Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 24: Crisis and Disaster Instructor’s Manual Thoughts About Teaching the Topic The basic concepts necessary to understand crisis theory and crisis intervention are contained in this chapter. The instructor will emphasize the following: • Classification of crises • Characteristics of crises of relevance for nurses • Impact of crisis intervention on patients in crisis • Goals for patients in crisis: return to precrisis state, patient safety, and reducing anxiety • Emotional reactions and common problems faced by beginning practitioners When lecture time is very limited, the instructor may elect to discuss crisis intervention theory using examples and situations drawn from the chapters on family violence and rape trauma. The topics can also be shared with stress and anxiety topics, as well as suicide. Key Terms and Concepts adventitious crisis coping coping methods crisis crisis intervention critical incident stress debriefing (CISD) disasters maturational crisis mental health emergency mental health first aid (MHFA) phases of crisis primary care secondary care situational crisis tertiary care trauma Objectives 1. Differentiate among the three types of crisis. 2. Delineate six aspects of crisis relevant for nurses involved in crisis intervention. 3. Understand areas of assessment and approaches to the assessment during crisis. 4. Discuss four common problems in the nurse–patient relationship encountered by beginning nurses when starting crisis intervention. Discuss resolutions to these problems. 5. Compare and contrast the differences among primary, secondary, and tertiary intervention, including appropriate intervention strategies. 6. Identify modalities of crisis intervention. 7. List at least five resources in the community that could be used as referrals for a patient in crisis. Chapter Outline Teaching Strategies Crises A crisis is defined as an acute state of psychological imbalance resulting in poor coping with evidence of distress and functional impairment. Crisis is not a pathological state; rather, it is a struggle for equilibrium and adjustment when problems are perceived as unsolvable. A crisis presents a danger to personality organization and a potential opportunity for personality growth. The experience of violence in our society is one element of increasing crisis triggers, as are environmental disaster, civil unrest, and other occurrences. Crises are acute and time-limited, usually lasting four to six weeks. They are associated with events that are experienced with overwhelming emotions of increased tension, helplessness, and disorganization. As shown in Figure 24-,1 resolution from the state of crisis depends on (a) the realistic perception of the event, (b) adequate situational supports, and (c) adequate coping mechanisms. Crisis both threatens personality organization and presents an opportunity for personal growth and development. Successful crisis resolution results from the development of adaptive coping methods, reflects ego development, and suggests the employment of physiological, psychological, and social resources. Crisis, or rather coping with crisis, is an essential component of individual growth and development. Coping can be defined as “finding ways to accomplish goals despite obstacles and challenges” (Goldner et al., 2011, p.197). Coping methods are the thinking, behavioural, and emotional processes individuals use to support functioning in the face of stressors (Registered Nurses’ Association of Ontario, 2006). Crisis Theory Lindemann was an early crisis theorist, and crisis theory was further developed by Caplan. Aguilera and Mesnick have set the standard for crisis work by nurses. Albert R. Roberts’s seven-stage model of crisis interventions (Figure 24-2) is another useful model to address the suffering experienced in acute situational crises, as well as acute stress disorder. Co-Morbidity A psychological crisis refers to an individual’s inability to solve a problem. Factors that limit problem solving include the number of other stressful life events with which the individual is dealing, the presence of unresolved losses, concurrent psychiatric disorder, concurrent medical problems, excessive pain or fatigue, and the quality and quantity of a person’s usual coping skills. Types of Crisis Maturational Crisis Occurs when a person arrives at a new, unpredictable stage of development where formerly used coping styles are no longer appropriate. An example is the passage from school-age child to adolescent or from adolescent to adult. Temporary disequilibrium ensues. If support systems and adequate role models are absent, successful resolution may be difficult or may not occur at all. If alcohol or drugs interrupt progression through maturational stages, the result may be diminished coping skills (i.e., skill development is arrested at the age at which substance abuse began). Situational Crisis Involves a critical life problem and arises from an external source (e.g., job loss, death of a loved one, abortion, job change, change in financial status, divorce, pregnancy, severe illness). The stressful event involves a loss or change that threatens a person’s self-concept and self-esteem. Adventitious Crisis An unplanned, accidental event that is not part of everyday life. The event may be a natural disaster (such as a flood, fire, or earthquake), a national disaster (such as war or a riot), or a crime of violence (such as a bombing, rape, murder, or spousal or child abuse). Studies have shown a critical need for psychological first aid and debriefing for