CRISIS

INTRODUCTION
Crisis can be viewed as an integral component of everyday life situations. A crisis
may influence people’s lives in different ways. As a consequence of a crisis
experience, the individual may go down to a lower or less healthy level of functioning
than what was before the crisis, or he may resume the same level of functioning by
repressing the crisis and the related emotions. On the other hand, he may function at a
healthier level than prior to the crisis, because the challenge of a crisis can bring out
new strengths, skills and coping mechanisms.
Intervention at a crisis is extremely important to prevent mental illness, because long-
standing problems make the person totally incapable of handling the situation. If
proper guidance is provided at the correct time, the victim will come out of it better
equipped to handle future problems in life.

Definition
Crisis is a state of disequilibrium resulting from the interaction of an event with the
individual’s or family’s coping mechanisms, which are inadequate to meet the
demands of the situation, combined with the individual’s or family’s perception of the
meaning of the event (Taylor 1982).

Crisis can be defined as a situation that produces psychological disequilibrium in an

individual and constitutes an important problem in which they cannot escape or solve
with their customary problem-solving resources.

CHARACTERISTICS OF INDIVIDUALS PRONE TO CRISIS

The following are characteristics often found in individuals who are regarded as being
more susceptible to crisis:
• Dissatisfaction with employment or lack of employment
• History of unresolved crisis
• History of substance abuse
• Poor self-esteem, unworthiness
• Superficial relationships with others
• Difficulty in coping with everyday situations
• Under utilization of resources and support systems
• Unsociability and lack of caring.
It is important to note that individual personality traits must also be considered in
conjunction with these characteristics. Crisis is defined by the individual; what is a
crisis for one is merely an occurrence for another.
This factor is a critical component that must be evaluated in relation to crisis prone
characteristics as well as personality traits.

TYPOLOGY/TYPES OF CRISIS
1. Maturational Crisis
Maturational crisis can be defined as the predictable processes of growth and
development that evolves over a period of time, the ultimate goal of these processes is
maturity.
The transition points where individuals move into successive stage often generate
disequilibrium. Individuals are required to make cognitive and behavioural changes
and to integrate those physical changes that accompany development.
The extent to which individuals experience success in the mastery of these tasks
depends on previous successes, availability of support systems, influence of role
models and acceptability of the new role by others.
The transitional periods or events that are most commonly identified as having
increased crisis potential are adolescence, marriage, parenthood, midlife and
retirement.

2. Situational Crisis
A situational crisis is one that is precipitated by an unanticipated stressful event that
creates disequilibrium by threatening one’s sense of biological, social or
psychological integrity.
Examples of events that can precipitate situational crises are premature birth, status
and role changes, death of a loved one, physical or mental illness, divorce, change in
geographic location and poor performance in school.

3. Social Crisis
Social crisis is accidental, uncommon and unanticipated and results in multiple losses
and radical environmental changes. Social crises include natural disasters like flood,
earthquakes, violence, nuclear accidents, mass killings, contamination of large areas
by toxic wastes, wars etc. This type of crisis is unlike maturational and situational
crisis because it does not occur in the lives of all people.
Because of the severity of the effects of social crisis, coping strategies may not be
effective. Individuals confronted with social crisis usually do not have previous
experience from which to draw expertise. Support systems may be unavailable
because they may also be involved in similar situations. Mental health professionals
are called upon to act quickly and provide services to large numbers of people and in
some cases, the whole community.

PHASES OF CRISIS
Caplan (1964) describes four phases of crisis as described below:
Phase I
Perceived threat acts as a precipitant that generates increased anxiety. Normal coping
strategies are activated, and if unsuccessful, the individual moves into Phase II.
Phase II
The ineffectiveness of the Phase I coping mechanisms leads to further disorganisation.
The individual experiences a sense of vulnerability. The individual may attempt to
cope with the situation in a random fashion. If the anxiety continues and there is
reduction, the individual enters Phase III.
Phase III
Redefinition of the crisis is attempted and the individual is most conformable to
assistance in this phase. New problem solving measures may also affect a solution.
Return to pre-crisis level of functioning may occur. If problem solving is
unsuccessful, further disorganisation occurs and the individual is said to have entered
Phase IV.
Phase IV
Severe to panic levels of anxiety with profound, cognitive, emotional and
physiological changes may occur. Referral to further treatment resources is necessary.

