to call the authorities for “emergency involuntary commitment,” whereby the individual is restrained and taken to a locked facility for evaluation and treatment. Emergency departments and telephone crisis

centers often develop standardized procedures called clinical protocols to assist caregivers in giving more appropriate and effective emergency care to people in crisis. For example, when a victim of sexual assault comes to an emergency department, clinicians implement what is called a “rape protocol.” As well as physical and forensic interventions, this type of protocol will include mental health interventions such as:

Providing emotional support and privacy Staying with the patient Referring the person to a rape advocacy program

EVALUATION

The effectiveness of an intervention is judged by its outcome. When outcome goals are met, the crisis is resolved, and the person in crisis is returned to a prior level of functioning, then the healthcare professional can rightfully say the intervention was successful. Ideally, as a result of the intervention and anticipatory guidance, individuals who have been in a crisis also learn new coping skills, increase their social support network, and are better equipped to cope with future disruptive events in their lives.

EMERGENCY-PRODUCING CRISES

Emergency-producing crises can be grouped into five categories: 1) mood-related (mania, depression, and suicide), 2) anxiety-related, 3) anger-generated, 4) substance use, and 5) major mental illness. All of the conditions require immediate assessment and knowledgeable interventions from caring professionals.

 Mood-Related Crises

All people experience a range of moods, from great joy to profound sadness. They express these moods in an array of behaviors, from laughing and smiling to weeping and withdrawing. When moods become exaggerated at either end of the emotional spectrum, they become disorders, limiting the ability of the person to function socially or occupationally.

In their extremes, mood disorders produce the frenzy of mania, the melancholy of depression, and suicide. When people experience mood disorders and seek help in emergency departments or on crisis hotlines, clinicians need to recognize typical

symptoms, identify their cause, plan a course of action, implement the plan, and evaluate its effectiveness.

MANIA

Manic episodes are periods of extreme elevation of mood when people feel expansive, energetic, grandiose, and, sometimes, irritable and short-tempered. Typical manic behaviors are:

Inflated self-esteem or grandiosity Decreased need for sleep (feel rested after only 3 hours of sleep) More talkative than usual or pressured to keep talking Subjective experience that thoughts are racing or flight of ideas Distractible, attention easily drawn to unimportant or irrelevant external

stimuli Intense, goal-directed activity either socially, sexually, or occupationally Hyperactive behaviors and symptoms occurring in episodes of a week or

more Excessive involvement in pleasurable activities with a high potential for

painful consequences, such as unrestrained buying sprees, gambling, foolish business investments, and sexual indiscretions(APA, 2013)

Hypomanic episodes last less than a week and are more moderate than manic episodes. The symptoms, though noticeable, are not severe enough to keep the person from functioning. During these times many individuals are exceptionally creative, productive, and focused, often becoming successful standup comedians, performers, inventors, teachers, and artists.

Assessment: Caregivers assess patients who suffer mood disorders for a potential danger to themselves and to others and the need for hospitalization. Patients who are experiencing a manic episode may not eat or sleep for several days, may harm themselves or others because of their poor impulse control, and may become exhausted to the point of death. Thus, emergency assessment includes:

Medical status, by means of a physical examination to determine if mania is primary or secondary to a medical condition or to a substance disorder

Behaviors that indicate a psychiatric condition, such as bipolar disorder and schizoaffective disorder, using diagnostic criteria identified in ICD-10 and DSM-5

Level of understanding by patients and their family about the disorder, prescribed medications, support groups, and medical care

Diagnosis

Medical Diagnoses. DSM-5 identifies mania as a symptom in all of the following medical diagnoses:

Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/medication-induced bipolar and related disorder Bipolar and related disorder due to another medical condition Other specified bipolar and related disorder Unspecified bipolar and related disorder

Caregiver/Nursing Diagnoses. Because patients exhibit constant and excessive motor activity, poor judgment, difficulty evaluating reality, probable dehydration, and lack of impulse control, the following NANDA diagnoses may be appropriate:

Risk for other-directed violence Risk for self-directed violence Risk for suicide Ineffective coping Defensive coping Disturbed thought processes (delusions) Disturbed sensory perception (hallucinations) Impaired verbal communication Impaired social interaction Imbalanced nutrition Deficient fluid volume Self-care deficit Disturbed sleep pattern

Planning

The goal of care for patients in an acute manic episode is to prevent injury and instill hope for the future. Therefore, outcome criteria for the patient are as follows:

Be well hydrated within 24 hours, as evidenced by good skin turgor and normal urinary output and concentration

Maintain or obtain stable cardiac status as evidenced by stable vital signs within normal limits

Maintain or obtain tissue integrity as evidenced by absence of infection or wounds

Get sufficient sleep and rest as evidenced by 4–6 hours of sleep at night Demonstrate self-control with the help of staff or medications as evidenced

by absence of harm to others Make no attempt at self harm with the help of staff or medications as

evidenced by safety checks during acute mania(Varcarolis, 2013)

Intervention

To meet outcome criteria and ensure safety, medical stabilization, and external control, people in crisis manifesting manic symptoms need hospitalization. If they are not cooperative and are a danger to themselves or others, emergency involuntary commitment may be necessary (see “Legal Issues” above). To gain their cooperation and communicate more effectively, clinicians:

Use short and concise statements and explanations Use a calm but firm approach Remain neutral, avoiding power struggles Coordinate care with other staff members to avoid manipulation

Medications prescribed for acute manic episodes include:

Mood stabilizers and anticonvulsants: lithium and valproic acid Atypical antipsychotics: olanzapine, risperidone, quetiapine Typical antipsychotics: chlorpromazine, haloperidol Benzodiazepines (anxiolytics): diazepam, lorazepam, clonazepam

The most successful treatment is with a combination of medications such as lithium and quetiapine. Lithium and valproic acid are the drugs of choice for maintenance therapy for persons with bipolar disorders (Preston et al., 2013).

