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MJA Practice Essentials, Mental Health:
7. Crisis management in the community
Alan Rosen
"Paradoxically, if you survive them, it's in the bad conditions that you learn most about yourself."
-- Tim McCartney-Snape, mountaineer
(quoted in The Weekend Australian, 18-19 May 1996)
MJA 1997; 167: 633-638
Synopsis - Introduction - What is a crisis? - Types of crisis - Contention in the crisis literature - Stages of a crisis - When to intervene - Practical management of a crisis - Practical points in intervention - A crisis is different from an emergency - The place of crisis intervention in psychiatric services - Who should manage crises? - Gaps in services - Conclusion - Acknowledgements - References - Authors' details - Box 1: Stages of crisis - Box 2: The process of crisis assessment and intervention - Box 3: Useful crisis resources - Case history: Stages of crisis and "depathologising" - Case history: Crisis intervention early in the course of a psychiatric illness
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Synopsis |
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Introduction |
"Crisis" was first used as a specific term in psychiatry by Gerald Caplan1,2 after considering earlier evidence that survivors of severe trauma, such as those in Lindemann's study of the "Cocoanut Grove" nightclub fire in Boston in 1942, had much better outcomes if they received immediate psychiatric help.3 A "crisis" was seen as a brief non-illness response to severe stress, and "crisis intervention" emerged to detect maladaptive responses to crises and to convert them into effective coping and learning experiences.
Caplan's concept of crisis was influenced by the theories of his time. It relied on concepts of disease rather than health, and on mechanistic theories from Freud and General Systems Theory regarding "homeostasis" and "equilibrium". But these limitations were far outweighed by Caplan's contribution in emphasising the importance of preventive care, achieving mastery of the crisis, the social, cultural and material "supplies" necessary to avoid or resolve a crisis, and his pioneering advocacy of a community mental health approach.1,2,4 |
What is a crisis? |
Caplan's1,2 classic definition of crisis is an upset in the person's steady state provoked when an individual finds an obstacle to important life goals. This obstacle seems insurmountable, at least for a good while, by use of customary methods of problem solving.
A crisis is a period of transition in the life of the individual, family or group, presenting individuals with a turning point in their lives, which may be seen as a challenge or a threat, a "make or break" new possibility or risk, a gain or a loss, or both simultaneously. Most crises are part of the normal range of life experiences that most people can expect, and most people will recover from crisis without professional intervention. However, there are crises outside the bounds of a person's everyday experience or coping resources which may require expert help to achieve recovery. |
Types of crisis |
Developmental crises: These are the transitions between the stages of life that we all go through. These major times of transition are often marked by "rites of passage" at clearly defined moments (e.g., those surrounding being born, becoming adult, getting married, becoming an elder, or dying). They are crises because they can be periods of severe and prolonged stress, as described by Tyhurst, another pioneer in this field,5 particularly if there is insufficient guidance and support to prevent getting stuck while in transit.6 In small-scale cultures, there is a sense of continuity and retained value in transiting from before birth to beyond death (e.g., becoming an ancestral resource). In Western societies, rites of passage between these stages have become blurred, the extended kinship networks they depend upon for clear expression have become scattered, the cultural value ascribed to such transitions varies with occupational and economic status, and events surrounding birth and death tend to be experienced as clinical termini.6
Situational crises: Sometimes called "accidental crises", these are more culture- and situation-specific (e.g., loss of job, income and/or home, accident or burglary, or loss through separation or divorce). Complex crises: These are not part of our everyday experience or shared accumulated knowledge, so we find them harder to cope with. They include:
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Contention in the crisis literature |
Controversy still surrounds the concept of crisis. The term defies consistent definition, and "crisis theory" is just that: mainly theoretical speculation based on descriptive accounts, with the cultural and clinical concepts of crisis deriving from seemingly different fields of inquiry.
