Comprehensive Crisis Management

Comprehensive Crisis Management
A Program of the Western Psychiatric Institute and Clinic of UPMC Crisis Training Institute Comprehensive Crisis Management is a program of the Western Psychiatric Institute and Clinic’s Crisis Training Institute. The mission of the WPIC Crisis Training Institute is to provide professional staff with the knowledge and skills necessary to prevent the occurrence of crisis situations in clinical settings, thus reducing the need for restrictive procedures, as well as injuries to staff and the individuals they serve. These trainer notes are provided to help support you as a trainer and are not intended to be read verbatim in the class. Please use them as a guide and reference. These are not to be handed out to the class and they are only for your use as a trainer. This material is protected by copyright and/or other intellectual property laws and is considered proprietary by UPMC. Use of this material except as set forth herein and/or selling, editing, altering, enhancing, distributing or reproducing this material is strictly prohibited. This material is presented “as is” for informational purposes only and does not constitute medical advice. ©WPIC/UPMC All Rights Reserved Revision date 9/ CCM Trainer Manual

Contributing Authors Robert Fonte RN MEd CTR, Jeff Magill CTR,
& Bobbi Jo Wendel MA NCC LPC David Julian MEd, Noreen Fredrick MSN, Mary Kay Rahuba MSN, Michael Boland MSEd, John McGonigle PHD, Kimberley Saft Rentschler LCSW PHD, and Richard Boland MBA EMT-P The authors of Comprehensive Crisis Management would also like to thank the hundreds of CCM trainers for their support, commitment to quality training, and the opportunity to learn together over the years. Revision date 9/ CCM Trainer Manual

Goals of Comprehensive Crisis Management
To promote the safety of individuals receiving and providing care To reduce the use of seclusion and restraint To encourage the use of best practices To promote an environment of partnering and collaboration To eliminate the use of aversive/coercive interventions Revision date 9/ CCM Trainer Manual

Program Components Holistic assessment Suicide awareness
Trauma Informed Care Staff self assessment and self care Prevention and Crisis Communication Intervention Postvention Physical escape intervention Emergency safety intervention Revision date 9/ CCM Trainer Manual

Prevalence of Assault It is important to start to discuss the prevalence of assaults in the areas that we work. Do the staff that we work with believe that there is a high likelihood of being verbally or physically assaulted while at work? Or do they believe that there is a low likelihood of being assaulted? Some staff come to our fields being prepared for assaults, but some of the staff we work with, may not have any preparation for this. From experience we know that there is a high likelihood of experiencing verbal assaults and depending on where you work, there may be a high or low incident of physical assault. Revision date 9/ CCM Trainer Manual

From 2005 through 2009, of the occupational groups examined, law enforcement occupations had the highest average annual rate of workplace violence (48 violent crimes per 1,000 employed persons), followed by mental health occupations (21 per 1,000) (U.S. Department of Justice, 2011) The following statistic highlights that between that Law Enforcement had the highest incident of assault with mental health occupations following. This is important to realize and see how this relates to our own programs. For people working in schools, teachers have 6 incidents per 1000 staff members. The following information is important to note as well. It is important to note the relationship for victims to the staff members who were assaulted. Of the total number of instances of workplace violence: The patients/customers was the perpetrator in 5.4% and 12.5% of workplace violence cases towards male and female workers respectively. Co-worker perpetrated 16.3% against male workers and 14.3% against female workers Intimate partner, other relatives, and well-known acquaintances perpetrated 13% against male workers and 21.3% against female workers. Below are some more statistics/information that you can use for this section. “The occupations with the incident of assault, primarily due to robberies, in 2009 were service station attendants, barbers, taxi drivers, security guards, and lodging managers.” (National Council on Compensation , 2012) “Assaults and violent acts accounted for 44 percent of [injury] cases to psychiatric aides...” – to keep this in perspective, psychiatric aides are typically younger workers and less prone to other workplace injuries. Revision date 9/ CCM Trainer Manual

Care should be taken not to over-emphasize any single factor in the etiology of violence…..there is usually a host of factors at the individual, organizational and environmental levels (Beech, Leather, 2005) It’s easy to choose a single reason for the violence manifested by an individual but in order to work with the individual, when they are not violent, we need to sort out as many of the precipitating factors as possible. For example, we often will say that someone is acting violent because they don’t like me, they are trying to be manipulative, they are trying to intimidate, etc. but often we fail to look at underlying causes such as trauma, symptoms of mental health, substance abuse and other causing factors. We often associate violence with anger, but what about frustration, fear, bullying, embarrassment, poor coping skills just to name a few. There are also financial difficulties, chaos in the family, emotional losses etc. And we need not forget being overheated, being intimidated, etc. Our task always is to explore the difficulties faced by others and then to see if there are factors or skills that can be acquired to give the individual an alternative way to act. Revision date 9/ CCM Trainer Manual

Holistic Assessment Goal of this slide is to brainstorm about what are all the risk factors of violence and aggression, reflecting back on all the factors of the individuals we’ve worked with who have been aggressive. We DO NOT want to get pigeonholed into a specific perspective. For example, PTSD as a risk factor? Sure, but not useful in an inpatient unit with 80% of people meeting criteria. Autism as a risk factor? Sure but again this is more useful in a classroom with 1 of 30 kids with autism than an program designed for kids with Pervasive Developmental Disorder. We can start to look at the core risk factors: History of violence especially in similar situations, expressed intent or threats, agitation/overt escalation …. Everything else depends (and even these may not be useful in some circumstances) Revision date 9/ CCM Trainer Manual

A wholistic approach to violence risk assessment
Be aware of yourself Appropriate apparel? Fatigued? Distracted? Trust your gut! When in doubt, get out! Be aware of your patient Overt threats, posture, history, etc.? Be aware of the environment Visibility on milieu Staffing Wholistic – in the “looking at the whole situation” sense (not the “crystals and incense” sense) Look at individual (staff), individual (consumer/patient) A good approach to violence risk awareness is not limited to looking at patients – critical to also look at environment and what we ourselves (or our colleagues) bring to the equation. Some patients may be much more or less likely to engage in aggressive behavior depending on the environment or the staff they are interacting with; some environments or some “professionals’” behaviors may be more or less likely to evoke a violent response. I once heard a security guard loudly ask a patient in a medical ER, “what part of sit the f*** down and shut the f*** up didn’t you understand?” Guess what happened next? If you guessed the guard got punched hard enough that one of his teeth flew across the exam room, you were right. There are many more personal, patient, and environmental factors than those listed (encourage participants to brainstorm and list factors they have noticed in their own experience or work) Self factors – fatigue, counter transference, distracted, appearance (stethoscope, lanyard or scarf around the neck? Provocative, tight-fitting or revealing clothing? Practical shoes?), adequate training and practice, enough physical space between you and the patient Patient factors – diagnosis, history of aggression, substance use / intoxication, expressing threats, psychosis, pain, etc. Environmental/unit factors – crowding, noise level, are all areas visible to staff (and is there enough staff to watch all those areas)? Do you know who/what is behind you? Is dinner running late? Did another staff member just turn off the TV because it is lights out (with three minutes to go in the 4th and the Steelers and Ravens in a tie)? Do you know where the nearest panic alarm or fellow staff member is? Some days, you walk onto a unit (or home or classroom) and can just feel the tension. Take it seriously If you have a hard, objective, clinical reason to be concerned about a person being violent, take it seriously. If you have a gut instinct that you can’t put your finger on making you concerned that a person might be violent, take it seriously. When in doubt, get out -- retreat, regroup and review your concerns, options and plans with your teammates. Revision date 9/ CCM Trainer Manual

Impact of Stress on the Human System (Fredrick and Rahuba 1994)
Goal of this slide is for the participants to understand how stress impacts the human system both on the individuals that we work with but also on ourselves. Below is background information that is useful to explain the slide, the goal would be to use an example or examples that allow the participants to understand the concept. For example: You wake up in the morning and things are off to a good start, you are starting your day at your baseline. As you are getting ready to leave for work you spill coffee all over your clothes and have to change. You are running late which is creating a change or a stressor. You start to drive to work and you realize that the traffic is bad and you are going to be late. You begin to have a buildup of energy- you start tapping the steering wheel and you can feel your patience wearing thin, you start to drive more aggressively, etc. At this point you can use a coping or defense mechanism. If you use an effective coping or defense mechanism, you may smoke a cigarette, talk to a friend, listen to music, or practice deep breathing. You realize that you may be late but that things could be worse and quickly your mood returns to baseline. Or if you use a non-effective coping or defense mechanism, you may start to have more road rage, yell at the other drivers or even get into a physical altercation with someone who cuts you off. This is a tool similar to those used in many other crisis management training programs. It is designed to show the impact of stress on human beings and the possible outcomes of that stress. Baseline: Baseline refers to an individual’s normal level of functioning, that is, how they usually present themselves. It is important to know an individual’s baseline in order to assess their level of escalation. Change or Stressor: From our baseline, a change or stressor is introduced. Many staff members are aware that either positive or negative change can create stress. It is also important to remember that we also experience external and internal stress. External stress is more obvious. It is some event that causes stress. Internal stress cannot be seen, but individuals may escalate to aggression from symptoms of their illness, intrusive thoughts, worrying, guilt, fear, etc. Buildup of Energy: Following the change or stressor, there is a buildup of energy. Individuals may begin to pace, perspire, become flushed, clench their fists, etc. While these are some of the more obvious signs that an individual is escalating, staff should be aware that any significant change that happens too quickly could be an indication that the individual is in crisis. For example, if a normally very talkative and active individual becomes quiet and withdrawn, staff should be sure to investigate and offer appropriate assistance. Coping and defense mechanisms: Once we experience this buildup of energy, individuals use coping and defense mechanisms in an effort to release this energy. Coping mechanisms are generally behaviors or “things that we do” to help ourselves calm down. Examples of coping mechanisms include exercise, smoking, listening to music, sleeping, eating, etc. Defense mechanisms are thought processes or “things that we think” to help us calm down. Examples of defense mechanisms include denial, projection, reaction, formation, etc. Effective or Non-effective: Our coping and defense mechanisms will either be effective or non-effective at releasing the buildup of energy that we can experience. If they are effective, we return to our baseline and do not become aggressive. If they are non-effective, we may escalate to verbal or even physical aggression. One main point is that it is important not to “label” every behavior as “healthy” vs. “unhealthy” or “appropriate” vs “inappropriate”. This is because we tend to use coping and defense mechanisms that work for us regardless of how unhealthy or inappropriate they may be. We can also look at effective vs non-effective as the strategies that we use to interact with individuals we work with. If the strategies/interventions we are using are effective for that individual we can help them return to baseline. On the other hand, if the interventions/strategies that we are using are non-effective, we need to switch intervention styles or it may escalate the individual to acting out verbally or physically. Early Intervention: Obviously, in preventing crisis situations, it is very important to intervene as early as possible in this process. To take it a step further, consider the “restaurant example”. That is, when working with groups of individuals, it is important to treat your area like a restaurant. This doesn’t mean that staff must walk around and serve people. It means that staff must intermittently touch base with everyone in their care the way a waiter or waitress would. Functioning in this manner has proven time and again to decrease the number of crisis situations that arise. Revision date 9/ CCM Trainer Manual

