PPN 303 Class 8: Partnering with persons experiencing crisis, self-harm, suicidality, abuse or violence

Transaction (Evolution of the concept of stress)

• the person and environment interactions that is appraised by the mind and deemed as exceeding the person's resources 

Woolfolk, Lehr, and Allen (New understanding of stress)

• stress is probably best thought of as a generic. Non technical term, analogous to disease or to addiction 

• Stress as medical term has to benefit 

Allostasis (Sterling and Eyer) (New understanding of stress)

• describe how the cardiovascular system adjusts to resting and active states of the body 

• Homeostasis: single optimal state 

Allostatic load (McEwen)(New understanding of stress)

• Continuous requirement to change due to environment, sum of wear and tear to maintain normal body conditions n the face of change. 

Lazarus  (New understanding of stress)

• argued that while the concept of stress is a useful one, it is not a simple, unitary phenomenon

Lazarus & Folkman "appraisal & coping” (1984) 

• Transnational model

• Cognitive appraisal

Transnational model (Lazarus & Folkman "appraisal & coping” 1984)

• stress deepens on how stressor is appraised in relation to the individual’s resources for coping with it 

  • Central premise is that stress is "neither an environmental stimulus, a characteristic of the person, nor a response, stress is the relationship between the person and the environment that is appraised as exceeding the person’s resources and endangering their well-being 

Cognitive appraisal Lazarus & Folkman "appraisal & coping” (1984)

• The process by which individuals examine the demands and constraints of a situation in relation to their own personal and network resources 

Responses to stress

• The freeze-hide response: The tendency to produce a passive response to stress 

• Tend and befriend: 

  • Tending involves nurturant activities designed to protect the self and offspring 

  • Befriending is the creation and maintenance of social networks that aid in the process

Physiologic stress responses

• The physiologic response to stress begins in the central nervous system (CNS) but quickly involves all body systems

  • Sympathetic response

  • Immune system functioning affects negatively

  • Over time, biologic responses to stress comprise a person’s health status 

Physiological stress-related symptoms

• Physiologic

• Emotional

• Cognitive

• Behavioural

Physiologic (Physiological stress-related symptoms)

• Headaches 

• Fatigue 

• Restlessness

• Sleep difficulties indigestion 

Emotional (Physiological stress-related symptoms)

• Crying 

• Feeling of pressure 

• Easily upset 

• Edginess

• Increased anger 

• Feeling sick 

• Nervousness 

• Increased impatience 

• Feeling of tension 

• Overwhelmed 

Cognitive (Physiological stress-related symptoms)

• Memory loss 

• Problems with decision-making 

• Loss of humour 

• Forgetfulness

• Feeling of tension 

• Difficulty thinking clearly 

Behavioural (Physiological stress-related symptoms)

• Isolation 

• Difficulty functioning

• Compulsive eating 

• Lack of intimacy 

• Intolerance resentment 

• Excessive smoking 

Emotional responses to stress 

• There is still debate about the relationship between emotion and cognition 

• Cognitive appraisal is fundamental to the experience of emotion because it shapes the meaning of a situation or an event 

Coping

• Is an individual’s constantly changing cognitive and behavioral efforts to manage specific external or internal demands that are appraised as taxing or exceeding the individuals resources 

  • Leads to adaptation or maladaptation 

• Problem-focused coping

  • Changes the relationship between the environment and person 

• Emotion-focused coping

  • Manage emotional distress 

• Ways of coping

Social support and stress 

• Enhances health and well-being 

  • Broadly defined as resources provided to us by others 

• A lack of social support increases the risk of morbidity and mortality 

• Social network is important 

Crisis

• Time-limited response to event/situation 

• Overwhelms a person’s usual coping mechanisms

• Threatens and impacts sense of security, self-concept, efficacy, and esteem 

Some consideration (Crisis)

• Individuals may be more open and amenable to interventions during a crisis 

• Opportunity for personal revolution and growth 

• Resiliency and gain skills and hopefulness for future 

• Timely crisis stabilization is essential to mitigate further negative impact 

Types of Crisis 

• Developmental/ maturation crisis

• Situational crisis

• Disaster or unexpected situation

Developmental/ maturation crisis (Types of crisis)

• Developmental life stage that creates internal conflict 

• adolescence, moving away, marriage, becoming a parent, retirement, etc 

Situational crisis (Types of crisis)

