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A study of psychological crisis intervention with family members of patients who died after emergency admission to hospital.

Caplan (1964) first presented psychological crisis theory in his book Principles of Preventive Psychiatry, stating that when individuals face sudden or critical problematic situations, and when their former coping methods and support systems are not sufficient to deal with these situations - in other words, the difficulties at hand surpass the individual's coping ability - the person will fall into a state of temporary psychological distress. This distress is considered as psychological crisis. Since Caplan's research was carried out, many scholars have presented various understandings about and explanations of psychological crisis theory. Generally speaking, it is now widely accepted that psychological crisis is a strong psychologically stringent state that leads to psychological disequilibrium and even severely influences the affected individual's physical and mental health. Hoff (1984) has classified the sources of psychological crisis into three major categories: developmental crisis, situational crisis, and existential crisis. According to Lazarus (1976) situational crisis is caused by external visible events, and hyper-normal, unpredictable, and uncontrollable accidents, which are characterized by randomness, suddenness, shock, intensity, and calamity, such as disasters like earthquake and fire, various kinds of diseases, death of family members, divorce, occupational obstacles, and so on.

It is generally accepted that psychological crisis may last for 4-6 weeks. Four consequences can be observed. First, the person, or people, concerned can not only live through the crisis, but also learn much from the crisis and further master new coping methods so that their psychological health is improved. Second, after the crisis, the person may experience psychological trauma. When facing the same crisis in the future, the person may still find it hard to grapple with. Third, the person may commit suicide out of intense psychological pressure and desperation. Fourth, relatively serious mental aberration may be produced due to the crisis (see e.g., Zhang, Fang, & Gao, 2008).

As a state of strong mental stress, psychological crisis initiates many kinds of arousal responses, such as perception failure, tension, anxiety, fear, depression, and anger. This acute stress may also arouse behavioral responses like avoidance of stressors, regression to a previous level of functioning (e.g., thumbsucking or bedwetting), substance dependence and abuse (e.g., alcohol and drugs), feelings of helplessness, hostility, and fixation and can also result in physiological changes in the nervous, endocrine, and immune systems, such as an increase in corticosteroid levels and loss of normal circadian change, insulin-induced hypoglycemia caused by growth hormone decrease, and the passivation of thyrotropin releasing hormone. These psychological and physical responses are normal stress reactions. However, if the influence of the reactions exceeds the determinate coping ability of an individual, the intense psychological crisis will gravely affect the person's mental and physical health, in spite of the buffer power of firm character, strong social support system, reasonable coping methods, suitable defense mechanism, and abundant life experience (e.g., Miao & Wang, 2004). Thus, psychological crisis intervention has all-important practical significance in the maintenance of mental and physical health.

Psychological crisis intervention refers to the helping and supporting technique utilized to assist individuals under psychological pressure. In a crisis people need to call on their own resources and inner strength to rebuild or recover their former and formal psychological balance to obtain new skills and prevent passive results of psychological crisis (see e.g., Gilliland & James, 2000). Caplan (1964) presented three principles of crisis intervention: first, trying to make the person concerned accept support and help; second, doing one's best to help the person confront the crisis and adopt suitable coping behaviors; and third, communicating with the person for information, to build up trust and to reduce tension. Thus, the key aims of crisis intervention are to gain the person's trust, assist the person concerned to act appropriately under crisis, and finally to assist the person in regaining psychological equilibrium. With the guidance of these principles, many scholars have proposed intervention models and intervention approaches, such as the equilibrium model, cognition model, and psychologicalsocial transformation model (Belkin, 1988), and also the approach proposed by Gilliland and James that proceeds through the six steps of problem identification, safety assurance, support supply, introduction and validation of accommodation methods, plan making, and commitment procurement. Currently, psychological crisis intervention has aroused increasing attention from scholars with studies aimed at examining various types of crisis events. Some studies have been experimental but the majority of research has involved case reports of suicide (Chen, 2007), natural disasters, earthquake (e.g., Hu, Shao, Fu, & Liu, 2008), and Sudden Acute Respiratory Syndrome (SARS; Shen, 2003).

