THEORIES OF CRISIS, CRISIS INTERVENTION

1. THEORIES OF CRISIS, CRISIS INTERVENTION

2. DEFINITIONS OF CRISIS • Caplan (1960) defines crisis:brief episode of psychological unbalance which occurs when the subject is faced with a problem that cannot be solved or avoided. • Triggers of a crisis: • traumaticevents • life changes entailed by the life cycle

3. CRISIS • Stressful event or perceived threat + lack of efficient coping skills, resulting in emotional unbalance • Limited in time: 1-6 weeks • During the crisis, the subject asks for help • During the crisis, the subject is more compliant to external intervention • The evolution in crisis depends on the timing of the intervention

4. COPING AND CRISIS • Stages of coping in crisis: • Stage I. Immediate response: astonishment, denial • Stage II. Emotional reactions: anxiety, anger, guilt, regression, depression • Stage III. Resolution: acceptance, planning the future

5. THREAT EMOTIONAL BALANCE Automatic resolution of the problem-situation INCREASE OF PSYCHOLOGICAL TENSION (brief, unnoticed) STAGE 1 Problem-solving strategies FURTHER INCREASE OF PSYCHOLOGICAL TENSION (acknowledged) STAGE 2 New problem-solving strategies PSYCHOLOGICAL DISTRESS (anxiety, discomfort) STAGE 3 SEVERE PSYCHOLOGICAL TENSION, DISORGANISATION, SYMPTOMS, UNBALANCE, CRISIS STAGE 4 Model of crisis (G. Caplan, 1961)

6. TYPES OF CRISIS • MATURATIONAL CRISIS • Periods in life which entail changes in social roles, biological and social pressures; • Adolescence, marriage, birth of a child, retirement; • Adolescence: maturational crisis – originality, hormonal and psychological unbalance

7. TYPES OF CRISIS 2. SITUATIONAL CRISIS • A specific external eventdisrupts the internal psychological balance of the individual; • Holmes & Rahe Scale: Death of spouse, divorce Illness, accidents Pregnancy, childbirth Sexual dysfunction …

8. SITUATIONAL CRISIS • The experience of loss (of a loved one, of self-esteem, of normal functioning, of status, of job…) 2. Issues concerning change (transition in Romania, marriage, birth of a child, moving, change of job…) 3. Interpersonal issues (family conflicts) 4. Environmental factors (polution, work environment…)

9. TYPES OF CRISIS 3. CATASTROFIC CRISIS (SOCIAL) • accidental, unusual, unexpected: fire, earthquake, flood, kidnapping, nuclear accidents… • They do not occur in any subject’s life • Severe stress, requiring maximal coping strategies and abilities

10. CATASTROFIC CRISIS - STAGES • Impact • Heroic stage • “Honeymoon” stage • Disillusionment stage • Reconstruction, reorganisation

11. CATASTROFIC CRISIS - STAGES Impact: shock, extreme fear; poor/ distorted assessment of reality, and self-destructive behaviour Heroic stage: Cooperative spirit between friends, neighbours, and emergency teams; constructive activity at this time may help overcome anxiety and depression but excessive activity can lead to "burnout" Honeymoon: 1 week-several months after the disaster; the need to help others is sustained; psychological problems may be overlooked Disillusionment: 2 months to 1 year; disappointment, resentment, frustration, anger; victims often begin to show hostility toward others Reconstruction: Individuals admit that they must come to grips with their own problems; they begin to behave in a constructive manner

12. THE CONSEQUENCE OF UNRESOLVED CRISIS→SUICIDE!!!!

13. SPECIFIC GOALS OF CRISIS INTERVENTION (Korchin) a) Releasing the psychological tension and distress (anxiety, despair, confusion, agitation) b) Restoring the level of functioning and activity that the subject had prior to the crisis c) Reassuring the subject that the coping resources (internal, external) and support are available

14. TECNIQUES OF CRISIS INTERVENTION 1. Abreaction – remembering the highly emotionally charged events decreases the tension: "ventilation of emotions"; 2. Clarifying – encouraging the subject to rationalize the relationship between previous life events and current situation; 3. Suggestion – persuasive discourse in order to improve personal and overall situation; 4. Manipulation – employing patient’s emotions and desires in the therapeutic process;