Signs and Symptoms of Crisis

• The major feeling in a crisis situation is anxiety. The individual experiences a heavy
burden of free-floating anxiety.
• The anxiety may be manifested through depression, anger and guilt. The victim will
attempt to get rid of the anxiety using various coping mechanisms, healthy or
unhealthy.
• The individual may become incapable of even taking care of his daily needs and
may neglect his responsibilities.
• The individual may become irrational and blame others for what has happened to
him.

Resolution of Crisis
Healthy resolution of a crisis depends upon the following three factors:
1. Realistic appraisal of the precipitating event, i.e. recognition of the relationship
between the event and feelings of anxiety is necessary for effective problem-solving
to occur.
2. Availability of support systems.
3. Availability of coping measures over a life-time: A person develops a repertoire of
successful coping strategies that enable him to identify and resolve stressful
situations.

There are three ways by which the individual may resolve the crisis:
1. Pseudo-resolution
In this, the individual uses repression and pushes out of consciousness the incident
and the intense emotions associated with it, so there will not be any change in the
level of functioning of the individual. But in future, if and when a crisis occurs, the
repressed feelings may come to surface and influence the feelings aroused by the new
crisis. In such a situation, the particular crisis may be more difficult to resolve because
the feelings associated with the earlier crisis are neither expressed nor handled at that
time.

2. Unsuccessful Resolution
In this, the victim uses pathological adaptation at any phase of crisis, resulting in a
lower level of functioning. The victim, rather than accepting the loss and reorganising
his life, keeps ruminating over the loss. An example is prolonged grief reaction, which
results in depression.

3. Successful Resolution
In this, the victim may go through the various phases of crisis, but reaches Phase III
where various coping measures are utilised to resolve the crisis situation. The
individual develops better skills and problem solving ability, which can be and will be
used in various situations in future.

CRISIS INTERVENTION/MANAGEMENT
Crisis intervention is a technique used to help an individual or family to understand
and cope with the intense feelings that are typical of a crisis.
Community health practitioners function as part of the interdisciplinary team in the
use of crisis intervention as a therapeutic modality.
Community health practitioner may employ crisis techniques in their work with high-
risk groups such as clients with chronic diseases, new parents and bereaved persons.
Community health practitioner may also use crisis intervention in dealing with intra-
group staff issues and client management issues.

Aims of crisis intervention technique

• To improve a correct cognitive perception of the situation.
• To assist the individual in managing the intense and overwhelming feelings
associated with the crisis.

Intervention
A. Steps to provide a correct cognitive perception
I. Assessment of the situation
• This may be achieved by direct questioning with the purpose of identification of the
problem and the people involved.
• It is necessary to identify the support systems available and to know the depth in
which the individual’s feelings are affected.
• Assessment should also be done to identify the strengths and limitation of the
victim.

II. Defining the event

• The victim at times may not be able to identify the precipitating event because of
possible denial, or due to reluctance to talk about it.
• It may be necessary for the therapist to review the details of the incidents in the past
2 to 4 weeks in order to identify the event that precipitated the crisis. Such a review
will also help to bring the precipitating event to the awareness of the victim.

III. Develop a plan of action

• The victim and the people closely associated with him should have actual
involvement in developing the plan of action.
• The therapist must be aware that the victim may not be in a condition mentally to
comprehend complicated information due to the overwhelming anxiety experienced
by him. The instructions given by the therapist must be simple and clear, and too
much information should not be given at a time. The instructions may have to be
written down, as the victim may not be able to retain all the information.

B. Steps to assist the victim in managing the intense feelings

I. Helping the individual to be aware of the feelings

• The victim needs help in identifying his own feelings, which is the first step in
handling them.
• The therapist should use appropriate communication technique so that the victim
will feel comfortable to express his feelings without the fear of being judged or
criticized.
• The therapist also should be efficient in observing the non-verbal and verbal
behaviour of the victim, so that he will be able to make a careful assessment of his
feelings.

