comprehensive crisis managementdavid julian med, noreen fredrick msn, mary kay rahuba msn, michael...
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A Program of the Western Psychiatric Institute and Clinic of UPMC
Crisis Training Institute
Comprehensive Crisis Management
©WPIC/UPMC 2012. All Rights Reserved
Contributing Authors
Robert Fonte RN MEd CTR, Jeff Magill CTR,
& Bobbi Jo Wendel MA NCC LPC
David Julian MEd, Noreen Fredrick MSN, Mary Kay Rahuba MSN,
Michael Boland MSEd, John McGonigle PHD, Kimberley Saft
Rentschler LCSW PHD, and Richard Boland MBA EMT-P
Goals of Comprehensive Crisis Management
To promote the safety of individuals receiving and providing care To reduce the use of seclusion and restraint To encourage the use of best practices To promote an environment of partnering and collaboration To eliminate the use of aversive/coercive interventions
Program Components
Holistic assessment
Suicide awareness
Trauma Informed Care
Staff self assessment and self care
Prevention and Crisis Communication
Intervention
Postvention
Physical escape intervention Emergency safety intervention
Prevalence of Assault
From 2005 through 2009, of the occupational groups examined, law enforcement occupations had the highest average annual rate of workplace violence (48 violent crimes per 1,000 employed persons), followed by mental health occupations (21 per 1,000). (U.S. Department of Justice, 2011)
Care should be taken not to over-emphasize any single factor in the etiology of
violence…..there is usually a host of factors at the individual, organizational and
environmental levels.
(Beech, Leather, 2005)
Holistic Assessment
• Be aware of yourself – Appropriate apparel? – Fatigued? Distracted? – Trust your gut! When in doubt, get out!
• Be aware of your patient – Overt threats, posture, history, etc.?
• Be aware of the environment – Visibility on milieu – Staffing
A wholistic approach to violence risk assessment
Impact of Stress on the Human System (Fredrick and Rahuba 1994)
Predicting cold weather and snow
is easier to do correctly
in Alaska
than in Ecuador
For a risk factor to be useful, it needs to be
Specific
Sensitive Accurate Reliable
Practical
• Recent Acts or Intent > Ideation or Fantasy • Past history of violence, esp. with the identified target
(e.g., domestic violence) • Explicit threats > implicit threats • More specific plan (esp. with “evasive” features) • Limited coping mechanisms or supports (or loss
thereof) • Recent increase in psychosocial stressors • Impulsivity • Substance use (esp. alcohol, cocaine, speed) • Suicidality, hopelessness • Untreated/under-treated mental illness
Risk Factors for Violence
• Male > Female in the community • Male = Female in inpatient settings • Generally
1. SUD + Major Psychiatric Disorder 2. SUD alone 3. No SUD/psychiatric disorder 4. Psychiatric disorder
• Psychiatric patients are victims > perpetrators
Risk Factors
What can a diagnosis tell us? (DSM-IV-TR)
Axis I Clinical Disorders
Axis II Personality Disorders & Cognitive
Disabilities
Axis III General Medical Conditions
Axis IV Psychosocial and Environmental
Factors
Axis V Global Assessment of Functioning
(GAF)
• Adam, an older adolescent with early onset schizophrenia and a history of gang involvement shoots and kills Billy who was having sex with Cathy, Adam’s ex-girlfriend
What’s the real story?
Anxiety
“During a crisis situation,
anxiety may be the biggest roadblock to a positive
outcome”
• Perceptual field narrows • Distortion of time • Negative thinking • Physical symptoms
(Sapolsky 2003)
As Anxiety Increases
• Difficulty processing information • Difficulty with new information • Short-term memory impairment
Therefore,
Individuals may require frequent reminder
(Sapolsky 2003)
Increased anxiety can also cause
Suicide Awareness
Startling Statistics (2009 United States data)
http://www.cdc.gov
• One suicide every 14.2 minutes
• 10th ranking cause of death in the US
• 922,725 suicide attempts every year (est.)
• 5 million living Americans have attempted suicide
• 1 in every 65 people are a survivor of suicide
• Firearms used in 51% of suicides
Which person is suicidal?