Loss is a situational crisis event, that is also unavoidable in life. The loss of beloved family member(s) brings great pain to the people concerned. According to Holmes and Rahe (1967) in their evaluation of the important events in one's life, the loss of a spouse creates the greatest stress, while loss of other family members ranks fifth (Rice, 2000), illustrating the huge impact of family member loss on individuals. Hong Kong scholar Weiliang Chen has defined bereavement as a condition faced by anyone who lost his/her beloved ones or attached objects (mainly people). Bereavement is a situation as well as a process, including responses of grief and mourning (see e.g., Chen & Zhong, 1988).

Individuals in bereavement frequently show obvious psychological disturbances like somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychosis. The normal procedure of bereavement includes shock, ascendance, emotional response, and gradual calm. After about six months, most people who have been bereaved are able to accept the fact of their family member's death. Their life will then gradually revert to peace and quietness, but the feeling of bereavement may still surround them and emerge from time to time. If those who experience the loss of a loved one do not go through the complete process of bereavement, psychological trauma will follow. As a result, the primary goal of psychological crisis intervention is to carry through the bereavement intervention; in other words, to assist the bereaved person to experience the normal response process, so that their psychological symptoms can be reduced and chronic bereavement can be prevented.

The family members of patients who die suddenly after admission to a hospital emergency department witness the process their loved ones experience from being in danger, then undergoing active clinical treatment, and finally death. Because of the urgency and suddenness of the event, strong stressors usually act directly on the witnesses, causing serious psychological trauma. In the present study the focus was psychological crisis intervention with the family members of 167 patients who died after emergency admission to a general hospital from October 2007 to December 2008. The effects of intervention were also evaluated, providing practical evidence for further psychological crisis intervention in clinical emergency work.

METHOD

PARTICIPANTS

The participants were family members of 175 patients who received treatment in the emergency department of a general hospital and who died within 24 hours from acute trauma (wound), acute heart attack, and/or cerebral artery problems, intoxication, or breathing and digestive system problems. The age of these family members ranged from 35 to 75 years, including 90 males and 85 females. They were randomly divided into an intervention group (88 people) and a control group (87 people). None of them had a mental disorder or severe functional disturbance in vital organs such as heart, lungs, liver, or kidneys. No serious family accidents or acute psychological trauma had occurred in the past. The patients who had died had been basically healthy and were previously expected to continue to live a normal life in spite of any chronic disease. Factors which would create a huge financial or psychological burden for the family such as marital discord, divorce, or long-term chronic disease in the families of patients (either paternal or maternal relatives), were all excluded. From the 175 family members who agreed to take part in the study, eight were excluded so that 167 valid questionnaires were included in the study.

RESEARCH TOOL

The Symptom Checklist-90 (SCL-90; Derogatis, Rickels, & Rock, 1976, revised by Wang, Wang, & Ma, 1999) was used to carry out the evaluation of the effects of intervention. There are 9 explicitly defined factors in the SCL-90: somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychosis. These factors are evaluated by 90 items, with each item given a score from 1 to 5, and the higher the score, the more severe the symptoms. When the total score is 160 or over, or when the total number of positive items is more than 43, or when any respective factor score is 2 or more this is considered a positive result and further checks will need to be performed. When the score of any of the factors is over 3 this may indicate moderate to severe psychological disequilibrium. The SCL-90 includes extensive content of psychosis semeiology, from aesthema, passion, thinking, consciousness, and behaviors to living habits, interpersonal relations, and diet. It can accurately describe rational symptoms, reflect the extent of problems, and changes of the interviewees, thus serving as the most widely used measuring scale in the study of neurosis and in psychological consultation in both inpatients and outpatient departments in general hospitals.

