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R
EVIEW
A
RTICLE
Nursing interventions for adults following a men-
tal health crisis: A systematic review guided by
trauma-informed principles
Nafsin Nizum,
1
Rosanra Yoon,
2
Laura Ferreira-Legere,
3
Nancy Poole
4
and Zainab Lulat
1
1
Guideline Development Methodologist, Registered Nurses’ Association of Ontario,
2
Nurse Practitioner, The Jean
Tweed Centre,
3
Former Guideline Development Methodologist, Registered Nurses’ Association of Ontario, Toronto,
Ontario; and
4
Centre of Excellence for Women’s Health, Vancouver, British Columbia, Canada
ABSTRACT: There exists a growing need for health and service providers to respond to persons
in a manner that recognizes the prevalence and impact of trauma in individuals and prevent
inadvertent re-traumatization in the routine process of care. The experience of mental health crisis
in of itself can have traumatic and impactful effects on individuals. Trauma-informed approaches
to care offer a framework to provide crisis intervention responses that are based on the
acknowledgement of the prevalence and impact of trauma and define trauma not by the event per
se, but by the impact of an experience of trauma. The integration of trauma-informed principles in
the context of crisis intervention is a current practice gap. In order to inform a portion of a best-
practice guideline for registered nurses and the interprofessional team, a systematic literature
review was conducted to primarily identify nursing interventions within four weeks of a mental
health crisis, with a secondary focus on identifying particular interventions that included trauma-
informed principles. The systematic review yielded 21 quantitative and qualitative studies related
to nursing interventions for mental health crisis, 10 of which referred to one or more principles of
trauma-informed approaches. There was a lack of studies on nursing interventions explicitly linked
to implementation of trauma-informed principles, highlighting future research needs and focused
efforts to integrate trauma-informed principles into crisis intervention practices.
KEY WORDS: best-practice guideline, mental health crisis, mental health nursing, trauma-
informed.
Correspondence: Nafsin Nizum, Guideline Development Methodologist, Registered Nurses’ Association of Ontario, 158 Pearl Street, Tor-
onto, Ontario M5H 1L3, Canada. Email: nnizum@RNAO.ca
Authorship Statement: All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated
sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revi-
sion of the manuscript. N. Nizum, L. Ferreira-Legere, and Z. Lulat conducted the systematic review. N. Nizum, N. Poole, and R. Yoon
drafted the manuscript. N. Nizum, R. Yoon, L. Ferreira-Legere, N. Poole, and Z. Lulat revised the manuscript critically for important intel-
lectual content.
Conflicts of Interest: The authors declare that they have no competing interests.
Funding Source: This work was funded by the Ontario Ministry of Health and Long-Term Care.
Nafsin Nizum, RN, MN.
Rosanra Yoon, NP, MN, PhD.
Laura Ferreira-Legere, RN, MScN.
Nancy Poole, PhD, MA, Dip.C.S., BA.
Zainab Lulat, RN, MN.
Accepted December 15 2019.
©2020 Australian College of Mental Health Nurses Inc.
International Journal of Mental Health Nursing (2020) ,– doi: 10.1111/inm.12691
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INTRODUCTION
Crises are subjective experiences that threaten and
overwhelm a person’s ability to deal with the situation
using their normal problem-solving abilities, coping
mechanisms, or current resources (Caplan 1961; East-
ham et al. 1970; James & Gilliland 2001). The over-
whelming experience can have detrimental effects on
mental health, including intense feelings of personal
distress (e.g. panic, numbness, anger, numbness,
depression) (Jakubec 2014; Substance Abuse and Men-
tal Health Services Administration [SAMHSA] 2009).
This mental health response can bear implications on
physical health (e.g. headaches, loss of appetite, shak-
ing) as well as changes in functioning (e.g. inability to
meet basic needs or unusual behaviour) (Jakubec 2014;
SAMHSA 2009). The precipitating events of a mental
health crisis can vary and may include disruption in
personal relationships, support systems or living
arrangements; loss of autonomy, death of a loved one,
the onset of illness, victimization or experience of natu-
ral disasters (Jakubec 2014; SAMHSA 2009). Experi-
encing a mental health crisis may also lead to long-
term harm, such as the potential risk of post-traumatic
stress disorder (Poole, Urquhart & Jaisura, 2013;
SAMHSA 2009). The harmful short-term and potential
long-lasting effects of a mental health crisis call for
timely and effective interventions. More importantly,
there is a need for providers to be responsive to per-
sons experiencing crisis in a trauma-informed way, in
order to minimize re-traumatization and reduce further
emotional and psychological harm. Nurses, in particu-
lar, are in a unique position to respond to mental
health crisis as they may care for persons in various
healthcare settings (within and outside mental health
settings), and across the care continuum. Furthermore,
professional nursing standards of care emphasize build-
ing relationships based on trust, compassion, and
patient-centredness. Thus, enacting trauma-informed
principles has the potential to strengthen nurse–client
relationships and improve outcomes.
Personal histories of trauma are pervasive among
individuals seeking help for mental health and/or sub-
stance use concerns (Harris & Fallot 2010; SAMHSA
2014). Past trauma can have lasting effects on both the
psychological and physical health of individuals, fami-
lies, and communities (Bateman, Henderson & Kezel-
man 2013; Poole et al. 2013). Historically, health and
social services have not integrated an awareness of
trauma into routine processes of care, resulting in
inadvertent re-traumatization or misinterpretation of
behaviours and responses to triggers (Harris & Fallot
2010). Consequently, there is recognition of the need
for services and providers to become responsive to the
impact of trauma through trauma-informed)
approaches (Bateman et al. 2013; SAMHSA 2014).
Trauma-informed approaches to service delivery
acknowledge the prevalence and impact of trauma and
are based on trauma-informed principles applied uni-
versally across systems of care to resist re-traumatiza-
tion. Trauma-informed principles of practice include
the following: promoting safety, trustworthiness and
transparency, fostering collaboration and mutuality,
supporting empowerment, choice and control, provid-
ing opportunity for peer support, and generating
awareness and responsiveness to cultural, historical,
and gender issues (SAMHSA 2014). Although the prin-
ciples of trauma-informed practice (such as choice, col-
laboration, safety, empowerment) can be found as
guiding principles of existing frameworks of patient-
centred care and recovery-oriented practice, what is
unique in trauma-informed practice is that these prin-
ciples are enacted and framed from a reference point
of recognizing the impact and the widespread preva-
lence of trauma. In essence, the principles of trauma-
informed practice are held together by trauma aware-
ness that influences how the principles of choice and
collaboration are enacted when one appreciates the
impact of trauma in the person’s context. Trauma-in-
formed approaches do not require extensive history
taking and disclosure of trauma, and are particularly
relevant and helpful in the immediacy of crisis situa-
tions where the priority is to attend to and be respon-
sive to the person’s needs for emotional, psychological,
and physical safety.
More recently, trauma-informed frameworks, princi-
ples, and approaches have been integrated into services
and systems addressing child welfare, homelessness,
mental health and substance use, criminal justice, edu-
cation, and primary care (Akin, Strolin-Goltzman &
Collins-Camargo, 2017; Branson et al. 2017; Green
et al. 2015; Howell, Thomas & Crosby, 2018; Kirst
et al. 2017; Williams, 2016). However, there is greater
potential for the widespread understanding and use of
trauma-informed approaches relevant to crisis interven-
tions. Currently, there is a lack of evidence-based guid-
ance for health and services providers, in particular
registered nurses, on what is required to provide crisis
interventions for individuals, and more specifically, how
crisis interventions can be provided in a trauma-in-
©2020 Australian College of Mental Health Nurses Inc.
