Focus on Mental Health

Crisis Intervention In Office Practice

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

Routinely, primary-care physicians are faced with requests from their patients to solve a wide range of psycho-social problems. Many physicians do not consider themselves competent to work with their patients to formulate the problem in a way that practical solutions can be developed within the time limitations of a general office medical practice. Crisis intervention provides a theory and treatment model that can be readily applied to helping patients with their psycho-social problems. Patients entering crisis treatment should expect that they will be treated immediately and recover from crisis. Patients can be treated while living in their natural environment, and should be able to return to normal life as soon as possible.

The purpose of this document is to review crisis intervention in office practice. Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. The document encourages mental health policy-makers to shift the responsibility to the primary care sector. Although professional training in mental health for primary care workers exists in many countries, it is not rigorously evaluated. World Health Organization (WHO) has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy.

History of Crisis Theory:

During World War I Thomas Salmon (1917) a British military physician, was asked to evaluate severe "shell shock", which was producing a psychological paralysis in allied soldiers. He discovered that the French soldiers suffered less psychological causality from the horrors of wars than did the British soldiers. The factor that seemed to account for the French advantage was that French soldiers were told that they could expect to recover from their psychological trauma and they received immediate psychological treatment.

Eric Lindermann (1944) applied and expanded on Salmon's theories. He studied the acute grief reactions of many individuals who had lost family members in the Coconut Grove fire, a disaster in Boston that claimed approximately 500 lives. He discovered that normal people, surviving such a horrific experience, develop an emotional crisis of pain, confusion, anxiety, and temporary difficulty in daily functioning. He found that these reactions are natural states that last for about 6 weeks. He also noted that the psychological trauma caused by the crisis had little relation to preexisting psychiatric illness. Instead, the outcome of the crisis was more closely related to the severity of the stressor, the personal reaction to the trauma, and the effect the trauma had on the person's support network of family and friends. He found most survivors recovered spontaneously, and a smaller group seemed to decline to a low level of functioning.

Eric Erickson (1959), a sociologist, introduced the idea of a life cycle comprised of development stages and crises. He described 8 periods throughout the life span that involved age-specific. He described adolescence as a period in which a normal individual seeks an adult identity with social roles that eventually permit autonomy, away from parents. Those who cannot successfully traverse this crisis period do not progress from their child-like dependence on parental figures. Erickson described normal developmental crisis throughout the life cycle that must be worked through and resolved if a person is to be able to progress successfully into next life phase. His basic concept of "developmental crises" has been expanded to include crises such as leaving home for the first time, midlife crisis, and parents experiencing the "empty nest syndrome". For many patients, a crisis is experienced at transitional points between life phases, such as the crises of marriage, divorce, retirement, and death.

Gerald Caplan (1961, 1964) synthesized many of these earlier ideas into modern-day crisis theory and treatment. He defined the crisis state as a brief personal psychological upheaval precipitated by a stressor, or "hazard", that produces emotional turmoil such that persons are temporarily unable to cope, adapt, or function in their daily activities. A crisis implies both a potential for danger and an opportunity for growth. He added that a crisis might also be based on failure of a person's individual coping style and ability to adapt. Caplan confirmed that most crises resolve in about 6 weeks with four possible outcomes: (1) improved functioning; (2) functioning restored to pre-crisis levels; (3) incompletely restored functioning with a susceptibility to the development of future crises; and (4) a severely impaired, but stable, level of lower functioning. Some individuals coped with a crisis by spontaneously and flexibly developing novel coping or problem-solving styles and developed a crisis treatment that focused on developing better coping mechanisms and adaptations to life's trauma.

Evaluating the Crisis:

When a crisis develops, it may be evaluated and treated by understanding the interplay of the elements or the dynamics that contributed to its formation. These elements are the normal equilibrium state, precipitant or stressor, the personalized interpretation or meaning of the events to the individual, the crisis state, the selective history, the system of social supports, and the preexisting personality or psychiatric condition.

Crisis State: The crisis state has been defined as a brief psychological upheaval that is precipitated by a stressor. This upheaval produces an intense state of inner turmoil or disorganization that overwhelms a person's ability to cope and adapt. Patients who seek help while in a crisis have impaired normal functioning and may be in obvious psychological distress and pain. Typically, the pain of a crisis is so intense it is denied, unconsciously perceived as overwhelming distress, and may lead to an inability to cope. A family physician can assist in such cases by finding out "why now?" aspect of crisis. Answering this question initiates the crisis treatment and begins to facilitate resolution. Frequently, people in crisis do not seek help by themselves, but instead are brought in by concerned family members, friends or perhaps by the police or ambulance. Successful resolution of a crisis can be growth promoting and can lead to improved functioning. For most patients, however, crisis resolution means a return to their normal baseline functioning. Denial of the crisis and its causes can lead to partial crisis resolution and continuing poor adaptations. Unresolved crises predispose a patient to future crises caused by even less stressful precipitants. In addition, these patients' stable functioning subsequently remains at a lower level.