Predicting cold weather and snow is easier to do correctly in Alaska than in Ecuador
Understanding violent behavior requires an understanding of the context in which any given behavior has occurred or may occur. The context includes characteristics of the person we are working with (history of aggression, mood, impulse control, feelings of frustration or powerlessness), environment (too hot, too cold, too crowded, too noisy or over stimulating), ourselves as clinicians (are we tired, abrupt, or just somebody that the person we are working with doesn’t like). High frequency events are inherently easier to predict than rare or unique events. If a person became agitated and violent 15 out of the last 15 times he ran out of his medications and he has been out of his medications for the past week, then the odds of him becoming violent are pretty good and caution should be taken. If a person has had a slowly evolving delusional system about aliens replacing elected officials and that she has been told to kill one representative in particular leading to a crafted plan to obtain a gun, the representatives public appearance schedule, etc. it is likely to be much more difficult to predict. Both types of violence are concerning; we want to prevent or mitigate both if possible, but they both prevent very different types of challenges Recognize that all violence is not the same – not the same type of violence, the same scale or the same frequency Revision date 9/ CCM Trainer Manual

For a risk factor to be useful, it needs to be Specific
For a risk factor to be useful, it needs to be Specific Sensitive Accurate Reliable Practical For any given behavior we want to adjust – aggression, suicide, etc. – we can identify risk and protective factors. They can be either dynamic or static. Risk factors – increase likelihood of unwanted behavior (substance use, undertreated depression, history of violence) Protective factors – decrease likelihood of unwanted behavior (supportive family, job, good insight, hope) Dynamic factors – something that we can change with a clinical intervention (pain, fatigue/insomnia, substance withdrawal) Static factors – Something that we cannot change (gender, race/ethnicity, age, socioeconomic status) We want to be aware of static risk and protective factors. We should look for ways to correct dynamic risk factors (e.g., remove the gun from the home, treat the depression, give the hungry person a snack). We should be aware of dynamic protective factors, work to strengthen them, and increase our vigilance for risk when the dynamic protective factor is in jeopardy or is lost (e.g., the patient identifies her good relationship with her coworker as a major factor helping her feel safe and in control; that coworker broke her leg over the weekend and will be out for at least 4-6 weeks). There are lots of ways of looking at risk and risk factors. For most clinical settings, there are no “magic formulas,” equations or other purely objective tools. A fair bit of the process comes down to good clinical assessment and consideration of known/knowable risk factors. There are many risk factors that have been studied. The most useful risk factors are practical (easy to find/confirm), reliable (two clinicians are likely to correctly recognize the presence or absence of the risk factor), sensitivity (the risk factor is likely to predict violence risk) and specific (the risk factor is not common in people who are not violent) There are actuarial tools (e.g., an instrument or checklist that yields a score predictive of violence risk) that are quite useful – but they are tightly limited to the specific population that was studied. The most useful and practical risk factors will be those that are easily identifiable in our usual clinical assessment and history taking. Serotonin receptor mutations? In utero exposure to maternal smoking? Large classroom size during elementary school? Yes, all increase the risk of violence. Generally, though, none are especially sensitive, specific or practical Current/very recent threatening acts or statements? Useful! Past history of violence? Useful! Especially in a consistent context – if a patient has a frequent history of physical assaults on nurses during multiple prior admissions, then increased caution is warranted when he is about to be admitted. If a patient has a long history of bar fights but has never been aggressive during multiple prior psychiatric admissions – well, maybe less risk, but certainly not no risk. Revision date 9/ CCM Trainer Manual

Risk Factors for Violence
Recent Acts or Intent > Ideation or Fantasy Past history of violence, esp. with the identified target (e.g., domestic violence) Explicit threats > implicit threats More specific plan (esp. with “evasive” features) Limited coping mechanisms or supports (or loss thereof) Recent increase in psychosocial stressors Impulsivity Substance use (esp. alcohol, cocaine, speed) Suicidality, hopelessness Untreated/under-treated mental illness High risk factors are highlighted in blue; not a comprehensive list Recent acts or expressed intent and a past history of violence are the two strongest risk factors for future violence – especially in similar or related contexts. That said, some people who have chronic low level fantasies of violent acts do go on to carry out those fantasies and every person with a long history of violence was violent for the first time at some point. “I’m gonna f*** you up” is concerning; “I’m gonna wait until shift change, then when everybody is back in report I’m going to shove you in the bathroom and rape you before I choke you to death” is more concerning. Specific plans – Operational planning of where to attack, what to use, obtaining or improvising weapons, etc. all very concerning, especially when there is consideration of evading intervention or capture Substances – Substances which cause agitation or disinhibition with intoxication (cocaine, meth/speed, EtOH, K2, Bath Salts) Substances which cause agitation or disinhibition in withdrawal (Benzos, opiates, EtOH, THC) Substances which cause dissociation or altered sense of reality (K2, Bath Salts, PCP, ketamine) Suicidality and hopelessness can be significant facilitating risk factors for planned violence: if you are planning to be dead or suicide by cop, then you are likely unconcerned with the repercussions of assaulting or killing somebody else Revision date 9/ CCM Trainer Manual

Risk Factors Male > Female in the community
Male = Female in inpatient settings Generally SUD + Major Psychiatric Disorder SUD alone No SUD/psychiatric disorder Psychiatric disorder Psychiatric patients are victims > perpetrators In the community, Men are more likely to be aggressive than women; also in the community, adolescents and young adults are at the highest risk for aggression and violent behavior – but a low GAF score (i.e., the basic criteria for a psychiatric admission) becomes a powerful equalizer. On an inpatient unit, any patient has the potential for violence Important to note that acute psychiatric treatment settings “distill” violence risk – in general, people with MH issues are not at especially heightened risk for aggression and are in fact more likely to be a victim than a perpetrator of violence. We always need to be vigilant and care for our own safety and that of our team – we also need to be careful that we do not become jaded or prejudiced from the reality of violence and MH. In the community, on release from a psychiatric facility, people with addiction issues (with or without other comorbid psychiatric illnesses) have the highest risk for future violence. People with only a non-addiction MH diagnosis tend to be less likely to engage in violent behavior than people with neither a substance nor any other MH dx. --Monahan et al. Rethinking Risk Assessment: The MacArthur study of mental disorder and violence. New York: Oxford University Press, 2001. In one study, people with SMI (serious mental illness) – e.g., schizophrenia, severe Major Depressive Disorder or bipolar disorder – have about a 15% risk/year of being a victim of a violent crime and are at least 4 times more likely to be victims of violent crime compared with the general population. See Teplin et al. “Crime victimization in adults with severe mental illness.” Archives of General Psychiatry 2005 August 62 (8): Amongst several other studies with similar findings. SUD= substance use disorders Revision date 9/ CCM Trainer Manual

