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Crisis Planning Tools: Training for Managers June, 2011 Facilitated by Kappy Madenwald, MSW

Participants will: Goals for Today Leave with take-away tools that can be used in staff development and training Have a broadened understanding of risk assessment and REAL risk reduction Have advanced knowledge of and gain practice in using Crisis Planning Tools Apply Wraparound principles and person-centered concepts to risk assessment and safety planning Exchange supervisory strategies with peers 2

Take-Away Tools The training tools are not intended to be prescriptive modify them to match your own style As internal trainers, take notes as we go re: the components of this consultation that particularly meet the need of your staff Consider what you can integrate into your current training plans and approach to clinical supervision. You have permission to use any/all training materials. Appreciate citation. 3

Connecting the Dots Between Safety Planning and Wraparound Principles of Care Family Voice and Choice Use of Natural Supports Community-Based Individualized Culturally Competent Team Based Collaboration Persistence Strengths-Based Outcome-based 4

Connecting the Dots Between Safety Planning and Wraparound Principles of Care What value does adherence to Wraparound principles of care have in safety planning? How does adherence to the principles make risk reduction REAL? 5

Supervisory Considerations COMPETENCY: Ability to guide safety planning and crisis intervention through a Wraparound framework Supervisory question: What are the person s/family s priorities in resolving this crisis? What is most important to them? 6

REAL Risk Reduction 7

REAL Risk Reduction REAL risk reduction includes: 1. identifying and addressing the nature of the crisis in a way that reduces harm or provides sufficient resolution. 2. Identifying through Shared-Decision Making not just the potential benefit of an action, but also the potential harm 3. Looking for and building on inherent strengths 4. Keeping it authentic having no answer is better than a pat answer, having no safety plan is better than a bad or forced safety plan 8

REAL Risk Reduction REAL risk reduction includes identifying and addressing the nature of the crisis in a way that creates sufficient resolution. When working with families and systems the nature of the crisis will almost always be different for each person/system. What words in the following definitions of crisis indicate its essence or nature? 9

REAL Risk Reduction A personal difficulty or situation that disables a person. It is also a hardship that can prevent one from controlling his or her life (Belkin, 1984, p. 424). An event as that is viewed as unbearable; it is also one that exceeds a person s usual resources and coping mechanisms (Gilliland & James, 1997, p.3). A state of disorganization in which people face frustration of important life goals or profound disruption of their life cycles and methods of coping with stressors (Brammer, 1985, p.94) An event made up of three parts: 1) a precipitating event; 2) a perception of the event that leads to distress; and 3) the failure of usual coping mechanisms, which lead to a decreased level of functioning (Kanel, 2003, p.1) 10

REAL Risk Reduction So if those words are examples of the nature or toxin in a particular crisis Disabling, unbearable, disorganizing, difficult, disruptive, distressing, uncontrolled, poor perception Then, what are the antidotes that will aid resolution? 12

The Art of Resolution-Focused (Risk Reduction) Work Definition of Antidote: A remedy or other agent used to neutralize the effects of a poison An agent that relieves or counteracts 13

The Art of Resolution-Focused (Risk Reduction) Work Sample Antidotes for crises Structure is the antidote for chaos Cognition for excessive emotion Catharsis/disclosure for tension Understanding for loss of control Action for helplessness. 14

Question: If the facts haven t changed, can there be crisis resolution? 15

What might be evidence of crisis resolution? 16

Resolution The Act or process of RESOLVING: as The act of analyzing a complex notion into simpler ones The act of answering: SOLVING The act of determining 2010 Merriam_Webster, Incorporated 17

Resolution The condition or quality of being resolute; firmness or determination Something resolved or determined; decision Return from a pathological to a normal condition Collins English Dictionary Complete and Unabridged HarperCollins Publishers 1991, 1994, 1998, 2000, 2003 18

REAL Risk Reduction Mindbenders Does suicidal thinking always mean a person is in crisis? Does the presence of psychotic symptoms always mean a person is in crisis? Does the absence of a psychiatric diagnosis mean that that a person is not experiencing a psychological crisis? 19

