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181

C H A P T E R

13 Crisis and Disaster Intervention

Gail W. Stuart

He knows not his own strength that hath not met adversity.

Francis Bacon, Of Fortune

Stressful events, or crises, are a common part of life. They may be social, psychological, or biological in nature, and there is often little that a person can do to prevent them. As the largest group of health care providers, nurses are in an excellent position to help promote healthy outcomes for peo-ple in times of crisis and disaster ( Happell et al, 2009 ).

Crisis intervention is a brief, focused, and time-limited treatment strategy that is effective in helping people adap-tively cope with stressful events. Knowledge of crisis and disaster intervention techniques is an important clinical skill for all nurses, regardless of clinical setting or practice specialty.

CRISIS CHARACTERISTICS A crisis is a disturbance caused by a stressful event or a per-ceived threat. The person’s usual way of coping becomes inef-fective in dealing with the threat, causing anxiety. The threat, or precipitating event, usually can be identifi ed. It may have

occurred weeks or days before the crisis, and it may or may not be linked in the individual’s mind to the crisis state the individual is experiencing. Precipitating events can be actual or perceived losses, threats of losses, or challenges.

Crisis Responses After the precipitating event, the person’s anxiety begins to rise, and three phases of a crisis response emerge: 1. The anxiety activates the person’s usual methods of cop-

ing. If these do not bring relief, anxiety increases because coping mechanisms have failed.

2. New coping mechanisms are tried or the threat is rede-fi ned so that old ones can work. Resolution of the problem can occur in this phase. However, if resolution does not occur, the person goes on to the last phase.

3. The continuation of severe or panic levels of anxiety may lead to psychological disorganization. In describing the phases of a crisis, it is important to

consider the balancing factors shown in Figure 13-1 . These

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L E A R N I N G O B J E C T I V E S

1. Describe a crisis and its characteristics, including crisis responses, types of crises, characteristics of disasters, and crisis intervention.

2. Analyze aspects of the nursing assessment related to crisis and disaster responses.

3. Plan and implement nursing interventions for patients related to their crisis and disaster responses.

4. Develop a patient education plan to cope with crisis. 5. Evaluate nursing care for patients related to their crisis

and disaster responses. 6. Describe the settings in which crisis and disaster

intervention may be practiced. 7. Discuss modalities of crisis intervention.

182 UNIT II Continuum of Care

include the individual’s perception of the event, situational supports, and coping mechanisms. Successful resolution of the crisis is more likely if the person has a realistic view of the event; if situational supports are available to help solve the problem; and if effective coping mechanisms are present ( Aguilera, 1998 ).

The phases of a crisis and the impact of balancing fac-tors are similar to the elements of the Stuart Stress Adapta-tion Model used in this textbook and described in Chapter 3. However crises are self-limiting. People in crisis are too upset to function at such a high level of anxiety indefi nitely. The time needed to resolve the crisis, whether it is a positive

State of equilibrium

Human organism

State of disequilibrium

Need to restore equilibrium

Distorted perception of the event

No adequate situational support

AND/OR

AND/OR

No adequate coping mechanisms

RESULT IN

Problem unresolved

Disequilibrium continues

Crisis

Realistic perception of the event

Adequate situational support

Adequate coping mechanisms

Resolution of the problem

Equilibrium regained

No crisis

A. Balancing factors present B. One or more balancing factors absent

Stressful event Stressful event

PLUS

PLUS

RESULT IN

FIG 13-1 Paradigm: the effect of balancing factors in a stressful event. (From Aguilera DC: Crisis intervention: theory and methodology, ed 8, St Louis, 1998, Mosby.)

183CHAPTER 13 Crisis and Disaster Intervention

solution or a state of disorganization, may be 6 weeks or longer.

It also is important to recognize that periods of intense confl ict ultimately can result in increased growth. It is how the crisis is handled that determines whether growth or dis-organization will result. Growth comes from learning in new situations. People in crisis feel uncomfortable, often reach out for help, and accept help until they feel that their lives are back to normal. The fact that crises can lead to personal growth is important to remember when working with patients in crisis.

Critical Reasoning Think of a crisis you have experienced. Do you feel that the way you handled it made you a better person in some way? If so, how?

Types of Crises . The two types of crises are maturational and situational. Sometimes these crises can occur simultane-ously. For example, an adolescent who is having diffi culty adjusting to a change in role and body image (maturational crisis) may at the same time undergo the stress related to the death of a parent (situational crisis).

Maturational Crises . Maturational crises are develop-mental events requiring role changes. Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are key times for the onset of maturational cri-ses. For example, successfully moving from early childhood to middle childhood requires the child to become socially involved with people outside the family. With the move from adolescence to adulthood, fi nancial responsibility is expected. Both social and biological pressures to change can precipitate a crisis.

The nature and extent of the maturational crisis can be infl uenced by role models, interpersonal resources, and the response of others. Positive role models show the person how to act in the new role. Interpersonal resources encourage the trying out of new behaviors to achieve role changes.

Other people’s acceptance of the new role is also impor-tant. The greater the resistance of others, the more stress the person faces in making the changes. Some confl icts related to maturational crises are seen in the clinical examples that follow.

CLINICAL EXAMPLE

Ms. J was a 19-year-old African-American, single, unem-ployed woman who came to the mental health clinic 1 month after the birth of her fi rst child. Ms. J complained of feeling depressed. Her symptoms included diffi culty fall-ing asleep, early-morning awakening, crying spells, a poor appetite, and diffi culty in caring for the baby because of fatigue and apathy. The patient lived with her parents and siblings and had never lived on her own. She had always depended on her mother to take care of her. Her mother worked, however, and the patient was totally responsible for her daughter’s care each day. Also, Ms. J’s mother was angry that she had a child and often refused to care for the

baby. The patient’s boyfriend, who was the baby’s father, had promised to marry her, but he had recently decided he was too young to handle the responsibility of a wife and child. In summary, the young woman who had unmet dependency needs of her own was now a parent and had to meet the dependency needs of her infant. This precipi-tated a crisis for her. Selected Nursing Diagnoses • Ineffective coping related to birth of a child, as evi-

denced by feelings of depression • Interrupted family processes related to birth of a grand-

child, as evidenced by lack of family support • Impaired parenting related to being a single mother, as

evidenced by diffi culty caring for her baby

CLINICAL EXAMPLE

Mr. R was a 67-year-old white, married pharmacist who came to the mental health clinic complaining of anxiety, depression, and insomnia. His symptoms had begun 2 weeks ago when his wife decided that they should move to a retirement community in Florida. He described his wife as a strong, determined woman who was outgo-ing and charming and made friends easily. He considered himself a quiet, nervous person who was comfortable only with old friends and his two sons and their families. Mr. R, although at retirement age, had continued to work as a pharmacist, doing relief work for a drugstore chain when the regular pharmacists were absent. In moving to Florida, he would lose his pharmacist’s license, which was valid only in his state of residence. He expressed diffi culty in making the transition from work to retirement. He had fears of becoming directionless and useless. He was anx-ious about leaving his sons and his friends. The prospect of complete retirement and moving to another state pre-cipitated his distress. Selected Nursing Diagnoses • Relocation stress syndrome related to pending retire-

ment, as evidenced by feelings of anxiety • Interrupted family processes related to confl ict about

lifestyle changes, as evidenced by inability to plan future

Situational Crises . Situational crises occur when a life event upsets an individual’s or group’s psychological equilib-rium. Examples of situational crises include loss of a job, loss of a loved one, unwanted pregnancy, onset or worsening of a medical illness, divorce, school problems, and witnessing a crime.

The loss of a job can result in fi nancial stress, feelings of inadequacy, and marital confl ict caused by a family mem-ber’s anger over the lost job. The loss of a loved one results in bereavement and also can cause fi nancial stress, change in roles of family members, and loss of emotional support. Homelessness is another possible outcome of the loss of a job or a loved one. The onset or worsening of a medical illness causes anticipatory grief and fear of the loss of a loved one. Again, fi nancial stress and change in roles of family members often occur. Divorce is similar to the stress of losing a loved one, except that the crisis can recur with the stress of dealing with the ex-spouse.