• Events that are external and unexpected 

• loss/change in job, death of loved one, financial troubles, sudden illness 

• These events have the potential to become crisis if the person does not  have resources or coping to overcome

Disaster or unexpected situation

• unexpected, unplanned, or random) crisis results from events that are not part of everyday life (such as natural disasters or violent crime). These crises may threaten survival. Experiencing or witnessing such events can also overwhelm a person’s ability to cope 

Infancy (birth -18months) (Stages of Development in Erikson’s psychosocial theory) 

• Trust vs Mistrust

• To develop a basic trust in the mothering figure and learn to generalize it to others

Early childhood (18 months- 3 years) (Stages of Development in Erikson’s psychosocial theory) 

• Autonomy vs shame and doubt

• To gain some self-control and Independence within the environment

Late childhood (3-6 years) (Stages of Development in Erikson’s psychosocial theory) 

• Initiative vs guilt

• To develop a sense of purpose and the ability to initiate and direct own activites

School age (6-12 years) (Stages of Development in Erikson’s psychosocial theory) 

• Industry vs Inferiority

• To achieve a sense of self-confidence by learning, competing, and performing successfully, and receiving recognition from significant others, peers, and aquaintances

Adolescence (12-20 years) (Stages of Development in Erikson’s psychosocial theory) 

• Identity vs role confusion

• To integrate the tasks mastered in the previous stages into a secure sense of self

Young adulthood (20-30 years)(Stages of Development in Erikson’s psychosocial theory) 

• Intimacy vs isolation

• To form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort

Adulthood (30-65 years)(Stages of Development in Erikson’s psychosocial theory) 

• Generativity vs stagnation

• To achieve the life goals established for oneself, while also considering the welfare of future geenerations

Old age (65 years-death) (Stages of Development in Erikson’s psychosocial theory) 

• Ego Integrity vs Despair

• To review one’s life and derive meaning from both positive and negative events, while achieving a positive sense of self-worth

Signs and symptoms of Crisis

• Inability to meet basic needs

• Decreased us of social support

• inadequate problem-solving

• Inability to attend to information

• Isolation

• Denial

• Exaggerated startle response

• Hypervigilence

• panic attacks

• feeling numb

• confusion/incoherence

• depression/self-hatred, weeping

• feels strange

• Perceived lack of control

• Irritability

• Being on guard or jumpy

• physical symptoms (shaking, headaches, fatigue, loss of appetite, and aches and pains

Phase 1 (Phases of a crisis)

• Problem arises that threatens self-concept 

• Increasing anxiety stimulates use of usual problem-solving techniques

Phase 2 (Phases of a crisis)

• Usual problem-solving techniques are not effective 

• Anxiety continues to rise 

• Trial and error efforts to restore balance 

Phase 3 (Phases of a crisis)

• If trial and error attempts fail, the anxiety escalates to severe levels/panic 

• Adopts automatic relief behaviors -compromising needs or redefining the situation to reach acceptable solution 

Phase 4 (Phases of a crisis)

• All attempts ineffective to reduce anxiety/distress 

• State of overwhelming anxiety which can lead to cognitive impairment, emotional instability, and behavioural disturbances that signal the person is in crisis

Roberts 7 stage crisis intervention model 

• Conduct crisis and psychosocial assessment (including lethally measure) 

• Establish rapport and rapidly establish relationship 

• Identify dimensions of presenting problem (s) (including the “last straw” of crisis  precipitants 

• Explore feelings and emotions (including active listening and validation) 

• Generate and explore alternatives (untapped resources and coping skills 

• Develop and formulate an action plan

• Follow up-plan and agreement

Crisis intervention (Nursing care)

• Early intervention 

• Stabilization 

• Facilitate understanding 

• Focus on problem-solving 

• Encourage self-reliance

The goals of crisis intervention are to:

• Assist individuals to return to an adaptive level of functioning 

• Prevent or moderate the potentially negative effects of extreme stress

Crisis intervention 

• Stage 1: conduct crisis assessment

• Stage 2: Establish the therapeutic relationship

• Stage 3: identify dimensions of presenting problem

• Stage 4: explore feelings and emotions

• Stage 5: generate and explore alternatives

• Stage 6: Develop a plan

• Stage 7: Follow-up

Stage 1: conduct crisis assessment (Crisis intervention)

• Assess immediate safety

• Bio/psycho/social/spiritual assessment

• Suicide, homicide

• Assessment will become focused as more information is obtained

Stage 2: Establish the therapeutic relationship (Crisis intervention)

• Be genuine, respectful and patient

• Discuss purpose and scope

• Provide clear, concise communication

• Eliminate distractions 

• Ensure continuity

Stage 3: identify dimensions of presenting problem (Crisis intervention)

• Attempt to understand “Why now?”

