10.21.2011

Handling Crisis Situations



by Tabetha Cooper


Introduction
healthline.com
When a person experiences a crisis it can seem like the end of the world.  In addition, it is important to remember that what one person can consider a mere problem can be a complete disaster for another.  It is important for a person who is experiencing a crisis to get the help that they need if there is to be any hope of returning order to their life.  A crisis can be a psychiatric emergency, which is defined by Antai-Otong (2001) as extreme disruptions in thoughts, feelings, or behaviors that warrant immediate treatment.  Many professionals in differing careers undergo training in order to deal with crisis situations.  As a new mental health professional, I am going to walk you through my experience with my first two crisis intervention cases.  For the first case I am going to discuss the things I wanted to know prior to approaching the person in crisis as wel as how I handled it once contact was made.  I will then discuss my second case, describing how I began the interaction with the subject, assessed his mental state, and secured his safety.
Case 1
For my first case I received a call to go out to the scene of a suicide.  The woman in crisis was the wife of the victim.  There were few details other than that she was a thirty-five year old woman.  The reason I was called to the scene was that the woman had become very distraught about the death of her husband.  The information I was provided with was limited so I wanted to acquire more prior to arriving at the scene.  Also, once I arrived at the scene I wanted to talk to others to make sure I was fully prepared to make the initial contact with the subject.  For the purpose of this paper we call her Mary.
Since Mary’s husband had just committed suicide I was not sure what her mental state was going to be once I got there.  To help fill me in on the situation I wanted to run a background check on her through the local police.  I was looking for any charges but with an emphasis on violent crimes. I also wanted to see if she had a noted history of drug use.  Whether or not Mary has a history of mental illness is also good information to have.  These things can help determine the risk of the subject becoming violent.
After I was able to secure that information I needed to find out what method the husband used for his suicide.  If the method that he used could have been painful or messy I wanted to know that upfront.  Sometimes if a patient believes their loved one suffered or if the body is in such a state that an open casket funeral would not be possible, it can make coping with the loss harder.  I was also interested in whether or not she had actually witnessed his death or if she happened to be the one to find the body.  In both of those situations her mental state directly following the incident could be extremely delicate and I would need to be very careful in the way that I approached her.  If Mary did witness the suicide or happen to be the one that stumbled upon the body, her chances of developing post traumatic stress disorder (PTSD) increase notably (Salvatore, 1999).
There is also the issue of whether or not Mary and her husband had any children or other close relative living in the residence.  This information would let me know if Mary was going to be my only concern or if I was going to be dealing with multiple clients.  Even if they were not at the scene, they too would be affected by the death and would need to have some support to get through their own issues with the death.  If Mary does have children, this could make her crisis even worse.  She would not only have to deal with the death of her husband but she would have to worry about the well-being of her children as well.  This could potentially make the coping process even longer for Mary.  Although, there is a chance that it could also be the factor that could give her the strength to pull through this situation.
The best approach in a crisis situation is to use the six-step model to intervene.  The six-step model entails defining the problem, ensuring client safety, providing support, examining alternatives, making plans, and obtaining a commitment from the client (James & Gililand, 2007).  In order to begin this six-step model I needed a quiet place to talk to Mary.  Once I arrived at the scene I found a room that was away from all the events happening at her house and asked her to join me.  At that time we made our introductions and I was able to begin.
Obviously, I already knew what the problem was.  But I wanted to define the problem from Mary’s perspective.  Suicide survivors go through many stages of grief, including shock, anger, guilt, and depression (Cooke, 2010).  I needed to find out where Mary was in this process.  After I found out what Mary felt like she was going through, then I wanted to ensure that she was safe.  I assessed her mental state and determined that she was not a threat to either herself or to others.  I wanted to be sure that she had someone to talk to, so inquired about friends and family that she could call on to help her through this difficult time.  I also gave her my card and told her that even after we ended things for the day that she would still be able to call and talk to me anytime she needed it. 