An unwanted pregnancy is stressful because it requires decisions to be made about whether to complete the preg-nancy or to abort it and whether to keep the baby or place the baby for adoption. If the pregnancy is aborted or adop-tion occurs, the mother may need to deal with feelings of grief or anger. If the baby is to be kept, changes in lifestyle are required. Finally, being the victim of or witnessing a crime can cause feelings of helplessness, distrust of others, fear, nightmares, and guilt about causing or not stopping the crime.

Situational crises can be accidental, uncommon, and unexpected events including natural and man-made disas-ters such as fi res, tornadoes, earthquakes, hurricanes, or fl oods. These disrupt entire communities and cause wide-spread damage. Disasters, such as killings in the workplace or in schools, airplane crashes, suicide bombings, and acts of terrorism, also can precipitate situational crises.

The terrorist attacks of September 11, 2001, in which air-planes were hijacked and fl own into the World Trade Center in New York City, presented unprecedented trauma and cri-sis to people throughout the United States. Entire communi-ties, especially people living in New York City, experienced a sudden and unexpected violent act that resulted in multiple losses and extensive community disruption.

In addition, the safety felt by all people across the United States was affected. One study found that more than half of the people who lived or worked in New York had some emo-tional sequelae 3 to 6 months after September 11; however, only a small portion of those with severe responses were seek-ing treatment ( DeLisi et al, 2003 ).

Disaster-precipitated emotional problems can surface immediately, or weeks or even months after the disaster. After the September 11 attack, individuals who lost family members accounted for 40% of mental health visits in the fi rst month but dropped to 5% by 5 months. Uniformed per-sonnel used many more mental health services after the fi rst year ( Covell et al, 2006 ).

Researchers have identifi ed several common character-istics of disasters that are particularly important when dis-cussing emotional distress and recovery. These are listed in Box 13-1 .

Disaster responses usually occur in seven phases. These are described in Table 13-1 . Individuals and communities prog-ress through these phases at different rates depending on the type of disaster and the degree and nature of disaster expo-sure. This progression may not be sequential, because each person and each community is unique in the recovery pro-cess. Individual variables such as psychological resilience, social support, and fi nancial resources infl uence a survi-vor’s capacity to move through the phases.

Critical Reasoning Some crises, such as obtaining a divorce, develop over time and are of longer duration. Other crises, such as an earthquake, are sudden and unexpected. How do you think the element of time affects the response to crisis?

CRISIS INTERVENTION Crisis intervention is a short-term therapy focused on solv-ing the immediate problem. It is usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. Often the person advances to a level of growth that is higher than the pre-crisis level because new ways of problem solving have been learned.

It is important for the nurse to remember that culture strongly infl uences the crisis intervention process, includ-ing the communication and response style of the crisis worker. Cultural attitudes are deeply ingrained in the pro-cesses of asking for, giving, and receiving help. They also affect the victimization experience, as seen in Box 13-2 , so it is essential to understand and respect the sociocultural con-text of crisis care. Specifi c cultural factors to be considered in crisis intervention include the following: • Migration and citizenship status • Gender and family roles • Religious belief systems • Child-rearing practices • Use of extended family and support systems • Housing and living conditions • Socioeconomic status The age of the survivors is also important for the nurse to consider when providing crisis intervention. Responses to stressful events differ across the life span. Therefore age-appropriate interventions are most effective in helping survivors return to their previous level of functioning. For example, 4-year-old children may best express themselves through play, whereas adolescents may best work through crisis issues in peer group discussions.

• Intensity of the impact: Disasters that result in intense destruction within a short period of time are more likely to cause emotional distress among survivors than are disasters that spread their impact over a longer period of time.

• Impact ratio (i.e., the proportion of the community

sustaining personal losses): When a disaster affects a signifi cant proportion of a community’s population, few individuals may be available to provide material and emo-tional support to survivors.

• Potential for recurrence of other hazards: The real or perceived threat of recurrence of the disaster or of associ-ated hazards can lead to anxiety and heightened stress among survivors.

• Cultural and symbolic aspects: Changes in survivors’ social and cultural lives and routine activities can be pro-foundly disturbing. Both natural and human-caused disas-ters can have symbolic implications.

• Extent and types of loss sustained by survivors: Prop-erty damage or loss, deaths of loved ones, injury, and job loss all affect emotional recovery.

BOX 13-1 CHARACTERISTICS OF DISASTERS


TABLE 13-1 PHASES OF DISASTER RESPONSE

PHASE RESPONSE

Warning or threat phase Disasters vary in the amount of warning communities receive before they occur from little or no warning to hours or even days of warning. When no warning is given, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies.

Impact phase The impact period of a disaster can vary from the slow, low-threat build-up associated with some types of fl oods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects.

Rescue or heroic phase In the immediate aftermath, survival, rescuing others, and promoting safety are priorities. For some, postimpact disorientation gives way to adrenaline-induced rescue behavior to save lives and protect property. Although activity level may be high, actual productivity is often low. Altru-ism is prominent among both survivors and emergency responders.

Remedy or honeymoon

phase During the week to months following a disaster, formal governmental and volunteer assistance

may be readily available. Community bonding occurs as a result of sharing the catastrophic experi-ence and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more read-ily accepted and have a foundation from which to provide assistance in the diffi cult phases ahead.

Inventory phase Over time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted because of enormous multiple demands, fi nancial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue.

Disillusionment phase As disaster assistance agencies and volunteer groups begin to pull out, survivors may feel aban-doned and resentful. The reality of losses and the limits and terms of the available assistance be-come apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle. Stressors abound—family discord, fi nancial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of preexisting condi-tions emerge because of ongoing, unrelenting stress and fatigue.

Reconstruction or

recovery phase The reconstruction of physical property and recovery of emotional well-being may continue for

years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and gradually assume the responsibility for doing so. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin.

When people come to see meaning, personal growth, and opportunity from their disaster experi-ence despite their losses and pain, they are well on the road to recovery. Although disasters may cause profound life-changing losses, they also bring the opportunity to recognize personal strengths and to reexamine life priorities.

From U.S. Department of Health and Human Services: Training manual for mental health and human service workers in major disasters, ed 2, Washington, DC, 2000, U.S. Government Printing Offi ce.

Survivors of Katrina

Many of the African-American survivors of Hurricane Katrina in New Orleans were at high risk for physical and mental health problems because of their residence in high-poverty areas, the residential segregation that existed before the storm, and the enormous dislocation that resulted from the hurricane. A study of this population found that survivors who lacked fi nancial resources faced higher risks for general mental health prob-lems and that racial discrimination increased the health-related risk for Katrina survivors. Further, female African-American survivors reported more posttraumatic stress disorder (PTSD) symptoms and worse mental health ( Chen et al, 2007 ). In con-trast, support provided by network members enhanced physi-cal and mental health. This study of African-American survivors

of Hurricane Katrina highlighted the social inequities in U.S. society and the need to directly address the issues of race, class, and gender inequality in disaster preparation, postdisas-ter rescue, and recovery mission and rebuilding efforts.

Another study examined the use of mental health services among adult survivors of Hurricane Katrina to evaluate the impact of disasters on persons with existing mental illness who were living in the community. As a result of the storm, entire mental health delivery systems were destroyed, and few Katrina survivors with mental disorders received adequate care ( Wang et al, 2007, 2008 ). The sociocultural, fi nancial, structural, and attitudinal barriers that prevented those with mental illness from obtaining needed treatment also will need to be over-come in future disasters.

BOX 13-2 SOCIOCULTURAL CONTEXT OF CARE


Critical Reasoning Describe how sociocultural factors might affect a woman’s decision to seek help after being raped.

ASSESSMENT The fi rst step of crisis intervention is assessment. At this time, data about the nature of the crisis or disaster and its effect on the patient must be collected. From these data an interven-tion plan will be developed. People in crisis experience many symptoms, including those listed in Box 13-3 . Sometimes these symptoms can cause further problems. For example, problems at work may lead to loss of a job, fi nancial stress, and lowered self-esteem.

Crises also can be complicated by old confl icts that resur-face as a result of the current problem, making crisis resolu-tion more diffi cult. For example, a woman who was orphaned at an early age may have more diffi culty resolving a crisis pre-cipitated by the work injury of her husband than a woman who had not experienced an earlier loss.

Anger is one of the most understandable responses to a crisis or disaster but it also may be the most diffi cult one to manage. Anger can be productive if it is channeled in the right way but also can become a serious obstacle to recov-ery, creating problems for one’s physical and mental health, as well as family and community cohesion. Questions that should be considered are as follows: • Is the anger justifi ed? • Is the anger purposeful? • Can the anger be used in a positive way? • Does the anger pose an immediate threat or danger?

