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Midterm exam

Raffy V. Tabalbag, RN
C 218 PSY Crisis Interventation
1st Semester 2019 -2020

1.Discuss the psychosocial development theory of Erik Erikson and sigmund

freuds psychosexual development theory . Give the similarities of these theories
and how can an individual develop crisis at one particular stage of development

The two theories of development both focus on the importance of early

experiences, but there are notable differences between Freud's and Erikson's
ideas. Freud centered on the importance of feeding, while Erikson was more
concerned with how responsive caretakers are to a child's needs.
Freud's Stages of Psyhosexual Development
 Freud's called this the oral stage.
 At this point in development, a child's primary source of pleasure is
through the mouth via sucking, eating, and tasting.
 Problems with this stage can result in what Freud referred to as an
oral fixation.
Erikson's Stages of Psychosocial Development
 Erikson called this the trust versus mistrust stage.
 Children learn to either trust or mistrust their caregivers.
 The care that adults provide determines whether children develop this
sense of trust in the world around them.
 Children who do not receive adequate and dependable care may
develop a sense of mistrust of others and the world.
While there are a number of differences between Erikson's and Freud's ideas,
their theories both focus on how children develop a sense of independence and
Psychosexual Development:
 Freud called this the anal stage of development.
 Children gain a sense of mastery and competence by controlling bladder
and bowel movements.
 Children who succeed at this stage develop a sense of capability and
 Those who have problems at this stage may develop an anal fixation. As
adults, they might be excessively orderly or messy.
Psychosocial Development:
 Erikson called this the autonomy versus shame and doubt stage.
 Children develop self-sufficiency by controlling activities such as eating,
toilet training, and talking.
 Those who succeed at this stage develop a sense of independence
while those who struggle will be left doubting themselves.
During the preschool and early elementary years, Freud's theory was much
more concerned with the role of the libido while Erikson's theory was more
focused on how children interact with parents and peers.
Freud's Theory:
 Freud referred to this as the phallic stage.
 The libido's energy is focused on the genitals. Children begin to identify
with their same-sex parent.
 Boys experience the Oedipus complex while girls experience
the Electra complex.
Erikson's Theory:
 Erikson's called this the initiative versus guilt stage.
 Children begin to take more control over their environment.
Those who are successful at this stage develop a sense of purpose while those
who struggle are left with feelings of guilt.Freud believed that this age served as
more of a transitional period between childhood and adolescence. Erikson, on
the other hand, believed that kids continue to forge a sense of independence
and competence.
Psychosexual Development:
 Freud referred to this as the latent period.
 The libido's energy is suppressed and children are focused on other
activities such as school, friends, and hobbies.
 Freud believed this stage was important for developing social skills and
Psychosocial Development:
 Erikson called this the industry versus inferiority stage.
 Children develop a sense of competence by mastering new skills.
 Kids who succeed at this stage develop pride in their accomplishments
while those who struggle may be left feeling incompetent.

Age: Adolescence

Adolescence played a critical role in both Freud's and Erikson's theories of

development. In both theories, teens begin to forge their own sense of identity.
Freud's Theory:
 Freud referred to this point in psychosexual development as the genital
 Children begin to explore romantic relationships.
 The goal of this stage is to develop a sense of balance between all the
areas of life. Those who have successfully completed the earlier stages
are now warm, caring and well-adjusted.
Erikson's Theory:
 Erikson's called this point in psychosocial development the identity
versus role confusion stage.
 Children develop a personal identity and sense of self.
 Teens explore different roles, attitudes, and identities as they develop a
sense of self.
 Those who receive support and encouragement will emerge with a
strong sense of who they are and what they want to accomplish.
 Those who struggle to forge a strong identity will remain confused about
who they are and what they want to do with their life.

Age: Adulthood

Freud's theory focused exclusively on development between birth and the teen
years, implying that personality is largely set in stone by early childhood.
Erikson, on the other hand, took a lifespan approach and believed that
development continues even in to old age.
Freud's Theory of Psychosexual Development:
 Freud's theory largely focuses on the period between birth and
 According to Freud, the genital stage lasts throughout adulthood. He
believed the goal is to develop a balance between all areas of life.
Erikson's Theory of Psychosocial Development:
 Eriksons' theory includes three more stages that span adulthood. These
three stages are:
 Intimacy vs Isolation: Young adults seek out romantic love and
 Generativity vs Stagnation: Middle-aged adults nurture others and
contribute to society.
 Integrity vs Despair: Older adults reflect on their lives, looking back with
a sense of fulfillment or bitterness.

Freud's and Erikson's theories of development share a number of important

similarities. Both stressed the importance of social experiences and recognized
the role that childhood plays in shaping adult personality. Unlike Freud's
psychosexual approach, Erikson's psychosocial stage theory took a more
expansive view of development, encompassing childhood, adolescence, and
adulthood. While Freud believed that development was largely complete fairly
early on, Erikson felt that it was a process that continued throughout the entire
course of a person's life.
2.Genetic and environmental factors are involved in determining the behavior
of individuals. Give a brief discussion on their influence in these aspects. How
do individual maintain their sanity?

Every individual on this earth is different from the other. No one person is fully
like other person.Every person differs from the other, either physically or
psychologically. Even the twins are no exception to this. They differ in some
aspects or other. Particularly when we look at people from psychological point
of view these differences are quite obvious. In many instances even the
children differ from their parents.The psychological state of mother like over
excitement, depression also may cause damaging effect on the child.After nine
months, the child is born and enters a new environment which is entirely
different. A new life begins in a new environment. This new environment will
have a different culture, ideology, values, etc.

The home atmosphere, parental love and affection, association with sibling,
neighbours, peers, teachers, etc. will create an entirely different and new
atmosphere. This is called social environment. All the social factors stated
above shape the personality of the child.Innumerable studies have been
conducted on both sides. However, the results indicate that heredity and
environment are interdependent forces. Whatever the heredity supplies, the
favourable environment brings it out. Personality characteristics attained by
heredity are shaped by environment. To control or change our behaviour we
need to change our bad side, and learn it to change into a better person.

3.State the definition of crisis given by aguilera, caplan and linderman,Give

your own definition as well.

It is concerned with the maintenance of mental health and the prevention

of mental illness. Specialists in this filed used psychoanalytic theory as a base
for a theoretical framework that explored brief intervention for persons having
stressful life experiences.

Foremost among those involved in preventive psychiatry was Eric

Lindeman. Lindeman studied the bereavement seen in the surviving relatives
and friends of the hundreds of people who died in the disastrou7s Coconut
Grove nightclub fire in Boston in 1943. He hypothesized that numerous
threatening situations might arise in a person’s life and that the person either
adapts to the situations or fails to adapt and has impaired functioning.
Later, in the early 1960’s, Gerald Caplan defined crisis theory and
described crisis intervention. He utilized principles of preventive psychiatry-
primary. Secondary and tertiary prevention- as a basis for his work.

All individuals experiences crisis at one time or another. Crisis is precipitated by

specific identifiable events and is determined by an individual’s personal
perception of the situation. Crisis occurs when an individual is exposed to a
stressor and previous problem solving techniques are ineffective. Crisis
intervention is designed to provide rapid assistance for individuals who have an
urgent need. Nurses regularly respond to the individuals in crisis, in all types of
setting. Nursing process is the vehicle by which nurses assist individuals in
crisis with a short term problem solving approach to change. Nurses have many
important skills that can assist individuals and communities in the wake of
traumatic events.

Stressful events or crisis are a common part of life. Any stressful

situation can precipitate a crisis. Crisis results in a disequilibrium from which
many individuals require assistance to recover. Crisis intervention requires
problem solving skills that are often diminished by the level of anxiety
accompanying disequilibrium. Knowledge of Crisis Intervention techniques is
an important skill of all nurses, regardless of clinical settling or practice

4.Discuss the maturational and situational type of crisis ,lite an example for
each situation.

1. Maturational Crises
Maturational crises, sometimes called developmental crises, are
predictable life events which normally occur in the lives of most people.
A person’s life is continually changing because of the ongoing process of

The onset of a maturational crisis is gradual and occurs over time as the
person moves through a period of change. Such transitional periods are
characterized by internal disequilibrium and disorganized behavior. The
person may experience mood swings and variations of normal behavior
in terms of roles and relationships.

1. The success with which previous life transitions have been

mastered. If previous stages of maturational change have been
mastered successfully, the residue of unresolved developmental
issued is minimized and the person in able to move on to the next
transition with a firmer foundation for future growth. People who have
unresolved maturational issues from the past often experience
greater stress in current life transitions that involve old “unfinished
business” than people who are not burdened or vulnerable in this
way. Unresolved maturational issues include dependency and
authority conflicts, value conflicts, sexual-identity confusion, and lack
of capacity for emotional intimacy.
2. Adequate role models. These provide the person with examples of
how to act in the new role. Teachers, parents, mentors, and peers
are examples of people who can act as role models.
3. Interpersonal resources. These offer the person a cast of characters
with whom to try out new behavior and skills in the attempt to achieve
role changes.
4. The degree to which others accept or resist the new role. This
influences the ease with which role changes are made. The greater
the resistance of others, the more difficulty the person experience in
making the change.
Mr.Jack, 68 years old came to the crisis clinic with the complaints of a
“nervous stomach”, insomnia, and fatigue. His symptoms had begun 1 month
before, after he was forced into retirement by business reverse that resulted in
the unexpected sale of a previously successful business. All of Jack’s friends
and acquaintances still worked, as did his wife. His lifetime involvement with
work had left little time for or interest in the development of recreational
pastimes. He now found himself sitting at home each day by himself with little
to do besides read the newspaper and watch television. Although he did little
each day he felt exhausted and nervous. He felt directionless, useless, and
lonely. he consulted his family doctor for his “nervous stomach,” and she
referred him to the crises clinic.
An older man who was having difficulty dealing with an abrupt transition
into retirement. His self-worth was tied to his involvement with work, and he
was unprepared with alternative interests to provide meaning in his life. He
had no situational supports or role models to ease the transition. His former
coping methods were ineffective in the situation.