2 N. NIZUM ET AL.
formed way. To our knowledge, there has been no sys-
tematic review conducted examining to what extent
trauma-informed principles are integrated in nursing
interventions for mental health crisis and its subse-
quent impact on individuals. Thus, the primary aim of
this review is to synthesize the available literature on
nursing interventions for mental health crisis, with a
secondary aim to identify trauma-informed principles
within the literature on mental health crisis interven-
tions, in order to inform a portion of an evidence-based
guideline for registered nurses and the interprofes-
sional team.
AIMS
In June 2016, fifteen experts in the area of crisis
response and/or trauma-informed approaches convened
for the development of a best-practice guideline on cri-
sis intervention guided by trauma-informed principles
(Registered Nurses’ Association of Ontario 2017). The
guideline panel consisted of experts from diverse disci-
plines such as nursing, medicine, social work, the jus-
tice system, research, and persons with lived
experience. The guideline was developed for registered
nurses and other members of the interprofessional
team. The guideline aimed to include healthcare inter-
ventions that are within registered nurses’ scope of
practice (based on Canadian licensure), acknowledging
that some nursing interventions would have overlap
with interventions provided by other members of the
interprofessional team (for instance, social workers,
counsellors, and physicians). Expert panel members
were consulted throughout the guideline development
process and determined recommendations for the best-
practice guideline based on findings from systematic
reviews. Four systematic reviews were conducted to
inform the best-practice guideline. This paper will
report on the findings from one systematic review
Records idenfied through database searching
(n = 36 381)
gnineercS
dedulcnI
ytilibigilE
acifitnedInoit
Records aer duplicates removed
(n = 25 833)
Records screened
(tle and abstract)
(n = 25 833)
Addional records idenfied by panel
(n = 37 )
Records excluded
(n = 25 303)
Full-text records
assessed for relevance
(n = 530)
Full-text records
excluded
(n =400)
Studies included
(n =21)
Full-text records
assessed for quality
(n =130)
Full-text records
excluded
(n = 109)
FIG. 1: Article Review process Flow Diagram. Flow diagram adapted from D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and The PRISMA
Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. BMJ 339, b2535, https://doi.org/
10.1136/bmj.b2535.
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 3
guided by the research question: ‘What are effective
and trauma-informed interventions that can be utilized
by registered nurses with adults experiencing crisis?’
The systematic review used and adhered to the
PRISMA guidelines for reporting systematic reviews
(Moher et al. 2009). A protocol for this systematic
review was also registered on the PROSPERO website
(Protocol number: CRD42016046142).
Crisis intervention is an action-oriented, situation-fo-
cused short-term response to re-establish immediate
coping skills, provide support, promote a sense of con-
trol and self-efficacy, restore pre-crisis functioning, and
provide access to further services and resources (Dass-
Brailsford 2007; Hoff 1995). For the purposes of our
systematic review, crisis interventions included any
nursing healthcare intervention (i.e. not limited to
mental health interventions). Studies of interest were
restricted to nursing interventions as the target audi-
ence for the best-practice guideline is predominately
nurses. Additional health or social service providers
may have a larger scope of practice specific to their
licensure that is beyond the focus of this review. Fur-
ther, crisis interventions included support provided
immediately and up to four weeks after a crisis event.
The time frame was chosen as an attempt to narrow
the focus of the literature on interventions that was for
an acute crisis event, as well as to be in alignment with
general expert consensus on an appropriate timeframe
for practice. Further, trauma-specific interventions,
which require extensive history taking and disclosure of
trauma and are therefore provided by practitioners
with specialized knowledge and skill to treat the conse-
quences of trauma (Poole et al. 2013), were not in
scope. The research question was intentionally broad in
an effort to include a variation of effective interven-
tions that nurses and the interprofessional team could
perform within the first four weeks of a crisis event.
Results are reported through narrative synthesis of the
included studies.
METHOD
Search strategy and screening
The search strategy was developed by a health science
librarian in consultation with the authors, and with
consideration of key terms identified by the expert
panel. The search strategy was created to encompass
two research questions that were similar in nature:
research question one –‘What are effective and
trauma-informed interventions that can be utilized by
registered nurses with adults experiencing crisis?’ and
research question two –‘What are effective and trauma-
informed interventions that can be utilized by registered
nurses to mitigate or prevent future crisis in adults?’.
The health science librarian conducted a literature
search in November 2016 for peer-reviewed articles
published in the last five years, in the following seven
academic health databases: MEDLINE, ePub & in Pro-
cess, Embase, Cochrane CT, Cochrane SR, PsycInfo,
and CINAHL. The search was restricted to the last five
years as per organizational protocol to develop guidelines
with the most up-to-date and contemporary literature.
The search strategy included MEDLINE MeSH head-
ings and keywords that were relevant to crisis (such as
‘stress disorders’ OR ‘psychological trauma’ OR ‘life
change events’ OR ‘distress’) and crisis intervention
(such as ‘crisis intervention’ OR ‘psychiatric emergency
services’ OR ‘early medical intervention’ OR ‘secondary
care’). The two search strings were combined using the
Boolean operator AND. Similar search terms were used
when searching all seven databases. The full search strat-
egy for the MEDLINE database, including all search
terms and applied limits, can be found in Supplementary
File S1. The expert panel was also invited to submit
hand-searched articles from their personal libraries,
which underwent the same screening process as article
identified from the literature search.
The search yielded 36, 381 studies from all databases
and an additional 37 articles were identified by the
panel. The inclusion criteria specific to both research
questions were as follows: studies that (i) had a primary
focus on crisis intervention(s) that occurred within four
weeks after the crisis event, (ii) focused on adults, aged
18 and older, (iii) were nursing interventions, (iv) were
inclusive of all patient outcomes, and (v) were inclusive
of all health settings; (vi) studies that followed a qualita-
tive and/or quantitative design; (vii) systematic or litera-
ture reviews that included a search strategy; (viii) studies
published in an English peer-reviewed journal; and (ix)
studies that were accessible for retrieval. Articles were
required to report on crisis intervention(s); however, it
was not mandatory for articles to include or explicitly
state the use of a trauma-informed principle. When
applicable, the six key principles fundamental to trauma-
informed approaches as outlined by SAMHSA (2014)
were identified in crisis intervention studies. Disserta-
tions, commentaries, narratives, non-English studies,
studies published prior to January 2011, and unpub-
lished literature were excluded.
After duplicate removal, there were 25, 833 studies
that were divided among three reviewers, ensuring that
©2020 Australian College of Mental Health Nurses Inc.
4 N. NIZUM ET AL.
each title was screened independently by two reviewers.
Discrepancies were resolved by the third reviewer. Five
hundred and thirty full-text articles answered the two
research questions and met the inclusion criteria. During
relevance review, the articles were divided among three
reviewers, ensuring that each full text was reviewed in
duplicates and a third reviewer resolved discrepancies.
At this stage, studies were more closely examined to
address research question one. Studies were excluded
for the following reasons: they did not follow a research
methodology (no evidence of a methods section); inter-
ventions were outside nursing scope of practice; inter-
ventions included exposure therapy, or reimagining,
rewriting, or retelling the traumatic event; interventions
took place four weeks after the crisis event; it was not
clear whether participants experienced a crisis; partici-
pants were under the age of 18; focused on primary pre-
vention of crisis; medical crisis related to physiological
processes; interventions were trauma-specific (rather
than trauma-informed); not retrievable or not published
in English.
