10.5 Example of an escalating crisis

A Family Guide to Concurrent Disorders - Part III: Treatment

Sometimes a sudden change in daily routine triggers a crisis that escalates into an emergency. Sometimes there is nothing that family members can do to prevent a crisis. Other times family members can prevent—or trigger—a crisis.

Read the following scenario and think about whether, had family members acted differently, the outcome could have been less severe.

Being prepared

Being prepared can help to prevent a situation from developing into a crisis and can also ease the person’s pain and anxiety once a crisis does occur. John’s family might think about the following:

• ensuring that John’s doctor and day treatment program workers are aware of (a) his difficulties in coping with change, (b) how change affects him (he develops severe anxiety and depression), (c) how he copes with these feelings (he turns to alcohol to self-medicate) and (d) what happens when he drinks alcohol (he is unable to stop at one drink, and it only takes four or five drinks before he starts experiencing rage and paranoia; he often becomes violent and makes threats).
• determining that John’s doctor and day treatment program workers are willing and able to work with both his mental health and substance use problems.
• ensuring that John’s doctor and workers are helping him learn to cope with change in his life.
• finding a program that provides support and education for family members—this can help John’s family learn how to cope with conflict and crises more effectively and can provide them with professional and peer support, experience and validation.
• starting to set limits to help John manage his feelings and behaviours. For example, to continue receiving an allowance from his parents, John must not avoid his responsibilities (such as attending his day program and keeping appointments with his doctor). John must smoke outside at all times to respect the health of his family members. John must use his allowance for necessary items such as clothes and bus fare, not for alcohol. John, like every member of the family, cannot be allowed to engage in threatening remarks or behaviours.

When John is ready (and is in a calm frame of mind), the family can talk with him about his smoking and give him some information about ideas for quitting smoking, including information about nicotine replacement therapy (such as the patch or nicotine gum).

During a crisis

When John does experience a crisis, the family should:

• try to be calm and supportive
• offer to call John’s doctor or one of his day program workers and ask John if he wishes to talk with them on the phone
• if he is agreeable, offer to take John to his doctor’s office or to his day program so that he can meet with one of his workers in person
• offer help and suggestions about what John can do to ease his anxiety and fear about whatever is concerning him.

Once John returned home obviously drunk, angry, paranoid and demanding money from his mother, several things might have helped prevent this crisis from becoming an emergency:

• Vera was right in that it was too late to try to reason with John. Knowing his usual pattern of drinking alcohol to cope with conflict, and his routine of calming himself in his room until he fell asleep, it would be better to avoid questioning John about what he did with his allowance.
• Knowing that John always smoked cigarettes when he was intoxicated and feeling angry and paranoid, it might have helped for Vera to give him the ten dollars this time, since he was unlikely to respond very well to attempts at limit-setting when he was in crisis. When John is calmer, the family could talk to him about asking for money for cigarettes, and establish some ground rules.
• Vera could have accompanied him to the store to buy cigarettes (preferably with a third person, if John is agreeable), and then taken him home and given him time to calm down in his room alone until he fell asleep (his usual pattern), while family members monitored his smoking and ensured that he did not unintentionally harm himself or fall asleep with a lit cigarette.
• Vera might have considered asking a close family friend to come over and help monitor John. Either Vera or another family member might have then phoned his doctor, therapist or another health professional who knows John and asked for help or advice on how to proceed.
• When talking to John, Steven should have spoken more softly and avoided direct eye contact with him, since shouting, judging, accusing and blaming him increased his fear and paranoia.
• Anna was wise to stay quiet and in the doorway. She knew from past incidents that when John was intoxicated, he was easily provoked into threatening behaviour. Too many people “cornering” him could worsen an already precarious situation.

Steven could have helped by:

• not crowding John when he was upset and intoxicated
• speaking softly and gently
• not making accusations
• avoiding direct eye contact with John, especially staring at him
• keeping a safe distance from John (this would have helped to keep Steven safe and prevent John from feeling more paranoid and “imprisoned”)
• letting one person (in this case, his mother) speak to John and handle the conflict.

Following through on these suggestions might have helped prevent a crisis from becoming an emergency. However, families should be aware that sometimes an emergency cannot be avoided. It is helpful to know what they can do in the event of an emergency.