Psychiatric Emergencies & Nursing Action

Online Course #9225 or #1225 - 12 Contact Hours
Author: Silvia Prodan Lange, RN, MN
©2008 National Center of Continuing Education, Inc.

For your convenience, this course has been divided into 5 sections:
Below is Part 1 of 5.
Table of Contents …Part 2 …Part 3 …Part 4 … Part 5 … Independent Analysis … Evaluation

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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.
Nurses 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. Nurses need an understanding of attitudes and reactions, a body of knowledge, and action approaches in order to meet the challenge of a crisis situation.

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 Exploration

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 nurses 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 nurse, 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 the nurse 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 nurse, 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:

I

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 is brought to an emergency room or crisis center by self, family, friends or the police.
3. The person is referred by a physician, another health professional, or an agency for more 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 supportive human 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, which 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. This course presents general guidelines for addressing and treating the most frequently encountered psychiatric emergencies including suicide, violence, anxiety, and substance abuse.

RIGHTS of the MENTAL HEALTH PATIENT

• The right to be treated as a human being, with decency and respect
• The right to be guaranteed every right given to United States citizens by the Declaration of Independence and the Constitution of the United States of America
• The right to integrity of mind and body
• The right to receive treatment and medication only when administered with informed consent
• The right to have access to one's own legal and medical counsel
• The right to refuse to work in a mental hospital and to receive the minimum wage for any work done there
• The right to decent and prompt medical attention
• The right to uncensored communication by phone or letter and with visitors
• The right to refuse to be locked up involuntarily, and to refuse to give fingerprints and photographs
• The right to decent living conditions
• The right to keep one's own personal possessions
• The right to counsel and a court hearing about any mistreatment
• The right to refuse to be a part of research for experimental drugs or treatments and the right to refuse to be used as a learning experience for students
• The right to protection from defamation of character
• The right to an alternative to commitment in a mental hospital

Significance of Psychiatric Emergencies to Health Care and Nursing

As health care patterns in the United States change, more and 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 which 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 recognition 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 of general hospitals is where the initial psychiatric evaluation often occurs. Human beings have highly complex psychosocial/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, nurses also treat patients who show chronic patterns of self-destructive behavior. Any behavior that over a period of time significantly shortens or threatens a person's life span can be considered self-destructive. Included are the person who chronically abuses alcohol or drugs, the obese woman who gains alarming amounts of weight during pregnancy, 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 for the person who swallows lye and needs massive medical/ surgical repair 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.
Maternal/child nurses 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. Change in the acuity level of each patient is influenced by the number and severity of the psychosocial stressors in the individual's primary environment. 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. Nurses 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 very important for the nurse to seek appropriate help. Sometimes this is very difficult for nurses 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 physicians abuse drugs and alcohol, and many die by suicide. The suicide potential of a person should never be underestimated because of education or profession.
It is the skilled and properly educated nurse who will be asked to provide psychiatric emergency care to those individuals in need. The present and future of nursing practice require that all nurses be prepared to administer safe and competent psychiatric care to those who need it. Nursing skills in assessment, diagnosis, intervention, treatment, and evaluation of psychiatric emergencies are demanded in all areas of nursing practice. It is the astute nurse who realizes that a psychiatric emergency may occur anywhere and at any time.

Reactions to Psychiatric Emergencies

Anxiety is a common denominator in all 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 very 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 often 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 find it very 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 nurses need to recognize and accept 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 nursing 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 very 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 nurse 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. Nurses 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 all common 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 nursing diagnosis and assessment are necessary before intervention and appropriate treatment can be given to the patient in crisis.
Nurses 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. Accidental, spontaneous crisis intervention probably took place in the caveman days. Intentional crisis intervention based on crisis theory dates from the 1940's, primarily from work done by Gerald Caplan and Eric Lindemann.
Gerald Caplan is considered the father of preventive psychiatry in the United States 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, for the time being at least, seems insurmountable when using the usual means of problem solving. New approaches are needed. 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 people who were able to confront the crisis at the time, turn to others, and express their conflicting feelings were better able to integrate this nightmare into their lives. Those people 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. During a crisis, an individual is open for major changes and will respond positively to relatively little outside help. However, it is extremely important that help be available in the form of other people, both health care 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.
The Chinese character for crisis combines two other characters - one for danger and one for opportunity. In a crisis, a person can risk and achieve greater integration, self-understanding, trust in others and mastery. 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'."
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.

Holmes-Rahe Social Readjustment Rating Scale

Major change in health or behavior of a family member

44

37

1466

From:
Holmes, T. H., and Rahe, R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11, 213-218.

According to Aguilera and Messick, development of a crisis follows a sequence of predictable steps, as outlined in the diagram (Figure 2).

Crisis Intervention: Theory and Methodology

First, because of a stressful event or 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, provided primarily by people to whom the distressed person can turn. 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 nurses should recognize and encourage.
For those people lacking interpersonal resources, the health care 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 creature comforts 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 overactivity, 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.

Practice of 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 he 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 does exist and its 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 needed 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 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 health care professional must concentrate on the events within the previous six-week period. If the patient goes back much further, he/she 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 an educated guess might help: "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. For many people this is an unusual experience. 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. One depressed man, feeling completely ineffective and nonproductive, was congratulated when he reported he had driven around town to check on sites of difficult construction jobs he had completed. In this way, he reminded himself that he had been capable of working and would be again, despite current feelings of helplessness.
In crisis intervention, the family and significant others in a person's life may be enlisted to help in the current situation. Generally, they are already involved in the complicated social network. The crisis worker may interview them in the emergency room or call on the phone for information and contact. It is best to explain the need for these contacts to the patient and receive his/her 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. Nurses should know the laws in their state and their hospital's 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. These options are explored in detail in later sections of the course.
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 unmet 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.

Nursing Can Be One Crisis After Another

Crisis theory and crisis intervention are important concepts for nurses in every clinical setting. People bring their characteristic coping patterns into any situation. The health/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.
Nurses 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 nursing are very stressful which may lead to crisis for the nurse. Nurses 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.
On the other hand, individuals may not realize or accept that nurses are professionally prepared to help in an emotional crisis. Also, nurses themselves may feel that this type of therapeutic intervention is beyond their skill. Actually, whether they know it or not, many nurses are already involved in various aspects of crisis intervention. With proper educational programs and adequate supervision, support and guidance, nurses can become even more competent and confident in crisis intervention.

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