National Center
of Continuing Education|
Managing the Psychiatric Crisis Updated 2005
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About The Author
Silvia Prodan Lange, R.N., M.N., is a clinical specialist in psychiatric/mental health nursing in California. She did her graduate work at the University of Washington, Seattle. Over the past 35 years she has worked in a variety of psychiatric settings - acute inpatient units, long-term state hospitals, VA units (acute and long-term), day treatment centers and outpatient work. The latter includes emergency room consultation and crisis intervention. She has taught psychiatric/mental health nursing and has formerly directed the Mental Health Program at the Seattle University School of Nursing. Her many professional publications include material on the violent patient, suicide and hope. As a mental health integrator, she applies concepts from psychiatric nursing to other clinical nursing situations.
Excerpts provided by Shelda L. Shank, RN, BSN, PHN. She is the Nurse Supervisor of the Instructional Systems Development section of the National Center of Continuing Education.
Purpose and Goals
Psychiatric emergency? Suicide! Violence! Panic! Be ready for these disturbed and disturbing situations. Fortunately, true psychiatric emergencies do not occur often. When they do, the health team must act to convert a dangerous or life-threatening crisis into problems to be solved.
Healthcare professionals are involved in these situations in the emergency room, general hospital, psychiatric unit and community. Although nothing can take the place of actual clinical experience for one to become more competent and confident in handling psychiatric emergencies, prior preparation can help. Health professionals need an understanding of attitudes and reactions, a body of knowledge, and action approaches in order to meet the challenge of a crisis situation. This course presents general guidelines for addressing and treating the most frequently encountered psychiatric emergencies including suicide, violence, anxiety, and substance abuse.
Instructional Objectives
Upon completion of this course the student will be able to: 1. Define and describe the most common psychiatric emergencies. 2. Outline the Crisis Intervention Model of Aquilera and Messick. 3. Apply crisis theory and intervention to clinical situations. 4. List common signs and symptoms of depression, anger, and anxiety. 5. Assess suicide and violence potential. 6. Outline psychological, pharmacological, and environmental treatment approaches for the psychiatric patient. 7. Recognize professional and personal reactions to psychiatric emergencies. 8. Define and clarify the following terms: psychiatric emergency and crisis. 9. Learn the mnemonic code device for psychiatric emergencies. 10. Identify three categories of psychiatric emergencies. 11. Expand and improve psychiatric nursing terminology. 12. Utilize the Social Readjustment Rating Scale.
Self-awareness Explorations
Write down your initial response to the question. There are no right or wrong answers. Refer back to this section as you go through the unit.
1. What's the first thing that comes to your mind when you hear the term psychiatric emergency? 2. Remember one crisis event that turned out to be tragic. How did you feel about it at the time? Now? 3. Remember one crisis event that turned out well. What was your part in it? What did you learn? 4. What makes you most anxious about a psychiatric emergency? 5. What's the most memorable dramatization of a psychiatric emergency that you've seen on TV, in the movies, in a play or read about in a book or newspaper? 6. What's the difference in your reactions to a crisis situation at work and in your personal life? 7. Homicidal maniac! What does this conjure up for you? Have you ever been faced with a violent person? What happened? 8. How do you feel about people who make multiple suicide attempts and who get repeatedly detoxified from alcohol or drugs and go back on them? 9. In your opinion, should people have the right to decide when and how they will die? Does this conflict with your professional ethics? 10. What do you think your reactions would be if you had to be part of restraining, medicating or hospitalizing patients against their wills? 11. In your wildest imagination, what possible psychiatric emergencies could happen to you or a significant other? How would you want others to help you? 12. List several areas where you feel that you may need some assistance as a nurse regarding the psychiatric aspects of patient care. (Helps identify weakness) 13. Make a list of several interpersonal interactions that you have experienced between staff to staff, patient to staff, which you feel required an improvement in communication techniques and/or required someone to intervene and facilitate problem solving.
Introduction
An elderly man has recently been discharged from an alcohol detoxification unit. He calls one of the staff on the floor to "thank" her again and say good-bye. Sounding angry and intoxicated, he adds that he is in a phone booth at the Golden Gate Bridge and as soon as he hangs up, he is going to jump. If you were that nurse, how might you feel? What would you do?
Following cardiac surgery, a woman begins to whisper to her husband that she's afraid of being cloned in the ICU. She begs him to take her home before the staff destroys her. The husband turns to the nurse, terrified that his wife has lost her mind and will need to be "put away." If you were that professional, what would you say to him? What would you do for the woman?
The police surround a house where a man is holding his family hostage with an arsenal of guns. He rants, "God will punish the wicked!" The police recruit the man's priest to encourage him to give up and come to the nearest emergency room for help. You are the nurse working in the ER. How might you feel? What would you do?
On a psychiatric unit, a woman rips down the holiday decoration of Santa Claus and is heading right toward the Christmas tree. You are coming in the door at that moment. What will you do now?
An elderly man hears that his best friend has just died. Immediately, his heart begins to pound and he starts to breathe rapidly. Sweat pours off as he feels a sense of impending doom. When the ambulance brings him to the hospital, he is yelling, "I'm dying! Help!" As the health professional, what would you do to help him now? And when it's determined that he hasn't had an MI?
A young girl sits in the corner of the waiting room, eyes wide and frightened. Her friends mention that she's taken some sort of hallucinogen as they head toward the exit. What would you do? How could they help her?
On a surgical floor, a woman is making a very slow recovery from a mastectomy. The aide tells you that she has refused breakfast again, saying, "What's the use?" As the team leader, what would you do now? What do you need to know?
All of the above have the potential to be psychiatric emergencies. There is no exact definition of a psychiatric emergency, but each generally involves a sudden serious psychological disturbance that affects behavior, with one or more of the following characteristics:
. sense of urgency: something must be done now or very soon, or else . and a feeling of intolerable anxiety if relief is not immediate . sense of being overwhelmed . lack of adequate coping abilities . recognition of a need for assistance from others to manage and alleviate the psychological distress
Psychiatric emergency and crisis are often used interchangeably. A psychiatric emergency can be viewed as a sudden, specific behavioral state that, if not responded to, will result in life-threatening or psychologically damaging consequences. A crisis is less immediate in that it has been developing over time within a psychological stress situation. If not alleviated, a crisis situation may develop into a psychiatric emergency specifically if it leads to acts of suicide, violence or severe agitation.