persons of all ages after any adventitious crisis. Phases of Crisis Phase 1 A crisis event stimulates anxiety, which stimulates use of problem-solving techniques and defence mechanisms to lower the anxiety. Phase 2 If the usual defensive response fails, anxiety continues to rise, and an individual becomes disorganized. Trial-and-error problem solving begins in an effort to restore balance. Phase 3 If trial-and-error attempts fail, anxiety escalates, and a person mobilizes automatic relief behaviours such as withdrawal and flight. Phase 4 If the problem remains unsolved and anxiety continues at severe or panic levels, serious personality disorganization occurs (e.g., confusion, immobilization, violence against others, suicide attempts, aimless running and shouting). Application of the Nursing Process Assessment General Assessment Equilibrium may be adversely affected by (1) unrealistic perception of the precipitating event, (2) inadequate situational supports, or (3) inadequate coping mechanisms. Assessment should include determining the individual’s need for external controls because of suicidal or homicidal ideation (Have you considered killing yourself or someone else since this problem began?), perception of the precipitating event, situational supports, and personal coping skills. Assessing Perception of the Precipitating Event Clear definition of the problem is necessary for resolution. Sample questions: • Has anything particularly upsetting happened to you within the past few days or weeks? • What was happening in your life before you started feeling this way? • What leads you to seek help now? • Describe how you are feeling right now. • How does this situation affect your life? • How do you see this event affecting your future? • What would need to be done to resolve this situation? Assessing Situational Supports It is necessary to determine resources available to the person. If resources are not available, the nurse acts as a temporary support system while relationships with individuals or community groups are established. Questions to ask: • Who do you live with? • Who do you talk to when you feel overwhelmed? • Who is available to help you? • Do you belong to a spiritual community? • Where do you go to school or to other community-based activities? • During past difficult times, who did you want most to help you? Who is the most helpful? Assessing Personal Coping Skills The individual’s level of anxiety should be assessed. It is necessary to determine whether the patient has exhausted all coping resources and whether hospitalization is required. Questions include: • Have you thought of killing yourself or someone else? If yes, have you thought of how you would do this? • What do you usually do to feel better? • Did you try it this time? If so, what was different? • What helped you through difficult times in the past? • What do you think might happen now? Self-Assessment The nurse must self-monitor feelings to ensure that he or she is not preventing expression of painful feelings by the patient. Problems faced by beginning practitioners include the following: • The need to be needed • Unrealistic goals • Difficulty dealing with the issue of suicide • Difficulty terminating Nurses working in disaster situations may become overwhelmed by witnessing catastrophic events. They too need support and debriefing. Assessment Guidelines: Crisis There are six guidelines indicated in the text, including identifying whether the patient’s response to the crisis warrants psychiatric treatment and identifying whether the patient was able to identify precipitating factors. The other assessment factors include assessment and identification of situational supports, coping styles, religious or cultural beliefs, and identification of primary, secondary, and tertiary needs of the patient in crisis. Diagnosis Possible diagnoses include the following: Risk for self-directed violence, Chronic low self-esteem, Hopelessness, Powerlessness, Anxiety, Acute confusion, Disturbed thought processes, Sleep deprivation, Social isolation, Risk for loneliness, Impaired social interaction, Ineffective coping, Interrupted family processes, Risk for post-trauma syndrome, Rape-trauma syndrome, and Dysfunctional grieving. Outcomes Identification Criteria must be realistic and be established with the patient. They must consider the patient’s cultural and personal values. Helping the patient return to the precrisis state is always one of the most important primary considerations. Table 24-2 Planning The nurse may be involved in planning for an individual (abuse), a group (suicide), or a community (disaster). Data from two questions will guide planning: (1) What is the effect of the crisis on the person’s life (i.e., can he or she still work, go to school, care for family?) and (2) How is the crisis affecting significant people in the patient’s life? As planning begins, the nurse will want to help the patient gain a feeling of safety and may even offer a solution to help the patient understand that options are available. Mental Health First Aid Mental health first aid (MHFA) is the help provided to a person developing a mental health problem or experiencing a mental health crisis. We know that physical first aid is administered to an injured person before medical treatment can be obtained. Likewise, MHFA is given until appropriate treatment is found or until the crisis is resolved and is often lifesaving. The approach and training of people in MHFA is a growing area of health promotion in Canada. This approach aims to provide skills and knowledge to help people manage