Evaluation

The mental healthcare team achieves treatment goals when outcome criteria are met, the person is safe, and families are informed of resources for ongoing assistance. If these goals are not met, the team needs to begin the steps of the medical/nursing process over again, adjusting the plan to make changes for the future.

DEPRESSION AND SUICIDE

Depression is a “dis-ease” in a true sense of the word. Those who experience depression feel sad, joyless, and empty. They believe that life is not worth living. According to the World Health Organization (2012), depression is the leading cause of disability worldwide. Depression is twice as common in women as it is in men and is not related to education, income, ethnicity, or marital status. Many of those who suffer from the disorder also suffer from anxiety. Typical symptoms of major depression are:

Depressed mood most of the time Lack of interest or pleasure in almost everything, most of the time Significant weight gain or weight loss when not dieting Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue and loss of energy Feelings of worthlessness and inappropriate guilt Diminished concentration Indecisiveness Recurrent thoughts of suicide and death, but without a specific plan Symptoms that are not attributable to the effects of a substance or to another

medical condition Morbid preoccupation with worthlessness and guilt Symptoms are not better accounted for by the normal grieving process Clinically significant distress or impairment in social, occupation, and other

areas of functioning(APA, 2013)

Adolescents with depression have most of those same symptoms, with the addition of the following:

Anger or irritability, rather than sadness, as the predominant mood Frequent unexplained aches and pains, such as stomachaches or headaches Extreme sensitivity to criticism Unlike adults who isolate from everyone, withdrawal from some, but not all,

people(Smith et al., 2014)

Sufferers of persistent depressive disorder (dysthymia) have less severe symptoms than those who suffer major depression. Nonetheless, the symptoms occur over two or more years and cause significant distress in every area of life (APA, 2013).

Assessment

Guidelines for assessing depressed patients include the following:

Evaluate the person’s risk of harm to self or others. Perform a thorough medical and neurologic examination to determine if

depression is secondary to another disorder or to drugs. Evaluate whether the person is psychotic, has taken drugs or alcohol, has

medical conditions, or has a history of psychiatric syndromes. Ask if the person has a history of depression. Assess support systems, family, significant others, and the need for referral.

In crisis situations, there may not be time to complete an assessment according to these guidelines. Assessing a person in these circumstances requires observing for:

Verbal clueso Expressing strong feelings of hopelessnesso Making covert statements such as “Things will never work out”o Making overt statements such as “I wish I were dead” Delusional thinkingo “God wants me dead.” Cognitive functiono Slowed speech and understandingo Difficulty concentrating or making up one’s mind

Behavioral clueso Psychomotor agitationo Giving away prized possessionso Acting recklessly Affecto Flat, without expressiono Exhibiting a sudden and unexpected improvement in affect after

being depressed or withdrawn(Varcarolis, 2013)

The risk for suicide in people with major depressive disorder is higher than that of the general public. It is the tenth leading cause of death in the United States and third leading cause of death for ages 15–24 years (NAMI, 2013a).

Guidelines for assessing suicidal patients include the following:

Assess risk factors, including history of suicide, degree of hopelessness and helplessness, and lethality of plan (gun, poison, hanging).

If there is a history of suicide attempts, assess intent, lethality, and injury. Determine whether the patient’s age, medical condition, or psychiatric

diagnosis puts the person at higher risk. Note whether a patient’s mood changes suddenly from sadness to a happier

state. Often a decision to commit suicide gives a feeling of relief and calm. If the patient is to be managed on an outpatient basis, assess social supports

and knowledge of potential suicide signs.

ASSESSMENT QUESTIONS FOR THOSE AT RISK OF SUICIDE

Are you feeling hopeless about the present or future? Have you had thoughts about taking your life? When did you have these thoughts? Have you ever attempted suicide? Do you have a plan to take your life? Have you ever had a suicide attempt?

Source: U.S. Dept. of Veterans Affairs, 2011.CASE

SHEILASheila came to the community counseling center for help. She told Mary, the

counselor, that the man she had been dating had left her and returned to Mexico to marry a girl from his home village. Sheila burst into tears: “I don’t think I can live without him.”

Mary listened attentively and asked, “Have you been thinking about not living? Sheila nodded and whispered, “Yes,” and began to sob. The counselor said, “And what have you thought about doing?” After a long pause, Sheila said, “I just want to go to sleep and never wake up.”

Mary hypothesized that Sheila did not have a specific plan to end her life but was at risk of overdosing on alcohol or drugs, the most common means women use to commit suicide. She told Sheila to refrain from taking alcohol in any form until she felt better; asked if Sheila had a friend or relative who could stay with her for a few days, just to be there for her; gave Sheila her card and the crisis hotline number to call if she felt like harming herself; and referred Sheila to a support group of others who had suffered loss.(continues)

Diagnosis

Medical Diagnoses. The APA (2013) recognizes eight types of depressive disorders that do not have manic features. The eight types of depressive disorders are:

Disruptive mood dysregulation disorder in children Major depressive disorder Persistent depressive disorder (dysthymia) Premenstrual dysphoric disorder Substance/medication-induced depressive disorder Depressive disorder due to another medical condition Other specified depressive disorder Unspecified depressive disorder

Caregiver/Nursing Diagnoses. Because depressed individuals have many needs and may suffer from other psychological and physical disorders, numerous nursing diagnoses may be appropriate. However, risk for suicide is a constant. Other diagnoses may be:

Hopelessness

Ineffective coping Social isolation Spiritual distress Self-care deficit Powerlessness Chronic low self-esteem Imbalanced nutrition Sexual dysfunction

(NANDA, 2014)

Planning

The planning of care for depressed individuals in crisis is based on the circumstances that bring them to emergency care. For example, the outcome criteria for the nursing diagnosis of risk for suicide might be: Patient will 1) value and nurture himself/herself and 2) refrain from hurting himself/herself.