Data extraction and quality appraisal
Twenty-one studies met the inclusion criteria and were
included for data extraction and quality appraisal, and
results were reported through narrative synthesis. The
systematic review process is summarized in (Fig. 1).
Meta-analysis could not be conducted due to hetero-
geneity in the interventions and outcomes. Study
details (such as study type, objective, method, setting,
sample, outcome measures, results) of the 21 articles
were extracted in data tables. At this point, studies
were examined if they included trauma-informed prin-
ciple(s) and the specific trauma-informed principles
were extracted in the data tables. For quality appraisal,
inter-rater reliability was established wherein 20% of
included studies were independently quality appraised
in duplicate by two reviewers. There was a high level
of agreement between the reviewers, indicated by a
sufficient kappa score of 0.86. Thus, the remaining
studies were divided equally between reviewers for
independent quality appraisal. Studies were quality
appraised using validated and published assessment
tools. For systematic and literature reviews, studies
were appraised using the Assessment of Multiple Sys-
tematic Reviews (AMSTAR), which assesses the com-
prehensiveness and rigour of reviews (Bruyere
Research Institute 2017). Randomized controlled trials
(RCT), case–control, cohort and cross-sectional, and
qualitative studies, were appraised using the Critical
Appraisal Skills Program (CASP UK), which assesses
potentials for bias (CASP UK 2008). Finally, mixed-
methods studies were appraised using the Mixed Meth-
ods Appraisal Tool, which assesses the rigour of both
qualitative and quantitative aspects of a study (Pluye
et al. 2011). A prior established point system was used
to give each study a quality appraisal score, with points
given when studies adhered to the components of its
respective quality appraisal tool. The individual study
quality appraisal scores were then converted to a per-
centage and based on a scoring system, rated as strong
(>82.5%), moderate (62.5–82.4%), or weak (<62.4%).
RESULTS
Studies
The 21 studies varied in design and included: system-
atic reviews (n=4), a literature review (n=1), RCTs
(n=3), observational studies (n=3), quasi-experimen-
tal studies (n=3), and qualitative studies (n=6). The
settings of the studies included Canada, the United
States, Europe, Asia, and Australia. Of the 21 studies,
four were rated strong in quality (19%), eleven were
rated moderate quality (52%), and six were rated weak
quality (29%). Further details of the studies included
can be found in Tables 1, 2, and 3.
As the definition for crisis and nursing healthcare
interventions was kept broad in the inclusion criteria,
the included studies were heterogeneous in nature, with
various interventions and outcomes measured. The
majority of the studies did not explicitly utilize trauma-
informed principles for crisis interventions within the
four weeks of a crisis event. Only two studies (one litera-
ture review and qualitative study) explicitly aimed to
identify or report on trauma-informed crisis interven-
tions (Lewis-O’Connor & Chadwick, 2015; Muskett
2014). In the remaining nineteen articles, elements of
trauma-informed approaches were either mentioned
within crisis interventions in quantitative studies (n=7),
elicited from patient perspectives in receiving crisis
interventions in qualitative studies (n=5) or were not
evident (n=7). In quantitative studies analysing effec-
tiveness of interventions, outcomes focused on mental
health symptoms and/or access to referrals/care. Fur-
thermore, the populations across the studies varied.
Explicit trauma-informed approaches in crisis
interventions
One literature review of weak quality aimed to identify
studies for observable and practical trauma-informed
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 5
nursing care that could be readily adopted in acute
mental health settings (Muskett, 2014). However, the
article was descriptive and did not measure the effec-
tiveness of trauma-informed interventions. Articles in
the review highlighted the nurses’ role in being emo-
tionally supportive with persons who have significant
trauma histories, and being inclusive and honouring
participation of persons and families in care decisions
(Muskett 2014). The author noted that multiple articles
focused on reducing the rates of restraint and seclu-
sion as a key outcome for trauma-informed care. Fur-
ther, the focus of acute mental health inpatient
settings on risk management, illness assessment, and
medical stabilization also deemphasized the importance
of therapeutic relationships and ‘talking therapies’ with
patients (Muskett 2014). Features of care reported as
contributing to revictimization included, staff focusing
on non-interactive tasks, appearing disinterested or dis-
respectful, and not making an effort to empower cli-
ents as decision-makers in their own care (Muskett
2014). In this particular review, the principles of
ensuring physical and psychological safety, making
decisions through collaboration, and mutuality were
notable.
Further, one qualitative study of moderate quality
explored perspectives in care approaches by persons
who had experienced gender-based violence (Lewis-
O’Connor & Chadwick 2015). The study used a
trauma-informed, relationship-based framework to
guide a quality improvement initiative at a gender-
based violence-specific clinic. Patients stated that they
were well cared for and felt safe during their visit, but
many reported ‘long waits’ and ‘confusion’ about what
to do after their acute care visit (Lewis-O’Connor &
Chadwick 2015). Furthermore, some participants
expressed concerns about the need for, and the con-
sent process surrounding, evidence collection (Lewis-
O’Connor & Chadwick 2015). The authors recognized
that it is important for patients to understand the bene-
fits and limitations of evidence collection so that they
are fully informed in decision-making, which from a
trauma-informed lens means that trauma-informed
principles of safety and collaboration in decision-mak-
ing were enacted (Lewis-O’Connor & Chadwick 2015).
TABLE 1: Characteristics and findings of studies with explicit trauma-informed principles
Citation
Study type &
Quality rating Setting Sample Intervention Control
Trauma-informed
principle Key findings
Muskett,
2014
Literature
review,
Weak
Acute
mental
health
inpatient
settings;
countries
not
specified
13
quantitative
and qualitative
papers
Any
trauma-
informed
approach to
patient care
in mental
health
settings
No
control
group
Ensuring
physical
and psychological
safety, making
decisions through
collaboration and
mutuality
With the exception of specific
training and screening
recommendations, effective
trauma-informed care in acute
inpatient settings involves the
use of strategies that most would
consider basic ingredients of
contemporary, effective mental
health care. Trauma-informed
care starts with, and goes to the
heart of, the enabling nature of
the nurse–client relationship,
and the value services place
upon client-centred care.
Citation
Study type,
quality rating Setting Sample
Data
collection
method
Trauma-informed
principles embedded
within service
received Key findings
Lewis-
O’Connor &
Chadwick,
2015
Qualitative,
Moderate
United
States
310 survivors of
gender-based
violence
Interviews All trauma-informed
principles
Patients affected by gender-based violence
require an improved coordinated and
trauma-informed approach. Explicit
consent related to evidence collection is
needed and not all patients who have
been sexually assaulted should have
evidence collected.
©2020 Australian College of Mental Health Nurses Inc.
6 N. NIZUM ET AL.
TABLE 2: Characteristics and findings of quantitative studies
Citation
Study type &
quality rating Setting Sample Intervention Control
Trauma-informed
principle Key findings
Brief crisis interventions
Li & Hu, 2012 Randomized
controlled
trial,
Moderate
Long-stay
hospital,
China
107 family members of
patients in a vegetative
state (intervention group:
n=54 & control group:
n=53)
Brief single psychological
session group intervention
with four steps
No intervention Building of
strengths and skills
through
empowerment
The intervention group
improved significantly more
than the control group on
most subscale measures for
psychological distress,
including somatization,
obsessive–compulsive
behaviour, depression, and
anxiety.