A mnemonic or code device for remembering the usual patterns of psychiatric emergency is the phrase, "I've had it!" This stands for the elements of:
Acute subjective distress and/or disturbed behavior can be very alarming to the affected person and others, who may come to the attention of the health team by any of the following routes:
1. The emergency arises while the person is already a hospitalized patient, in either a general hospital or psychiatric unit. 2. The individual comes to an emergency room or crisis center or is brought in by family, friends or the police. 3. The person is referred by a physician, another health professional, or an agency for additional evaluation and treatment. 4. There is a crisis phone call seeking help, direction and resources.
In addition to helping the identified patient, it is important to consider the needs and problems of the other people involved in the situation. Family and friends are valuable allies in assessing the crisis, especially if the patient is unable or unwilling to give information. They are also vital to treatment decisions. The decision to hospitalize an acutely disturbed individual, for example, may depend on whether or not there is a support system network for the person. Significant others may also be contributing to the emergency situation, and interventions may need to target them as well.
Psychiatric emergencies can be grouped into the following categories:
. Life threatening behavior, including threatened or attempted suicide, assault, homicide, or other violent acts. . Life disrupting behavior, resulting from severe anxiety, loss of contact with reality, mood disorders such as depression or mania, or conversion reactions, among others. . Life impairing behavior, that may result from intoxication or withdrawal from alcohol or drugs, toxic or idiosyncratic reactions to medication, or cerebral dysfunction.
These groupings cut across many categories of psychiatric and medical diagnoses. The focus in any psychiatric emergency is the immediate problem behavior, and how the person can regain equilibrium without destructive outcome for self or others.
Impact on Health Professionals
As health care patterns in the U.S. continue to change, more people are using emergency rooms and crisis units for help with pressing emotional problems. Part of this is due to the shift in psychiatric care from large state hospitals to community based treatment programs. Fewer patients are kept in psychiatric hospitals for any length of time. These people are treated rapidly and discharged to community facilities for follow-up care. During periods of increased stress that leads to decompensation, these patients may turn to the emergency room for medication, rehospitalization, or other resources, including food and shelter.
There is also increasing public health awareness that suicide, violence, and substance abuse are serious problems that must be addressed. Various types of programs have been developed to meet these needs.
The emergency room is where the initial psychiatric evaluation often occurs. Human beings have highly complex psychosocial and biological interactions. What seems to be a primary physical disorder may mask underlying anxiety or depression. And these syndromes may in turn mask or accompany other conditions that are organic in etiology. It takes skilled assessment and evaluation techniques to make the differential diagnosis. Physical examination, including appropriate tests and lab work, is often essential.
Suicide attempts and threatened suicide are among the most common psychiatric emergencies seen in nursing situations. Stressors connected with illness that may lead to depression and suicide include the threat of surgery with an unknown outcome, death of a loved one, agony of chronic pain with little relief, the prospect of chronic illness and incapacitation, and disfigurement from a radical burn or operation.
Suicide ranks among the leading causes of death in the United States, and the Surgeon General has designated it as one of the top public health concerns of today. The statistics generally quoted are conservatively misleading. Many suicides are not reported or recorded, and others are listed as alcohol-related accidents. Suicide is considered the tenth leading cause of death overall; it is probably closer to fifth, and among young adults (aged 15 to 34) it ranks third.
In addition to treating acutely suicidal patients, professionals also treat patients who show chronic patterns of self-destructive behavior. Any behavior, over a period of time significantly shortens or threatens a person's life span can be considered self-destructive. Included are chronic alcohol and substance abuse, anorexia and bulimia, the daredevil who has broken almost every bone in his body, the person with emphysema who refuses to quit smoking, and the person with an MI who insists on going right back to work.
A suicide attempt may result in a series of difficult and painful long-term disabilities, such as the person who swallows pills and needs extensive medical/surgical treatment or the person who sets herself on fire and lives, despite third-degree burns. Psychiatric emergency states may occur in the family members of a person who dies, especially if the death is sudden, particularly horrible or by suicide. The family and significant others need the opportunity to talk and express their grief, anger, bewilderment and sometimes relief. They may need temporary medication for sedation.
Other health professionals are involved with psychiatric emergencies that occur within families. Stillbirth or delivery of an infant with a congenital defect may bring on overwhelming anxiety and depression, but the extreme reaction called postpartum psychosis can sometimes be precipitated even by normal childbirth. Acute or chronic illness in a child may develop into a crisis for the family as well as for the young patient.
School nurses are involved with young people in many significant ways. Health education and recognition and treatment of depression and drug/alcohol abuse are important parts of their job. Death, illness, or separation and divorce of parents can have a very significant impact on growing children. They may turn to the nurse in times of crisis.
Large numbers of previously hospitalized psychiatric patients are discharged to the community after the treatment of the psychiatric emergency. Follow-up care is usually needed, and the public health nurse or community mental health nurse then becomes responsible for providing care to this group of individuals. The number and severity of the psychosocial stressors in the individual's environment influence change in acuity level. These former patients are a population at high risk for catastrophic reactions to increased stress. They may develop acute psychosis, depression and/or suicidal and violent behavior. Crisis intervention and the patients' successful return to the community are the goals of health care workers.
Another group at risk for psychiatric emergencies is the elderly. Faced with loneliness, death of loved ones, increasing disability and /or financial pressures, they begin to feel depressed and overwhelmed. Deterioration of emotional and social support systems is common. Deficits in brain function may lead to confusion, reduced problem solving ability, and less effective use of previously acquired coping skills. Professionals in long-term care facilities and home health settings are often uniquely positioned to recognize and address crises in these patients.
Nurses are looked upon by many people as authorities on health problems and care, and families and friends often seek their advice and support. First and foremost, nurses are people. They may find that their personal lives and professional responsibilities are getting out of hand. They may feel the grinding disappointment and despair of burnout. Furthermore, they may be faced with crisis situations and potential psychiatric emergencies in themselves or significant others. When this occurs, it is important to seek appropriate help. Sometimes this is difficult for health professionals to do, especially if it involves issues that seem shameful or make them feel weak or inadequate. Just as they reach out to many troubled patients in need, distressed professional people should reach out themselves when the need arises. It is well known that a sizable number of healthcare professionals abuse drugs and alcohol. Some even resort to suicide. The suicide potential of a person should never be underestimated because of education or profession.
