Registered Nurses´ Association of Ontario
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Phases of the Integrative Model of Crisis Intervention
The following three sequential phases incorporate the work of Kanel (1999), Hoff (1995, 2001), and other crisis theorists.
- Develop Rapport and Maintain Contact
- Identify the Problem
- Explore Client Coping and Negotiate an Action Plan
1. Develop Rapport and Maintain Contact
- Rapport, trust and active listening skills are foundational to the development of the therapeutic relationship. Contact with a nurse who is empathic, present, non-judgmental, respectful and genuine will permit the client to move into subsequent phases of the crisis resolution model. (See Registered Nurses Association of Ontario (2002b) best practice guideline “Establishing Therapeutic Relationships”, for additional therapeutic skill development).
- It is important to maintain ongoing contact with the client in crisis.
- Therapeutic communication skills are necessary to be successful with this phase of the model. Ensure that the client feels understood, accepted, and supported. Recognition and validation of the client’s personal meaning, feelings and perception of the event are the desired outcomes. One must consistently strive to make the client feel understood (Registered Nurses Association of Ontario, 2002b).
- Avoid dangerous assumptions based on non-factual or stereotypical data.
- Avoid asking “why” questions as these have connotations of a blaming, or accusatory stance, which is counterproductive to the therapeutic relationship.
- Verbal communication and empathic understanding are always implemented as a first step to de-escalate acute client distress, regardless of the degree of client disturbance.
2. Identify the Problem
- It is essential to determine the reason the client is seeking help at this time. A clear focus on the immediate problem will prevent distracting issues from depleting the client’s needed coping energy.
- Collect information that is relevant and aids in understanding the nature of the crisis, which often involves a theme of loss (loss of control, loss of nurturance, forced role adjustment, etc.). A mechanical or checklist approach is avoided as this is non-therapeutic. Rather, information is gathered in a coherent, caring manner, following the lead of the client as much as possible. Be client centred in your approach. (See Registered Nurses Association of Ontario (2002a) best practice guideline on “Client Centred Care”).
- Clinical judgment and expertise are utilized to obtain relevant information to accurately assess the problem and crisis situation. Hoff (2001) suggests that assessment should focus on client functioning (emotional, cognitive, and behavioural), including a history of coping with stressful and traumatic life events. Do not challenge the client’s perception as this will only increase his/her frustration etc.
- Help the client gain an understanding of the crisis and curtail any client self-blame through thoughtful reflection of the event or problem. This will facilitate a more realistic perception of the crisis by the client.
- Be direct but not directive.
- Negotiate and collaborate with the client to discover new ways to think about, perceive and reappraise the situation using positive reframing techniques, empowering statements, educational and normalizing comments, support statements, validation and reflection (see Appendix A for examples of how to frame questions).
- Identifying perspective, subjective distress and current and previous functioning encompass most of this phase of the model. Impairments in behavioural, cognitive, social, academic and occupational functioning are assessed in relation to a client’s pre-crisis level of functioning. Formal and informal mental status exams for individuals with a previous history of mental illness are particularly important. Identify legal and ethical issues involving suicidal/homicidal risk, abuse of all types, substance abuse and organic or physiological precipitants.
3. Explore Client Coping and Negotiate an Action Plan
- Once the therapeutic contact with the client is successfully achieved and the crisis identified, together the nurse and client explore new coping methodologies, which may involve new ways of problem solving and decision-making. These processes can foster greater personal growth and mastery.
- Encourage clients to consider alternative coping strategies. Trusting clients with their own ability to create solutions is imperative, as doing things to a person in crisis without his or her active participation can lead to failure (Hoff, 1995), and a lack of client commitment to the crisis resolution process.
- The plan must be problem-oriented, focus on the immediate problems that directly contributed to the crisis, and reflect the client’s culture and functional level and personal commitment to the problem-solving process (Hoff, 1995) .
- Avoid probing in-depth personality patterns or underlying psychological problems. If the client is so anxious or incapable of thinking clearly or able to make a decision, the nurse assumes a more active role temporarily. According to Hoff (1995), the client at this point, is allowed to borrow some of the ego functions of the counselor until adequate cognitive/emotional abilities to problem- solve are restored.
- If the client is highly emotional, allow sufficient time to express feelings. Provide the client with simple directions for action if the client’s behaviour and thinking are very disturbed. This approach is based on the intrinsic belief in a person’s ability to help himself or herself once the acute crisis is over (Hoff, 1995). Nurses need to know when to let go of the control so the client can once again take charge of his/her life. Experienced, self-aware and self-confident nurses can more easily do this through a process of ongoing clinical supervision, as described by Rolfe (1990).
- Mobilize client support networks to bolster renewed coping through referrals to appropriate community resources. Include significant others in the planning for a client, particularly if they are a future resource for the person. According to Hoff (1995), the plan should assess if the family or significant others are part of the problem or part of the solution. The nurse, in collaboration with the client (individual or family), may also suggest alternative options to assist with crisis resolution.
- The plan must be realistic, time-limited, concrete and flexible. The client needs to know that specific actions will be occurring at agreed-upon times and places. This structure will allow for the ongoing changes in the client’s life, and will enhance hopefulness and coping.
- Follow-up is an essential component of best practices in crisis intervention. It involves assessing whether clients’ coping strategies are effective, enhancing supports as needed, and evaluating the outcomes of crisis resolution. This follow-up is best planned and arranged by the professionals who help the client work through the crisis event.
- Areas of consideration during the follow-up phase include:
- Did the client carry out the crisis plan, and what was the outcome?
- Does the client have a plan to work towards meeting, through alternative actions, his/her goals?
- Does the client require additional or alternative linkages to community resources and supports?
