| ADVANCING
YOUR PRACTICE
Crisis
counseling: Be prepared to intervene
By Helen Michalopoulos, RN, MSN, PhD, and Antigone
Michalopoulous, RN, MSN, PhD
During any crisis, especially
one involving a serious illness or death, patients and
their families may become overwhelmed by fear, anger,
and other powerful feelings. Crisis intervention is
a form of counseling that can help them cope until they
regain a sense of control over their life. You can establish
effective working relationships with troubled patients
by using good communication and interpersonal skills.1,2
If you’re an experienced
nurse, you may have been counseling patients for years
without realizing that you’re using a special
skill. In this article, we’ll examine counseling
skills in detail and discuss how you can refine them
to intervene effectively in various crisis situations.
Crises, predictable
or not
Life crises can be categorized as developmental or situational.
A developmental crisis is anticipated and predictable,
such as the stages of adolescence or a change in role
brought about by parenthood. In contrast, a situational
crisis develops from an unexpected event. Examples include
a traumatic loss of limb, the sudden death of a loved
one, and natural or manmade disasters.
Most crises you'll deal
with in hospitals are situational, but some involve
both types; for instance, when a woman in midlife (developmental
crisis) has a mastectomy (situational crisis).2,3
The anticipated death of a loved one, such as from cancer,
also involves both types of crises. The onset of cancer
is a situational crisis. The patient and his family
have time to prepare for the events to come, which may
help them deal with this developmental crisis effectively.
No one can predict whether
a given event will create a crisis because it depends
on how the individual perceives it. For most people,
the sudden death of a loved one or a life-threatening
injury or diagnosis triggers a crisis, but so can less
serious events, such as surgery (even a minor procedure)
and changes in function or capability. Loss of self-esteem
or change in body image can also trigger a crisis.
Patients in crisis feel
as though they’re losing control over their life.
Crisis intervention counseling helps support them until
they can regain control. Properly handled, it can provide
the opportunity for personal growth and the development
of effective coping mechanisms, which we’ll discuss
next.
How patients cope
with a crisis
Disequilibrium and disorganization are symptoms of the
most critical phase of a crisis, when the person affected
feels as if he’s losing control of his life and
surroundings. He feels confused because the balance
in his everyday life has been disrupted, creating new
situations and events that have to be solved. In this
phase, the person’s search for escape from a threatening
experience is hindered by distorted perceptions, irrationality,
and confusion.
Patients who cope effectively
with these symptoms focus on problem solving, avoid
blaming others, and express their feelings honestly.
Most important, they accept help. Those who employ ineffective
coping strategies-avoidance of the problem, denial of
emotional distress, blaming, and refusing help-may emerge
from the crisis weaker and prone to similar crises in
the future.
With crisis intervention,
you can encourage a patient to adopt effective coping
strategies. Without intervention, he may try to resolve
the crisis in a negative or destructive way, such as
by using drugs or alcohol or even by committing suicide.4
Building a framework
for effective coping
Someone who’s trying to cope with a crisis uses
a framework to put the incident in some kind of order.
This framework has three components: his perception
of the event, his external resources (such as his family
and other sources of support), and his internal resources
(his usual coping mechanisms).
His perception of the event
is that it constitutes an imposition and a threat to
him. It may change his hopes and plans, causing pain,
and he may need to protest. Feelings of anger may overwhelm
him as he asks, “Why me?” He may direct
his anger and hostility at you, his nurse, as he goes
through the steps of the mourning process. He may also
be agitated, hyperactive, and unable to concentrate.
Ideally he’d call
on family and other external resources for support,
but he may be too agitated and distressed to do so.
And because the event is unusual, his normal coping
mechanisms (inner resources) may not be sufficient.
If you can help him examine and work positively with
these three factors, you can help him defuse or manage
the crisis.
As his bedside nurse,
you won’t be able to provide long-term counseling
or problem solving. Your interventions should focus
on helping the patient deal with the problem himself,
in a positive and constructive way. As always, start
with a good assessment.
Assessing your
patient
To determine if the patient is in crisis, investigate
unusual behavior, look for a triggering event, evaluate
how involved the patient is in the problem, and assess
his ability to maintain his equilibrium—that is,
the balance of his life’s routine. As you assess
him, you’ll need to ask him about his support
system and his perception of the situation. For instance,
is he more concerned about the results of his biopsy
or the effect the results will have on his relationship
with his fiancée?
You’ll need to assess
how he’s dealt with crises in the past to evaluate
his strengths and weaknesses. For example, is he unusually
quiet? If he's not normally so quiet, this may be a
sign he’s having difficulty adjusting. Be sure
to document your findings so nurses on the following
shifts can assess for further changes. He needs counseling
if he experiences high levels of anxiety, has low self-esteem,
or is socially isolated.