When depressed persons are judged to be a danger to themselves or others, clinicians must consider the need for emergency hospitalization (see also “Legal Issues” above).

Intervention

There are three phases in the treatment and recovery of persons with major depression:

Acute phase (6–12 weeks). The goal of treatment is to reduce depressive symptoms and restore psychosocial and work function. Hospitalization during this phase may be necessary.

Continuation phase (4–9 months). The goal of treatment is to prevent relapse with pharmacotherapy, education, and depression-specific psychotherapy.

Maintenance phase (1 or more years). The goal of treatment is to prevent further episodes of depression.

Antidepressant interventions are classified as first line (preferred) and second line (back-up, used when a preferred intervention cannot be used).

First-line interventions include:

Selective serotonin reuptake inhibitor (SSRI) drugs

Serotonin/norepinephrine reuptake inhibitor (SNRI) drugs Atypical, newer antidepressant drugs Cyclic antidepressants, such as tricyclic drugs

Second-line interventions include:

Monoamine oxidase inhibitor (MAOI) drugs Electroconvulsive therapy (ECT)

For children and adolescents, SSRI drugs are the preferred pharmacological treatment for depressive disorders (Halverson, 2014). The FDA warns, however, that antidepressants can increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults ages 18–24 during initial treatment (FDA, 2013).

The most common psychosocial interventions for depression include:

Psychotherapy Cognitive-behavioral therapy Interpersonal therapy Problem-solving therapy Supportive therapy Psychosocial intervention Bereavement groups Family counseling Participation in social events Psychoeducation Exercise

Nursing interventions for severely depressed patients include providing food and fluids, suicide precautions, personal hygiene, supportive communication, and psychotherapy using cognitive-behavioral, psychodynamic, and interpersonal approaches. If a person is hospitalized because they are deemed at risk for suicide, suicide risk precautions are implemented.

Suicide risk precautions include:

Search patient and belongings for harmful objects. Make sure visitors do not leave potentially harmful objects or gifts in

patient’s room.

Keep electric cords to minimal length. Hang-proof and jump-proof bathrooms. Provide plastic eating utensils. Do not assign patient to a private room. Lock utility rooms, kitchens, stairwells, windows, and offices. Conduct one-to-one nursing observations and interaction 24 hours a day.

Occupational therapists most often work in hospital settings and provide interventions to help patients with depression examine how to balance leisure, work, and relationships so they are able to meet the responsibilities of the roles that are meaningful to them.

Evaluation

Treatment of depressed persons is considered successful if, after treatment, they are able to think clearly, behave appropriately, and express greater hope and self-esteem.

CASE

SHEILA   (continued)Eight days following her visit to the community counseling center, Sheila was taken to the emergency department by a coworker, Liz, who stopped by to see why Sheila had been absent from work for the past week. Liz said that she found Sheila lying on the sofa, tearful, and saying she wanted to die.

When Sheila arrived at the hospital emergency department, she was interviewed by a nurse, who obtained her history. Sheila indicated she had not attended the recommended support group and had forgotten about the hotline number the counselor had given her. The nurse noted that Sheila had a very flat affect, her speech and movements were slow, and she had problems understanding some of the questions asked. She was unkempt and admitted that she had not been eating or drinking much over the past week. She denied using any medications or alcohol during this time. Sheila told the nurse, “I don’t want to live anymore. I’m so tired.”

The nurse asked Sheila if she was thinking of harming herself, and Sheila replied that she was. She admitted that she was planning to lay in a tub of hot water and slit her wrists, but “I haven’t gotten the energy to do it so far.” The nurse

assigned an ER tech to stay with Sheila until the emergency department physician could see her.

The ED physician interviewed Sheila, performed physical and neurological examinations to rule out medical conditions, and recommended she be hospitalized for treatment of major depression with the need for suicide precautions. Sheila agreed to voluntarily enter the hospital.

Nursing diagnoses for Sheila on admission included:

Risk for suicide, related to depressed mood, as evidenced by statements of patient

Hopelessness, related to depressed mood, as evidenced by statements of patient

Self-care deficit, related to depressed mood, as evidenced by statements of patient and patient appearance

Imbalanced fluids and nutrition, related to depressed mood, as evidenced by statements of patient

Her care plan included:

Appropriate medications Serial laboratory tests to accurately determine her fluid and electrolyte

status A nutritional assessment leading to a meal plan including preferred foods,

small frequent meals and snacks, and documentation of food intake Individual and group therapy Assistance with and reinforcement of personal care practices Suicide precautions Early start of discharge planning to allow adequate time to develop an

outpatient support plan

Anxiety-Related Crises

Anxiety is a feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or imagined threats whose actual source is unknown or unrecognized. Unlike fear, which is a reaction to a specific danger, anxiety affects us at a deeper level. Anxiety “invades the central core of the personality. It erodes the individual’s feeling of self-esteem and personal worth” (Varcarolis, 2013). Anxiety disorders

“develop from a complex set of risk factors, including genetic, brain chemistry, personality, and life events” (ADAA, 2011).

