Key Points

• Develop a timeline of events starting with the "Why now?" and work from the initial presentation backward in time.

• Focus on acute risk assessment, including risk of suicide, violence, and acute medical conditions.

Witnessed father abusing mother

Married, moved away from family, became pregnant, husband hit her for the first time, suspecting infidelity

Moved for 5th time in 6 years; arguing escalated as she desires to move closer to parents

Husband threatened to kill her; she called police for the first time

Called police after fight, Disclosed second incident; pregnancy to visited physician Positive husband, who complaining of pregnancy test, hit and migraine and migraine and threatened to IBS symptoms insomnia worsen kill her

Childhood

10 years earlier

6 months earlier

1 month earlier

2 weeks earlier

1 week earlier

1 day earlier

Figure 45-2 Crisis timeline: Case Study 3.

Migraine, insomnia, fear of dependency

Office visit

• Develop an eco-map or support network map, beginning with a three-generational genogram and other psychosocial supports.

• Select a single problem or symptom to begin crisis treatment.

• Build a wheel-and-spoke treatment plan with the single problem or symptom in the center and biopsychosociocultural factors as spokes.

• Treat the problem or symptoms by fostering the use of adaptive coping skills.

• Use a crisis resolution strategy.

• Use psychiatric medication, as needed, for symptom relief.

The focus of a crisis assessment involves the evaluation of the precipitants of the crisis or trauma, personal meaning of the events, crisis state itself, selective past history, support network, and current psychiatric illness, if relevant. These assessments are subsequently used to help formulate the causes of the crisis, so that if necessary, specific crisis intervention treatment and problem-solving approaches can be implemented.

A tailored crisis intervention treatment is typically one to five sessions, offered on a voluntary basis. The treatment is specifically geared toward helping the patient survive and cope with the acute biopsychosocial or cultural effects from the crisis. The time required for each session depends on the complexity of the case and the practitioner's skill. A family physician can begin the crisis assessment and treatment by exploring the "Why now?" or acute precipitant of the crisis. This inquiry can be followed by detective-style questioning designed to uncover the specific chronology and sequence of events, feelings, thoughts, and behaviors that led to the development of the acute crisis. Patients seeking help should be encouraged to tell the details of their traumatic experiences.

Helping the patient to describe the stressors and evolution of the acute problem may offer clues to problem-solving approaches to crisis resolution. Crises or disasters involving the lack of food, clothing, shelter, poor sanitation, or inadequate medical care should be given first priority. Crises involving violence, suicide, or a life-threatening medical illness have secondary priority and should become the focus of the crisis treatment. Crises in everyday life can be treated according to the patient's preferences.

Crisis treatment focuses on the dynamic interplay of events from the most recent precipitants and days, the previous 6 weeks, and selective elements from the patient's past history. Important tools and approaches that can guide a crisis formulation and treatment are the timeline, ecologic (eco) map/ support network tool, wheel-and-spoke formulation, symptom-oriented treatment, and assessment and development of more adaptive coping styles. All these components can be used for the development of a general crisis resolution strategy.

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