Anger is most common in the “disillusionment phase” noted in Table 13-1 . In some cases, it can even pose a danger to the health care responders who have come to assist survi-vors. Thus, safety issues should be a priority for the nurse in working with patients in crisis.

Although the crisis situation is the focus of the assessment, the nurse may identify more signifi cant and long-standing problems. Those individuals with preexisting psychological problems may have more postdisaster health problems . For example, those with serious mental illness will need help in ensuring access to their medications and caregiver stability ( Milligan and McGuinness, 2009 ).

It is important, therefore, to identify which areas can be helped by crisis intervention and which problems must be referred to other sources for further treatment. During this phase the nurse begins to establish a positive working relationship with the patient. A number of balancing factors are important in the development and resolution of a crisis and should be assessed: • Precipitating event or stressor • Patient’s perception of the event or stressor • Nature and strength of the patient’s support systems

and coping resources • Patient’s previous strengths and coping mechanisms

Precipitating Event To help identify the precipitating event, the nurse should explore the patient’s needs, the events that threaten those needs, and the time at which symptoms appear. Four kinds of needs that have been identifi ed are as follows: 1. Self-esteem needs are achieved when the person attains

successful social role experience. 2. Role mastery needs are achieved when the person attains

work, sexual, and family role successes. 3. Dependency needs are achieved when a satisfying interde-

pendent relationship with others is attained. 4. Biological function needs are achieved when a person is

safe and life is not threatened. The nurse determines which needs are not being met and

looks for obstacles that might interfere with meeting the patient’s needs.

Coping patterns become ineffective and symptoms appear usually after the stressful incident. When did the patient begin to feel anxious? When did sleep disturbances begin? At what point in time did suicidal thoughts start? If symptoms began last Tuesday, ask what took place in the patient’s life on Tuesday or Monday. As the patient connects life events with the breakdown in coping mechanisms, an understanding of the precipitating event can emerge.

Anger Apathy Backaches Boredom Crying spells Diminished sexual drive Disbelief Fatigue Fear Flashbacks Forgetfulness Headaches Helplessness Hopelessness Insomnia Intrusive thoughts

Irritability Lability Nightmares Numbness Overeating or undereating Poor concentration Sadness School problems Self-doubt Shock Social withdrawal Substance abuse Suicidal thoughts Survivor guilt Work diffi culties

BOX 13-3 BEHAVIORS COMMONLY EXHIBITED AFTER A CRISIS

QUALITY AND SAFETY ALERT

• As a helper, do not sacrifi ce one’s personal safety to estab-lish a relationship.

• Trust your instincts and exit a situation too soon rather than too late.

• Don’t run from danger; rather have an exit plan and run to safety.


• The safety of the patient is the fi rst priority. • Only when biological needs of food, shelter and physical

integrity are met can other needs be addressed.


Perception of the Event The patient’s perception or appraisal of the precipitating event is very important. In times of disaster, perceptions of the event may be very similar. With other events it may not be so clear. What may seem trivial to the nurse may have great meaning to the patient.

For example, an overweight adolescent girl may have been the only girl in the class not invited to a dance. This may have threat-ened her self-esteem. A man with two unsuccessful marriages may have just been told by a girlfriend that she wants to end their relationship; this may have threatened his need for sexual role mastery. An emotionally isolated, friendless woman may have had car trouble and been unable to fi nd someone to give her a ride to work. This may have threatened her dependency needs. A chronically ill man who has had a recent relapse of his illness may have had his need for biological functioning threatened.

Themes and surfacing memories of the patient give fur-ther clues to the precipitating event. Current issues of con-cern are often connected to past issues. For example, a female patient who talks about the death of her father, which occurred 3 years ago, may, on discussion, reveal a recent loss of a relationship with a male. A patient who talks about feel-ings of inadequacy he had as a child because of poor school performance may, on discussion, reveal a recent experience in which his feelings of adequacy on his job were threatened.

Because most crises involve losses or threats of losses, the theme of loss is a common one. In assessment, the nurse looks for a recent event that may be connected to an underly-ing theme.

Support Systems and Coping Resources The patient’s living situation and supports in the environ-ment must be assessed. Does the patient live alone or with family or friends? With whom is the patient close, and who offers understanding and strength? Is there a supportive clergy member or friend?

Assessing the patient’s support system is important in determining who should come for the crisis therapy sessions. It may be decided that certain family members should come with the patient so that the family members’ support can be strengthened. If the patient has few supports, participation in a crisis therapy group may be recommended.

Assessing the patient’s coping resources also is vital in determining whether hospitalization would be more appro-priate than outpatient crisis therapy. If there is a high degree of suicidal or homicidal risk along with weak outside resources, hospitalization may be a safer and more effective treatment.

Critical Reasoning Identify people in your social system that you would turn to in a time of crisis. Compare your list with that of a friend.

Coping Mechanisms Next, the nurse assesses the patient’s strengths and previ-ous coping mechanisms. How has the patient handled other crises? How were anxieties relieved? Did the patient talk out

problems? Did the patient leave the usual surroundings for a period of time to think things through from another per-spective? Was physical activity used to relieve tension? Did the patient fi nd relief in crying? Besides exploring previous coping mechanisms, the nurse also should note the absence of other possible successful mechanisms.

PLANNING AND IMPLEMENTATION The next step of crisis intervention is planning; the previ-ously collected data are analyzed, and specifi c interventions are proposed. Dynamics underlying the present crisis are for-mulated from the information about the precipitating event.

Alternative solutions to the problem are explored, and steps for achieving the solutions are identifi ed. The nurse decides which environmental supports to engage or strengthen and how best to do this, as well as deciding which of the patient’s coping mechanisms to develop and which to strengthen.

This process is outlined in the Patient Education Plan for coping with crisis in Table 13-2 . The expected outcome of nursing care is that the patient will recover from the crisis event and return to a precrisis level of functioning. A more ambitious expected outcome would be for the patient to recover from the crisis event and attain a higher than precrisis level of functioning and improved quality of life.

Nursing interventions can take place on many levels using a variety of techniques. The four levels of crisis intervention— environmental manipulation, general support, generic ap proach, and individual approach—represent a hierarchy from the most basic to the most complex ( Shields, 1975 ) ( Figure 13-2 ).

Each level includes the interventions of the previous level, and the progressive order indicates that the nurse needs addi-tional knowledge and skill for implementing high-level inter-ventions. It is often helpful to consult others when deciding which approach to use.

Environmental Manipulation Environmental manipulation includes interventions that directly change the patient’s physical or interpersonal situa-tion. These interventions provide situational support or remove stress and include mobilizing the patient’s supporting social sys-tems and serving as a liaison between the patient and social sup-port agencies. After a disaster, agencies such as the American Red Cross often provide temporary shelter, food, and clothing.

At other times, unaffected family members may be help-ful. For example, a patient who is having trouble coping with her six children may temporarily send several of the children to their grandparents’ house. In this situation some stress is reduced. Similarly, a patient having diffi culty on the job may take 1 week of sick leave to be removed temporarily from that stress. A patient who lives alone may move in with his


• Individuals who have experienced a crisis can grow from it and function at a higher level afterwards based on the coping skills they learned in dealing with the situation.


closest sibling for several days. Likewise, involving the patient in family or group crisis therapy provides environmental manipulation for the purpose of providing support.

General Support General support includes interventions that convey the feeling that the nurse is on the patient’s side and will be a helping person. The nurse uses warmth, acceptance, empa-thy, caring, and reassurance to provide this type of support.

Generic Approach The generic approach is designed to reach high-risk individu-als and large groups as quickly as possible. It applies a specifi c method to all people faced with a similar type of crisis or disas-ter. The expected course of the particular type of crisis is studied

and mapped out. The intervention is then set up to ensure that the course of the crisis results in an adaptive response.

Grief is an example of a crisis with a known pattern that can be treated by the generic approach. Helping the patient to overcome ties to the deceased and fi nd new patterns of rewarding interaction may effectively resolve the grief. Apply-ing this intervention to people experiencing grief, especially with a high-risk group such as families of disaster victims, is an example of the generic approach.