Normal anxiety is a natural response to the demands of life. It provides energy to achieve goals and carry out the activities of daily living. It energizes people and helps them manage the usual demands of life, including such things as arriving for work on time, fulfilling commitments, and pursuing worthwhile goals.

Acute anxiety is a sudden, intense feeling of fear caused by an imminent threat to one’s sense of security. It is the feeling new graduates may experience as they sit for a licensing examination, singers may experience as they walk to center-stage to audition for a leading role, and patients may feel as they climb into a dentist’s chair. Like other emotions, the intensity of anxiety varies with the situation, ranging from mild to panic.

Mild anxiety can improve performance, sharpen focus, increase attention, and help people grasp information. Even so, as anxiety increases, the perceptual field narrows and people are less able to see, hear, and grasp information. Their ability to think lessens, and their bodies respond with profuse perspiration and rapid pulse and respirations.

As anxiety intensifies to severe, people feel dazed and confused, unable to solve problems or focus on more than one thing at a time. They may feel dizzy and experience a sense of impending doom.

Panic is the most extreme level of anxiety. Persons experiencing panic have a sudden, overwhelming fear, with or without cause, which produces hysterical or irrational behavior. They may behave automatically, lose touch with reality, and experience false sensory perceptions.

Chronic anxiety is a long-lasting, fear-based condition that persists over many years. Children with this condition appear apprehensive and high-strung. Adults with the disorder experience unrelenting angst and often develop physical and emotional disorders such as insomnia or chronic fatigue syndrome.

Self-harm is the most severe complication of acute anxiety and panic. The majority of persons experiencing acute anxiety or panic do not really want to die, but

they genuinely want to break free from suffering. They may see suicide as a way to escape from oneself, rather than from daily life.

ASSESSMENT

As with everyone who comes to an emergency facility for help, a physical examination and at least a modified mental status examination should be performed. Although all anxiety disorders are fear-based, the symptoms they display differ greatly.

Assessment guidelines for anxious individuals in crisis include the following:

Assess for potential self-harm, because people with high anxiety are more likely to become desperate and suicidal.

Conduct a physical and neurologic examination to determine whether the anxiety is the cause or the result of substance use or a medical or psychiatric disorder.

Assess for psychosocial and environmental problems that may be affecting the person, such as stressful relationships, recent loss of job, and economic pressures.

Consider cultural differences that may affect the way people exhibit anxiety.

ANXIETY VERSUS CARDIAC CONDITIONS

Persons experiencing acute anxiety or panic may appear in the emergency department with symptoms that closely resemble cardiac conditions, including:

Palpitations, heart pounding Diaphoresis Shakiness, unsteadiness Sensation of choking Chest pain Nausea Dizziness Feeling of impending doom

Evaluation must ensure that there is no underlying medical condition to explain these symptoms.

DIAGNOSIS

Medical Diagnoses

DSM-5 identifies anxiety as a symptom in all of the following medical diagnoses:

Anxiety Disorders

Separation anxiety disorder Selective mutism Specific phobia Social anxiety disorder (social phobia) Panic disorder Panic attack (specifier) Agoraphobia Generalized anxiety disorder Substance/medication-induced anxiety disorder Anxiety disorder due to another medical condition Other specific anxiety disorder Unspecified disorder

Obsessive-Compulsive and Related Disorders

Obsessive-compulsive disorder Body dysmorphic disorder Hoarding disorder Trichotillomania (hair-pulling disorder) Excoriation (skin-picking) disorder Substance/medication-induced obsessive-compulsive and related disorder Obsessive-compulsive and related disorder due to another medical condition Other specified obsessive-compulsive and related disorder Unspecified obsessive-compulsive and related disorder

Trauma- and Stressor-Related Disorders

Reactive and attachment disorder Disinhibited social engagement disorder Posttraumatic stress disorder Acute stress disorder

Adjustment disorders Other specified trauma- and stressor-related disorder Unspecified trauma- and stressor-related disorder

Caregiver/Nursing Diagnoses

Although many anxiety disorders described by the APA differ markedly from one another, certain NANDA diagnoses may appear in all of the anxiety conditions. For example:

Ineffective coping Fatigue Anxiety Disturbed sleep pattern Chronic low self-esteem Hopelessness Self-care deficit Powerlessness

(NANDA, 2014)

PLANNING

Patients in crisis with anxiety disorders usually do not require hospitalization. However, clinicians encounter these people in homes, clinics, and acute and skilled nursing facilities. Healthcare professionals encourage people with symptoms of anxiety to participate in planning their treatment. For example, if the nursing diagnosis is “self-control of anxiety,” the outcome criteria might be “patient will monitor the intensity of anxiety and use relaxation and regular exercise to decrease anxiety.”

INTERVENTION

Medical Interventions

Both psychotherapy and pharmacotherapy are used to treat anxiety disorders.

Psychotherapy of various types has proved useful, especially cognitive therapy in which patients learn to recognize behaviors and take action to change them. Therapists teach cognitive restructuring or reframing (replacing irrational negative statements and beliefs with positive statements), relaxation to help reduce anxiety,

systemic desensitization to overcome phobias, and thought-stopping to reduce obsessions.

