Assessment and management in a crisis

Clinicians should adopt a calm, non-judgemental and non-confrontational approach. It is important that clinicians should actively listen to the story and reflect the patient’s perception of events back to them. It is important to validate the patient’s experience and avoid minimising, inappropriately reassuring, or jumping to premature problem solving. Interpretations or hypotheses about the reasons why a crisis occurred are likely to be of limited value at this stage and the focus should remain on containment as far as possible.

Patients often report that it feels more containing in a crisis to have the validating experience of feeling understood in the “here-and-now” in the context of recent (proximal) situational factors, rather than to understand the historical (distal) factors which may have led to the crisis. Distal factors are more usefully explored in depth after resolution of the acute crisis. In practice lengthy exploration during an acute crisis is unlikely to be helpful and may even contribute to further destabilisation. Where the patient is new or unknown to the assessor then background information on their psychiatric history and social context should be obtained if possible through medical notes or CPA records. This can help maintain focus on the ‘here and now’ or proximal factors during the crisis assessment. A picture of the current situation should be developed with a view to promoting a return to previous level of functioning as soon as possible by supporting a self-management and problem solving approach It is helpful to use validating language to clearly acknowledge the distress of the patient.

Challenging the perspective of the patient on their own thoughts and feelings is likely to be perceived as invalidating and this can put the therapeutic relationship at risk. An exception to this is if a pattern of invalidating negative self-judgement is noted. In such a case, self-invalidation should be gently challenged by highlighting the difference between facts and judgments.

The clinician, after actively listening and then reflecting their understanding of the situation back to the patient, can explore solutions together with the patient in a collaborative manner using formal problem solving or solution analysis.

The assessor should:

• Draw on the patient’s own resources and skills
• Reflect on solutions and promote an alternative perspective to the patient
• Highlight the patient’s responsibility in their own recovery
• If appropriate, involve the patient’s social network In general, when the patient has a crisis self-management plan and/or crisis care plan, these should be utilised in the crisis management process.

In general, when the patient has a crisis self-management plan and/or crisis care plan, these should be utilised in the crisis management process.