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IHBT Risk Assessment, Safety Planning Overview

April 29, 2014

OACCA Conference

Rick Shepler, Ph.D., PCC-SPatrick Kanary, Director

Center for Innovative PracticesThe Begun Center of Violence Prevention

© Center for Innovative Practices Use by permission only

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Learning Objectives

This workshop will present an overview of key issues in managing risk and safety issues in Intensive Home-based Treatment. Main areas of focus for risk and safety assessment will be presented. The central elements of safety planning will be discussed.

  Participants will learn the major types of risk in IHBT

practice Participants will learn main areas to assess for risk

and safety Participants will learn basic components of safety

planning

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Components of Risk Assessment, Safety Planning,

and Crisis Stabilization Risk screening Crisis functional analysis Safety Planning Crisis stabilization Monitoring Documentation

Understanding Family’s Response to Stress and Crisis

By the time you are called in– so many things may have happened and the family may be overwhelmed, frustrated, discouraged, and hopeless.

Families may need direct intervention and help

Do not assume families can stabilize a crisis by themselves

Do not assume that they cannot

Community Dynamics of a Crisis Risk situations and crises heighten

tensions Increased frustrations

With family With other systems

Self-protectiveness and finger pointing are possible

Increased likelihood of more restrictive responses and decisions (i.e., Placement)

Managing Safety Together No single system can manage the multiple issues

of at-risk youth and their families alone Commitment to keeping youth in your community

if safe and possible: requires community ownership, responsibility, responsiveness and participation

The community works together in sharing community risk and in planning for safety and success

Need strong community relationships Need to create understanding—appreciative

perspectives on what each system can and cannot do in crisis situations

Overarching Goals of Risk and Safety Management

Increase safety

Minimize risk

Minimize liability

Managing Risk and Safety Concerns: Roles of IHBT Provider

Active and direct intervention Active safety planning and monitoring Problem prediction and problem solving Rallying the reinforcements and convening

collaborative partners Reduce the amount of exposure to risk

generating environments Prevent a chain reaction of negative life

events (Katz) Create safety nets

Global Vision

Comprehensive risk and safety assessment across contexts

Use your supervisor and team in identifying risk and planning for safety

Continue to broaden your vision: Expand outward Safety planning does not just occur in the child’s home

Wherever the child may go.. Is the child safe in that environment?

Need to be flexible and adaptable based on current information

You may need to do additional safety steps every session based on new information

Use extended family and community supports in safety planning

Plan for 24 hour day (including 24/7 availability to the family)

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Risk Factors, Risk Behaviors, and Immediate Safety

Immediate Safety: People, places, and things that contribute to an immediate or imminent threat to personal safety or safety of others Requires immediate intervention and/or active

monitoring and supervision (active association with drug using and criminally involved youth; run away behaviors; physical and sexual child maltreatment; problem sexual behaviors; etc.)

Risk Behaviors and Contexts: Those youth behaviors and risk generating environments that pose an emerging or impending threat of harm. These conditions if not addressed could spiral into a chain reaction of negative life events.

Risk Factors: Environments that lead to compromised development or detrimental effects over time (lack of nurturing; lack of monitoring; lack of connection to school; chronic stress; etc.)

Risk Factors, Risk Behaviors, and Immediate Safety

Risk Factors

Risk Behaviors

Immediate Safety

Prioritizing risk factors, risk behaviors, and immediate safety concerns

First determine if there are any immediate safety concerns (youth, family, community) that need stabilized (e.g. self harm, other harm, etc.)

Identify major risk behaviors in each life domain What risk behavior(s) if not addressed will spiral into

a chain reaction of negative life events?(e.g. running away; hanging with drug using peers)

What risk factors if not addressed will lead to compromised development? (e.g. staying in school)

Identifying Risk and Safety Concerns

Self Harm Behaviors – Suicidal ideation,

gestures, attempts– Self Injurious Behaviors

Community Safety – To persons– To property

Trauma– Abuse and neglect– Family violence

Temperament: Poor emotional

regulation; Reactivity; Impulsivity Risk taking/ Thrill

seeking

Personal Safety/Risk― Runaway― Sexual acting out― Unrestricted internet access― Sexting― Cyberbullying

Ecological Risk– Neighborhood– Negative peer involvement:

Gang activityDestabilizing Factors

– Lack of parental monitoring and supervision

– Parental disabilities: MH, MRDD, SA

– Availability of weapons– Youth substance use

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Crisis Scenario 1

Darrel is a ten year old who has been in services for 3 weeks.

After being told by the teacher to not disrupt the youth sitting next to him, he throws a stapler at a teacher, and then bolts out of the room. He then starts running down the hall kicking lockers and knocking on all the classroom doors.

You get a call from the school principal.

What do you do?