Maturational Crisis Stressors

Infancy Separation at birth
Separation from symbiotic relationship
Early childhood Giving up certain pleasures
Conforming to social demands
Separation and autonomy
Gender and sexual identity
School age Separation from the nurturing person
Interaction with new authority figures
Formation of peer relationships
Group cooperation
Adolescence Change in body image
Consolidation of psychosexual identity
Heterosexual relationships
Educational demands
Parent-child separation
Independence from parental supports
Young adulthood Preparation for work and career
Commitment to intimate relationships or
Psychosexual maturity
Adulthood Pursuit of career goals
Marital or other intimate relationships
Sexual relationships
Childbearing and child rearing
Independence and interdependence
Middle adulthood Launching of children or empty-nest
Work stressors (promotion end of the line,
loss of job, retirement)
Illness or death of a parent Physical
Changes in marital status
Late adulthood Unproductive, less valued role of the retiree
Declining physical health problems
Loss of spouse and peers
Economic problems
Loss of independence

2. Situational Crises
Situational crises occur when unanticipated events threaten a
person’s biological, social, or psychological integrity. There is an
accompanying degree of disequilibrium. The person’s coping
mechanisms become ineffective, or chosen solutions prove to be
impractical. The stressful event involves a fundamental loss or
deprivation which threatens the person’s self-concept.
A situational crisis is precipitated by the loss of systematized
support that had enhanced the person’s feelings of security and control
and was essential to maintaining the integrity of the self-concept.
Examples of situational crises include loss of a loved one, loss or
change of a job, change in financial status, geographic move, school
failure, divorce, unwanted pregnancy, birth of a premature or disabled
child, and physical or mental illness. Each of these crises has the
potential to create stress, initiate grieving, threaten feelings of self-worth,
create conflict and role change among family members, and precipitate
loss of emotional support system.
Patty A., age 19, comes alone to the general hospital emergency room
on a Saturday night. She paced the waiting room in an agitated manner, crying
and muttering to herself. When interviewed by the triage nurse, she
complained of abdominal pain and two missed menstrual periods. As she
spoke, she began to sob, saying that she was afraid that she was pregnant.
She was afraid to tell her parents because they’d throw her out. She was afraid
to tell her boyfriend because he would insist that they get married and she did
not want to marry for that reason. She attended a local community college and
did not know what she would do with a baby if she had one. She did not want to
quit school and did not know if she wanted an abortion. He finished by sating,
“My head is in a whirl. I never had so much to decide, and I have no one to talk
to who could help me.”
An unmarried young woman, with no situational supports, attempting
to make major decisions about commitments, roles, and lifestyles with no
previous coping experience in this or a related area.

3.Social Crises
Social crises are accidental, uncommon, and unanticipated crises
that involve multiple losses or extensive environmental change.
Examples of social crises are natural disasters such as fires, floods,
volcanic eruptions, and earthquakes; national disasters such as wars,
riots, racial persecution, and nuclear contamination; and violent crime
such as rape and murder. Social crises do not commonly occur in the
everyday lives of people. When they do occur, the stress level is so high
that the coping resources of each person are maximally challenged.
Tyhurst in his study of individual responses to community disasters
found that victims experience three overlapping phases.
1. Period of impact
2. Period of recoil
3. Posttraumatic period

During social crises mental health workers must reach out to the
community and intervene with a large number of people.


In a small city of 75,000, it had been raining heavily for 3 day. Power
failures were widespread, and telephone lines were down in several parts of
town. Many rivers and streams had over flowed, flooding many main streets.
People were wondering how the dam at the edge of the city would hold in this
downpour. They reassured each other by saying, “the old dam has been there
for a hundred years it has withstood worse than this.” Many people left their
homes to move to higher ground. Others, however stayed clinging to the belief
that, “It could not happen to us.” They sat by their radios and waited and
listened in the darkness.
Early on the fourth morning, people were awakened by a deafening roar.
A huge torrent of water was pouring downhill, overturning everything in its path.
People raced to second floors attics and roofs. It was too late to get away.
They watched neighboring houses break loose from their foundations. They
heard the screaming voices of friends and neighbors, adults and children alike,
who clung to anything that would keep them afloat in the churning water.
The massive flood caused by the dam break destroyed houses, stores,
and schools everything in its path was ruined. Hundreds of people were
trapped and drowned in their houses or trying to escape, especially those living
in the lower parts of town. Survivors many of whom had failed to save their
loved ones, slowly made their way to higher ground, where they found
makeshift emergency shelters. Many appeared numb, in shock many could not
describe in a coherent way what had happened. They sat rigidly still, paced
agitatedly, or busily involved them selves in rescue work. Some wept
hysterically about lost family members, homes, and business others were
unnaturally calm and contained still others alternated between the two affective
states. Many people had sustained physical shock and needed minor or
extensive medical treatment. Rescue assistance arrived by helicopter,
because the city was cut off from other transportation routes. The critically
injured were evacuated to regional medical centers those less seriously injured
remained in emergency shelters. The unhappy task of cleaning up the city
began finding and burying the dead, cleaning debris, fixing the dam, and
rebuilding the city.
Unanticipated natural disaster which destroyed a city and resulted in the
death of hundreds. Following the impact phase, emergency interventions
were instituted to deal with shock and acute disorganization. In the
posttrauma phase, survivors will have to be observed for later sequelae such
as persistent intense fear phobias about weather apathy depression despair,
preoccupation with thoughts of dead relative’s guilt about survival vivid
memories and dreams constricted living patterns diffuse rage reactions. Such
behaviors would be the evidence of ineffective mourning, anxiety, and intense
feelings of helplessness and lack of control.


Phase Definition Characteristics

Impact The period in which Calm, effective action;
people are hit with the shock and confusion;
reality of what has hysteria, confusion, or
happened. This phase paralyzing fear
lasts from a few minutes
to 1 or 2 hours.

Recoil The period in which Looking for connection

there is at least a with support systems such
temporary suspension of as surviving friends or
the initial stresses of the relatives; desire to be
disaster. Lives are no taken care of; desire to
longer in danger, share the horror of the
although many stresses experience; weeping
remain, including
gradual awareness of
the full impact of the

Post trauma The period in which Guilt, nightmares, anger,

survivors become fully frustration, anxiety
aware of what occurred reactions, reactive
during the impact depressions, psychotic
phase-loss of families, episodes
homes, belongings,
security. Resolution of
loss and reconstruction
of lifestyle will occur to
lesser and greater
degrees. This phase can
last for the rest of a
person’s life.

Classification According to Severity

Situational and maturational crises also can be classified based on the
severity of the precipitating events. A classification system developed by
Burgess and Baldwin (1981) systematically describes six types of crises based
on the severity of the situation. Each classification is briefly summarized below.

1. Class 1: Dispositional or situational crisis in which a problem is

presented with a need for immediate action, such as finding housing for
the homeless during subzero temperatures
2. Class 2: Life transitional or maturational crisis that occurs during normal
growth and development, such as going away to college or experiencing
a planned pregnancy.
3. Class 3: situational crisis due to a sudden, unexpected, traumatic event
or disaster, such as the loss of a home during a hurricane or earthquake
4. Class 4: Maturational or developmental crisis involving an internal
stress and psychosocial issues, such as questioning one’s sexual
identity or lacking the ability to achieve emotional independence
5. Class 5: Situational crisis due to a preexisting psychopathology, such as
depression or anxiety, that interferes with activities of daily living (ADL)
or various areas of functioning
6. Class 6: Psychiatric situational crisis or emergency, such as attempted
suicide, drug overdose, or extreme agitation, resulting in unpredictable
behavior or the onset of an acute psychotic disorder

Behaviors Commonly Exhibited After a Crisis

Anger Irritability

Apathy Labiality

Backaches Nightmares

Boredom Numbness

Crying spells Overeating or under eating

Diminished sexual drive Poor concentration

Disbelief Sadness

Fatigue School problems

Fear Self-doubt

Flashbacks Shock
Forgetfulness Social withdrawal

Headaches Substance abuse

Helplessness Suicidal thoughts

Hopelessness Survivor guilt

Insomnia Work difficulties

Intrusive thoughts

5.What is anxiety ? discuss the difference stages of anxiety , give the nursing
intervention for this kind of disorder

Distinctions between:
 Fear (a present-oriented alarm reaction to danger)
 Anxiety (a future-oriented reaction, usually with feelings of tension) and
 Panic (an abrupt experience of intense fear or acute discomfort,
accompanied by physical symptoms that usually include heart
palpitations, chest pain, shortness of breath and possibly dizziness).
There are also 3 sub-types of panic:
o Situationally bound – when the person knows they will have a panic
attack in that situation
o Unexpected – when the person cannot predict when they will have
a panic attack
o Situationally predisposed – when the person knows they are more
likely to have a panic attack in a situation, but they don’t know for
sure if they will have one.

Two things are needed to differentiate between an anxiety disorder and just
feeling anxious:
Over-activation of the sympathetic division of the ANS
Feelings of dread.
The different types of anxiety disorder differ in the cognitive component –
intrusive thoughts are features of PTS and OCD, but less a feature of the
specific phobias and very little in GAD.

Causes of anxiety

Multiple genes contribute to a proneness to anxiety and also probably to panic.

The main model at the moment suggests weak contributions from multiple

Anxiety seems to be associated with the neurotransmitter GABA. The

noradrenergic and serotonergic systems also seem to be involved.
Corticotrophic Releasing Factor (CRF) is receiving increasing attention and
that is related to levels of GABA.