It is the skilled and properly educated professional who will be asked to provide psychiatric emergency care to those individuals in need. The present and future of healthcare practice require that all be prepared to administer safe and competent psychiatric care to those who need it. Skills in assessment, diagnosis, intervention, treatment, and evaluation of psychiatric emergencies are demanded in all areas of professional practice. It is the astute person who realizes that a psychiatric emergency may occur anywhere and at any time.
Reactions to Psychiatric Emergencies
Anxiety is a common denominator in psychiatric emergencies. Anxiety is often referred to as the fear of the unknown. This fear is certainly a very human response to a psychiatric emergency and affects everyone involved -- the patient, family and staff. Anxiety itself is contagious. Persons who are in tenuous control over impulses to hurt themselves or others can be very frightening. This is especially true in an emergency room where the patient is often a stranger and the staff has little information immediately available on which to base a treatment plan.
If the disturbed behavior occurs on a general hospital unit, the staff may feel inadequate and overwhelmed by uncertainty. They may feel angry toward the person or family for causing "a scene" and taking them away from other patients who are acutely physically ill. Generally, if the behavior of such people is identified as coming from an organic basis, it is better understood and tolerated. If it seems that the patient should have more control over the confused, belligerent, peculiar or depressed behavior, the staff may be more critical, even judgmental.
On a psychiatric inpatient unit or in a crisis center, the staff may be better able to take episodes of disturbed behavior in stride. However, the usual emphasis there is on assessment, intervention and provision of adequate treatment so that psychiatric emergencies don't arise. When they do, the staff may feel guilty or angry with each other. They may feel they have failed. This is particularly true with suicidal behavior, especially if a patient in treatment attempts suicide. Patients who present recurrent emergencies may cause the staff to become frustrated, angry and rejecting of them. This generally stems from the staff's feelings of helplessness and inadequacy. They have done all they know to do and it has not worked or has not been effective for long.
Recurrent episodes of physical and psychiatric emergencies are often due to alcohol and drug use, and the patients sometimes encounter a negative attitude in treatment settings. There is the feeling that these patients "did it to themselves" and "deserve to suffer" to "teach them a lesson." Because health personnel put a high premium on health and recovery, they can find it difficult at times to cope with people leading highly self-destructive lives. They may feel a sense of social injustice, pity, fear or anger toward these patients.
These are all very human reactions and we need to recognize and deal with them when they occur. Increased understanding of the patient may help, along with awareness of what can and can't be done in the on-going situation. The important thing to keep in mind is that the patient and family come for some sort of help and the staff must be physically and emotionally able to provide it.
If a given agency or staff is not equipped to offer appropriate services, the professional obligation is to work out the best possible alternative plan. There are usually several resources available. A characteristic of a crisis situation is that those involved see few options or alternatives. Anxiety places "emotional blinders" on an individual and interferes with problem solving. The crisis worker, whether a nurse or other staff member, helps by providing objectivity and support, and by developing and reinforcing good coping strategies.
A professional who is responsible for the care of a patient in a psychiatric emergency empathizes and attempts to understand how the patient feels at the time of the crisis. Professionals must be aware that an individual in a crisis is highly anxious. The patient also feels many other highly charged emotions along with the anxiety. A primary feeling of lack of trust for those around him is typical of the patient in a psychiatric emergency. Feelings of fear, doom, lack of hope, anger, hostility, loss of control, disorganization and decreased perceptual ability are common symptoms in a psychiatric crisis.
During a psychiatric emergency a patient usually experiences physiological changes as well. These changes may include: altered appetite, thirst, sweating, dehydration, and an increase or decrease in blood pressure, pulse, respirations and temperature. Changes in all of the above can lead to electrolyte imbalances, leaving the patient exhausted and susceptible to other medical problems. Accurate and comprehensive diagnosis and assessment are necessary before intervention and appropriate treatment can be given to the patient in crisis.
Professionals need to stay calm and work together, not adding to the chaotic situation but doing their part to help. This requires knowing what general types of emergencies can be expected, and how to assess the specific situation including available treatments and other dispositions; and learning from each emergency in order to increase confidence and competence. The task of the treatment team is to convert the state of psychiatric emergency into a set of problems to be solved. Application of crisis theory and crisis intervention techniques is the first step.
Crisis Theory and Intervention
A specific approach to helping people in acute emotional trouble is called crisis intervention. Caring for people in crisis is an enduring feature of family and community functioning. As a facet of professional health services, however, crisis intervention is quite young in the annals of history. Intentional crisis intervention based on crisis theory dates from the 1940's, primarily from work done by Gerald Caplan and Eric Lindemann.
Caplan and Lindemann
Gerald Caplan is considered the father of preventive psychiatry in the U.S. for his work in research and development of crisis intervention techniques. Caplan defined crisis as a state provoked when a person faces an obstacle to important life goals. The obstacle, during crisis, seems insurmountable when applying the usual means of problem solving. This definition led to the concept that constructive resolution of a crisis could lead to greater personality integration and coping ability. Furthermore, inability to master the situation results in reintegration on a lower level.
Much of the early work in this area came from studies of the survivors of the Coconut Grove nightclub fire, in which many people were trapped and burned to death. Those who survived had multiple long-term physical and psychological effects. Dr. Eric Lindemann studied the survivors and relatives of those in the tragedy. From his work and from subsequent applications came much of the present understanding of grief, mourning, reactions to death, and crisis intervention.
Those who were able to confront the crisis, turn to others, and express their conflicting feelings were better able to integrate this nightmare into their lives. Those who denied both the importance of the tragedy and their reactions to the tragedy continued to have symptoms and recurrent problems, especially chronic depression.
From the above study and subsequent research, it was postulated that in the face of a significant psychosocial stressor, there are adaptive and maladaptive patterns of behavior. The ways in which people meet and deal with challenging situations will have a major influence on their lives.
Danger and Opportunity
According to Caplan, a dichotomy exists associated with crisis. Danger and opportunity exist. A crisis can be an opportunity when the individual grows from the crisis experience by developing new coping skills and altering perceptions. It can also be a danger when the individual does not seek help and rather comes out of the crisis state by use of defense mechanisms, resulting in a lowered functioning level and possibly psychosis or even death. When this concept was presented to a group of patients, one man reflected on the word "emergency." He suggested, "It could mean 'emerge and see'."