SCL-90 EVALUATION

An individual questionnaire test was used for the evaluation in this study. Three days after the death of the patient, the family members were asked to answer the questionnaire. It was made clear that their participation was completely voluntary. Thirty minutes were allowed to complete the questionnaire. For those who could not read or write well explanations were provided by the researchers, and the answers were written down by another person based on the participants' full understanding and consent. After one month, reevaluation was carried out during a return visit, during which the questionnaire was distributed and retrieved on the spot. After the two evaluations, 167 pairs of questionnaires (intervention group 81, control group 86) were collected with a recovery rate 95.4%.

PSYCHOLOGICAL CRISIS INTERVENTION

Following Caplan's three principles (1964), the three models proposed by Belkin (1988), the fundamental 6-step approach of Gilliland and James (2000), and Mitchell's (1988) Critical Incident Stress Debriefing (CIDS), the intervention methods in this research were established and practiced with the participants three days after the death of their family member. There were four steps in this method. (1) Self-introduction to gain trust, to decrease numbness and build communication. (2) Expressing feelings and emotions to prevent denial, and to ensure that these people could deal with their sorrow without wanting to harm themselves. (3) Providing information to break down feelings of helplessness, to help to build up effective support. (4) Assisting abreaction to guide learning, and carrying out appropriate training to increase coping ability.

STATISTICAL ANALYSIS

T test, ANOVA, and regression analysis were carried out using SPSS 13.0 software (p < 0.05).

RESULTS

COMPARISON OF PSYCHOLOGICAL HEALTH STATUS OF ALL PARTICIPANTS AND NATIONAL NORM

A single sample t test was performed on the SCL-90 total and respective factor scores of all participants and these were compared with corresponding national norms (e.g., Jin, Wu, & Zhang, 1986). The results are shown in Table 1.

Table 1 shows that both the total average and the respective factor scores of family members of the patients who had died were significantly higher than the scores of the national norm (p 10 < 0.001). The respective ranking of the factors from the highest to the lowest are depression, phobia anxiety, anxiety, paranoid ideation, summarization, hostility, interpersonal sensitivity, psychosis, and obsessive-compulsive, among which the first six factor scores were above 2, indicating psychological disequilibrium. Screening tests showed positive results with clinical significance.

COMPARISONS OF SCL-90 TOTAL SCORES AND RESPECTIVE FACTOR SCORES BETWEEN INTERVENTION AND CONTROL GROUPS

Single factor ANOVA was carried out on the SCL-90 total and respective factor scores of the intervention and control groups, and the results are shown in Table 2.

RESULTS OF INTERVENTION EFFECTS EVALUATION

A t test was carried out on both rounds of the SCL-90 total and respective factor scores of both groups, and the results are shown in Table 3 (see over page).

In both the intervention group and the control group, the SCL-90 total and respective factor scores in the second round of evaluation were significantly lower than those in the first round (p < 0.05). The results may not demonstrate definitely the intervention effects since there is the possible influence of the time factor. To preclude this possible influence, the minus value of two evaluation scores was set as dependent variable (DV), and the grouping intervention was set as independent variable (IV), with the intervention group being labeled 1 and control group 2. Then regression analysis was carried out, and the significant results of the test are shown in Table 4 (constant quantity omitted).

Results show that the minus values of total score, scores of somatization, the factors of depression, anxiety, and phobic anxiety were significantly related to intervention (p < 0.05).

DISCUSSION

The loss of a loved one is a sorrow-stricken event in life. Grief is unavoidable for the family members of patients who die after admission to the emergency department of a hospital.

Lindemann (1963) found that, for persons who have lost family members, the bereavement response is natural, temporary, and necessary. Psychological intervention must be provided through short-term crisis intervention methods. Based on this theory, in this study the intervention method was designed to follow the four steps of self-introduction, expressing feelings and emotions, providing information, and assisting abreaction.