• What were the antecedents?

• Has this happened before?

• Consider demands vs resources

• Have new risks been identified?

Stage 4: explore feelings and emotions (Crisis intervention)

• Active listening,paraphrase, reflect, probe

• Validation

• Non-judgemental and supportive

• Motivational Interviewing techniques

Stage 5: generate and explore alternatives (Crisis intervention)

• Assess internal coping & resources

• Explore external resources

• Discuss what worked previously or role play future scenarios

Stage 6: Develop a plan (Crisis intervention)

• Integration of new skills and resources

• Is a process

• Anticipate setbacks

• Recovery oriented

• SMART goals-identification of barriers

Stage 7: Follow-up (Crisis intervention)

• Establish terms with the patient

  • Establish time frame for follow-up

• Assess current state and risk for relapse

• Review initial crisis and debrief

• Evaluate new coping skills and need for additional support

Trauma-informed approach principles 

• Safety

• Trust

• Choice

• Collaboration

• Shared power

• Cultural, historical and gender issues

Safety (Trauma-informed approach principles)

• Prioritize psychological, emotional and physical safety 

Trust (Trauma-informed approach principles)

• Act in ways that are trustworthy and transparent 

Choice (Trauma-informed approach principles)

• Enable choice 

• Ask permission

Collaboration /mutuality (Trauma-informed approach principles)

• Work collaboratively with the person 

Shared power (Trauma-informed approach principles)

• Empowerment and recognition of power imbalances 

Cultural, historical and gender issues (Trauma-informed approach principles)

• Mindful or intersectionality 

Trauma-informed approach applied to crisis 

• Realize 

  • Prevalence & impact of trauma 

• Recognize 

  • The signs of trauma 

• Respond

  • Ways that reduce re-traumatization 

Guiding principles (Trauma-informed approach)

• Establish feelings of personal safety 

• Intervening in person-centered ways 

• recovery , resilience & natural supports 

• Services are provided in the least restrictive manner 

• Rights are respected

Communication techniques (Trauma-informed approach)

• Demonstrate empathy & respect

• Talk openly 

• Be self-aware;including body language and facial expressions

• Feel comfortable with the unknown 

• Stay calm and demonstrate emotional regulation 

• Show genuine interest by being a good listener 

Risk to personal safety or safety of others (Acute crisis intervention) 

• Active suicidality 

• Risk to self due to functional impairment 

• Risk to others 

• Intention to harm others

Mental Health Act 

• Form 1

• Form 2

• Community treatment order

Form 1 (Mental health act)

• Physician completes when person is at significant risk to themselves or others

• Legally authorizes the person remain in hospital to be assessed for up to 72hrs for emergency assessment

Form 2 (Mental health act)

• family/ friend. non-MD professional can request from justice of peace (court) 

• Allows the police to take the person to a hospital for assessment

Community treatment order (Mental health act)

• Allows a physician to mandate supervised treatment of a patient when discharged from the hospital 

• The goal is to prevent mental health deterioration due to medication non-compliance

Ethical & legal considerations? 

• Rights of the person 

• Limits of the law 

• Safety 

• Therapeutic relationship vs safety of client 

• Professional duty and ethical code of conduct 

• Least restrictive measures 

Safety plan (CAMH, 2016, personal safety plan) 

• What makes me feel safe/unsafe? 

• How do I know when I am becoming or in a crisis? 

• What does it look like when I am in distress or losing control? 

• When I am in distress/crisis, I need 

• What activities or coping strategies can I try to calm and comfort myself? 

• What can others do to help 

Background (Self-harm and suicide)

• Canada ranks 61st in the world for reported suicides (WHO,2021) and, within canada, suicide is the 19th leading cause of death overall 

  • This jumps to 2nd for those ages 20-29; 3rd for those ages 30-44; and 7th for those ages 45-54

• Suicide is the 9th leading cause of death for men and 15th for women 

Factors that affect suicide risk differently by gender include:

• Experiences of violence 

• Family upbringing 

• Economic deprivation 

Indigenous people and mental health

• In 2013, Inuit males aged 15 to 19 years are 40 times more likely to kill themselves than their non-Inuit peers.

