Summary of Main PointsSummary of Main PointsAugust 15, 2007August 15, 2007

Therapeutic Therapeutic Crisis Crisis

InterventioInterventionn

Goals Of Crisis InterventionGoals Of Crisis Intervention

To provide immediate emotional To provide immediate emotional and environmental support in a and environmental support in a way that reduces the stress and way that reduces the stress and riskrisk

To teach better, more To teach better, more constructive and effective ways constructive and effective ways to deal with stress or painful to deal with stress or painful feelingsfeelings

TCI TRAINING [4]

4 Questions We Ask Ourselves 4 Questions We Ask Ourselves In A CrisisIn A Crisis

What am I feeling now?What am I feeling now? What does this young person What does this young person

feel, need, or want?feel, need, or want? How is the environment affecting How is the environment affecting

the young person?the young person? How do I best respond?How do I best respond?

TCI TRAINING [7]

Active ListeningActive Listening

Identifies and expresses emotionsIdentifies and expresses emotions Is respectful of a young personIs respectful of a young person Responds to feelings, rather than Responds to feelings, rather than

just behavior just behavior Communicates that we care and Communicates that we care and

understand understand Helps young people “talk out Helps young people “talk out

rather than act out”rather than act out”

TCI TRAINING [26]

Active Listening Is NotActive Listening Is Not

Throwing up roadblocksThrowing up roadblocks Premature problem-solvingPremature problem-solving Arguing or establishing factsArguing or establishing facts Permission givingPermission giving Necessarily time consumingNecessarily time consuming

TCI TRAINING [27]

Behavior Management Behavior Management TechniquesTechniques

Managing the environmentManaging the environment Prompting Prompting Caring gesture (hypodermic affection)Caring gesture (hypodermic affection) Hurdle help Hurdle help RedirectionRedirection ProximityProximity Planned ignoring and Positive attentionPlanned ignoring and Positive attention Directive statementsDirective statements Time awayTime away

TCI TRAINING [28]

Crisis CycleCrisis Cycle

TCI TRAINING [30]

Stressful SituationIncident

Young Person's Feelings

Young Person's Behavior

Adult's Response THE CRISIS CYCLE

Elements of a Potentially Violent Elements of a Potentially Violent SituationSituation

A potential trigger to violenceA potential trigger to violence A targetA target A weaponA weapon Level of stressLevel of stress

TCI TRAINING [37]

To De-escalate the Crisis To De-escalate the Crisis Remove:Remove:

The potential trigger to violence by:The potential trigger to violence by: Never touching an angry and potentially Never touching an angry and potentially

violent person violent person Avoiding any aggressive moves and Avoiding any aggressive moves and

provocative statements provocative statements Avoiding the crisis cycle and counter Avoiding the crisis cycle and counter

aggression aggression Removing others that might trigger the Removing others that might trigger the

violenceviolence

——Body language is critical—Body language is critical—

TCI TRAINING [38]

To De-escalate the Crisis To De-escalate the Crisis Remove:Remove:

The target by:The target by: Asking the targeted person to leave Asking the targeted person to leave If it’s you, reminding young person If it’s you, reminding young person

of your relationship orof your relationship or Leaving the situation and asking a Leaving the situation and asking a

“neutral” staff to manage the “neutral” staff to manage the incidentincident

— — The target may shift during the The target may shift during the episode —episode —

TCI TRAINING [39]

To De-escalate the Crisis Avoid:To De-escalate the Crisis Avoid:The weapon by: The weapon by: Discretely removing objects Discretely removing objects Maneuvering away from Maneuvering away from

weaponsweapons Staying a safe distance awayStaying a safe distance away

TCI TRAINING [40]

To De-escalate the Crisis To De-escalate the Crisis Remove:Remove:

The level of stress by:The level of stress by: Using your relationship Using your relationship Actively listening to identify Actively listening to identify

feelings feelings Using non-confrontational limit-Using non-confrontational limit-

setting (I ASSIST)setting (I ASSIST)

TCI TRAINING [41]