Interventions following an acute stress are sometimes referred to as debriefi ng. Originally a military concept, debriefi ng has been used as a therapeutic intervention to help people recall events and clarify traumatic experiences. Inter-ventions consist of ventilation of feelings within a context of group support, normalization of responses, and education about psychological reactions to traumatic events.

Although debriefi ng may be effective for some indi-viduals, research evidence does not support the usefulness of psychological debriefi ng in reducing symptoms after psychological trauma and suggests that it may be harmful ( Sijbrandij et al, 2006 ).

Individual Approach The individual approach is a type of crisis intervention similar to the diagnosis and treatment of a specifi c problem

Individualapproach

Generic approach

General support

Environmental manipulation

FIG 13-2 Levels of crisis intervention.

TABLE 13-2 PATIENT EDUCATION PLAN

Coping with Crisis

CONTENT INSTRUCTIONAL ACTIVITIES EVALUATION

Describe the crisis event. Ask about the details of the crisis, including the following: • A timeline of the crisis • Who was affected • The events of the crisis • Any precipitating events

Patient describes the crisis event in detail.

Explore feelings, thoughts,

and behaviors related to

the crisis event.

Determine precrisis level of functioning. Discuss patient’s perception of the crisis event. Determine acute and long-term needs, threats,

and challenges.

Patient discusses precrisis level of functioning and perceptions of the crisis event.

Patient’s needs are identifi ed. Identify coping mechanisms. Ask how stressful events have been handled in the past.

Analyze whether these are adaptive or maladaptive for the current crisis event.

Suggest additional coping strategies.

Patient identifi es adaptive coping mechanisms for the current crisis event.

Develop a plan for coping

adaptively with the crisis

event.

Reinforce adaptive coping mechanisms and healthy defenses.

With the patient, construct a coping plan for the aftermath of the crisis event.

Patient develops a plan for cop-ing with the crisis event.

Assign the patient activities

from coping plan. Review implementation of the coping plan. Help patient generalize coping strategies for use in future

crisis events.

Patient reports satisfaction with coping abilities and level of functioning.


• Debriefi ng is not an evidence-based practice. • It has not been shown to be an effective psychological

intervention. • Some studies suggest that it actually worsens the trauma

symptoms.


in a specifi c patient. The nurse must understand the specifi c patient characteristics that led to the present crisis and must use the intervention that is most likely to help the patient develop an adaptive response to the crisis.

This type of crisis intervention can be effective with all types of crises. It is particularly useful in combined situational and maturational crises. The individual approach is also helpful when symptoms include homicidal and suicidal risk. In addi-tion, the individual approach should be applied if the course of the patient’s crisis cannot be determined and if resolution of the crisis has not occurred using the generic approach.

Interventions are aimed at facilitating cognitive and emo-tional processing of the traumatic event and at improving coping. Five core interventions to assist survivors of acute stress are as follows: • Restore psychological safety. • Provide information. • Correct misattributions. • Restore and support effective coping. • Ensure social support.

Critical Reasoning How might each level of crisis interven-tion be used in a high school after a star player of the football team commits suicide?

Techniques The nurse should be creative and fl exible, trying many differ-ent techniques. These should be active, focused, and explor-ative techniques that can achieve the targeted interventions. Some of these include catharsis, clarifi cation, suggestion, reinforcement of behavior, support of defenses, raising self-esteem, and exploration of solutions.

The intervention must be aimed at achieving quick res-olution. The nurse also must be active in guiding the crisis intervention through its various steps. A passive approach is not appropriate because of the time limitations of the crisis situation. A brief description of these techniques follows.

Catharsis is the release of feelings that takes place as the patient talks about emotionally charged areas. As feelings about the events are discussed, tension is reduced. Cathar-sis is often used in crisis intervention. The nurse explores the patient’s feelings about the specifi c situation, recent events, and signifi cant people involved in the particular crisis.

The nurse asks open-ended questions and repeats the patient’s words so that more feelings are expressed. The nurse does not discourage crying or angry outbursts but rather sees them as a positive release of feelings.

Only when feelings seem out of control, such as in cases of extreme rage or despondency, should the nurse discourage catharsis and help the patient concentrate on thinking rather than feeling. For example, if a patient angrily talks of want-ing to kill a specifi c person, it is better to shift the focus to a discussion of the consequences of carrying out the act rather than to encourage free expression of the angry feelings.

Clarifi cation is used when the nurse helps the patient iden-tify the relationship among events, behaviors, and feelings.

For example, helping a patient see that it was after being passed over for a promotion that the patient felt too sick to go to work is clarifi cation. Clarifi cation helps the patient gain a better understanding of feelings and how they lead to the development of a crisis.

Suggestion is infl uencing a person to accept an idea or belief. In crisis intervention the patient is infl uenced to see the nurse as a confi dent, calm, hopeful, empathic person who can help. By believing the nurse can help, the patient may feel more optimistic and less anxious.

It is a technique in which the nurse engages patients’ emotions, wishes, or values to their benefi t in the therapeu-tic process. Suggestion is a way of infl uencing the patient by pointing out alternatives or new ways of looking at things.

Reinforcement of behavior occurs when healthy, adaptive behavior of the patient is reinforced by the nurse, who strength-ens positive responses made by the patient by agreeing with or positively acknowledging those responses. For example, when a patient who has passively allowed himself to be criticized by the boss later reports being assertive in a discussion with the boss, the nurse can commend the patient on this assertiveness.

Support of defenses occurs when the nurse encourages the use of healthy defenses and discourages those that are mal-adaptive. Defense mechanisms are used to cope with stressful situations and to maintain self-esteem and ego integrity. When defenses deny, falsify, or distort reality to the point that the per-son cannot deal effectively with reality, they are maladaptive.

The nurse should encourage the patient to use adap-tive defenses and discourage those that are maladaptive. For example, when a patient denies that her husband wants a sep-aration despite the fact that he has told her so, the nurse can point out that she is not facing facts and dealing realistically with the problem. This is an example of discouraging the mal-adaptive use of the defense mechanism of denial. If a patient who is furious with his boss writes a letter to his boss’s super-visor rather than assaulting his boss, the nurse should encour-age the adaptive use of the defense mechanism of sublimation.

In crisis intervention, defenses are not attacked but rather are more gently encouraged or discouraged. When defenses are attacked, the patient cannot maintain self-esteem and ego integrity. Also, the immediacy of crisis intervention does not allow enough time to replace the attacked defenses with new ones. Returning the patient to a prior level of functioning is the goal of crisis intervention, not the restructuring of defenses.

Raising self-esteem is a particularly important technique. The patient in a crisis feels helpless and may be overwhelmed with feelings of inadequacy. The fact that the patient has found it necessary to seek outside help may further increase feelings of inadequacy.

The nurse should help the patient regain feelings of self-worth by communicating confi dence that the patient can fi nd solutions to problems. The nurse also should convey that the patient is a worthwhile person by listening to and accepting the patient’s feelings, being respectful, and praising help-seeking efforts.

Exploration of solutions is essential because crisis interven-tion is geared toward solving the immediate crisis. The nurse


and patient actively explore solutions to the crisis. Answers that the patient had not thought of before may become apparent during conversations with the nurse as anxiety decreases. For example, a patient who has lost his job and has not been able to fi nd a new one may become aware of the fact that he knows many people in his fi eld of work whom he could contact to get information regarding the job market and possible openings.

These crisis intervention techniques are summarized in Box 13-4 . In addition to using these techniques, the crisis worker should have some other particular attitudes toward the care being given in order to be effective.

The crisis worker should see this work as the treatment of choice for people in crisis rather than as a second-best treatment. Assessment of the present problem should be viewed as necessary for treatment, whereas a complete diagnostic assessment should be recognized as being unnecessary. The goal and time limita-tions of crisis intervention should be kept in mind constantly, and material unrelated to the crisis should not be explored.

The crisis worker must take an active directive role and maintain fl exibility of approach. If more complex problems are identifi ed that are not suitable for crisis intervention, the patient should be referred for further treatment. Table 13-3 describes interventions for helping individuals and families cope with stress resulting from crisis.

EVALUATION The last phase of crisis intervention is evaluation, when the nurse and patient evaluate whether the intervention resulted in a positive resolution of the crisis. Specifi c questions the nurse might ask include the following: • Has the expected outcome been achieved, and has the

patient returned to the precrisis level of functioning? • Have the needs of the patient that were threatened by

the event been met?