This is why it is extremely important that help be available from both healthcare professionals and others. The discomfort felt is a catalyzing agent in asking for help and making changes. Crisis intervention aims at helping people to achieve a higher level of mental health than they experienced going into the crisis.
Stressors
Stressors are the events or combinations of events that lead to crises and psychiatric emergencies. They usually occur within the year before the crisis - often as recently as the month before - and their effects are cumulative. Occasionally, the stressor is anticipation of a future event, such as pending surgery or retirement.
Biological stressors include illness and injury. Not only is the degree of actual impairment important, the meaning of the condition to the individual also has an influence on the degree of associated stress. Lack of sleep, inadequate nutrition, dehydration and chronic pain may contribute to a person's difficulty in coping with ongoing and new difficulties.
The specific psychosocial stressors vary in severity from minimal to catastrophic. These conditions are significant not only singly but also in combination. It is important to remember that changes for the "good" can result in stress just as do changes for the "bad." The Holmes/Rahe Social Readjustment Scale (Figure 1) is a popular representation of the relative stress inherent in many common life events.
Aguilera and Messick
According to Aguilera and Messick, development of a crisis follows a sequence of predictable steps, as outlined in the diagram (Figure 2). First, because of a stressful event or a series of events, the individual experiences a rise in tension and an inability to organize his behavior successfully enough to solve the problem. The individual experiences this lack of success in handling the tension, which in turn increases it. Existing internal and external resources are then mobilized. If successful, the mobilization results in diminished or solved problems as the individual uses emergency coping mechanisms; defines the problem in a new way; or gives up the goal as unreachable. If the problem cannot be solved or avoided, major personal disorganization may take place, manifested by anxiety, depression, confusion, or lack of impulse control, leading to suicidal or violent behavior.
One of the factors contributing to the restoration of equilibrium is situational support. A social network of close friends and family members can mean a great deal in weathering the storm of a crisis situation. This is a resource that health professionals should recognize and encourage.
For those lacking interpersonal resources, the healthcare system and professional workers can become a support system. Emergency facilities, hot lines, crisis centers, and drop-in clinics have support systems as part of their services. An important goal beyond emergency intervention is to help the person develop autonomous support systems.
Physical aspects of support include the basic needs of warmth, food, and shelter, as well as a balance between environmental stimulation and deprivation. One explanation for the degree of psychiatric disturbance in an intensive care unit, for example, is the level of incoming sensory stimulation from machines, lights, and action. The person may be overloaded and respond temporarily with psychotic disorganization.
Coping mechanisms are the individual's habitual patterns of dealing with stress and other problems. They are generally characteristic of a person and may occur on a conscious or subconscious level. Coping mechanisms are what a person usually does to solve problems or feel better. In the formation of a crisis, a person's usual patterns may not be working or the person may not be able to use them. Even psychotic behavior is a primitive form of coping and may bring the response of help and treatment from others.
One of the most common coping mechanisms involves turning to others for support. Our earliest, most primitive way of handling anxiety was to turn to mother, and this response was adapted as we matured to include other sources of support such as friends, spouse, medical personnel, and clergy.
Physical movement and sustained action often result in tension relief; a variety of repetitive activities may be incorporated into coping mechanisms, including pacing, coughing, scratching, moving about restlessly, engaging in pointless hyperactivity, finger tapping, experiencing increased urination and defecation, increased sexual behavior, fighting, hand wringing, eating, smoking, using drugs and alcohol, playing sports, swimming, taking a long warm bath, having a massage, or being rocked.
More complex activity patterns may also serve this purpose, including such things as cleaning the house, gambling, fast driving, or going on a shopping spree. Repetitive vocalizations provide tension relief for some individuals; these may include screaming, cursing, crying, joking, laughing, "talking it out." Indeed, repetitive themes in routine conversation and rapid, "pressured" speech are often symptoms of significant psychological distress.
A variety of mental processes have been identified that can serve as coping mechanisms, including fantasy, imagination, dreams, daydreams, mental rehearsing, lies, and humor. Ego defense mechanisms are more elaborate processes and are more likely to arise in the face of more serious, ongoing stressors. These include denial, repression, suppression, compensation, rationalization, reaction formation, projection, intellectualization and regression.
Crisis Intervention
Crisis intervention in psychiatric emergency situations is divided into four steps: assessment of the individual and his current problems, determination of the therapeutic intervention, intervention, and resolution of the crisis and anticipatory planning for the future. In actual practice, the steps are overlapping rather than consecutive. Also, the concept of crisis intervention may follow through in more than one place. For example, a person may call a crisis worker saying that she has made a suicide attempt with pills. The worker assesses the immediate situation and instructs a friend of the person to bring the person at once to the emergency room. There, medical evaluation and an extended suicide evaluation are done. Depending on the outcome, the person is referred for continued crisis work by the appropriate therapist, is hospitalized to prevent a further psychiatric emergency, or is discharged. The crisis model operates in many areas of medicine and nursing.
Assessment: First and foremost, it is necessary to assess the individual to determine if a crisis exists and the degree of severity. This is done during the initial interview, which reviews the immediate present. The precipitating events and the person's ability to cope are evaluated.
Sometimes initial assessment shows there is no true crisis. The person may be in no particular discomfort and may be seeking treatment for other reasons: avoiding jail, punishing a spouse, getting drugs to maintain a habit, seeking compensation for an injury, getting a letter for disability or for release from responsibilities. In these cases, the coping devices have not failed. Instead, the person is using a characteristic pattern of manipulation to meet needs, and the crisis worker clarifies what is possible and available and what is not.
During the initial interview, the crisis worker should appear calm, interested, confident and resourceful. This may sound easier or harder to do than it is. One thing to remember is that most people in psychiatric emergencies really do want help. They are frightened and eager for relief. It is important to acknowledge the patient's sense of urgency, while providing assurance that there is time to work out the problems. The patient must know that help is available, that there are solutions to be explored and used. The crisis worker must be an active, involved participant. This style of interviewing is more direct, empathic and active than traditional styles of psychotherapy in which the main thrust is taken by the patient and silence is used as a therapeutic technique. The crisis worker often develops a pattern of setting the framework for the interview, encouraging the patient to express thoughts and concerns with attention paid to feelings, directly asking for information, stating back to the patient and family what the problems seem to be, and suggesting treatment options.
