Stress Management�and �Crisis Intervention

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Stress and stressors

• Stress is part of living.
• Stressors:- physical, mental, psychological, social, spiritual, and environmental events that require change or adaptation.
• Minor stressors (ADLs):- caring for children, meeting work deadlines, cleaning or repairing house.
• Major stressors:- taking a crucial examination, losing a relative by death, losing possessions in a fire, losing a job, getting married.
• Problem-solving strategies and coping mechanisms are used successfully by some people to get through the stressful event in a healthy manner.
• If causes of stress are so overwhelming that the usual coping methods are ineffective, then stressful events will not be successfully managed.

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Symptoms of stress

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Stress and crisis…Differentiation

• Stress is a specific reaction to a life event.
• Person reacting to stressors in a stress state.
• How the person copes with the stressor and the person’s perception of the stressor determine whether the event will lead to a state of crisis.
• Positive change (eustress); negative change (distress).
• Stress is associated with biological changes contributing to emotional, cognitive, and behavioral dysfunctions (e.g., chemical abuse, suicide, or violence) and, if chronic, to pathologies such as migraine headaches, HTN, G.I. disorders, and arthritis.
• In contrast, crisis is a self-limiting state, usually lasting from 1 to 6 weeks. Crisis has beginning, middle, and end. Crisis intervention usually occurs around 4^th week and lasts from 1 to 12 weeks.

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Stress and crisis…Dynamics

• Crises are turning points, upset in a steady state, dramatic changes in one’s life.
• Crisis occurs when a person faces an obstacle to important life goals that are for a time insurmountable through the customary methods of problem solving. A period of disorganization follows, a period of upset, during which many unsuccessful attempts at solution are made.
• Stress, such as illness or threat of danger, produces a disturbance to equilibrium and the person activates problem-solving strategies and coping mechanisms to restore equilibrium. If stress pushes the person beyond the ability to restore equilibrium, a crisis will result.

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Stress and crisis…Dynamics

• Three types of solutions for problems:
• Person can tolerate the problem (a temporary situation).
• Changing the situation (adapt to stressful situation and attempt to resolve it).
• Escape the situation (temporary solution; it provides time to restore the ability to cope).
• Three interrelated factors that can produce a crisis:
• There is a hazardous event that poses a threat.
• A threat to an instinctual need is linked symbolically to earlier threats and leads to vulnerability or conflict.
• There is inability to respond with adequate coping mechanisms (cognitive appraisal-perception of stressor as threat to well-being so that one is unable to cope with that threat).

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Balancing factors affecting consequences of stress

1. Ability to perceive the event realistically: once the situation is identified, the individual must actively seek information to resolve the problem.
2. Presence of situational support: need other people for help solve problems. If individuals think they have no interpersonal or institutional resources for situational help, disequilibrium will result, possibly leading to crisis.
3. Presence of adequate coping mechanisms: individual manages by personal thoughts and feelings and expressing them verbally or by using other forms of behavior to decrease tension and master the stressful situation. If not able to do this, tension levels continue to rise and may result in crisis.

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Stress management

• Good nutrition; adequate sleep; rest; and exercise; and supportive social relationships help strengthen individuals’ resources against stress.
• Physical, emotional, and problem-solving interventions should be directed at increasing resources and coping skills through education and social support.
• Cognitive therapy helps individuals work with their thoughts, beliefs, feelings, and physical experiences toward healthier, more effective outcomes.
• Coping is the art of finding a balance between acceptance and action, of letting go and taking control.

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Types of crisis

• Two main types of crisis:
• Developmental:- a period of disorganization that occurs at a time of role transition during normal growth and development.
• Situational:- results from an external event perceived as hazardous.
• Developmental crisis:
• As we try to maintain our balance, we are faced with certain inevitable changes in our lives that must be confronted and resolved to continue the process of normal growth.
• Critical transition points include birth, school, marriage, and death. If these developmental crises are resolved, equilibrium is maintained and growth continues.

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Types of crisis…Developmental

• Erikson describes human development as a series of crises that must be coped with by using maturational and social experiences.
• These crises evolve over time and may require changes in behavior and thought processes.
• Developmental crises are not easily recognized. They do not stand out distinctly but are interwoven (interlinked) in a complex mixture of life events.

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Types of crisis…Situational

2. Situational crisis:
1. Caused by sudden unexpected external events over which a person has no control.
2. Unpredictable and unplanned (i.e., a mother gives birth to a handicapped child; fire destroys a family’s home).
3. Such situations create stress for all people who are exposed to them, but they become crises for those individuals who by personality, previous experience, or other factors in the present situation are especially vulnerable to this stress and whose emotional resources are taxed beyond their usual adaptive resources.