O’Connor
et al., 2015
Randomized
controlled
trial,
Moderate
Medical/
surgical
floor, United
States
30 admitted suicide
attempt survivors
(intervention group:
n=15 & control group:
n=15)
Teachable Moment Brief
Intervention (TMBI)
Usual care Ensuring
psychological
safety and making
decisions through
collaboration and
mutuality
Patients in the TMBI group
rated the intervention as
‘good’ to ‘great’ in all items
related to satisfaction. The
TMBI group experienced
greater improvements in
motivation to address their
problems and improvements
on reasons for living compared
to the control group.
Van Oenen
et al., 2016
Randomized
controlled
trial,
Moderate
Psychiatric
emergency
centre,
Netherlands
287 patients with acute
and severe psychosocial or
psychiatric problems
referred in the middle of
a crisis(intervention group:
n=72 and control group:
n=129)
Every session,immediate
feedbackobtained from
patients about progress in
their functioning and about
the therapeutic alliance and
this was discussed by the
therapist and the patient
together
Usual care –
feedback
obtained every
six weeks
without feeding
results back to
the patient or
therapist
No trauma-
informed
principles
mentioned
Patients with psychiatric
problems and severe distress
seeking emergency psychiatric
help did not benefit from
direct feedback.
Post-Disaster Interventions
Dieltjens et al.,
2014
Systematic
review, Strong
Not
specified
5 practice guidelines, 2
systematic reviews
identifying 0 studies, and
0 individual studies
Psychological first aid (PFA) No PFA Ensuring physical
and psychological
safety, building of
strengths and skills
through
empowerment
The scientific literature on
psychological first aid available
to date does not provide any
evidence about the
effectiveness of PFA
interventions. Currently, it is
impossible to make evidence-
based guidelines about which
practices in psychosocial
support are most effective to
help disaster and trauma
victims.
(Continued)
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 7
TABLE 2: (Continued)
Citation
Study type &
quality rating Setting Sample Intervention Control
Trauma-informed
principle Key findings
Fox et al.,
2012
Systematic
review,
Moderate
Not
specified
50 peer-reviewed journal
articles and 8
organizational guidelines
PFA No PFA Ensuring physical
and psychological
safety and building
of strengths and
skills through
empowerment
Adequate scientific evidence
for psychological first aid is
lacking but widely supported
by expert opinion and rational
conjecture.
Haga et al.,
2015
Cross-
sectional,
Moderate
Utoya,
Norway
453 parents of the Utøya
survivors
Proactive early outreach
programme –included both
municipal interdisciplinary
psychosocial crisis teams and
a designated contact person
for each survivor, their
families, and the families of
the deceased
No control
group
No trauma-
informed
principles
mentioned
Engagement with the contact
person was associated with use
of a family doctor, but not
with mental health specialists.
North &
Pfefferbaum,
2013
Systematic
review, Weak
Not
specified
222 unique articles on
disaster and emergency
mental health response,
interventions, and services
Mental health interventions to
individuals appropriate to
their needs in the wake of a
disaster
No mental
health response
No trauma-
informed
principles
mentioned
In post-disaster settings, a
systematic framework for case
identification, triage, and
mental health interventions
should be integrated into
emergency medicine and
trauma care responses.
Telecommunication and Computer-Based Interventions
Gelkopf et al.,
2015
Pre–post,
Weak
Community
setting,
Israel
142 callers Crisis intervention hotline,
but offers also continuous
therapeutic interventions (i.e.
psychosocial education, self-
help tools)
No control
group
Building of
strengths and skills
through
empowerment,
making decisions
through
collaboration and
mutuality
Results show a significant
decrease in functioning
problems following the
telephone intervention. A
significant decrease was also
found in post-traumatic stress
symptomatology.
Bidargaddi
et al., 2015
Before-and-
after, weak
Emergency
department,
Australia
241 patients Telephone-based low-intensity
therapy
No control
group
Building of
strengths and skills
through
empowerment,
and making
decisions through
collaboration and
mutuality
Patients had a significant
improvement in depression,
anxiety and functioning at
follow-up compared to initial
assessment and patients (80%)
experienced reductions in the
frequency of suicidal ideation.
(Continued)
©2020 Australian College of Mental Health Nurses Inc.
8 N. NIZUM ET AL.
TABLE 2: (Continued)
Citation
Study type &
quality rating Setting Sample Intervention Control
Trauma-informed
principle Key findings
Chavan et al.,
2012
Descriptive,
Moderate
Chandigarh,
India
3273 callers 24-hour suicide prevention
helpline
No control
group
No trauma-
informed
principles
mentioned
Since the helpline was set up,
there was a decline in the
number of suicides in the
following years: compared to
the 130 suicides in year 2003,
the total number of suicides in
the city was 75 in 2004, 89 in
2005, 80 in 2006, 82 in 2007,
83 in 2008, 75 in 2009, 71 in
2010, and 105 in 2011.
Furber et al.,
2014
Pre–post,
Weak
Emergency
department,
Australia
45 patients in intervention
group157 patients in
control group
Individually tailored text
messages alongside telephone-
based psychotherapy
Telephone
psychotherapy
only
Building of
strengths and skills
through
empowerment,
making decisions
through
collaboration and
mutuality
There were no significant
differences in clinical
outcomes between participants
who received SMS and those
in the control group.
Nielssen et al.,
2015
Retrospective
observational,
Moderate
Australia 2599 enrolled in online
treatment
The MindSpot Clinic provides
remote screening assessments
and therapist-guided
treatment for anxiety and
depression
No control
group
No trauma-
informed
principles
mentioned
Around 0.6% of people
seeking assessment or
treatment by MindSpot were
referred to local mental health
services for urgent face-to-face
care.
Crisis intervention for people living with major mental illnesses
Berrino et al.,
2011
Pre–post test
with control,
Weak
Hospital in
Geneva,
Switzerland
200 patients meeting
DSM-IV borderline
personality disorder
criteria (100 in control
group and 100 in the
treatment group)
Short-term hospitalization in a
crisis intervention service
individual psychotherapy
intervention provided by
experienced supervised nurses
Treatment as
usual –assigned
to treatment
according to the
clinical
judgement of
attendant
psychiatrist
Making decisions
through
collaboration and
mutuality
During the 3-month follow-up,
the total number of days in
supplementary standard
inpatient treatment and crisis
intervention at the general
hospital after discharge was
significantly less in the
intervention group (194 and
23, respectively) than in the
comparison group
Borshmann
et al., 2012
Systematic
review,
Strong
UK and
France
2 RCTs Crisis interventions for adults
with borderline personality
disorder (BPD) in any setting
No crisis
intervention
No trauma-
informed
principles
mentioned
There is no RCT-based
evidence for the management
of acute crises in people with
BPD, and therefore, we could
not reach any conclusions
about the effectiveness of any
single crisis intervention.