It was observed in the SCL-90 results that both the total average and the respective factor scores of the family members who took part in the study were significantly higher than those of the national norm (p < 0.01). The scores exceeded two in six factors. These results indicated that when they had witnessed the whole process of emergency treatment followed by death of a loved one, a relatively severe psychological stress response appeared, the mental health of the family members was adversely affected, and psychological intervention was necessary. In the second round of evaluation, both the intervention group and the control group recorded significantly lower total and respective factor scores. Regression analysis showed that the value changes in these scores were significantly related to the effects of intervention. The 4-step method adopted in this research could effectively improve the general mental health of family members of patients who died after admission to hospital for emergency treatment, and decrease symptoms of somatization (mainly reflecting subjective physical discomfort), depression (clinical depressive disorder), anxiety (clinical anxiety symptoms and experiences), and phobic anxiety (phobic feelings and experiences).

The results of the present study do not necessarily lead to the conclusion that the 4-step approach used in this research effectively prevents posttraumatic stress disorder because of the short period of intervention and observation. However, this approach certainly did promote the psychological health of the group of family members who took part in the study. The influences and the differences caused by age, educational background, and gender of the participants were not examined and also remained unclear. Further research work should be conducted with a larger number of people taking part.

DOI 10.2224/sbp.2010.38.4.469

references

Belkin, G. S. (1988). Introduction to counselling (3rd ed.). Dubuque, Iowa: W. G. Brown.

Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.

Chen, J. (2007). A case of psychological crisis intervention with a suicide attempt patient. Nursing Supervision Journal, 7(12), 7-8, 11.

Chen, W. L., & Zhong, X. J. (1988). Bereavement psychological consultation: Theory and practice (pp. 2-3). Beijing: China Light Industry Press.

Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, 280-289.

Gilliland, B. E., & James, R. K. (2000). Crisis intervention strategies. Beijing: China Light Industry Press.

Hoff, G. L. (1984). Serratia. In G. L. Hoff, F. L. Frye, & E. R. Jacobson (Eds.), Diseases of amphibians and reptiles (pp. 59-67). New York: Plenum Press.

Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11, 213-218.

Hu, X. H., Shao, R., Fu, M., & Liu, X. F. (2008). A case of urgent psychological crisis intervention on acute stress disorder patients during the Wenchuan earthquake. Nursing Supervision Journal, 14(30), 3221-3222.

Jin, H., Wu, W. Y., & Zhang, M. Y. (1986). Initial analysis of SCL-90 with healthy Chinese adults. Chinese Journal of Nervous and Mental Diseases, 12(5), 260-263.

Lazarus, A. A. (1976). Multimodal behavior therapy. New York: Springer.

Lindemann, E. (1963). Symptomatology and management of acute grief. Pastoral Psychology, 14(6) 8-18.

Miao, D. M., & Wang, J. T. (2004). Clinical psychology. Xi'an: FMMU Press.

Mitchell, J. T. (1988). Stress: The history, status and future of critical incident stress debriefings. Journal of Emergency Medical Services, 13(11), 47-52.

Rice, P. L. (2000). Health psychology (pp. 145-146). Beijing: China Light Industry Press.

Shen, J. (2003). A case of psychological crisis intervention with a SARS patient. Journal of Clinical Psychological Medicine, 13(5), 320.

Wang, X. D., Wang, X. L., & Ma, H. (1999). Mental Health Assessment Scale (revised version), Beijing: Chinese Encyclopedia Press.

Zhang, F. H., Fang L. L., & Gao, P. (2008). Study on psychological crisis and intervention. World Scientific Technology Research and Development, 30(4), 504-508.