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Crisis Scenario 2

Chantel is a 16 yr old girl 3 months into treatment she tells her

mother she is pregnant and has taken a number of pills

Mother responds to this news by slapping her daughter in the face.

Daughter calls worker

What do you do?

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Crisis Scenario 3

You are transporting Janese. You can see that she is agitated and fidgety. She states being suicidal and threatens to jump out of car.

What do you do?

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Crisis Scenario 4

Mother calls and asks for you to come over immediately. You hear elevated voices and things breaking in the background. Her 14 year old daughter, LaToya, grabs the phone, while still shouting expletives to her mother, but takes shouting breaks to share her side of the story with you.

You…..

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Risk and Safety Scenario 1

Tamara (16) has been hospitalized for frequent episodes of self-injurious behaviors (cutting on her arms) and suicide ideation

Tamara alleged that she was sexually abused by mother’s boyfriend, but her mother did not believe her and refused to have the boyfriend leave

Tamara gets into verbal fights with her mother and frequently leaves to get high with her 20 year old boyfriend, whom she is sexually active with but does not use any protection

What are your safety/risk concerns? What would you put in Tamara’s safety plan? What are the treatment issues?

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Risk and Safety Scenario 2

Marcus is 16 years old and stays up late every night playing violent themed video games.

He refuses to get up in the morning for school and physically threatens his parents when they try to wake him in the morning.

He has a previous domestic violence charge for getting into a fight with his step-father.

When he does go to school he frequently sleeps at his desk and when challenged by school staff he verbally threatens them.

The school deals with his threats by calling the police and having him removed.

What are your safety/risk concerns? What would you put in Marcus’s safety plan? What are the treatment issues?

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Risk and Safety Scenario 3

Alonzo is 11 years old and is fascinated with fire and frequently lights small fires to watch them burn.

He recently set fire to the carpeting in his room. Alonzo also has a collection of knives given to him by

his father, who likes to hunt. Mother reports that last year he deliberately harmed

their family cat by throwing him by his tail down the stairs.

Alonzo is diagnosed with ADHD and is quite impulsive.

What are your safety/risk concerns? What would you put in Alonzo’s safety plan?

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Risk and Safety Scenario 4

Jermaine is 14 years old and lives with his mother, step-father, half-brother and half-sister (ages 8 and 9).

Jermaine was sexually molested by a neighbor at age 7.

When Jermaine was 12, he was found naked, in bed with his younger sister.

Jermaine and his younger brother share a bedroom

What are your safety/risk concerns? What would you put in Jermaine’s safety plan?

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Factors Associated with Youth Suicide

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Suicide by firearm, hanging/suffocation, and poisoning together comprise 92% of all suicides.

In 2005, suicide by firearm comprised 52% of all suicides.

Hanging/suffocation accounting for 22% of all suicides in 2005, and

Poisoning accounted for 18%.

Trends in U.S. Suicide Mortality by Method

Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

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Gender Disparities in Suicide Rates

Males represent 79.4% of all U.S. suicides. Of the reported suicides in the 10 to 24 age

group, 83% of the deaths were males and 17% were females.

However, during their lifetime, women attempt suicide about 2 to 3 times as often as men.

Firearms are the most commonly used method of suicide among men, while poisoning is the most common among women.

Source: CDC 2005

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Youth Suicide Facts American Association of Suicidology; CDC

Suicide is the third leading cause of death for youth 15-24 Firearms remain the most commonly used suicide method for

youth (49%) Suicide rates by suffocation increased Access to and the availability of firearms a factor:

Guns are twice as likely to be found in the homes of suicide victims as in the homes of attempters or in the homes of control group (Brent et al 1991)

Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide

Average age of onset for suicide ideation: 11 to 16 depending on the study

Risk management point: Inquire about firearms when indicated and document instructions and response.

http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-24.pdf

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Facts on Youth SuicideAmerican Association of Suicidology

Research has shown that most adolescent suicides occur after school hours and in the teen’s home.

The typical profile of an adolescent nonfatal suicide attempter is a female who ingests pills, while the profile of the typical suicide completer is a male who dies from a gunshot wound.

Any deliberate self-harming behaviors should be considered serious and in need of further evaluation.

Most adolescent suicide attempts are precipitated by interpersonal conflicts. The intent of the behavior appears to be to effect change in the behaviors or attitudes of others.

Repeat attempters (those making more than one nonfatal attempt) generally use their behavior as a means of coping with stress and tend to exhibit more chronic symptomology, poorer coping histories, and a higher presence of suicidal and substance abuse behaviors in their family histories.

http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-24.pdf

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LGBTQ Youth: Social Support (Hatzenbuehler, Medscape Medical News; CDC)

Lesbian, gay, and bisexual teens are up to four times more likely to attempt suicide than their heterosexual peers.