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 9
Brief crisis interventions
Three RCTs of moderate quality utilized brief interven-
tion for persons who had experienced a crisis event. The
studies examined outcomes of patient satisfaction, readi-
ness to change problematic behaviours, reasons for living
and suicidal ideation, psychological symptoms, social role
functioning, and interpersonal relationships. Compo-
nents of brief intervention varied throughout the studies;
however, brief crisis interventions that considered
trauma-informed principles had positive outcomes (Li &
Xu 2012; O’Connor et al 2015), as opposed to brief crisis
interventions that did not consider trauma-informed
principles (Van Oenen et al. 2016). A brief, group psy-
chological session for relatives of patients in a vegetative
state was associated with a decrease in psychological
symptoms such as somatization, obsessive–compulsive
behaviour, depression, and anxiety compared to the con-
trol group who did not receive the intervention (Li & Xu
2012). The brief single-session group intervention was in
the format of a critical incident stress debriefing, which
included participants describing what happened and
their first thoughts concerning the event, discussing their
emotional reactions, and receiving training to increase
coping abilities (Li & Xu 2012). In another RCT, a teach-
able brief intervention for persons who attempted sui-
cide was associated with greater patient satisfaction,
improvement in motivation to address their problems,
and significant improvements on reasons for living com-
pared to the group who received usual care (O’Connor
et al. 2015). The majority of patients in both groups
reported no desire for suicide at the one-month assess-
ment (O’Connor et al. 2015). The teachable moment
brief intervention involved a functional assessment, crisis
planning, and discussion of further outpatient mental
health services (O’Connor et al. 2015). Overall, the stud-
ies that examined brief interventions for crisis events uti-
lized trauma-informed principles of ensuring
psychological safety, establishing a collaborative relation-
ship (O’Connor et al. 2015), and offering training to
increase coping abilities (Li & Xu 2012; O’Connor et al.
2015).
One RCT investigated the efficacy of immediate
feedback during brief therapy session in the treatment
of patients with acute and severe psychosocial or psy-
chiatric problems referred in the middle of a crisis.
The intervention group received immediate feedback
during brief therapy sessions, wherein therapists pro-
vided feedback to patients every session, and together,
they discussed the patient’s progress and their thera-
peutic alliance (Van Oenen et al. 2016). In the
comparator group, feedback was obtained every six
weeks without feeding results back to the patient or
the therapist. Neither the intervention nor the com-
parator incorporated trauma-informed principles. It
was found that patients did not benefit from direct
feedback when compared to the control group (Van
Oenen et al. 2016).
Post-disaster interventions
Four articles focused on crisis response interventions
in the context of disasters. Two systematic reviews
specifically focused on the effectiveness of psychologi-
cal first aid (PFA) as form of supportive response that
can be carried out by any responders, from trained lay
responders, to mental health specialists and presumably
nurses (Dieltjens et al. 2014; Fox et al. 2012). PFA
includes facets of trauma-informed principles such as
ensuring physical and psychological safety and building
of strengths and skills (Dieltjens et al. 2014; Fox et al.
2012). The systematic reviews (one quality appraised to
be strong and the other as moderate) concluded that
there is inadequate scientific evidence for PFA effec-
tiveness; however, PFA is widely supported by expert
opinion and one of very few described brief crisis
interventions available for interveners to draw upon
(Dieltjens et al. 2014; Fox et al. 2012).
Another systematic review, which was rated weak in
quality, explored the evidence on identification and
triage to appropriate services for individuals who have
experienced community disasters (North & Pfeffer-
baum 2013). The study did not identify trauma-in-
formed principles among the primary studies it
analysed, and concluded that processes for case identi-
fication, triage, and mental health interventions need to
be incorporated into emergency medicine and trauma
care responses (North & Pfefferbaum, 2013). Lastly,
one strong quality cross-sectional study aimed to inves-
tigate the effectiveness of an early outreach programme
for parents of young survivors of a massacre (Haga
et al. 2015). Haga et al. (2015) did not incorporate any
trauma-informed principles within the intervention but
found that early outreach visits by the crisis team were
associated with follow-up to a family doctor, but not
with mental health specialists.
Telecommunication and technology-based
interventions
Five studies explored the effectiveness of telephone,
text messaging, and Internet-based interventions for
©2020 Australian College of Mental Health Nurses Inc.
10 N. NIZUM ET AL.
crisis intervention. The studies focused on outcomes of
mental health symptoms, referral to care, number of
suicide ideation or suicide, and functioning. The major-
ity of the quantitative studies found that care delivered
through telecommunication and technology-based
modalities had positive outcomes in the areas of symp-
tom reduction and referral to appropriate healthcare
services (Bidargaddi et al. 2015; Chavan, Garg & Bhar-
gava 2012; Furber et al. 2014; Gelkopf et al., 2015;
Nielssen et al. 2015).
Two weak quality studies (one observation and one
pre–post study with no control) and one moderate qual-
ity descriptive study specifically explored the use of tele-
phones to provide crisis interventions (Bidargaddi et al.,
2015; Chavan et al. 2012; Gelkopf et al. 2015). The inter-
vention components were variable and included all or
some of the following aspects: brief counselling, symp-
tom management strategies and skill building, and
opportunities for face-to-face support (i.e. visits from cri-
sis intervention teams) (Bidargaddi et al. 2015; Chavan
et al. 2012; Gelkopf et al. 2015). Two of the three studies,
which included trauma-informed principles of collabora-
tion between provider and patient and promoting skill
building, demonstrated positive outcomes including
reductions in anxiety, suicidal ideation, and post-trau-
matic stress symptoms and improvements in functioning,
social adjustment, and overall health (Bidargaddi et al.
2015; Gelkopf et al. 2015). The remaining moderate
descriptive study, which did not include any trauma-in-
formed principles, was associated with a reduction in a
number of suicides in the city (Chavan et al., 2012).
One weak pre–post study (with control group)
explored the impact of between-session text messaging
as an adjunct to telephone-based psychotherapy, which
included skill building regarding self-regulation (Furber
et al. 2014). However, text messaging did not demon-
strate statistically significant differences in outcomes
between the intervention and control group (Furber
et al. 2014). One retrospective, observational study,
that did not include any trauma-informed principles,
found that an Internet-based mental health service
(that provided screening assessments, therapist-guided
treatment for anxiety and depression, and referrals to
local services), resulted in appropriate and timely refer-
rals in crisis situations (Nielssen et al. 2015).
Crisis intervention for people living with
borderline personality disorder
Two studies aimed to explore the effectiveness of crisis
interventions in persons living with borderline
personality disorder (Berrino et al. 2011; Borschmann
et al. 2012). One weak pre–post study investigated the
effectiveness of a short-term intensive inpatient treat-
ment in a psychiatric crisis unit among patients who
were in the emergency room for deliberate self-harm
(Berrino et al. 2011). The crisis intervention program
included cognitive and affective support with an aim to
integrate/move away from the stress disorder; help to
express emotions; convey insight on repetitive patterns
of idealized masochistic attachment; focus on life
events involving separation, loss and mourning; and
involve the family/close friends to facilitate communica-
tion among them. Therapy also involved trauma-in-
formed principles of facilitating a therapeutic alliance,
while also developing a working alliance and teaching
the patient and their families adapted coping beha-
viours (Berrino et al. 2011). At three-month follow-up,
rates of repeated deliberate self-harm and hospitaliza-
tion were lower in the intervention group (8% repeated
deliberate self-harm and 8% psychiatric hospitalization,
versus 17% and 56% in the control group who received
usual care) (Berrino et al., 2011). One systematic
review reported on two ongoing RCTs for the manage-
ment of acute crises in people with borderline person-
ality disorder, and thus was not able to report on
definitive conclusions (Borschmann et al., 2012).