It is interesting to note that different brain circuits seem to be involved in panic

and in anxiety.

The limbic system is involved as a mediator between cortex and brain stem in
anxiety but not panic. Different mid-brain structures seem to be involved in
mediating panic attacks.

Factors in the environment change the sensitivity of these circuits – smoking

during adolescence seems to be a particularly influential factor.

Parental influence over perceptions of control seems to be important to the

experience of anxiety later in life. Overprotective and intrusive parents, who
don’t let their children experience control over the environment, produce higher
anxiety in their children.

Triple vulnerability theory.

This theory incorporates generalised biological vulnerability (a diathesis);
generalised psychological vulnerability (a viewpoint about the dangerousness
of the world); and specific psychological vulnerability (experiences of being
taught that certain situations or things are dangerous).
There are high levels of comorbidity between the various anxiety disorders and
the mood disorders. The main differences are in the focus of the anxiety and
the pattern of panic attacks. The most common extra diagnosis for all anxiety
disorders is major depression (lifetime comorbidity of 50%).

There is also comorbidity with a number of physical disorders (thyroid disease,

migraine, arthritis and allergies, for example).

Finally, in this section, there is also an elevated risk of suicide, particularly

associated with panic disorder.

Generalised Anxiety Disorder (GAD)

According to DSM-IV-TR it must last for at least 6 months and be experienced

most days.
It must also be difficult to control.
People with GAD worry about minor, everyday things.

Another distinguishing feature is sustained, high muscle tension, which often

leads to fatigue.

GAD is a chronic disorder that is more common in females and the elderly. It
affects about 4% of the general population.

There is an interesting physiological distinction between GAD and other anxiety

disorders – autonomic restriction. They show less physiological reactivity on
most physiological measures.

People with GAD are also very reactive to threats, even unconscious threats
(MacLeod & Mathews, 1991).

It looks as though these individuals have strong emotional reactions, without

conscious cognitive processes – they don’t think through or work through, the
things that evoke their anxiety. It suggests that there is a need to bring back the
unconscious into psychology.


Benzodiazepines, such as the early diazepam (valium), bring some relief in the
short term. Unfortunately they slow people down and create dependence so
they tend to be used just to help someone through a crisis. However, they are
safer than the previously used barbiturates, which they largely replaced.

Antidepressant medication is also sometimes used successfully.

Psychological treatments focus on deep relaxation and helping people work

through the things they find threatening, using CBT for example.

The text also cites more recent studies showing that acceptance-based
mindfulness techniques can be helpful.

Panic Disorder with or without Agoraphobia

To meet the criteria for panic disorder, a person must experience an

unexpected panic attack and develop anxiety about the possibility of another
attack or the implications of the attack.

Agoraphobia is fear and avoidance of ‘unsafe’ situations where a panic attack

may occur (it is not a specific fear of a marketplace, as the name implies).
People with panic disorder with agoraphobia (PDA) experience severe
unexpected panic attacks during which time they feel a loss of control or
endangered. People may also experience panic disorder without agoraphobia,
although this is rarer and some researchers wonder if it exists at all.

Agoraphobic avoidance appears to be one complication of severe, unexpected

panic attacks, and agoraphobic behaviour can become independent of panic
attacks. According to the DSM-IV, agoraphobia may be characterised either by
avoiding situations or enduring them with marked distress.
Approximately 60% of people with panic disorder experience nocturnal panic
attacks (i.e., panic during sleep). Nocturnal panic occurs most often between
1:30 am and 3:30 am than at any other time, and such attacks have been
shown to occur during delta wave sleep (the deepest stage of sleep, but not
dream sleep). Possible causes include physiological changes due to shifts in
sleep stages and sleep apnea (interruption of breathing during sleep).


The causes of panic disorder are numerous, and include an interaction of

psychological, biological, and social-experiential influences.

The textbook suggests that a biologically inherited vulnerability to be

over-reactive to daily events, coupled with stress, may establish a
predisposition to associate the response with internal and external cues (i.e.,
moving from a false alarm to a learned alarm response). Such factors, coupled
with a psychological vulnerability to catastrophically misinterpret such events
and the development of anxiety over the possibility of future panic attacks may,
in turn, lead to panic disorder.

Interoceptive awareness, or attentiveness to internal sensations, is enhanced

in people with panic disorder.


Medications for anxiety and panic largely affect the serotonergic,

noradrenergic, and GABA neurotransmitter systems, blocking panic attacks. As
before, Benzodiazepines, though effective in reducing panic symptoms, may
cause dependence.

SSRIs (e.g., Prozac and Paxil) are currently the preferred drug for panic
disorder, though sexual dysfunction (mainly loss of libido) is a common
side-effect. Relapse rates for panic are high once the medication is
Psychological interventions such as CBT are quite effective for panic disorder.
Such treatment typically involves gradual exposure exercises combined with
anxiety-reducing coping skills, such as relaxation and breathing retraining.
About 70% of people undergoing these treatments substantially improve, but
very few achieve complete remission of symptoms.

Panic Control Treatment (PCT) is a cognitive-behavioural treatment that

arranges for mini-exposures to panic sensations in therapy, and includes
cognitive therapy to address attitudes and misperceptions about the feared
sensations and situational triggers, relaxation, and breathing retraining.

New evidence on combined treatments (i.e., medications plus CBT) suggest

that combined treatment was no better than individual treatments in the short
term; however, in the long term persons receiving CBT alone maintained most
of their treatment gains, whereas those taking medication alone or in
combination with CBT deteriorated somewhat.

This result led to the recommendation that psychological treatment should be

offered initially, followed by drug treatment for those patients who do not
respond adequately or for whom psychological treatment is not available. New
evidence suggests that when patients are initially given CBT, non-responders
may benefit from SSRI treatment; this process of “stepped care” may help to
benefit a greater percentage of people with panic disorder.


These involve:

 Extreme and irrational fear of a specific object or situation

 Significant impairment in functioning
 Recognition of the fears as unreasonable
 Avoidance of the object or situation

Interestingly, among those diagnosed with antisocial personality disorder, the

incidence of agoraphobia is 0%, which gives interesting clues about causes.
Among the specific phobias, xenophobia, Islamophobia and homophobia are
political labels. They have nothing to do with the kind of dread or anxiety
experienced by people with actual phobias.

Specific fears are quite common, and the most common phobias are of snakes
and heights. With the exception of fear of heights, most persons with specific
phobia are female (4:1 ratio). Specific phobias affect about 12.5% of the
population, although people with the disorder are often not referred for
treatment. Phobias tend to run a chronic course.

There are as many phobias as there are objects and situations. The major
subtypes of specific phobia are as follows:

1. People suffering from blood-injury-injection phobia differ from all the other
phobias in that they experience drops in heart rate and blood pressure and
increased urges to faint. This vasovagal reaction occurs in response to blood,
injury, or the possibility of an injection and seems to have a strong genetic
component. Mean age of onset for this phobia is 9.

2. A situational phobia refers to a group of phobias characterised by fear of

public transport or enclosed places (e.g., planes, trains, lifts / elevators, small
enclosed spaces). Onset of this phobia is in the early to mid-20s. People with
situational phobias do not experience panic attacks outside their feared

3. Natural environment phobia concerns extreme fears of situations or events

occurring in nature, such as heights, storms, or water. People may be
biologically prepared to fear some of these stimuli; so, to call such fears a
phobia, requires that the response be persistent and that it interferes with life

4. Animal phobia refers to fears of animals and insects. To be considered a

diagnosable phobia, these fears must interfere with functioning. The age of
onset for these phobias, and natural environment phobias, peaks at around 7.

5. Other phobias - a category that includes phobias that do not neatly fit into
one of the other four categories (e.g., fear of choking or vomiting). Other
phobias that are frequent and cause substantial problems include:
a. Illness phobias, or fears of contracting a disease or of settings where germs
could be found.
b. Choking phobia, or fear and avoidance of swallowing pills, food, or fluids,
which can result in significant weight loss.


The causes of phobias are quite complex. Some, but not all, specific phobias
are caused by exposure to traumatic events. People may develop a specific
phobia by experiencing a false alarm or panic attack (e.g., during driving),
observing someone else (a parent, for example) experience severe fear (e.g.,
during a dental visit), or being told of some danger (information transmission).
There is a likely genetic transmission of specific phobias, influenced also by
one's cultural background and gender roles.


The basic treatment of a specific phobia is straightforward and involves

structured and consistent exposure-based exercises in a supervised
therapeutic context. In addition, tension and release of muscle groups may be
utilised to induce relaxation.

These exposure techniques are very similar to exposure and response

prevention, a method that is often used to treat obsessive-compulsive disorder
(see below).

The techniques are modified for blood-injury-injection phobia by tensing muscle

groups to keep blood pressure high enough to prevent fainting.

Social Phobia

Social phobia refers to individuals who are extremely and painfully shy in
almost all social and performance-related situations; however, social phobia is
more than shyness. People who are extremely and painfully shy in almost all
social situations meet DSM-IV-TR criteria for a subtype of social phobia -
generalised type, occasionally called social anxiety disorder. Social phobia is
illustrated in the textbook with the case of Billy.
As many as 12.1% of the general population suffer from social phobia at some
point in their lives, making social phobia second only to specific phobia as the
most prevalent anxiety disorder. Females are slightly more represented than
males. Social phobia begins during adolescence with a peak age of onset at
about 13 years; most are also single. Social phobia seems to be on the rise
among young people.

Taijin kyofusho, a fear of looking people in the eye, and a corresponding fear
that some part of one's presentation will be offensive to others, is a
culturally-specific presentation of social phobia in Japan. This condition is more
prevalent in males than in females (3:2 ratio).

