MENTAL HEALTH CRISIS INTERVENTION PROCESS

Mental health crisis intervention refers to methods that offer immediate, short-term help to individuals who are experiencing an event that is producing emotional, mental, physical, and behavioral distress or problems. Mental health crises are usually temporary, short-lived, and last approximately one month. The length of crisis intervention may range from one session to an average of four weeks, and session lengths may range from 20 minutes to more than two hours. Crisis intervention is appropriate for all ages and can take place in a range of settings.

The goals of mental health crisis management are to:

• Ensure the physical safety and emotional stability of the person experiencing a mental health crisis
• Reduce the intensity of emotional, mental, physical, and behavioral reactions to the crisis in order to avoid further deterioration of the person’s mental status and development of serious long-term problems
• Assist in recovery from crisis and the return to a precrisis level of functioning
• Assist in the development or enhancement of more effective coping skills and support system
• Ensure that services are clinically appropriate and in the least intense or restrictive setting
• Provide assistance and referral for ongoing care
  (Shiva, 2017)

Triage Considerations

Triage refers to the assessment that takes place when a patient first makes contact with a health service. Triage may occur in many settings, including an emergency department, community mental health clinic, ambulance call-out, primary care setting, telephone hotline, crisis center, or individual’s home.

The aims of triage are:

• To determine that it is likely the person has a mental health problem, and if so, what the nature of the problem is
• To establish priority for response based on immediate safety issues
• To inquire about concurrent social or health problems that require attention
• To determine what intervention is best suited for the person and to whom the person should be referred

Triage is usually followed by a comprehensive assessment once immediate issues of safety have been addressed (Evans et al., 2019).

In every crisis event, triage must address both safety concerns and immediacy challenges. This is accomplished most often utilizing a triage assessment tool that offers step-by-step guidance.

MENTAL HEALTH TRIAGE ASSESSMENT SCALE

Acuity Level / Response	Observed / Reported Behaviors
(Zun, 2016)
Emergency (Requires treatment within 10 minutes)	Violent, aggressive, or suicidal Danger to self or others Requires police escort
Urgent (Requires treatment within 30 minutes)	Very distressed or acutely psychotic Likely to be aggressive May be a danger to self or others
Semi-urgent (Requires treatment within 60 minutes)	Long-standing or nonacute mental disorder or problem Patient has supporting agent or escort
Nonurgent (Requires treatment within 2 hours; referral to an appropriate community resource)	Long-standing or nonacute mental disorder or problem Patient has no supportive agent or escort

TRIAGE FOR CHILDREN AND ADOLESCENTS

The HEADS-ED is a mental health screening tool used with children and adolescents between the ages of 6 and 18 years who are presenting for primary care or for mental health crisis care. HEADS-ED can be completed within a few minutes by a healthcare practitioner or allied health professional (e.g., crisis worker, school counselor). The tool includes seven components of a patient history, giving a concise picture of the main concerns, and a total score that can indicate overall severity of symptoms. On the basis of this score, the clinician can make determinations as to the patient’s disposition and follow-up, which may include:

• Immediately providing a meaningful score (a score of 8 or a suicidality score of 2 indicates that a mental health consultation should be obtained)
• Suggesting whether a consultation for inpatient services may be required
• Identifying appropriate local community resources based on the needs identified that will facilitate continuity of care

HEADS-ED SCREENING TOOL

Component		Question	Responses (Score) 0=No action needed 1=Needs action but not immediate 2=Needs immediate action
(Cappelli & Cloutier, 2017)
H	Home	How does your family get along with each other?	Supportive (0) Conflicts (1) Chaotic (2) Dysfunctional (2)
E	Education	How is your school attendance?	On track (0) Grades dropping (1) Absenteeism (1) Failing (2) Not attending school (2)
A	Activities	How are you getting along with your friends?	No change (0) Reduced activities (1) Peer conflicts (1) Fully withdrawn (2) Significant peer conflicts (2)
D	Drugs and alcohol	How often have you been using alcohol or other drugs?	None (0) Infrequently (0) Occasionally (1) Frequently (2) Daily (2)
S	Suicidality	Do you have any thoughts of wanting to kill yourself?	No thoughts (0) Ideation (1) Plan (2) Apparent attempt made (2)
E	Emotions, behaviors, thought disturbance	How have you been feeling lately?	Mildly anxious (0) Mildly sad (0) Mild acting out (0) Moderately anxious (1) Moderately sad (1) Moderate acting out (1) Significantly distressed (2) Unable to function (2) Out of control (2) Bizarre thoughts (2)
D	Discharge resources	Are you getting any help, or are you waiting to receive help?	Ongoing (0) Well connected (0) Receiving some (1) Not meeting needs (1) None (2) On wait list (2) Noncompliant (2)