I could see that Mary was beginning to relax and that she started to talk more.  She was going over all the feelings she was dealing with; all the fears that she had.  I wanted to be sure that she understood suicide.  I could not possibly tell her why her husband did what he did but I let her know some facts.  I was able to let her know what to expect in the days, weeks, and possibly even months to come.  I explained that she may experience nightmares, have difficulty concentrating, have trouble getting involved in the activities that she generally participated in, and may even go into withdrawal (Mayo Clinic Staff, 2010). 
I also explained the different emotions that she may experience in a short amount of time.  Grief can take a toll on a person.  Mary needed to know that during the shock stage that things would begin to seem surreal and she may even want to deny that her husband was dead.  She may begin to feel angry that her husband had killed himself leaving her to deal with life alone.  If her husband had been depressed or had acted out of the ordinary, she may even feel angry or guilty because she had not noticed the warning signs (Cooke, 2010).  Although, this is a feeling that many suicide survivors have, I wanted her to know that it was not her fault and that many times the warning signs are not clear until after the suicide.  I also wanted her to be aware that there was a chance that she would experience depression.  Sadly, suicide survivors are at a greater risk of becoming suicidal themselves (Cooke, 2010; Salvatore, 1999; Mayo Clinic Staff, 2010).
The next thing that I did was to go over some coping strategies with Mary.  I told her that first and foremost she needed to stay in contact with her family and friends (Mayo Clinic Staff, 2010).  This is important regardless of how you are feeling about social interactions at the moment.  I informed her that she did not need someone that was going to be there to talk her ears off but she needed to have some sort of support around her that would allow her to cope in her own way and in her own time and be there to talk to when she needs it (Mayo Clinic Staff, 2010).  I let her know that she would have painful reminders of her husband.  Their anniversary, his and her birthdays, and holidays were going to be trying times for her (Mayo Clinic Staff, 2010) and I suggested that she have her support system around on those dates.  I informed her that she should not rush her healing process (Mayo Clinic Staff, 2010).  Some people can get over a tragedy in a matter of days while other people require years to heal.  I let Mary know that she should allow herself to take as much time as she needed.  Setbacks in recovery are expected (Mayo Clinic Staff, 2010), especially around times that are significant to the victim and survivor.  I let her know that it was completely normal to take two steps forward just to have to take a step backward.  Last thing I wanted her to know was that there are local support groups that are designed as a place for people to talk with their peers; people dealing with the suicide of a loved one (Mayo Clinic Staff, 2010).  I suggested that she find one of these support groups to help her cope.
Steps three through six were easy for me and Mary to accomplish.  My biggest concern for Mary at the moment was her being alone.  Together we decided to call her best friend to come and sit with us.  I wanted to watch the two interacting with each other to determine if I thought this was the best support system for her.  I personally felt that she needed to have family members with her at a time like this but she felt that her best friend was her best bet for making it through the night.  After the plan was made and she had committed to it, we made the call.  I could see a change in Mary’s demeanor when her friend walked through the door and knew that in time she would be just fine.
Case2
My second case was a whole different experience, one that I had never experienced before.  I was called out to a public disturbance call.  The gentleman at the scene was clearly suffering from delusions of some sort.  When I arrived he was running around in the street without any clothes on and looking very unkempt.  He was ranting about UFO’s coming down from outer space to “get” him.
We are going to call this client Bob.  It was clear that I needed to assess his mental state quickly.  Unfortunately in this initial assessment I did not have the time to gather all the information that I would like to have had.  In the first assessment it is important to gather as much information as possible (Antai-Otong, 2001).  The assessment stage is vital because it allows the mental health professional to determine how bad the crisis situation is, what the client’s emotional status is, what resources are going to need to be used, and the patient’s danger to self and others (James & Gililand, 2007).  Unfortunately all I had to go on at the moment was what I could observe.  Bob clearly was not able to tell much more than that he thought aliens were on their way to destroy him.  I could clearly tell from Bob’s presenting symptoms that we were going to be dealing with a dangerous situation if it we couldn’t deescalate it soon. 