Hikikomori is a Japanese term to refer to the phenomenon of reclusive

adolescents and young adults (mainly young men) who have chosen to
withdraw from social life - often seeking extreme degrees of isolation and
confinement due to various personal and social factors in their lives. According
to estimates by psychologist Saito Tamaki, who first coined the word, there may
be 1 million hikikomori in Japan, 20 percent of all male adolescents in Japan, or
1 percent of the total Japanese population. Surveys done by the Japanese
Ministry of Health as well research done by health care experts suggest a more
conservative estimate of 50,000 hikikomori. As reclusive youth, by their very
nature are difficult to poll, the true number of hikikomori most likely falls
somewhere between these two figures.


The causes of social phobia are complex. Humans may be biologically

predisposed or prepared to fear angry, critical, or rejecting people or faces. In
addition, some infants are predisposed to agitation and hyperarousal when
faced with new stimuli. Such infants may also be predisposed to increased

Three pathways to developing social phobia include:

1. Biological vulnerability to develop anxiety or to be socially inhibited. This
vulnerability may be increased under stress or when events are perceived as
2. A person may also experience an unexpected panic attack (i.e., false
alarm) during a social situation or experience a social trauma resulting in
conditioning (i.e., a learned alarm). In these scenarios, conditioning may occur
and social settings may be avoided.
3. Modelling of socially anxious parents may also play a role in the
development of social phobia. Indeed, for a social anxiety disorder to develop,
an individual with pre-existing vulnerabilities probably also learned growing up
that social evaluation can be dangerous.


Cognitive-behavioural treatment for social phobia includes rehearsal or

role-play of feared social situations in a group setting. In addition, intensive
cognitive therapy and social support may be employed. Evidence suggests that
the exposure component is more important in treatment than the cognitive
component. Psychological treatments are generally highly effective.

Beta-blockers may control physical symptoms such as shaking hands, but are
of little or no help with the feelings of anxiety. Tricyclic antidepressants and
monoamine oxidase inhibitors are drugs that have been found to reduce social
anxiety, though relapse is common when medications are discontinued and the
side-effects mean that people are inclined to discontinue.

A recent study indicated that adding d-cycloserine (DCS) to CBT significantly

enhances treatment outcomes. This drug is different from SSRIs in that it
targets the glutamatergic system. Glutamate is a neurotransmitter that plays a
role in memory formation and information processing. Disturbances in this
system are also seen in ADHD and possibly other disorders such as
psychoses, depression, Alzheimer's Disease and obsessive-compulsive

Posttraumatic Stress Disorder

The emotional disorder that often arises after a trauma such as war, assault,
natural disaster, or sudden death of a loved one is posttraumatic stress
disorder (PTSD). According to the DSM-IV-TR, a person with PTSD must have
been exposed to some event during which he/she feels fear, helplessness, or
horror. After the event, the person continues to re-experience the event through
memories, re-enactments, nightmares, or flashbacks. Cues that remind the
person of the event are avoided and emotional responsiveness is numbed.
Often such individuals are chronically over-aroused, easily startled, and quick
to anger. PTSD is illustrated in the textbook with the case of the Joneses.
The DSM-IV-TR subdivides PTSD into acute and chronic types.
1. Acute PTSD may be diagnosed 1-3 months after the traumatic event,
whereas chronic PTSD is diagnosed after 3 months. PTSD cannot be
diagnosed sooner than 1 month post-trauma.
2. Chronic PTSD is associated with more long-term avoidance and greater
co-morbidity than acute PTSD.
3. If a person does not show any symptoms until long after the traumatic
event, then a diagnosis of delayed onset PTSD is used.

Acute stress disorder is a new disorder in the DSM-IV, and refers to a disorder
occurring within the first month after a trauma. The different name emphasizes
the very severe reaction that some people have immediately following a
traumatic event. PTSD symptoms are accompanied by severe dissociative
symptoms. This disorder was included in the DSM-IV so that people with early
severe reactions could receive insurance coverage for immediate treatment.

Recent surveys indicate that among the population, approximately 6.8% have
experienced PTSD, and that combat and sexual assault are the most common

Many people experience a trauma but do not go on to develop PTSD. Some

even experience Post-Traumatic Growth.

Some normal reactions to trauma include:

Crisis responses

 Shock
 Disbelief
 Realisation (gradual acceptance)
 Frozen survival state (emotionally frozen and focussed on survival – this
may be mistaken for calmness)

Recovery phase
 Shock (may re-occur)
 Depression
 Mood swings
 Anger (may result in social isolation when support is most needed)
 Reflection (trying to understand what happened to try and prevent it
happening again)
 Laying to rest (when the traumatic event becomes an ugly memory, but
not one that interferes with the quality of life)

According to Richard Bryant of UNSW (writing in In Psych magazine, April

2009) rates of PTSD are high in the initial months after a disaster, but
subsequently decline. For example, a survey conducted in the 5-8 weeks after
the 9/11 terrorist attacks in New York, close to the site, found 7.5% of adults
had developed PTSD. Five months after the attack, another survey in the same
area found that 1.7% had PTSD. After the 2004 tsunami in Thailand, the rate of
PTSD in displaced people was 12% 2 months after the event. This dropped to
7% after 9 months. These patterns have implications for treatment because
most people get better without mental health interventions.

Two important issues for deciding on the appropriateness of interventions are:

 The extent to which the threat still exists as far as that person is
 Whether the person has sufficient resources to manage the intervention.
After bushfires, for example, people will be rebuilding homes for many
months and may not be able to cope with having therapy at that stage.

The on-going stressors after many disasters can complicate the recovery


The intensity of the trauma has an effect.

Biological/genetic vulnerability to anxiety is also a significant factor, as are

possible neurobiological effects and changes in the locus coeruleus.
Trauma may alter brain structure and function, with studies showing damage to
the hippocampus (which plays an important role in learning and memory) in
groups of patients with combat PTSD and adult survivors of childhood sexual

Finally, social and cultural factors, particularly having strong and supportive
people around, seem to lessen the risk of developing PTSD.


The psychological treatment of PTSD typically focuses on having the person

gradually re-experience aspects of the traumatic event within a supportive
context to develop effective coping procedures and to produce corrective
emotional learning. Because recreating the trauma is not desirable, imaginal
exposure is usually conducted, in which the therapist works with the trauma
victim to develop and review a narrative of the trauma in therapy.

Interventions immediately after a trauma may be helpful for some, but it

appears that debriefing sessions after a trauma may actually be detrimental.

Eye Movement Desensitisation and Reprocessing (EMDR) is a recent addition

to the treatments for PTSD. In 2006 it was validated by the National Institute for
Health and Clinical Excellence (NICE) in the UK as one of the preferred
treatments for PTSD. It is a technique that can be integrated into other
psychotherapeutic approaches.

The technique involves the bilateral stimulation of the brain by using either
sideways tracking movements of the eyes, tapping the client's hands or
auditory cues that alternate between left and right using headphones. This
replicates the brain activity found in REM sleep when we process information
and consolidate memory. EMDR allows people to reach an adaptive resolution
to their PTS experience.
6.What is depression ? give the different symptoms and its predisposing
factors. What are some of the measure that can be help in alleviating such

Most people have felt sad or depressed at times. Feeling depressed can be a
normal reaction to loss, life's struggles, or an injured self-esteem. But when
feelings of intense sadness -- including feeling helpless, hopeless, and
worthless -- last for days to weeks and keep you from functioning normally, your
depression may be something more than sadness. It may very well be clinical
depression -- a treatable medical condition. More women are diagnosed with
depression than men, with the median age of onset being 32 for both genders.

Most people when asked what depression is think that it’s when someone is so
sad that they feel worthless and constantly think about taking their own lives.
What they don’t know is that it’s much more than that. The definition of
depression is a mental state characterized by a pessimistic sense of
inadequacy and a despondent lack of activity which reflects a sad and/or
irritable mood exceeding normal sadness or grief. The signs and symptoms are
not only characterized by negative thoughts, moods, and behaviors but also
specific changes in bodily functions (for example: crying spells, body aches and
pains, low energy, as well as problems with eating, weight, and sleeping.) In
spite of clear research evidence and clinical guidelines regarding therapy,
depression is often undertreated and misunderstood. Hopefully, this situation
can change for the better. If this illness is not treated correctly, it can cause
severe damage towards a person and their families and friends. This research
paper will go in depth on the things that cause depression, the effects it has on
patients, their families, and friends, as well as the solution to treating this

Family History and Physical Conditions

Depression runs in families for generations but researchers have not yet
located a single, defective gene responsible for the condition. When a family
member has depression, spouses, siblings, or children are inevitably affected
emotionally by the illness and while depressed parents don’t pass on
depression per se to children, the way they pass on hair or eye color, they can
pass on a vulnerability to depression. Whether inherited or not, depression is
often associated with changes in brain structure or brain function.

Serious medical conditions like heart disease, cancer, and HIV/AIDS can
contribute to depression, partly because of the physical weakness and
stress they bring on. Depression can make medical conditions worse, since
it weakens the immune system and can make pain harder to bear. In some
cases, depression can be caused by medication used to treat medical
conditions. Depression also can increase the risk for subsequent physical
illness, disability, and premature death. The symptoms of depression can
also be caused by undiagnosed medical conditions, including epilepsy,
multiple sclerosis, Huntington’s disease, Parkinson’s disease,
hyperthyroidism, Lyme disease, and pancreatic cancer.

 Heart Disease- For people with heart disease, depression

increases the risk for an adverse cardiac event such as a heart
attack or blood clots. For people who do not have heart disease,
depression increases the risk of heart attack and coronary
disease. During recovery from cardiac surgery, depression can
intensify pain, cause worsened fatigue and sluggishness, or
cause a person to withdraw into social isolation. Patients who
have had coronary artery bypass graft (CABG) surgery and have
untreated depression after surgery also have an increased
morbidity and mortality rate.