• It is important to note that Aboriginal suicide rates may be underreported.

• In indigenous communities where there is autonomy and a strong sense of ownership, culture, and community, there are much lower rates of suicide

Autism, self-harm, and suicidality 

• Autistic people at higher risk for self-harm events than non-autistic people

• Autistic girls/women more likely than non-autistic females to die by suicide, especially if they have other psychiatric diagnoses

  • In a population-based study in Ontario, almost 2 times higher risk than non-autistic girls/women (Lai et al., 2023)

2SLGBTQIA+ and suicidality 

• Experiences after “coming out” may contribute in some cases

• During adolescence, LGBTQIA+ youth’s search for self-identity, the effects of heteronormativity, structural violence, and other contextual factors may heighten depression and suicidality.

• The risk factors associated with LGBTQIA+ individuals are in addition to those common to all ages and sexual orientations.

Regional variations 

• Provincial statistics from 2023 show varied rates of suicide mortality across Canada.

• Eastern and central regions of the far north have some of the highest mortality rates from suicide.

• As of 2023, the suicide rate per 100,000 people for Nunavut was 90.9,while for the Northwest Territories, it was 22.4 and for Ontario, 9.1.

Guns and suicide 

• Between 2002 and 2016, almost 68% of all firearm deaths are suicides. Firearms are used in 15-20% of all suicide fatalities.

• Urban areas show the highest rates of completed suicides by firearms.

Suicidal Ideation and Self-Harm

• It is estimated that 36,560 (0.1%) people have unstated thoughts of suicide or suicidal ideation

• Suicidal ideation and self-harm are more common among adolescents than other age groups.

Etiology of Suicidality

• Suicidal behaviour occurs in the context of an individual’s stresses that include:

  • Physiologic

  • Psychological

  • Social situations

• Usually triggered by stressors that are unmanageable and exceed typical coping efforts.

Psychological Theories

• MDD, generalized anxiety disorder, personality disorders, bipolar disorder, schizophrenia, substance use disorders, and other psychiatric illnesses are frequently present.

• Substance use disorders have been determined as responsible for approximately two thirds disability adjusted life years allocated to suicide globally in 2010.

• Cognitive approaches attribute suicide to learned helplessness and hopelessness as an automatic and pervasive pathologic scheme or organizing and interpreting experience.

• Attachment theory explains social isolation and disrupted interpersonal relationships as being a part of the spectrum of suicide

Social Theories

• Durkheim classified suicide under four headings: egoistic suicide, altruistic suicide, anomic suicide, and fatalistic suicide.

• Cohen and colleagues: socioeconomic status is a driving factor in what happens to an individual, affecting the physical and social structures available to him or her.

• Suicide contagion and suicide clusters have occurred.

• Bullying, cyberbullying as a risk for suicide.

Spiritual Theories

• Spirituality has reemerged as an important component of holistic nursing care.

• Spirituality can mean a search for meaning, connectedness, energy, and a person’s worldview.

• Spirituality is being recognized as a source of resilience and coping.

• It has been hypothesized that not only personal but also contextual differences in religious beliefs may determine an individual's willingness to consider suicide.

Effects of Suicide

• Suicide has devastating effects on everyone it touches.

• Average cost of hospitalization for suicide and attempted suicide was $5,500 per admission in Canada.

• Family survivors of suicide report increased stigmatization and rejection than other causes of death.

Suicide (suicide terminology)

• the intentional act of killing oneself 

• Attempted

• Completed

Parasuicide (suicide terminology)

• may mimic suicidal behaviour, but the primary motivating force of action is not to kill oneself

Suicide ideation (suicide terminology)

thinking about or planning one’s own death

Lethality(suicide terminology)

 the probability that an individual will be successful in completing suicide

Assessment (suicide)

• Nursing practice reflects diverse health care settings and can play an important role in suicide prevention.

• Comprehensive assessment of risk:

  • Stressors

  • Symptoms

  • Prior behaviour

  • Current plan

  • Resources and support

Contracting for Safety

• Having the patient agree and commit to no self-harm or suicide attempt for an agreed upon period of time states that patient will not engage in suicidal behaviour for a specific period of time.

• Avoid or reduce use of substances.

• The patient must be competent to enter a contract.