Technique: Catharsis Defi nition: The release of feelings that takes place as the

patient talks about emotionally charged areas Example: “Tell me about how you have been feeling since you

lost your job.” Technique: Clarifi cation Defi nition: Encouraging the patient to express more clearly the

relationship among certain events Example: “I’ve noticed that after you have an argument

with your husband you become sick and can’t leave your bed.”

Technique: Suggestion Defi nition: Infl uencing a person to accept an idea or belief, par-

ticularly the belief that the nurse can help and that the person will in time feel better

Example: “Many other people have found it helpful to talk about this and I think you will, too.”

Technique: Reinforcement of behavior Defi nition: Giving the patient positive responses to adaptive

behavior

Example: “That’s the fi rst time you were able to defend your-self with your boss, and it went very well. I’m so pleased that you were able to do it.”

Technique: Support of defenses Defi nition : Encouraging the use of healthy, adaptive defenses

and discouraging those that are unhealthy or maladaptive Example: “Going for a bicycle ride when you were so angry

was very helpful because when you returned you and your wife were able to talk things through.”

Technique: Raising self-esteem Defi nition: Helping the patient regain feelings of self-worth Example: “You are a very strong person to be able to manage

the family all this time. I think you will be able to handle this situation, too.”

Technique: Exploration of solutions Defi nition: Examining alternative ways of solving the immedi-

ate problem Example: “You seem to know many people in the computer

fi eld. Could you contact some of them to see whether they might know of available jobs?”

BOX 13-4 TECHNIQUES OF CRISIS INTERVENTION

TABLE 13-3 NURSING INTERVENTIONS FOR CRISIS AND DISASTER EVENTS

TARGET AREAS NURSING INTERVENTIONS

Basic Needs Provide liaison to social agencies.

Physical Defi cits Attend to physical emergencies. Refer to other health care providers as

necessary.

Psychological Effects

Shock Attentively listen to telling of the crisis details.

Confusion Give nurturing support; permit regression.

Denial Permit intermittent denial; identify patient’s primary concern.

Anxiety Provide structure; enact antianxiety interventions.

Lethargy/heroics Encourage sublimation and construc-tive activity.

Protective Factors

Coping Encourage patient’s favored, adaptive coping mechanisms; emphasize ratio-nalization, humor, sublimation.

Self-effi cacy Support patient’s previous successes and belief in own abilities; dilute ir-rational self-doubts; emphasize power of expectations to produce results.

Support Add social supports to the patient’s world; provide professional support; re-fer for counseling when necessary; help patient develop new coping strategies.

Modifi ed from Hardin SB: Catastrophic stress. In McBride AB, Austin JK, editors: Psychiatric – mental health nursing , Philadelphia, 1996, Saunders.


• Have the patient’s symptoms decreased or been resolved?

• Does the patient have adequate support systems and coping resources on which to rely?

• Is the patient using constructive coping mechanisms? • Is the patient demonstrating adaptive crisis responses? • Does the patient need to be referred for additional

treatment? The nurse and patient also should review the changes that

have occurred. The nurse should give patients credit for suc-cessful changes so that they can realize their effectiveness and understand that what they learned from a crisis may help in coping with future crises. If the goals have not been met, the patient and nurse can return to the fi rst step, assessment, and progress through the phases again.

At the end of the evaluation process, if the nurse and patient believe referral for additional professional help would be useful, the referral should be made as quickly as possible. All phases of crisis intervention are presented in the Case Study in Box 13-5 .

Critical Reasoning Given that stress is experienced by all people, why aren’t all nurses required to be competent in crisis intervention skills, just as they are in cardiopulmonary resuscitation (CPR) skills?

SETTINGS FOR CRISIS AND DISASTER INTERVENTION Disasters can occur anytime and anywhere. Nurses live and work in settings in which they often see people in crisis. Hos-pitalizations of any type are stressful for patients and their families and are precipitating causes of crises.

The patient who becomes demanding or withdrawn or the spouse who becomes bothersome to the nursing staff is a possible candidate for crisis intervention. The diagnosis of an illness, the limitations imposed on activities, and the changes in body image because of surgery can all be viewed as losses or threats that may precipitate a situational crisis. Simply the stress of being dependent on nurses for care can precipitate a crisis for the hospitalized patient.

Nurses who work in obstetric, pediatric, adolescent, or geriatric settings often observe patients or family members undergoing maturational crises. The anxious new mother, the acting-out adolescent, and the newly retired depressed patient are all possible candidates for crisis therapy. If physi-cal illness is an added stress during maturational turning points, the patient is at an even greater risk.

Emergency department and critical care settings also are fl ooded with crisis cases. People who attempt suicide, psy-chosomatic patients, survivors of sudden cardiac arrest, and crime and accident victims are all possible candidates for cri-sis intervention. If the nurse is not in a position to work with the patient on an ongoing basis, a referral should be made.

Community and home health nurses work with patients in their own environments and can often spot and intervene in

family crises. The child who refuses to go to school, the man who resists learning how to give himself an insulin injection, and the family with a member dying at home are possible candidates for crisis intervention. Community health nurses are also in an ideal position to evaluate high-risk families, such as those with new babies, ill members, recent deaths, and a history of diffi culty coping.

Finally, nurses in primary care, community health centers, managed care clinics, schools, occupational health centers, long-term care facilities, and home health agencies also may see patients in crisis, such as those experiencing depression, anxiety, marital confl ict, suicidal thoughts, illicit drug use, and traumatic responses. Crisis intervention can be imple-mented in any setting and should be a competency skill of all nurses, regardless of specialty area.

MODALITIES OF CRISIS INTERVENTION Crisis intervention modalities are based on the philosophy that the health care team must be aggressive and go out to the patients rather than wait for the patients to come to them. Nurses working in these modalities intervene in a variety of community settings, ranging from patients’ homes to street corners, with great success.

Disaster Responses As part of the community, nurses are called upon when situ-ational crises and disasters strike the community. Floods, earthquakes, airplane crashes, fi res, nuclear accidents, and other natural and unnatural disasters precipitate large numbers of cri-ses. Key concepts that should be understood by all disaster men-tal health providers are presented in Box 13-6 (DHHS, 2003).

It is important that nurses in the immediate postdisaster period go to places where victims are likely to gather, such as morgues, hospitals, shelters, and areas surrounding the disas-ter site. Rather than waiting for people to publicly identify themselves as being unable to cope with stress, it is suggested that nurses work with the American Red Cross, talk to people waiting in lines to apply for assistance, go door-to-door, or, at a relocation site, ask people how they are managing their affairs and explore their reactions to stress ( Weeks, 2007 ).

Common psychiatric responses to disaster should be con-sidered when developing plans. These are listed in Box 13-7 . Experts in the fi eld of disaster response suggest that orga-nized plans for crisis response be developed and practiced during nondisaster times ( Sederer et al, 2011 ).

A study of World Trade Center rescue and recovery workers indicated that disaster preparedness training and shift rotations, which allowed for shorter time worked, may have reduced post-traumatic stress disorder (PTSD) among workers and volun-teers. Furthermore, PTSD was signifi cantly higher among those who did not have disaster training and who performed tasks not common for their occupation ( Perrin et al, 2007 ).

Disaster plans are needed for large and small communi-ties so that multiple complex needs can be met and effective triage implemented ( Beach, 2010; Culley and Effken, 2010 ). Specifi cally, disaster plans need to have a way of identifying


Assessment

Mr. A is a 39-year-old, medium-build, casually dressed, African-American man who was referred to the mental health clinic by his primary care provider. The patient came to the center alone. The nurse working with Mr. A collected the following data.

The patient worked in a large naval shipyard that was recently scheduled for closing. It was laying off many workers and reas-signing others. One month earlier Mr. A was assigned to an area where he had diffi culty 2 years ago. The patient believed that the foreman was harassing him as he had done previously.

Two weeks ago the patient had become angry with the foreman and had thoughts of killing him. Instead of acting on these thoughts, Mr. A became dizzy, and his head ached. He requested medical attention but was refused. He then passed out and was taken by ambulance to the dispensary. Since that time Mr. A had a comprehensive physical examination and was found to be in excellent health. He was prescribed diazepam (Valium) on an as-needed basis, which was only slightly helpful. He returned to work for 2 days this week but again felt sick.