Without being judgmental,
try to understand why the patient may exhibit negative
behavior. Expressing disapproval of his anger or other
difficult behavior would only increase his stress. Don’t
let your feelings influence your assessment of his stress
level.5
Timing is everything
Once you’ve identified a patient who needs crisis
intervention, how do you proceed? Good counseling requires
good timing, so before intervening, assess the patient’s
level of trust, his stress level, and the strength of
his defense mechanisms. If he’s very angry, for
example, he may have little tolerance for hearing another
perception.
Developing a sense of when
the time is right takes practice. Although many courses
are available to help you develop this skill, you’ll
learn the most from face-to-face interactions with patients.
The patient may need to
be challenged because he may be confused and anxious
about his upcoming surgery, for instance. Verbalizing
his possible feelings for him with phrases such as,
“You must be anxious about your surgery today”
or “It must have been difficult to arrange child
care while you were hospitalized” enables him
to express his feelings and concerns. Other therapeutic
communication techniques such as clarification and reflection
will help the patient to feel comfortable enough to
discuss the crisis he’s facing.
Genuine warmth
The three clusters needed for an effective therapeutic
relationship are warmth and genuineness, empathetic
understanding, and unconditional positive regard.
- For the patient and
his family to feel comfortable enough to reveal their
true feelings, they must feel that you’re approachable,
open, warm, and willing to treat them as equal human
beings without placing blame. Genuineness is a sincere
desire to improve the patient’s situation.
- For empathetic understanding,
you’ll try to imagine how your patient feels
and communicate this understanding to him. Of course,
because we’re all different, true empathy is
difficult. The greater your cultural sensitivity and
open-mindedness to the views of others, the greater
will be your potential for empathetic understanding.
- Giving your unconditional
positive regard means treating the patient with dignity
and as a worthwhile and positive human being. You’ll
need self-awareness to listen and attend without passing
judgment.3,6
Using counseling
skills
Use your therapeutic listening and attending skills
when you conduct crisis counseling. Listening requires
paying attention to the patient’s words; attending
is paying close attention to nonverbal messages so you
fully understand the patient’s state of mind.
Listen for the meaning behind his words. For instance,
he may seem very self-involved, talking about himself
and his accomplishments soon after being diagnosed with
cancer. One phrase of his in the midst of such conversation,
such as “my daughters are so little,” can
reveal his fears about how his children will be cared
for in the future.
Listen without passing
judgment or inserting your own opinions. Listen so that
you:
- focus on the message
being communicated
- gain full understanding
of the message
- show interest, concern,
and attention
- encourage full, open,
and truthful statements.
When the patient is reluctant
to express his feelings and may be exhibiting negative
behavior, examine the cause. Use open-ended questions,
always making sure to focus on the patient, to prompt
him to discuss his feelings, experiences, or behaviors
concerning the specific situation. Asking the patient
too many questions at once may make him feel threatened
or as if he’s being attacked or interrogated.
Use purposeful questions to help him focus and lead
him to a solution.
Draw him out by asking
open-ended questions, such as ones beginning with “what,
how, when, and where?” Because he’ll have
to answer in more detail, he’ll reveal more of
his thoughts and feelings.
Don't be afraid of silence,
which gives him a chance to reflect on his thoughts
and feelings and may help him sort out his emotions
and make decisions. By encouraging him to use such words
as feel and think, you can help him focus on his feelings
and his ability to take matters into his own hands again.
Finally, you can summarize
by pulling together important parts of the conversation
to focus on his concerns. Help him develop a plan, guide
him to other resources, or refer him to hospital social
workers.
Regaining equilibrium
As a nurse, you're constantly encountering people in
the midst of crisis. By listening and attending to them
nonjudgmentally, you can help them deal with the situation
in a positive way.
References
1. Donnelly E, Neville L. Health and Social Care
Knowledge and Skills: Communication and Interpersonal
Skills. Exeter, UK: Reflect Press; 2008.
2. Burnard P, Hulatt I. Nurses Counselling:
The View from the Practitioners. Oxford, UK; Boston,
MA: Butterworth-Heinemann; 1996.
3. Burnard P. Counseling Skills for Health Professionals.
Cheltenham, UK: Nelson Thornes; 2005.
4. Ananian P, Houvenaeghel G, Protière C, et
al. Determinants of patients' choice of reconstruction
with mastectomy for primary breast cancer. Ann Surg
Oncol. 2004;11(8):762-771.
5. The Cancer Council New South Wales. Emotions and
cancer-body image and sexuality. http://www.cancercouncil.com.au/editorial.asp?pageid=210.
6. Burnard P, Morrison P. Nurses' perceptions of their
interpersonal skills: A descriptive study using six
category intervention analysis. Nurse Educ Today.
2005;25(8):612-617.
Source:
Nursing2009. September 2009.
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