developing mental health problems in themselves, family members, friends or coworkers. It does not attempt to train amateur therapists, but rather teaches people to (1) recognize the signs and symptoms of mental health problems, (2) provide initial help, and (3) guide a person towards appropriate professional help. Implementation There are two basic goals: (1) patient safety: external controls may be applied for protection from suicidal or homicidal urges, and (2) anxiety reduction allows for use of inner resources. Some important considerations: crisis intervention requires a creative, flexible approach; the patient solves the problem; the patient is in charge of his or her life; the patient is able to make decisions; the crisis intervention relationship is between partners. Counselling There are three levels of nursing care in crisis intervention: primary care, secondary care, and tertiary care. Primary Care Promotes mental health and lowers the incidence of crisis. Examples: (1) evaluating stressful life events the person is experiencing to recognize potential problems; (2) teaching coping skills such as decision making, problem solving, assertiveness, and relaxation as ways to handle stress; (3) assisting in evaluation of timing of or reduction of life changes to decrease negative effects of stress. Secondary Care Establishes intervention during a crisis to prevent prolonged anxiety from diminishing personal effectiveness and personality organization. It occurs in hospitals, emergency rooms, clinics, and mental health centres. Tertiary Care Provides support for patients who have experienced a disabling crisis and are recovering. Examples of agencies providing tertiary care are rehabilitation centres, sheltered workshops, day hospitals, and outpatient clinics. Critical Incident Stress Debriefing CISD consists of a debriefing intervention that offers individuals who have experienced a crisis the opportunity to share their feelings and thoughts in a safe and controlled environment. The approach has some criticism, and it is emphasized that CISD must be part of a comprehensive approach to crisis intervention. Evaluation Evaluation compares goals with outcomes to determine effectiveness and is usually done 4 to 8 weeks after the initial interview. If the intervention has been successful, patient anxiety and function should be at precrisis level.
Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 25: Suicide Instructor’s Manual Thoughts About Teaching the Topic Many faculty choose to coassign this material to the unit on alterations in mood. The rationale for this is that many depressed patients are considered to be suicidal, and the student must learn about both suicide precautions and no-suicide contracts in order to give care to selected patients. It is, however, necessary to make students aware that patients other than those diagnosed with affective disorder may present a risk for suicide. This is also an appropriate chapter to coassign alongside the unit on crisis and disaster, where suicide is a product and produces an outcome of crisis. Faculty should also be sensitive to the fact that students in the group may have entertained suicidal ideation or may have made suicidal gestures at one time or have family or friends who have, or who may have completed suicide. Often such a student will seek to discuss this privately with the faculty member, some for the purpose of seeking reassurance that earlier behaviours will not disqualify him or her from graduating, others to seek help. Key Terms and Concepts copycat suicide death by suicide lethality postvention primary intervention SAD PERSONS scale secondary intervention suicidal behaviour suicidal ideation suicide survivors of suicide tertiary intervention Objectives 1. Describe the profile of suicide in Canada, noting psychosocial and cultural factors that affect risk. 2. Identify three common precipitating events. 3. Describe risk factors and warning signs for suicide, including coexisting psychiatric disorders. 4. Name the most frequent coexisting psychiatric disorders. 5. Use the SAD PERSONS scale to assess suicide risk. Instructor’s Manual 6. Describe three expected reactions a nurse may have when beginning work with suicidal patients. 7. Give examples of primary, secondary, and tertiary (postvention) interventions. 8. Describe basic-level interventions that take place in the hospital or community. 9. Identify key elements of suicide precautions and environmental safety factors in the hospital. Chapter Outline Teaching Strategies Epidemiology The suicide mortality rate for both sexes and all ages was 11.5 per 100 000. Males were three times more likely to commit suicide than females. However, the rate of male suicide has been generally decreasing since 1999. The highest rates of suicide were in those aged 40 to 59. However, suicide was the leading cause of death for people aged 15 to 34. After the age of 35, the rate of suicide actually decreased, while other causes of death became more common (Statistics Canada, 2012). By province, rates for both sexes and all ages ranged from 8.5 per 100 000 in Ontario to 12.5 per 100 000 in Quebec. Among the territories, rates ranged from 5.1 per 100 000 in the Yukon to 27.8 per 100 000 in Nunavut. Risk Factors It is estimated that 90% of people who die by suicide are experiencing depression, another mental health illness, or a substance use disorder, all of which are potentially treatable. Loss of relationships, financial difficulty, and impulsivity are contributing factors in this population. Suicide risk is 50 times higher among patients