Determination of the therapeutic intervention: This is the data-gathering step and treatment planning component in handling the immediate crisis. In deciding what type of intervention is most appropriate, it is important to consider precipitating factors, the amount of disruption in the person's life, the duration of the problem, and its impact on others.
The healthcare professional must concentrate on the events within the previous six-week period. If the patient goes back much further, they may be attempting to avoid, deny or confuse present events. Ask until clear, "Why now?" It is important to determine when the person was last adequately functioning, and specifically what happened to disrupt the balance. Memory is better for current events, and the events are less likely to be distorted. This is true of the patient as well as relatives, friends and co-workers. For people who want to delve extensively into the past, it is best to tell them gently that these are issues they may bring up in the future, especially if they go into psychotherapy.
It is important in this first emergency interview to determine if medication for immediate relief is necessary. Sometimes medication is essential before the assessment interview if the person is highly agitated or hostile.
Another important focus for decision-making is whether or not hospitalization is necessary. This is decided based upon 1) the degree of anxiety or depression, 2) the ability of the person to maintain control of impulses to hurt self or others and 3) the availability of other people to provide emotional and practical support.
In an emergency room a man was markedly anxious and agitated, showing poor judgment and unable to sleep. The diagnosis was a manic episode. It was decided that he would not have to be hospitalized as long as he could follow this treatment plan: Begin appropriate medication; come daily to the Day Center; drink no alcoholic beverages; and discontinue sailing his boat, on which he lived. He and his family agreed to this contract. Over the first weekend, the nurse made a "boat call" to check on any adverse reactions to the medication, to reinforce the expectations about the boat and drinking and to further her therapeutic relationship with him by showing her concern.
Intervention: This third stage begins as soon as the person presents for treatment; actually, it is part of the first two stages but continues after they are completed. As individuals in crisis share what they perceive is happening, they often experience some immediate relief simply from having someone listen. People who have been struggling with feelings of depression, anxiety, hopelessness, and a battery of unpleasant physical symptoms often feel much better after talking, obtaining some release of feelings and getting direct and indirect reassurance that help is available.
In many instances, it is essential that patients deal with feelings before they can do any problem solving on an intellectual basis. The crisis worker can describe the discomfort by saying something like, "I can see you're very unhappy (angry, afraid, anxious, etc.)." or "Most people in your situation would feel very angry" or "You must feel very confused by the mixed messages you're getting."
The crisis worker gives permission and encouragement for the patient to experience, recognize and express emotions. Many people are not in touch with the feelings behind their extreme discomfort. With the death of a loved one, the griever may be completely unaware of feelings of rejection, anger, guilt and resentment. A mother may be consciously aware of her happiness over the marriage of her last child and bewildered by feelings of depression and anxiety.
As the patient experiences some relief and begins to explore the immediate situation, some understanding occurs, but a full realization of the link between precipitating events and responses is not yet clear. The crisis worker may put a speculated conclusion into words for the person to think about.
It is important to identify strengths, abilities and unmet needs. Exploration into the significant life areas such as work, home, school and relationships with others will help: What is most distressing and disappointing right now? What coping mechanisms have been used successfully in the past? Alternative ways to cope with the current situation may also be suggested.
Throughout the process of crisis intervention, it is important to focus on the ability of the patient to regain mastery and to accept responsibility for self. The crisis worker is an active partner in the problem-solving venture but continues to give the credit to the patient.
Externalizing the events in a crisis makes it easier for everyone to take a look at the factors. The patient may expect that the crisis worker will "figure me out, know what's best, make me feel better and tell me how to live happily ever after." If this kind of unrealistic belief in magic and power is encouraged, it will boomerang. It is important to restore gently the power of change to the patient and to present the crisis worker as an ally who will help the person to figure out the problems and possible solutions.
An emphasis on positive assets and strengths is an effective tool in resolving the crisis. What and when was the previous optimal level of performance? What are the strengths in the patient and the family? What are the advantages of increased coping? What are the advantages of decreased coping? Can these advantages be obtained by means successfully used in the past? Many people in crisis at the time experience only the frightened, helpless, incapacitated parts of themselves. They forget or neglect the ways in which they have mastered other life crises. Strengths should be identified, encouraged and reinforced.
In crisis intervention, the family and significant others in a person's life may be enlisted to help. The crisis worker may interview them in the E.R. or call for information. It is best to explain the need for these contacts to the patient and receive consent, but in certain circumstances confidentiality may be waived if in the patient's best interests. With suicidal persons, the family needs to know the extent of the problems and risks involved. With homicidal problems, laws vary as to who should be notified, the intended victim and the police in some instances. Professionals should know the laws in their state and hospital policies. Some crisis teams make home visits or ask that the total social network meet together for intensive planning.
If the crisis has been precipitated by death, divorce or separation from a significant person, a step in resolution is to "re-people" the individual's world. After the initial grief work is done, the person is actively encouraged to seek out others in old or new social settings. Organized clubs, social groups, church activities, and recreational settings are places where potential friends are available.
These psychological intervention strategies are often supplemented by the use of psychotropic medications and/or one of a variety of institutional placements.
Resolution: This is the final stage of crisis intervention and generally takes place within a six-week period. Psychological equilibrium is reestablished, whether at the previous level, or lower or (hopefully) higher on the mental health scale. Crisis is often a turning point at which important learning can take place. Shakespeare noted this in the phrase, "Sweet are the uses of adversity."
How well did the crisis intervention work? This is indicated by the answers to the following questions: . Have the original presenting symptoms and manifested anxiety decreased to manageable proportions? . Does the person feel better? . Does the person experience more hope and have the ability to cope? . Do the individuals involved feel they have been helped? . Have they learned how to approach problem-solving more effectively? . Are previously unsatisfied needs being recognized and satisfied in healthy, appropriate ways? . Do the individuals feel able to make it on their own with their own resources? . Does the crisis worker have positive feelings about the outcome? . Can a plan for future action be described?
During the resolution stage, the crisis worker helps by summarizing the changes, describing the increased effectiveness in living and encouraging the person to experience the gains again. To be forewarned is to be forearmed! Future possible conflicts are discussed, along with possible alternative responses.
