CRISIS INTERVENTION

1. CRISIS INTERVENTION Components of crisis intervention Guidelines Crisis at various stages of life Special challenges

2. Definition • “the helping response of a crisis worker to a victim in crisis”. (Mitchell, Resnik) • An active but temporary entry into the life situation of a person, family or group during a period of stress • Paramedic needs to be alert, flexible, resourceful and willing to get involved • Intervention targets the response – NOT the event per se.

3. Goals of crisis intervention Earmarked by narrow goals of short duration 1. Shield the person from additional stress 2. Assist the person in organizing and mobilizing their resources 3. Return the person, a much as possible, to a pre-crisis level of functioning

4. Five major components of crisis intervention • Intervention is flexible but structured – not haphazard or sloppy • Consider the stages the individual is going through during your intervention • Assist you [the paramedic] to decide what to do

5. 1. Assessment • First priority is safety – is there any danger to you or others • What has happened? • Who is involved? • What was the cause? • How serious is the problem?

6. 2. The plan • Preliminary plan of action based on assessment • Does not need to be detailed; the crisis will not wait! • Doing something positive is better than doing nothing

7. 3. Implementation of the plan • Act, intervene • What ever the plan, get going!

8. 4. Reassessment • Once a plan has been implemented, it needs to be monitored for success • If the plan is working, keep going! • If not, formulate a new plan

9. 5. Recapping • Victims of crisis have a difficult time following what is going on around them • The person may need someone to tell them what is happening • This may need to be done repeatedly

10. Remember Most important tools are verbal and non verbal communication. Careful use of these skills will: • Help the person reduce emotional reactions • Make sense out of what is happening • Find short term solutions to the problem

11. Guidelines The DO’s and DON’T’s of Intervention • Application • Crisis pt • Most incidents

12. 1. Provide a reality base • Be calm • Identify yourself and your position • Explain the presence of others such as police and fire fighters • Use the person’s name • Reassure the person of confidentiality • Give supportive and truthful information

13. Let the person know what you expect of them and what they can expect of you • Explain why you are doing or not doing something • Explain unusual equipment or procedures • Anticipate the concerns of the person and family • Be non judgmental • Be aware of your reactions

14. 2. Provide verbal and non verbal support • Maintain a relaxed posture • Be near and at their level, if appropriate • Touch is important, if appropriate • Encourage communication • Realistic reassurance with reasonable expectations • Stay with them if possible

15. 3. Listen and respond Effective listening • Attending • Paraphrasing • Reflection of feelings • Summarizing • Probing • Helper self disclosure

16. 4. Ask clear, simple questions • Ask open ended questions • Questions should be understandable and focused • One at a time • A definite plan of questioning is helpful

17. Remember the Goal • Get the person to talk freely and frankly about the present situation • Obtain background info about the problem - detail • Help the person understand about the situation • Consider if time permits alternative to resolve problems...usually more the crisis Interventionalist

18. Precautionary Measures (the don’ts ) • 1. Don’t deny the possibility of violence when the early signs of agitation are first noticed. • 2. Don’t dismiss warnings from records, family authorities or fellow workers (dispatch). • 3. Don’t become isolated with potentially violent patients • 4. Don’t engage in certain behaviors that may be interpreted as aggressive.

19. Precautionary Measures (don’ts) continued • 5. Don’t allow a number of emergency personnel to interact simultaneously with the pt. • 6. Don’t make promises that can’t be kept !! • 7. Don’t argue, give orders, or disagree unless absolutely necessary. • 8. Don’t become condescending by using cynical, satirical or otherwise confrontational mannerisms. • 9. Don’t attempt to reason with pts who are under the influence of a mind altering substance.

20. Precautionary Measures (don’ts) continued • 10. Don’t attempt to gain compliance based upon the assumption that the patient is as reasonable about things as you are. • 11. Don’t keep the pt waiting or leave a potentially violent pt alone with freedom to move about. • 12. Don’t allow a crowd to congregate as spectators to an altercation. • 13. Don’t use why and what questions that put the pt on the defensive.