Mr. A complained of being depressed, nervous, and tense. He was not sleeping well, was irritable with his wife and chil-dren, and was preoccupied with angry feelings toward his fore-man. He denied suicidal thoughts but admitted that he felt like killing the foreman. He quickly added that he would really never do anything like that.

He appeared to have good comprehension, above-average intelligence, adequate memory, and some paranoid ideation related to the foreman at work. His thought processes were organized, and there was no evidence of a perceptual disorder. Ego boundary disturbance was evident in the patient’s paranoid thoughts. It seemed that the foreman was a diffi cult man to get along with, but the description of personal harassment was not based on any specifi cs.

Mr. A was raised by his parents. His father beat him and his siblings often. His mother was quiet and always agreed with his father. The patient had a younger brother and sister and an older sister. The patient and his brother had always been close. The two of them had stopped their father’s beatings by gang-ing up on him and “psyching him out.” As a child, Mr. A hung around with a tough crowd and fought frequently. He believed that he could physically overpower others but tried to keep out of trouble by talking to people rather than fi ghting.

Mr. A had no psychiatric history. His physical health was excellent, and he was taking no medication other than the pre-scribed Valium. He had a tenth-grade education, and his work record up to this time was good. His interests included bowling and other sports. He had been married for 17 years and had three daughters, ages 16, 13, and 9 years. Mr. A stated that he had a good relationship with his wife and daughters and that both his wife and his brother were strong supports for him.

His usual means of coping were talking calmly with the threatening party and working hard on his job, at home, and in leisure activities. These coping mechanisms failed to work for him at this time, but they had been successful in the past. He had no arrest record and was able to think through his actions rather than act impulsively. Mr. A showed strong motivation for working on his problem. He was reaching out for help and was able to form a therapeutic relationship with the nurse. Although his wife and brother were supportive, he felt a need for outside support because his previous coping skills were not working.

Diagnosis

Mr. A was in a situational crisis. The threat or precipitating stress was his job transfer and supervision by a former boss, whom he felt was harassing him. The patient’s need for role mastery was not being met because he was not feeling suc-cessful at his job. Soon after the transfer, Mr. A’s usual means of coping became ineffective and he experienced increased anxiety. His nursing diagnosis was ineffective coping related to changes at work, as evidenced by physical complaints of diz-ziness and tension . His DSM-IV-TR diagnosis was adjustment disorder with mixed anxiety and depressed mood .

Outcomes Identifi cation and Planning

The expected outcome of treatment was for Mr. A to return to his precrisis level of functioning. If possible, he could reach a higher level, having learned new methods of problem solving. The patient showed good potential for growth, and the nurse made a contract with him for crisis intervention. Mutually iden-tifi ed short-term goals included the following: • Mr. A will explore his thoughts and feelings about recent

work events. • Mr. A will not harm his boss. • Mr. A will describe coping mechanisms that have been

successful for him in the past. • Mr. A will identify three new ways of coping with work

stress. • Mr. A will implement two of the new coping strategies. • Mr. A will be free of symptoms and function well at work.

Implementation

The level of intervention used by the nurse was the individual

approach, which includes the generic approach, general sup-port, and environmental manipulation.

Environmental manipulation involved having the patient remain home from work temporarily. Letters were written by the nurse to his employer explaining Mr. A’s absence in general terms. Mr. A was encouraged to talk to his wife about his dif-fi culties so that she could understand his anxiety and provide emotional support.

General support was given by the nurse, who provided an atmosphere of reassurance, nonjudgmental caring, warmth, empathy, and optimism. Mr. A was encouraged to talk freely about the problem, and the nurse assured him that his problem could be solved and that he would be feeling better soon.

The generic approach was used to decrease the patient’s anxiety and guide him through the steps of problem solving. Lev-els of anxiety were assessed and ways of reducing anxiety and helping the patient tolerate moderate anxiety were identifi ed. The patient was encouraged to use his anxiety constructively to solve his problem and develop new coping mechanisms.

The individual approach was used in assessing and treating the specifi c problems of Mr. A, who was strongly sensitive to mistreatment as a result of early childhood experiences. His emotional response was to strike out physically, as his father had struck out at him. Intellectually, Mr. A knew this would not be good, and his confl ict was solved by becoming sick and passing out so that he could not assault his boss. Mr. A’s intense anger was recognized, and a high priority was placed on channeling the anger in a positive direction. He stated that he had no intentions of hurting his boss.

BOX 13-5 CASE STUDY


The fi rst two meetings were used for data gathering and establishing a positive therapeutic relationship. Through the use of catharsis the patient vented angry feelings but did not concentrate on wanting to kill his boss. The nurse used clarifi -

cation to help the patient begin to understand the precipitating event and its effect on him. Suggestion was used to allow the patient to see the nurse as one who could help. The nurse told the patient the problem could be worked out by the two of them and that he would soon be feeling better. Mr. A decided to contact several people at work to obtain information about transferring to another department and fi ling a formal complaint against the foreman. The patient and nurse therefore were exploring solutions. The nurse reinforced the patient’s use of problem solving by telling him that his ideas about alterna-tive solutions were good ones. Throughout these and other sessions the nurse raised his self-esteem by communicating her confi dence that he could fi nd solutions to his problems. She listened to and accepted his feelings and treated him with respect. By contacting others at work, the patient also found some supportive people.

During the third session the patient described an incident in which he became furious at a worker in an automobile repair shop. The repairs on the patient’s car were repeatedly done incorrectly, and the patient had to keep returning the car. The patient shoved the worker but limited his physical assault to just that. He then felt nervous and jittery. The patient had previ-ously expressed pride in his ability to control his angry feelings and not physically strike out at others. Suggestion was used by telling the patient that he showed control in stopping the assault before it had become a full-blown fi ght and he could continue to do so. During this session the patient spoke of old, angry feelings toward his father. Some of this venting was allowed, but soon thereafter the focus was guided back to the present crisis.

In the fourth session the patient reported no episodes of uncontrollable anger. However, he still put much empha-sis on being harassed by others. The nurse questioned the notion that others were out to intentionally harass the patient.

Mr. A’s defenses were not attacked, but his use of projection was discouraged.

In the fi fth session the patient reported that a car tried to run him off the road. At a red traffi c light the patient spoke calmly to the offending driver and the driver apologized. The nurse reinforced this behavior and supported his use of sublima-

tion as a defense. Discussion of termination of the therapy was begun.

In the sixth session Mr. A said that things were going well at work and that he would soon be going to a different depart-ment. He also talked about a course he had begun at a com-munity college. He showed no evidence of anxiety, depression, or paranoia and thought he didn’t need to come back to the mental health clinic.

Evaluation

The interventions resulted in an adaptive resolution of the cri-sis. The patient’s need for role mastery was being met. He was once again comfortable and successful at work. His symptoms of anxiety, paranoia, dizziness, headaches, passing out, and homicidal thoughts had ended. He no longer felt harassed. His original coping mechanisms were again effective. He was talk-ing calmly to people with whom he was having diffi culty, and he was again working hard in a goal-oriented way (his college course).

He had learned new methods of coping, which included talking about his feelings to signifi cant others, following administrative or offi cial avenues of protest, and seeking support. The patient and nurse discussed how Mr. A could use the methods of problem solving he had learned from the experience to help cope with future problems. The expected outcome, return to the precrisis level of functioning, had been attained.

It was also recommended to the patient that he engage in psychotherapy so that he could deal with the old angers that continued to interfere with his life. Mr. A rejected the recom-mendation and said he would contact the clinic if he changed his mind.

BOX 13-5 CASE STUDY—cont’d

• No one who sees a disaster is untouched by it. • There are two types of disaster trauma—individual and

community. • Most people pull together and function adequately during

and after a disaster, but they are less effective due to the effects of the event.

• Stress and grief in disasters are normal reactions to abnor-mal situations.

• Many emotional reactions of disaster survivors stem from problems of daily living brought about by the disaster.

• Disaster relief assistance may be confusing to some survi-vors. They may experience frustration, anger, and feelings of helplessness related to federal, state, and private-sector disaster assistance programs.

• Most people do not see themselves as needing mental health services following a disaster and will not seek such services.

• Survivors may reject disaster assistance of all types. • Disaster mental health assistance is often more practical

than psychological in nature. • Disaster mental health services must be tailored to the cul-

ture of communities where they are provided. • Mental health workers should set aside traditional meth-

ods, avoid mental health labels, and use an active outreach approach to intervene successfully in disaster.