A personal crisis is not a clinical disorder. However, a severe or protracted response to crisis may lead to one (e.g., major depression, or, more commonly, an "adjustment disorder",10 defined as the development of clinically significant emotional or behavioural symptoms in response to an identifiable psychosocial stressor). Adjustment disorder should be distinguished from bereavement and other non-pathological reactions to crises which do not lead to marked distress in excess of what is expected, and which do not cause significant or lasting impairment in social or occupational functioning. Stress is not a synonym for crisis11 as all people face stress as part of the human condition. By no means all stressful experiences produce crises and the same type of stressor may be linked to crises, or even clinical disorders, in some but not in others. In contrast to crisis theory, some crisis interventions have been subjected to rigorous empirical study, demonstrating their effectiveness with specific problems (e.g., individuals and families seriously affected by mental illness).12,13 Crisis intervention can no longer be seen as a unified strategy for care, as many divergent practices in different settings have developed since its origin, from walk-in clinics to mobile home intervention, but Waldron has identified a number of common features.14 These include rapid service, intense work in the short term, and a practical here-and-now therapeutic focus. |
Stages of a crisis |
Box 1 presents a summary of the main stages, from the pre-crisis steady state, to crisis disequilibrium, to re-establishment of a new steady state, hopefully at an equal or higher level of organisation.11 It is often reported that a crisis state lasts several weeks, usually subsiding within one to two months, if successful resolution occurs. |
When to intervene |
Primary prevention: Strategies aimed at preventing the development of psychiatric illness altogether may be appropriate for people experiencing developmental or situational crises who have limited personal, social or cultural resources. Bereavement counselling, telephone counselling services and "How to survive Christmas" seminars18 are examples of practical primary prevention interventions in the community.
Critical incident counselling may be offered to survivors or witnesses of traumatic events and disasters to prevent emergence of protracted grief reactions or post-traumatic stress disorder (PTSD),8 although efficacy in preventing PTSD remains unclear. Secondary and tertiary prevention: Secondary prevention implies that a psychological disorder has already emerged, and aims at reducing the severity, duration or the risk of recurrent relapse. Tertiary prevention is aimed at reducing the disability attendant on a disorder that is already prolonged. Indications include: |
Practical management of a crisis |
Crisis management is the entire process of working through the crisis to the point of resolution (Box 2). It usually includes not only the activities of the individual in crisis but also the members of the person's social network.4 Not all crises require crisis intervention, which is that aspect of crisis management carried out by crisis workers (e.g., clinicians, counsellors, police or chaplains). |
Practical points in intervention: |
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A crisis is different from an emergency |
An emergency is a life-threatening situation demanding an immediate response. A crisis is often not immediately life-threatening and the timing of the response should be such as to include all participants in the crisis and existing or potential personal supports.
Appropriate personnel to respond to an emergency are Police, Ambulance, Fire or Hospital Emergency Departments and/or State Emergency Services. Appropriate people to call in a crisis include general practitioners, community mental health professionals, community services officers, or lay crisis response organisations. The appropriate type of early response in an emergency is life preserving: securing physical safety, removing the person from the source of danger, and defusing physical violence. In a crisis, the early response should be crisis assessment and support, defusing stress and interpersonal strife. The use of the terms "crisis intervention" and "emergency psychiatry" are often confused by clinicians, and used interchangeably in the names and descriptions of services.17 But what difference does it make to patients and their families when they feel distressed and just know they need help now?19 In fact, they benefit by more appropriate referrals and settings for intervention when these distinctions are clearly made, while professionals are able to deliver such services more safely and effectively when they know the difference between a crisis response and an emergency response. Sometimes there is an overlap between a crisis and an emergency. When there is any hint of a crisis turning into an emergency, it is considered a skill, not a failure, if a mental health professional or general practitioner chooses not to work alone and calls for expert advice, police assistance, or other emergency services. |
The place of crisis intervention in psychiatric services |
