The Crisis Continuum

By Tony Salvatore, MA

Mental health consumers and providers, and often family members and others, often use the term “crisis” to encompass a wide range of personal, interpersonal, and environmental situations with current or anticipated negative consequences. This “one size fits all” concept of a crisis is overly simplistic, obscures or minimizes the complexity of the situation, and impedes effective intervention and resolution.

Mental illness-related crises vary in scale and in terms of how they affect the individual. They also seem to follow trajectories and may move to higher levels of risk. All may be triggered by life events (or an individual’s anticipation of an adverse life event) that produces emotional discomfort or even the recurrence of psychiatric symptoms.

Four types of crisis situations can be distinguished:

1. Pre-crisis

This is a non-crisis episode characterized by some disturbance of the psychosocial equilibrium. It is not necessarily a mental health issue at all but may give rise to one. Such episodes may become the initial phase of a subsequent crisis when the precipitant has become a stressful life event. This stage is characterized by rising stress. Relief is sought through customary problem-solving methods.

The pre-crisis stage is the optimal time to divert an individual from a crisis. Peer support, family, case management, and in-home supports can be effective in forestalling the onset of crisis situations. Most individuals resolve pre-crisis situations on their own, but some lack resources or resilience. Stress may increase and raise the risk of a mental health crisis or psychiatric emergency, and jeopardize recovery.

2. Crisis

This is a brief, temporary non-illness response to severe stress typically related to a life event that is perceived as problematic by the individual. It may overwhelm coping skills and supports, but not involve relapse or recurrence. It does not require clinical intervention, but may lead to a mental health crisis if not resolved.

The crisis stage presents an opportunity to mobilize the support system to manage a a stressful life event before it affects wellness and recovery. Most individuals deal effectively with crises by using their recovery-based strengths and supports. Conceptually, in a recovery-oriented crisis response system, provider-based resources would be used sparingly at this stage. Self-help and/or peer-based responses would be sufficient to assure that basic crises do not become mental health crises.

3. Mental Health Crisis

This is a temporary illness-related response to severe stress that ensues if coping efforts are overcome. It affect mental health and wellness. It may require clinical intervention if it involves recurrence, but it is not imminently life threatening. Common triggers are trauma, substance misuse, conflict, income or housing issues, and criminal justice contact. An unchecked mental health crisis may lead to a psychiatric emergency.

A mental health crisis calls for a response to prevent the situation from rising to the level of a psychiatric emergency. A mental health crisis threatens one’s sense of control because symptoms may be exacerbated and recurrence may follow. These situations generally require provider involvement. Serious mental health emergencies may require psychiatric hospitalization for stabilization and safety.

4. Psychiatric Emergency

This is a potentially life-threatening situation involving an acute disturbance of thought, mood, and/or behavior. It may be situational or illness-based. It has the potential to rapidly lead to self-harm or harm to others. An immediate clinical intervention is indicated. Common psychiatric emergencies are exacerbations of psychosis, a suicide attempt or voicing serious intent and a specific plan, uncontrollable anxiety or panic, or homicidality. Psychiatric emergencies engender trauma that persists beyond the episode and heightens the risk of future episodes.

A psychiatric emergency requires an emergency response by the crisis response system, often on an involuntary basis, and often other community resources such as the police and hospital emergency departments. It may overtake an individual despite their best efforts and those of the support system. As noted above, some psychiatric emergencies are rooted in less serious situations so every effort must be made to leverage their prevention at the earliest stage possible.

These episodes may emerge in sequence or independently. An individual may experience a more serious crisis-related event without immediately experiencing a less serious preceding situation. Of course, in real life crisis situations obviously do not lend themselves to tidy classification, and do not necessarily emerge in a linear manner. Nonetheless, seeing crisis situations in terms of a continuum facilitates assessment of individual situations and aids planning of services to meet the range of mental illness-related crisis needs that may arise in the community.

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