Pharmacotherapy includes:

Antidepressants: selective serotonin reuptake inhibitors Antiseizure medications that replace the use of anxiolytics Anxiolytics (benzodiazepines) only for short-term treatment of acute

anxiety(Bystritsky et al., 2013)

Caregiver Interventions

Teaching interventions include:

Medication management Behavioral therapy techniques to reduce anxiety Relaxation exercises Cognitive reframing (changing negative thoughts to positive ones) Lifestyle personal care, such as nutrition, exercise, and sleep

Referral interventions include:

Community resources, such as an obsessive-compulsive disorder (OCD) support group

Personal psychotherapy to gain self-knowledge

EVALUATION

The treatment of anxiety disorders is considered successful if symptoms of anxiety in patients are reduced and they are able to live a happier, less fearful life.

Anger-Generated Crises

Anger-generated crises that involve assault and battery are well known to clinicians in emergency departments and on crisis hotlines. In recent times, violence has become a serious public health issue, affecting individuals, families, entire communities, and healthcare providers. For this reason it is essential that clinicians understand anger and aggression, recognize its signs and symptoms, plan appropriate

interventions, and evaluate those interventions. The goal of such care is to ensure safety for everyone concerned.

In his classic study of human emotions, Robert Plutchik (1991) identified anger as one of the primary emotions, an inborn response to the frustration of desire. The purpose of anger is to remove whatever is blocking a desire or need.

Aggression is the physical or verbal action people take to overcome obstacles that block their desires. As with other emotions, a stimulus event evokes a feeling and the feeling motivates a response. The decision to express anger aggressively depends on many factors, including cultural influences, genetic predisposition, low serotonin levels, and brain abnormalities, especially in the limbic system.

As with other crises, anger and aggression are mediated by three balancing factors: 1) the perception of an event, 2) the availability of a support system, and 3) coping mechanisms. On feeling angry, some people use aggression as their primary coping mechanism. Such a response is common in disorders like substance abuse, mania, antisocial personality, and cognitive deficit.

ASSESSMENT

Because of the danger to themselves and others in aggressive patients, it is important for clinicians to recognize common predictors of violence. These include:

A history of recent acts of violence Intoxication with alcohol or drugs Possession of a potential weapon Situations that lead to violence: overcrowding, arbitrary rules, apparent

favoritism Signs and symptoms of violence: hyperactivity, restlessness, clenched jaw,

fierce facial expression, increasing tension, mumbling to self, clenched fist, profanity, loud voice, soft voice, argumentative, avoidance of eye contact, and intense eye contact

Guidelines caregivers can use to assess anger and violence in patients include:

Hyperactive, irritable, impulsive behavior Risk factors: wish or intent, plan to harm, means to carry out plan

Demographic factors: male aged 14–24, low socioeconomic status, lack of support system, limited coping skills, frequent use of intimidation to meet needs

Intolerance of limit-setting by authorities

AGGRESSION AND MEDICAL CONDITIONS

Assessment must include ruling out medical conditions that can lead to aggression, such as:

Head injury Substance use and intoxication Underlying mental illness Metabolic disturbances (hypoglycemia) Hypoxia Infection (sepsis, encephalitis, meningitis) Seizures Vascular stroke Subarachnoid hemorrhage

Guidelines caregivers can use to assess their own anger:

Personal triggers, such as physical characteristics of patients or situations Sense of personal competence in a situation of potential danger Ability to ask for assistance

DIAGNOSIS

Medical Diagnoses

DSM-5 identifies loss of self-control of emotions and behaviors leading to aggressive acts in all of the following medical diagnoses:

Disruptive, Impulse-Control and Conduct Disorders

Oppositional defiant disorder Intermittent explosive disorder Conduct disorder Antisocial personality disorder Pyromania Kleptomania

Other specified disruptive, impulse-control, and conduct disorder Unspecified disruptive, impulse-control, and conduct disorder

Caregiver/Nursing Diagnoses

Diagnoses for patients who display aggressive behavior include

Risk for self-directed violence Risk for other-directed violence Aggression self-control Ineffective coping

(NANDA, 2014)

PLANNING

Without question, de-escalation of anger and prevention of violence is the primary outcome criteria for interventions with angry patients. Such planning takes into account resource availability and situations in which violence may occur, is occurring, or has occurred.

In planning interventions, it is important to consider the stages of violence. These are the:

Pre-assaultive stage: tension increases and person becomes increasingly agitated

Assaultive stage: person loses control and becomes violent Post-assaultive stage: person is calm and incident is reviewed

INTERVENTION

Pre-assaultive stage interventions focus on de-escalation of anger. Clinicians follow these practices:

1. Assess patients and their situation and reassure them of your concern and expectation that they will stay in control of themselves.

2. Place patient in a quiet and secure area and inform staff of what is happening. When possible, interact with patients in a quiet place that is in plain view of other caregivers.

3. Never turn your back on or walk ahead of the individual.4. Ensure you have a safe escape route.

5. Demonstrate respect for personal space, thus decreasing the threat. If the person is sitting, sit. If the person is standing, stand.

6. Remain calm and nonconfrontational in words and actions.7. Interact with patients respectfully in a slow, low, and nonthreatening

voice.8. Verbalize options. Encourage patients to assume responsibility for the

choices they make and acknowledge the difficulties they have in making choices.9. Use time wisely. Give adequate time for depressed or suicidal patients

to consider options. Set limits with manipulative patients.10. Provide continuous observation and record behavior changes in patient

notes.11. Secure personal safety: Avoid dangling jewelry. Alert other caregivers. Eliminate hazards caused by furniture or other objects. Stand to the side of patients, not directly in front of them in a

threatening way. If patients begin to escalate, provide feedback, assure them that they

will be safe. Avoid confrontation and “show of force” by security guards. Wear an alarm if available.12. Use LEAPS: Listen Empathize Ask questions Paraphrase Summarize

(Butler, 2011)

Assaultive stage interventions include application of restraints, administration of medication, and seclusion. These measures should be used only after alternative interventions have been tried (verbal intervention, decreased sensory stimulation). Restraints, medications, and seclusion are used only when patients present a clear and present danger to themselves or others and have been legally detained for involuntary treatment, or when they request seclusion.