Selective History: From a crisis point of view, the patient's history is relevant to help and resolve the current crisis. This telescoping and inquiry about how the patient's history relates to the current crisis may be difficult to untangle and understand. Many patients wishing to avoid the pain of the current crisis lead the physician to chronic complicated problems that cannot be helped in a single office visit. To avoid this situation, the physician must first try to understand the dynamics of the current crisis, and then look for similar events in the patient's past that are the same as, or have a configuration similar to that of the current situation. A selective history that relates to a current suicide attempt might include the timing, circumstance, and effects of past suicide attempts or hospitalizations, or the past precipitants of such suicidal behavior. Additional history of helpful deaths, separations, severe medical illnesses, depression, alcoholism, or family suicides is also helpful in understanding and the management of the patients. Selective history that might be relevant for violent crisis could include the timing and circumstances of past episodes of violence, childhood experiences of abuse or neglect, prior hospitalizations for violence, prior incarcerations, other legal problems, and past neurological or medical history.

Social Systems: Every individual lives within a network of social interaction and social support. In general, a stable, interested, helpful, available social support system tends to prevent crises. Sometimes a dysfunctional support system produces or contributes to the crisis. Relative damage to a support network can have profoundly different effects. The death of a spouse produces a more severe crisis if the deceased was also the sole financial provider. Even minor disturbance in a small or dysfunctional support network can produce a major crisis. To assess the support network, a family physician must consider if the network members are capable of helping, are interested, and are available.

Previous Personality or Psychiatric Disorder: For most people, there is no correlation between a previous personality or psychiatric disorder and their capacity to deal with a crisis. A schizophrenic may be just able to handle an acute crisis as others who do not have psychiatric problems. There are some cases in which a preexisting psychiatric disorder may cause or influence the development of a crisis. Those with severe personality disorders who have rigid coping styles are at risk for developing a crisis. They have less adaptive capacity to develop new coping styles to aid in the resolution of a crisis.

Crisis Intervention Treatment:

The focus of a crisis treatment is the evaluation of the precipitants of the crisis, the personal meaning of the events, the crisis state itself, the selective history, the support network and if relevant the current psychiatric illness. This information is used to formulate the causes of the crisis, so that specific problem-solving interventions may be used for crisis resolution. If crisis involves suicide, violence, or a life-threatening medical illness, these factors take priority over everything else and become the focus of the crisis treatment. The next priority level involves the immediate crises of a lack of food, clothing, shelter, or adequate medical care. Finally, the physician must examine the crises of everyday living. The crisis treatment should focus on the dynamic interplay of recent events over the last few days to 6 weeks that have contributed to producing the crisis. Important aids that can guide identification of the crisis components and treatment of these specific elements are the timeline, support network map, and wheel- and-spoke formulation of the crisis.

Timeline: A timeline is a pictorial representation of recent and past events that have led to crisis. Developing such a timeline with a patient helps focus on recent events and begins the process of formulating what can be done to help. A primary care physician can build a timeline of events with the patient by discussing the immediate crisis and working backward over the last 6 weeks, looking for precipitants, contributing events, and the selective history that relates to the current crisis.

Support Network Map: A support net-work map can be organized around the patient's genogram and immediate environment supports. This map includes the patient's immediate family, the family of origin for three generations, and all the people who are in the patient's immediate living environment, such as neighbors, landlord, and physician. In addition it is helpful to include close friends and the religious or social agencies that are or could be involved for the benefit of the patient. With this map of the patient's support network, a physician can help decide who needs to be more involved in the patient's care, who should be excluded, and what social, religious, legal, or economic agencies can be mobilized to assist the patient in crisis. To choose the most helpful participants, look for individuals and agencies that are interested, available, and capable of assisting.

Wheel-And-Spoke Formulation of the Crisis: It is important to develop a formulation that specifies the multiple causes of the crisis. The wheel-and-spoke format helps the clinician and patients identify and formulate the crisis, as well as focus on setting the priorities for problem resolution. This format can also be used to suggest any required specific acute treatment. A pictorial way to represent a case is to think of the acute crisis at the center of a metaphorical wheel. The spokes of the wheel are the problems that are thought to be causing, contributing to, or feeding into the crisis. The physician can establish the priorities regarding the problems that are to be solved and in what order. This list of priorities can be indicated by numbers. For each problem listed, the family physician can recommend a specific assessment or evaluation, tests or treatment approach that would be most helpful to the patient.