What can a diagnosis tell us? (DSM-IV-TR)
Axis I Clinical Disorders Axis II Personality Disorders & Cognitive Disabilities Axis III General Medical Conditions Axis IV Psychosocial and Environmental Factors Axis V Global Assessment of Functioning (GAF) Today we understand so much more about why individuals may exhibit challenging behaviors. This slide is designed to explore many of the reasons that individuals may become aggressive. We start to look at and understand that every behavior has a purpose or etiology. If we know the reason for the behavior, we will be much more effective with our interventions and treatment. Axis I: An Axis I diagnosis is the primary clinical disorder or primary psychiatric diagnosis. Examples of Axis I disorders include: Schizophrenia, Bipolar Disorder, ADHD, Obsessive-Compulsive Disorder, Post Traumatic Stress Disorder, Substance Abuse and Chemical Dependency, Anxiety, Depression, etc. The behaviors that may present with these disorders are more commonly symptoms of the illness that are treatable with a combination of medication and therapy. With each diagnosis, there is a list of both positive and negative symptoms that we should expect individuals to exhibit. Some of these symptoms can lead to situations where the individual may become aggressive, especially if not fully understood by the staff member intervening. An example may be an individual diagnosed with Schizophrenia that is experiencing paranoid delusions. If the staff member does not understand the fear that accompanies these delusions, they may accidently force the individual into a situation where he/she feels no alternative but to become aggressive. Axis II: Axis II disorders include: Personality disorders and cognitive/learning disabilities. Regarding personality disorders: many staff members have reported difficulty providing treatment for individuals with personality disorders. It is important that we treat individuals diagnosed with Personality Disorders with the same respect that we afford to anyone else and provide the highest level of care possible at all times. This is important for two reasons: 1. It’s our job and our obligation As with anyone else, failure to do so can make it more likely that the individual will become aggressive. We also want to consider that people in these categories have often been through years of repeated trauma and look at their behaviors through Trauma Informed Care lens. Regarding Cognitive Disabilities: programs that are specifically designed to provide treatment for individuals diagnosed with cognitive disabilities tend to assess and accommodate each individual’s strengths and weaknesses well. However, it is at times when we do not know that an individual may have this type of disability that we may put them in a very frustrating position. For example, we often ask individuals in our care to complete written documents. However, if we are not aware that the person is unable to read or write, they may become frustrated and embarrassed. Axis III: Axis III refers to general medical conditions. Several medical conditions can cause an individual to become aggressive. The most common of these may be pain. Individuals experiencing a high level of pain are more likely to become aggressive. The most common of these may be pain. Individuals experiencing a high level of pain are more likely to become aggressive. Other examples include hypoglycemia, urinary tract infections, seizures, side effects of medications, head injuries, etc. Hypoglycemia, in particular, may be initially misunderstood because the individual may appear to be intoxicated. In other words, their gate may become unsteady, their speech may be slurred, and they may be disoriented. In addition, individuals who are “non-verbal” may exhibit what appears to be self-abusive behaviors but in reality, this behavior is due to a medical condition. For example, a gentleman began to punch himself in the face because he was unable to communicate to staff that he had a sore tooth. Axis IV: Axis IV refers to psychosocial and environmental factors. This includes an almost infinite number of possibilities that must be considered when providing treatment. Examples include, but are certainly not limited to: homelessness, legal issues, family conflict, divorce, loss of job, financial issues, history of abuse or trauma, etc. Axis V: Axis V refers to an assessment of the individuals level of functioning. A higher Global Assessment of Functioning “GAF” score indicates a higher level of functioning, and a lower “GAF” score indicates a lower level of functioning. *Note to trainers: These brief descriptions provide some examples that may be helpful for staff. All trainers should provide detail on the most common diagnoses in each Axis encountered at their specific facility. Also, you want to remind staff that there is no diagnosis for violent behavior! Revision date 9/ CCM Trainer Manual

What’s the real story? Adam, an older adolescent with early onset schizophrenia and a history of gang involvement shoots and kills Billy who was having sex with Cathy, Adam’s ex-girlfriend We need to fight the temptation to come up with a psychiatric/MH/pathology for every violent act. Take the Adam story set up above (taken from an actual case). Adam and Cathy broke up. A few weeks later, at a house party, Adam finds Billy and Cathy having sex at which point he shoots and kills Billy. Law enforcement professionals often hear the case and say that it was about pride and revenge after he lost his girlfriend. MH professionals often wonder about command hallucinations. In reality, Adam was slowly decompensating – acting stranger and attending to hygiene more poorly leading to the breakup. He went to a neighborhood party to blow off some steam and smoke some pot. While wandering around the house he hears Cathy scream for help from behind a locked door. He kicks the door down and sees Billy raping her at knifepoint; Billy pivots and heads towards Adam with clear intent to stab him. Adam draws, shoots and kills. Encourage trainers to come up with similar scenarios that may have more salience for their clinical setting. -- Maybe elderly demented woman in a nursing home hit a male resident in head with a cane leading to coma; was act in self defense because he was sexually disinhibited or aggressive? Alternatively, what do you think about the guy who leaves home every day, carries a high caliber handgun, owns more guns, sometimes leaves the house even wearing a vest, he reviews neighborhood crime reports almost every day and thinks there may be an increase in gang activity; he says he is always watching his back and that most days he just drives around the neighborhood “looking for trouble?” Paranoid or law enforcement professional? Keep in mind that a little healthy paranoia and hypervigilance can save your life in some lines of work. Moral of the story – not all violence is pathological or linked to a mental health issue; it is a false assumption to think that understanding MH issues alone is enough to have a reasonable understanding of violence risk and management. Revision date 9/ CCM Trainer Manual

Anxiety Regardless of diagnosis or situation, anxiety is probably one of the biggest factors affecting any crisis situation. It will present anytime a person is in “crisis”. As our anxiety increases, we are affected in several different ways. Anxiety is part of the holistic assessment- we want to begin to assist if we believe that anxiety is something that is getting in the way of a positive intervention. Have the participants start to think about the last time that they were anxious and how they acted, how their thoughts were and how the experience was for them. Have them continue to think about this as we talk about anxiety over the next couple of slides. Revision date 9/ CCM Trainer Manual

“During a crisis situation, anxiety may be the biggest roadblock to a positive outcome”
Since anxiety is universal it’s effects can impact either the individual in our care or the staff member intervening. In the next several slides you see how anxiety impacts us through our thoughts and behaviors as well as how it can become the biggest roadblock. Revision date 9/ CCM Trainer Manual

Perceptual field narrows Distortion of time Negative thinking
As Anxiety Increases Perceptual field narrows Distortion of time Negative thinking Physical symptoms (Sapolsky 2003) The following are symptoms or behaviors that can occur as our anxiety increases. It is important to remember that this can happen both for the individuals we work with as well as us. It is important to be aware of how anxiety can impact us. Perceptual field narrows: As our anxiety increases, we develop “tunnel vision” and are only able to see directly in front of us. This is important for a few reasons. The first is that staff members must be sure to interact with the individual in crisis only when they are directly in the person’s line of sight. If the person cannot see us, we should not assume they can hear us. Also, with such small visual field, it is important that only one staff member at a time interacts with the individual. More than that will most likely be confusing and frustrating. Distortion of Time: Time is a very abstract concept. Anxiety makes it difficult for us to gauge the passing of time. This concept is easy for most staff to understand by recalling the last time they had to visit a hospital emergency room to seek treatment. Most people report that even a few minutes of waiting for care while in pain or while ill feels like much more lengthy period of time. Example: One of the trainers was honored to meet a gentleman at the Que Creek Mine (Pennsylvania) incident. When asked how long he had been on the scene, the gentleman was unable to respond. He had lost all sense of time. Most troublesome to this gentleman was that he could not remember how long it had been since he called home to check on his wife and children. In general when explaining time, it is better to give concrete markers for when events will happen. An easy example is saying that an event will occur after dinner as opposed to six o’clock. More humorously, individuals working with small children will remember explaining time in terms of number of “Sponge Bob” episodes rather than time according to a clock. Negative thinking: Negative thinking does not require much explanation. It can range from overall pessimism to catastrophizing. Cognitive reframing may be beneficial if the person is capable. Physical symptoms: Many individuals report the presence of physical symptoms during times of high anxiety. Headaches, stomachaches, shortness of breath, etc. are not uncommon. Revision date 9/ CCM Trainer Manual

Increased anxiety can also cause
Difficulty processing information Difficulty with new information Short-term memory impairment Therefore, Individuals may require frequent reminder (Sapolsky 2003) We continue to look at how anxiety impacts. We want to remember that this can happen for both staff and the individuals we work with. Difficulty Processing Information: Processing is a very complex topic. For our purposes, we are talking about an individual’s ability to receive information, sort, and make sense out of information, and communicate information. All three of these areas will be affected regardless of diagnosis. It is also important to consider that many psychiatric diagnoses include some type of processing difficulty. This can compound an individual's ability to process and greatly diminish the amount of information they can handle at any point in time. Most individuals will just require brief simple directions or statements. In the extreme, individuals may lose all ability to interpret auditory information. Staff may need to revert to visual gestures and modeling in order to gain compliance. This is due to the fact that visual stimuli are easier to process than auditory stimuli. An example of this technique can often be seen with small children where most instruction includes modeling. In other words, show them what to do, don’t tell them. Difficulty with New Information: It’s well known that individuals have difficulty taking on new information when they are anxious. What this means is that you cannot teach a new coping skill during a crisis situation. For this reason, it is important that staff members ask individuals in their care what coping methods they have found effective in the past. Many services include this on their initial assessment or treatment plan. Short-Term Memory Impairment: Short-term memory impairment is rather self-explanatory. We simply don’t remember well from one minute to the next when we are anxious. This can often be misinterpreted by staff as non-compliance because it brings on the Need for frequent reminders. Staff members often have to answer the same questions or repeat the same directives many times. As a general rule, it is better to continue this process because it allows the individual to relieve some stress. Staff should be very careful not to say things like “I’m not telling you again.” Once this occurs, the individual’s anxiety may increase and the result can be aggression. Revision date 9/ CCM Trainer Manual

Suicide Awareness In 2009, suicide was ranked as the 10th leading cause of death among persons ages 10 years and older, accounting for 36,891 deaths. ( Since suicide is such a universal and highly impactful topic you may see a variety of responses in your class. During this time, it is ideal to have a plan in place that as one trainer is speaking about suicide, the other trainer is overseeing reactions that the participants may have. If someone would leave the room due to being upset, the trainer not teaching should check on that person. Its also important to emphasize confidentiality during this part of the training because suicide could be impactful for any of the participants. Revision date 9/ CCM Trainer Manual