It is important to convey the message that the person is now able to cope again, using what has been learned from the experience; and if more help is needed in the future, it will be available. Some patients who have successfully mastered a crisis feel ashamed if later they again feel unable to cope. They may feel that they have let the crisis worker down and have difficulty asking for assistance again. During the resolution period of crisis intervention, plans for longer-term psychotherapy may be worked out if indicated, desired and available.
One Crisis After Another
Crisis theory and crisis intervention are important concepts for health professionals in every clinical setting. People bring their characteristic coping patterns into any situation. The health and illness continuum provides multiple opportunities for the development of crisis, including the prospects of sudden alteration in the ability to function, fear of impending disability or death, sudden shifting or reversing of social roles, and pain. Illness and accidents may necessitate sudden shifts in reality with which a person copes in many ways. Some methods of coping may lead to crisis and psychiatric emergencies.
Professionals are involved with people in potential crisis situations outside as well as inside the hospital setting. They see varying needs for crisis intervention in clinics, doctors' offices, schools, and day centers and in the home. Also, many areas of healthcare are stressful which may lead to crisis for the professional. They must recognize the need to get help when they are experiencing a crisis. Furthermore, they may see developing crises in patients and fellow staff. Sensitive, appropriate referral for services can make a great deal of difference.
In some crisis centers and mental health settings, nurses function as primary therapists, working directly with individuals and families. They receive from and give consultation to other members of the mental health team or to the general hospital units.
Centers that specialize in crisis intervention have made deliberate attempts to reach out to people in distress. Rather than regarding these people as "sick" or "crazy," they consider them as having difficulty with problems of living. This kind of agency may be more acceptable to many people than traditional psychiatric centers. There is less stigma involved.
Many people have distorted or negative stereotypes of psychiatrists, psychologists and psychiatric social workers. Their stereotypes of nurses may be more positive. Nurses are seen as accessible and helping people. They bring a background of working with emergencies along with an understanding of family interactions.
With proper educational programs and adequate supervision, support and guidance, health professionals can become even more competent and confident in crisis intervention.
Life-Threatening Conditions
Suicide
Why did he do it?
I really thought she was bluffing.
How
could he have done that to his
What will they do now?
Nothing could be that bad.
Maybe it was just an accident...
What did I do wrong?
Suicide is the act of killing oneself. Suicide burdens those left behind with many painful feelings and perplexed thoughts. Whether those people are family, friends or members of the medical professions, they are touched by the inherent tragedy and haunting thoughts that things could have worked out differently. Death from any cause leaves the living with many feelings, such as grief, anger, resentment, guilt and relief. Death from suicide intensifies these feelings because it leaves questions that will never be completely answered.
The thought of suicide is threatening to most people because it is an extreme act, frightening and final. However, suicidal behavior can be recognized, interrupted and neutralized. Suicide is not inevitable. In fact, it is often preventable. Acute suicidal behavior is a psychiatric emergency that demands immediate assessment and treatment.
If the person has already acted on suicidal thoughts (taken pills, cut wrists, jumped from a building, or shot himself), the first aspect of the emergency is to assess and treat the physical consequences and needs. Following this, assessment of the potential for continued self-destructiveness is imperative.
If the person is threatening suicide, intervention involves alleviating the immediate discomfort and desperation in order to "buy time" to consider other alternatives. This is one reason for hospitalization of the acutely suicidal-providing protection and trained staff to explore with the patient what precipitated the suicidal crisis and alternative solutions. Many patients weather these periods of extreme distress without going into the hospital. Unfortunately, it is found that many people who later kill themselves have had recent contact with the medical profession. They have often given overt or subtle clues about the possibility of killing themselves. This is why suicidal behavior is often considered a "cry for help."
Are all human beings capable of murder and murder of self, which is suicide? Many people do not want to consider this potential within themselves; they repress or deny it. In reality, most have had at least transient thoughts of destroying themselves or never waking up. Children say in angry, guilt-provoking tones (to themselves if not aloud to parents), "You'll be sorry when I'm dead and gone."
Some people think of suicide as the final, desperate alternative. Others consider it quickly and often, and then put the thought into action. These people get labeled in emergency rooms and crisis centers as "repeaters," and sometimes the treatment staff gets calloused or demoralized by the seeming futility of helping. Most people who kill themselves succeed on the first or second attempt, BUT the large majority of suicide attempters do not try again, especially if effective treatment is offered.
Many suicidal actions are intentional, deliberate, and the result of considerable thought and planning. Others are impulsive or carried out while usual emotional controls are lessened by alcohol or drugs. Those who are suicidal often have mixed feelings about ending their lives. This ambivalence is reflected in talk, thoughts, action and body language. These signal the despairing person's conflict to others so that they can supply the vital human needs which help to tip the balance from death to life.
Suicidal behavior should always be taken seriously, especially in the initial phases of assessment. The stakes are high even though the odds for survival are good in this gamble. A suicidal crisis is often part of the highly complex pattern of an individual's past, present and anticipated future. In regard to the degrees of intent, there are three main clusters.
Mild intent reflects the actions of a person who has thought of suicide and may be trying to solve a problem situation through a suicidal threat or gesture. The person often has an intense need for attention and recognition. Without asking directly, these people are trying to test others as to how much they care. In some cases it may involve use of suicidal behavior to manipulate or emotionally blackmail another.
In mild intent suicidal behavior, the methods used often do not result in serious harm and may be carried out in circumstances where rescue is certain. Someone may gulp aspirin in front of a spouse or superficially scratch a wrist. A difficulty with the suicide "gesture" is that others may not take the message seriously. Shaming, ridiculing or scolding the person will not help the situation. It is important to find out what the problems are and how to solve them in other ways besides through suicidal acts. If the interpersonal context does not change or the person becomes less able to cope, the suicidal potential may escalate to more dangerous levels. The tragedy of individuals who use suicidal threats and superficial gestures is both the unhappy atmosphere they generate while living and the potential danger that they might eventually succeed in killing themselves.
Many people with suicidal ideation are in the moderate intent category. They are seriously thinking about ending their lives if circumstances remain the same or get worse. These people are ambivalent, however, and hold out for a change. If they attempt suicide, they generally use methods that leave the final decision to other people or to fate. Suicidal individuals who take barbiturates, for example, and leave open the possibility that someone will find them are in this group.