When physical restraint is necessary, a team of at least five staff members trained in the techniques of management of assaultive behavior (MAB) subdues the

patient. Guidelines for MAB allow for one member (the leader) to speak to the patient and instruct other members of the team. Only the leader communicates with the patient. When the patient is restrained, caregivers administer physician-prescribed sedatives and the patient is placed in a quiet, secluded area.

MAB certification requires that staff receive training and demonstrate current competency in all aspects of dealing with behavioral emergencies, including seclusion and restraint. All healthcare workers should be familiar with the techniques of MAB and be prepared to become trained as a member of a team if that should be necessary. MAB training courses are available through the Internet or provided by healthcare facilities.

Post-assaultive stage interventions begin when the patient has become calm. These measures include establishing rapport, engaging in a therapeutic discussion of stressors, and teaching alternative coping behavior. When it is available, patients are referred to longer-term counseling and anger management group therapy.

EVALUATION

After an assault by a patient, clinicians need time to regroup and regain a sense of personal safety, control, and security. It is important to take time to debrief and to discuss what happened, what went right, what went wrong, and what they will do in future situations. All incidents of violence are reported and documented according to agency protocol.

CASE

Curt and his nine-year-old son were tossing a football back and forth when the son fell backward onto a sharp rock, which cut a deep gash in his scalp. Curt rushed the boy to the emergency department (ED) at the local hospital and stood by anxiously as the triage nurse examined his injury. She said the doctor would come to see the boy soon and left, closing the cubicle curtain behind her.

Curt waited as minutes went by. Getting anxious, he went to the curtain, pushed it aside, and gazed out at the busy unit. Workers rushed this way and that, but no one came to see his son. Curt went to the desk and asked the clerk when the doctor would come to see his son. The clerk said the doctor was seeing other patients and would be there shortly. Curt returned to his son’s cubicle and waited, leaving the curtain open.

After some time, Curt went back to the clerk. “How much longer is it going to be?” The clerk barely looked up and said, “It won’t be much longer.”

More minutes crawled by, and Curt became more and more agitated. His perception of the event was that this was a life-and-death situation. He had no support system except the ED staff, and they were too busy to help. His usual coping mechanism was action—often aggressive—not passivity. His son groaned in pain, and Curt became angrier by the minute. He set his jaw and went to the clerk, clenched his fist, pounded on the counter, and shouted, “You said the doctor would come and take care of my son! That was ages ago! Where is he? Where’s the f**king doctor?!”

A nurse overhearing this exchange immediately approached Curt and quietly and calmly asked if she could be of assistance. She listened to Curt, asking open-ended questions and acknowledging his anger. She empathized with his concern and frustration, paraphrasingCurt’s frustration about how hard it is to have a child hurting and not be able to help him right away. She guided Curt back to the cubicle, while asking him what happened to his son. She carefully examined the boy and offered reassurance to Curt that he was not in imminent danger. She spoke to the boy, who told her his head hurt but that he was “okay.” By this time, Curt’s anger had subsided and he was speaking calmly. The nurse summarized the event and acknowledged that emergency rooms are busy places in which someone else might need attention sooner than his son.

At this point, the nurse told Curt she would return to check on them both in a few minutes. Shortly thereafter the physician entered, apologized for the delay, closed the wound, and discussed the boy’s care with Curt.

The nurse's use of the mnemonic LEAPS was effective in reducing Curt's anger and avoided an incidence of violence in the ED.

Substance Use Emergencies

We are a drug-oriented society. We use drugs to reduce pain, lessen anxiety, induce sleep, increase energy, restore health, create feelings of euphoria, and enhance alertness. At least two thirds of the U.S. adult population consume alcohol regularly, and more than half of those with mental illnesses use or have used mind-altering substances (Smith-Dijulio, 2011).

Because of the widespread use of substances, clinicians in emergency departments and on crisis hotlines must assess, diagnose, plan, intervene, and evaluate not only physical but also psychiatric disorders, including substance use disorders.

SUBSTANCE USE–RELATED TERMINOLOGY

Term Description

Physical dependence

Physiologic adaptation to a drug, confirmed by the appearance of signs and symptoms that occur if the drug is withheld

Psychological dependence (addiction)

Compulsive and maladaptive dependence on various substances, such as methamphetamine, cocaine, and tobacco

Polysubstance abuse

The simultaneous use of many legal and illegal mind-altering, addictive substances

Substance abuse

The repeated use of mind-altering substances, resulting in a failure to meet obligations at home, work, or school

Substance use The ingestion of a chemically active agent, such as legally prescribed medication, alcohol, tobacco, or illegally obtained drug

Tolerance A condition in which people take progressively higher doses of a substance to achieve a desired effect; withdrawal symptoms appear when individuals stop taking the substance

Withdrawal syndrome

A group of symptoms that occur when a drug is discontinued or when its effect is counteracted by a specific antagonist

ASSESSMENT

People in crisis often resort to mind-altering substances to dull their senses, lift their spirits, or in some way relieve their discomfort. Usually, they appear in emergency departments because they have been brought there by someone else for some other reason than abuse of a substance. In any case, clinicians routinely assess patients for substance use, especially when they exhibit bizarre behavior typical of mind-altering substances.