Startling Statistics (2009 United States data)
One suicide every 14.2 minutes 10th ranking cause of death in the US 922,725 suicide attempts every year (est.) 5 million living Americans have attempted suicide 1 in every 65 people are a survivor of suicide Firearms used in 51% of suicides When discussing suicide, it is important for the participants in your class to have an understanding of the impact of suicide. According to the CDC there is one suicide every 14.2 minutes (which is over 101 suicides a day). In the 8 hours that it takes to teach or participate in a CCM class, it is estimated that approximately 33 people in the United States have died by suicide. It is also important to realize that every 14.2 minutes that there are at least 6 more survivors of suicide. It is important to have the people in the class acknowledge and start to understand the impact that suicide has on our country by reviewing some of the other statistics. It is also important to note that suicide has been increasingly getting worse in the United States. From 2006 to 2009 the numbers have increased significantly. In 2006 it was 15.8 minutes vs 14.2 in In 2006, it was the 11th leading cause and in 2009 it is the 10th. The number of suicide attempts from 2006 to 2009 (reported) went up well over 100,000 attempts. Another important statistic is that there are 3.7 male deaths by suicide for every female death of suicide yet there are 3 female attempts for every male attempt. You can get specific state statistics from the following website: These statistics were found on the CDC’s website. ( Revision date 9/ CCM Trainer Manual

Young Adults and Suicide
Suicide is the 2nd leading cause of death among year olds and the 3rd leading cause of death among year olds (CDC). Revision date 9/ CCM Trainer Manual

Which person is suicidal?
Which person seems suicidal? Do you notice any warning signs? Why? Start a discussion with the class about assumptions and clinical reasons why they would believe that either or neither of these individuals may be at risk for suicide. Some common ideas about why they may feel that these individuals are suicidal are: affect, tears, dress, somber look, age group, ethnicity, gender, etc. Some common ideas about why neither of them may feel suicidal are: support system, reasons to live, friends, family, religious beliefs (ie. protective factors) Revision date 9/ CCM Trainer Manual

Are there any risk factors?
What are the risk factors associated with this couple in relation to suicide? Again create a short discussion about whether or not the class sees any risk factors for suicide. Often times, people will assume that this is still the highest age category of concern, but please see statistics below. Make sure to pay attention to age but also create discussion about what a suicidal persons affect may or may not be like. (i.e smiling can be seen as happiness or it can be also seen as a sign of relief after the decision to complete suicide was made) According to the CDC, an average of one older person every 1 hour and 30 minutes dies by suicide. Elderly individuals (65+) 5,858 died by suicide in 2009, which is 16 per day. This is about 15.9 percent of the annual reported suicides. For the longest time white males over the age of 65 were at the highest risk for completion of suicide. According to the CDC in the most recent statistics (2009), the age group is actually much higher and there has been a decrease in risk for the 65 and over category. In this age group, the highest risk is the age ranges from 45 to 54. Revision date 9/ CCM Trainer Manual

Common myths about Suicide
If a person talks about suicide they are seeking attention Suicide happens without warning signs If you ask about suicide you will put the thought in their head If someone doesn’t leave a note, it wasn’t a suicide Once suicidal, always suicidal Doesn’t run in the family All of the above are current myths but are commonly believed, especially ‘don’t mention suicide.’ Some of these myths will currently be held by the participants in your class. It is important for staff and ourselves to see what values and myths we hold true that can sometimes interfere with the care that we provide. For more information on myths about suicide, see “The meaning behind popular myths about suicide” by Charles Neuringer, Omega, 18(2), or Ed Shneidman’s book, “Suicide as Psychache” published in 1993. Revision date 9/ CCM Trainer Manual

Motivations for Suicide
Loss or change Feeling as if a situation won’t change To not feel pain of a situation Impulsivity Point out the common theme of subjectivity in top three lines. The person who is considering suicide defines the words loss, change, important, perceived, and intolerable. What may be intolerable for them, for instance, may seem very tolerable to you. Please don’t judge them based on your experiences and values! Relationship problems are present in approximately 2/3 of completed suicides. Listen for relationship issues. Ending pain is a common theme. May be hard to understand but many don’t want to die - they just want to end the pain they feel. Revision date 9/ CCM Trainer Manual

Direct vs. Indirect Clues for Suicide
The goal of this slide is to create a discussion with the participants about ideas that they have about direct vs. indirect clues for suicide. See the information below for ideas and themes that may come to us as well as a definition of each. Direct Verbal Cues about suicide is a very direct way that someone may let someone else know that they are contemplating suicide. Some examples of direct verbal cues are: I’m going to kill myself, I wish I were dead, You’d be better off without me, I might as well be dead, If …doesn’t happen, I’m going to end it, I’m going to commit suicide. Indirect Verbal Cues about suicide are non direct or vague ways that people may talk about suicide. Some examples of indirect verbal cues are: I can’t go on any longer, I’m taking the plunge, We all have to say goodbye sometime, Nobody needs me anymore, I’m tired of life, You won’t be seeing me any more, Life has lost meaning for me, I can’t take it any more, You’d be better off without me, I can’t take the pain, Eat my gun, You’re going to regret how you treated me, Cash in my chips, Fold my hand. Direct suicide indicators: These are ways that someone might make a gesture or indicate to someone else that they are thinking about suicide without directly coming out and telling them. Buying a weapon Giving away possessions Making a will Talking about a long trip Taking unusual risks Changes in personality The “practice run” Sudden religious interest/ disinterest Substance abuse relapse Revision date 9/ CCM Trainer Manual

Decreased Probability Increased Probability
Striking a Balance / Daniel Clark, PhD Risk Factors Vulnerabilities Problems Develop Decreased Probability Of Suicide Increased Probability Protective Factors Strengths and Competencies “Resilience” Protective Factors Keep Risk Factors In Balance Protective Factors Balance Risk Factors Every person is at some risk for experiencing a serious behavioral health problem based on their balance of risk and protective factors. Key Is To Increase Protective Factors And Decrease Risk Factors The key for suicide prevention is to increase the protective factors and to decrease those risk factors that can be modified. The take away in this is that we are not just focusing on getting rid of negative factors but to make sure positive factors are present in the lives of individuals. The balance may not be as shown on this screen by the end of the intervention, the goal is to decrease the probability of suicide. Revision date 9/ CCM Trainer Manual

Treatment or Hospitalizations Trauma Present (Now): Means
Past: Previous Attempts Mental Health Drug/Alcohol Family History Treatment or Hospitalizations Trauma Present (Now): Means Plan/Ideation Medication Drug/Alcohol Psychiatric Illness Intent Furtherance Medical Conditions Feelings Life Problems Military Experience Future: Hope Protective Factors Resources Willingness for safeplan There are a lot of areas of someone’s life that we want to focus on when discussing suicide. We want to look at the past, present and future. The goal of this slide is for the participant’s to understand that there is a multitude of reasons why someone may be more likely to turn towards suicide as an option than others. First starting with the past we would like to know about: Previous attempts: Past behavior is always the best predictor of future behavior. This is also true of suicide. Those who have attempted suicide in the past are more likely to attempt suicide in the future. Mental Health/Psychiatric Illness: Research reports that those who have a psychiatric illness are at greater risk of suicide. Alcohol or Drug Use: Alcohol and/or drug use increases an individual’s risk of suicide as well as increases their impulsivity while reducing their decision making skills. Knowing that someone has a past history of this allows us to know what risk factors we currently have. Family History: Research reports that those who have a family history of suicide are at greater risk of completing suicide themselves. Treatment or Hospitalizations: Research reports that a fair number of completed suicides occur after someone has recently seen a doctor, left treatment or left the hospital. Trauma: Individuals who have a history of severe trauma are at risk for suicidal thoughts and behaviors, so it is important to know if someone has a history of trauma. After we have looked at someone's past, we really want to know what is occurring in the present. Some of the areas we want to focus on are: Access to lethal means: Much of the research reports that those who have access to firearms are at greater risk of completing suicide. However, there are many other means to suicide that are extremely lethal. We want to make sure that we realize that if someone is so desperate to commit suicide that anything can be used for a lethal means. People often just think of the big ones- pills, gun, bridge, rope, etc, but in reality there are a lot more. Suicide Plan vs. Suicide ideation: We want to be able to understand if the person has taken the suicidal thoughts and started making a suicide plan. Have they thought about which means they would use, when they would go through with this, how to wrap up lose ends, etc. Suicide ideation can turn into suicidal plan over a quick or short period of time. Knowing if the individual has a plan is just one piece of putting the “puzzle” together. Plans range from very simple and direct to very detailed and intricate. Medication: It is important to know if the individual is currently taking medication, whether that medication has a side effect of suicidal ideation or whether they are supposed to be taking a medication and are not currently doing so. Psychiatric Illness: Some psychiatric illnesses make someone more likely to have suicidal thoughts than other. It is also good to know if someone is active in treatment or if they have been non compliant. Intent: Above all else, knowing the individuals is vital. A person may have a plan and the means, but no intention of committing suicide. On the other hand, and individual may have already made a decision and have very high intent. Furtherance: Furtherance is looking to see if the individual has taken any step towards suicide. This can often be writing a note, giving away belongings, sending out text messages, stocking up on pills, buying a firearm, looking up or purchasing poison from the internet. We really are looking for whether they are having suicidal thoughts or whether those thoughts have turned into any action. Medical conditions: Medical conditions are often overlooked as a risk factor for suicide. However, the presence of a medical condition is extremely important. Medical conditions that cause chronic pain, are terminal, untreatable, or limit a person’s ability to work and enjoy life are of the greatest concern. Feelings: Most often the feelings that people look for in someone who is suicidal are feelings of hopelessness, helplessness, and sadness (depression). These are common feelings/emotions that someone who is feeling suicidal may feel. We also want to look for someone who has had periods of depression or hopelessness that then has a period of being at peace as a warning too. Often times, once an individual has made a decision about suicide, there may be a period of being at peace or seem happy. We need to watch for changes in emotion. Life Problems: Not everyone who has feelings of suicide has a mental health or substance abuse issue. People struggle with life problems (losing a job, a bad breakup, divorce, losing custody of children, failing out of school, etc). Not everyone who has a struggle in life will think about suicide, but at times these struggles become too much and suicide becomes an option. Military Experience: There has been an increase in military suicides. It is important to know if someone has a past or current history with the military. We want to look for if they have frequent deployments, lengthy deployments, experienced severe combat or had sexual assault during their service. For more information about this, you can watch this video: or read this article: After looking at the past and present, we really want to explore the future. Hope: It is important for the individuals that we work with to have hope, to see that there are reasons for living and that this is a temporary feeling that there is help for. As staff, we want to help instill hope in the individuals we work with. Protective factors: Knowing what has kept the individual alive to this point is extremely important. Individuals may have a plan and the means to commit suicide, but report that their children, their religion, their pet, etc. keep them from following through. Having this information also helps the professional to keep them safe. For example, if a person reports that his/her religion is the “only thing” that prevents him/her from attempting suicide, it may be appropriate to include their religious leader in the intervention (of course, with the individual’s consent). Resources: When someone is having thoughts of suicide, it is important for them to have resources to turn to. It is important for us as providers to know what those resources are. The National Suicide Prevention Lifeline ( has a national 24/7 suicide hotline that people can reach out to. ( ) Having this resources as well as other local resources for our individuals to use is vitally important. Willingness for a safeplan: We start to look at whether the individual is committed to choosing life and willing to have a safeplan. Every agency has a different way of making a safeplan, it is important to have the individual be committed and have an active role in making this safeplan. ***It is extremely important that staff members are able to identify individuals who are at greater risk to complete suicide. The above is a list of identified risk factors found in research. The greater the number of risk factors, or the more severe the risk factors, the greater likelihood that an individual will attempt suicide. It is also important to note that even with the best assessment and the best intervention that we may still not have the desired outcome that we would have hoped for. Revision date 9/ CCM Trainer Manual