Patient perspectives of crisis interventions from
qualitative studies
Five qualitative studies explored the perception of per-
sons who experienced crisis and their preferences and/
or values for the care they received or hoped to
receive. Four moderate qualitative studies explored
perceptions and experiences of persons with regard to
crisis response services. One moderate qualitative study
in particular explored perceptions of how police and
mental health providers worked together (Evangelista
et al. 2016). Persons who experience crisis commented
on the benefit of a joint police mental health clinical
team response (Evangelista et al. 2016). Interview
themes revealed that persons appreciated the team’s
communication strategies, their ability to de-escalate
the crisis, their ability to be proactive in providing
assistance, their quick response under pressure, and
their ability to effectively handover information to the
emergency department or psychiatry staff, and help
persons to achieve their preferred outcome (Evange-
lista et al. 2016). Persons also identified areas for
improvement such as reducing the visible presence of
the police officers, the need for further training and
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 11
education in mental health for police officers, and the
need for intensive follow-up and communication with
their usual point of care after being approached by the
team (Evangelista et al. 2016).
One study explored person’s experiences with a
strength-based crisis intervention service in which crisis
management workers collaborate with the client to
determine the key life area(s) to focus on for improve-
ment, so they are able to live at their optimal level of
independence while utilizing community supports
appropriately (Hootz et al. 2016). Persons’ experiences
were generally positive, with participants identifying
that they appreciated the support from staff and were
learning steps to attain new skills and increasing their
TABLE 3: Characteristics and findings of qualitative studies
Citation
Quality
rating Setting Sample
Data col-
lection
method
Trauma-informed prin-
ciples embedded within
service received Key findings
Evangelista
et al., 2016
Moderate Melbourne,
Australia
12 mental health
consumers who had
direct contact with
joint police and mental
health services
Semi-
structured
interviews
Ensuring physical and
psychological safety,
making decisions
through collaboration
and mutuality
Consumers expressed benefits of
receiving service including their
ability to communicate and des-
escalate the crisis. Suggestions for
areas of improvement included
reducing the visible presence of
the police officers, need for
further training and education in
mental health for police officers
and the need for intensive follow-
up.
Gudde
et al., 2013
Moderate Community
mental health
centres
Norway
19 mental health users
with major mental
illness
Interviews No trauma-informed
principles mentioned
Being believed, taken seriously,
listened to and seen was
emphasized as an important part
of a trusting relationship.
Participants also expressed a
strong wish to help themselves
through the crisis and expressed
that lack of communication and
dialogue in mental crisis was a
recurring issue.
Hootz et al.,
2016
Moderate Canada 14 clients and 7
service providers
Semi-
structured
interviews
with 14
clients
Ensuring physical and
psychological safety,
making decisions
through collaboration
and mutuality.
Clients’ experiences regarding staff
were mixed and most participants
felt that they were learning skills
to increase their independence
Sands et al.,
2016
Moderate Adult mental
health triage
services in
Melbourne,
Australia
75 mental health
consumers
Telephone
interviews
No trauma-informed
principles mentioned
Participants appreciated access
and timeliness of services and for
the most part, had positive
experiences with telephone mental
health triage services. Some
participants felt that they needed
to escalate their concerns in order
to receive services.
Tetterton &
Farnsworth,
2011
Strong Not specified 2 women (63 and
65 years old)
Interviews No trauma-informed
principles mentioned
Interview findings lend themselves
to effective interventions such as
welcoming and engaging the
client, encouraging and supporting
the telling of one’s story, assisting
in the process of empowerment,
and providing appropriate
information regarding support
services.
©2020 Australian College of Mental Health Nurses Inc.
12 N. NIZUM ET AL.
independence, both on a personal and financial level
(Hootz et al. 2016). Another study explored the percep-
tion of persons accessing telephone-based mental
health triage services in Australia (Sands et al. 2016).
In general, persons expressed that they benefitted from
a 24-hour telephone-based mental health triage service,
‘valued prompt attention and easy access to crisis ser-
vices, especially when feeling suicidal’ and felt that the
service provided help options, strategies, and advice
(Sands et al. 2016). While most aspects of the service
were favoured, some participants felt that they needed
to escalate their concerns in order to receive services
(Sands et al. 2016).
Further, in terms of crisis response, persons living
with major mental illnesses valued meeting familiar,
trusted providers who knew what the individual’s needs
in periods of crisis (Gudde et al. 2013). Other impor-
tant elements of a trusting relationship included being
believed, taken seriously, and listened to (Gudde et al.
2013). Persons also described experiences of treatment
decisions being made too quickly, without dialogue and
time for reflection. Many persons emphasized the need
for providers to pay more attention to patient experi-
ences and their problem-solving strategies to facilitate
decision-making in treatment planning (Gudde et al.
2013). In a strong quality qualitative study, authors
summarized effective interventions based on responses
of older women who experienced gender-based vio-
lence (Tetterton & Farnsworth 2011). Effective inter-
ventions included welcoming and engaging the person
through an open and reassuring professional stance,
encouraging and supporting the telling of one’s story,
and assisting in the process of empowerment through
listening, supporting, and providing appropriate infor-
mation regarding support services (Tetterton & Farns-
worth 2011).
DISCUSSION
The purpose of this systematic review was to synthesize
evidence regarding nursing interventions within the
first four weeks of a mental health crisis. Our sec-
ondary aim was to identify crisis interventions that
align with trauma-informed principles that are based
on an awareness of the widespread prevalence and
impact of trauma. The results of the systematic review
highlight the lack of research on nursing interventions
for mental health crisis while also demonstrating an
overall lack of studies that explicitly link trauma-in-
formed principles within a crisis intervention context.
The lack of literature may signify a gap in interventions
that can be conducted by registered nurses. Despite
the ability of registered nurses to connect with persons
along the spectrum of care, which makes nurses well-
suited to intervene with proper clinical skill, there
remains a paucity of research measuring the outcomes
of these interventions.
In the 10 studies that referred to one or more ele-
ments of trauma-informed principles, 7 studies demon-
strated efficacy through positive results or positive
experiences elicited from patients in relation to brief
interventions, technology- and computer-based inter-
ventions, and broader crisis and trauma-informed ser-
vice programming. The trauma-informed principles in
crisis interventions varied, with some of the key princi-
ples in interventions being related to building strengths
and skills through empowerment, or making decisions
through collaboration and mutuality. It is also likely
and important to note that use of those trauma-in-
formed principles may not have been intentional, as
the authors did not specifically denote this approach
within their intervention description. This may be
attributed to the fact that the principles of trauma-in-
formed care are not considered novel or unique in iso-
lation, and are often underlying of a patient-centred
framework. However, the strength lies in the compre-
hensive and conscious integration of the principles in
unison to create a true trauma-informed approach to
practice.
Nevertheless, our findings support the benefit of
nurses enacting key principles and relational aspects of
interventions that are experienced by the persons in
crisis to be safe, responsive, empowering, and collabo-
rative. In particular, first-hand experiences from the lit-
erature highlight that persons value prompt attention,
having trusting relationships with providers, being
active members in decision-making, learning skills to
empower themselves, and receiving appropriate infor-
mation for further supports. In this way, a trauma-in-
formed lens to crisis intervention allows nurses to
acknowledge the experiences, strengths, and prefer-
ences for care, as well as the evidence for effective cri-
sis responses. However, a more explicit connection and
articulation of enacting principles of trauma-informed
practice within a crisis intervention context for the pur-
pose of being more aware and responsive to impacts of
trauma is lacking.
