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