An unsupportive social environment significantly increases (20%) the risk for attempted suicide in gay, lesbian, and bisexual youth (LGB).

Conversely, a supportive social environment may significantly reduce suicidality in this high-risk population.

More Facts on Youth Suicide

Bullying and Violence Youth threatened or injured by a peer were 2.4

times more likely to report suicidal thoughts, and 3.3 times more likely to report suicidal behavior than non-victimized peers (CDC).

Bullying doubles risk for teen suicide (Fernando; APHA; Medscape)

Rape triples risk for teen suicide (Fernando; APHA; Medscape)

Adopted Youth and Suicide Adopted offspring were nearly 4 times more likely

to attempt suicide than non-adopted offspring (Pediatrics)

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Risk Factors for Suicide (CDC)

History of previous suicide attempts History of depression or other mental illness Recent interpersonal conflict Family history of suicide Alcohol or drug abuse (Increasing use) Stressful life event or loss Easy access to lethal methods Exposure to the suicidal behavior of others (friends, family,

media) Lifetime traumas Hopelessness Talking/writing about thoughts of suicide, death, dying (in a

context of sadness, boredom, hopelessness) Impulsive and aggressive behavior, frequent expressions of rage

http://www.cdc.gov/ncipc/dvp/suicide/youthsuicide.htm

Warning Signs (SAMHSA)

Talking about wanting to die or to kill themselves.

Looking for a way to kill themselves, such as searching online or buying a gun

Talking about feeling hopeless or having no reason to live.

Talking about feeling trapped or in unbearable pain.

Talking about being a burden to others. Increasing the use of alcohol or drugs.

Warning Signs (SAMHSA)

Acting anxious or agitated; behaving recklessly. Any significant change: Sleeping too little or

too much eating too little or too much Secretiveness Withdrawing or isolating themselves. Showing rage or talking about seeking revenge. Change in mood. Someone who is quiet and

depressed becomes happy or at peace with themselves

Displaying extreme mood swings.

Protective Factors for Preventing Suicide(Suicide Prevention Resource Center)

Effective clinical care for mental, physical and substance use disorders

Easy access to a variety of clinical interventions Restricted access to highly lethal means of suicide Strong connections to family and community

support Support through ongoing medical and mental health

care relationships Skills in problem solving, conflict resolution and

handling problems in a non-violent way Cultural and religious beliefs that discourage suicide

and support self-preservation

Crisis Prediction and Safety Planning

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Re-framing Crisis Situations

Crises have a beginning, middle and end They occur over a certain period of time Do not last forever Crises offer opportunity for positive

change and new learning

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Crisis Escalation Pattern (Baltrinic)

Sequence/Pattern (Escalation):

Sequence/Pattern (De-escalation):

Teachable Teachable

TargetBehavior

Sequence/Pattern (Peak):

Map The Sequence of Events/Patterns (Before, During, & After Youth Target Behavior)

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Crisis Functional Analysis

Completed when family is not in a crisis Preparation for developing a plan Assess for triggering events and behaviors

Persons, places, things, emotions, physical issues (sleep), trauma

Assess for internal and interactional escalation patterns Explore early warning signs and cues that youth or

situation is escalating Who escalates situations? Who joins the crisis? Who avoids crisis situations? Who is helpful in deescalating youth or situation?

Look for patterns over time, environments, and events Determine the function of the behavior

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Triggers and Crisis Extenders

A trigger is something that sets off an action, emotion, events

Crisis extenders occur in response to the initial “outburst” and serve to accelerate (faster), escalate (bigger), or exacerbate (compound) a crisis.

Get as much detail around the triggers and crisis extenders as possible People, places, things Particular time of day or night Interaction/contact with particular family

members Identify barriers to de-escalation and problem

solve

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Integrated Contextual Functional Analysis

Youth

SU Disorder

MH Disorder

De-stabilizingEvent or Trigger

Risks Factors, Skills, Resources, and Supports

Trauma Filter

ExacerbatingResponse

Salient Behavior/Symptom

Dispositional Factors

Contextual & Relational Dynamics: Family, Peers,

School, Community

Safety Issue

Escalation Cycle

© 2011, R. Shepler, Center for Innovative Practices

Safety Planning Steps (Neil Brown)

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Identify the safety concerns Assess for precipitant factors, escalation sequence, and

crisis patterns (Triggers, stressors, contexts, etc) Prevent: Identify and implement pre-crisis strategies and

supports Create secure and monitored environments Expansion of youth and family safety net (informal and formal) Creation and implementation of new skill sets and coping

strategies (youth and family) Plan for what to do if the crisis does occur (Crisis

intervention) Delineate roles, response, & responsibilities (Who does

what and when, including lead crisis responder) Distribute plan to family and support team Follow-up, monitor, and adapt as needed

Protective Measures in the Home: Safety Walk Through

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Safety tour of the house Completed with parent or caretaking adult (and not

the youth) Walk through each room of the house prompting

the parent/adult with safety questions: Tell me what is in this room that could pose a danger to

someone? Think about your son or daughter and what they may

have done before– what is in this room that we need to secure?