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Phases of crisis

1. Shock: begins when the person is initially faced with the crisis event (receiving a diagnosis of cancer, going through a divorce); feelings of unreality last anywhere from minutes to hours; anxiety even to a point of panic; person is unable to decide in which direction to turn; person finds usual methods of coping ineffective in solving the problem; person at this phase is most open to help and suggestions from others.

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Phases of crisis

2. Defensive retreat: a fight-or-flight response; person’s main goal is to reduce sense of overwhelming stress; individual attempts to “shut out” the imposed threat because he/she is unable to tolerate the imposed threat; denial and wishful thinking (flight response); blaming others and anger (fight response); these avoidance mechanisms are necessary for a time so a person can maintain a sense of “self” or equilibrium; when denial, wishful thinking, and anger occur over a prolonged period, they become unhealthy and may lead to physical and emotional illness.

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Phases of crisis

3. Acknowledgment (renewal stress): person acknowledges the reality of the situation; person must admit that a change in life has occurred. Stress arises again at this point, sense of loss develops, with feelings of depression and confusion; if person is too withdrawn or depressed, suicidal thoughts may emerge; if individual is apathetic, thoughts of retreating and giving up may dominate the plans; most constructive direction is to recognize strengths of personal systems and ability to cope with the present situation; if suicide attempt occurs or if a psychotic depression develops, then person is unable to enter the final phase (adaptation and change).

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Phases of crisis

4. Adaptation and change: person regains a new sense of self and decides that life is worth living and hope exists for the future; feelings of anxiety and tension decrease, and individual views problem in a more realistic manner, more openly talking about the crisis event; person begins to recognize strengths and sense of self-worth and tests them against the vicissitudes of reality; external resources are used more freely during this adaptation phase.

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Crisis intervention

• A short-term mode of therapy for helping individuals and families cope with current crisis event.
• Psychotherapy is necessary to prevent a crisis in those who have deeper problems.
• Crisis intervention “the active entering into the life situation of an individual, family or population to (1) lessen the impact of stress that throws the person (or persons) off balance and (2) help mobilize the resources of those affected directly by the stress.

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Phases of crisis

• Nurse is responsible for two areas of crisis intervention:

(1) to become actively involved with the client to help restore equilibrium, and

(2) to obtain the help of the client’s significant others to assist in solving the immediate crisis.

• The two main outcomes of crisis intervention:

(1) reduce the impact of the stressful event

(2) use the crisis situation to help those affected deal with present problems and learn new and more effective ways of coping with subsequent crises.

• Ultimate goal of crisis intervention is to help people function at a higher level than they did at their precrisis state.

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Primary prevention

• Preventing the crisis from occurring.
• With both situational and development crises, this is not always possible or even desirable. A person does not know when a situational crisis will occur, nor can a person prevent the biological changes that occur from one developmental period to another.
• Emphasis of primary prevention for crisis is not to prevent stressful event per se but to prevent it from becoming a crisis by minimizing its effects on the client, group, or population through interventions of health promotion and specific protection.

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Primary prevention…Health promotion

• Healthy people (physically, psychologically, and spiritually) are better equipped to cope with what life offers than those people who are unhealthy in these areas.
• Physical and psychological resources of healthy people equip them with a reserve that can be called on in the crisis event to alleviate or diminish its effects.
• So, promotion of healthy behaviors (physical examinations, good nutrition, and health education) are major deterrents in prevention of crises.

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Primary prevention…Specific protection

• Anticipatory planning is intervention that may specifically protect clients, groups, or communities from crisis events. It provides opportunities to try out new behaviors and to plan for future before a crisis occurs because anxiety levels are low and learning can occur more readily during the precrisis state.
• Anticipatory planning is helpful to those who are considered at high risk for crisis because, when these people are identified early, primary prevention is most effective in either preventing a crisis or minimizing crisis effects.

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Primary prevention

• Goals of primary prevention of crisis are to promote health and healthy behavior and to identify people, groups, or communities at risk for crisis.
• Intervention should be directed toward encouraging them to use appropriate coping mechanisms and assisting them in identifying external resources that may help to avoid the crisis or minimize its effects.

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Grief and mourning as responses to loss

• Grieving is usually preceded by a loss.
• Why do people mourn a loss?
• During the course of normal growth and development, a person becomes dependent on a variety of external objects to provide a basis for self-concept.
• To varying degrees these become necessary for effective ego functioning and for the continued and sustained sense of intactness, fulfillment, success, and hope.
• This dependence accounts for a person’s vulnerability to loss or threat of loss and the compensation for such loss through the process of mourning.
• The meaning that an object (home, job, antique automobile) has for one person may be different than for another, depending on the details of his/her life experiences.

