Creating a Safe and Comfortable Home: Crisis Prevention and Management Training for Limited Mental Health Assisted Living Facility Staff

Transcription

1 Creating a Safe and Comfortable Home: Crisis Prevention and Management Training for Limited Mental Health Assisted Living Facility Staff Trainer Guide Course Description The purpose of this training is to increase the knowledge of mental health and behavioral issues, and skills of Limited Mental Health Licensed Assisted Living Facility staff to identify, prevent, and manage crises that potentially occur in the LMH ALF home. The training contains information from Assisted Living Facility Training for Limited Mental Health Licensure developed by representatives of the Florida Department of Children and Families, and from Mental Health First Aid USA supported by the National Council for Behavioral Health. The intent of the training is to reduce the incidence of crises in the LMH ALF by reducing stigma and misunderstanding related to mental illness and behavioral issues that may trigger agitation, to promote positive relationships between staff and residents, to increase staff basic skills to assist residents that may be developing or in crisis to become more calm and safe, to provide information on how to obtain professional help and resources in a crisis if necessary, and to increase staff members personal sense of value and efficacy. Course Objectives

2 Training participants will receive information in the following areas: What to expect in a Limited Mental Health ALF: The ALF Home, Stigma, Discrimination, Mental Illness Myths and Facts Suicide Risk in the LMH ALF, and How to Help Non-Suicidal Self Injury and How to Help Medical Emergencies Verbal and Physical Aggression, and De-Escalation Trauma Informed Care, Triggers, Veteran ALF Residents, and Traumatic Brain Injury Equipment/Materials Needed Power Point projector and screen Flip chart or white board Vignettes Handouts Slides # Title Discussion Activity Title Creating and Maintaining a Safe and Comfortable Home: Crisis Announce the start of Prevention and Management Training for Limited Mental Health the training, give 1 Assisted Living Facility Staff housekeeping 2 Presenter Introduce yourself and why you are delivering this training. If the group is small enough, take introductions from participants and ask them to briefly talk about their role in the LMH ALF. information. Introductions

3 3 Acknowledgements This training is based on information from Assisted Living Facility Training for Limited Mental Health Licensure, the eight-hour certification program developed by the Department of Children and Families and the University of South Florida Louis de la Parte Florida Mental Health Institute Department of Mental Health Law and Policy, with contributions from members of Central Florida Behavioral Health Network and South Florida Behavioral Health Network. The training also includes material from Mental Health First Aid USA, an eight-hour certification and evidence-based course supported by the National Council for Behavioral Health designed to prepare community members to assist people experiencing symptoms of a mental illness or crisis until professional help arrives. 4 Contents Briefly discuss the training contents and objectives 5 An ALF is a Home Begin a discussion on how a safe, comfortable ALF is a home environment. This is where people live and we wish to treat the program as a home, respecting individuals space and providing for dignity. People that work in an ALF not only bring important knowledge and skill, but the caring and sensitivity they have may be just as important or more important in helping residents live successfully in the community. Stigma Blank the screen while sharing the story or reading the vignette. In talking about the story/vignette, focus on the reactions of friends, family members, or coworkers to the person s behavior, hospitalization, or treatment. Encourage a discussion on how others might react if the illness were a primary medical one, such as a heart Share, read, or have a participant read a vignette (Jeremy or 6 attack. Laura). If using a vignette, choose one that seems a good fit for the group.

4 7 Discrimination Talk about how mental illness contributes to unemployment, economic losses, and homelessness. Not all mental illness leads to disability, and not everyone that becomes disabled is permanently disabled, but some do, and people residing in the ALF may need help long-term. 8 Language Blank the screen while doing the exercise. When the board is covered with words, show the screen and talk about the effect of the words on the board. Draw a line through the words, erase them, or tear off and crush the paper, discussing how we want to be mindful of our language and eliminate stigmatizing words. Acknowledge that some of the words and expressions used have become part of our culture in a non-productive way, and we want to change that -- when we know better, we do better. Talk about how words can be triggers -- think of times you or someone else may have been set off by words someone used Mental Illness: Myths and Facts (1) Mental Illness: Myths and Facts (2) Having a mental illness at some time in our lives is kind of normal ( normal is just a setting on the dryer). It is very likely that we live with or are close to people that live with mental illness outside of our work, and we would not treat them differently or worry about what they are going to do from one day to the next. Talk about how some mental illnesses are more common that many people think (anxiety and depression), while others are less common (bipolar disorder and schizophrenia). Anxiety disorders are the most common mental illnesses, with an occurrence of nearly one in five people in any given year. Ask participants, what might it mean that the median onset of anxiety is age 11? (Typical answers might involve discussion of stresses unique to childhood, or trauma) What might it mean that 90% of people with co-occurring disorders had symptoms of mental illness or emotional disturbance first, and experimentation with drugs or use came later in adolescence or early adulthood? (self-medication) Write or have a volunteer write words on the board or flip chart -- ask participants, what words do we hear used to describe people that have mental illness? (Typical responses: crazy, bipolar, nuts, psycho, freak, retard, etc.)