Common myths about Suicide
• If a person talks about suicide they are seeking attention
• Suicide happens without warning signs
• If you ask about suicide you will put the thought in their head
• If someone doesn’t leave a note, it wasn’t a suicide
• Once suicidal, always suicidal • Doesn’t run in the family
Motivations for Suicide
Loss or change Feeling as if a situation won’t change
To not feel pain of a situation Impulsivity
Striking a Balance
Risk Factors
Vulnerabilities
Problems Develop
Decreased Probability Of Suicide
Increased Probability Of Suicide
Protective Factors
Strengths and Competencies
“Resilience”
Protective Factors Keep
Risk Factors In Balance
www.criticalconcepts.org / Daniel Clark, PhD
Past: • Previous Attempts • Mental Health • Drug/Alcohol • Family History • Treatment or
Hospitalizations • Trauma
Present (Now): • Means • Plan/Ideation • Medication • Drug/Alcohol • Psychiatric Illness • Intent • Furtherance • Medical Conditions • Feelings • Life Problems • Military Experience
Future: • Hope • Protective Factors • Resources • Willingness for safeplan
Do’s of Intervention
• Engage & Support • Understand reasons for
wanting to die and live • Add additional resources if
needed • Keep individual talking • Validate feelings • Remain as long as possible or
find someone to stay with them
• Help identify resources • Facilitate risk review • Help find hope
Things to Avoid in an Intervention
• Don’t judge • Don’t invalidate thoughts and
feelings • Don’t leave the individual alone • Don’t instantly assume the
individual needs hospitalized • Don’t remain quiet • Don’t give up and assume that
they’ve already made up their mind
AID LIFE
Ask Intervene immediately Don’t keep it a secret Locate help Inform Find Expedite
www.criticalconcepts.org / Daniel Clark, PhD
Barriers to Seeking Help
Trauma Informed Care
When you think about
Trauma Informed Care, what comes to mind?
Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW.
First, trauma happens in your life… Then, trauma affects your life… Then Trauma becomes your life… Hadar Lubin, MD Co-Director, The Post Traumatic Stress Center
Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW.
Trauma Informed Care means providing services and
interventions that do not cause harm, inflict further
trauma, or reactivate past traumatic experiences.
What is Trauma Informed Care
(Hodas, G.R. MD, 2006)
• 90% of public mental health clients have been exposed to trauma (Mueser et all, in press; Mueser et al., 1998)
• 97% of homeless women with serious mental
illness have experienced physical and sexual abuse (Goodman et al., 1997)
• Trauma is so prevalent that we must use
universal precautions
Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW.
Statistics of Trauma Informed Care
Overall Impact on Behaviors
Trauma Reenactment
Trauma Informed Not Trauma Informed
• Being knowledgeable about trauma
• Providing dignified options and choices
• ___________________________
• ___________________________
• ___________________________
• ___________________________
• Touching without asking
• Staff Yelling/ Power Struggles
• ___________________________
• ___________________________
• ___________________________
• ___________________________
Staff Self Assessment &
Self Care
Why am I here?
Why do I stay?
What “baggage” am I carrying today?
• The stress response is activated by our perception
• Our ability to change our interpretation of stressful situations is a key to developing resiliency
• Shelving of Events
STRESS and our perception
The 3 C’s of stress hardiness
Traumatic Stress
Sources: • Traumatic • Cumulative • Vicarious
Responses to stress can be either: • Physical • Cognitive • Emotional • Behavioral • Spiritual
Drink Water Exercise / Physical Activity Sleep Using your support system Maintain a normal routine Relax / vacation / escape Avoid Alcohol
Friends & Family
Work resources (EAP, supervisor, coworker)
Spiritual care
Professional support (therapist, counselor)
Health coach / Life Coach
Primary care physician
Community support (crisis line, crisis center)
Community response teams (CISM, NOVA, DCORT, Red Cross)
Stress management resources
Prevention
At your facility, where and when do critical incidents
happen?
*Times of the day
*Places
*External reasons
*Internal reasons
The trusting relationship
Crisis Communication
Self assessment
Previous experiences
Trust and relationship
Communication style (Verbal and Physical)
Situational Alliance
Switch lead if necessary
Effective Crisis Communication Strategies
Situational Alliance
Consistent and unconditional respect
Respond to needs and “demands”
Active listening
Ability to remain objective
Empathy
Honesty
Situational Alliance
Be careful of your approach
Offer dignified choices/alternatives
Use of “We” statements to promote partnership
Perception - are we really there to help?
Providing Reassurance
Assessing
Calming
Gaining Voluntary Compliance
Informing
Setting Limits
Verbal Intervention Goals
One person speaking
Anger = Distance x 2
Use of silence
Timing should not be a factor
Compassion fatigue vs. burnout
General Communication Guidelines
Environmental & Personal Safety
Safety Factors
Physical Position Dress
Community Safety
Building Safety
Instinct
Intervention
Least Restrictive Treatment Model (McGonigle 2000)
Challenging Behaviors
Dangerous Behaviors
Please consider: • Imminent danger • Risk vs. Risk • Weapon • Medical response • Safety of environment
When going to physical intervention
• Team approach
• Monitor the staff
• Call for additional assistance
• Attend to others
Intervention Approaches
Used as a LAST RESORT
Only for Imminent Danger
Applied Only By Trained Staff
Must Consider Individual’s Medical Status
Can’t Be Applied as Punishment or for Staff Convenience
Applied for the Briefest Amount of Time Possible
Emergency Safety Interventions
Postvention
Formal Processing Attended by Staff and Individual
Highlights Learning Points
Helps Avoid Future Problems
Aids In Eliminating Future Need for Restraint
Promotes Communication
Addresses Inconsistency
Post Crisis Debriefing
Questions to Consider
What Triggered the Event?
What Interventions Were Attempted?
What Part of the Response Went Well?
Could the Situation Have Been Prevented?
What Could Have Been Done Differently?
How Can We Work Together Next Time?
Post Crisis Debriefing