As mentioned above, an acute psychiatric crisis is very serious and is different from a situational struggle. When we discuss an acute psychiatric crisis, we are talking about a situation when someone is behaving in a way that seems out of their control. If we know them, this behaviour might seem out of character for them. When someone is in a state like this, they most likely need professional support. Some types of behaviours you might see in an acute psychiatric crisis are:

• Acute psychosis; hearing voices, hallucinations, delusions. These symptoms can be normal for some people, for example someone with schizophrenia. It’s a crisis if their behaviour is elevated, and they can’t be calmed down with the usual things that support them
• Suicidal with a plan
• Exhibiting volatile behaviour
• Extreme out of control panic

The way we support someone depends on their unique situation and experience. Sometimes, a crisis can be experienced as persistent, lower intensity and spanning several months or even years in length. At other times, a crisis can be experienced as immediate, intense, and sometimes episodic (occasional and irregular) in nature. This is what we mean by an acute crisis. An acute crisis may present itself as a very intense, one-time, or a possibly aggressive, or violent situation.

In this section, we look at how you can support someone you’re working with when they  experience an acute crisis. This can include many different types of situations.

The following are some potential acute crisis situations:

• Psychosis
• Panic attack
• Potential overdose
• Delusional state because of alcohol withdrawal
• Physical health crisis
• Re-traumatization
• Suicidal ideation, a plan, or is in process (we will cover this further on in the module)
• Severe depressive episode
• Episode of mania

If there is a way to avoid intervention from law enforcement, that is ideal, as not all officers are trained in mental health best practices. An altercation with law enforcement can cause trauma for someone in an acute psychiatric crisis. However, there might be times when calling 911 is the only option. If that is the case, the immediate safety of the person and everyone around them must be considered.

Each of the situations listed will require a different approach. Being prepared for anything is important. Have a phone close-by. Naloxone training is essential. Be ready to call 911 if you come across anything you feel you can’t handle.

A Note About a Non-Acute Crisis

We mentioned that the word crisis means different things to different people. It is also a term that can be used often in casual conversation. This can add to potential misunderstandings of what the word crisis means within a mental health context.

For example, though the following situation is certainly stressful, and definitely a crisis of sorts, it is not an acute psychiatric crisis: “I had a huge crisis the other day when I spilled water on my laptop and lost the whole paper I was working on. I had to start from scratch. It caused me so much anxiety and stress!”

A situation like this can still be a crisis for someone; we don’t ever want to negate or minimize that. However, the way we would support someone through that crisis will be very different than how we support someone experiencing an acute psychiatric crisis. Anytime a situation comes up for someone where they feel overwhelming negative stimulus, and a lack of control, can be defined as a crisis for them. (This can be when something terrible happens to someone, such as a death in the family, failing to get into an academic program one really wanted to get into, experiencing COVID-19 or a serious medical issue, an intense argument, loss of a valued relationship, a serious financial loss, or anything along those lines.) Any of these situations could possibly be a trigger for an acute psychiatric crisis, but most often it wouldn’t escalate to require professional medical interventions.

A person may very well need support and a listening ear when experiencing a serious non-medical crisis, and this is exactly where peer support can come in! You can be a listening ear, and support someone to access different tools to get through their really tough situation. In fact there is much research that suggests that when people have a tangible crisis plan to support themselves through hard times, they can get back on their feet faster. This is the case for any type of crisis.

De-Escalation and Support

If we are working with someone who is experiencing a more acute intense crisis, it is important to know some ways to create a relaxed environment. De-escalation is the more clinical term for this.

During an acute crisis, the stress response is active and the sympathetic nervous system is engaged. Stress hormones like adrenaline and cortisol are pumping through the body. This can cause a fight, flight, or freeze response. This is the case both for the person experiencing the crisis, and for you the person in the supportive role.

The first thing you can do is try to regulate your own stress. As you calm your sympathetic nervous system, you will feel better able to support someone else. A simple way to do this is utilizing some breathing techniques.