Crisis Intervention Communication

The goals of crisis intervention communication are to:

• Establish rapport
• Identify the most important concern at that moment
• Assess the person’s perception of the problem
• Facilitate the person’s expression of emotion
• Recognize the person’s needs
• Implement interventions designed to address the needs
• Guide the person toward identifying a plan of action to an acceptable resolution
  (Belleza, 2020)

In order to be effective in the process of intervention with an individual in crisis, it is essential that the clinician use effective communication techniques. The most essential of these are active listening skills. Active listening involves listening with all the senses. This means:

• Seeing the person in front of you
• Hearing the person’s voice as they speak
• Observing how the person’s speaking and presence makes you feel
• Noticing any smells and sometimes even what you taste

It is the ability to completely focus on a speaker, understand the speaker’s message, comprehend the meaning of the information, and respond effectively. The practice of active listening is complex, as each skill involved is used concurrently with the others while also trying to remain empathetic and objective. Active listening is, essentially, a form of feedback.

ATTENDING/ACKNOWLEDGING

It is important to provide verbal and nonverbal awareness of the speaker and to convey an interest in what the speaker is saying. This provides an invitation to continue to talk.

Examples

• “Uh-huh.”
• “Oh?”
• “When?”
• “Really?”
• “I see.”
• “Yes.”

Nonverbally, the listener can convey interest by facing the speaker, maintaining eye contact, nodding, and smiling. Small smiles combined with nods can be powerful in affirming that messages are being heard and understood. Because eye contact can be intimidating and culturally specific, it is essential to gauge how much is appropriate. It is often best to use eye contact along with smiles and other nonverbal messages.

The listener’s posture can indicate attentive listening. These may include leaning slightly forward or sideways while sitting, slanting the head slightly, or resting the head on one hand.

Another nonverbal technique is referred to as mirroring. This may involve the automatic reflection of the facial expressions of the speaker and can indicate empathy. The slight mirroring of posture or gestures also can build rapport. Mirroring may also include speech pacing, vocabulary choices, volume and tone of voice, as well as speech patterns. Mirroring, however, must be genuine to be effective (Cournoyer, 2017; Belleza, 2020).

CLARIFYING

Clarifying involves seeking information to make clear that which is not meaningful or that which is vague in order to avoid making assumptions that understanding has occurred when it has not. It is the ability to reflect back to the speaker the words and feelings expressed in order to ensure that they have been understood correctly and that both the speaker and listener agree upon a true representation of what has been said.

Examples

• Listener: “I am not quite sure I understand. Can you tell me …?”
• Listener: “Do you mean that …?”
• Listener: “Are you telling me …?”
• Listener: “Are you saying …?”
• Listener: “Have I heard you correctly?”

Clarifying uses restating and paraphrasing to show an understanding of what the speaker has said and to help the speaker evaluate feelings by hearing them expressed by someone else.

Restating is repeating the main idea expressed in approximately or nearly the same words the patient has used, while paraphrasing involves the use of other words to reflect back to the speaker what has been said. When paraphrasing, it is essential that the listener does not ask questions, is nondirective, and is nonjudgmental. It shows the speaker that the listener is attempting to understand what has been said.

Examples

• Speaker: “I don’t sleep. I stay awake all night.”
• Listener (restated response): “You don’t sleep, you stay awake all night.”
  or
• Listener (paraphrased response): “You have difficulty sleeping.”

When restating and paraphrasing, it is important to observe for nonverbal and verbal cues that confirm or refute the accuracy (Cournoyer, 2017; Videbeck, 2020).

EMOTIONAL LABELING

During a mental health crisis, feelings may often be confusing and hard to define. Some people experience greater difficulty labeling their emotions than others do. This inability has been found to be associated with deficits in the ability to regulate those emotions. The less aware a person is of their emotions, the less likely they may be able to regulate them.

Emotional labeling allows a clinician to apply a tentative label to the feelings the person is expressing or implying by words and actions. Labeling emotions lets the person know they are being heard and helps the person make sense of them and gain some control. The simple act of thinking about and then labeling an emotion can distract from and disrupt the intensity. It is important not to assume one knows how another person feels. It is helpful to ask if a label is correct.

Examples

• Listener: “You sound very frustrated. Is that right?”
• Listener: “Am I correct in saying that you feel overwhelmed by everything?”
• Speaker: “I’m stuck out in the middle of the ocean.”
• Listener: “You’re feeling alone or deserted. Is that true?”