with schizophrenia than among the general population, especially during the first few years of the illness, and suicide is the number-one leading cause of early death of those with the illness. About 40% of all patients— and 60% of males—with schizophrenia attempt suicide at least once. Patients with alcohol or substance use disorders also have a higher suicide risk. Co-morbidity of substance abuse and depression or antisocial personality disorder is also associated with increased risk. Up to 15% of those with alcohol or substance abuse die by suicide (Sadock & Sadock, 2008). Keep in mind that suicide is not necessarily synonymous with a mental health disorder. The act of purposeful self-destruction represented by taking one’s own life is usually accompanied by intensely conflicted feelings of pain, hopelessness, guilt, and selfloathing, coupled with the belief that there are no solutions and that things will not improve. Self-harming actions have been associated with the feeling that there is no one to turn to for support. Risk and protective factors are listed in Box 25-1. Etiology Biological Factors None of the biological markers identified to date are sensitive or precise enough for use in the clinical setting. Evidence suggests a potentially causal association between suicidal behaviour and the serotonin neurotransmission system (Carballo, Akamnonu, & Oquendo, 2008). Further, low cerebrospinal fluid 5- hydroxyindoleacetic acid (5-HIAA, the main serotonin metabolite) is considered a promising biological predictor of suicidal behaviour (Ganz, Braquehais, & Sher, 2010). In the context of acute stress response to life events, dysregulation of hypothalamic–pituitary–adrenocortical (HPA) axis function, particularly nonsuppression of the HPA axis by dexamethasone, may also be involved in suicidal behaviour (Currier & Mann, 2009). Psychosocial Factors Freud originally theorized that suicide resulted from aggression turned inward. Karl Menninger added to Freud’s base by describing three parts of suicidal hostility: the wish to kill, the wish to be killed, and the wish to die. Beck identified hopelessness as a central emotional factor underlying suicide intent. The suicidal people most likely to act out their fantasies are those who have suffered a loss of love, suffered a narcissistic injury, experienced overwhelming moods like rage or guilt, or identify with a suicide victim. Cultural Factors Cultural factors include religious beliefs, family values, and attitude toward death. The highest rate of suicide in Canada is among Inuit and Aboriginal people. Societal Factors Canadian society continues to hold taboos against openly discussing death more broadly. Suicide is even further invisible from conversation, More recently euthanasia and assisted suicide are gaining some discussion and, while against the law at present, various efforts are being made to advocate for changes at the highest courts. Application of the Nursing Process Assessment The process of suicide risk assessment is based on identification of specific risk factors, psychosocial and medical history, and interaction with the interviewer. The nurse usually completes this assessment in conjunction with a physician or another clinician. Note that not all patients who show suicidal ideation or who engage in suicidal behaviour truly want to die. Nonacute suicidal or self-destructive thoughts and feelings can be treated in the outpatient setting. Suicidal behaviour can include a variety of behaviours, including self-harm either with or without clear intent to cause bodily harm or death. Any previous suicidal behaviour is, however, a risk factor for suicide, and all thoughts and behaviours require careful assessment. Verbal and Nonverbal Clues Clues are usually sent out to supportive people. An example of overt verbalization is, “Life isn’t worth living anymore.” A covert
verbalization would be, “You won’t have to bother with me much longer.” Most often it is a relief for people contemplating suicide to talk to someone about their despair. Asking specific questions is appropriate for the nurse (e.g., “Are you experiencing thoughts of suicide?” “Do you have a plan for committing suicide?” If yes, “What is your plan?”). Behavioural clues include writing farewell notes and giving away prized possessions. Somatic clues include sleep disturbance, weight loss, and focus on somatic symptoms in lieu of psychological pain. Emotional clues include social withdrawal, feelings of hopelessness, and complaints of exhaustion. Lethality of Suicide Plan Three main elements to consider are (1) specificity of details of the plan (the more details included in the plan, the higher the risk); (2) lethality of the proposed method; and (3) availability of means (if the means are available, the risk is greater than when one still has to secure the means). Lethality of the method indicates how quickly a person would die by the method and is classified as higher or lower risk. Higher-risk methods, also termed “hard” methods, include using a gun, jumping off a high place, hanging, carbon monoxide poisoning, and staging a car crash. Lower-risk methods or “soft” methods include wrist slashing, inhaling natural gas, and ingesting pills. Assessment Tools The SAD PERSONS scale is used to evaluate 10 major risk factors for suicide potential. The higher the score, the greater the risk and the greater the need for hospitalization. Self-Assessment Universal reactions include (1) anxiety related to latent suicidal inclination in self or feelings of personal rejection by the patient, (2) irritation associated with