21. Danger signs to watch out for • Living in a fantasy world, has difficulty separating fact from fiction • Won’t accept or ask for help • Uses extreme withdrawal, retreat, avoidance • Turns to drugs/alcohol • Consumed with rage • Acts on impulse after the stage of emotional shock has passed

22. Danger continued… • Becomes hopeless and gives up • Very dependent on others • Comes across as ‘a rock’ – may be denying or suppressing emotions • Usual patterns are disrupted to the extreme Can apply to the patient, family member or the paramedic – watch out for them

23. Do’s and Don’ts use the Dual Action Approach In approaching the situation A – Assess C – control T – treat I – Inform O – Okay N - Notate

24. Check personal Action A – Attitudes C – Concern T – Thinking ability I – Interactions O – Objectivity N - Needs

25. Crisis at various stages of life • Beyond the expected… Consider a “Normal” cycle of events

26. Children • Children in various age groups have specific needs and respond to crisis in different ways • May regress or return to behaviour of another age

27. Assessment and Intervention • Consider the child’s age, past experience with injury, what they were doing when the event occurred and their developmental level • Look at the child’s relationship with adults – if his physical, social and emotional needs are being met, his response to you will be different than if they are not being met

28. Children under six years old • Greatest anxiety is separation from a parent or caregiver – include the parent in care provided • Fear pain and disapproval • Allow them to keep a favorite toy or blanket

29. Children between 6 and 12 • Often fear retaliation or punishment from a parent • Let the parent know that although they may be angry, they need to give support and comfort

30. All children • Remember; children listen to everything that is said • Escort away from the scene • Give brief explanation of what is happening • Always tell the child if you will be doing something painful before hand and tell them when you are finished

31. Don’t • Leave a child alone • Threaten a child with punishment if they are unco-operative • Lie or frighten • Talk about the child’s family or living conditions • Criticize the parents

32. Student [17-?] • Not doing well at school • Lost scholarship • $$ • School complete NOW WHAT • Job search • Interview...

33. Adult [beyond school] • Job loss • 2nd career – forced on them • Marriage • May have more conflict • Sexual difficulties often increase due to health problems or fear of health problems

34. Retirement – the mature adult • May have a sense of worthlessness • Possibly forced to retire due to age • Some become depressed

35. Sensory loss – not age dependent • Decrease in sight, hearing and smell • May increase anxiety • Does not mean they are intellectually inferior

36. Physical appearance • Accept the changes of aging • Never joke about or unnecessarily discuss these changes

37. Emotional changes • Slowed thinking, forgetfulness, rigid thought patterns, irritability • May be anxious about security • Depressed and feel a loss of social status • Grief is common due to loss of loved ones, friends, health status and activity level • Suicide risk increases in the elderly

38. Illness or death of a spouse • Linked to decline in the health and functioning of the survivor • Often the most serious loss the person faced

39. Crisis intervention with the elderly • Often find it difficult to ask for help because of sense of privacy and pride • May have a sense of immediacy – may become demanding • Reassurance is important • Use touch – if appropriate • Be patient

40. Sudden Infant Death Syndrome • Make every attempt to resuscitate the baby • Do not give false hope • Do not be overly silent • Do not accuse the parent • Gather information from the parents • Listen • Provide supportive care to the family • Only provide the information you can

41. The silent patient • Depression, organic brain condition, muscular impairment, stroke, lack of trust, quiet person • Observe for non verbal clues • Encourage speech • Are your actions contributing to the silence – talking too fast, have you frightened or offended • Always keep safety in mind - yours

42. Language barriers • Try to locate an interpreter (verbal) • The interpreter may paraphrase what is being said. The true meaning may not be conveyed • Don’t try to interpret yourself unless you are fluent

43. Most Common Interpreter ErrorsGlenn Flores, MD, FAAP, Medical College of Wisconsin • Omission (52%), in which the interpreter left out an important piece of information. • False fluency (16%), in which the interpreter used words or phrases that didn’t exist in a specific language. • Substitution (13%), in which a word or phrase is replaced with another word or phrase of a different meaning. • Editorialization (10%), in which the interpreter’s opinion is added to the interpretation. • Addition (8%), in which a word or phrase is added by the interpreter.

44. Blindness • Identify yourself • Explain who you are and what you are doing • Touch is important • Remember; your voice is your only means of communication • Guide dogs are working dogs. Do not touch or feed them

45. Cultural differences • Both you and the patient bring cultural stereotypes to the situation • Some are more comfortable with different distances and may or may not be receptive to touch • It is important to be aware of various cultures

46. Recap… Remember you may encounter the pt at any point during their critical event • Emotional shock • Denial • Anger • Remorse • Grief • Reconciliation

47. Crisis Intervention • A short term helping process • Acute intervention designed to mitigate the crisis response • Not psychotherapy

48. Crisis Intervention Goal: To foster natural resiliency through... • Stabilization • Symptom reduction • Return to adaptive function or • Facilitation of access to continued care