• Survivors respond to active, genuine interest, and concern. • Interventions must be appropriate to the phase of the

disaster. • Social support systems are crucial to recovery.

BOX 13-6 KEY CONCEPTS OF DISASTER—MENTAL HEALTH


those individuals who are at greatest risk for developing or worsening psychiatric illnesses.

Examples of agencies, organizations, and individuals to be included in disaster planning include hospitals, mental health programs, substance abuse agencies, departments of health, employee assistance programs, housing programs, univer-sity-affi liated nurses, and school district nurses. The Ameri-can Nurses Association has guidance for professionals during disasters, pandemics, and other extreme emergencies that includes ethical principles, emergency preparedness compe-tencies, and specifi c emergency event care ( ANA, 2008 ).

Nurses providing crisis therapy during large disasters use the generic approach to crisis intervention so that as many people as possible can receive help in a short amount of time. Tragedies such as workplace violence and school shootings may affect fewer people and may at times require the indi-vidual approach. The nurse may choose to work with families or groups rather than individuals during situational crises so that people can gain support from others in their family or community who are undergoing stresses similar to theirs.

It is important to prioritize those in need of crisis inter-vention. At the top of the list are those who have themselves been physically attacked or injured. This is followed by those who suffer immediate and direct loss, such as the families and neighbors of victims. Below that are people who have been less directly affected but have still experienced some signifi -cant changes in their lives, such as friends and co-workers of the injured person and rescue workers. Next are those who have not been directly affected but who are particularly sen-sitive to environmental uncertainty, such as those who are physically and mentally ill. And fi nally, at the bottom, are the masses of people who have experienced some changes in their lives and feel fear as a result of the disaster.

Providing culturally competent care requires a concerted effort by disaster mental health planners and frontline work-ers. Successful programs share common practices that are defi ned by nine guiding principles listed in Box 13-8 .

Finally, attention also has been focused on offering support and help to the helpers involved in disasters. Health and men-tal health professionals who are victims of disasters as well as providers of care during disasters often feel overwhelmed with stress ( Adams, 2007; Chaffee, 2006 ). These care provid-ers describe feelings of concern for their patients and their own families, as well as themselves. Thus crisis intervention strategies for the caregivers in times of disaster are essential.

Critical Reasoning Nurses are often called on to help out in times of disaster. What special needs might nurses have in situations where they are both victims and caregivers?

Mobile Crisis Programs Mobile crisis teams provide frontline interdisciplinary crisis intervention to individuals, families, and communities. The nurse who is a member of a mobile crisis team may respond to a desperate person threatening to jump off a bridge in a sui-cide attempt, an angry person who is becoming violent toward family members at home, or a frightened person who has bar-ricaded himself in an offi ce building. By defusing the imme-diate crisis situation, lives can be saved, incarcerations and hospitalizations can be avoided, and people can be stabilized.

Mobile crisis programs throughout the United States vary in the services they provide and the procedures they use. How-ever, they are usually able to provide on-site assessment, crisis management, treatment, referral, and educational services to patients, families, law enforcement offi cers, and the community at large. Studies of mobile crisis services show favorable out-comes for patients and families, lower hospitalization rates and fewer arrests ( Compton et al, 2006; Skeem and Bibeau, 2008 ).

Critical Reasoning Ask if you can shadow a mobile crisis team in your community for a day. Observe the work they do and share your experience with your peers.

Psychiatric Diagnoses

• Organic mental disorders secondary to head injury, toxic exposure, illness, and dehydration

• Acute stress disorder • Adjustment disorder • Substance use disorders • Major depression • Posttraumatic stress disorder • Generalized anxiety disorder

Psychological/Behavioral Responses

• Grief reactions and other normal responses to an abnormal event

• Family violence • Self-directed violence • Other-directed violence

BOX 13-7 COMMON PSYCHIATRIC RESPONSES TO DISASTER

• Recognize the importance of culture and respect diversity. • Maintain a current profi le of the cultural composition of the

community. • Recruit disaster workers who are representative of the

community or service area. • Provide ongoing cultural competence training to disaster

mental health staff. • Ensure that services are accessible, appropriate, and

equitable. • Recognize the role of help-seeking behaviors, customs and

traditions, and natural support networks. • Involve as “cultural brokers” community leaders and orga-

nizations representing diverse cultural groups. • Ensure that services and information are culturally and lin-

guistically competent. • Assess and evaluate the program’s level of cultural

competence.

BOX 13-8 GUIDING PRINCIPLES FOR CULTURAL COMPETENCE IN DISASTER MENTAL HEALTH


Telephone Contacts Crisis intervention is sometimes practiced by telephone or Internet communication rather than through face-to-face contacts. When individuals in crisis use the telephone or Internet, it is usually at the peak of their distress. Nurses working for these types of hotlines or those who answer emer-gency telephone calls or electronic mail may fi nd themselves practicing crisis intervention without having visual cues to rely on. Referrals for face-to-face contact should be made, but often, because of the patient’s unwillingness or inability to cooperate, the telephone or Internet remains the only con-tact. A variety of listening skills must therefore be emphasized in the nurse’s role.

Most emergency telephone and Internet services have extensive training programs to teach this specialized type of crisis intervention. Manuals written for the crisis worker include content such as suicide-potential rating scales, com-munity resources, drug information, guidelines for helping the caller or crisis worker discuss concerns, and advice on understanding the limitations of the crisis worker’s role.

Group Work Crisis groups follow the same steps that individual inter-vention follows. The nurse and group help the patient solve the problem and reinforce the patient’s new problem-solving behavior. The nurse’s role in the group is active, focal, and present oriented. The group follows the nurse’s example and uses similar therapeutic techniques. The group acts as a sup-port system for the patient and is therefore of particular ben-efi t to socially isolated people.

Often the way the patient functions in the group suggests the faulty coping pattern that is responsible for the patient’s current problem. For example, a patient’s interaction with group members may show that he does not appear to listen to anything said by others. This same patient may be in a crisis because his girlfriend left him because she thought he did not care about her thoughts and feelings. The nurse can comment on the faulty coping behavior seen in the group and encour-age group discussion about it.

Nurses practicing on acute psychiatric units also can use crisis intervention in working with patients and families to prepare for discharge and prevent rehospitalization. With the shortened lengths of hospital stays, crisis intervention is often the treatment of choice. The hospitalization itself may be viewed as an environmental manipulation and part of the crisis intervention.

Victim Outreach Programs Crisis intervention is not considered the appropriate treat-ment for serious consequences of victimization, such as PTSD or depression. However, it is very useful as a com-munity support for victims in the immediate aftermath of crime and may provide an important link for referral to more comprehensive services when needed.

Violent crime has become a global issue, concerning people in every walk of life and in every country. Many vic-tim outreach programs use crisis intervention techniques to

identify the needs of victims and then to connect them with appropriate referrals and other resources. Patient concerns such as the personal meaning of the crime, who to tell, and the reaction of others should be discussed. A victim advocate can contact employers regarding the need for temporary time off, can mobilize community resources for food and shelter if necessary, and can arrange for grace periods with debtors to delay payment of bills without penalty until the victim recovers.

Crisis intervention is successful in the immediate after-math of rape. It uses an integrated framework of outreach, emergency care, and advocacy assistance. Nurses often work in rape crisis centers, where victims commonly are seen immediately after the rape. These victims need thorough evaluation, empathic support, information, and help with the legal system.

Another important issue is that of abusive relationships. Whether the victim is a spouse, a child, a date, an elderly per-son, or a caregiver, abusive relationships are experienced by people of both genders and of all racial, ethnic, economic, educational, and religious backgrounds. Chapter 38 presents more information regarding care of survivors of violence.

Health Education Although health education can take place during the entire crisis intervention process, it is emphasized during the evaluation phase. At this time the patient’s anxiety has decreased, so better use can be made of cognitive abilities. The nurse and patient summarize the course of the crisis, and the intervention is to teach the patient how to avoid other similar crises.

For example, the nurse helps the patient identify the feelings, thoughts, and behaviors experienced following the stressful event. The nurse explains that if these feelings, thoughts, and behaviors are again experienced, the patient should immediately become aware of being stressed and take steps to prevent the anxiety from increasing. The nurse then teaches the patient ways to use these newly learned coping mechanisms in future situations.

