Clinical Practice Guidelines for Assessment and Management of Patients Presenting with Psychosocial Crisis

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INTRODUCTION

Traumatic and crisis inducing events are increasing in the world. The spectrum of crisis events includes both public events that have a significant social impact, such natural catastrophes that affect entire communities, airplane crashes, or terrorist attacks, and private events, including interpersonal domestic violence, suicide attempts, the loss of a loved one, or the start of serious physical or mental illness. A person’s life can change dramatically as a result of exposure to a crisis situations and incidents. Crisis situations and natural disasters, which disrupt daily life, can affect every community. A crisis frequently involves adversity, which are defined by a very distressing state of uncertainty, a perceived threat to core beliefs, and disruptions to daily routines. Crisis can be a challenge or an opportunity for efficient problem solving and growth, or it can be a crippling event that results in sudden disequilibrium, unsuccessful coping mechanisms, and dysfunctional behavioral patterns.[1] Crisis are also distinguished in two main ways. A one-time, acute single event crisis or more chronic state of crisis also sometimes called as complex trauma. Terr also used the term type 1 and 2 crisis for the above subtypes, respectively.[2]

Crises may have a significant impact on a person’s health, functioning, and general well-being. Stress, worry, uncertainty, physical discomfort, and trauma-related mental health issues are typical outcomes. Health effects due to exposure to crisis have been studied extensively, and in recent decades there has been an emphasis on various mental health consequences including post-traumatic stress disorder (PTSD). Several other psychiatric disorder like major depression, anxiety disorders, dissociative disorders, substance use disorders, personality disorders, etc., are reported to be having higher prevalence in people exposed to traumatic events of different kind in various phases of the life. However, the disorders specifically related to exposure to crisis, trauma, and stress are grouped separately both in ICD-11 and DSM-5. For these disorders, exposure to stressor in necessary for making a diagnosis. The details are given in following Table 1 .

Table 1

Disorders related to stress in ICD-11 and DSM-5

The crisis interventions have a very long and rich history. The evidence for successful application of psychotherapeutic interventions in military settings were reported since long.[3] The politicians, administrators, other policymakers, at the society and local community level, should better understand psychosocial difficulties and problems encountered after traumatic events exposure for facilitation of service provisions and health force training and supervision.

This clinical practice guideline aims to integrates psychosocial principles of crisis intervention. The model of psychosocial crisis management (PCM) describes how the tasks of crisis managers or crisis intervention workers (CIW) can be guided by principles of psychosocial support. Crisis management insights and psychosocial support principles originated from different several different disciplines and research. Currently, integrating strategies from various models helps in formulating better guidelines and strategies.

Several different models of early interventions were tried in forms of disaster mental health programs, crime crisis intervention, or community mental health-based crisis intervention for early identification and help of the individuals suffering from the effect of crisis. Experts have cautioned, nonetheless, that even if a great desire and willingness to assist is not based on factual and scientific strategies, it may be ineffective or even detrimental to the clients.[4]

Crises are disruptions with a potential psychosocial impact [ Table 2 ]. The psychosocial dimension of crisis management, and can, therefore, strengthen crisis management in general. Crisis often refers to normal stresses and strain. Each crisis has a continuum, from negative to positive, and the resultant outcome depends upon a balance between the two opposing forces. Crisis in the context of current context is defined in specific terms. The following are important terms in context of crisis intervention.

Table 2

Components of crisis

Roberts defines a crisis as “a period of psychological disequilibrium, experienced as a result of a hazardous event or situation that constitutes a significant problem that cannot be remedied by using familiar coping strategies [ Figure 1 ].”[1] An intensely stressful, traumatic, or serious event combined with the person’s faulty perception resulting into psychological disruption and the individual’s inability to resolve it are the primary factors requiring crisis intervention. Coping mechanisms that could have helped the person cope are either insufficient or not used at all. Later, James and Gilliland define crises as events or situations perceived as intolerably difficult that exceed an individual’s available resources and coping mechanisms.[5]

Core conceptualization of crisis

Critical incident is a term which refers to an event which is exceptional and outside the individual’s usual range of experience and challenges one’s ability to cope successfully. The critical incident has the potential to cause a crisis condition by overwhelming one’s usual psychological defenses and coping mechanisms [ Table 3 ].

