WHAT IS A MENTAL HEALTH CRISIS?

A mental health crisis is defined as any non-life-threatening situation in which people experience an intensive behavioral, emotional, or psychiatric response triggered by a precipitating event and whose behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community (NAMI, 2020).

Types of Crises

Crises can be categorized as maturational, situational, adventitious, or sociocultural. Individuals may simultaneously experience more than one type in a given situation.

MATURATIONAL CRISES

Maturational or developmental crises may occur at any transitional period in the normal process of bio-psychosocial growth and development. The transitional periods into successive stages of life require cognitive and behavioral changes, and a crisis can develop at any stage of transition when the person is unable to envision being in a new role, lacks adequate resources or communication skills, or others in their social system refuse to see the person in a different role. Life stages and related concerns may include:

Childhood

• Beginning school
• Establishing peer relationships
• Peer competition

Adolescence

• Puberty
• Relationships involving sexual attraction
• Exploring independence
• Choosing a career

Young Adulthood

• Leaving home
• Continuing one’s education
• Getting started in an occupation
• Getting married
• Managing a home
• Pregnancy
• Childbirth

Middle Adulthood

• Physical changes of aging, menopause
• Maintaining social status and standard of living
• Dealing with changes in adolescent children

Older Adulthood

• Decreased physical abilities and health
• Changes in residence
• Retirement and reduced income
• Death of spouse
• Death of friends
• Facing one’s own death
  (Dwivedi, 2018)

SITUATIONAL CRISES

Situational crises often revolve around grief and loss, usually the loss of an established support or role. They arise suddenly and unexpectedly from an external source and are events or circumstances that threaten the physical, social, and psychological integrity of individuals. These events may originate in the physical body as a result of disease or injury or in social or emotional situations. Such events may include:

• Unexpected job loss
• Change in financial status
• Academic failure
• Divorce
• Mental illness
• Birth of a child with a disability
• Diagnosis of chronic or terminal illness
• Serious injury
• Death of a child
• Loss of a spouse
  (Sabu, 2017)

ADVENTITIOUS CRISES

Adventitious crises have been called events of disaster. They are rare, unexpected happenings that are not part of everyday life and may result from:

• Natural disasters, such as floods, fires, and earthquakes
• Global pandemics, such as influenza and COVID-19
• National disasters, such as airplane crashes, riots, and wars
• Interpersonal disasters, such as assault and rape
• Acts of terrorism

Because of the severity of the effects of such events, normal coping strategies may not be effective, and support systems may not be available because mental health professionals must respond quickly and to large numbers of people, at times including an entire community.

The Federal Emergency Management Agency (FEMA) provides a systematic approach to the work necessary during such disaster situations. Training material for Community Emergency Response Teams (CERT) can be found on the Department of Homeland Security website (DHS, 2020). (See “Resources” at the end of this course.)

SOCIOCULTURAL CRISES

Sociocultural crises occur when an individual or members of a community cease to function in conformity with the interests and values embedded in the social structure of that community. This may involve discriminatory practices based on age, race, sex, sexual preference, or class distinction (Shiva, 2017).

MENTAL ILLNESS CRISES

Individuals with diagnosed mental illness are at greater risk of experiencing crisis, but very often a crisis occurs before a mental illness has been diagnosed. Individuals living with mental illness face the same stressors as persons who do not have a mental illness, but these stressors can be especially difficult to deal with for someone living with a mental illness.

Crises can be difficult to predict because often there are no warning signs. Crises can occur even if the person has been complying with treatment or a crisis prevention plan, using techniques learned from mental health professionals. At times the person may present with behaviors that indicate an impending crisis, but other times a crisis can occur suddenly and without warning. It is possible the first point of contact may be with law enforcement personnel instead of medical personnel since behavioral disturbances and substance use are frequently part of the difficulties associated with mental illness (NAMI, 2020).

Phases of Crisis

Gerald Caplan (1964), a pioneer in the field of crisis intervention, identified four predictable phases of crisis:

• Initial threat or triggering event. People are faced with a problem or conflict that threatens their self-concept, and they respond with increased feelings of anxiety. In an effort to lower the level of anxiety (fear), they employ various defense mechanisms, such as compensation (using extra effort), rationalization (reasoning), and denial. For some people with strong coping skills, the problem may be resolved, the threat disappears, and there is no crisis.
• Escalation. If the problem persists and the usual defensive response fails, anxiety continues to rise to serious levels, causing extreme discomfort. Problem-solving ability is arrested or becomes unsuccessful. The person becomes disorganized and has difficulty thinking, sleeping, and functioning. Trial-and-error efforts are initiated to solve the problem and restore emotional equilibrium. Lack of success in finding an appropriate coping strategy leads to a sense of helplessness.
• Crisis. The individual expands the trial-and-error search for helpful resources in an effort to relieve the psychological discomfort, drawing on all available resources. When all attempts fail, anxiety intensifies to a severe level and then to panic, and the person mobilizes automatic relief behaviors (flight or fight). At this point, some people may seek assistance from professionals for possible answers and resolution. Some form of resolution may be made, such as redefining the problem, attacking it from a new angle, compromising needs, or redefining the situation. If new methods are successful, the crisis will resolve and the person will return to a functional level that may be the same, higher, or lower than previously.
• Personality disorganization. If the problem is not resolved in the second or third phase and new coping skills are ineffective, anxiety may overwhelm the individual and lead to panic or despair, a hallmark of this phase. Serious disorganization, confusion, depression, possible psychotic thinking, or violence against oneself or others may be present, and it is at this point that external supports become necessary (Halter, 2018).