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Grief and mourning as responses to loss

• A loss refers to an external object suddenly being made no longer available or accessible to the person (loss of body parts or functions; loss of membership or status in social, political, professional, military, or religious groups; failure of plans or ventures; changes in way of life and living; loss of home, house, personal possessions, and valued gifts; loss of job, profession, or occupation; loss of pets).
• How a person progresses through the mourning (sadness) process usually depends on how well previous losses have been resolved. Cumulative effect of a loss impacts health and life itself.

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Grief and mourning as responses to loss

• Grief: refers more to what is felt or experienced, and mourning to the responses involved.
• Grief work is the process of resolving a loss and renewing life without the lost person or object.
• Grief is usually associated with death but includes the mourning and resolution that occurs with any loss.
• Characteristics of grief reactions: bodily symptoms (need for sighing; lack of muscular power; exhaustion; digestive problems such as tightness in the throat, chocking with shortness of breath, and an empty feeling in the abdomen); tension or mental pain (ability to attend to other matters is reduced; strong feelings of guilt; accuse self of negligence and exaggerate minor deeds); feelings of hostility are directed toward others; daily pattern of conduct is lost.
• Duration of grief reaction depends on the success with which the person does the grief work.

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Stages of mourning

1. Shock and disbelief: person cannot accept the reality of the event; feelings of numbness follow as the survivor attempts to block out or escape this reality; bereaved persons often appear disoriented, making it difficult to get their attention.
1. Main defense mechanism is denial, which protects from intense stress and overwhelming feelings caused by the death.
2. Lasts from a few minutes to hours or sometimes days.

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Stages of mourning

2. Awareness of loss: admitting the reality of the death. When thoughts of death come to conscious awareness, acute feeling of sadness occurs, followed by feelings of anxiety, helplessness, and hopelessness.
1. Anger may be directed toward people who the bereaved individual thinks might be responsible for the death or toward him/herself if they feel responsible or believe they could have prevented the death.
2. Crying is a natural reaction; it is necessary to release unexpressed emotions.
3. Sometimes the person is unwilling to cry in presence of others, either because of stoicism or cultural practices, therefore will cry in privacy.
4. Inability to cry is a serious matter, usually caused by guilt or ambivalent feelings toward the deceased person.

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Stages of mourning

3. Restitution (Restoration): funeral symbolizes the finality of the relationship with the deceased. Bereaved person is able to give support to other family members and friends as well as receive it.
1. The person accepts the loss of the loved one and attempts to fill the painful void by turning to family and friends.
2. Person spends much of this phase in talking about the deceased, retelling incidents and stories about their relationship together; the mourner emphasizes only the good aspects of the deceased.
3. The bereaved lifts the self-imposed ban on pleasure and enjoyment, allowing oneself to again feel happiness.
4. The work of mourning usually lasts 6 to 12 months; its resolution is complete when the mourner can remember realistically, without intense pain, both the pleasures and the disappointments of the lost relationship.

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Factors influencing satisfactory acceptance of loss

1. Importance of the deceased as a source of support: the more dependent the mourner was on the deceased, the more difficult it is to resolve the loss.
2. Degree of ambivalence toward the deceased: the presence of unresolved anger, hostility, and guilt toward the deceased obstructs the progression of resolution.
3. Age of the lost object and the mourner: it is more difficult to resolve the loss of a child than that of an elderly relative. Also, children as mourners have fewer capabilities for loss resolution than do adults.

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Factors influencing satisfactory acceptance of loss

4. Number and nature of previous grief reactions: losses build on one another, and any unresolved loss is revived during subsequent ones, making the work of mourning more difficult.
5. Degree of preparation for the loss: anticipatory grieving by the mourner may occur when a person is terminally ill, but unexpected death leaves no room for such preparation.
6. Physical and psychological health of the mourner: the stronger the physical and psychological health of the mourner at the time of the loss, the greater the capacity to cope with the loss.

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Distortions and normal grieving

• Abnormal reactions to the normal grieving process are manifested by delayed and distorted reactions.
• Delayed reactions are caused by the person’s involvement with important tasks or the need to maintain the spirits of others.
• Grieving may be postponed, with no obvious reaction to the death for weeks or years; the process may occur after a time through a deliberate effort by the bereaved person or spontaneously at a specific point (for example, grieving may begin when a son reaches the same age as his father at the time of his death).

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