Table 3

Factors influencing reactions to the crisis

Coping behaviors are active efforts to resolve stress and create new solutions to the challenges of the situation. Coping involves the ability to gain and process new information; the ability to maintain control of one’s emotional state; and the ability to move freely within one’s environment. Coping behaviors are the source of new, original, unique, and creative solutions or behaviors. In this process, one develops adaptive ego functions that provide resources for coping in the subsequent stages or situations. If a crisis is not resolved in a positive manner, it can lead to destructive forces and psychopathology.

Few examples of crises

Death/loss of a loved one,

Onset or deterioration of Physical illness,

Clinicians need to address the level of distress, impairment, and instability in a rational and methodical way while confronted with a person in crisis.[5] Although, many clinicians may be aware about the best approaches for the crisis intervention, being in stressful situations, they may revert to strategies that are less than effective. Hence, it is important to have a quick and useful reference guide for do’s and don’ts for crisis intervention workers [ Tables 4 - ​ -6 6 ].

Table 4

Characteristics of the crisis intervention

Table 6

Factors influencing long term recovery

Immediate aftermath of acute crisis event, there are factors that help in long-term recovery and prevention of adverse sequalae over a period of time.

Several practice models have been developed to help in assessment and intervention during crisis intervention over the years.

MODELS OF CRISIS ASSESSMENT AND INTERVENTION

Models of assessment

Triage Assessment System: it was developed by Myer,[6] who proposed to assess crisis reactions in three domains:

Affective (emotional) reactions: include three pairs of emotions anger/hostility, anxiety/fear, and sadness/melancholy. If more than one pair of emotions are present, it is rated as primary, secondary, and tertiary. Accurate assessment of primary emotion provides an opportunity to deal with the feeling and proving appropriate support.

Cognitive (thinking) reactions: client’s perception of how the crisis has affected, is affecting or will affect his or her physical, psychological, social, and moral/spiritual life. The perceptions may include transgression, threat, and loss.

Behavioral (actions) reactions: include approach/avoidance and immobility. It may be constructive or maladaptive.

Each domain is rated on a scale of 1 (no impairment) to 10 (Severe impairment). The score of all the domains is added together to give an overall severity. The higher is the severity, the more is the impairment.

In addition to this, the client assessment includes assessment for suicidality, lethality, risk of harm to others, etc., based on the clinical situation. The details of these aspects are not included in this guideline and can be seen at other relevant places.

MODELS OF MANAGEMENT

1. Gilliland’s Six-Step Model: it was developed by James and Gilliland[5] and is a useful crisis intervention model. It includes three listening and three action steps.

A few important components of listening are observing, understanding, empathetically responding, respect for the client, acceptance, non-judgmental attitude, and caring. Action denotes those steps done in a nondirective and collaborative manner. It is also important to assess the needs of the client and the environmental supports available to him.

2. Seven-Stage Model of Crisis Intervention: It was developed by Roberts[1] and it contains the following seven stages:

i. Conducting a thorough biopsychosocial and crisis assessment (including assessment of suicidal and homicidal risk, need for medical attention, drug, and alcohol use, etc.).

iii. Examining and defining the dimensions of the problem or crisis (including Identification of the precipitant to the crisis).

iv. Exploration of feelings and emotions mainly by actively listening and responding with encouraging statements.

vi. Implementation of the action plan. It is important to identify supportive individuals and contact referral sources

Location

Location of crisis intervention strategies is dependent on the crisis intervention program, target population, and available resources. Crisis intervention is offered in clinical settings including emergency settings, makeshift offices in disaster sites, military settings, workplace, schools, and in community outreach centers or at homes. Additional factors influencing location might be local norms, culture, stigma of mental health, and administrative support, etc.