Do’s of Intervention Engage & Support
Understand reasons for wanting to die and live Add additional resources if needed Keep individual talking Validate feelings Remain as long as possible or find someone to stay with them Help identify resources Facilitate risk review Help find hope This is a guide for some examples of things to do when you are working with someone who is having thoughts of suicide. It is important to avoid judgmental statements, we really need to reminder ourselves that it is “It’s not about us”. It is about making the individual feel safe and supported during this time of darkness We want to remember to be calm, accept the feelings that the individual may be having. Sometimes an individual may need help rephrasing something that they have said, but we want to make sure that we are not putting words into their mouths or rephrasing in a way that they did not intend. It is important to stay close- we NEVER want to leave someone alone that is having thoughts of suicide. We really want to allow the individual to talk about why they are having thoughts of suicide and then be able to help the person get connected with the appropriate resources. Ideally we would like to do the following: Engage & Support individual- by staying with them in the moment, practice active listening and validating their feelings. It is important to feel comfortable having a discussion with someone who is having suicidal thoughts and not avoid speaking with them. Understand reasons for wanting to die and live- We want the person to feel supported and understood. So it is important that we start to understand why they are feeling this way. Add additional resources- Sometimes we may not be the most prepared to deal with this situation alone. Do not be ashamed to ask for additional help/support if needed. Do not keep this to yourself. Keep the individual talking- It is important for the individual to start to express their thoughts and feelings surrounding suicide. For many individuals this may be the first time that they have verbalized these feelings. Remain as long as possible or find someone else to stay with them- Again, we never want to leave someone alone who is having thoughts of suicide. Help identify support systems and resources- We want them to start making connections with people that they already know who can continue to be a support for them. Family members, neighbors, friends, coworkers, case managers, therapists, etc. Facilitate risk review – We want to understand their risk and have them understand their risk (see slide 29) Help find hope- We need to help them realize protective factors that have been keeping them safe and give them hope for the future. Revision date 9/ CCM Trainer Manual

Things to Avoid in an Intervention
Don’t judge Don’t invalidate thoughts and feelings Don’t leave the individual alone Don’t instantly assume the individual needs hospitalized Don’t remain quiet Don’t give up and assume that they’ve already made up their mind There are basic things that we want to avoid when doing an intervention surrounding suicide. The goal is to make someone feel comfortable and what you will notice is that a lot of the examples from above will not make someone feel comfortable. We want to make sure that we aren’t making individuals promises and the goal of the intervention is for them to not act upon their suicidal thoughts, not for us to try to cheer the individual up. It’s important as a staff member to remember not to leave the individual alone and to ask for help and support if we feel as though this is not something that we are prepared for. Asking for help is highly recommended, this shouldn’t be something that you do completely on your own. Revision date 9/ CCM Trainer Manual

Intervene immediately Don’t keep it a secret Locate help Inform Find
AID LIFE / Daniel Clark, PhD Ask Intervene immediately Don’t keep it a secret Locate help Inform Find Expedite A simple tool that we can use to help someone who is having thoughts of suicide would be AID LIFE ( / Daniel Clark, PhD). When looking at this we really want to remember the following: Ask: It is always important to ask someone clearly and directly if they are having thoughts of suicide. Asking someone “do you want to hurt yourself” is often not sufficient when asking about suicide. We would like to think “Are you having thoughts of suicide?” or “Are you thinking about killing yourself?” It is important to allow the individual to know that we are comfortable asking about suicide as well as receiving their answer. Intervene immediately: Once you know if someone is having thoughts of suicide, it is important to intervene at that moment and not wait until later. We don’t want to wait until the next shift comes in, until our lunch break is over, etc. to intervene. It is important to let the individual know that we care and are ready to listen. Don’t keep it a secret: Often times individuals may ask us not to tell their social worker, clinician, doctor, etc. about how they are feeling. We can not keep their suicidal thoughts a secret from our treatment teams. It is important for us not to be doing this alone and having other people to consult with is ideal. Locate help: It is important to figure out what resources are available- whether those be internal and immediate resources (security/safety officer, other staff, etc.) or long term external resources (counselors, therapists, treatment). We want to look at are we the best person to help out with this situation or does someone else need to come in and take the lead. Inform: It is important to figure out who needs to know about the individual’s thoughts of suicide (parents, supervisor at program, etc.) We should see who the individual feels comfortable knowing among their family and friends. It is also important to know who your agency wants you to inform (direct supervisor, doctors, social worker, etc.). Find: It is important to find someone to wait with the individual if you need to step out for any reason. Again it is really important to NOT LEAVE the individual alone. Expedite: Get help now! An at-risk person needs immediate attention from professional caregivers which include psychiatrists and counselors who are sensitive and knowledgeable about suicide as well and can give them a way to communicate their thoughts and feelings. Revision date 9/ CCM Trainer Manual

Barriers to Seeking Help
fear Anger Denial What Prevents People From Seeking Help? There are many reasons that people do not seek help, below is a list of several themes why people don’t seek help when thinking about suicide. Fear: The individual may have a fear of possibly being embarrassed if others know their feelings. There is also a fear about the impact of seeking help on one’s job, relationships and fear of what others may think. There is also a fear that they may be hospitalized for these thoughts. Anger: The individual may not seek help because they blame the helping agencies for their current difficulties or will not go to their friends and family because they blame them. Denial: The individual considering suicide and the people around them convince themselves the situation is not that serious. Always remember if there is any question about suicidality a mental health person needs to make that decision. Avoidance: Many people hope that by avoiding a problem it will go away. Joking with the person and changing the topic is the wrong approach. You may be the only person they are confiding in, don’t you want to make sure their faith in you is warranted by getting them the help they may be indirectly asking you to get for them. Avoidance Revision date 9/ CCM Trainer Manual

Trauma Informed Care Trauma Informed Care is a relatively new but extremely important topic in treatment. The following slides on Trauma Informed Care are not intended to provide staff with all of the necessary information on this topic. This information is intended to show the importance of Trauma Informed Care as it relates to the field of crisis prevention. Revision date 9/ CCM Trainer Manual

When you think about Trauma Informed Care, what comes to mind?
This is an activity designed to start a discussion between the trainers and participants around what knowledge and beliefs that they currently have about Trauma Informed Care. To start the discussion you can ask “When you think about Trauma Informed Care, what comes to mind?” At this point write the suggestions on white board, chalk board or paper. This activity should take around 5 minutes. You can discuss any suggestions that participants bring up. The goal of the activity is to see how much knowledge the participants come with. It is important to note that participants should start to understand that Trauma does not just mean physical trauma or a medical trauma, but these slides about trauma are really about the emotional or psychological trauma that the individuals we work with may be dealing with. Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW. Revision date 9/ CCM Trainer Manual

First, trauma happens in your life… Then, trauma affects your life…
Then Trauma becomes your life… Hadar Lubin, MD Co-Director, The Post Traumatic Stress Center This is a quote by Hadar Lubin. Dr. Hadar Lubin is a psychiatrist and director of the Post Traumatic Stress Center in Connecticut. This is an important slide to help staff realize that trauma is not just an event but it is an event that can greatly impact the individual and their life. Sometimes it is multiple events that can shape someone’s life. Often times staff don’t realize the impact that trauma may have on someone. It is not about the actual event, but how the event has shaped the individual. Once I heard a staff member say “She was raped 15 years ago, it’s time for her to stop using that as an excuse.” Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW. Revision date 9/ CCM Trainer Manual