5 11 Mental Illness: Myths and Facts (3) Though of course people with a greater degree of disability tend to reside in Limited Mental Health ALFs, so mental illness would seem more disabling. Many people experience disability with mental illness, but not in the longterm. 12 Mental Illness: Myths and Facts (4) Blank the screen poll the participants about the contributions of mental illness to community violence. In the unusual events that people with mental illness do violent acts, it is more likely that the violence is done against themselves or someone they know random acts against strangers and gun violence driven specifically by mental illness are exceptionally rare. Here can be a discussion about how anger, access to weapons, and substance use are better predictors of violence than mental illness. As the poster suggests, the misconception of the dangerous person with mental illness comes from the media and our general culture. There are other cultures for example, in which persons with psychosis or other symptoms are revered. People living with mental illness are much more likely to be victims of violence than perpetrators. If we do not expect escalation and violence, we are less likely to have it. Ask participants, what percentage of violence in our communities is caused by mental illness? Participant with the closest answer can win a prize. 13 Types of Possible Crises in the LMH ALF All of that about stigma and myths being said, there may be times a crisis can start to develop or emerge with people living in the LMH ALF. Though mental illnesses are relatively common and most people that experience mental illness are not permanently disabled, people living in the LMH ALF are there because they have some long-term disability due to mental illness. These are some of the situations we will address. 14 Suicidal Thoughts -- Risks Some discussion to facilitate thoughts about risk and prevention. Other disorders increase the risk of suicide, such as bipolar disorder, anxiety disorders, and disorders with psychosis. One does not need to have a mental disorder to go into crisis to become suicidal; people have and act on suicidal thoughts when they feel helpless, hopeless, or trapped. Attempt survivors often say that they did not wish to die; rather they wished to If the group is small enough, read the Suicide Myths/Facts, and for each statement have participants go to one side of the room if the

6 escape from intolerable pain. Suicide risk may be higher in young people because young people have incomplete cognitive development, have fewer coping skills, may be more impulsive and have poorer judgment, may be more susceptible to influence, and may have more intense moods and emotions. Elderly people may be more at risk because of increased social isolation, loss of resources when employment ends, medical problems and pain, relationship losses and grief, and diminished value in our culture for the aged. Men tend to use more aggressive or lethal means in suicide attempts than women. People who have attempted before may find it easier to attempt again because they become more invested in and comfortable with the idea of suicide once having completed an attempt. statement is fact, and the other if the statement is fiction. if the group is large, they can point to one side of the room or the other Suicide Warning Signs How to Help Someone with Suicidal Thoughts Get Help for Someone with Suicidal Thoughts It is a warning sign if someone who really seemed to be struggling suddenly becomes peaceful because it may mean that in ending their life they have found a solution to their problem. We should ask them about this. Talk about how this may seem confusing, but people with suicidal thinking are not thinking as clearly as they do when they are well. Feeling anxious about this is normal, but we should strive to project calmness and acceptance. It is very reassuring to a person in crisis that someone is ready to help. Talk about how asking someone about their suicidal thoughts reduces the isolation that contributes, that it is often a relief to people to talk about their secret. Discuss how asking this question does not make the problem worse, but it potentially can save a life. We wish to practice using these words with calmness and directness. Talk about crisis intervention and stabilization resources that are local (many communities do not have a mobile crisis team, not all residents will have a therapist or case manager). Talk about why we do not agree to keep suicidality a secret or make other deals, why we don t threaten them with scripture about going to hell or harm it would cause loved ones. Participants can talk about what they might say about the action they take that they are doing what they are doing because they are concerned and they care. Have participants role play asking each other these questions for a few minutes.

7 18 Non-suicidal Selfinjury Non-suicidal self-injury is harm intentionally inflicted as a means of coping. People that use it say that it helps dissipate intense anger, anxiety, or sadness. They say they do it when they feel they need to be punished. They say it is a way of expressing unspeakable feelings to others. Some say they do it to relieve feelings of numbness. It should not be treated as an emergency unless the harm becomes an immediate medical concern, and it is not a failed suicide attempt. This is a good opportunity to talk about the difference between Medical Emergencies Verbal and Physical Aggression attention seeking and attention needing. Most of us are not qualified to determine if what someone is presenting is a behavioral issue, minor medical issue, or major medical emergency -- so if in doubt get your administrator and/or call 911. Remember that aggression and violence are not at all necessarily part of the person s mental illness, but anyone can become agitated when under stress (and the stress can be part of the mental illness) Nonverbal Communication (1) Nonverbal Communication (2) Blank the screen and have participants model closed body language. Then show the screen and have the group talk about how it feels to use this body language and to see it. Blank the screen and have participants model open body language. Then show the screen and have the group talk about how it feels to use this body language and to see it. Have the group talk about how it feels to watch the demonstration. Talk about how it may seem to take more time to use calm speech and nonverbals, but deescalating a crisis, cleaning up and the paperwork would take much longer. Participants can do this with a partner, or a volunteer can model for the group. Participants can do this with a partner, or a volunteer can model for the group.