 Cancer- People diagnosed with cancer may face an increased

risk of depression that persists for years, according to research
published online Feb. 17 in the Journal of Clinical Oncology and
up to 1 in 4 people with cancer have clinical depression which
causes great distress, impaired functioning, and may even make
the person with cancer less able to follow their cancer treatment
plan. When someone is diagnosed with cancer, their “normal
reaction” is depression, which means that it doesn’t require any
special treatment-the prevalence of depression among cancer
patients ranges from 23 percent to 60 percent. While doctors
today are better than ever at fighting the disease, a new study by
the Institute of Medicine in Washington, D.C., finds that the
anxiety, fear and depression associated with cancer often go
untreated. Of the country’s top 20 cancer care centers, eight
reported screening for emotional stress in only some of their
patients. "It's becoming a chronic illness, so now we have to take
a wider view and treat the whole patient and take care of all their
needs, including their cancer," said Dr. Lee Schwartzberg,
co-author of the study and the medical director of the West Clinic
in Memphis, Tenn.

 Huntington’s Disease- a disorder passed down through families

in which nerve cells in the brain waste away, or degenerate.
American doctor George Huntington, who traveled over the bleak
countryside five miles to the larger town of Middleport, Ohio, first
described the disorder in 1872 to the local medical society,
composed of physicians of sparsely populated Meigs and Mason
Counties. His brief, uniformly anecdotal and entirely
unreferrenced address, not suffering publication delay, was put
eight weeks later in the Medical and Surgical Reporter of
Philadelphia (v 26, no. 15, April 13, 1872). This has become one
of the classical descriptions of neurological disease. People with
Huntington’s disease have progressive motor problems, cognitive
deficits (dementia) and psychiatric symptoms (the most common
is depression) that usually start to appear in mid-life. There is no
cure and death usually results within 10 to 20 years of symptom
onset, or faster in the childhood-onset form of the disease. The
disease is caused by a mutation in a single gene and when this
defective gene is passed from parent to child, 50 percent of the
offspring inherit the disorder, which can be detected by genetic

Trauma and Stress

When dealing with trauma, most people who become depressed can recall a
single traumatic event that happened just prior to their becoming depressed.
Painful experiences such as the death of a loved one, divorce, a medical
illness, or losing everything in a natural disaster may be so impactful as to
trigger depression. Events like these take away a sense of control and cause
great emotional upheaval. A person’s recovery from depression may also be
affected by traumatic events. The more trauma and difficulty a person
experiences, the longer a recovery from depression may take. If a person is run
down psychologically, suffers from anxiety or depression or has endured
previous traumatic experiences; it’s more difficult to handle another setback. As
a result, additional grief symptoms can be unbearable. In order to cope, the
traumatized individual may attempt to avoid grieving altogether.

 It is clear that some people develop depression after a

stressful event in their lives such as the death of a loved
one, the loss of a job, or the end of a relationship are often
negative and traumatic and cause great stress for many
people. It is not certain why stress may lead to depression
in this way. However, researchers have theorized an
explanation called the "kindling effect," or
"kindling-sensitization hypothesis." This theory surmises
that initial depressive episodes spark changes in the
brain's chemistry and limbic system that make it more
prone to developing future episodes of depression. This
may be compared to the use of kindling wood to spark the
flames of a campfire. Since early episodes of depression
make a person more sensitive to developing depression,
even small stressors can lead to later depressive
episodes. It is not certain why stress may lead to
depression in this way. However, researchers have
theorized an explanation called the "kindling effect," or
"kindling-sensitization hypothesis." This theory surmises
that initial depressive episodes spark changes in the
brain's chemistry and limbic system that make it more
prone to developing future episodes of depression. This
may be compared to the use of kindling wood to spark the
flames of a campfire. Since early episodes of depression
make a person more sensitive to developing depression,
even small stressors can lead to later depressive

Pessimistic Personality

Someone with a pessimistic personality is often not as easy going or fun to be

around. They have a negative view of the current world around them and the
future does not look a lot better. Things can never go right, other people are
only nice because they want something from them and there is no point in
having dreams or goals because they will never happen or be achieved.
Pessimistic people tend to feel that they have no real purpose in life and that
there really doesn't seem to be any reason for them to try or even be around.
There are people who are only a little pessimistic at times, but there are also
people out there who are more consistently pessimistic about themselves, their
life and the world around them. It is these people who are more prone to fall into
serious depression, though it can sometimes be depression that can cause a
person to develop a more pessimistic outlook. Oftentimes, depression and
emotional health are further exacerbated by how others react to negativity.
Negative people are frequently perceived as "wet blankets" and may be
avoided. For some people a pessimistic attitude serves as a source of sardonic
humor and might even be a coping mechanism. People that fall into this
category might feel they are actually warding off negativity by being prepared
for the worst. "If you continually expect the worse, you are apt to be pleasantly
surprised a lot. If you always expect the best, you may be disappointed
frequently." This can be a reasonable rationale for a pessimist.
However, some researchers believe that a pessimistic attitude might negatively
affect health. Studies conducted in the Netherlands between 1995 and 2001
suggest a possible link between pessimism and heart disease. The studies,
published in The Archives of General Psychiatry, followed over 900 Dutch
citizens from ages 65 to 85 over the six-year period. Each participant was
ranked on a scale of optimism and pessimism. The study found that 30.4% of
the optimistic participants died during the study period, compared to 56.5% of
the pessimistic participants. While factors like diet and smoking were
accounted for, it should be noted that participants were not screened for
depression. Whether or not a link does exist between pessimism and heart
disease, it has become widely accepted that a positive attitude is certainly
helpful in life. If being a pessimist doesn't shorten life, being an optimist will
make it more enjoyable. Virtually anyone who nurtures a habitually negative
temperament can transform from a pessimist to a more positive person with
time and effort. Psychotherapy and cognitive behavior therapy can help a
person to change his or her thinking habits. If the cost of therapy is prohibitive, a
more affordable method might be to seek out self-help books that teach how to
recognize negative thinking patterns and replace them with positive habits of
thinking. Local classes and seminars might also be of assistance. With practice
and diligence, positive thinking can become a habit as easily as pessimism

Families and Friends

Depression can be especially cruel in that it doesn't affect just the depressed
person, but everyone around them, too. Someone who is depressed can be
very difficult and draining to deal with. What makes this so cruel is, that as a
depressed person's relationships become strained--to the point where others
actively avoid having anything to do with them. This further contributes to a
worsening self-image and makes the person feel even more isolated,
intensifying the depression. Depressed patients must learn to understand how
their illness affects other people, and expect that their relationships will not be
what they were, for some time. By the same token, those around them must
understand that it is not the person, but the illness, which is an inconvenience.
The best way for them to be relieved of the stress, is to help the patient toward
recovery. Friends and family must remember that the depression patient did not
ask for this illness, it is not a character flaw, and the patient often doesn't have
much control over what he or she does. They cannot afford to take the
symptoms of depression in someone else, personally. Most primary
relationships, however strong, go through trying times during the course of
normal life even when everyone is in the best possible state of mind. Therefore,
one can only imagine the difficulties and setbacks experienced by people
suffering from depression. It is also equally challenging and difficult for the
other person or people in such relationships, because, as part of the negative
effects of depression, depressed people often fail to see reason, do not want to
believe there is hope, and ultimately give up any and all effort towards making
relationships work.


Depressed individuals will tend to avoid friends and social gatherings, and be
unable to derive satisfaction from hobbies and leisure interests. It impairs their
ability to sleep, eat, work, and get along with others. It damages their
self-esteem, self-confidence, and the ability to accomplish everyday tasks.
People who are depressed find daily tasks to be a significant struggle. They tire
easily, yet cannot get a good night's sleep. They have no motivation and lose
interest in activities that were once enjoyable. Depression puts a dark, gloomy
cloud over how they see themselves, the world, and their future. This cloud
cannot be willed away, nor can we ignore it and have it magically disappear.

Work and School

Ongoing stress and pressure can cause work depression. It is a reality of the
fast paced work environment of today. More than $43 billion are lost each year
as a result of so-called work depression. It is a rather common illness affecting
1 out of every 20 adults at any given time. Work depression affects three out of
every ten workers at least once a year. Most people see the workplace as a
secure environment where they obtain some form of stability and structure.
When a person struggles with symptoms of work depression, the very same
place of structure can become a cage where he/she feels trapped without a
means to get out. Depressive can affect an employee's productivity, judgment,
ability to work with others, and overall job performance. The inability to
concentrate fully or make decisions may lead to costly mistakes or accidents.
Changes in performance and on-the-job behaviors that may suggest an
employee is suffering from a depressive illness include:
o Decreased or inconsistent productivity
o Absenteeism, tardiness, frequent absence from work station
o Increased errors, diminished work quality
o Procrastination, missed deadlines
o Withdrawal from co-workers
o Overly sensitive and/or emotional reactions
o Decreased interest in work
o Slowed thoughts
o Difficulty learning and remembering
o Slow movement and actions
o Frequent comments about being tired all the time

School depression is the type of depression that occurs in school going children
and research shows this is a more common illness than was previously
thought. Numbers of students are affected by depression every year and due to
the age group that can be affected by depression it is important at the first signs
to have the child diagnosed. School depression is not a strange kind of
depression; it is just the same as some of the other types of depression.
Following are the symptoms of school depression:
o The first and the foremost symptom of depression in school
going children is the inability to concentrate while studying.
o Irritation at school without a proper reason.
o Poor appetite.
o School going children may exhibit sleeping problems; these
consist of too little sleep or too much sleep.
o Little interest in extra curricular activities.
o Nervousness or hesitation without any reason.
o Fatigue.
o Negative thoughts and poor self-confidence also are the
symptoms of depression in school going children.