MANAGEMENT

Pharmacological treatment

The choice of treatment is determined by several factors. Availability of treatment options, time and resources available, and choice of treatment by the patient are some of the important considerations. Although, psychological interventions remain the treatment of choice, unavailability of therapist, unwillingness, or inability of the clients to undertake psychological interventions are important reasons for choosing pharmacological treatment options. In practice, most patients with sufficiently severe psychopathology receive a combination of pharmacological and non-pharmacological interventions. The pharmacological treatment options available have following important caveats that all medications have some potential for adverse reactions and the empirical base for effectiveness of pharmacological treatment options is limited.[7] Hence, the treatment approach remains symptom based and empirical. SSRIs are considered the first line agents. However, SDAs, mood stabilizers, sedative/hypnotics, and antihypertensives are commonly used for the management of symptoms. Best practice prescribing strategies are followed for drug treatment. It primarily includes information prior to commencement, regular monitoring of response, adverse effects, and suicidal risk. Minimum number of medications is used, and polypharmacy is avoided as far as possible. Appropriate discontinuation and withdrawal practices are followed [ Table 7 ].

Table 7

Commonly used medications for psychiatric conditions related to stress

Psychological interventions

The crisis intervention strategies are offered in various settings including outpatient psychiatric clinics, community mental health centers, counseling centers, or crisis intervention settings.

Crisis theory is developed over a period of time using inputs from a variety of disciplines and schools of thought. The commonly used crisis intervention models nowadays are often eclectic mixtures of psychoanalytic, existential, humanistic, cognitive-behavioral, and family system theories.[8]

Crisis interventions (CI) are problem-focused, brief mental health interventions that are typically used within 4 to 6 weeks of exposure to a stressor or crisis. It is one of the most commonly used time-limited treatment modalities in the world.[9] This clinical practice guidelines outline broader model and approaches useful in crisis situations. The crisis intervention worker can adapt it appropriately according to the local cultural and contextual issues. An earlier clinical practice guidelines of Indian psychiatric society has been developed for supportive psychotherapy which deals with a related topic.[10] It can also be referred for additional information and further details.

The mental health needs of the people exposed to a significant stressor or crisis are different and distinctive. Several different models of interventions are available. This article doesn’t aim to comprehensively elaborate and enlist all the available models. Although each situation and client’s needs are different, a few common steps can be applied across the situations. It is aimed to discuss common components of these models and essential strategies found successful across different models.

Crisis intervention can be offered in multiple settings to a variety of individuals or groups including primary and secondary victims. The deceased, the injured, and their family and friends are examples of primary victims because they were directly involved in the critical event. The term “secondary victims” refers to anyone who is somehow witnesses to the immediate traumatic consequences on the initial victims, such as eyewitnesses, rescuers, and converging rescuers. Accordingly, the strategies can be for individual or group settings. A broad range of possible crisis and individual reactions, the severity of distress, and the use of coping strategies call for a reasonable individualization in approaches for every situation [ Table 5 ]. A variety of professionals can conduct crisis intervention (CI). A psychiatrist, a clinical psychologist, psychiatric social worker, or psychiatric nurse can learn to use these skills and can conduct successful crisis intervention. For this document, for the brevity of writing, any professional conducting CI is referred to as crisis intervention worker (CIW).

Table 5

Primary aims of the crisis interventions

The important steps of crisis intervention are discussed below [ Figure 2 ].

Core conceptualization of crisis intervention

Establishing a rapport

There are certain general strategies for establishing and strengthening rapport with the client. Many clients have limited attention span, feel distracted, have difficulty at focusing, or are extremely anxious owning to emotional upheaval after experiencing a psychosocial crisis. The crisis intervention worker should be vigilant about these issues and make appropriate alterations in the interview style for the same. Initial success in crisis intervention is largely dependent on the crisis intervention workers’ ability to put the client at ease and alleviate these emotional reactions. Asking small questions, and frequently checking if the client can understand and appreciate what is being said is important.

At the beginning of the interview, crisis intervention worker has to introduce himself/herself and need to inform the reasons for speaking to the client. Unless the reason for the consultation is implicit (the client himself/herself has come to the crisis intervention workers), crisis intervention workers should take consent for further proceeding. The crisis intervention workers should also inform about the nature of the interview and the approximate amount of time needed. The client is informed that they are free to make suggestions regarding the intervention format and they will not be pushed to talk or cooperate against their wishes.