Specifically, caregivers inquire about:

History of substance abuse: What substance have you taken, how long ago, what symptoms? Have you had blackouts, overdoses, complications, recent accidents, head trauma? Do you have a family history of substance abuse? Have you been treated previously for substance abuse?

Medical history: What medical disorders do you have? What medicines do you take?

Psychiatric history: Have you been diagnosed with any psychiatric disorder? Have you undergone treatment for a specific disorder? Do you have a history of physical or sexual abuse or family violence?

Suicide attempt history: Have you ever thought about ending your life or hurting yourself? Have you tried to end your life? When, and under what circumstances? Are you currently having suicidal thoughts?

Psychosocial issues: Do you have a family or friends? What do you do for a living? What do you do to feel happy? Have you had a crisis in your life recently? How has substance use affected your ability to meet usual role expectations? Do you have a police or criminal record or legal problems related to substance use?

When people do not know or will not tell caregivers what substance they have taken, clinicians look for typical signs of stimulants, depressants, inhalants, hallucinogens, intoxicants, opiates, and other drugs. Signs and symptoms of the most common types of drugs are described in the following table.

SIGNS AND SYMPTOMS OF SUBSTANCE USE

Type of Intoxication

Examples of Substances

Signs and Symptoms

Source: Webb et al., 2000.

Central nervous system (CNS) stimulants

Cocaine, crack, amphetamines

Tachycardia, dilated pupils, elevated blood pressure, nausea and vomiting, insomnia, belligerence, grandiosity, impaired judgment, impaired social and occupational functioning, euphoria, increased energy, severe to panic levels of anxiety, paranoia with delusions, hallucinations (visual, auditory, and tactile)

Opiates Opium, heroin, meperidine, morphine, codeine, fentanyl, methadone, hydromorphone

Constricted pupils; decreased respiration; drowsiness; decreased blood pressure; slurred speech; psychomotor retardation; initial euphoria followed by impaired judgment, attention, and memory

Hallucinogens

Lysergic acid diethylamide (LSD), mescaline, psilocybin

Pupil dilation; tachycardia; diaphoresis; palpitations; tremors; elevated temperature, pulse, and respirations

Phencyclidine piperidine (PCP)

n/a Vertical or horizontal nystagmus; elevated blood pressure, pulse, temperature; ataxia; muscle rigidity; seizure; blank stare; chronic jerking; agitation; repetitive movements; belligerence; impulsiveness;

SIGNS AND SYMPTOMS OF SUBSTANCE USE

Type of Intoxication

Examples of Substances

Signs and Symptoms

impaired judgment and functioning

Inhalants Volatile solvents that vaporize at room temperature, such as model airplane glue, nail polish, rubber cement

Excitement, then drowsiness, agitation, and lack of self-control

Nitrates Room deodorizers Enhanced sexual pleasure, euphoria

Anesthetics Nitrous oxide Giggling, acting silly

CNS depressants

Alcohol, benzodiazepines, barbiturates

Slurred speech; unsteady gait; drowsiness; decreased blood pressure; impaired judgment, memory, and occupational function; irritability; aggressiveness

Alcohol withdrawal

n/a Irritability, hyper-alertness, jerky movements (“shakes”), usually developing within a few hours after the last drink, peaking sometime between 24–48 hours, and then gradually disappearing

Complicated alcohol withdrawal with delirium tremens

n/a Disorientation, agitation, tremors, anxiety, visual and tactile hallucinations, paranoid delusions, fluctuating levels of consciousness,

SIGNS AND SYMPTOMS OF SUBSTANCE USE

Type of Intoxication

Examples of Substances

Signs and Symptoms

(DTs) hypertension, tachycardia, diaphoresis, fever (100 °F–103 °F), usually occurring 48–72 hours after the last drink; death, if untreated

DIAGNOSIS

Medical Diagnoses

In the DSM-5, the APA (2013) lists a large number of substance-related disorders: 6 alcohol, 4 caffeine, 6 cannabis, 9 hallucinogen, 4 inhalant, 5 opioid, 5 sedative/hypnotic/anxiolytic, 5 stimulant, 4 tobacco, and 6 other substance disorders.

Studies have suggested that almost one third of persons with a mental illness and about one half of persons with severe mental illness also experience substance abuse. Likewise, more than one third of all alcohol abusers and one half of all drug abusers have mental illness. When more than one disorder presents, patients are described as suffering from dual diagnoses or co-morbid conditions (NAMI, 2013b).

Caregiver/Nursing Diagnoses

Many caregiver/nursing diagnoses are appropriate to substance abusers, indicating just how dysfunctional their lives may be. Some common diagnoses include:

Disturbed sleep pattern Ineffective health maintenance Imbalanced nutrition Deficient fluid volume Risk for electrolyte imbalance Ineffective impulse control Impaired environmental interpretation

Disturbed thought processes Hopelessness Nonadherence to healthcare regimen Anxiety Self-care deficit Ineffective coping Dysfunctional family processes Risk for suicide or violence to others

(NANDA, 2014)

PLANNING

The goal of emergency care of substance-using individuals is to provide immediate, life-saving measures, identify the drug or drugs the individual has taken, and give supportive emotional care. The goal of long-term care is to encourage abstinence from substance abuse, meet physical and emotional needs, restore self-respect, and assist patients to establish a support system.