School depression or depression in school age children exhibit the above listed
symptoms commonly, but these symptoms might vary child to child. The
prevalence of depression in school going children is 3 to 4 out of 100 children.
School depression occurs equally in boy and girls. The relationship of students
amongst their friends and teachers play a big role in school depression. Some
of the causes that may lead to depression in school age children are:
o Extra pressure of parents or schoolteachers on students to
perform well in examinations.
o Too many expectations from parents.
o Students that do not join activities may also develop
o Bookworms may also develop depression.
o Low self-confidence can also develop depression in school
age children.
o The fear of bad performance in activities such as sports or bad
performance in studies could also be the reason of depression
in school age children.
o Students that have no friends are often found stressed, the
stress may also lead to depression.
o Inferiority complex in students is also a reason that they may
develop depression.

School depression is a treatable illness and can be treated if the proper

treatment technique is followed. Parents need to identify the symptoms in their
school age children, as most of the children do not even know that they are
suffering from depression. Parents need to take their child to a specialist and
look for proper treatment plan. Talk therapy, Cognitive behavioral therapy,
family therapy or interpersonal therapies are good method in these cases. The
parents can also help the child getting over school depression.


Antidepressants are medication used for people who have depression. Most
antidepressants are believed to work by slowing down the removal of certain
chemicals from the brain. According to the chemical imbalance theory, low
levels of the brain chemical serotonin lead to depression and depression
medication works by bringing serotonin levels back to normal. Researchers
agree that when depression is severe, medication can be helpful – even life
saving. The most widely prescribed antidepressants come from a class of
medications known as selective serotonin reuptake inhibitors (SSRIs).
Selective serotonin reuptake inhibitors are available only with a doctor's
prescription and are sold in tablet, capsule, and liquid forms. Commonly used
selective serotonin reuptake inhibitors are fluoxetine (Prozac), paroxetine
(Paxil), sertraline (Zoloft), and fluvoxamine (Luvox).

 Prozac is the registered trademarked name for fluoxetine

hydrochloride and the world's most widely prescribed antidepressant
to-date, the first product in a major new class of drugs for
depression12 called selective serotonin re-uptake inhibitors. Prozac
was first introduced to the US market in January 1988. It took two
years for Prozac to gain its 'most prescribed' status and had become
the world’s most widely prescribed antidepressant. The team of
inventors behind Prozac was lead by Ray Fuller. Fuller was
posthumously awarded the Pharmaceutical Discoverer's Award from
NARSAD for discovering fluoxetine or Prozac. Also awarded were
Bryan Molloy and David Wong, both members of the Eli Lilly
Company research team.


The most common treatment for depression includes the combination of

antidepressant medicine and psychotherapy (called "therapy" for short, or
"counseling"). Psychotherapy is a general term for a process of treating mental
and emotional disorders by talking about your condition and related issues with
a mental health provider. During psychotherapy, you learn about your condition
and your mood, feelings, thoughts and behavior. A licensed mental health
professional helps people with depression focus on behaviors, emotions, and
ideas that contribute to depression, and understand and identify life problems
that are contributing to their illness to enable them to regain a sense of control.
Psychotherapy can be done on an individual or group basis and can include
family members and spouses.Using the insights and knowledge you gain in
psychotherapy, you pick up healthy coping skills and stress management.
Psychotherapy often can be successfully completed in just a few months, but in
the case of a severe mental illness, long-term treatment may be helpful. There
are many specific types of psychotherapy, each with its own approach to
improving your mental well-being. The type of psychotherapy that's right for you
depends on your individual situation. Psychotherapy is also known as talk
therapy, counseling, psychosocial therapy or, simply, therapy.

Alternative Methods of Treatment

Another way of treating depression is through alternative methods of treatment

such as acupuncture, guided imagery, chiropractic treatments, yoga, hypnosis,
biofeedback, aromatherapy, relaxation, herbal remedies, massages, and many
more. Of all of these treatments, the one that seems to help the most is
Aromatherapy. Aromatherapy is particularly effective in dealing with stress,
depression and stress related disorders. 'Depression' is a term which
encompasses a wide spectrum of psychic problems and symptoms which, in
turn, can lead to more serious illnesses. Aromatherapy, in helping to relax the
patient and by reducing stress, may actually help to prevent such conditions.
Depression related disorders, such as digestive problems, stress and other
mental problems, can be treated by Aromatherapy. As depression is reduced,
there is a corresponding improvement in sleep patterns and energy levels.
Aromatherapy is an alternative treatment that uses the highly concentrated
essential oils that are extracted from plants to treat symptoms and assist in the
healing process. Aromatherapy is aimed at revitalizing the body and mind while
lifting your spirits. Aromatherapy will aid in promoting a sense of well being.
Aromatherapy is also known for easing mental fatigue and insomnia. When you
use these wonderful essential oils in the correct blend for massages, baths,
diffusers and even personal perfumes you will begin to benefit from the use of
aromatherapy. Using aromatherapy for depression will give you the peace of
mind and the well being that you need. You will enjoy the uplifting feeling that
will rid your life of depression.


Most people have felt sad or depressed at times and have wondered if the
world would be a better place if they weren’t in it but by researching this topic,
I’ve learned that even though 6.7 % of the United States population is affected
by depression, there are options and treatments available for those unfortunate
ones who feel like they have nothing left to live for. Depression is a mental state
characterized by a pessimistic sense of inadequacy and a desponent lack of
activity which reflects a sad and/or irritable mood exceeding normal sadness or

The causes of depression can vary between patients but for the majority
depression is caused mainly by grief due to the death of a loved one, an illness,
a traumatic event and sometimes stress that occurs during work and/or school.
Depression can also run in families for generations and can be caused by
someone who has a pessimistic attitude towards life as well. Depression can
take its toll on both the individual and his or her families, friends, classmates
and co-workers. When the patient has finally admitted to being depressed, the
next step is to get help from their doctor who can perscribe an antidepressant
such as Prozac, Zoloft, Paxil, or Symbolta. Other options besides
antidepressants could be psychotherapy which helps the patient learn about
their condition and how to treat it, or Aromatherapy which helps relax the
patient by reducing stress, allowing the body to recouperate and prevent such a
condition from happening again.

About 7 out of 100 men and 1 out of 100 women who have been diagnosed with
depression at sometime in lifetime will go on the complete suicide. In 2005,
suicide was the 11th leading cause of death in the U.S., claiming 32,637 lives.
Many suicides are preventable. Most suicidal people desperately want to live
but they are just are unable to see an alternative solution to their problem.
Suicidal individuals will show numerous symptoms of depression and if these
symptoms are discovered early on, then the first step to recovery has been put
into motion. Admitting that you have a problem and are dealing with depression
is getting you one step closer to a complete and total recovery. Depression is
preventable and if people are willing to seek help, then many lives will be saved
each year because if people get treatment for their depression, then no one will
have to say goodbye to a loved one ever again.

7.State and describe the difference therapeutic techniques of communication .

Give an example for each techniques

Therapeutic techniques include:

Active listening is the basis of all nurse client interactions. Listening is more

than hearing. It is a dynamic and active process that requires enormous

concentration and energy. It literally means using all the senses to assess

verbal and non-verbal message.

Active Listening conveys concern and respect for the client. It fosters a

trusting relationship that encourages the client to express feelings and share

thought. “Knowing the patient” and encouraging her to “tell their story”

(Chamber Evans , Stelling & Goodwin, 1999) is essential in providing

individualized and quality nursing care.

Students and nurse clinicians can enhance their communication skill by

identifying barriers to active listening. The art of active listening requires

perseverance and patience.

Questioning is a valuable tool that nurse use to encourage the expression

and feelings and self-disclosure and to gain insight into the meaning of present
stressors. The basis of the client response depends on her level of trust and

security or in the comfort with questions. Nurse can put their clients at ease by

introducing themselves and calling them by name, making eye contact and

shaking hands at the same time helps nurses connect with clients both verbally

and nonverbally. This establishes a safe environment that promotes trust, care,

and empathy. The nurse can use questioning as a tool to elicit pertinent

information from the client.

Clarifying techniques refers to the use of certain methods to clear up or

make message understandable. Communication is complex, dynamic process

that involves interaction between people. The likelihood of confusion exists in

all human interactions.

Specific clarifying techniques are paraphrasing or restatements.

Paraphrasing involves listening to the client basic message and repeating them

using similar words. This technique focuses on the content of the message. It

affords the nurse with a clearer understanding of the client distress.

Touching is another powerful, sometimes controversial nonverbal

communication. It is critical aspect of human relationships throughout the

lifespan. Touching is the key to survival, particularly during infancy, because it

conveys trust, safety, and love, and it nurtures neurobiological and

psychosocial development. Therapeutic touch enables the client to experience

trust, reassurance, and acceptance.

Silence is a natural phenomenon; it is deliberate restraint from verbal

expression. Therapeutic use of silence is another effective communication

technique, but it requires practice and skill to master. Silence can be use to

help clients explore the meaning of feelings and thoughts.

Humor is important but underutilized therapeutic communication

techniques. It values includes physiological, psychological, social, and

cognitive benefits. Physiologically, it stimulates the circulatory and respiratory

system, relaxes the muscle and increase the productions of endorphins. Humor

helps client express their feeling, thereby reducing anxiety and tension or

stress (King, Novic, & Citrebaum, 1983, Lachman, 1983), particularly during

intense situations.

Focusing refers to clarifying a perception or spotlighting certain aspects of

communication. This technique is useful when clients are vague and need

assistance with goal directed communication. Focusing is useful when clients

don not express their feelings clearly, when they ramble, or when they

discussed several issue at one time.