People with serious or unquestionably lethal intent fully expect to die as the result of their actions. Many completed suicides come from this category. The method and timing are designed to be fatal. Lethal methods include shooting oneself with a gun or jumping from a high place. Only ignorance of the actual lethal potential, a chance occurrence, or medical intervention saves them. People in the lethal group often feel that life is meaningless and hopeless. They have no significant relationships with others or no longer feel worthy to live. They no longer care, whereas individuals in the other groups are concerned with the impact of their actions on significant others.
The combination of factors which suggests that the suicide intent has reached emergency proportions can include:
. An agitated, impatient, insistent attitude that something must be done immediately to reduce the anguish and to remedy the situation. The person needs immediate relief. . A definite, feasible and lethal suicide plan for which the person is unable or unwilling to consider alternatives. . Character traits of pride, hyper-independence, distrust of others and insistence on self-reliance, which make asking for and receiving help from others very difficult. . Lack of a supportive interpersonal network. The person lives alone and/or has few external resources.
Factors affecting the suicidal risk associated with lethal intent include the specificity of the plan, the potential lethality of the method chosen, and the availability of means to carry out the plan.
Suicidal ideation and attempt are the most important risk factors for completion. Recent large-scale studies of a cross section of adults aged 17 to 39 showed that one in six had thought seriously of suicide, and one in eighteen had made an attempt. Interestingly, although suicidal behavior is a key symptom of major depression, many people who commit suicide have no apparent psychiatric diagnosis or history of psychiatric problems. There are a number of unrelated factors, such as demographics and simple access to weapons, which are independently associated with suicidal behavior. Suicidal behavior tends to peak in the spring of the year. The proportion of suicide attempts that are successful rises with age. Men have a higher rate of successful suicide, although women have more attempts. Stresses associated with life transitions, from adolescent turmoil to midlife crisis, to the losses experienced in old age, can affect suicide risk. Family history of suicide may be significant. Persons with an unstable lifestyle, a history of multiple unsatisfactory relationships, and problems with alcohol and drug abuse may be at greater risk. Homosexual men have a higher rate of suicide in comparison to their heterosexual peers.
Serious medical illness is also a significant risk factor. Medical illness alone raises the odds from 1.0 to 1.3 for ideation and 1.6 for a suicide attempt. Persons with more than one serious medical condition face odds of 1.8 for ideation and 2.4 for attempt. Asthma and chronic bronchitis are associated with a two-thirds increase in the likelihood of ideation, and asthma or cancer is linked to a four-fold increase in frequency of attempted suicide. It should be noted that only one third of the positive respondents in this study met the criteria for major depression, so screening for suicide potential must go beyond general depression inventories in order to be effective. Another study reported that patients with chronic, unexplained medical symptoms were also at high risk for suicidal behaviors.
Notable signs and symptoms of suicide potential include a depressive or sub-depressive syndrome, with vegetative signs such as loss of appetite and sleep disturbances, and feelings of helplessness and hopelessness. Agitation associated with tension, guilt, shame, rage, anger, and a desire for revenge also warrants attention. Sudden changes in behavior, from active to reclusive and vice versa, and changes in mood from depressed and withdrawn to relaxed and content, may be significant. Psychotic states with poor reality testing may lead to bizarre attempts, and increased or excessive alcohol consumption increases risk.
Assessment of Suicidal Behavior
Many people believe the myth that, if a person talks about suicide, he won't do it. This myth simply does not hold up. Most people who are considering killing themselves give multiple warnings, verbal and nonverbal, to people in their immediate environment. They may consult with physicians, nurses or other helpers in both inpatient and outpatient settings. They generally indicate that some sort of internal struggle is occurring around the question, "Is my life worth living?" Clues to suicide include:
1. Direct verbal warnings 2. Depressed behavior 3. Changes in social behavior 4. Making of final plans 5. Suicidal history 6. Use of drugs and alcohol 7. Intuition of a person close to the individual
Direct verbal warnings
A certain number of people seek help for suicidal thoughts simply by telling health professionals of these impulses. Other fairly direct signals include:
1. Inability to keep going "If I could only go to sleep and never wake up." 2. Feelings of hopelessness and despair "I have nothing to live for." 3. Bids for reaction from another person "You'd (they'd) be better off without me." "It's too bad I failed the last time. It won't happen again." 4. Hints as to specific plans "How many sleeping pills does it take to kill a person?"
The above statements may be voiced by patients in many clinical situations. Health professionals have heard them, especially from people with painful, chronic conditions; from the elderly; and from people diagnosed as clinically depressed. They may or may not signal imminent suicidal intent. It depends on the context as well as on other behavior.
Another myth of suicide is that talking about suicide with a person will suggest the act. This is not so. Most suicidal people welcome the relief of sharing their burden. Asking specific questions about suicidal thoughts and feelings is the way to determine the lethal possibility as well as to provide initial relief and problem-solving potential.
Depressed behavior
What makes depressed behavior part of potential psychiatric emergencies is the link between this and suicide. Many people who are depressed consider suicide. They express feelings of emptiness, deep sadness, futility and hopelessness.
The physical symptoms of depression include insomnia, restlessness and early morning awakening. The darkness and aloneness of the long nighttime hours symbolically echo the bleakness of the person's life. Other physical symptoms include loss of appetite (for food and life), weight loss, fatigue, difficulty with concentration, and the inability to follow through. Loss of sex drive, impotence, and lack of pleasure are frequent and reduce the bonds between people. The physical symptoms can give rise to thoughts of a delusional quality as the person begins to fear cancer or heart disease.
When individuals coming out of a deep depression, their suicidal potential increases. During the misery of an acute depression, they are often immobilized but may be thinking steadily and deliberately about suicide. With energy and opportunity, they may act. Even after apparent successful psychiatric hospitalization for acute depression, there is still an approximate three-month period in which suicidal acts may take place. An apparent change for the better may signal a suicidal decision in depressed people. They become more cheerful, calm and active once the ambivalence is resolved. It's then a matter of time.
Feelings of depression are common among those who are suicidal. However, the most significant single predictor of suicidal intent is the feeling of hopelessness that may be present without the syndrome of depression. Signs and symptoms of depression are listed in Figure 3.