Trauma-informed frameworks, principles, and
approaches are being integrated into services and sys-
tems addressing child welfare, homelessness, mental
health and substance use, criminal justice, education,
and primary care in ways that are intentional and aim
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 13
to be responsive to trauma prevalence and impact and
reduce/minimize inadvertent re-traumatization. In
these interventions, immediate trauma responses are
noticed, how these responses are likely linked to past
experiences is understood, and non-judgemental, com-
passionate, and non-traumatizing support is provided.
Clearly more evidence on trauma-informed approaches
to supporting people in crisis across all these systems
of care is required so that the lessons arising can be
applied in all settings by nurses and other providers. It
is to note however that through a trauma-informed
lens, a crisis event is not defined by the event per se,
but by the impact. As such, trauma-informed
approaches to crisis can be applied universally in all
crisis as an approach to prioritizing psychological and
emotional safety based on the acknowledgement of the
prevalence and impact of trauma. It is also important
to realize that reactions and/or impacts of crisis for a
person may also be a cumulative response to prior
trauma.
From a practice perspective, core principles of col-
laboration and choice, trustworthiness and trans-
parency, safety, peer support, and understanding of
gender, historical, and cultural issues may seem intu-
itive and constitute basic taken-for-granted foundations
of clinical practice. However, what is evident in the
results of the systematic review is that no studies exam-
ined nursing interventions for crisis with all of the prin-
ciples collectively enacted as a driving framework,
including the recognition and awareness of trauma. As
a registered nurse, without an appreciation of the total-
ity of the principles, there is a risk for losing sight of
the presence and impact of trauma for both providers
and person experiencing crisis. Furthermore, a trauma-
informed framework affords the opportunity for a com-
mon understanding and approach to service delivery
across sectors and service providers, which is relevant
in the case of crisis intervention, as it often involves
multisectoral collaboration across one or more service
providers. Going forward, there is an opportunity for
studies to examine effectiveness of crisis interventions
from an integrated trauma-informed framework that
examines not only outcomes, but important trauma-in-
formed processes of care that are associated with
improved outcomes for persons in crisis as well. Fur-
ther, more research is required to understand the
impact of trauma-informed principles when it is inte-
grated into crisis interventions relating to brief inter-
ventions, telecommunication and technology-based
strategies, post-disaster management, and crisis inter-
ventions for those living with underlying mental illness.
The systematic review identified several gaps in the
literature. Most notably, it highlighted the need for fur-
ther research in the area of trauma-informed crisis
interventions, specifically for nurses, and their practice.
There was also a lack of exploration of crisis support
needs and preferences in ethnically and sexually
diverse men, women, and transgender persons. There
were no studies exploring holistic interventions with
indigenous persons and the need to recognize historical
trauma as trauma requiring holistic and culturally rele-
vant approaches. More research is also needed that
explores effective crisis interventions for those living
with severe mental illness and addictions. Finally, there
were no studies identified on effective strategies for
assessment by a registered nurse of a person experienc-
ing crisis.
The systematic review is not without limitations.
Despite reviewing extensive literature, the possibility
remains that other studies related to the topic may not
have been identified and reviewed. The literature was
also heterogeneous, and therefore, a meta-analysis
could not be conducted. As the review was limited to a
nursing scope of practice, there are certainly additional
bodies of literature with more advanced intervention
approaches that may include medication prescribing or
advance psychotherapy. Further, because unpublished
literature was not part of the literature review, findings
may not be representative of all work in the field. In
addition, since reviewers determined the trauma-in-
formed principles referred to in some studies, conclu-
sions could be subject to interpretation as this may not
have been intentional by the study author(s). Finally,
results may be difficult to generalize due to the small
sample sizes and the variation in populations among
studies.
CONCLUSION
This systematic review provides an important assess-
ment of the current available evidence and points to
opportunities and gaps for future research and evalua-
tion regarding nursing interventions for mental health
crisis from a trauma-informed practice lens. The inte-
gration of trauma-informed principles within quantita-
tive studies that explored effectiveness of nursing
interventions for mental health crisis across various
high-risk groups demonstrated improvements in mental
health symptoms and access/referral to care. Further-
more, qualitative study findings reaffirm person’s values
and requests for providers and services that consider
trauma-informed principles. There was a lack of studies
©2020 Australian College of Mental Health Nurses Inc.
14 N. NIZUM ET AL.
on crisis intervention explicitly linked to trauma-in-
formed principles that can be undertaken by registered
nurses, highlighting future research needs and more
conscious efforts to integrate trauma-informed princi-
ples to crisis intervention practices.
RELEVANCE TO CLINICAL PRACTICE
This review and the associated best-practice guideline
primarily inform the work of registered nurses, in addi-
tion to other health providers, first responders, and
peer support workers to provide evidence-based
trauma-informed crisis interventions. The review sup-
ports a principle-based approach to providing brief
intervention, as well as technology-assisted interven-
tions in the period immediately following crises, includ-
ing those arising from disasters, with an emphasis on
supporting the active involvement of persons experi-
encing crisis in ways that are connective, empowering,
collaborative, skill-building, and strengths-based. Inte-
gration of a trauma-informed framework to crisis inter-
vention that is driven by the core principles of safety
(psychological, emotional, physical), trust, choice, col-
laboration, and shared power allows providers to bring
to awareness an acknowledgement of the prevalence
and impact of trauma in the lives of individuals and
communities but also to recognize the signs of the
impact and respond in ways that seek to avoid re-
traumatization through routine processes of care
(SAMHSA 2014). A trauma-informed approach to crisis
intervention helps to ground clinical interventions on a
common understanding that prioritizes not only what
intervention is provided to persons in crisis but how
we provide interventions in ways that feel safe and pro-
mote resilience.
ACKNOWLEDGEMENT
The authors would like to thank UHN HealthSearch for
the systematic search, Sabrina Merali for the oversight in
the development of the best practice guideline as co-
lead, the expert panel for their guidance in the develop-
ment of the best practice guideline and Megan Bamford
for her editorial review of this manuscript.
REFERENCES
Akin, B. A., Strolin-Goltzman, J. & Collins-Camargo, C.
(2017). Successes and challenges in developing trauma-
informed child welfare systems: A real-world case study of
exploration and initial implementation. Children and
Youth Services Review, 82, 42-52.
Bateman, J., Henderson, C. & Kezelman, C. (2013). Trauma-
informed Care and Practice: Towards Cultural Shift in
Policy Reform Across Mental Health and Human Services
in Australia, A National Strategic Direction. New South
Wales, Australia: Mental Health Coordinating Council.
Berrino, A., Ohlendorf, P., Duriaux, S., Burnand, Y.,
Lorillard, S. & Androli, A. (2011). Crisis intervention at
the general hospital: An appropriate treatment choice for
acutely suicidal borderline patients. Pyschiatry Research,
186, 287–292.
Bidargaddi, N., Bastiampillai, T., Allison, S. et al. (2015).
Telephone-based low intensity therapy after crisis
presentations to the emergency department is associated
with improved outcomes. Journal of Telemedicine and
Telecare,21, 385–391.
Borschmann, R., Henderson, C., Hogg, J., Phillips, R. &
Moran, P. (2012). Crisis interventions for people with
borderline personality disorder. Cochrane Database of
Systematic Reviews,6,1–25.
Branson, C. E., Baetz, C. L., Horwitz, S. M. & Hoagwood,
K. E. (2017). Trauma-informed juvenile justice systems: a
systematic review of definitions and core components.
Psychological Trauma: Theory, Research, Practice and
Policy,9, 635–646.