There are some things you can do to support the person you are working to de-escalate. However, there is no recipe. There is no one size fits all approach to this. You might find yourself in a situation where nothing you are doing seems to help.

These tips are not about suppressing a person, but instead they are about tapping into empathy and compassion so you can connect with the person and support them to be seen and heard.

If at any point you are concerned about the safety of the person you are with, your own safety, or that of anyone around you, please treat it like an emergency situation and follow your campus emergency protocol.

Communication

Communication is the key to managing a crisis situation. Awareness of our own communication is essential. If no one is in immediate danger, you have time to slow down and be deliberate with your communication. Choosing to slow down and work on connection and communication can possibly stop the situation from getting worse.

Ask for support. You likely won’t be alone on campus. If you are dealing with an acute crisis, ask someone close-by to find someone to help. Know who to call.

Tools for De-Escalation and Support

Here are some things to remember that can help de-escalate an acute psychiatric crisis situation, and support the person struggling:

• Safety: Notice any potential safety issues for all in the vicinity. Are you in a location where someone could potentially fall or be hurt in some way?
• Be empathetic. Accept the person’s feelings exactly as they are. They are real and powerful to them in the moment. Responding to them with empathy is very validating, and it acknowledges their reality.
• Be aware of your tone. Manage your own responses in the moment. If you are very anxious, fearful, and aggressive, the other person will likely respond in kind, and continue to experience intense stress and fear.
• Be aware of your own biases and judgements. Work to withhold them. Being judgemental and harsh with someone is never supportive, and especially to someone who is in a crisis.
• Be aware of your words. The fewer words you use in the moment the better. When our brains are in crisis mode, our comprehension goes down. The stress response puts us into survival mode. Choose simple language and avoid too many words. This way the person is more likely to be able to take in the information.
• Be aware of your non-verbal communication. You can say all the right things, but if your non-verbal communication or tone is aggressive or defensive, it can make the person feel worse. Be as aware as you can be about facial expressions.
• Do not ever try to restrain someone. Restraints can be very traumatic for people. It’s best to give someone space, and not crowd them. People can feel ganged up on, if everyone is up in their personal space. This can continue to escalate them.
• Do not challenge the person. This is not the time to challenge someone or ask a lot of questions. Don’t try to convince someone that they are wrong. Don’t argue. Just be with them exactly where they are in the moment.
• Focus on feelings. Instead of challenging, focus on the feelings they are experiencing. You don’t have to validate exactly what they are saying, by validating their feelings is so important. Offer kindness, compassion, and empathy for where they are at. If you have been through something similar, you can share that in a way that creates connection and doesn’t cause overwhelm. Saying something like, “you’re not alone. I’m here with you. I have been in a similar place myself” can be comforting. If sharing appears to make the person more agitated, then hold back.
• Always offer choices and options. Rather than telling someone what to do, offer some potential options. But not too many–that can be overwhelming. Choice is always very important.
• Be clear on any limitations you may have as far as your program expects and requires of you. Follow the policies and procedures that your campus has outlined and be clear with the person on what those policies are. Don’t leave room for ambiguity. It’s very important to have clarity on the limits within the situation. Again, be aware of your tone and non-verbal communication. If you must repeat this several times, that’s ok.
• Allow time for reflection. Be ok with silence. Create opportunities for reflection and silence. These moments allow for the person to de-escalate, breathe, and begin to relax.
• Deep breathing, and grounding exercises are scientifically proven to relax us. Some people might be agitated if you push this on them though. Ask first. Grounding and mindfulness techniques support us to connect to the room, our bodies, our senses, our breath. Sometimes if you choose to intentionally focus on your own breathing, the person might follow suit.

Reach out and Debrief.

Once you feel like the situation is de-escalated, reach out to someone on campus for support.

After we have supported someone through an acute crisis, it is important to find someone to debrief with. We will find that our sympathetic nervous system is engaged after a crisis, so attending our own well-being is necessary.

We can close off the stress response through talking to someone, moving our bodies, journaling, or even a meditative practice.