It is important that the speaker’s emotions are validated and not minimized. Labeling and acknowledging emotions help to restore equilibrium (Cournoyer, 2017; Videbeck, 2020).

PROBING SKILLS

Probing skills involve questioning, and the most useful forms of questions are open-ended. These types of questions encourage exploration and begin with probing words such as when, what, where, how, or who. They elicit more and fuller information than closed-ended questions by requiring more than a simple yes or no answer. The use of open-ended questions encourages the individual to continue to talk. It is also important to avoid “why” questions, as they may be interpreted as accusations, resulting in the person feeling defensive. Why questions may also imply that the person should know something that they may not know.

Examples

• Listener: “What were you thinking/feeling?”
• Listener: “How did you act?”
• Listener: “When did that happen?”
• Listener: “Where did you go afterward?”
• Listener: “Whom did you go with?”
  (Cournoyer, 2017)

EFFECTIVE PAUSES/SILENCE

Part of effective communication includes the use of silence and waiting or pausing before speaking. Silence and pauses can be used effectively for several purposes. Silence allows the person to take control of the discussion. Most people are not comfortable with silence and will talk in order to fill it. Therefore, a period of silence may encourage a person to continue speaking. Silence can also be used to emphasize a point just before or just after saying something important (Cournoyer, 2017).

“I” MESSAGES

“I” messages can be used to convey feelings, concerns, needs, and expectations without making the other person feel attacked. “You” messages tend to put people in defensive positions, whereas an effective “I” message places the responsibility and focus on the communicator instead of the recipient. “I” messages allow people to know in a nonthreatening way how the other person feels, why they feel that way, and what the patient can do to remedy the situation. Clinicians use this technique to refocus the patient or when the clinician is being verbally attacked.

Examples

• Listener: “I feel uncomfortable when I’m spoken to that way. Please don’t yell at me.”
• Listener: “I need to better understand what I heard you say. Tell more about that.”

Fogging is a related empathic technique used to slow down a potentially explosive situation. It is a way to accept critical remarks by using “I” messages. When a patient is being critical, the listener accepts the criticism, or part of the criticism, even if is untrue and repeats it back to the speaker.

Example

• Speaker: “You’re so stupid!”
• Listener: “Yes, I can see that you don’t think I’m that smart.”

The word yes takes the person by surprise, slows them down, and reduces tension. The listener is not agreeing that they are stupid; rather they are acknowledging that the speaker thinks so (Cournoyer, 2017; Townsend, 2018).

Crisis Intervention Model

There are many crisis intervention models, one of them being the ACT Model of Crisis Counseling. ACT stands for assessment, crisis intervention, and trauma treatment and is a three-stage model emphasizing:

1. Assessment of the presenting problem
2. Connecting patients to support systems
3. Helping those in crisis work through the distress and emotional pain

This three-stage intervention model integrates assessment and triage protocols with Robert’s Seven-Stage Crisis Intervention Model (R-SSCIM) and is useful with persons calling or walking into an outpatient psychiatric clinic, psychiatric screening center, community mental health center, counseling center, or crisis intervention setting. The R-SSCIM model identifies seven critical stages a clinician goes through to help the individual reach stabilization, resolution, and mastery. The stages are sequential but may overlap in the process:

1. Assessment
2. Rapidly establish rapport
3. Identify major problems
4. Explore feelings and emotions
5. Generate and explore alternatives
6. Develop and formulate an action plan
7. Plan follow-up

STAGE 1: ASSESSMENT

The first step in the assessment of an individual experiencing a mental health crisis is to begin a fast but thorough biopsychosocial assessment, which includes inquiring about the major physical, psychological, and social issues of the person. This assessment should provide a brief medical history, medications being taken, current and past history of alcohol or drug use, environmental resources and supports available to the person, mental health problems and symptoms, as well as cultural considerations.

Assessment should inquire about the support system and resources available to the person in crisis. Family and friends, social clubs, church groups, and networks of professional associates are all sources of support. When these resources are not available, caregivers act as a temporary support system for the patient. Some questions a clinician might ask about a support system are:

• “With whom do you live?”
• “When you feel lonely and overwhelmed by life, whom do you talk to?”
• “Is there someone in your life whom you trust?”
• “In the past, during difficult times, whom did you want to help you?”
• “Where do you go to school (to worship, to have fun)?”

Assessment of the level of anxiety the person is experiencing is conducted as well as the person’s usual coping methods. Some people drink, some eat, some sleep, and some gamble. Others engage in physical activity, work harder, pick fights, or talk to friends. Some questions clinicians may ask about coping methods are:

• “What do you do to make yourself feel better?”
• “Did you try doing that this time?”
• “If you did, what was different this time?”