II. Helping the individual to attain mastery over the feelings

• The individual should be given adequate support and guidance through the
therapeutic process in order to handle the feelings associated with the crisis but
special care should be taken not to give any false reassurance.
• He should not in any way be encouraged to blame others, as this will only let him
escape from taking any responsibility.
• Care must be taken that the individual may not develop too much dependency on the
therapist, which is unhealthy.
• After the victim and the support groups make the plan of action under the guidance
of the therapist, this should be discussed with the victim and the concerned others, so
that they will have a clear understanding of the methods of implementation of the
plan.
• To improve coping with the situation necessary environmental manipulation must be
done in physical or interpersonal areas.
• It is advisable to have another appointment for the victim to visit the therapist within
a week, in order to assess how the plan is working out, and if needed, to revise and
modify the plan.
GRIEF
Grief is a subjective state of emotional, physical and social responses to the loss of a
valued entity. The loss may be real, in which case, it can be substantiated by others
(e.g. death of a loved one) or perceived by the individual alone, in which case, it can
not be perceived or shared by others (e.g. loss of feeling of femininity following
mastectomy).

Stages of Grief
Kubler-Ross (1969) having done extensive research with terminally ill patients
identified five stages of feelings and behaviours that individuals experience in
response to a real, perceived or anticipated loss:
Stage I-Denial
This is a stage of shock and disbelief. The response may be one of “No, it cannot be
true!”. Denial is a protective mechanism that allows the individual to cope within an
immediate time-frame while organising more effective defense strategies.

Stage II-Anger
“Why me?” and “It is not fair!” are comments often expressed during the anger stage.
Anger may be directed at self or displaced on loved ones, caregivers and even God.
There may be a preoccupation with an idealised image of the lost entity.

Stage III-Bargaining
“If God will help me through this, I promise I will go to church every Sunday and
volunteer my time to help others”. During this stage, which is generally not visible or
evident to others, a bargain is made with God in an attempt to reverse or postpone the
loss.

Stage IV-Depression
During this stage, the full impact of the loss is experienced. This is a time of quiet
desperation and disengagement from all associations with the lost entity.

Stage V-Acceptance
The final stage brings a feeling of peace regarding the loss that has occurred. Focus is
on the reality of the loss and its meaning for the individuals affected by it.
All individuals do not experience each of these stages in response to a loss, nor do
they necessarily experience them in this order. Some individuals grieving behaviour
may fluctuate and even overlap between stages.

Resolution of Grief
Resolution of the process of mourning is thought to have occurred when an individual
can look back on the relationship with the lost entity and accept both the pleasure and
the disappointments (both the positive and negative aspects) of the association. Pre-
occupation with the lost entity is replaced with energy and desire to pursue new
situations and relationships.
The length of the grief process may be prolonged by a number of factors:
1. If the relationship with the lost entity had been marked with ambivalence, the
reaction to the loss may be burdened with guilt, which lengthens the grief reaction.

2. In anticipatory grief where a loss is anticipated, individuals often begin the work of
grieving before the actual loss occurs. Most people experience the grieving behaviour
once the actual loss occurs, but having this time to prepare for the loss can facilitate
the process of mourning, actually decreasing the length and intensity of the response.

3. The number of recent losses experienced by an individual also affects the length of
the grieving process and whether he is able to complete one grieving process before
another loss occurs.

Maladaptive Grief Responses

Maladaptive grief responses to loss occur when an individual is not able to
satisfactorily progress through the stages of grieving to achieve resolution. Several
types of grief responses have been identified as pathological (Lindemann (1944),
Parkes (1972)].
These are prolonged, delayed/inhibited and distorted responses.
1. Prolonged Response
It is characterized by an intense preoccupation with memories of the lost entity for
many years after the loss has occurred.

2. Delayed or Inhibited Response

The individual becomes fixed in the denial stage of the grieving process.
The emotional pain associated with loss is not experienced, but there may be evidence
of anxiety disorders or sleeping disorders. The individual may remain in denial for
many years until the grief response is triggered by a reminder of the loss or even by
another unrelated loss.

3. Distorted Response
The individual who experiences a distorted response is fixed in the anger stage of
grieving. The normal behaviours associated with grieving, such as helplessness,
hopelessness, sadness, anger and guilt are exaggerated out of proportion to the
situation. The individual turns the anger inward on the self and is unable to function in
normal activities of daily living.
Pathological depression is a distorted grief response.

Treatment
Normal grief does not require any treatment while complicated grief requires
medication depending on the prevailing behaviour responses.

Health Care Intervention

• Provide an open accepting environment.
• Encourage ventilation of feelings and listen actively.
• Provide various diversional activities.
• Provide teaching about common symptoms of grief.
• Reinforce goal-directed activities.
• Bring together similarly aggrieved persons, to encourage communication, share
experiences of the loss and to offer companionship, social and emotional support.

ASSIGNMENT
Describe the processes involved in maintaining mental health