Before I could begin to assess Bob I needed to get him out of the street and in a place that I knew was safe for the both of us.  After about ten minutes I was able to talk to Bob and distract him long enough for the police to come in and restrain him.  He was then transported to the local police station.  I knew talking to him in an interrogation room probably was not the best idea.  I needed him to be able to relax and I just did not feel that was the right environment.  Reducing anxiety was my number one concern and I needed a noise-free, cozy place to talk to Bob (Antai-Otong, 2001).  I was able to secure the lieutenant’s office.  I had made sure that the lieutenant cleared all dangerous items from the room and positioned chairs in a way that I was going to be seated between Bob and the door (Antai-Otong, 2001).  This was the safest option for me since I did not know Bob’s potential for violence and since I was not sure exactly what his mental state was, I only knew that he was suffering from delusions. 
I decided that the Triage Assessment System was the quickest and most efficient way to determine Bob’s mental state.  Before I began the assessment I had to get Bob to calm down and try to establish a therapeutic relationship with him.  I want him to see that I could empathize with him, that I genuinely wanted to help him, and that no matter what he was going to answer to the questions I was about to ask that I accepted both him and his answers (Antai-Otong, 2001; James & Gililand, 2007).  I asked him both open and closed-ended questions to determine affective, behavioral, and cognitive domain (James & Gililand, 2007).  I was able to determine that Bob’s affective domain was mainly fear and anxiety because of the pending doom that he felt was upon him.  He did display issues with anger and hostility but I determined that these were just part of his defense mechanism.  I rated him at a ten on the 1-10 severity scale.  I then proceeded to assess his behavioral domain.  I concluded that he was is in a state of immobility.  There was no chance of normal functioning as long as these delusions were present.  I rated him a ten on this scale as well.  He was alright for the moment but given the delusion that his safety was at stake and the behaviors he was engaged in at the scene (being naked and ranting profusely) I felt that his behavior was unpredictable.  Lastly, I evaluated his cognitive domain.  I thought that for the time being all his cognitive domains were at a loss.  He was clearly not in tune with reality.  Again, I rated him a ten on the severity scale in this domain category (James & Gililand, 2007).
Since I was certain that Bob was completely out of touch with reality I needed to secure his safety.  I did not feel that spending the night in jail would do him any justice, but I knew that the option to release him to the custody of family was unwise and dangerous.  I decided that the only way to keep Bob safe from himself and to keep him from inadvertently harming someone else I needed to get him checked into a mental hospital for further evaluation and to hopefully get him some help for the delusion.  I was sure he needed to be on medication.  I did not want to force Bob into going so I decided I would try to convince him to check himself in.  I assured him that the aliens could not penetrate the walls of the hospital and that was going to be the safest place for him to escape capture for the night. 
After Bob was there a few days they were able to get him properly medicated.  After a week and a half he was thinking clearly.  I continued to see Bob for several months.  He did well as long as he stayed on his medication.  I worked the six-step model with him and he eventually was able to make a plan and a commitment, which of course involved remaining on his medication.  He still stops in to see me from time to time and he is doing fantastic!
Conclusion
What I learned from my first two cases was that it is important, but not always feasible to have information available prior to a crisis intervention.  Once confronted with the patient, a mental assessment is vital to knowing how severe the situation is; thus allowing the mental health professional to know where to begin the intervention.  Securing a safe place to start the intervention can be just as important to the intervention itself.  It allows the worker to have peace of mind, which in turn allows the worker to focus on the client.  After gaining insight into the problem from the clients’ perspective and securing everyone’s safety then the action steps can begin.  At this point in the intervention both the professional and the client need to start working on alternatives to the issue and then making and executing a plan.  Only then can the patient begin to get on with their life! 





References
Antai-Otong, D. (2001). Psychiatric Emergencies: How to Accurately Assess and             Manage the Patient in a Crisis. PESI Healthcare, LLC. Eau Claire, Wisconsin.    Retrieved from: www.pagecomposition.com/samples/pdf/psychemer.pdf
Cooke, A. (2010). Stages of Grieving a Loss Through Suicide. Livestrong.com.     Retrieved from: www.livestrong.com/article/140608-stages-grieving-loss-through-    suicide/
James, R. K. & Gililand, B. (2007). Crisis intervention strategies (6th ed.). Belmont, CA:             Cengage/Thomson-Wadsworth.  
Mayo Clinic Staff. (2010). Suicide Grief: Healing After a Loved One’s Suicide. Mayo       Clinic. Retrieved from: www.mayoclinic .com/health/suicide/MH00048
Salvatore, T. (1999). Suicide Loss FAQs. Springfield, PA. Retrieved from:             lifeguard.tripod.com/ssfaqs.html

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