Supervisory Considerations COMPETENCY: Ability to get beyond the concrete facts to the essence of a situation, often from multiple views Strengthening ability of staff to identify the nature of the crisis (for child, parent, school) and, To align this with safety planning or crisis resolution strategies that mitigate (relieve, serve as antidote) accordingly Supervisory question: Stand in the person s shoes What is the nature of the crisis from their perspective? 20

REAL Risk Reduction 2. REAL risk reduction involves considering through Shared-Decision Making not just the potential benefit of an action, but also the potential harm 21

REAL Risk Reduction Mindbenders Is bringing in the police or the MCI team an example of real risk reduction? Is psychiatric hospitalization an example of real risk reduction? Is having someone sign a contract for safety an example of real risk reduction? Is a referral to the appropriate level of care an example of resolution? 22

REAL Risk Reduction Staff Exercise Stand in the shoes of the child or parent What might be the potential benefit of calling the police? What might be the potential harm? What might be the potential benefit of psychiatric hospitalization? What might be the potential harm? 23

Supervisory Considerations COMPETENCY: Ability to guide a Shared- Decision Making process that includes a consideration of pros and cons Supervisory question: How might the proposed action bring relief to what is the essence or nature of the crisis? 24

REAL Risk Reduction 3. Looking for and building on inherent strength 25

Question: Can a person/family solve a serious mental health crisis without us? 26

REAL Risk Reduction Guard against a deficit approach in safety planning gain momentum by focusing on what works Build plans and strategies around what is natural Build on the basic goodness or wellness of the person/family Help them discover: What are our core talents? Help them discover: What do we do best? Help them discover: Strategies that are sustainable 27

Appreciative Inquiry Appreciative Inquiry employs a particular way of asking questions and envisioning the future that fosters positive relationships and builds on the basic goodness in a person, a situation, or an organization. SOURCE: Appreciative Inquiry Commons http://appreciativeinquiry.case.edu/intro/wh atisai.cfm 28

Appreciative Inquiry Ap-pre ci-ate, v., 1. valuing; the act of recognizing the best in people or the world around us; affirming past and present strengths, successes, and potentials; to perceive those things that give life (health, vitality, excellence) to living systems 2. to increase in value, e.g. the economy has appreciated in value. Synonyms: VALUING, PRIZING, ESTEEMING, and HONORING. In-quire (kwir), v., 1. the act of exploration and discovery. 2. To ask questions; to be open to seeing new potentials and possibilities. Synonyms: DISCOVERY, SEARCH, and SYSTEMATIC EXPLORATION, STUDY. 29

When you change the way you look at a person, the person you look at changes. 30

Supervisory Considerations COMPETENCY: Ability to see and elicit strengths, talents, natural solutions Supervisory question: What evidence is there that person/family feels good about/has confidence in the plan? 31

REAL Risk Reduction 4. Keeping it authentic having no answer is better than a pat answer, having no safety plan is better than a bad or forced safety plan 32

Keeping it Authentic Staff Exercise Have you ever received a pat answer when seeking advice from someone? Stereotypical Trite Insincere Superficial Automatic Overly simplified Un-thoughtful Missing the mark 33

What are some examples of pat answers that you have received? Examples: 34

Put yourself back in that moment How did you feel/what did you think when you received the advice? Thoughts/feelings: 35

What do you think is the reason the person gave you pat advice? Possible reasons: 36

Striving for Authenticity What is the danger of the pat answer? Possible Danger: 37

Striving for Authenticity What did you do about it, or because of it, and why? Actions: 38

Striving for Authenticity Think back to the moment and consider the person who gave you the advice. How do you think they felt after the encounter? Possible thoughts/feelings of advice-giver 39

Striving for Authenticity What do you think is the reason the person gave you pat advice? Possible reasons: 40

Striving for Authenticity From our collective, lived experience in being the recipients of pat answers what are the strategies we can use to avoid falling in the same trap in safety planning? Strategies: 41

Crisis Planning Tools 42

Lasting change cannot be externally imposed 43

Review of Key Concepts Providers must be equipped to offer and provide safety planning and development of any or all of the Crisis Planning Tools 100% of the time as laid out in performance specifications Individual/family voice and choice guides the if, when, what and how of using any of the Crisis Planning Tools 44