• Consider Advantages and disadvantages

Inpatient care and acute treatment 

• Hospitals were once used for extended periods to protect the patient from suicide and establish treatment of underlying psychiatric disorder. This is no longer the case.

Objectives of hospitalization

• Maintain the patient’s safety.

• Decrease the level of suicidal ideation.

• Initiate treatment for underlying disorder.

• Evaluate for substance abuse.

• Reduce the level of social isolation.

• Connect patient and family with ongoing outpatient resources and therapy 

Biologic Interventions

• Ensuring safety

  • Hospital protocol for safety

  • Engaging in a therapeutic relationship

  • Observing the patient regularly

  • Removing dangerous objects

• Somatic therapies

  • Medications

  • ECT

• Assisting with treatment of substance abuse

Psychological Interventions

• Evaluating the patient’s ways of thinking about problems and generating solutions

• Cognitive interventions

• Developing plans to prevent future suicide attempts

Social interventions 

• Improving communication

• Networking and discharge planning 

• Education the patient and family  

Supporting persons with a history of abuse or violence 

• Most abuse of women, children, and elderly is intimate violence.

  • Perpetrator loved and trusted person

• World is no longer safe.

• Empowerment is foreign.

• Empowerment is the promotion of the continued growth and development of strength, power, and personal excellence.

Gender-Based Violence

• Violence against someone based on their gender, gender expression, gender identity, or perceived gender

  • Intimate partner violence

  • Victimization, bullying, etc.

  • Hate-based violence

  • Sexual violence

  • Human trafficking

Violence Against Women

• More than 11 million people in Canada have experienced intimate partner violence at least once since age 15

• Single, divorced, and separated women at higher risk

• Patterns of violence and assault are frequently established in early relationships.

Violence Against Men

• Now higher in men than traditionally believed.

• Women remain significantly overrepresented in IPV reports, the rates for men increased by 22% between 2018 and 2024 (Statistics Canada, 2025)

• Rates of violence against men and boys were significantly higher in most rural communities than in urban centers (Statistics Canada, 2023)

• Males were also more likely to be victims of more serious assaults, with the exception of sexual violence (Statistics Canada, 2023).

• Men are less likely than women to seek help.

Child abuse

• Prevalence is far reaching.

• The most common forms of child maltreatment include:

  • Witnessing intimate partner violence (34%

  • Neglect (34%)

• Physical violence (20%)

• Emotional neglect (9%)

• Physical abuse.

• Sexual abuse. 

• Emotional abuse.

• Factitious disorder by proxy: Munchausen’s syndrome by proxy.

• Secondary abuse: children of battered women

Elder Abuse

• Elder abuse, in the context of a growing aging population, is increasingly recognized as a serious problem in Canada and other countries.

• Adult children (34 per 100,000) have been identified most often as responsible for family violence against older adults.

  • Women are particularly vulnerable.

Risk Factors for Elder Abuse

• Risk within the environment such as a caregiver who is depressed and/or inadequate economic resources/strained

• Characteristics of the vulnerable elder individual which predispose to abuse, such as cognitive impairment, lack of empowerment or difficulty with activities of daily living (ADLs)

Battering

• Battering can be defined as repeated physical or sexual violence with the intent of coercive control.

• Estimates of injury related to battering seen in EDs range from 14% to 50%.

• Single greatest cause of injury to women.

• The realistic fear of being killed is one factor that keeps many women from leaving abusive partners.

• A significant danger to unborn children.

Human Trafficking

• Human trafficking in Canada is a lucrative activity with well organized and extensive trafficking networks reaching across the country and international borders (Oxman Martinez et al., 2005; Public Safety Canada, 2012).

• Most cases involve sexual exploitation in large urban areas although the reach can extend to smaller centres. Rates are highest in Ontario and Nova Scotia.

• The majority of victims of human trafficking in Canada are women and girls, Indigenous women and girls disproportionately represented, and over 40% are 18-24 y.o. and 1 in 4 are children and youth.

Special Considerations in Sexual Assault

• Early treatment & support crucial

• Diminish survivor distress

• Supportive, caring, non-judgemental

• Unwanted pregnancies

• STI, HIV

• Interventions

  • Education

  • Counselling

  • Emotional support

Sexual Assault & Domestic Violence (interventions)

• Empathic Support

• Provide Information and offer Choice

• Assess for injuries.

• Refer to SA/DVCC:

• Collect evidence for forensic evaluation.

• Specially trained