Have parents secure items of concern and confirm actions were taken

Items to Secure41

Knives Guns Martial arts weapons Medicines: all Items to hang self with: Ropes; belts Harmful ingestibles: Poisons; Cleaning

products: bleach and other Other

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Safety Strategies

Lock boxes for medicines or knives Ask for gun to be kept at another house

(do not tell youth where it is) Or keep gun locked with safety lock and

ammunition locked separately Door alarms Baby monitors

Safety Planning Lessons Learned

Safety planning is a proactive and ongoing process

No safety plan is 100% fool proof Take lead role in safety planning: Don’t assume

because other services are involved that someone else is monitoring safety issues

Psychiatric hospitalization of a youth does not complete your intervention. Youth is still coming home– need updated safety plan.

For multi-system involved youth, collaboration that results in shared risk decision-making is necessary Utilize child and family teaming for safety planning

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Safety Planning Lessons learned (Con.)

Build in redundancy: Have a back-up plan Just taking the family’s verbal response that the

home is safe and not actively safety proofing What evidence do you have that the home is safe?

Safety plans that are not reviewed over time Lack of follow-up and monitoring Not including the family in safety planning Being a lone ranger Not utilizing consultation or your community

team

45Crisis Response and Stabilization

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Crisis Recognition: Early Warning Signs

A signal of distress is a physical precursor and manifestation of possible crisis. Some signals are not observable, but some are: Restlessness Agitation Pacing Change in breathing Sweating

Ask family members, “What might you or others notice or feel just before losing control?”

Crisis Response and Stabilization

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Crisis Triage: Decide on level of intervention and type of response (when to call 911)

Assist family in implementing safety plan Who is available to help?

Current family members and family supports Who/what might destabilize the situation? What is in the home that could pose a danger?

Medicines; weapons; etc. What helps to de-escalate the youth/family?

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De-escalation Strategies Ask family members:

“What are some of the things that help each of you calm down when you start to get upset?”

“What doesn’t work to calm you when you are upset?” Behavioral redirection: Changing the environment so that

the client can re-establish self-control. Go outside, take a walk, get a drink, etc. Space Diversionary activity Ease demands and requirements

Individual self-regulation strategies to manage or minimize stress: Time away from a stressful situation Physical exercise: going for a walk; working out Deep breathing, relaxation, self-calming strategies Listening to music

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Crisis Response Approach

Model calm, non-threatening, yet directive approach Thoughtful Action:

First step: breathe Mindful response Do not add to the family’s reactivity

Verbal responses should be short and simple Use repetition Encourage Problem Solving

Remember, your client is stuck right now and looking to you to get them out of this state

It might be appropriate to propose an outright suggestion for something

Explore how the family resolved crises previously? Match intensity of service with intensity of concerns Active and direct intervention (This is not enabling)

Crisis Response and Stabilization

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Direct action: de-escalation/stabilization Create safe environment:

Secure unsafe items Commitment to safety Therapeutic separation Mobilize supports Respite: Arrange for short term out of home

stay Hospitalization or psychiatric assessment Determination of youth and family safety

prior to leaving the home Stepped up monitoring (by family; IHBT

staff)

Follow-Up: Remediation

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Process with family what happened (family session): Sequence of events; Triggers etc.

Process the effects and consequences of the behaviors.

Process lessons learned and what could be done differently next time (triggers, contexts, vulnerabilities – e.g. lack of sleep- etc.)

Use crisis as motivation for family to develop new skill sets, change unhealthy family dynamics and behaviors, build new supports

Revisit and review safety plan

Stepped up monitoring and intensity

Consultation & Documentation

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Consultation and documentation are essential components of crisis stabilization and safety planning

Use your IHBT team and supervisor Use the family and family supports as

consultants (they are experts on their family)

Monitor plan and Document

Risk and Safety Management Checklist53

Did you assess for it? Did you consult with your supervisor? Did you take reasonable action? Did you create a safety plan with the family? Did you distribute safety plan to team? Did you put a copy of the safety plan in the chart? Did you add incorporate safety goals and

objectives into treatment plan? Did you follow-up and monitor? Did you document all the above?

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Contact Information

and AcknowledgementsContact Information:Richard Shepler, Ph.D., PCC-SCenter for Innovative PracticesThe Begun Center for Violence PreventionRichard.shepler@case.edu

Acknowledgements:• A.P.A. Practice Guidelines, part A, p. 16, 2003• CDC• American Association of Suicidology• Medscape• Eric Baltrinic• Neil Brown, Wraparound Consultant