Nurses also are involved in identifying people who are at high risk for developing crises and in teaching coping strate-gies to help them avoid the development of the crises. For example, coping strategies that can be taught include how to request information, access resources, and obtain support.

Critical Reasoning Explain how conducting a group on stress management for critical care nurses is an example of health education as crisis intervention.

Finally, members of the public also need education so that they can identify those requiring crisis services, be aware of available services, change their attitudes so that people will feel free to seek services, and obtain information about how others deal with potential crisis-producing problems. Nurses, as health care professionals, have a great opportunity to pro-vide health education and crisis intervention, thus preventing mental illness and promoting mental health.


A Student’s View

The doctor brought us to Firehouse 10, located at Greenwich and Liberty. I stood in amazement, taking in the environment that would be my home for the next few days. There was no front

door or wall to the station house because it had been blown out. It was dark, dim, and fi lthy with thick layers of dust, ash, and debris from the fallout. There were two small tables, one gurney, a coat rack that was fashioned into a makeshift IV pole, hung with a few bags of solution and tubing. There were also a few tanks of oxygen, a defi brillator, and an emergency crash box. Two other people, a retired lawyer turned emergency medical technician (EMT) from Pennsylvania and a medical resi-dent, walked into the station and joined us. We all sat down and looked out. For the fi rst time that day, I really saw what no pho-tograph, news report, or television footage could ever capture.

Ground Zero was a mountain of concrete, mangled steel, dirt, debris, and rubble … absolute devastation and destruction. Silently we sat, exchanging a sober moment. There was noth-ing for us to do. Or was there?

Hundreds of people were working in a synchronized bucket brigade. A community banded together on their hands and knees trying to clear and unearth anything to bring home to the thousands waiting to celebrate or mourn. Our duty was right there in front of us. We joined the digging effort. On our hands and knees, we dug with a purposeful rhythm. The ground underneath me was very hot, and the air was dense with choking fumes. I fi lled buckets with dirt and debris. Then signs of what was once a work force of thousands began to appear.

First it was the occasional business card, parts of a day planner with smeared notes, then pieces of a briefcase. This brought me closer to what I feared the most. A shoe—and then the foot. I called out to a rescue worker, a towering man, rough and fi lthy with the day’s events. He placed the remains carefully into a container and walked it down the mountain, cradling it like a baby. I said a silent prayer for this kind man who had just taught me one of the gravest lessons a nurse could learn:

In life we celebrate, in death we respect.

COMPETENT CARING

A Clinical Exemplar of a Psychiatric Nurse: Nurses Remember 9/11

Maria Gatto , New York University, Division of Nursing

A Faculty’s View

This is what I want to tell you about the profes-sion of nursing. Nursing is not a nine-to-fi ve job. It’s a way of life that you have pledged your-selves to follow.

In school, professors cram your head with knowledge and nursing diagnoses. We help you develop critical thinking and try to show you how a nurse functions in clinical settings. We give you the tools you need to perform your professional duties. But you have to internalize this knowledge and make it your own.

We are nurses, members of a group that enjoys the high-est level of trust of any profession. Patients believe nurses act as their advocates. In turn, we accept them as they are. We leave the security of our own selves and enter into the patients’ worlds. When we are truly there, we can see their point of view and are able to help them to achieve healing and wellness.

Here’s what I learned from September 11: keep learning , for nurses must function in unexpected settings and carry out a wide range of duties; share yourself , for it takes a brave heart to open yourself to pain and suffering; always do your best , for when you show that you care you are giving the best of clinical nursing.

COMPETENT CARING

A Clinical Exemplar of a Psychiatric Nurse: Nurses Remember 9/11

Angela Apuzzo , New York University, Division of Nursing

C H A P T E R I N R E V I E W

• A crisis is a disturbance caused by a stressful event or a per-ceived threat. The person’s usual way of coping becomes ineffective in dealing with the threat, causing anxiety.

• Successful resolution of the crisis is more likely if the per-son has a realistic view of the event, if situational supports are available to help solve the problem, and if effective coping mechanisms are present.

• There are two types of crises: maturational and situational. • Maturational crises are developmental events requiring

role changes. • Situational crises occur when a life event upsets an individ-

ual’s or group’s psychological equilibrium. They include natural and man-made disasters.

• Disaster responses typically occur in seven phases and the nature of the disaster often can determine its mental health impact.

• Crisis intervention is a short-term therapy focused on solving the immediate problem, usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. Often the per-son advances to a level of growth that is higher than the precrisis level because new ways of problem solving have been learned.

• A number of balancing factors are important in the devel-opment and resolution of a crisis and should be assessed: precipitating event or stressor; patient’s perception of the


event or stressor; nature and strength of the patient’s sup-port systems and coping resources; and patient’s previous strengths and coping mechanisms.

• To help identify the precipitating event, the nurse should explore the patient’s needs, the events that threaten those needs, and the time at which symptoms appear. Four kinds of needs that have been identifi ed are related to self-esteem, role mastery, dependency, and biological function.

• There are four levels of crisis intervention— environmental manipulation, general support, generic approach, and individual approach—that represent a hierarchy from the most basic to the most complex.

• Environmental manipulation includes interventions that directly change the patient’s physical or interpersonal situ-ation. These interventions provide situational support or remove stress.

• Important elements of this intervention are mobilizing the patient’s supporting social systems and serving as a liaison between the patient and social support agencies.

• General support includes interventions that convey the feeling that the nurse is on the patient’s side and will be a helping person. The nurse uses warmth, acceptance, empathy, caring, and reassurance to provide this type of support.

• The generic approach is designed to reach high-risk indi-viduals and large groups as quickly as possible. It applies a specifi c method to all people faced with a similar type of crisis.

• The individual approach is a type of crisis intervention similar to the diagnosis and treatment of a specifi c prob-lem in a specifi c patient. The nurse must understand the specifi c patient characteristics that led to the present crisis and must use the intervention that is most likely to help the patient develop an adaptive response to the crisis.

• The nurse should be creative and fl exible, trying many different techniques. These should be active, focused, and explorative to carry out the interventions. Some of these include catharsis, clarifi cation, suggestion, reinforcement of behavior, support of defenses, raising self-esteem, and exploration of solutions.

• The nurse should give patients credit for successful changes so that they can realize their effectiveness and understand that what they learned from a crisis may help in coping with future crises.

• Crisis intervention can be implemented in any setting and should be a competency skill of all nurses, regardless of specialty area.

• Crisis intervention modalities are based on the philosophy that the health care team must be aggressive and go out to the patients rather than wait for the patients to come to them. Nurses working in these modalities intervene in a variety of community settings, ranging from patients’ homes to street corners.

• As part of the community, nurses are called upon when situational crises and disasters strike the community. Common psychiatric responses to disaster should be con-sidered when developing plans.

• Organized plans for crisis response should be developed and practiced during nondisaster times. Disaster plans need to have a way of identifying those individuals who are at greatest risk for developing or worsening psychiatric illnesses and prioritizing care.

• Providing culturally competent care requires a concerted effort by disaster mental health planners and frontline workers.

• Crisis intervention strategies for the caregivers in times of disaster are essential.

• Mobile crisis programs throughout the United States vary in the services they provide and the procedures they use. However, they are usually able to provide on-site assess-ment, crisis management, treatment, referral, and edu-cational services to patients, families, law enforcement offi cers, and the community at large.

• Crisis intervention is sometimes practiced by telephone or Internet communication rather than through face-to-face contacts. When individuals in crisis use the telephone or Internet, it is usually at the peak of their distress.

• Crisis groups follow the same steps that individual inter-vention follows. The nurse and group help the patient solve the problem and reinforce the patient’s new prob-lem-solving behavior.

• Many victim outreach programs use crisis intervention techniques to identify the needs of victims and then to con-nect them with appropriate referrals and other resources.

• Although health education can take place during the entire crisis intervention process, it is emphasized during the evaluation phase. Nurses are involved in identifying people who are at high risk for developing crises and in teaching coping strategies to avoid the development of the crises. Members of the public also need education so that they can identify those needing crisis services, be aware of available services, change their attitudes so that people will feel free to seek services, and obtain information about how others deal with potential crisis-producing problems.

C H A P T E R I N R E V I E W — c o n t ’ d


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