15. TECHNIQUES OF CRISIS INTERVENTION 5. Positive reinvestment - positive answers to patient’s successful adaptive behaviors; 6. Supporting effective defense mechanisms that maintain integrity of the ego; 7. Encouraging the increase of self-esteem – regaining the purpose of living, reassuring the subject of his/her value and meaning; 8. Exploring solutions – finding specific alternative solutions and problem-solving through teamwork;

16. PROBLEM-SOLVING SEQUENCE IN CRISIS INTERVENTION • Step-by-step sequence: • Assessment of severity of crisis • Planning the actions according to available resources • Intervention • Reassessment of the situation and planning of future actions • If the specific goal has not been attained after these 4 steps, the crisis team has to start over and retrace the 4 actions.

17. a) ASSESSMENT • The first action in crisis intervention: assessment of the subject and of triggers • The therapist gathers specific information concerning the triggering event • The current risk for suicide and violence are assessed • If the assessment indicates that hospitalization is not required, the therapist may proceed with the intervention

18. b) INTERVENTION PLANNING • The decisive factor in planning: the time passed from the outbreak of crisis (commonly: the event occurs 1-2 weeks prior to the subject’s “cry for help”) • The impact of the event on subject’s life • The impact on people close to the subject • Coping styles previously (but not currently) employed by the subject in difficult situations • Time required for intervention • Size and structure of the intervention team • First specific actions • Estimated time until the first signs of improvement

19. c) INTERVENTION • First contact with the person in crisis • Employing a set of specific questions in order to find out specific information about the case • Involving the family, facilitating communication • Accurate assessment of the situation, drawing up a “therapeutic contract”between all parties involved • Inventory of the problems and establishing priorities

20. FIRST CONTACT • Establishing a “normal” environment • The subject, other people present and their relationship with the subject are identified • The triggering event is debated • The therapist informs all parties involved that they will all be required to take part in the resolution of crisis

21. SPECIFIC QUESTIONS • About the triggering event of the crisis • About symptoms generated by the impact with the event • About the subject’s coping resources in front of psychological aggression • Practical issues: clinical and gynecological assessment, nutritional status… • Events/changes within the previous 2-3 weeks • Brief psychiatric assessment – possiblesymptoms (anxiety, depression) prior to the crisis

22. FAMILY, COMMUNICATION • Crisis (acute psychological unbalance) in a subject: sign of disturbed family system, will also affect other family members • Roles in the family system will have to change in order to accommodate the needs of the patient • A list of problems for each family member to solve is drawn up – this enhances the feeling of cohesion and involvement in therapy • Optimal communication in the family – listening to all parties, excluding critiques, objective and sensible assessment of alternatives to proposed solutions • Active listening and unconditional support of the subject by all parties involved is needed

23. THERAPEUTIC CONTRACT • The therapist expresses his viewpoint • The connection between symptoms of subject and traumatic events • The necessity of admittance is assessed, according to severity of symptoms • Benefits and disadvantages of admittance • Subjects without psychiatric disorders are kept in their home environment • A contract is drawn up with family members – responsibilities of each party involved is detailed (family, friends, neighbors, volunteers in NGO’s, physicians, psychologists, social worker, nurse) • If the situation progressively improves, regular follow-up at-home visits continue for a predetermined period (3 – 6 weeks)

24. PRIORITIES OF ACTION • The specific problem of the subject in crisis is avoided, if it cannot be solved in a short time • If the problem can be solved, the specific actions to eliminate the consequences of “disaster” will be the focus of intervention • The family is involved in action planning • Multiple solutions are explored • Tasks are divided • All support resources are identified, mobilized • Support resources for the therapist are identified

25. d) REASSESSMENT • The last stage: the subject and intervention team evaluate the degree of positive outcomes and resolution of crisis • The best assessment tool: level of functioning – the extent to which the subject has returned to the level of functioning prior to the crisis • Inventory of specific activities, daily routine • Coping abilities in family and professional situations