The information regarding privacy and confidentiality is also provided to the client. The information is shared with others only if there is a serious concern related to the safety and security of the client or relevant others (e.g., suicidal or homicidal intent).

A respectful, non-judgmental, and considerate environment is created during the interaction. Clients are often going through considerable distress, emotional pain, and feeling vulnerable and uncertain about several things. It must be acknowledged, and due consideration is given during the interaction. This respectful and considerate environment significantly contributes to the development of rapport.

Few key clinical skills are discussed in this regard

Active listening- The most basic yet most important skill in psychological therapeutic interventions remains active listening. Active listening is paying attention to the verbal and non-verbal speech of the client and ongoing reactions to it so that clients know that they are being heard and understood. The components of active listening include adequate eye contact, attentive, and encouraging body language like appropriate head nodding, slight leaning toward the client while talking, appropriate facial/hand gestures, and vocal style showing concern.

Questioning techniques- A combination of open-ended and closed-ended questions is used during the interview. As usual, it is better to start with open-ended questions and gather information. Close needed questions are useful in completing important areas which are missed like the further elaboration of the information provided till now and evaluating the risk of suicide/homicide or other risky behaviors. Certain interviewing techniques are also useful.

Clarifying: It aims at clearly understanding what is being said. The crisis intervention workers may ask questions to clarify and to also show that he/she is actively listening.

Paraphrasing: Crisis intervention workers restate what clients have already spoken in simpler words emphasizing factual and cognitive aspects.

Summarizing: Summarizing is used to bring focus to the most important aspects of crisis intervention workers’ understanding. Feedback is taken from the client so that both mutually agree on the extent of the problems and difficulties.

Reflection: Reflection is a statement that emphasizes the affective or emotional part of verbal or nonverbal speech of the client, e.g., sounds like you are angry with your boss, you seem to undergo humiliation while living with xxx. Reflection is a powerful technique to express empathy. Expressing empathy means letting the client know that crisis intervention worker understands the emotions and feelings being experienced by the client.

Matching and mirroring nonverbal communication: Consciously matching and mirroring the postures, gestures, and facial expressions in subtle way improves rapport and communication.

It is also important to note that crisis intervention workers should avoid confrontation, getting into debates and argument with the client. It should be accepted that every client’s situation, needs, and context are different and “clients” are expert in their situation. Whenever appropriate, taking “one-down position” to client is useful to foster better therapeutic relationship in many situations.

Evaluating the problem

Crisis intervention workers need to evaluate several aspects of the crisis. The areas of inquiry include precipitating event, client’s perceptions of meaning and reasons of the event, amount of subjective distress, and identifying different emotions being experienced by the client, as well as functioning in various areas of life like personal, familial, social, academic, and occupational, etc. The client’s level of comfort and amount of distress is monitored while talking about the event. It is important to know that the clinician does not have to know everything about client’s difficulty and the goals in order to successfully provide crisis intervention effectively. Exact and minute details of the event are not important and even maybe counterproductive to ask.

Therapeutic strategies

Assessment of the client’s perception is one of the most important tasks in crisis intervention. This aspect is often the most important target for intervention in crisis intervention. It is the perception of the client and his/her ability to cope with the event that led to the current problem. Once the cognitions, perceptions, meaning of the event, and frame of reference regarding various aspects of the event are assessed, crisis intervention worker aims at addressing them to identify the thinking errors made by clients and alter these cognitions into more adaptable and helpful cognitions. This strategy of cognitive restructuring is an essential aspect of crisis intervention. Once this has been achieved, it leads to a reduction of the accompanying emotional distress. Usually, the dysfunction and distress originate from the following areas.

The subjective distress and functioning levels of the client need to be independently assessed. It is helpful for the client if they can ventilate their difficult emotions, distressing feelings, and other associated behavioral and somatic symptoms. Functioning should be assessed in each area as improving functioning early during the treatment process is an important goal of therapy.

Identifying and evaluating medical, psychiatric (including suicidal, homicidal, and substance use-related issues), social, and legal needs are other important tasks. These needs may be contributing to the effective application of healthy coping strategies. Appropriate referrals must be made once a client needs help in an important area that falls outside the expertise area of crisis intervention worker.

