1.7 Crisis and Crisis Intervention

If you were asked to describe someone in crisis, what would come to your mind? Many of us might draw on traditional images of someone anxiously wringing their hands, pacing the halls, having a verbal outburst, or acting erratically. Health care professionals should be aware that crisis can be reflected in these types of behaviors, but it can also be demonstrated in various verbal and nonverbal signs. There are many potential causes of crisis, and there are four phases an individual progresses through to crisis. Nurses and other health care professionals are often the frontline care providers when an individual faces a crisis, so it is important to recognize signs of crisis, know what to assess, intervene appropriately, and evaluate crisis resolution.

Definition of Crisis

A crisis can be broadly defined as the inability to cope or adapt to a stressor. Historically, the first examination of crisis and development of formal crisis intervention models occurred among psychologists in the 1960s and 1970s. Although definitions of crisis have evolved, there are central tenets related to an individual’s stress management.

Consider the historical context of crisis as first formally defined in the literature by Gerald Caplan. Crisis was defined as a situation that produces psychological disequilibrium in an individual and constitutes an important problem in which they can’t escape or solve with their customary problem-solving resources.^[1] This definition emphasized the imbalance created by situation stressors.

Albert Roberts updated the concept of crisis management in more recent years to include a reflection on the level of an individual’s dysfunction. He defined crisis as an acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail with evidence of distress and functional impairment.^[2] A person’s subjective reaction to a stressful life experience compromises their ability (or inability) to cope or function.

Causes of Crisis

A crisis can emerge for individuals due to a variety of events. It is also important to note that events may be managed differently by different individuals. For example, a stressful stimulus occurring for Patient A may not induce the same crisis response as it does for Patient B. Therefore, nurses must remain vigilant and carefully monitor each patient for signs of emerging crisis.

A crisis commonly occurs when individuals experience some sort of significant life event. These events may be unanticipated, but that is not always the case. An example of anticipated life events that may cause a crisis include the birth of a baby. For example, the birth (although expected) can result in a crisis for some individuals as they struggle to cope with and adapt to this major life change. Crisis situations are more commonly associated with unexpected life events. Individuals who experience a newly diagnosed critical or life-altering illness are at risk for experiencing a crisis. For example, a client experiencing a life-threatening myocardial infarction or receiving a new diagnosis of cancer may experience a crisis. Additionally, the crisis may be experienced by family and loved ones of the patient as well. Nurses should be aware that crisis intervention and the need for additional support may occur in these types of situations and often extend beyond the needs of the individual patient. Other events that may result in crisis development include stressors such as the loss of a job, loss of one’s home, divorce, or death of a loved one. Large scale events may precipitate crisis responses. War or natural events such as hurricanes or earthquakes may necessitate disaster management programs.

Categories of Crises

Due to a variety of stimuli that can cause the emergence of a crisis, crises can be categorized to help nurses and health care providers understand the crisis experience and the resources that may be most beneficial for assisting the client and their family members. Crises can be characterized into one of three categories: maturational, situational, or social crisis. Table 1.7a explains characteristics of the different categories of crises and provides examples of stressors associated with that category.

Table 1.7a Categories of Crises

Phases of Crisis

Crisis response can be described as four distinct phases. The phases progress from initial exposure to the stressor, to tension escalation, to an eventual sense of being overwhelmed. These phases reflect a sequential progression in which resource utilization and intervention are critical for assisting a client in crisis. Table 1.7b describes the various phases of crisis, their defining characteristics, and associated signs and symptoms that individuals may experience as they progress through each phase.

Table 1.7b Crisis Phases^{[3], [4]} 

Crisis Assessment

Nurses must be aware of the potential impact of stressors for their patients and the ways in which they may manifest in a crisis. The first step in assessing for crisis occurs with the basic establishment of a therapeutic nurse-patient relationship. Understanding who your patient is, what is occurring in their life, what resources are available to them, and their individual beliefs, supports, and general demeanor can help a nurse determine if a patient is at risk for ineffective coping and possible progression to crisis.

Crisis symptoms can manifest in various ways. Nurses should carefully monitor for signs of the progression through the phases of crisis such as the following:

• Escalating anxiety
• Denial
• Confusion or disordered thinking
• Anger and hostility
• Helplessness and withdrawal
• Inefficiency
• Hopelessness and depression
• Steps toward resolution and reorganization

When a nurse identifies these signs in a patient or their family members, it is important to carefully explore the symptoms exhibited and the potential stressors. Collecting information regarding the severity of the stress response, the individual’s or family’s resources, and the crisis phase can help guide the nurse and health care team toward appropriate intervention.

Crisis Interventions

Crisis intervention is an important role for the nurse and health care team to assist patients and families toward crisis resolution. Resources are employed, and interventions are implemented to therapeutically assist the individual in whatever phase of crisis they are experiencing. Depending on the stage of the crisis, various strategies and resources are used.

The goals of crisis intervention are the following:

• Identify, assess, and intervene
• Return the individual to a prior level of functioning as quickly as possible.
• Lessen negative impact on future mental health

During the crisis intervention process, new skills and coping strategies are acquired, resulting in change. A crisis state is time-limited, usually lasting several days but no longer than four to six weeks. Various factors can influence an individual’s ability to resolve a crisis and return to equilibrium, such as realistic perception of an event, adequate situational support, and adequate coping strategies to respond to a problem. Individualized interventions will be explored in chapters on stress and coping and anxiety.

Crisis Resources

Depending on the type of stressors and the severity of the crisis experienced, there are a variety of resources that can be offered to patients and their loved ones. Nurses should be aware of community and organizational resources that are available in their practice settings. Support groups, hotlines, shelters, counseling services, and other community resources like the Red Cross may be helpful. Read more about potential national resources in the following box.