Confrontation refers to an encounter or face-to-face meeting. Nurses often

associate this term with conflict or angry discussion between opposing bodies.

In reality, confrontation is necessary aspects of Nurse-clients interaction. Like

other techniques, it is and art that involves pointing out contradictions or

incongruities between feelings, thoughts, and behaviors.

Summarizing is a communication tool that helps clients explores key points

of a nurse-client interaction. This dynamic and collaborative process integrates
perceptions from the nurse and client. Major points are reviewed and used to
generate future client outcomes

8.What is the role of the psychiatric mental health nurse practioner during crisis
Role of Nurse
Phases and techniques of crisis intervention are similar to the steps of nursing
Phase I: Assessment
The first step of crisis intervention is Assessment. At this phase data about the
nature of the crisis and its effect on the patient must be collected. Assess the
 Identification of precipitating event or stressor and when it occurred.
 Explore the needs of the client like
(1) Self-Esteem- Achieved when the person attains successful
social role experience.
(2) Role Mastery- Achieved when the person attains work, sexual
and family role successes.
(3) Dependency- Achieved when a satisfying interdependent
relationship with others is attained.
(4) Biological function- Achieved when a person is safe and life is
not threatened.

 Ability for the perception of the event.

 Client’s abilities and limitations in dealing with the problem.
 Nature and strength or adequacy of clients supporting systems and
coping resources.
 Nature of crisis and its effects on the individual and family.
 Associated behavioral problems.
 Physical and mental status of an individual
 History of previous exposure and adapted strategies
 Exploration of problematic situation

Phase II: Nursing Diagnosis

After analyzing the information gathered through assessment, appropriate
nursing diagnosis can be formulated to solve the crisis situation. Nursing
diagnosis may be related to any aspect of the client’s life which can reflect the
variety of nursing problems.
For eg:-
 Disturbed thought processes
 Risk for emergency situation like suicide or violence
 Altered family processes
 Maladaptive crisis responses
Phase III: Planning
Based on the assessment, diagnosis the short term and long term goals will be
formulated with a specific and appropriate plan of activities. In planning the
interventions the type of crisis, as well as the individual’s strength and available
resources for support are taken into consideration. Goals are established for
crisis resolution and a return to or increase in, the pre-crisis level of functioning.

Phase IV: Implementation of Intervention

During phase IV, the actions that identified in phase 3 are
implemented. The following interventions are the focus of nursing in crisis
1. Use a reality- oriented approach
2. Remain with the individual who is experiencing panic anxiety
3. Establish a rapid, positive working relationship by
 Showing unconditional acceptance
 Active listening
 Attending to immediate needs
 Appropriate communication technique to make the client to feel more

4. Discourage length explanation by rationalizing the situation

5. Provide adequate situational support and guidance
6. Handle the feelings gently, don’t give false reassurance
7. Maintain consistency
8. Clarify the problem that the individual is facing
9. Guide the individual in problem solving process and to alleviate future
10. Identify external support system and new social network for the individual to
scale assistance and advice for follow up visit.

Nursing intervention can take place on many levels using a

variety of techniques. There are four levels of crisis intervention that represent
a hierarchy from the most basic to the most complex (shields, 1975)

Levels of Crisis Intervention

1. Environmental Manipulation
Environmental manipulation includes interventions that directly
change the patient’s physical or interpersonal situation. These interventions
provide situational support or remove stress. Important elements of this
intervention are mobilizing the patient’s supporting social system and
serving as a liaison between the patient and social support agencies.
For eg:- if an individual is facing problem in working environment to avoid
stress, she/he may change another job.

2. General Support
General support includes interventions that convey the feeling
that the nurse is on the patient’s side and will be a helping person. The
nurse uses warmth, support, acceptance, empathy, caring, concern and
reassurance has to be providing general support.

3. Generic Approach
The generic approach is designed to reach high-risk individuals
and large groups as quickly as possible. A specific method will be used to
the persons who have similar problems. The intervention is then setup to
ensure that the course of the crisis results in an adaptive response.
For eg:- Grief , disasters
Debriefing- an acute stress is a therapeutic intervention will be used to
recall the traumatic events and to clarify painful experiences and to prevent
maladaptive responses.

4. Individual Approach
The individual approach is a type of crisis intervention,
similar to the diagnosis and treatment of a specific problem in a specific
patient. The nurse must understand the specific patient characteristics that
led to the present crisis and must use the intervention that is most likely, to
help the patient to develop an adaptive response to the crisis.

Phase V: Evaluation
The last phase of crisis intervention is evaluation. When the
nurse and patient evaluate whether the intervention resulted in
 A positive resolution of the crisis or
 Behavioral change has been achieved or not
 Whether the client returned to the normative level of functioning
 Does the patient have adequate support systems
For eg:- additional treatment have to be planned to resolve crisis

9.Discuss caplan’s principle of preventive psychiatry.

Preventive psychiatry:
It is concerned with the maintenance of mental health and the prevention
of mental illness. Specialists in this filed used psychoanalytic theory as a base
for a theoretical framework that explored brief intervention for persons having
stressful life experiences.

Foremost among those involved in preventive psychiatry was Eric

Lindeman. Lindeman studied the bereavement seen in the surviving relatives
and friends of the hundreds of people who died in the disastrou7s Coconut
Grove nightclub fire in Boston in 1943. He hypothesized that numerous
threatening situations might arise in a person’s life and that the person either
adapts to the situations or fails to adapt and has impaired functioning.

Later, in the early 1960’s, Gerald Caplan defined crisis theory and
described crisis intervention. He utilized principles of preventive psychiatry-
primary. Secondary and tertiary prevention- as a basis for his work.

Primary prevention:

He viewed it as a vehicle for promoting mental health and reducing mental

illness. Interpersonal action involves helping people deal with specific stress
such as death or job loss.

Secondary prevention:

Caplan saw secondary prevention as a means of reducing the number of

existing cases of mental illness through early diagnosis and treatment.
Secondary prevention includes screening programs, prompt referral,
improvement in the use of diagnostic tools, and prompt treatment.

Tertiary prevention:

It was seen as a vehicle for reducing the rate of chronic disability resulting
from mental illness. Tertiary prevention includes rehabilitation programs
designed to restore the person to a maximum level of well-being. Tertiary
prevention includes both primary and secondary prevention insofar as it aims at
prevention and reduction of chronic disability and its inherent crises through
maximum rehabilitation

Whenever the individual is exposed to a precipitating stressor, it
results into anxiety to overcome it. If individuals uses effective problem solving
techniques and situational support is provided then the problem will be resolved
and no crisis occurs.

When previous problem-solving techniques do not relieve the
stressor or when coping mechanisms are ineffective, anxiety, discomfort,
helplessness further increases hence person’s ability to overcome the stressor
will decrease. Feeling of confusion, personal disorganization prevails.

Individual feels more pressure, unable to respond, anxiety still
increases; In this phase all external and internal resources will be tried to
resolve the crisis and to relieve discomfort. Individuals use every means like
cognitive emotional and physiological means, counseling etc. as a last resort. If
it fails the premorbid functioning will results.

If resolution does not occur in previous phases, Caplan states that “The
tension reaches to its peak. As time passes, burden increases to a breaking
point. Major disorganization of the individual with drastic results often occurs”.
Anxiety may reach panic levels. Cognitive functions are disordered, emotions
are labile and behavior may reflect the presence of psychotic thinking.

10 Give a brief discussion on crisis intervention. State at least 5 objections of

crisis intervention .
Since this is a very significant measured in helping individuals who are in crisis,
conducting such should only be limited from 6-8 weeks, what is the rationale for
having such a limited period

Crisis Intervention

Crisis intervention refers to the methods used to offer immediate,
short-term help to individuals who experience an event that produces
emotional, mental, physical, and behavioral distress or problems


Crisis intervention is a short-term therapy focused on solving the

immediate problem. It is usually limited to 6 weeks. The goal of crisis
intervention is for the individual to return to a precrisis level of functioning. Often
the person advances to a level of growth that is higher that the precrisis level
because new ways of problem solving have been learned.

It is important for the nurse to remember that cultural attitudes strongly

influence the communication and response style of the crisis worker. These
attitudes are deeply ingrained in the processes of asking for, giving, and
receiving help. They also affect the victimization experience, so it is essential to
understand and respect the cultural values of the victims. Specific cultural
factors to be considered in crises intervention include the following:

 Migration and citizenship status

 Gender and family roles

 Religious belief systems

 Child-rearing practices

 Use of extended family and support systems

The age of the survivors is also important for the nurse to consider when
providing crisis intervention. Responses to stressor events differ across the life
span. Therefore age appropriate interventions are most effective in helping
survivors return to their previous level of functioning (Adams etal, 1999; Ball
and Allen, 2000). For example, 4-year old children may best express
themselves through play, whereas adolescents may best work through crisis
issue in peer group discussions.


Crisis intervention has several purposes. It aims to reduce the intensity

of an individual's emotional, mental, physical and behavioral reactions to a
crisis. Another purpose is to help individuals return to their level of functioning
before the crisis. Functioning may be improved above and beyond this by
developing new coping skills and eliminating ineffective ways of coping, such
as withdrawal, isolation, and substance abuse. In this way, the individual is
better equipped to cope with future difficulties. Through talking about what
happened and the feelings about what happened, while developing ways to
cope and solve problems, crisis intervention aims to assist the individual in
recovering from the crisis and to prevent serious long-term problems from
developing. Research documents positive outcomes for crisis intervention,
such as decreased distress and improved problem solving.


The first step of crisis intervention is assessment. At this time data

about the nature of the crisis and its effect on the patient must be collected.
From these data, an intervention plan will be developed.