Solution focused approach- The emphasis is on finding solutions rather than solving problems. The therapeutic skills are asking questions that achieve solutions through “solution talk or change talk” in comparison with “problem talk.” It is assessed that what has not worked till now. It is conveyed to the client that there are several approaches to feel better and improve in the current context. Emphasis is placed on the setting goals for future. It is important that goals are set by the client themselves and these are SMART (specific, measurable, achievable, realistic, and time limited) as far as possible. Goals should be stated in positive rather than negatives, i.e., rather than “I want to stop feeling depressed” or “I don’t want to keep laying all the day” it can be “I want to feel peaceful and safe” and “I want to start visiting markets and shops for my daily needs.”

During next part of the intervention, a few other strategies are also used as therapeutic interaction in crisis intervention.

Education: It is important to educate the clients about the universalities of crisis in human life as well as perceptions and emotional reactions of other people who have experienced similar events, e.g., although unfortunate, about 30% of women have experienced intimate partner violence in marriage. It is common to experience sadness, anger, and helplessness during this time. However, there is a lot that can be done to improve the present situation and future risk of violence by your spouse. This educational information may lead to a reduction in the feeling of loneliness as well as empower the clients to take appropriate action. Many clients suffer due to a lack of reliable information and a tendency to unreasonably blame themselves. Educational statements may include information related to statistics, frequency, psychological impact, social perspective as well as scientific understanding of the issues related to crisis events.

Empowerment: The process of becoming stronger and more confident, especially in controlling one’s life and claiming one’s rights. These statements are offered as a part of enabling the application of appropriate coping skills and healthy behaviors as part of recovery. Many clients believe that they have failed in anticipating or stopping the event hence they are unable to do so in the future also. They may also blame themselves or consider themselves weak, wrongful, or wicked. It is important to bring change in this perspective. Clients are presented with various choices and strategies to respond better presently. Crisis intervention worker who offers advice to and generate solution may sometimes quicken the crisis resolution; however, it may not lead to client empowerment. Concept of empowerment is helpful in improving resilience hence is helpful for current crisis as well as enable clients to deal with similar situations in the future more effectively.

Validation: Validation is defined as recognition or affirmation that a person or their feelings or opinions are valid or worthwhile. During the treatment process, crisis intervention worker reassures and supports the clients often that the emotional experiences and distress experienced are normal after experiencing such a crisis and it will get better. The aim is also to encourage adaptive and helpful coping strategies for the clients. However, the validation and support statements are not the ones that may be perceived as false or empty. The clients often listen from well-meaning friends and family members that “Don’t worry,” “Everything will be okay,” and “You are strong and get through this.” Crisis intervention workers are experts in dealing with such situations hence validation and support come from a deeper understanding of the client’s unique difficulties as well as a scientific understanding of the recovery process.

Reframe: The clients often have cognitive errors and may have a wrong frame of reference while interpreting crisis events. The clients are encouraged to adopt a realistic frame of reference.

Coping

At the end of the crisis intervention, crisis intervention worker should aim to summarize the formulation of the client’s problem from the medical point of view, address cognitive re-structuring related to events and discussions focus on successful coping strategies.

As the rapport with the client is established, the client starts becoming more comfortable due to a reduction in distress levels; he/she is encouraged to take a more active part during the interaction. The client is encouraged to enlist what they have been trying to do to cope with the event till now. Crisis intervention workers should focus on identifying and working with the client’s strengths. Emphasizing strengths rather than deficits can help in facilitating better engagement and success of intervention. Earlier research has found that clients want therapist to think positive about them. Making hostile, rejecting, critical, or blaming comments elicit negative reactions toward therapy and therapist. The impact of coping strategies used so far is jointly evaluated. It is attempted to distinguish healthy/adaptive coping strategies from unhealthy/maladaptive coping strategies [ Table 8 ].

