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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
A crisis occurs when an individual feels overwhelmed by events. The crisis may be precipitated by events which bring about sudden change to the person's environment - eg, bereavement, redundancy or childbirth. It may also be linked to factors unrelated to any mental health issues such as the illness of a carer, which in turn precipitates a crisis requiring intervention. Usual coping mechanisms fail and new strategies may be tried but, if these also fail, an increasing state of anxiety and poor morale develops. Maladaptive coping strategies, such as substance abuse, deliberate self-harm or violent behaviour, may also be applied. Further escalation leads to a state of decompensation in which normal psychological functioning breaks down, most commonly causing panic attacks and disabling anxiety, suicidal intent or psychosis.
Crisis therapy aims to intervene as soon as possible after the onset of the crisis in order to enable the individual to overcome it, minimise the usage of maladaptive coping strategies and avoid complete psychological breakdown. It is a short-term intervention, which may require intensive involvement of the therapist with the patient and sometimes also members of their family.
Crisis management is familiar to all in primary care - both supporting those with exacerbations of severe mental illness (often involving the Crisis Intervention Teams to prevent hospitalisation) and helping other patients to weather difficult times.
Crises are more common in those with severe mental illness and personality disorders. There are many potential causes of a crisis, including:
- Becoming homeless.
- Changes of role - eg, getting married, having a child, a more demanding job.
- Relationship problems - eg, with partners or a child.
- Conflict: usually due to a difficult choice where neither alternative is acceptable.
- Serious injury or loss of a limb.
- Post-traumatic stress.
- Non-compliance with medication in someone with pre-existing severe mental illness.
Key elements of management
- Management will depend on the severity and cause of the crisis, as well as the individual circumstances of the patient.
- Many relatively minor crises can be managed by providing friendly support in primary care, without referral.
- More severe crises will require referral to counsellors or the local Mental Health Team.
- The availability of crisis teams varies depending on location. Therefore, ahead of any crisis occurring, regular update of the contact details of local services that health professionals have ready access to is good practice.
- Crisis therapy includes short-term behavioural/cognitive therapy and counselling. Involvement of family and other key social networks is very important.
- Therapy should be relatively intense over a short period and discontinued before dependence on the therapist develops.
- The risk of suicide and self-harm must be assessed at presentation and at each review.
- The aims of treatment are to:
- Reduce distress.
- Help to solve problems.
- Avoid maladaptive coping strategies - eg, self-harm.
- Improve problem-solving strategies.
Performing crisis intervention
- The earliest stages of crisis therapy are concerned with the clarification of the patient's problem.
- The therapist then encourages the patient to express their emotions around the crisis - eg, grief.
- The patient is encouraged to seek support from their social network of friends and family.
- The patient is asked to discuss their coping mechanisms and the therapist encourages appropriate methods.
- Alternative problem-solving strategies are generated and their potential consequences discussed.
- The therapist attempts to discourage inappropriate beliefs and coping methods, either by direct suggestion or using cognitive methods such as:
- Keeping a diary of events and their surrounding thoughts and feelings.
- Practising and testing new behaviours.
- More adaptive methods of coping are identified and their use encouraged.
Crisis intervention for people with severe mental illness
- People with severe mental illness who are in a crisis often need hospital admission. If admission is not considered necessary or appropriate, urgent liaison with Community Mental Health Services is essential.
- A Cochrane review found that home care crisis treatment, coupled with an ongoing home care package, is a viable alternative to hospital admission for crisis intervention for people with serious mental illnesses.
- Nearly half of the people in crisis allocated to home care eventually needed to be admitted to hospital; however, the crisis/home care package may help to avoid repeat admissions.
- Home care is also probably more cost-effective.
- Ensure that the patient has a Care Plan that is up to date and has been thoroughly reviewed, is specific to the views and needs of the individual and is fully understood by the patient. It should include the action to be taken in a crisis by the service user, their carer and their care co-ordinator. The Care Plan should include contact details for all relevant support agencies, including out of hours, as well as clear guidelines for the patient to follow in order to prevent further crises.
- Joint Crisis Plans (advance agreements between the service user and care providers concerning what will happen when a crisis unfolds) are thought to help empower individuals and help them feel more 'in control'.
Crisis intervention for people with personality disorders
For those with emotionally unstable personality disorder, manage crises with calm assessment and seek to stimulate reflection about possible solutions. Community mental health services should be involved. Use drugs only in the very short term and choose medication carefully (avoid that with potential for abuse or dependency or hazardous in overdose). There is currently no strong evidence for the most effective method of intervention for people with emotionally unstable personality disorder.
Further reading and references
Murphy SM, Irving CB, Adams CE, et al; Crisis intervention for people with severe mental illnesses. Cochrane Database Syst Rev. 2015 Dec 312:CD001087. doi: 10.1002/14651858.CD001087.pub5.
Henderson C, Flood C, Leese M, et al; Views of service users and providers on joint crisis plans: Single blind randomized controlled trial. Soc Psychiatry Psychiatr Epidemiol. 2009 May44(5):369-76. Epub 2008 Oct 4.
Kendall T, Pilling S, Tyrer P, et al; Borderline and antisocial personality disorders: summary of NICE guidance. BMJ. 2009 Jan 28338:b93. doi: 10.1136/bmj.b93.
Borschmann R, Henderson C, Hogg J, et al; Crisis interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2012 Jun 136:CD009353.