Crisis Prevention & Intervention

Transcription

1 Crisis Prevention & Intervention How staff responds to persons in crisis is an integrated approach in which the staff responds to the person s behavior level in such a way as to de-escalate & communicate effectively in the situation. Crisis Development Behavior Levels & Staff Approach 1) Anxiety noticeable increase or change in behavior Behaviors Crying, giggling, quite, pacing, picking skin, shaking leg, rocking back & forth, rapid speech, repeating, biting nails, sweating, etc. Staff approach: Supportive, empathetic & nonjudgmental. Use an approach to alleviate anxiety and don t minimize, What do you need?, What can I do to help?, Can you tell me what happened? Feelings Sad, scared, frustrated, nervous, angry 2) Defensive starting to lose rationality, belligerent, challenging authority, threaten Behaviors Questioning, yelling, hard stare, fists folded, etc. Staff approach: Give direction. Take control of the situation; stay focused, repeat the instruction, provide natural consequences and choices. Use a positive approach.if you do x,then you can do y, or a natural consequence if you do x, we will have to call 911. Feelings Helpless or feels attacked. Scared, angry, frustrated 3) Acting Out Total loss of control, a danger to themselves or others Behaviors Punch wall, slapping, threaten, biting, cursing, throwing, melt down, etc. Staff approach: Nonviolent Physical Crisis Intervention, LAST RESORT ONLY at Crisis Centers if has a total loss of control and is a danger to others/self. This is a set of safe & non-harmful control or restraint techniques designed to help the acting out person regain control. All other programs, take it seriously, get assistance, isolate or remove audience, 911 if necessary. Feelings Rage, frustration, angry, scared, trapped 4) Tension Reduction - a decrease in emotional and physical energy & regains rationality. Behaviors Crying, quiet, exhausted, apologize, rational Establish therapeutic rapport; re-establish communication with that person & re-build the relationship, identify physical needs, I m here for you, next time you can come to me, I believe in you, can you try x next time? Do you want to talk about it now or later? Feelings Relief, remorse, embarrassed, sad, helpless

2 Proxemics = proximity; personal space. Maintain a distance that respects boundaries about one leg length away, then perhaps, depending on the behavior touch lightly on the shoulder, elbow, or wrist lightly. Personal space may also vary depending on the relationship with the client, their size, gender, the situation (received bad news), culture, body language, history, trauma, environment, disability. Kinesics = body language; facial expressions, a smile may be inappropriate, calm face, shoulders relaxed, arms/hands loose at your side, positive gestures, positive eye contact, (no finger pointing, no shocked look, no smirk, no folded arms, no rolling eyes, no closed eyes). Body language can be very subtle, we can t see ourselves, evaluate the client s body language and your body language. CPI Supportive Stance: 1. Have respect for personal space 2. Non-threatening and non-challenging body language; facing head-on could be intimidating as can standing over someone that is sitting or lying on the floor. 3. Safety sideways stance or you may risk injury head on. Be prepared if client becomes defensive or threatening, get in the supportive stance. Para-verbal communication How we say what we say; same statement in different tones of voice communicates different intentions on your part. Same statement with different facial expressions (eyes closed) communicates something different to clients. Does the person feel respected, validated, cared about, understood, or do they feel threatened, degraded, challenged, embarrassed, judged? 1. Tone of Voice communicates feelings and emotions. Think about adults around babies. a. Avoid sarcasm it communicates hostility how to say I am really glad to see you can be interpreted differently based on how you say it. b. Don t be condescending in your tone c. Don t be impatient; Clean your room tone can indicate impatience 2. Appropriate volume a. For the distance between you and the client b. For the situation, don t embarrass the client 3. Cadence be aware of the rate and rhythm of your statements How can I help you? Four stages of Crisis Development 3) Release 4) Intimidation 2) Refusal 5) Tension Reduction 1) Questioning

3 1) Questioning a. Seeking information perhaps in a loud or angry voice, crossing arms, etc., however, it is a rational question looking for a rational response. How long am I going to be here? i. Intervention: give a rational response, answer the question b. Challenging question i. Evasive, attempts to draw staff into a struggle Why do I have to go to bed? Why does he get to stay up?, Why can t I stay in group? 1. Intervention: stay focused and re-direct back to the issue. Ignore the challenge but not the person. 2) Refusal a. Non-compliance, for example medications, hygiene, clean room, etc. i. Intervention: set limits, give choices and consequences, state the positive consequences first, give them time to think and comply, give options do not threaten or order or get into a power struggle 3) Release a. Venting, screaming, swearing, high energy or temper tantrum i. Intervention: allow venting, isolate the person and remove the audience so others don t join in, let the person save face and maintain their dignity, get more information as they are venting, I ve been awake for 24 hours or I m hungry, I am not going to the family visit, my mom says I am not coming home and she hates me!. Listen for the real message. 4) Intimidation a. Verbal or non-verbal threats I m going to get you fired, I know where you live, Who s your supervisor?, I ll bust this window. Non-verbal posturing, getting too close, way they look, staring with arms folded Oh you think it s funny, you keep thinking that! i. Intervention: get assistance to keep you safe and to be a witness. Take it seriously if a person threatens suicide many times without trying suicide and threatens it today, it may be the time they attempt it pay attention, don t touch, hands off and document the event/intervention 5) Tension Reduction a. Decrease in emotional and physical energy, begins to be rational. i. Intervention: therapeutic rapport, re-establish communication and re-build relationship, I m not mad at you, This time you did not (throw the chair, threaten anyone, etc.). Positive encouragement. Keys to setting limits 1) Simple and clear what behavior is the problem? What do you need them to do? 2) Reasonable don t necessarily treat everyone the same 3) Enforceable be sure you have or can do what you promised Empathic listening DEFINITION: An active process to discern what a person is saying: qualities of a good listener 1) Understands the feeling I am having 2) Can repeat back what I said and does not interrupt 3) Asks relevant questions