Assessment of the person’s strengths and needs also begins in this stage and continues throughout the crisis intervention. It is also important to determine whether the patient is unable to take care of personal needs such as eating, sleeping, and tending to personal hygiene and safety.

Assessment of lethality is conducted to determine whether the person is suicidal or homicidal by asking:

• “Have you thought of killing yourself or someone else?”
• “How would you go about doing this?”

If there is any concern about suicidality, it is essential to find out what the person’s thoughts are, if there is intent and the strength of the intent, whether there is a plan and the lethality of the plan, any past history of suicide attempts, and other specific risk factors for suicide such as substance abuse, social isolation, or recent losses. In cases of imminent danger, emergency medical or police intervention is often necessary. (See also “Assessing for Risk of Harm to Self or Others” below.)

STAGE 2: RAPIDLY ESTABLISH RAPPORT

Stage 1 and stage 2 most often occur simultaneously. Establishing rapport and a collaborative therapeutic relationship begins with the initial contact between the crisis clinician and the person. The main task for the clinician at this point is to establish rapport by conveying genuine respect for and acceptance of the person’s feeling and circumstances. The person may need reassurance that they can be helped and that this is the appropriate place to receive such help.

The clinician demonstrates an understanding of the person’s situation and feelings by showing patience and empathy, engaging in active listening, and concentrating on what the person is communicating verbally and nonverbally. It is also important to reinforce any evidence of the person’s resiliency.

Other ways in which rapport can be made is through eye contact, being nonjudgmental, mirroring physical posture and movement to indicate listening intently, and the cautious use of touch to convey understanding.

STAGE 3: IDENTIFY MAJOR PROBLEMS

This stage involves identifying the major problem(s) the person is having, including the chain of events leading up to the crisis and the “last straw” that brought things to a head. The clinician encourages the person to examine when and how the crisis occurred, the contributing circumstances, and how the person attempted to deal with it. Questions clinicians might ask about a precipitating event are:

• “What happened to make you so upset?”
• “How are you feeling right now?”
• “How does this event affect your life?”
• “How will this event affect your future?”
• “What needs to be done to fix the problem?”

Exploration of other problems the patient is concerned about is also accomplished during this stage. It can be useful to prioritize the problems in terms of which problems the person wants to work on first, recognizing that the focus of crisis intervention is the current problem rather than issues from the past.

STAGE 4: EXPLORE FEELINGS AND EMOTIONS

It is extremely important to allow the person to vent feelings and emotions and to validate them by accepting them and recognizing them as understandable. This is best accomplished by using active listening skills, such as paraphrasing, reflective listening, and probing questions.

With caution, the clinician may also challenge maladaptive thinking and behavior. Challenging responses can include giving the person information, reframing and interpreting thoughts and behaviors, and playing “devil’s advocate.”

• “How many times in the past have you had this kind of thought? Have you ever been wrong?”
• “What could you do to determine if this thought is true?”
• “Even if that’s true, tell me if you can think of more positive behaviors you might engage in?”

When used appropriately, these challenging responses help the person take a second look at thoughts and behaviors and to consider other options.

STAGE 5: GENERATE AND EXPLORE ALTERNATIVES

This process may be the most difficult to accomplish in crisis intervention, People in crisis often lack the ability to see the big picture and hold on to familiar ways of coping even when they are not working.

The clinician draws conclusions about the patient’s strengths and needs related to the current crisis and evaluates the potential for recovery. The person’s strengths are tapped to improve self-esteem, which also provides the energy and skills for problem-solving.

During this stage of intervention, the clinician and the individual collaborate and negotiate to come up with options that will improve the current situation. It is important that such collaboration occur in order to ensure that the options selected are “owned” by the person. Brainstorming about possibilities or asking about what has been helpful in the past can elicit the person’s input.

STAGE 6: DEVELOP AND FORMULATE AN ACTION PLAN

At this point there is a shift from crisis to resolution. The person and the clinician begin to take the steps negotiated in stage 5, and the person begins to make meaning of the crisis event by exploring why it happened. It is important for the person to obtain a realistic picture and understanding of what happened and what led to the crisis. It is also important for the person to understand the specific meaning of the event and how it conflicts with expectations, life goals, and belief system. Working through the meaning of an event is important in order to gain mastery over the situation and for being able to cope with similar situations in the future.

During this stage, the person begins to restructure, rebuild, or replace irrational beliefs and erroneous thinking with rational beliefs and new thinking. Action plans may also involve options such as entering a 12-step treatment program, joining a support group, or entering a women’s shelter. These are often critical options for restoration of the person’s equilibrium and psychological balance.