Coping Resolution Strategy:

Most individuals find ways to handle or cope with a crisis within 6 weeks. Crisis resolution can be promoted by evaluating a patient's coping style and when necessary, suggesting to the patient alternative or novel coping styles. These new skills facilitate a patient's adaptation to the stressful life circumstances that produced the crisis. Coping styles are the unique way patients deal with stress. Everyone has a repertoire of coping styles. The lists of some typical and some pathological coping styles are:

Coping Styles:
Source: Primary Care Psychiatry and Behavioral Medicine by Springer Publishing Company

Adaptive Coping Styles

Intuitive: using imagination, feelings, and perceptions to solve a problem
Logical/rational: employing carefully reasoned, logical, deductive approach
Trial and error: trying a random solution and, if it fails, modifying it and trying again
Help seeking: asking others for help
Informational: gathering information, then deciding
Wait and see: allowing time or circumstances to determine the outcome
Action-oriented: taking an action to immediately rectify the problem
Contemplative: quietly thinking over the problem before action
Spiritual: asking for God's direction
Emotional: using emotion such as anger or fear to help problem solve
Controlling: controlling other people or oneself to gain the power to solve the problem
Manipulative: using a variety of manipulative styles to solve the crisis

Pathological Coping Styles

Deceptive/antisocial: being dishonest, lying, cheating, or stealing to solve a crisis
Suicidal: using the threat of suicide to coerce someone or to solve a problem
Violent: using the threat of or actual violence to establish control and problem solve
Impulsive: using unpredictable or impulsive responses without anticipation of possible outcomes
Random/chaotic: employing an unproductive and extreme form of trial and error and impulsive style, often seen in prolonged psychotic states.

Crisis Resolution Strategy

Recognize the early warning signs of a crisis
Talk over the problem with a crisis practitioner or trusted friend
Discuss painful feeling and emotions
Identify the specific area of one's life most effected by the crisis
Decide who from the support system can help and hurt. Draw a support network map
Formulate the crisis. Use wheel-and-spoke
Obtain necessary information that will help in crisis resolution
Learn about coping style and suggest the use of a new or additional one that might help
Make a specific plan based on new information, newly discovered feelings, and choose a new coping style
Implement the plan for resolution of one of the causes of the crisis
Identify the stressor over the past 6 weeks. Develop a timeline
Assess the results. If positive, go to step 13; if negative, go to step 14
Tackle another cause of the crisis, and so on
Try again, get help, and then consult with a psychiatrist, if necessary.

The most difficult part of the crisis treatment, for both the physician and the patient, is developing the crisis formulation and problems list, setting the priorities of the treatment, and developing treatment options for each problem. Learn about the patient's current coping styles that he or she may have forgotten to use, and help the patient develop a new coping style.

World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS): Utility and Limitations

WHO-AIMS allows for multi-dimensional evaluation and provides much needed evidence-based data, which can be used to inform public mental health policy. It provides information about financing, provision of services, management, and other key components of the mental health system of each country. Since the WHO-AIMS criteria are standardized, it is easy to evaluate mental health systems' strengths and weaknesses. The synchronization of mental health data between countries in a systematic uniform method allows for cross-regional comparisons that facilitate a useful exchange of information and experience. Furthermore, collaboration with mental health experts from other countries has played a large role in informing policy and service development in many countries. It is comprehensive and easy to use for non-specialists to use. The domains covered by WHO-AIMS were determined by hundreds of global health policy experts over many years. Developing countries presumably do not have the resources to develop, as well as pilot, such a comprehensive model for assessing mental health systems. In spite of its comprehensiveness, WHO-AIMS provides a template for local professionals to collect information relatively quickly, with minimal training and at little cost.

While the parameters used in WHO-AIMS model are useful in assessing mental health systems, they do not include critical dimensions such as cultural values and political processes within many countries. Furthermore, the WHO-AIMS parameters have limited ability to describe the scope or degree of problems in a country or region's mental health services and policies. WHO-AIMS lacks a section detailing the cultural context of the region of interest. Societies have their own distinct idioms of distress as well as indigenous methods for coping, some of which are quite effective. In many cultures, changes in mood are attributed to social or spiritual stressors, which can often be addressed by the social support systems, alternative caregivers and traditional healers as opposed to, or in conjunction with, psychotropic medications.