What is Trauma Informed Care
Trauma Informed Care means providing services and interventions that do not cause harm, inflict further trauma, or reactivate past traumatic experiences. The definition of Trauma Informed Care provided on this slide by Gordan Hodas, MD provides staff with an easy to remember guideline for both crisis prevention and overall treatment. Staff at every facility must thoroughly assess common procedures that may be in conflict with this definition. Probably the obvious procedures that must be considered are restraint (manual and mechanical) and seclusion. However, we are also aware that having individuals undress in the presence of others and touching someone without asking are also in conflict with this definition. Some procedures are more obviously in conflict with this definition than others. What is most important is a full and thorough assessment of the individual to investigate issues that may not prove to be as obvious. For example, one of our trainers was honored to meet a woman in a local Pittsburgh nursing home who had survived living in Auschwitz during the Holocaust. Initially, staff attempting to shower this woman caused her much distress because her history had not been communicated to her direct care providers. Also, another CCM trainer working with Veterans tells a story of a WWII Veteran to whom he was delivering dinner. A simple dinner of meat and rice caused the gentleman to escalate and demand a different meal. As it turns out, the gentleman, a former prisoner of war, had survived the “Bataan Death March” where he was forced to eat maggot-infested rice. These examples are not provided in an effort to be dramatic. They are provided to make the point that every possibility must be considered in an effort to avoid causing further trauma to individuals in our care. (Hodas, G.R. MD, 2006) Revision date 9/ CCM Trainer Manual

Statistics of Trauma Informed Care
90% of public mental health clients have been exposed to trauma (Mueser et all, in press; Mueser et al., 1998) 97% of homeless women with serious mental illness have experienced physical and sexual abuse (Goodman et al., 1997) Trauma is so prevalent that we must use universal precautions Materials used with permission from Lisa Maccarelli, PhD, Stacy Simon, PhD, and Cindy Perjon, LCSW. When focusing on trauma, the statistics are startling- we are talking about 90% of public mental health clients have been exposed to trauma. Over 80% of adults in psychiatric hospitals report physical or sexual abuse and 93% on adolescent inpatient units reported a history of trauma. It is important to realize when working with the homeless that 97% of homeless women with a history of severe mental health have experienced physical and sexual abuse. 87% of these women experienced this abuse both in childhood and adulthood. Most of the clients/consumers have been exposed to multiple experiences of Trauma. Since the numbers are so startling and impact many of the people that we may work with, the idea of using universal precautions with the people that we come in contact with is so important. This would be a good area to ask staff about what types of universal precautions that they should use with someone who has been through trauma. Some examples of universal precautions would be not touching without asking, not asking to disrobe/undress in front of others, not getting involved in power struggles with individuals, and being aware of body language and tone of voice. The purpose of the last two slides is to have staff understand the impact of trauma as well as understand how many individuals are impacted. Revision date 9/ CCM Trainer Manual

This is an image of the brains of two different children
This is an image of the brains of two different children. The one on the left is a healthy 3-year-old American boy. The one on the right is a three-year-old Romanian boy who lived in one of the many Romanian orphanages that were known for severely neglecting children, thousands of whom were imprisoned in cribs and rarely given attention. It is important to note that several parts of the brain will be changed. For what we do, it is not important to know which each of those parts are, but more so how these changes impact the individuals that we work with. We also need to realize and remember that sometimes the expectations for these children are the same and when they are adults, these carry forward to when they are adults. Start to discuss how trauma at a young age has impact later in life. CDC Website: Revision date 9/ CCM Trainer Manual

Overall Impact on Behaviors
Here are some the things that go on inside someone’s brain. If this was going on inside of your brain, imagine what the overall impact would be. As you are getting overwhelmed are you able to process the same and cope the same way? As we saw in the slide with the brain, that trauma impacts how our brain develops and works. People who have had multiple exposures to traumatic events often have problems in the following areas: Memory Impairment: An individual with this type of impairment will most likely require frequent reminders. Emotional deregulation: In addition, trauma impacts the part of the brain that allows us to attach words to our emotions. If an individual’s struggles with this, they may be unable to express how they are feeling. This is extremely important in crisis prevention. Staff may encounter an individual who reports feeling “fine” but visually appears to be angry or upset. Staff must consider this dynamic when attempting to provide an intervention. Hyperarousal/Dissocation: We all have an internal “alarm system”. This alarm system is constantly monitoring the level of danger we are in at any point in time. If we are presented with a potentially life threatening situation, our alarm system triggers the “fight or flight” response. Several chemicals are released into our system, the most well known being adrenaline, our blood flow changes, digestion stops, etc and our body prepares to defend itself and survive. In an individual with a history of trauma, the alarm system may “misfire”. In other words, a “fight or flight” response may be triggered even when danger is not present. This may be caused by a startle such as a loud noise or staff member’s tone of voice. Also, we know that smell is very closely tied to our memory and may also trigger this response. It is extremely important to fully assess each individual in care in order to determine which specific triggers may be of concern. Higher functional skills impaired: Often trauma impacts the higher functional skills such as reasoning and problem solving. In an individual with a history of trauma, these abilities may be impaired. The result could be an individual who seems to act without regard to consequences. It is extremely important for staff to consider that this may not be due to issues of non-compliance or conduct, but in fact, due to the resulting damage to the individual’s frontal lobe. We need to keep in mind the lenses of trauma when working with individuals. We need to remind ourselves that it’s not about us. By keeping this perspective it can change how we view the world, and how we view those individuals who are in our care. “Know trauma in all its forms and all things clinical will come unto you” (with apologies to Osler). If we can understand Trauma Informed Care in all it’s parts, everything else clinical will come to us. Revision date 9/ CCM Trainer Manual

Victim Rescuer Perpetrator
Trauma Reenactment Victim People in general love familiarity. We become comfortable in routines and become comfortable with familiarity. We attempt to recreate our experiences and relationships in our lives with people who are around us. This becomes dangerous when those experiences and relationships being reenacted are based on violence, danger, and trauma. For some individuals traumatizing experiences can become normal for them- trauma is what they know and are comfortable with. When they start to recreate what they know and what is comfortable, traumatized individuals tends to pull people in their lives into reenactments of their traumatic experiences. This is called trauma reenactment. It usually involves three roles: the victim, the perpetrator, and the rescuer. Roles often change, the individual may no longer play the victim, but may start to play the rescuer or the perpetrator. For example: There is a young man who comes into our program quite frequently. He has a long history of abuse, neglect, and trauma. This young man has been through a variety of horrible events. This young man has been a victim in many ways in most settings that he is in. He is often victimized in the community and home. When this young man comes into our facility, there are times that he attempts to rescue other consumers- allowing them to move in with him, giving them his food, providing money or cigarettes for these individuals. At times, this young man will act as a perpetrator towards staff or other consumers. Like the information stated above, the roles change at times. With this young man it often times happens after a recent event of trauma or victimization. Rescuer Perpetrator Revision date 9/ CCM Trainer Manual

Ashley Revision date 9/2012 CCM Trainer Manual Ashley Exercise:
What you need for this activity: Paper doll “Ashley” Give “Ashley” to one participant and instruct that participant to look at “Ashley”, say something to “Ashley” to highlight her faults, something that frustrates you about her or something you don’t like about her. This could be something to bring her down, maybe something that you have heard another staff member at some point say about an individual. Crumble her up and hand it to the next person. Continue passing it along to the group until everyone gets a chance to open up Ashley and then look/say something and crumble her up. Next, Give “Ashley” to the same first participant- this time asking the participant to try and flatten “Ashley” out as she looks at her and says something encouraging, something that will build Ashley up, or something that is great about her. End by showing the group what “Ashley” now looks like at the end of his activity. Ask the class what they notice about the picture now, vs the picture before. Have them relate it to the people that we work with. You can also discuss how even though we have tried to smooth things over, used positive encouragement that the effects are still there- that Ashley still has those scars. For Trainers: There are lots of themes that come out of this activity. As therapists, teachers, case managers, staff working with the Ashley now, we don’t often know about those horrible things from the beginning of her life. Even if we know about them, we can’t take them away from her. Often Ashley comes to our programs with her guard up, fearful about when the next person may crumble her up, so what we often see first are behaviors- cursing at staff, aggressive behavior, not showering/bathing, or any number of other behaviors. Staff often focus on these behaviors instead of seeing all of the years of wrinkling and trying to guide Ashley in a positive direction forward Feel free to discuss themes that come up in your class. Revision date 9/ CCM Trainer Manual

Trauma Informed Not Trauma Informed Being knowledgeable about trauma
Providing dignified options and choices ___________________________ Touching without asking Staff Yelling/ Power Struggles ___________________________ Often staff will start to understand the idea of trauma informed care but when they go to implement it into their daily functions, they often will go back into routine. It is important to for them to understand what is Trauma Informed Care and what is not Trauma Informed Care. Below you will see a list of things that are TIC and not TIC. Things that are Trauma Informed: Recognizing the high prevalence of trauma Assessing trauma history and symptoms Recognizes and minimizes the use of practices that re-traumatize (restraint/seclusion/forced IM) Nonjudgmental language, neutrally observes and describes behavior Power and control is minimized Spirit of genuine collaboration between staff and individuals Address training needs of staff to improve knowledge and sensitivity Staff attempt to understand the function of behavior Providing dignified options and choices System is open to outside parties helping individual Things that are NOT Trauma Informed: Lack of education on trauma prevalence and “universal precautions” Over diagnosis of schizophrenia, axis II, bipolar d/o, etc. No trauma assessment Tradition of Toughness or Control valued as best approach Labeling language- manipulative, needy, attention seeking Reliance on safety/security officers, staff demeanor and a tone that emphasizes power Focus on enforcing rules, passive compliance valued over skillful assertive behavior No attempt to understand the function of behavior, automatically labeled “manipulative” System is closed and advocates for the individual are discouraged To trainers: We need to remember that it is important not to go into detail on trauma until it is really the right time. In short term services, we often make a referral to a trauma therapist instead of re-opening those wounds and not being able to close them. Revision date 9/ CCM Trainer Manual