8 De-escalation Strategies Trauma Informed Care in the LMH ALF Know the Triggers A Veteran s Worst Wounds May Be the Ones You Can t See Suicide in the US Army Talk about the slide, emphasizing positive language, emotional and physical space, honoring reasonable requests, especially keeping everyone s safety the first priority. Talk about the differences between what s wrong with you and what happened to you, between trauma informed care and trauma-focused treatment. In a lot of ways we can support more healing with trauma informed care. George was triggered because though appropriate for the setting, the care had elements that matched things in his paranoid delusional system. John was triggered by experiences in the session that matched his experiences in childhood trauma. The psychological effects of service can be startlingly significant, and important to be aware of for residents that served in the military, whether they experienced deployment or not, or whether or not they saw action. Keep in mind that many people experience the onset of mental illness at the time or age they entered military service -- this can be correlated or not. Combine verbal and non-verbal communication: demonstrate announcing medication time by walking in abruptly, shouting MEDS!!, knocking on the wall loudly, and flicking the lights. Have the group suggest different ways to announce medication or wakeup time in a more calming manner. Read story about George, John, or another vignette

9 28 Trauma and Military Members Conditioned and Linked Triggers Traumatic Brain Injury Healing Happens in a Relationship This was presented by Dr. Robert Moore, consultant at Peace4Tarpon. Also demonstrated by Jose Narosky in Cognitive Behavioral Therapy for Combat- Related PTSD: A Manual for Service Members. Skills and knowledge are important, but what is most important is who you are to the person, how well you know them, and how much you care. We spend more time around the people for whom we provide care than with our own family members. If there is no relationship, nothing else matters! -- Juli Alvarado Narrate this animated slide, which shows the connection by fear conditioning of seemingly unrelated and otherwise neutral stimuli. 32 Conclusion

10 Vignettes Jeremy: Laura: While waiting in the emergency room to get stitches for an accidental cut on your hand, you meet Jeremy, who is in the bed next to yours. Jeremy s clothes are dirty, and his hair and beard are long. He is being treated for pneumonia. Most of the ER staff seem aloof to him, and he is quiet and passive with them. The staff members talk loudly to him and use words as if he were a small child. You hear the staff members chuckle to each other in the hall when they leave his bedside. You learn that Jeremy is only in his early 40s, though he seems much older. Jeremy tells you that when he is released from the hospital he hopes to get approved for disability. He said that he has a Master s degree in engineering, but lost his job when he became so depressed he could not get out of bed for days at a time and stopped going to work or calling. After he lost his home he began drinking to help him sleep when he could not get a bed at the shelter. Laura s family was pleased with how well she did living independently in her condo after her grandmother, whom shared the condo with her, passed away -- she worked part-time at the grocery store and kept up with activities at the drop-in center. As time passed, however, Laura became more anxious, and her obsessions and compulsions started getting worse. She stopped going to work, and her mother told the case manager that Laura s constant phone calls with complaints about not having the right food or being bored were stressing her out; she was being manipulative. After a suicide attempt Laura s psychiatrist recommended a medication change and placement in a LMH ALF. Both Laura and her mother said when she lived in the group home it was the happiest time in her adult life -- she had a roommate she liked, things to do, and she was a lot less stressed. Laura returned to part-time work and talked about taking some classes. George: John: You have known George for as long as you have worked in the ALF, and know that he had a fear of being kidnapped and tortured by the KGB. You learn that George has an appointment for his medication review at the clinic, and the new psychiatrist there is Dr. Petrovich. George didn t know that there was a new psychiatrist, and when you arrive at the clinic, he runs back to the car and refuses to come back inside. George looks around frantically like he might run away. John s roommate thought it might be funny to play a prank on him, and sneak up on him and scare him with a funny mask after lights out. The plan backfired when the roommate surprised him, and John jumped up screaming and hit his roommate, and chased him out of the room. John s roommate said it was just a joke, but John will not calm down -- he keeps pacing back and forth with a clenched fist.

11 Suicide -- Fact or Fiction