The evidence indicates that 24-hour home-visiting crisis response services should be integrated into local comprehensive services for people seriously affected by mental illnesses and their families. 9,12,13,15,20 The potential for new learning and personal growth in this population and their families has probably been vastly underestimated, often by the clinicians involved.17 Systematic interventions to promote such new learning out of "using the crisis" of acute psychiatric episodes are being developed to reverse the potentially erosive effects of early psychosis on self-esteem, identity and related maturational tasks.9,19 Family problem-solving techniques aimed at acquiring new coping techniques in crisis have been shown to prevent relapses.20,21
The principles of effective crisis intervention are consistent with current good practice in mental health services, regardless of the phase of care. There is evidence that people severely affected by psychiatric illnesses are much more likely to cooperate with interventions which are tailored to their individual needs, and when they feel listened to, are consulted and offered choices regarding types of proposed interventions. Cooperation is further enhanced when they and their families are provided with sufficient information and explanation, when time is taken to negotiate intervention goals, when low-key and low-dose interventions are offered (at home on their own "turf", if possible, rather than ours) and when the traumatising effects of involuntary hospital admission and heavy sedation are avoided.6,9,12,13,22 Inpatient psychiatric care is sometimes essential but should be arranged on a voluntary basis if possible. (See also "Case history: Crisis intervention early in the course of a psychiatric illness") |
Who should manage crises? |
General practitioners, community workers, police, ministers of religion, counsellors, as well as mental health professionals, are all in a position to be involved in crisis intervention. General practitioners are particularly well placed to help people in crisis and their families.
Should all crises be referred to psychiatric services? Emphatically no, although psychiatric services are most appropriate for people in crisis who have diagnosable psychiatric illnesses and who may be suicidal. Firstly, psychiatric services do not have the resources or mandate to handle all crises in the community. There are community services for domestic abuse, children at risk, and sexual assault crises, non-government and church organisations dealing with couple, family, existential and spiritual crises, and networks for bereavement and disaster counselling. Secondly, many people requiring help with crises do not wish to be seen by a psychiatric service or professional, which they may perceive as stigmatising, and therefore adding to their troubles. When the crisis is not complicated by significant psychiatric symptoms, it may be managed with significantly better outcome by a general practitioner who has the person's trust and does not need to label the person with a psychiatric diagnosis.23 Thirdly, some communal voluntary organisations run crisis hotlines (e.g., Lifeline) which may produce more timely referrals to clinical services, or care for people who would not present clinically . Whether they reduce the number of suicides is a more contentious issue. Peer-group and consumer-driven mutual support lines are developing further, via telephone "warm-lines", interactive radio, computer bulletin board chat-lines and the Internet. While these are a potential wellspring of support, they may make the caller feel more vulnerable through public exposure, and the recipients may feel helpless if their concern is ignored or abused by an anonymous caller. Arguably, basic training in crisis support and coping skills should be adopted as essential components of community and school education.14 |
Gaps in services |
There is still a lack of child and adolescent mobile crisis services operating extended hours to augment outpatient nine-to-five mental health services for these age groups. Adolescents are at a time of developmental transition and are particularly vulnerable to crisis. Early intervention services available on a 24-hour mobile basis which are specifically designed to deal with the crises and psychiatric problems of young people, their families and peers may help to reduce the exceptionally high youth suicide rates in Australia. |
Conclusion |
The National Mental Health Strategy24 has provided impetus to develop extended-hours mobile community psychiatric services integrated with local inpatient services in both urban and rural centres across Australia. Yet it is by no means possible, nor appropriate, for psychiatric services to provide the full range of crisis intervention services needed by our community. A broad network of formal and informal crisis support structures is required to enable us to more effectively "look after our own". |
Acknowledgements |
I thank Dr Kai Lin Lie, Dr Dorothy Kral, Dr Gary Walter, Mr Paul Clenaghan, Ms Vivienne Miller and Ms Sylvia Hands for advice on the text. |
References |
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