Staff Self Assessment & Self Care
“Often, staff are very good at taking care of others. The people they neglect to care for is themselves.” For staff members, self-assessment on a daily basis is vitally important. This section will discuss self-assessment on several different levels. This first will be reasons why we chose our perspective fields to begin with. The second will be simple day to day assessment of the factors in our lives that can impact us. Finally, we will explore the impact that particular traumatic events can have on our own level of functioning. At any level, it is important to remember that we must be aware of our own level of functioning before we can be effective helping others. Revision date 9/ CCM Trainer Manual

What “baggage” am I carrying today?
Why am I here? Why do I stay? What “baggage” am I carrying today? Why am I here? Every staff member should honestly answer this question with him or herself. There are many reasons to choose a particular field of work. For example, people choose careers in the field of human service for many different reasons. To be truthful, some reasons are better than others. In class discussion, staff members have said that they have always been interested in helping others and cannot imagine themselves doing anything else. Others have said that they or a family member has had some medical condition or psychiatric illness and they see it as their chance to make a difference. On the other hand, we have all met staff members who seem to be drawn to the field of human services because they seem to enjoy having “power” or “control” over the lives of others. One of the trainers once witnessed a staff member respond to an individual’s questioning by saying “Because I have the keys and you don’t!” Obviously, this type of mindset could be detrimental to the individual’s care. Why do I stay? As our careers continue and the years pass, our reasons for doing many things also change. This is no different for our careers. It is important to evaluate one’s reasons for staying at a specific job or field over time. What “baggage” am I carrying today? These are many personal factors that can impact us on a daily basis. In the past, we have been told that being a professional means being able to keep these things separate from our jobs. Phrases such as “you have to leave all your baggage at home” or “check it at the door” are very common. However, this may be difficult, if not impossible to do. It makes more sense to be aware of the factors that are influencing us on a daily basis. If we are aware that we are not “having a good day”, we may be better able to prevent this from having an impact on our interactions with those we provide treatment for. If any combination of these impacts us too greatly, we may need to take a step back and allow a co-worker to intervene in our place. This may be even more important if the individual is particularly difficult to deal with. Staff members should remember that doing this is not a sign of weakness of lack of skill but a sign of professionalism and insight into our own level of functioning. Revision date 9/ CCM Trainer Manual

These are just nine of the many factors that can impact us on a daily basis. In the past, we have been told that being a professional means being able to keep these things separate from our jobs. Phrases such as “you have to leave all of your baggage at home” or “check it at the door” are very common. However, this may be difficult, if not impossible to do. It makes more sense that we are aware of the factors that are influencing us on a daily basis. If we are aware that we are not “having a good day”, we may be better able to prevent this from having an impact on our interactions with those we provide treatment for. If any combination of these impacts us too greatly, we may need to take a step back and allow a co-worker to intervene in our place. This may be even more important if the individual is particularly difficult to deal with. Staff members should remember that doing this is not a sign of weakness or lack of skill but a sign of professionalism and insight into our own level of functioning. *Note to Trainers: Take a minute to provide examples of how each of these factors can be affected. Personal examples are often safe and powerful. Revision date 9/ CCM Trainer Manual

STRESS and our perception
The stress response is activated by our perception Our ability to change our interpretation of stressful situations is a key to developing resiliency Shelving of Events Individuals view stress and stressors differently, often times this is based on our perceptions. Perceptions can be altered based on our previous life experiences, trainings, exposures to similar stressors, and supports systems and other resources. Our support system and other resources allow us to combat the stress response. Resiliency is the art of being able to bounce back from stress. If we can change the interpretation of a stressful situation we are more easily able to bounce back from that situation. First example: If you have a rubber band over a deck of cards and it is kept there over time without taking it off, once that rubber band is eventually removed, there is a great likelihood of it breaking due to it being pulled to it’s max over time. If periodically that same rubber band was taken off and allowed to go back to it’s original form, the rubber band is more likely to last longer as result. Second example: Violence in the workplace. For some individuals violence in the workplace can be seen as a highly stressful situation. If that same staff member has taken CCM, the agency has developed a violence response team, they have communication devices in place to alert others, they have developed a team approach in responding, those individuals are more likely to view violence in the workplace differently. Shelving of events: This is our bodies ability or inability to make sense of stressful situations. This is also a way that the mind successfully and effectively processes an event. For example: Think about how we process a fun time with a friend or someone that you really care about. You go out, you spend the day with them doing whatever it is that you both enjoy doing together. After that event is over, you store that in your memory on a shelf or in a file cabinet in your head so that when you want to go back and revisit that time, you know exactly where to find that. You have a shelf labeled “good time with friends” and can easily find it. We don’t have a shelf for traumatic or worst case scenarios that may occur. Our mind needs create a shelf for this to be on. REM sleep, reliving the event, or playing the event over and over again in your mind are all ways that help us create the shelf. Finding meaning related to the event also lowers the tension of the event and also helps to build the shelf in our mind. If the event helps us to do more positive things in our life, like spending time with our children, relatives, friends, etc than this is the meaning that can help build the shelf. Revision date 9/ CCM Trainer Manual

The 3 C’s of stress hardiness
Control Commitment Stress hardiness is our ability to create resistance to stress in our lives. Often times this is developed through our views of stress and our stressors, using a 3 C model. Control: In facing challenge, feel power to influence outcome. Having a sense of control over the stress and stressors in our lives allows us to change our views on that stressor from a negative to either a neutral or a positive. Commitment: Do something important or do meaningful work, communities and family. Finding or having a passion in your work helps provide the meaning that may be necessary to overcome the stressors related to your work. Same thing will apply to other stressors. Challenge: Energy and excitement for life change and innovation. Some people see stressors as opportunities, something that can lead to growth and development (individual, personally or professionally). Challenge Revision date 9/ CCM Trainer Manual

Traumatic Stress Sources: Traumatic Cumulative Vicarious
Responses to stress can be either: Physical Cognitive Emotional Behavioral Spiritual “An Acute Stress Reaction is a normal reaction to an abnormal event.” The next step in self-assessment is to examine the impact that traumatic events may have on our ability to perform our jobs and function in our personal lives. Critical Incident Stress Management is worldwide and comes from the International Critical Incident Stress Foundation in Baltimore, Maryland. Doctors Mitchell and Everly et all have done research on the impact that traumatic events may have on human beings. Much of the information on this slide has been taken from their teaching. Their research identifies three primary causes of acute stress reactions related to traumatic events. Traumatic Events: Traumatic events refer to one single traumatic or catastrophic event that may cause a stress reaction. Cumulative Stress: Cumulative stress refers to multiple events relatively close in time. It is important to note that there is no real parameter for how much time can involve cumulative stress. Traumatic events, especially if similar in nature, can become cumulative even if years have passed between events. Vicarious Trauma: Vicarious trauma refers to having a stress reaction to a situation one was not a witness to. An example may be a therapist working with individuals who have been abused. The therapist may experience a stress reaction from simply hearing a horrific story. Someone who has experienced a traumatic event or went through traumatic stress can usually have strong emotional reactions that have the potential to interfere with the ability to function normally. Even though the event is over, they may have strong physical, cognitive, emotional, behavioral or spiritual reactions. It is very common, in fact quite normal, for people to experience emotional aftershocks when they have passed through a horrible event. Sometimes the emotional aftershocks (or stress reactions) appear immediately after the traumatic event. Sometimes they may appear a few hours or a few days later. And, in some cases, weeks or months may pass before the stress reactions appear. The signs and symptoms of a stress reaction may last a few days, a few weeks, a few months, or longer, depending on the severity of the traumatic event. The understanding and the support of loved ones usually cause the stress reactions to pass more quickly. Occasionally, the traumatic event is so painful that professional assistance may be necessary. This does not imply craziness or weakness. It simply indicates that the particular event was just too powerful for the person to manage by himself. Some of the most common from each of the groups are: Physical (disturbed sleep, gastrointestinal upset, headaches, etc). It is often encouraged and suggested that one should seek out medical attention for the physical symptoms to rule out a medical condition. Cognitive (confusion/”dumming down”, inability to make decisions, hypervigilance, etc) Emotional (anxiety, fear, crying spells, etc) Behavioral (isolation, substance abuse, avoidance, etc) Spiritual (questioning ones faith or beliefs, cessation of practice, etc.) For more information on Traumatic Stress, you can go to Revision date 9/ CCM Trainer Manual

Basic but necessary Self Care suggestions
Drink Water Exercise / Physical Activity Sleep Using your support system Maintain a normal routine Relax / vacation / escape Avoid Alcohol Often times people want a magic wand to deal with stress and to manage their self care. Often the suggestions for great self care are often basic but necessary. The primary goal is to provide participants with steps that they can take to help themselves. Drinking water is very important because many of the chemicals that are released during traumatic stress are water-soluble. That means that you can flush them out of your system. Exercise or physical activity is helpful for burning up the excess energy that comes with stress and for overall mental well-being. Sleep is very important when trying to clear stress, this is the time that our body processes stress and allows us to heal. Having someone to turn to in times of stress may be one of the most important factors in a speedy recovery. Maintaining a normal routine is important because, as human beings, we strive for homeostatis. Maintaining our normal routine allows us to feel more comfortable and decreases overall stress. Relaxing, vacationing and escaping for awhile is important to allow us to take a step away from some of the stress, become re-centered and allow us to get back to a stress free baseline, or close to it. And finally, it is important to avoid alcohol following traumatic stress. This is because trauma processes during R.E.M. (rapid eye movement) sleep. Alcohol can diminish or eliminate R.E.M. sleep, therefore, slowing our recovery. Revision date 9/ CCM Trainer Manual