Table 8

Few examples of coping strategies which can be useful after facing a crisis

The client is asked to suggest a list of healthy/adaptive coping strategies that they can use in the present and future to deal with the undergoing crisis. Once the client has exhausted their ideas about coping strategies, the crisis intervention workers can also suggest some of the coping strategies which the client is not able to think of or is unaware of so that it can be discussed if these are practical strategies and can be of use to the client. Joint decision-making is encouraged at this stage. However, if the client is not able to focus, unable to come up with possible coping strategies, or is indecisive regarding the practical utility of the strategy, they may be encouraged to try the technique and discuss its impact with the crisis intervention workers. Possible hurdles to the implementation of the strategies discussed are also inquired about. Once the list of hurdles, e.g., not having the motivation to go for a walk, feeling fatigued at the end of the day so that could not engage in my favorite hobby, not having the courage to make a call to my old friends as I have not connected with them for quite some time, etc., have been gathered, both crisis intervention workers and clients can jointly find out the plan to handle important issues. This activity significantly increases the chances of successful implantation of the discussion that happened in the session.

Some other approaches found useful

Support groups: The client may be encouraged to get in touch with local support groups. It might be more comfortable for the clients to receive support from a natural support group like peer groups, relatives, friends, religious groups, or co-workers if any such possibility is available to the client. There can be few organized peer support groups in certain parts of the country. The client is encouraged to try seeking the help of such groups.

Journaling: Clients may find it helpful to keep a journal. Crisis intervention worker may encourage clients to maintain a secret/personal journal. Writing once thoughts, emotions, and other experiences allows the person to evaluate these more objectively. This is helpful in the recovery process for several individuals.

Bibliography: There are several good books/websites/reading materials available for dealing with different kinds of crises. Advising quality reading material to interested clients is often helpful to people who like to read. Such resources are often developed both by experts and first-person accounts of persons who have gone through a similar crisis are available. Keeping a list of such resources and advising capable clients to use is helpful in several instances.

Medical and legal referrals: Many clients may require medical and legal referrals but may be avoiding the same due to several reasons. The crisis intervention worker can direct them to seek appropriate referrals and can help in making some provisions in this regard with any other helping agency, if available.

There are several specific models for crisis intervention that are developed over a period of time for different situations. A few of the important models are summarized below.

Psychological First Aid (PFA):[11] PFA is defined as a “humane, supportive response to a fellow human being who is suffering and who may need support.” PFA is aimed offered to the people who have immediately experienced extremely stressful events. This model of care takes into account both psychological and social aspects of care needed for persons during the early course of exposure to stressors. Special attention is given to focusing on the preservation of the dignity, culture, or abilities of the person to whom the intervention is being offered. The evidence of PFA has been compared with psychological debriefing and it was found that PFA is superior to psychological debriefing in crises. The strategies of PFA have evidence of successful application in low and middle-income countries and these can be offered even by non-professional people also. PFA can be used by non-professionals and professional both. Booklet of PFA is available for free download from https://www.who.int/publications/i/item/9789241548205 (Last accessed 22 June, 2022).

Critical Incident Stress Management (CISM):[12]

CISM is evolved from earlier CI programs and group psychological debriefing techniques. CISM was originally developed for emergency service personals like fire department, first line police, rescue or disaster teams and military settings. It is defined as an integrated, multicomponent, and comprehensive intervention program useful for both the primary and secondary victims. The strategies are included for pre-crisis preparation, acute crisis intervention, and post-crisis management. Both individual and group strategies are incorporated usually lasting from 4-12 sessions. Pre-crisis preparation may be thought of as a form of “psychological immunization.” The aim of this phase is to strengthen potential psychological vulnerabilities and enhance resilience in individuals specifically who are at risk of developing crisis reactions. It includes providing information so as to have realistic expectations about the stress responses. It also incorporates stress response management, behavioral regulation, improved coping, and practical strategies to help and support each other for people involved.

CONCLUSION

Crises are common human experiences and a subset of vulnerable people develops clinically significant difficulties necessitating intervention. Evidence-based clinical interventions are available that can be offered to persons in need. Typically, therapeutic interventions needed for crises are offered as early as possible, is problem focused, simple and brief. Therapeutic strategies used in crises are often derived from an eclectic mix of strategies from various psychological intervention models. The major clinical issues are assessed in domains of cognitive, emotional, and behavioral domains. Interventions are focused on handling psychological reactions as well as providing help, information, and support regarding social issues, if feasible.

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Conflicts of interest

There are no conflicts of interest.