Crisis

Crisis is a reaction, not necessarily a traumatic event. It is someone's reaction to a stressor, an obstacle, trauma or threat. It presents an opportunity for either growth or decline. It is important to take the necessary time to assist patients in crisis as they often present unexpectedly. Crisis counselling is a short term intervention which helps patients receive assistance, support, resources, and a change to stabilize their thinking. Examples of crisis can include suicidal risk, risk to others, decline in function/coping strategies, or a medical emergency.

Safety planning

 * It is important to prepare your practice for possible crisis situations
 * Office policies should be established for managing agitated or dangerous patients
 * Prepare and plan strategies for common emergencies encountered in the office (this can include both medical crisis and psychiatric crisis)
 * It is important to involve colleagues and staff in preparation and planning for both medical and non-medical crisis.
 * Examples of strategies: panic alarms, emergency signals, de-escalation strategy training to all staff, knowledge if violent patient to call police, consistent rules/policies, psychoactive medications available

Prevention
It may be possible to recognize a patient that is pre-crisis. It is important that the patient and the family have a plan and the necessary resources available to offer the most support to prevent or dampen a crisis.

Psychological First Aid
The management plan of someone in Psychological Crisis can be followed using the FIRST AID mnemonic. It is important to recognize when your safety or the safety of people around you may be in jeopardy and call the necessary support team. ** It is important to recognize and set boundaries for patients in Crisis. (e.g. lending money, appointments outside regular hours)**
 * 1) F - Feelings of safety, assure confidentiality, trust, availability
 * 2) * Attempting to calm the environment
 * 3) * Always explain limitations to confidentiality
 * 4) * Develop rapport
 * 5) I - Immediate safety
 * 6) * If immediate safety cannot be assured it is important to call for back-up
 * 7) R - Review history ( Can use BATHE technique + FIFE - see below)
 * 8) * Always address suicidal risk ( see suicide topic)
 * 9) * Always address homicidal risk
 * 10) * Evaluate for unhealthy coping strategies (substance use, eating, gambling, cutting)
 * 11) * Evaluate for co-morbid psychiatric disorders
 * 12) S - stabilize, assess supports, stressors
 * 13) * It is important to evaluate if anyone else requires support secondary to patient crisis - e.g. children, spouse
 * 14) T - treat practically - develop action plan and follow up plan
 * 15) A- Access community supports
 * 16) I - Information about stress reactions/coping strategies
 * 17) D- Directly link to additional services

** If patient is psychologically unstable and at risk of harm to themselves/others or at risk of deterioration consider urgent psychiatry review/emergency department review or involuntary commitment (form 1)**

Legal obligations

 * Homicidal - have duty to warn if there is a clear identifiable person that is at risk of serious and imminent harm
 * Child abuse - duty to report
 * Vitals of abuse - no duty to report

De-escalation Strategies

 * Respect personal space
 * Do not be provocative
 * Establish verbal contact
 * Be concise
 * Identify wants and feelings.
 * Listen closely to what the patient is saying. Empathize
 * Agree or agree to disagree
 * Lay down the law and set clear limits
 * Offer choices and optimism. Negotiate a compromise
 * Debrief the patient and staff

Psychoactive Medications in Crisis

 * use sparingly/rationally for patients in crisis
 * Goal is to decrease symptoms of experiencing/numbness/hyper-arousal, reduce suicidal/impulsive or aggressive behaviour, help with comorbid conditions
 * SSRIs (take 4-6 weeks to take effect)
 * Benzodiazepines - help with anxiety/sleep. Risk of dependence
 * Beta-blockers (propranolol acutely ?reduce later symptoms of PTSD)
 * If high risk patient + aggressive/physical threat may consider: anti-psychotic (e.g. haldol) + benzo (e.g. ativan)

BATHE Technique

 * B- Background "what has happened?"
 * A -Affect "what are you feeling right now?"
 * T - "Troubles you the most about this?"
 * H - How are you handling this
 * E - Empathetic statement

FIFE

 * Feelings/Fears
 * Ideas
 * Function
 * Expectations

Medical Crisis

 * Important to have office policies, planning prior to crisis
 * Important to have necessary equipment/medications to deal with anticipated emergencies
 * Necessary staff should receive training for these crisis, equipment and protocols
 * When a crisis occurs:
 * ABCs + Vitals
 * Call for help
 * Assess the environment for needed personnel/resources
 * Assign roles/delegate
 * Consider transfer with concurrent management
 * It is important to be calm, methodical during a crisis. Use close loop conversation.
 * Debrief after crisis

Crisis Numbers Ottawa

 * Mental Health Crisis Line 613-722-6914
 * Centre d'aide 819-595-9999
 * Distress Centre Ottawa and Region 613-238-3311
 * Ottawa Rape Crisis Centre 613-562-2333
 * Tel-aide Outaouais 613-741-6433
 * Youth Service Bureau 24/7 Crisis Line 613-260-2360

Resources
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181054/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298202/