Wei Wang

Fourth Military Medical University, Xi'an, People's Republic of China

Dong-dong Chen

Xijing Hospital, Fourth Military Medical University, Xi'an,

People's Republic of China

Yebing Yang, Xufeng Liu, and Danmin Miao

Fourth Military Medical University, Xi'an, People's Republic of China

Wei Wang, MD, Department of Psychology, School of Aerospace Medicine, Fourth Military Medical University, Xi'an, People's Republic of China; Dong-dong Chen, MD, Emergency Department, Xijing Hospital, Fourth Military Medical University, Xi'an, People's Republic of China; Yebing Yang, MD, Xufeng Liu, PhD, and Danmin Miao, MD, Department of Psychology, School of Aerospace Medicine, Fourth Military Medical University, Xi'an, People's Republic of China. Appreciation is due to anonymous reviewers.

Please address correspondence and reprint requests to: Xufeng Liu, Department of Psychology, School of Aerospace Medicine, Fourth Military Medical University, Xi'an, People's Republic of China. Phone and Fax: +86-29-8477-4803; Email: lllfmmu@fmmu.edu.cn or Danmin Miao, Email: miaodanmin@hotmail.com
TABLE 1
COMPARISON OF SCL-90 PSYCHOLOGICAL SYMPTOMS OF PARTICIPANTS AND
NATIONAL NORM ([bar.x] [+ or -] s)

                                     Family members
                                        in study
Factor                                  (N = 167)

SCL-90 total                      219.06 [+ or -] 17.34
somatization                        2.18 [+ or -] 0.54
obsessive-compulsive disorder       1.93 [+ or -] 0.41
interpersonal sensitivity           1.97 [+ or -] 0.33
depression                          3.01 [+ or -] 0.59
anxiety                             2.76 [+ or -] 0.60
hostility                           2.14 [+ or -] 0.41
phobic anxiety                      2.86 [+ or -] 0.50
paranoid ideation                   2.26 [+ or -] 0.42
psychosis                           1.95 [+ or -] 0.40

                                      National norm
Factor                                 (N = 1,388)           p value

SCL-90 total                      129.96 [+ or -] 38.76     10 < 0.001
somatization                        1.37 [+ or -] 0.48
obsessive-compulsive disorder       1.62 [+ or -] 0.57      10 < 0.001
interpersonal sensitivity           1.65 [+ or -] 0.51
depression                          1.50 [+ or -] 0.59      10 < 0.001
anxiety                             1.39 [+ or -] 0.43
hostility                           1.48 [+ or -] 0.56      10 < 0.001
phobic anxiety                      1.23 [+ or -] 0.41
paranoid ideation                   1.43 [+ or -] 0.57      10 < 0.001
psychosis                           1.29 [+ or -] 0.42

TABLE 2
COMPARISON BETWEEN INTERVENTION AND CONTROL GROUPS
([bar.x] [+ or -] s) OF SCL-90 TOTAL AND RESPECTIVE FACTOR SCORES

                                   Intervention group
Factor                                  (n = 81)

SCL-90 total                      220.67 [+ or -] 16.98
somatization                        2.18 [+ or -] 0.54
obsessive-compulsive disorder       1.91 [+ or -] 0.42
interpersonal sensitivity           2.00 [+ or -] 0.33
depression                          3.01 [+ or -] 0.57
anxiety                             2.87 [+ or -] 0.60
hostility                           2.09 [+ or -] 0.41
phobic anxiety                      2.91 [+ or -] 0.49
paranoid ideation                   2.27 [+ or -] 0.43
psychosis                           1.96 [+ or -] 0.40

                                      Control Group
Factor                                  (n = 86)            p value

SCL-90 total                      217.54 [+ or -] 17.63      0.246
somatization                        2.17 [+ or -] 0.53       0.852
obsessive-compulsive disorder       1.94 [+ or -] 0.39       0.696
interpersonal sensitivity           1.94 [+ or -] 0.32       0.214
depression                          3.02 [+ or -] 0.61       0.975
anxiety                             2.71 [+ or -] 0.58       0.078
hostility                           2.18 [+ or -] 0.40       0.180
phobic anxiety                      2.80 [+ or -] 0.49       0.109
paranoid ideation                   2.25 [+ or -] 0.40       0.785
psychosis                           1.95 [+ or -] 0.38       0.791