I ASSISTI ASSIST

II - Isolate the young person- Isolate the young person

AA - Actively listen - Actively listen

SS – Speak calmly, assertively, respectfully – Speak calmly, assertively, respectfully

SS – Statements of understanding precede – Statements of understanding precede requestsrequests

II – Invite the young people to consider positive – Invite the young people to consider positive outcomes and behaviorsoutcomes and behaviors

SS – Space reduces pressure – Space reduces pressure

TT – Time helps – Time helps young people respond to young people respond to requestsrequests

TCI TRAINING [43]

Goals of the LSIGoals of the LSI

1. Return young person to normal 1. Return young person to normal functioning functioning

2. Clarify events2. Clarify events

3. Repair and restore the 3. Repair and restore the relationshiprelationship

4. Teach new coping skills4. Teach new coping skills

5. Reintegrate young person back 5. Reintegrate young person back into routineinto routine

TCI TRAINING [45]

Steps to the LSISteps to the LSI

II – Isolate the conversation – Isolate the conversation

EE – Explore young person’s point of view – Explore young person’s point of view

SS – Summarize the feelings and content – Summarize the feelings and content

CC – Connect behavior to feelings – Connect behavior to feelings

AA – Alternative behaviors discussed – Alternative behaviors discussed

PP – Plan developed/Practice new behavior – Plan developed/Practice new behavior

EE – Enter young person back into the – Enter young person back into the routineroutine

Conducted by the direct care workerConducted by the direct care workerTCI TRAINING [46]

Potential Pitfalls of an LSIPotential Pitfalls of an LSI

Young person refuses to talkYoung person refuses to talk Convey calm support, sanction silenceConvey calm support, sanction silence Ask a focused questionAsk a focused question Reschedule LSIReschedule LSI

Young person gets off subjectYoung person gets off subject Allow exploration, relate to incidentAllow exploration, relate to incident Focus on issue at handFocus on issue at hand

Premature planPremature plan Don’t interrupt young person’s thought processDon’t interrupt young person’s thought process Don’t develop plan for young personDon’t develop plan for young person

TCI TRAINING [57]

Individualized Crisis Individualized Crisis Management PlanManagement Plan

Functional analysis of crisis Functional analysis of crisis behaviorbehavior

Strategy for intervening tailored Strategy for intervening tailored for the young personfor the young person

Periodic review and updatePeriodic review and update

TCI TRAINING [50]

Options To Handle Options To Handle Physical ViolencePhysical Violence

Eliminate one of the elements of a violent Eliminate one of the elements of a violent situationsituation

Make a directive statement that clearly Make a directive statement that clearly communicates that the violence must stopcommunicates that the violence must stop

Use releases and maintain a safe distance Use releases and maintain a safe distance with a protective stancewith a protective stance

Leave the situation and get assistanceLeave the situation and get assistance Employ physical restraint techniques (if Employ physical restraint techniques (if

indicated on the Individual Crisis indicated on the Individual Crisis Management Plan)Management Plan)

TCI TRAINING [47]

Goal of Physical InterventionGoal of Physical Intervention

To ensure safetyTo ensure safety

TCI TRAINING [51]

Definitions of Definitions of Physical RestraintPhysical Restraint

Physical Restraint: use of staff Physical Restraint: use of staff members to hold a young person members to hold a young person in order to contain acute physical in order to contain acute physical behaviorbehavior

Acute physical behavior: behavior Acute physical behavior: behavior likely to result in physical injurylikely to result in physical injury

The young person, other clients, The young person, other clients, staff members or others are at staff members or others are at imminent risk of physical harmimminent risk of physical harm

TCI TRAINING [52]

Physical Restraint Is Not Used Physical Restraint Is Not Used To:To:

Demonstrate authorityDemonstrate authority Enforce complianceEnforce compliance Inflict pain or harmInflict pain or harm Punish or disciplinePunish or discipline

TCI TRAINING [54]

Do Not Use Physical Restraint Do Not Use Physical Restraint When:When:

We cannot control the young person safely We cannot control the young person safely We are not in controlWe are not in control Sexual stimulation is the motivationSexual stimulation is the motivation We are in a public placeWe are in a public place Young person has a weaponYoung person has a weapon Young person’s medical condition prohibits Young person’s medical condition prohibits

itit Young person has emotional problems Young person has emotional problems

(trauma)(trauma) Young person is on medication(s) that Young person is on medication(s) that

affects his or her systemaffects his or her systemTCI TRAINING [58]

Definition of AsphyxiaDefinition of Asphyxia

Asphyxia:Asphyxia: the deprivation of the deprivation of oxygen to living cells oxygen to living cells

Positional asphyxia:Positional asphyxia: fatal fatal respiratory arrest in which the respiratory arrest in which the ability to breath is compromised ability to breath is compromised by the positioning of the body in by the positioning of the body in relationship to its immediate relationship to its immediate surroundingssurroundings

TCI TRAINING [59]

Predisposing Risk FactorsPredisposing Risk Factors

ObesityObesity Individual under the influence of Individual under the influence of

alcohol or drugsalcohol or drugs Prolonged violent physical agitationProlonged violent physical agitation Underlying natural disease (i.e. Underlying natural disease (i.e.

enlarged heart, asthma, high blood enlarged heart, asthma, high blood pressure, diabetes)pressure, diabetes)

Hot humid environmentHot humid environment Individual taking certain types of Individual taking certain types of

medicationmedication

TCI TRAINING [60]

Warning SignsWarning Signs

Asphyxia due to neck compression:Asphyxia due to neck compression: Goes limp and ceases to breatheGoes limp and ceases to breathe

Asphyxia due to respiratory interference:Asphyxia due to respiratory interference: States he/she can’t breatheStates he/she can’t breathe Respiration is labored, rapid, or abnormal Respiration is labored, rapid, or abnormal May make grunting noisesMay make grunting noises Vomiting or turning a dusky purple color, Vomiting or turning a dusky purple color,

especially the face especially the face Goes limp and ceases to breatheGoes limp and ceases to breathe

TCI TRAINING [61]

Recommendations For Recommendations For Reducing RiskReducing Risk

Never place weight on a young person’s chest or Never place weight on a young person’s chest or backback

Never put pressure on the young person’s neck Never put pressure on the young person’s neck Never place the head in a position that causes Never place the head in a position that causes

the neck to be compressedthe neck to be compressed Never allow a young person to stay in the prone Never allow a young person to stay in the prone

position once he or she is no longer a safety riskposition once he or she is no longer a safety risk—get the person up and in a seated position—get the person up and in a seated position

Never place a young person’s arms behind his or Never place a young person’s arms behind his or her back when that person is in a prone positionher back when that person is in a prone position

Never bend a child forward in a small child Never bend a child forward in a small child restraintrestraint

TCI TRAINING [62]

Recommendations For Recommendations For Reducing Risk, cont.Reducing Risk, cont.

Never place anything over or near the Never place anything over or near the young person’s face, mouth, or nose that young person’s face, mouth, or nose that can be inhaled or conform to the contours can be inhaled or conform to the contours of the faceof the face

Never conduct a restraint on a soft surface Never conduct a restraint on a soft surface such as a mattresssuch as a mattress

Never ignore any of the warning signs of Never ignore any of the warning signs of pending asphyxia pending asphyxia

Never fail to take immediate action if there Never fail to take immediate action if there is a need for emergency medical treatmentis a need for emergency medical treatment

TCI TRAINING [62]

DocumentationDocumentation Who, what, when, where?Who, what, when, where? What were the antecedents?What were the antecedents? What did staff do to de-escalate the situation?What did staff do to de-escalate the situation? If physical contact, who did what (be specific)?If physical contact, who did what (be specific)? How long did the restraint last? How long did the restraint last? Staff/young person injuries? Medical Staff/young person injuries? Medical

attention? attention? What plan was developed in the Life Space What plan was developed in the Life Space

Interview?Interview? Debriefing of staff?Debriefing of staff? Follow up needed? Was family notified?Follow up needed? Was family notified?

TCI TRAINING [63]