STAGE 7: PLAN FOLLOW-UP

A plan for follow-up with the person after initial intervention should be done to make certain the crisis is being resolved and to evaluate the postcrisis status of the person. Such an evaluation may include current functioning and assessment of progress as well as satisfaction with treatment. It is recommended for those individuals who are grieving that a follow-up session be scheduled around the one-month and one-year anniversary of a death. This is also recommended for individuals who are victims of violent crimes (Black & Flynn, 2021; Yeager & Roberts, 2015).

Assessing for Risk of Harm to Self or Others

Individuals experiencing a mental health crisis should always be assessed for the risk of harm to self or others. The routine practice of undressing all patients and placing them in a gown serves as a nonconfrontational way to search for weapons. The patient interview setting should be private, but not isolated. The patient and clinician may be seated roughly equidistant from the door, or the clinician may sit between the patient and the door. The patient, however, should not sit between the clinician and the door (Moore & Pfaff, 2020).

ASSESSING RISK FOR SUICIDE

The purpose of a suicide risk assessment is to determine a patient’s risk and protective factors with a focus on identification of targets for intervention. There are a number of standardized scales available to evaluate risk of suicide, but none of them is associated with a high predictive value (Schreiber & Culpepper, 2019).

A suicide risk assessment includes:

• Performing a clinical evaluation
• Identifying risk-enhancing factors
• Identifying risk-reduction factors
• Employing clinical judgment

Different kinds of organizations and settings may use different screening tools. The following table lists examples of validated, evidence-based screening tools.

SUICIDE RISK ASSESSMENT TOOLS

Tool	Setting	Questions / Areas Addressed
(TJC, 2018; NIMH, 2019)
Columbia-Suicide Severity Rating Scale (C-SSRS) Screening Version	For all ages in general healthcare settings; used by individuals trained in its administration	Suicidal ideation Intensity of ideation Suicidal behavior Actual suicide attempts
Suicide Behavior Questionnaire-Revised (SBQ-R)	Self-report questionnaire for use in ages 13 to 18	Lifetime suicide ideation and/or suicide attempt Frequency of suicidal ideation over the past 12 months Threat of suicide attempt Self-reported likelihood of suicidal behavior in the future
Ask Suicide-Screening Questions (ASQ)	For patients ages 10 to 24 in emergency departments, inpatient units, and primary care facilities	“In the past few weeks, have you wished you were dead?” “In the past few weeks, have you felt that you or your family would be better off if you were dead?” “In the past week, have you been having thoughts about killing yourself?” “Have you ever tried to kill yourself? If yes, how?”

Once it has been established that an individual is having suicidal thoughts or has attempted suicide, a complete assessment of suicidal thinking and behavior, including the nature and extent of the risk, should be obtained (ZeroSuicide, 2020).

ASSESSING FOR RISK FOR HARM TO OTHERS

The risk for harm to others increases in adolescence, with a peak from late teens to early 20s, then a dramatic reduction in the late 20s and a slow reduction until the 60s, when there is another dramatic reduction. A history of violence or risk to others is vitally important to ascertain. It is also important to remember that some risks are specific with identified potential victims (RCPsych, 2020).

Risk assessment tools provide a standard against which to evaluate individuals for potential harm to others, enabling all healthcare providers to share a common frame of reference and understanding. One such tool is described in the box below.

ASSAULT AND HOMICIDAL DANGER ASSESSMENT TOOL

Key to Danger	Immediate Dangerousness to Others	Typical Indicators
(Hoff, 2009; CDC, 2020)
1	No predictable risk of assault or homicide	No assaultive or homicidal ideation, urges, or history of same Satisfactory support system Social drinker only
2	Low risk of assault or homicide	Occasional assault or homicidal ideation (including paranoid ideas) with some urges to kill No history of impulsive acts or homicidal attempts Occasional drinking bouts and angry verbal outbursts Satisfactory support system
3	Moderate risk of assault or homicide	Frequent homicidal ideation and urges to kill but no specific plan History of impulsive acting out and verbal outbursts while drinking, on other drugs, or otherwise Stormy relationship with significant others Periodic high-tension arguments
4	High risk of homicide	Has homicidal plan and available means History of substance abuse Frequent acting out against others but no homicide attempts Stormy relationships and much verbal fighting with significant others Occasional assaults with significant others
5	Very high risk of homicide	Has current high-lethality plan Available means History of homicide attempts or impulsive acting out Feels a strong urge to control and “get even” with a significant other History of serious substance abuse Possible high-level suicide risk