Balancing Factors

Individuals respond to a crisis in their own unique ways. There are certain factors that determine the manner in which they respond, referred to as balancing factors. They include:

• Perception of the event. The perception one has of an event determines the reaction to the situation. If the person has a realistic perception and has access to adequate resources, restoration of homeostasis will occur, and there will be no crisis. A realistic perception occurs when a person is able to distinguish the relationship between an event and feelings of stress.
• Availability of situational supports. If the person utilizes support from available persons in the environment and receives assistance in solving the problem, a crisis can be averted. These individuals reflect appraisal of the person’s values. When this is not available, the person is more likely to define the event as more overwhelming, thus increasing vulnerability to crisis.
• Availability of adequate coping skills. Coping skills or mechanisms are those methods usually used by an individual to deal with anxiety or stress in order to reduce tension in difficult situations. People may have positive or negative coping mechanisms, and many people instinctively opt for a maladaptive coping mechanism. These may include denial, rationalization, repression, regression, dissociation, or avoidance. However, if the person is able to successfully use positive strategies from the past, a crisis can be averted. The inability to use strategies from previous experiences or unsuccessful attempts to use strategies that were successful in the past can lead to continued disequilibrium, tension, and anxiety.

Developmental factors can also impact a person’s response to stress and the development of a crisis. For adults, a crisis can be hard to accept and impossible to understand, which can erode feelings of personal and community safety. Adolescents and children may be even more deeply affected. The effects of crisis on a child may interfere with normal growth and development, leading to negative long-term physical and psychological health outcomes (Casale, 2017).

Crisis Resolution

Crises are acute, time-limited situations that can be resolved in one way or another within a one- to three-month time frame. Crises can become growth opportunities when individuals learn new methods of coping that can be preserved and used when similar stressors occur in the future.

However, when new coping mechanisms or balancing factors are not identified and incorporated, the crisis situation can evolve into longer-term problems and sometimes symptoms of emotional or mental illness, including depression, anxiety, and trauma/stressor-related disorders (Townsend & Morgan, 2018).

The goal of crisis intervention is to return the patient to at least the precrisis level of functioning. In order for problem-solving to be successful and for a healthy resolution of a crisis to occur, the person must have a realistic understanding of the precipitating event and their emotional response to it. There must be systems of support available, and there must be a supply of effective coping measures developed over a lifetime available for application to stressful situations.

At the resolution of a crisis, the patient will emerge at one of three different functional levels:

• A higher level of functioning
• The same level of functioning as before crisis
• A lower level of functioning
  (Halter, 2018)

RESOLUTION AND OCCUPATIONAL THERAPY

When individuals experience a mental health crisis or emergency, they may become involved with acute psychiatric services, whose main goal is to return each person back into the community or to a more appropriate setting. For this to occur, each patient requires an assessment of the ability to function safely and effectively in the environment they will return to. One reason why a patient may not be able to return to the community setting is the persistence of functional problems and deficits resulting from the crisis.

Skills that address these functional deficits are often present in any acute psychiatric multidisciplinary team; however, occupational therapists are uniquely qualified to assess and remediate functional performance. They have the skills to provide quality and consistency in outcomes. It has been found that occupational therapists contribute specialist skills to the multidisciplinary team, and individual assessments, therapeutic groups, individual treatment, and discharge planning play key roles in the acute psychiatric setting (Fitzgerald, 2016).

The National Alliance on Mental Illness (NAMI) and the Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for Assertive Community Treatment (ACT) teams include occupational therapists. The team members help patients address every aspect of their lives, whether it be medication, therapy, social support, employment, or housing.

Occupational therapists assist with crisis stabilization and help reduce the need for restraints or seclusion, and there is much evidence supporting occupational therapy interventions as part of psychiatric rehabilitation. These therapists also work with veterans and service members who have experienced other crises, including posttraumatic stress syndrome, traumatic brain injury, or polytrauma. ACT teams provide services to the following:

• People with severe symptoms of mental illness
• People experiencing psychiatric crises
• People with significant thought disorders
• Young adults with early-stage schizophrenia
• People with stigmatized mental illness
• People with high rates of substance abuse
• People with a significant history of trauma
• Those with frequent hospital stays
• People with overlapping physical and mental illness
• People who are homeless due to mental illness
• People unlikely to attend appointments at hospitals or clinics
• People who have not responded well to traditional outpatient care
  (NAMI, 2017c)

The occupational therapists included in these community behavioral health teams can:

• Complete assessments and evaluations that are capable of recognizing factors that contribute to mental illness
• Look for strengths that can enhance improved recovery and participation in the recovery process
• Assist in the removal of barriers to recovery through the establishment of an effective and comprehensive patient-centered treatment plan
  (AOTA, 2017)