TABLE 3
COMPARISON OF FIRST AND SECOND SCL-90 TOTAL AND RESPECTIVE FACTOR
SCORES OF INTERVENTION GROUP AND CONTROL GROUP ([bar.x] + s)

                                   Intervention group
                                        (n = 81)

Factor                                   Round 1

SCL-90 total                      220.67 [+ or -] 16.98
somatization                        2.18 [+ or -] 0.54
obsessive-compulsive disorder       1.91 [+ or -] 0.42
interpersonal sensitivity           2.00 [+ or -] 0.33
depression                          3.01 [+ or -] 0.57
anxiety                             2.87 [+ or -] 0.60
hostility                           2.09 [+ or -] 0.41
phobic anxiety                      2.91 [+ or -] 0.49
paranoid ideation                   2.27 [+ or -] 0.43
psychosis                           1.96 [+ or -] 0.40

                                      Intervention group (n = 81)

Factor                                   Round 2            p value

SCL-90 total                      171.42 [+ or -] 17.18     <0.001
somatization                        1.76 [+ or -] 0.54       0.037
obsessive-compulsive disorder       1.77 [+ or -] 0.38      <0.001
interpersonal sensitivity           1.63 [+ or -] 0.32      <0.001
depression                          2.12 [+ or -] 0.57      <0.001
anxiety                             2.05 [+ or -] 0.54      <0.001
hostility                           1.56 [+ or -] 0.37      <0.001
phobic anxiety                      1.75 [+ or -] 0.43      <0.001
paranoid ideation                   1.77 [+ or -] 0.43      <0.001
psychosis                           1.49 [+ or -] 0.36      <0.001

                                      Control group
                                        (n = 86)

Factor                                   Round 1

SCL-90 total                      217.54 [+ or -] 17.63
somatization                        2.17 [+ or -] 0.53
obsessive-compulsive disorder       1.94 [+ or -] 0.39
interpersonal sensitivity           1.94 [+ or -] 0.32
depression                          3.02 [+ or -] 0.61
anxiety                             2.71 [+ or -] 0.57
hostility                           2.18 [+ or -] 0.40
phobic anxiety                      2.80 [+ or -] 0.49
paranoid ideation                   2.25 [+ or -] 0.40
psychosis                           1.95 [+ or -] 0.38

                                        Control group (n = 86)

Factor                                   Round 2            p value

SCL-90 total                      173.58 [+ or -] 17.38     <0.001
somatization                        2.03 [+ or -] 0.55       0.006
obsessive-compulsive disorder       1.77 [+ or -] 0.38      <0.001
interpersonal sensitivity           1.64 [+ or -] 0.35      <0.001
depression                          2.57 [+ or -] 0.53      <0.001
anxiety                             2.20 [+ or -] 0.57      <0.001
hostility                           1.68 [+ or -] 0.36      <0.001
phobic anxiety                      1.97 [+ or -] 0.45      <0.001
paranoid ideation                   1.75 [+ or -] 0.38      <0.001
psychosis                           1.52 [+ or -] 0.33      <0.001

TABLE 4
REGRESSION ANALYSIS ON GROUPING FACTORS OF TWO-ROUND SCL-90
TOTAL AND RESPECTIVE FACTOR SCORES

Factor             Quotient      SE      t value     p value

SCL-90 total         6.88       3.00      2.29        0.023
somatization         0.28       0.11      2.45        0.015
depression           0.45       0.13      3.58       <0.001
anxiety              0.31       0.12      2.69        0.008
phobic anxiety       0.35       0.10      3.37        0.001
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Author:Wang, Wei; Chen, Dong-dong; Yang, Yebing; Liu, Xufeng; Miao, Danmin
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:1USA
Date:May 1, 2010
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