Introduction In this assignment I shall be defining the topic surrounding crisis throughout the field of mental health. I will be attempting to do this by using a various range of literature and theories of that can help us create a greater understanding and knowledge base of what a crisis is, why it occurs and how we can potentially prevent a crisis from occurring. I shall then be discussing how I would engage those individuals that are in crisis, exploring the engagement process and showing the skills that are necessary to provide support to the person in crisis.
I will then be discussing what challenges we meet as both professionals and the individual that is in crisis and what tools and strategies are placed in order to conquer these challenges. I will then move on to discuss risk management and how this could potentially help the person/client in crisis. Throughout this assignment I shall be using scenarios from my practice setting to use as examples to create a more personal setting of a person in crisis. To comply with the Nursing & Midwifery Code (NMC, 2008), I shall be changing all names used in order to maintain confidentiality. What is a crisis?
A psychological crisis refers to an individual’s inability to solve a problem. We all exist in a state of emotional equilibrium, a state of balance, or homeostasis (Aguilera,1998). This theory states that a crisis is unique to every individual, although our crisis may seem similar of that of another individual, the way we interpret and deal with our crisis is very much different. Aguilera states that we all at some point in our lives will find an inability that denies us from solving a problem. Aguilera describes crisis as the state of our psychological equilibrium being continuously threatened by stressors.
The better that people come through each crisis, the better they will tend to deal with what lies ahead, but this is not to say that all is lost and never to be recovered if a person has had a negative experience during any particular crisis stage. (Erikson,1982). There are 8 stages in Erikson’s psychosocial development theory of which he describes the impact of social experience across the whole lifespan. In each of these stages, Erikson believed people experience a conflict that serves as a turning point in development.
In Erikson’s view, these conflicts are centered on either developing a psychological quality or failing to develop that quality. During these times, the potential for personal growth is high, but so is the potential for failure. Throughout different points in our life we all experience some sort of crisis, but it’s how we deal with these and what coping mechanisms and strategies we use that differentiate us all from one another. The term crisis is defined by Kanel (2008) as a trilogy definition that is separated into three parts.
These being; a precipitating event; a perception of the event that causes subjective distress; and the failure of an individual’s usual coping methods, that causes a person experiencing the precipitating event to function at a lower level than before the event. So, the precipitating event would be the situation of that has led the individual into a crisis stage, the perception of the event is how we perceive it, leading onto whether it is a situation of that one can cope with or cannot, and the failure of an individual’s coping methods, being the way in that we will deal with the situation that has arisen.
This theory states that it is the individual’s perception of the crisis that is the influence on how we react and cope with it, rather than solely looking at the event itself. Gilliland and James (2001), who define the term crisis as the perception of an event or situation as an intolerable difficulty that exceeds the resources and coping mechanisms of the person. This again presents the theory that although it is important to focus on the event of crisis itself, it is strongly viewed that it is the individuals perception on this event and what their coping mechanisms and strategies are in order to overcome the period of crisis.
James (2001) also states that types of crisis can be divided into three categories, these being; developmental, situational and existential. A developmental crisis can be described as a drastic shift that occurs in the normal flow of human growth that produces abnormal responses e. g. career change, retirement. A situational crisis emerges with the occurrence of uncommon and extraordinary events that an individual has no way of foreseeing or controlling e. g. loss of job, bereavement.
Existential crisis includes the inner conflicts and anxieties of an individual that ultimately give their life purpose. This can occur at a certain age in life where an individual feels a state of worthlessness or underachieving throughout their life. Caplan (1961) also has a similar theory on crisis, stating that a period of disorganization leads to an upset in the individual’s steady state, somewhat of an obstacle, that for a short period of time proves exceedingly difficult to overcome with the strategies that are being attempted to use.
Many abortive attempts at the solution are made until the solution itself is resolved, therefore overcoming the crisis. So, this states that it may not be the crisis situation itself that can be overcome, such as bereavement or a rape, as situations like this cannot be changed, but it’s an individual’s perception on this event and their frame of mind that determines how we deal with this. The Tidal Model is similar to these theories, as it is a way of helping the individual make their own discovery into how the crisis can be resolved, by taking an active role into their own recovery.
This model focuses on helping people decide what needs to be done now to help address the individual’s present difficulties in order to continue living as full and meaningful life as possible. The Tidal Model states it is solely the individual that can change their perception on the crisis stage in order to achieve a once again stable life. (Barker and Barker, 2005). Strategies from the Ten Essential Shared Capabilities can be used for crisis intervention such as promoting recovery and identifying individual’s needs and strengths.
It also believes that however vulnerable, the individual should share in decision-making; that they are knowledgeable about themselves and the effect their conditions may have on their lives; and that they should be empowered and enabled to inform their own recovery. (DOH,2004). I will now be using a scenario I came across in my practice setting in order to show an example of an individual in crisis. Dennis is a single 43 year old man who had a steady job and a good income in concreting.
Over the years he has always a lot of work, earning a good income every month. Dennis doesn’t own a property, choosing to rent throughout his life. Due to a recent recession there has been a rapid decline in work whereby Dennis’ income has been rapidly decreasing. Dennis has never acquired qualifications as he has been in this trade since he started working. Dennis has recently lost his flat due to being unable to keep up with the repayments. Dennis’ mood has decreased considerably and feels somewhat lost.