believing the patient is trying to get attention, (3) avoidance in response to feelings of helplessness, and (4) denial of the seriousness of the suicidal ideation as way of avoiding experiencing feelings aroused by the suicidal person. Assessment Guidelines: Suicide These include assessing a patient’s risk factors, history of suicide attempts, and medical or psychiatric diagnoses. Other significant factors include: sudden changes in mood, relevant support system, or reports of significant others about changes in behaviour such as withdrawal, preoccupation, silence, and remorse. Diagnosis The nursing diagnosis with the highest priority is Risk for suicide. Other useful diagnoses include Risk for self-directed violence, Ineffective coping, Ineffective or compromised family coping, Disabled family coping, Hopelessness, Powerlessness, Social isolation, Spiritual distress, Risk for loneliness, Chronic low selfesteem, and Deficient knowledge. Outcomes Identification Goals should be consistent with the suicidal person’s perceptions and ability to achieve the goals. Outcomes and goals for the nursing diagnosis Risk for violence: self-directed are nearly always of concern (e.g., patient expresses feelings, maintains connectedness in relationships, seeks help when feeling selfdestructive, does not require treatment for suicide gestures or attempts). The reader is also referred to Nursing Outcomes Classification (NOC). Planning The plan of care for a suicidal patient is based upon the assessment of risk factors. Implementation Levels of Intervention Primary intervention—Activities that provide support, information, and education to avoid situations that could become serious. Secondary intervention—Treatment of the actual suicidal crisis; patient ambivalence is an important tool for the nurse. Tertiary intervention (or postvention)—Interventions with family and friends of a person who has either committed suicide or recently attempted suicide, and interventions with a person who has recently attempted suicide, are geared toward minimizing the traumatic aftereffects of the suicide or attempt. Milieu Management with Suicide Precautions Placing a suicidal person in a controlled hospital environment can provide structure and control; it can give the person time to evaluate his or her situation with professional staff. Monitoring of suicidal intent and extent of hopelessness should be ongoing. Hospitalization can provide time for the individual to re-establish relationships and make contact with appropriate community agencies. Counselling Counselling is practised in the community, in hospitals, on telephone hotlines. Counselling requires warmth, sensitivity, interest, concern, and consistency on the part of the helping person. It must include establishment of a personal relationship with the suicidal person, encouragement of more realistic problem-solving behaviours, and reaffirmation of hope. Counsellors should (1) remain calm and listen, (2) deal directly with the topic of suicide, (3) encourage problem solving and positive actions, (4) get assistance from other resources, and (5) convey to the person that the crisis is temporary, unbearable pain can be survived, help is available, and you are not alone. Health Teaching and Health Promotion The nurse teaches the patient about the psychiatric diagnosis, medications, age-related crises, community resources, coping skills, and communication skills, especially the expression of anger. The text lists a variety of intervention programs. Case Management Reconnecting patients with family or significant supportive friends can have a major impact on the patient’s recovery, and referrals to community services are essential. Pharmacological Interventions Selective serotonin reuptake inhibitors (SSRIs) provide an alternative to hospitalization. Suicide possibility increases with extreme anxiety and lack of sleep. Anxiolytics may be necessary, but medication for more than 1 to 3 days should not be supplied at any one time; follow-up plans must be made. Coexisting psychiatric conditions should be treated. ECT should be considered if the patient is seriously depressed and highly suicidal, since its effects are more immediate than those of antidepressants. Postvention for Survivors of Completed Suicide For friends and family of a suicide victim, postvention should be instituted within 72 hours and be continued through at least the first anniversary of the death. Confusion, stigma, isolation from supports, anger at the deceased, and guilt are issues to be resolved. Post-traumatic loss debriefing, a seven-stage process, can help initiate an adaptive grief process. Self-help groups for families of individuals who have committed suicide can be of considerable help. Staff should have the opportunity to work through self-blame, guilt, anger, and loss of self-esteem associated with caring for a patient who commits suicide. Advanced-Practice Interventions There are several types of psychotherapy used for treatment of suicidal patients. See text for more details. The APRN can also provide clinical supervision for direct care staff aftercare for the patient and consultation in inpatient, outpatient, ER, or forensic settings. Evaluation Evaluation of a suicidal patient is ongoing. Be aware that sudden behavioural changes can signal suicidal intent, especially when depression is lifting, and that anniversaries of losses are difficult times. Evaluation is focused on outcome criteria established during the planning phase. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400
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