4 4) Give undivided attention 5) Caring 6) Non-judgmental 7) Intelligent and mature response 8) Neutral facial expressions 9) Positive facial expressions and body language 10) Interested and trustworthy and silent 11) Re-state to clarify 12) Focus on the feelings not just the facts Precipitating factors the client 1) Internal functioning is low such as an IQ deficiency developmentally delayed, stomach ache 2) External causes of acting out behavior over which staff has little or no control Behavior is the Tip of the Iceberg The Behavior: Acting out Challenging Screaming Refusal Out of control What is causing the Behavior? Under the water Loss of power Fear Lack of control over life Low self-esteem Displaced anger Attention seeking Feels like a failure Trauma history Loss of loved one, divorce, death Grief Change un-settling Homelessness Medical Lack of Resources Financial Problems IQ Disability

5 Precipitating factors: Staff can be a precipitating factor: 1) Bad Day 2) Tired 3) Frustrated 4) Inappropriate Body Language 5) Tone of Voice 6) Fear Rational detachment ability to stay in control of one s own behavior and not take acting out behaviors personally It is not about you. Maintain professional boundary. What to do before/during/after the crisis Integrated experience the concept that the behaviors and attitudes of the staff impacts the behavior and attitudes of others and vice versa My behavior will affect you and your behavior will affect me What do we bring to the experience? Take care of yourself as in the airplane you put your oxygen mask on before putting one on your child Staff fear and anxiety fear of defensive or acting out behavior; fear not going to be god at their job; is a natural human response. Un productive Reaction to Fear 1) Freezing can cause self or others to be hurt Productive Reaction to Fear Increase in speed and strength; person lifts a car when someone is under the car, perhaps will be crushed. 2) Over-reacting makes things worse Increase in sensory acuity you see, hear and smell things more intensely you are more aware of the situation, resources, back-up 3) Act inappropriately volume, tone, physically threatening body language Can react quicker Verbal Intervention Tips & techniques What to Do Re-direct Listen Ask relevant questions Supportive Empathetic Provide options/choices Be mindful of your tone Ask relevant questions for clear understanding Build on the relationship What not to Do Don t Yell No poor/threatening body language Don t become defensive Don t stand too close It is not about you Don t minimize No arguing Watch you tone of voice Don t order

6 Positive Body language Be clear and precise Isolate Allow to vent Remain calm Enforce limits & boundaries Be aware of non-verbals Be consistent with client and staff Set Limits Be supportive & caring Don t touch Don t be sarcastic Don t interrupt Don t ignore Don t over-react Don t make false promises Don t threaten no ultimatums Avoid jargon Don t judge Don t punish Crisis Development Model Non-verbal behavior 1) Clients crisis behavior does not necessarily happen in sequence; you may not see the acting out coming, so always know your client and be aware of triggers 2) Staff response needs to match the behavior 3) Early intervention to nip it in the bud 4) Behaviors represent feelings 5) Take care of yourself 1) Proximity 2) Facial expressions 3) Gestures 4) Comfort zone 5) Culture 6) Rapport 7) Respect personal space 8) Know the history 9) Hygiene 10) Gender 11) Size 12) Situation 13) Respect disability 14) Watch posture and motioning Para-verbal communication How we say what we say for clarity and understanding 1) Tone 2) Feelings & emotions 3) Avoid sarcasm 4) Avoid sounding impatient 5) No condescending voice 6) Volume appropriate for the distance and situation 7) Cadence rhythm, even rate of speech 8) Be concise know the audience

7 Verbal Intervention 1) Statements are simple and clear 2) Be reasonable 3) Enforceable 4) Rational 5) Consistent 6) Allow to vent 7) Don t argue 8) No power struggle 9) Don t promise what you can t deliver 10) Be aware of body language yours and the clients 11) Don t be threatening 12) Re-reestablish therapeutic support 13) Give choices 14) Questioning a. Give rational responses b. Listen c. Avoid challenging questions d. Consistency in body language e. Speech f. Don t over-react g. Do not use jargon h. Give choices and consequences i. Don t touch j. Non-judgmental k. Undivided attention l. Focus on the feelings not only the facts m. Silence n. Remove the audience o. Ask for help Client can tell the difference between staff that care about them and want them to be safe or staff that are angry and want to control Key is Self-awareness what is my intention?

8 Postvention after the crisis - COPING Client C= Control Client is back in physical and emotional control, breathing changes, not resisting, calm and coherent, stops yelling or crying, is exhausted; ask Do you want to talk now or later? O = Orient What happened? Re-collecting remembering P = Patterns Patterns of behavior and triggers I = Investigate Look for alternatives look for and offer resources N= Negotiate Get agreement or a contract for the behavior, safety contract, treatment plans, make a handshake or have them write a contract and sign it list consequences if you comply here is what happens if you don t comply here is what happens G = Give Give back the responsibility for the behavior now it is up to you. They may backslide offer back-up so they don t sabotage out of fear low selfesteem or lacks skills and confidence Staff C = Control Back in physical and emotional control staff has had an emotional reaction or staff got hurt sometimes staff does not realize how they felt or reacted needs alone time or the chat with another staff O = Orient Give facts to co-workers what happened? Fill people in as to what happened P = Patterns Staff patterns of response don t point fingers ask are some teams/staff working better than others? I Investigate ways to improve what will we do next time? Each person needs to evaluate themselves honestly N + Negotiate Agree to needed changes among staff everyone has to be on the same page G = Give Give support and encouragement to each other Say Thank you Give Thank You notes.