Dennis rung the crisis line stating he had taken an overdose of 24 paracetamol and 24 ibuprofen and was subsequently taken to A+E after an ambulance was called. Dennis’ crisis could be deemed as a developmental crisis, one of that is a drastic shift in his normal daily flow of life that has caused him to have an abnormal response. Dennis may have also reached Erikson’s psychosocial stage 7 in his life being generativity vs stagnation. Those individuals who are successful during this stage will feel that they are contributing to the world by being active at home and in the community.
Those who fail to attain this skill will feel unproductive and uninvolved. This could have made Dennis more susceptible to experiencing crisis at this stage in his life. (Erikson,1982). Although, it could also be argued that this is a situational crisis, as Dennis could not foresee this event and a drastic shift from his normal working pattern, ultimately changing his life. Engaging the person/client in crisis Engagement is crucial when in contact and intervention with individuals in crisis, and the way in that we do this could be vital to the individual’s progress.
An intervention is an identifiable piece of verbal and/or non-verbal behaviour that is part of the practitioner’s service to the client (Heron, 2001). It is important that we as professionals do not stereotype or judge those individuals in crisis, or discriminate against them in terms of gender, religious beliefs or culture. Peplau (1952) developed the concept of the therapeutic nurse-patient relationship, that includes four phases; orientation, identification, exploitation and resolution.
The orientation phase is based around the client’s needs being identified and is directed by the nurse, engaging the client and answering questions the client may have. The identification phase is where the client will start to work with the nurse, expressing feelings and emotions. The exploitation phase will be where the client makes full use of the services provided for them. The resolution phase is the last, where the client will no longer feel it’s necessary to engage in services and become independent once again.
This is an engagement theory that is, although modified, still widely used throughout nursing today. This engagement theory is highly useful when engaging with those in crisis as it’s a good way of informing the individual that they are very much in control, and with a small amount of help and direction they can learn strategies on how to cope if a situation was to arise again. The person centered approach was proposed for new humanistic ideas for counselling. It was created to diminish the generalization that the professional knew everything about the client.
This approach states that if a safe psychological environment existed then all people would naturally move towards greater awareness and have a better fulfillment of their potential (Rogers,1957). Rogers also stated that there are core conditions needed as professionals in order to effectively engage with an individual and successfully bring a therapeutic change. These are; empathy, unconditional positive regard and congruence. Creating empathy shows our clients that we are experiencing an accurate, empathic understanding of the client’s awareness of their own experience.
Creating unconditional positive regard shows the individual in crisis that we are accepting the whole of them, and that we are completely non-judgemental. Developing congruence means that we as professionals are not hiding behind a facade or a front. These are all very important skills that need to be adapted and somewhat perfected when engaging with individuals in crisis, as it can help build sociability, trust, empathy and compassion that is key when discussing sensitive and more than often very private issues in that individuals may not be comfortable in sharing.
John Heron’s Six Category Intervention Analysis is a framework for understanding the interaction between helpers and people. This means analysis of the person in crisis’ situation, being able to effectively understand, explain and explore the therapeutic interactions between us and the individual in crisis. This can be described as six interventions and non-interventions to help us as professionals have a greater understanding of how to interact with others in different situations that may arise. (Heron, 2001). Heron states that an intervention must seek to address the current psychological needs and have an effect upon the client e. . enable, challenge and encourage. If all of these are met then it will be deemed as an appropriate intervention. John Heron’s authoritative interventions are ones that the practitioner can take a more dominant and assertive role, whereas the facilitative interventions looks at the practitioner enabling the client to be autonomous and take an active responsibility in their care. After Dennis’ initial call to the crisis line and his admission into A+E, it was agreed that Dennis would make an informal admission into an inpatient ward.
When first engaging with Dennis during his assessment he appeared very subdued and slightly hesitant to talk to me, as he stated he has never has contact with mental health services before, making him nervous and uneasy. I reminded Dennis that all individuals need help through difficult situations and that was perfectly normal. I used facilitative interventions throughout this assessment, using a supporting intervention to help affirm worth and value of Dennis’ qualities by showing genuine approval. After talking for 20 minutes Dennis appeared slightly more relaxed and was able to talk about positive factors in his life.
Although I deemed these interventions to be successful and useful throughout this particular assessment, Heron’s other interventions would have been useful for another outlook on the crisis. For example, if Dennis appeared to lack information and meaning into his crisis, then I would’ve used the informative approach, in order to impart knowledge, taking a more authoritative role. In this example I could also use a catalytic intervention, which is a facilitative approach, to help Dennis learn, develop and problem solve by encouragement.
Using the theories on engagement stated above I believe a more effective engagement process can be used when interacting with those individuals experiencing a crisis, as it allows the professional to have a more empathetic approach whilst using different engagement approaches suited to the individuals needs. Whilst engaging with the individual in crisis it is also important to implement risk assessment. Engagement with the client in crisis can give us a greater idea of how to assess their risk but also how to manage risk in their period of crisis.