INTERVENTIONS

In the emergency department, interventions for a substance-abusing individual include identifying the specific drug or drugs he or she has taken, giving immediate life-saving care, providing food and fluid, and transporting the patient to inpatient care or referring to outpatient care.

Sadly, many substance abusers are homeless and friendless and afflicted with serious co-morbid conditions. Some communities provide shelter and drug treatment facilities, but persons must agree to the rules and regulations of such facilities. Many refuse, preferring to live on the street until another crisis sends them back to the emergency department.

EVALUATION

Clinicians in emergency departments evaluate how well they have met the immediate needs of patients, though they may find it difficult to empathize with those who return over and over again. Nevertheless, it is important to determine the success of interventions by evaluating whether the principles of ethics were involved in providing care to each individual patient.

CASE

The owner of a small downtown café called the police. “One of those homeless drunks is out cold on my doorstep. Yep, I know the man … name’s Ken. He hangs around all the time, bothering customers and begging for leftovers … sells cheap newspapers and uses the money for booze.”

The owner hung up and went back to the entrance of his café. Ken had vomited all over himself. When the owner nudged him with his foot, Ken groaned but didn’t move. When the police arrived, they called an ambulance.

The emergency department (ED) staff knew Ken well. He had a long history of coming to the ED, responding to care, being discharged, and then repeating the cycle. This time the staff was determined to do things differently. They gave emergency care, admitted Ken to a medical unit, and referred him to social services. When Ken was sober and his condition stable, social workers devised a long-term plan that included housing and alcohol rehabilitation.

Major Mental Illness Crises

When precipitating events occur in the lives of people with major mental illnesses, they may become so distressed that they seek help in an emergency department or by means of a crisis hotline. This is not surprising, since the coping skills and support systems of these individuals often are limited. Clinicians need to assess the signs and symptoms of such individuals, diagnose their disorders, plan their care, intervene, make appropriate referrals, and evaluate the effectiveness of interventions. Some of the more common major mental illnesses seen in emergency departments are:

Delirium (acute confusional state): Individual experiences a disturbance of consciousness and change in ability to think that develops within a few hours or days. Delirium is a syndrome and is always secondary to another condition, such as a general medical condition, medications, or substance use.

Dissociative disorders: Individual experiences a disturbance of memory (amnesia), depersonalization (disconnected or detached), or confusion about personal identity. A dissociative identity disorder is present when the individual exhibits two or more distinct personalities.

Mania: Individual exhibits a period of expansive or irritable mood, lasting at least a week. The person is talkative, grandiose, sleeps very little and

experiences a flight of ideas, psychomotor agitation, distractibility and excessive involvement in pleasurable activities that have a high potential for painful consequences.

Panic disorder: Individual experiences intense fear that develops suddenly, reaching a peak within minutes, with rapid heart rate, palpitations, sweating, tremor, shortness of breath, feelings of being smothered or choked, fear of going crazy or dying, and dizziness. Symptoms gradually subside.

Posttraumatic stress disorder: Individual repeatedly experiences memories or dreams of an overwhelming traumatic event, causing intense fear, helplessness, horror, dissociative reactions, and avoidance of stimuli associated with the trauma.

Schizophrenia: Individual may experience delusions (false ideas), hallucinations (false perceptions),disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms such as flattened affect, diminished motivation, and disturbed work and social functioning.(APA, 2013)

ASSESSMENT

When individuals come to the emergency department with psychotic symptoms, caregivers interview them and, when possible, interview relatives and associates. Initial information may suggest the need for laboratory or other diagnostic studies. If patients have been hospitalized recently, their records may be available. If they are agitated and assaultive, it may be necessary to restrain or seclude them for a period of time, as described above under “Legal Issues.”

DIAGNOSIS

Clinicians consider carefully the signs, symptoms, history, medical record, and laboratory test of each patient. Medical and nursing diagnoses are made using the standard medical references: ICD-9-CM, DSM-5, and NANDA.

PLANNING

Individuals must have an individualized plan of care that includes their immediate needs as well as ongoing ones. Many patients require medication, some need hospitalization, and most will need referral to outpatient care. The goal of all care is stabilization and appropriate ongoing interventions.

INTERVENTIONS

Immediate interventions for individuals suffering from the disorders listed above are carried out in the emergency department in consultation with their personal physician. Ongoing interventions are provided by either a facility to which they are sent or to their family or other responsible caregivers. Discharge planning and referral to social service agencies is essential.

EVALUATION

As discussed earlier, clinicians evaluate the care they give patients, especially the care they give vulnerable persons who arrive alone, without family or friends. In a way, the arrival of a patient in an emergency department constitutes a precipitating event of a potential crisis for the staff. Clinicians use their coping skills (experience, knowledge, and reasoning) and support system (professional colleagues) to meet the needs of each patient. Thus, a potential crisis is resolved.

CONCLUSION

Individuals experiencing an emergency-producing mental health crisis need immediate, appropriate, and sensitive care, whether the crisis is caused by a mood disorder, anxiety, anger, substance use, or a major mental illness. Although clinicians who work in emergency departments and on crisis hotlines encounter these individuals every day, all healthcare professionals meet people in crisis who are overwhelmed by mental and emotional distress. It is important that all caregivers be educated to rapidly assess, diagnose, plan, and intervene in such situations.

Mental health crises have a high risk for poor outcomes, and it is imperative that healthcare professionals respond appropriately. Evaluation of responses requires the determination that ethical principles be followed and that these individuals receive compassionate care.