Review of Key Concepts The Crisis Planning Tools are family tools rather than part of required standardized clinical documents. As such they can be flexibly used to meet the person s/family s needs, or Replaced by an alternative format that is meaningful to the person/family 45

Review of Key Concepts Plans that are filled with things that you as the provider would do will give you a false sense of confidence that the risk of harm is reduced. If the family won't do it in a crisis, it does not reduce risk of harm and it should not be on the Safety Plan. 46

Review of Key Concepts It isn t necessary to have everyone on board Dragging someone kicking and screaming to the safety planning table is counterproductive Take a Stages of Change approach See if you can figure out and address why not? What isn t helpful about this? But, voice and choice prevail 47

Review of Key Concepts Risk assessment and safety planning is not a one-time event It is a an ongoing responsibility and a developmental process Person/family competency, mastery, instinct, insight, increase through experience and honing of strategies Crisis competency must exist at all levels of care 48

Review of Key Concepts It diminishes the authority of the parent and the credibility of the plan to have it filled with actions that a child (or anyone else) is unlikely to take. Attempts to implement this kind of plan may actually escalate the household rather than reduce risk or unwanted behaviors. 49

Guiding the Development of Effective Safety Plans If a family is not ready for much, the plan should not be much. The choice is theirs to make. Build an authentic relationship that respects where they are now. When they are ready for more, we are ready too. 50

Review of Key Concepts There are a wide range of ways to decrease unwanted behaviors, to improve management of a crisis, and to reduce risk of harm The right solutions, actions, strategies are unique to an individual/family What I think is good for you and what you think is good for you are often very different (Examples) 51

Supervisory Considerations In discussing or reviewing Safety Plans look for: Less cookie cutter and more idiosyncratic Less polished and comprehensive but more authentic More focus on harm reduction than elimination of unwanted behavior respecting stage of change readiness More indirect approaches Less dependence on use of formal services 52

Safety Planning Scripts Initial (non-mci) Safety Planning Conversation Introduction to Crisis Planning Tools Exploring Individual/Family Style in Crisis Management Establishing Safety Planning Goals 360 o Action Strategies Putting Together a Safety Plan Introduction to the Advance Communication tool 53

Safety Planning Scripts These have been developed as conversation starters for staff to have with families Additional resources include: Crisis Planning Tools: Companion Guide for Providers Tear-away sheets that are attached to each of the tools 54

Safety Planning Scripts Staff Exercise With your own staff you can do this in smaller groups of 2-3 with everybody rotating roles We are going to do a large-scale role play I will be the provider Each of you, individually will play the role of either a parent or a teenage child We will go through each of the scripts with you experiencing the lived side of Safety Planning 55

Safety Planning Scripts Staff Exercise In playing the role of the parent or child, tap into your own perspective, experiences, culture, preferences, biases and/or imagine standing in the shoes of a parent or child you know well who has had crisis experience Really try to see it from a non-provider perspective 56

Safety Planning Scripts Staff Exercise While I want you to say yes to each of the processes (because otherwise the exercise would be very short), I also want you to notice if you have any desire to say no and to notice how you are feeling about the process in general Any resistance Any it won t work Any this seems to be helping Any aha new idea kind of moments 57

Safety Planning Scripts Staff Exercise There will be points where I ask you to step out of the role play to process the experience and share elements of the Crisis Planning Tools that you are developing or to think about the role play from your program perspective One last request don t rely on red box solutions 58

Safety Planning Scripts Exercise Debrief Staff development considerations Building staff confidence Assessing staff competence 59

System Logistics in Safety Planning The effectiveness of these Crisis Planning Tools for families will be impacted by how the system responds, manages and communicates the information It is important to note and talk to families about the fact that the rest of the world may not be fully ready for it And it is important to continue Crisis System of Care development strategies so that the rest of the world catches up 60

System Logistics in Safety Planning This has been a topic of conversation among many of you in recent months What advances can you report in your service area? How has this topic captured the attention of the system of care? What is on your short list for development/improvement? 61

Closing Comments