Changes in social behavior
Individuals who are suicidal may show marked changes in social behavior, either dramatically or gradually. Some of these are the following:
1. Withdrawing and cutting off social relationships
2. Going into a frenzy of work and play to ward off depression
3. Losing interest in former activities
4. Avoiding, rejecting or clinging to family and friends
5. Voicing self-denigrating and negative statements
6. Alienating others by rendering them helpless and frustrated
7. Not taking care of or having pride in personal appearance
8. Declining ability to work in job, home and school
Another group of behaviors that may precipitate suicide are those of a person who is becoming psychotic and losing the ability to test reality. The person may dread the recurrence of a former psychotic episode and act suicidal to avoid it. Or they may begin to hallucinate by hearing voices telling them to kill themselves. People who become markedly paranoid, fear danger from many sources. They misinterpret other people and external stimuli and may act in suicidal ways in a desperate attempt (paradoxically) to be safe.
Changes in social behavior may be subtly coded as to suicidal meaning. A person may start philosophizing about life and death, become preoccupied with morbid subjects, death poetry, or the afterlife. They may ask or comment about a "friend" who is suicidal. Sometimes, planning a long trip or completing a long anticipated desire is a clue that the person is finishing up life's unfinished business before a suicide attempt.
Making of final plans
Signs that suicide is being actively considered include such activities as putting things in order, making or revising a will, taking out more life insurance, checking about organ donations and arranging for a cemetery plot. The suicidal person may make ritualistic last visits to favorite places and friends, give away prized possessions and make arrangements for pets.
Persons who put their suicidal thoughts into writing or who draft a farewell note are generally more intent on outcome. This is particularly true if they ask forgiveness from the family for the shame and consequences.
Actually obtaining the means to the suicide buying a gun or hoarding pills is preparation to put the plan into action. The more specific and detailed the plan is, the greater the risk of carrying it through.
Suicidal history
Another important element is a history of a previous attempt. Those who kill themselves have often made one or more prior attempts. It is important to find out what the situation was, the means of attempt, the impact on others and the subsequent outcome.
Death by suicide of a parent, family member or close friend may influence later suicidal behavior. Children are particularly affected by the suddenness and mystery surrounding this kind of death. They may feel confused, responsible and guilty. The child may also identify with the dead parent and later seek to rejoin the parent through suicide. This may occur on a conscious or subconscious level. The anniversary of the date of the suicide and the death age of the suicidal loved one are crucial times. Recent tragic death of one close to a person may precipitate suicide, especially if there is guilt or a strong desire to reunite.
An aging person with an increasing physical disability may go into a depression and suicidal crisis when cut off from friends, family and work. Death of a spouse may precipitate the wish for self-induced death.
There may be no suicidal history at all as with those attempting suicide due to a terminal disease such as cancer or AIDS. Over the years there has been an increase in the number of people with AIDS who have attempted and completed suicide.
Use of drugs and alcohol
Many people who are depressed and distressed use drugs and alcohol as self-medication. This is potentially very dangerous. Alcohol and barbiturates increase depressed feelings, lowering impulse control and reducing ordinary caution in automobile driving. How many fatal car accidents are really suicide-related is difficult to assess.
Alcohol use is part of many attempted and successful suicides. A person may purposefully or accidentally overdose on combinations of drugs and alcohol. This can lead to a serious medical emergency that, if not treated in time, may be fatal. Under the influence of alcohol or drugs, some individuals provoke others to attack physically and even kill them. Serious fights in families and standoffs with police may be part of this self-destructive pattern.
Intuition of a person close to the individual
A person who is emotionally close to an acutely suicidal person may pick up subtle clues that disaster is pending. Intuition is partially the result of the screening of many nonverbal messages. It is felt as a vague sense of foreboding, apprehension, a "hunch" that something bad may happen.
The dreams of both the suicidal person and significant others may give warnings. Typical suicide dreams include those of going into a dark, unknown territory, which may be either threatening or comforting; opening a door to the unknown; reuniting with a dead loved one; and jumping out a window or falling. Of course, these themes have many other meanings, depending on the individual involved.
Problems and Goals
The emergency aspect of suicidal behavior is that an individual has acted or is about to act in a self-destructive, potentially fatal way. This is the most immediate problem. The immediate goal is to preserve life.
The specific problems that lead to suicidal behavior are highly individualized. They will be identified through a careful history taking and an understanding of the larger picture. The long-range goal is that the person will develop alternative ways to cope with the conditions that led to the suicidal state. These goals include:
1. Increased impulse control
2. Increased willingness to live, even with difficulties
3. Increased hope, self-esteem and sense of mastery
4. Improved communication and interpersonal relations
5. Increased ability to deal with feelings: love, anger, depression, grief, loneliness, and guilt
6. Increased understanding of self-destructive patterns
Persons who are suicidal come to the attention of health professionals by several means. They may be patients in active treatment in either an inpatient or outpatient setting for physical or psychiatric reasons. There may be a change in their condition, life circumstances, and ability to cope. Often, depression is linked with an upsurge in suicidal ideation.
Many people who make suicide attempts go to an emergency room first. They may seek out this help or be brought by family. Cut wrists are sutured; early overdoses, lavaged. If the physical condition is serious, the patient is admitted for intensive care or lifesaving surgery. Psychiatric evaluation must wait until the person is medically clear.
Many emergency rooms ask for a psychiatric evaluation for each attempt or threatened attempt, if possible. After assessment, psychiatric treatment, either inpatient or outpatient, may be recommended.
Indications for psychiatric hospitalization include continued high risk of acting on suicidal impulses based on regrets that the attempt was unsuccessful and strong feelings of hopelessness and of being overwhelmed; increased depression, despite initiation of treatment; lack of available support system of family and friends; subtle suicide encouragement by family; severe personality disorganization or psychosis; gross disturbance of physiological balance; and need for specialized treatment.
The patient may not follow through with psychiatric treatment once the emergency is over. The stigma of mental illness stops many people from seeking help with their problems. They may be afraid to change or they may not be ready to face difficult interpersonal problems.
Another means by which a suicidal person comes for treatment is through telephone contact by self or others. Crisis centers and suicide prevention programs offer 24-hour services to the distressed. The professionals and volunteers in these programs are carefully tra |
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