People in crises experience many symptoms, Sometimes; these symptoms

can cause further problems. For example, problems at work may lead to loss of
a job, financial stress, and lowered self-esteem

Crises also can be complicated by old conflicts that resurface as a result of

the current problem, making crises resolution more difficult. For example, q
woman who was orphaned at an early age may have more difficulty resolving a
crisis precipitated by the work injury of her husband than a woman who had not
suffered an earlier loss.

Although the crisis situation is the focus of the assessment, more significant
and long-standing problems may be identified by the nurse. It is important,
therefore, to identify which areas can be helped by crisis intervention and which
problems must be referred to other sources for further treatment.

During this phase the nurse begins to establish a positive working

relationship with the patient. A number of balancing factors are important in the
development and resolution of a crisis and should be assessed:

 Precipitating event or stressor

 Patient’s perception of the event or stressor

 Nature and strength of the patient’s support systems and coping


 Patient’s previous strengths and coping mechanisms

Precipitating Event

To help identify the precipitating event, the nurse should explore the
patient’s needs, the events that threaten those needs, and the time at which
symptoms appear. Four kinds of needs that have been identified are related to
self-esteem, role mastery, dependency, and biological function.

1. Self-esteem is achieved when the person attains successful social role

2. Role mastery is achieved when the person attains work, sexual, and
family role successes.
3. Dependency is achieved when a satisfying interdependent relationship
with others is attained.
4. Biological function is achieved when a person is safe and life is not
The nurse determines which needs are not being met by asking the patient
to reflect on issues of self-image and self-esteem, the areas of life that are
considered a success, one’s relationships with others, and the degree of safety
and security in life. The nurse looks for obstacles that might interfere with
meeting the patient’s needs. What recent experiences have been upsetting?
What areas of life have had changes?

Coping patterns become ineffective and symptoms appear usually after the
stressful incident. When did the patient begin to feel anxious? When did sleep
disturbances begin? At what point in time did suicidal thoughts start? If
symptoms began last Tuesday, ask what took place in the patient’s life on
Tuesday or Monday. As the patient connects life events with the breakdown in
coping mechanisms, an understanding of the precipitating event can emerge.

Perception of the Event

The patient’s perception or appraisal of the precipitating event is very

important. What may seem trivial to the nurse may have great meaning to the
patient. An overweight adolescent girl may have been the only girl in the class
not invited to a dance. This may have threatened her self-esteem. A man with
two unsuccessful marriages may have just been told by a girlfriend that she
wants to end their relationship; this may have threatened his need for sexual
role mastery. An emotionally isolated, friendless woman may have had car
trouble and been unable to find someone to give her a ride to work. This may
have threatened her dependency needs. A chronically ill man who has had a
recent relapse of his illness may have had his need for biological function

Support Systems and Coping Resources

The patient’s living situation and supports in the environment must be

assessed. Does the patient live alone or with family or friends? With whom is
the patient close. And who offers understanding and strength? Is there a
supportive clergyman or friend? Assessing the patient’s support system is
important in determining who should come for the crisis therapy sessions. It
may be decided that certain family members should come with the patients so
that the family members’ support can be strengthened. If the patient has few
supports, participation in a crises therapy group may be recommended.

Assessing the patient’s coping resources is vital in determining whether

hospitalization would be more appropriate than outpatient crisis therapy. If
there is a high degree of suicidal or homicidal risk along with weak outside
resources, hospitalization may be a safer and more effective treatment.

Coping Mechanism

Next, the nurse assesses the patient’s strengths and previous coping
mechanisms. How has the patient handled other crises? How were anxieties
relived? Did the patient talk out problems? Did the patient leave the usual
surroundings for a period of time to thinks through from another perspective?
Was physical activity used to relieve tension? Did the patient find relief in
crying? Besides exploring previous coping mechanisms, the nurse also should
note the absence of other possible successful mechanisms.


The next step of crisis intervention is planning; the previously collected

data are analyzed and specific interventions are proposed. Dynamics
underlying the present crisis are formulated from the information about the
precipitating event. Alternative solutions to the problem are explored, and steps
for achieving the solutions are identified. The nurse decides which
environmental supports to engage or strengthen and how best to do this, as
well as deciding which of the patient’s coping mechanisms to develop and
which to strengthen.

The expected outcome of nursing care is that the patient will recover
from the crisis event and return to a precrisis level of functioning. A more
ambitious expected outcome would be for the patient to recover from the crisis
event and attain a higher than precrisis level of functioning and Improved
quality of life.

Nursing intervention can take place on many levels using a variety of

techniques. There are four levels of crisis intervention-environmental
manipulation, general support, generic approach, and individual approach-that
represent a hierarchy from the most basic to the most complex (Shields, 1975)
(Figure 14-2). Each level includes the interventions of the previous level, and
the progressive order indicates that the nurse needs additional knowledge and
skill for implementing high-level interventions. It is often helpful to consult with
others when deciding which approach to use.

Environmental manipulation

Environmental manipulation includes interventions that directly change

the patient’s physical or interpersonal situation. These interventions provide
situational support or remove stress. Important elements of this intervention are
mobilizing the patient’s supporting social systems and serving as a liaison
between the patient and social support agencies.

For example, a patient who is having trouble coping with her six children
may temporarily send several of the children to their grandparents’ house. In
this situation some stress is reduced. Similarly, a patient having difficulty on his
or her job may take a week of sick leave to be removed temporarily from that
stress. A patient who lives alone may move in with his or her closest sibling for
several days. Likewise, involving the patient in family or group crisis therapy
provides environmental manipulation for the purpose of providing support.

General support

General support includes interventions that convey the feeling that the
nurse is on the patient’s side and will be a helping person. The nurse uses
warmth, acceptance, empathy, caring, and reassurance to provide this type of
Generic approach

The generic approach is designed to reach high-risk individuals and

large groups as quickly as possible. It applies a specific method to all people
faced with a similar type of crisis. The expected course of the particular type of
crisis is studied and mapped out. The intervention is then set up to ensure that
the course of the crisis results in an adaptive response.

Grief is an example of a crisis with a known pattern that can be treated by

the generic approach. Helping the patient to overcome ties to the deceased and
find ne patterns of rewarding interaction may effectively resolve the grief.
Applying this intervention to people experiencing grief, especially with a
high-risk group such as families of disaster victims, is an example of the generic

Interventions following an acute stress are sometimes referred to as

debriefing. Originally a military concept, debriefing is used as a therapeutic
intervention to help people recall events and clarify traumatic experiences.
Interventions consist of ventilation of feelings within a context of group support,
normalization of responses, and education about psychological reactions to
traumatic events. Although debriefing may be effective for some individuals,
research findings about its effectiveness following extreme stress are
inconclusive. Thus further research is needed before it can be endorsed as an
evidence-based practice (Kaplan, Iancu, and Bodner, 2001).

Individual Approach

The individual approach is a type of crisis intervention similar to the

diagnosis and treatment of a specific problem in a specific patient. The nurse
must understand the specific patient characteristics that led to the present crisis
and must use the intervention that is most likely to help the patient develop an
adaptive response to the crisis.

This type of crisis intervention can be effective with all types of crises. It is
particularly useful in combined situational and maturational crises. The
individual approach is also helpful when symptoms include homicidal and
suicidal risk. The individual approach also should be applied if the course of the
patient’s crisis cannot be determined and if resolution of the crisis has not been
achieved using the generic approach.

Interventions are aimed at facilitating cognitive and emotional processing of

the traumatic event and at improving coping. Five core interventions to assist
survivors of acute stress are as follows (Osterman and Chemtob, 1999):

 Restore psychological safety

 Provide information
 Correct misattributions
 Restore and support effective coping
 Ensure social support

A General Model of Intervention and Crisis Counseling

Make Psychological Contact and Establish the Relationship.

Establish rapport by conveying genuine respect and acceptance of the client.

The client also needs assurance and reinforcement that he or she may receive
help. If this step is omitted, the client will not feel respected and will be resistant
to counseling.

Examine the Dimensions of the Problem to Define the Problem.

Identify the precipitating event, previous coping methods, and lethality. Focus
on the now and how, rather than the then and why. Use open-ended questions.

Explore Feelings and Emotions.

It is therapeutic for the client to vent and express feelings and emotions in an
accepting, supportive, private, and non-judgmental setting. The crisis
intervener must actively listen.

Explore and Assess Past Coping Attempts.

Identify and modify the client’s coping behaviors at both the preconscious and
conscious levels. Coping responses must be brought to the conscious level and
to educate the client in modifying maladaptive coping behaviors. Explore how
certain situations are handled: intense anger, loss of a loved one,
disappointment, failure, etc. Help the client understand how they have been
coping and why it has not worked. If this step is omitted, the client may continue
using maladaptive coping behaviors that continue not to work.

Generate and Explore Alternatives and Specific Solutions.

Clients need help conceptualizing more adaptive coping responses to the crisis.
If the client has little introspection or personal insights, the clinician needs to
take initiative and suggest coping methods.

Restore Cognitive Functioning Through Implementation of an Action


Help the client focus on why a specific event leads to a crisis state and,
simultaneously, what the client can do to master the experience and be able to
cope with future events. This is done in three stages:

1. The client needs a realistic understanding of the crisis and what led to
the event. Understand what happened, why it happened, who was
involved, and the final outcome.
2. Understand the specific meaning of the event, how it conflicts with
expectations, life goals, and belief system. The clinician should note
cognitive errors, distortions, irrational beliefs, and help the client
discover them.
3. Reconstructing, rebuilding, and replacing irrational beliefs with new
cognition. Provide new info through homework assignments or
referrals to others who have lived through and mastered a similar
crisis, such as a support group.


Clinician should leave her door for client to come back for future sessions.
Often, unforeseen events conjure up images and old feelings surrounding (i.e.
the anniversary of the event).