Bruyere Research Insitute (2017). AMSTAR. Retrieved from
https://amstar.ca/index.php.
Caplan, G. (1961). An Approach to Community mental
health. New York: Grune & Stratton.
CASP UK (2008). Critical appraisals skills programme.
Available at: http://www.casp-uk.net/casp-tools-checklists
(Accessed 4 April).
Chavan, B. S., Garg, R. & Bhargava, R. (2012). Role of 24-
hour telephonic helpline in delivery of mental health
services. Indian Journal of Medical Sciences,66, 116–125.
Dass-Brailsford, P. (2007). A practical approach to trauma:
Empowering interventions. SAGE Publishing.
Dieltjens, T., Moonens, I., Praet, K. V., Buck, E. D. &
Vandekerckhove, P. (2014). A systematic literature search
on psychological first aid: Lack of evidence to develop
guidelines. PLoS ONE,9,1–13.
Eastham, K., Coates, D. & Allodi, F. (1970). The concept of
crisis. Canadian Psychiatric Association Journal,15, 463–472.
Evangelista, E., Lee, S., Gallagher, A. et al. (2016). Crisis
averted: How consumers experienced a police and clinical
early response (PACER) unit responding to a mental
health crisis. International Journal of Mental Health
Nursing,25, 367–376.
Fox, J. H., Burkle, F., Bass, J., Pia, F. A., Epstein, J. &
Markenson, D. (2012). The effectiveness of psychological
first aid as a disaster intervention tool: Research analysis
of peer-reviewed literature from 1990–2012. Disaster
Medicine and Public Health Preparedness,6, 247–252.
Furber, G., Jones, G. M., Healey, D. & Bidargaddi, N.
(2014). A comparison between phone-based psychotherapy
with and without text messaging support in between
sessions for crisis patients. Journal of Medical Internet
Research,16, e219.
©2020 Australian College of Mental Health Nurses Inc.
NURSING INTERVENTIONS FOR MENTAL HEALTH CRISIS 15
Gelkopf, M., Haimov, S. & Lapid, L. (2015). A community
long-term hotline therapeutic intervention model for
coping with the threat and trauma of war and terror.
Community Mental Health Journal,51, 249–255.
Green, B. L., Saunders, P. A., Power, E. et al. (2015).
Trauma-informed medical care: A CME communication
training for primary care providers. Family Medicine,47,
7–14.
Gudde, C. B., Olso, T. M., Antonsen, D. O., Ro, M., Eriksen,
L. & Vatne, S. (2013). Experiences and preferences of
users with major mental disorders regarding helpful care
in situations of mental crisis. Scandinavian Journal of
Public Health,41, 185–190.
Haga, J. M., Stene, L. E., Wentzel-Larsen, T., Thoresen, S.
& Dyb, G. (2015). Early postdisaster health outreach to
modern families: A cross-sectional study. British Medical
Journal Open,5, e009402.
Harris, M. & Fallot, R. (2010). Envisioning a trauma-
informed service system: A vital paradigm shift. New
Directions for Student Leadership,2001,3–22.
Hoff, L. A. (1995). People in crisis: Understanding and
helping, 4th edn. San Francisco: Wiley Trade Publishing.
Hootz, T., Mykota, D. B. & Fauchoux, L. (2016). Strength-
based crisis programming: evaluating the process of care.
Evaluation and Program Planning,54,50–62.
Howell, P., Thomas, S. & Crosby, S. D. (2018). Social justice
education through trauma-informed teaching. Middle
School Journal,49,15–23.
Jakubec, S. L. (2014). Crisis and Disaster. In: J. H. Halter, C.
L. Pollard, S. L. Ray & M. Haase (Eds). Canadian
Psychiatric Mental Health Nursing (pp. 491–507).
Toronto, Canada: Saunders.
James, R. & Gilliland, B. E. (2001). Crisis Intervention
Strategies. No location: Brooks/Cole Thomson Learning.
Kirst, M., Aery, A., Matheson, F. I. & Stergiopoulos, V.
(2017). Provider and consumer perceptions of trauma
informed practices and services for substance use and
mental health problems. International Journal of Mental
Health and Addiction,15, 514–528.
Lewis-O’Connor, A. & Chadwick, M. (2015). Engaging the
voice of patients affected by gender-based violence:
Informing practice and policy. Journal of Forensic
Nursing,11, 240–249.
Li, Y. H. & Xu, Z. P. (2012). Psychological crisis intervention
for the family members of patients in a vegetative state.
Clinics,67, 341–345.
Moher, D., Liberati, A., Tetzlaff, J. & Altman, D. G. (2009).
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. The BMJ,339, b2535.
Muskett, C. (2014). Trauma-informed care in inpatient mental
health settings: A review of the literature. International
Journal of Mental Health Nursing,23,51–59.
Nielssen, O., Dear, B. F., Staples, L. G. et al. (2015).
Procedures for risk management and a review of crisis
referrals from the MindSpot Clinic, a national service for
the remote assessment and treatment of anxiety and
depression. BMC Psychiatry,15,1–6.
North, C. S. & Pfefferbaum, B. (2013). Mental health
response to community disasters: A systematic review.
JAMA,310 (5), 507–518.
O’Connor, S. S., Comtois, K. A., Wang, J. et al. (2015). The
development and implementation of a brief intervention
for medically admitted suicide attempt survivors. General
Hospital Psychiatry,37, 427–433.
van Oenen, F. J., Schipper, S., Van, R. et al. (2016).
Feedback-informed treatment in emergency psychiatry; a
randomised controlled trial. BMC Psychiatry,16,1–11.
Pluye, P., Robert, E., Cargo, M. et al. (2011). Proposal: A
mixed methods appraisal tool for systematic mixed studies
reviews. Available at: http://mixedmethodsappraisa
ltoolpublic.pbworks.com (accessed 6 April).
Poole, N., Urquhart, C., Jasiura, F., Smylie, D. & Schmidt,
R. (2013). Trauma-informed practice guide. Available at:
http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-
Guide.pdf (accessed 4 April).
Registered Nurses’ Association of Ontario (2017). Crisis
Intervention for Adults Using a Trauma-Informed
Approach: Initial Four Weeks of Management, 3rd edn.
Toronto, ON: Author.
Sands, N., Elsom, S., Keppich-Arnold, S., Henderson, K. &
Thomas, P. A. (2016). Perceptions of crisis care in
populations who self-referred to a telephone-based mental
health triage service. International Journal of Mental
Health Nursing,25, 136–143.
Substance Abuse and Mental Health Services Administration.
(2009). Core Elements in Responding to Mental Health
Crises. Rockville, MD: Centre for Mental Health Services,
Substance Abuse and Mental Health Services
Administration.
Substance Abuse and Mental Health Services Administration
(2014). Trauma-Informed Care in Behavioural Health
Services. Rockville, MD: Author.
Tetterton, S. & Farnsworth, E. (2011). Older women and
intimate partner violence: Effective interventions. Journal
of Interpersonal Violence,26, 2929–2942.
Williams, M. E. (2016). Integrating early childhood mental
health and trauma-informed care for homeless families
with young children. Pragmatic Case Studies in
Psychotherapy,12, 113–123.
SUPPORTING INFORMATION
Additional Supporting Information may be found in
the online version of this article at the publisher’s web-
site:
File S1. MEDLINE search strategy.
©2020 Australian College of Mental Health Nurses Inc.
16 N. NIZUM ET AL.