Stress management resources
Friends & Family Work resources (EAP, supervisor, coworker) Spiritual care Professional support (therapist, counselor) Health coach / Life Coach Primary care physician Community support (crisis line, crisis center) Community response teams (CISM, NOVA, DCORT, Red Cross) Many individuals will recover from stressful events without assistance, however, others will not. Since there is no way to predict who will need assistance, it is offered to everyone involved in stressful events. It is important for you as a trainer to have numbers of places that your staff can use. Have the numbers available for a local CISM team, your employeer’s EAP, etc. Revision date 9/ CCM Trainer Manual

Prevention Revision date 9/ CCM Trainer Manual

At your facility, where and when do critical incidents happen?
Critical Times At your facility, where and when do critical incidents happen? *Times of the day *Places *External reasons *Internal reasons Identify Critical Times in the Day/Schedule/Etc There are times when a particular part of the day present more challenging issues for staff than others. For example: Change of shift Bedtime Visiting Waiting (for Appointments, Medication, Meals) There are also places at your agency/facility that individuals are more likely to present challenging issues. For example: Cafeteria Non preferred activity (group, disliked subject in school, etc) Parking Lot Group Room Hallways There are also external and internal reasons that create critical times. Some of the external reasons are not liking the staff that they are working with, having a bad phone call or visit from family, not getting an answer that they like, feeling confined or trapped, etc. Some of the internal reasons are: hearing voices, feeling disrespected, not feeling good enough, feeling embarrassed, etc. Depending on an individual’s history, does bedtime present problems? Pinpointing critical times in the day can help staff develop a plan of action. As a trainer, your job is to ask your participants to identify crucial times in their schedule. When are people more likely to escalate? The idea is to make the participants aware of potential problems and think more proactively. Revision date 9/ CCM Trainer Manual

The trusting relationship
“Anecdotal evidence suggests that more than one assault has been prevented by the personal relationship established between the patient and a specific mental health worker” (Flannery & Walker, 2003) During a crisis situation, every effort must be given to locate the staff member that has a solid trusting therapeutic relationship with the escalated individual. Once trust has been established, the chances of calming the individual will increase. Revision date 9/ CCM Trainer Manual

From your experience…. Group discussion (someone can write on board, paper, etc). Split into two groups and one group focus on – qualities you look for in someone providing you care (doctor, dentist, child care, therapist, teacher, healthcare, etc) and the second group will come up with qualities that have made you never want to return to see the same group of people. The examples can also be from their work experience. Have groups review with one another. Below is some background information about some common themes that may come up during this section: Things that improve the trusting relationship are respect and dignity, situational alliance, active listening, objectivity, empathy, honesty, and humor. With respect and dignity every effort must be made to offer respect to the person involved in our intervention. As a trainer, you must make sure that your participants understand how they should display and show respect for the individuals in their care. For example, how do staff members show respect to an older adult suffering from dementia compared to how staff members show respect to an adolescent? Someone with substance abuse concerns? Someone who is homeless? This will be accomplished in very different ways as people interpret respect differently. A few examples for use in training include: Make eye contact with the individual, introduce yourself to them, find out what the individual would like to be called and pronounce their name correctly, address them appropriately, ask before taking vital signs or touching, knock before entering their room, etc. Providing dignity can be very empowering for the individual in crisis. This could be anything from allowing a person to make dignified choices of their own to not asking a patient to get undressed in front other staff. To provide dignity means to give value to the person in crisis. Take the time to ask your participants where they can provide dignity and make their individuals feel valued. In the end, how you treat the escalated individual and how you present to them during the crisis are often times the best tools that we use in order to diffuse a volatile situation. Situational Alliance: Creating situational alliance means working with the escalated individual so that they understand that they are not alone in this crisis and that you are there to help. The question to your participants should be; how are we getting the individual to understand that we are there to help them? Are there circumstances when we may inadvertently violate this concept, i.e. we are too busy to stop and talk or times when a show of force is unnecessarily used? Participants should understand that Situational Alliance includes active listening skills and the use of non-verbal cues. The goal is to make sure that the individual in crisis knows that you have heard them and that you are there to assist. Sometimes the barrier to this time of intervention is that the individual assumes or fears that staff members are there to harm them in some way. It is our duty to show the individual otherwise. Active Listening: This is an important piece of the foundation because if you have not heard what is being said, how will you know what intervention to use? There are a number of ways to let the individual know that you are listening to them. For instance, re-phrasing their statements back to them, attentive body language, and using clarifying and empathetic statements. Objectivity: Being objective when treating an individual is a key component to providing optimal care. We can’t allow our own personal agendas or values to impair our ability to provide quality care. In essence, we must be aware of how we are impacted by the individuals in our care. The goal to having this component as part of the relationship building is that we must be aware of how we are treating our individuals. Know your own professional limits and think about how this can impact a crisis situation. The goal is to know when to “take a step back” and allow another staff member to intervene if necessary. There are times in treatment when we may not be the best person during the crisis. If it is not possible to allow another person to intervene, make sure that you discuss your feelings with your supervisor (always use your chain of command) and/or co-workers. You can discuss and debrief before and after every intervention. This may help generate ideas for alternative intervention techniques. Empathy: It is difficult to imagine any treatment environment where staff members are not empathetic towards the individuals in their care. Especially during a crisis situation, empathy allows the staff member the opportunity to see the issue from the viewpoint of the escalated individual. Participants of crisis training should be informed that an empathetic approach allows for a better understanding of the crisis and what interventions may be attempted. In effect, an empathetic approach offers respect and some level of control. Allowing the individual to verbalize their problem may be all that is required in the safe de-escalation of the situation. Honesty: Always make sure that while intervening with someone, that you are being honest and forthright. There is no room for lying to someone that is escalated. This will typically only cause further escalation. Although it may seem difficult at the time, an honest intervention will lead to understanding and the building of trust. Avoid the temptation of knowingly using false statements to get the individual to calm down. In the end, prepare for the intervention. If the truth will likely cause further escalation, take the time to plan, prepare additional staff, and remove obstacles from the area. Humor: This is a great tool! Remember that humor is like a band-aid, you can use it intermittently, but it won’t cure the problem. It will relieve a little stress or anxiety, and allow you to continue with treatment. It should never be used in poor taste. Remember, if you are not funny, don’t try to be! The use of humor also shows that staff members are also human beings. This tool helps to build the connection, bond, or trust that is often needed for the delivery of treatment. *Important: Humor may not be appropriate with all individuals. Like any other tool that is used in the building of a structure, if it is not appropriate for the job, put it back in the toolbox for another day! A Therapeutic Relationship will most likely not exist in an environment that displays negative behaviors, unnecessary physical interventions, or otherwise harmful actions. These are seemingly obvious examples of factors that would break down a Therapeutic Relationship, however, there could be any number of examples that we could add to this list. It might help to ask your class for additional examples. The goal for this slide is to make your participants aware that these are some of the factors that could lead to a crisis situation. There is no place for them in treatment. Public Reprimands: It is never beneficial to reprimand an individual in front of a group of people. When possible, your intervention should be done in private or away from other individuals. Please note that reprimands of any sort can create further escalation of a crisis situation. Take the time to craft your verbal intervention and choose your intervention. Be prepared for any problems that could arise. If the staff members do not feel safe intervening away from the group, they should alert additional staff to their intervention. Sarcasm: Sarcasm is a form of verbal abuse and should never be used under any circumstance with an individual. Often times this is mistaken for humor. Favoritism: It is sometimes easy to break this rule, even if the intentions of the staff were good. Unfortunately, there are times when individuals in treatment receive unequal amounts of time with staff; thereby giving the impression that staff favors a particular person. Unknowingly, staff members have spent more time or resources on these individuals without understanding the consequences of their actions and how that can affect other individuals. Inconsistency: Sends mixed messages and tends to cause confusion amongst staff and individuals. Have we clearly communicated our expectations to other staff members and individuals receiving treatment? Staff must also make every effort to share information with each other concerning an individual’s treatment. For example, if a staff member learns from a patient’s family that a particular patient prefers listening to music when they become anxious, that important piece of information must be shared with every staff member involved in providing care for this patient. Arguing: There is no place in treatment for arguing. Disagreements of any sort must be handled professionally. Staff members must be aware of their own emotions and not allow that to affect a patient’s or individual’s treatment. A staff member should always consider “taking a step backward” and allowing another staff member to intervene. Dishonesty: Knowingly deceitful interventions can lead to problems in treatment. Are there times when this may be a factor? Staff should understand the consequences of being dishonest with the individuals in their care. Threats: Threats of any kind are considered abusive and should have no part in an individual’s treatment. Staff members should never use any type of coercion in attempts to force compliance. Disrespect: This is a seemingly obvious factor that is sometimes displayed with or without intent. Many people view respect differently. It is important for staff members to consider this while treating individuals in their care. Need for Control: Through efforts to produce positive results, a need for control can be a barrier to effective treatment. There is always a need to keep some level of control over your environment; however this can be problematic at times. Staff members should maintain a level of control so that safety is not compromised. *Note to Trainers The goal for this slide is to inform your participants that if used, these factors may only prolong a crisis situation. As clinicians and direct care staff members, we must make every effort to eliminate these factors from the treatment milieu. Participants should acknowledge and/or discuss how and why these factors have no place in treatment. We all should understand that building a Therapeutic Relationship and trust may take time and much effort on our part. All of this can be lost if any of these factors are used as a part of treatment. Revision date 9/ CCM Trainer Manual

Crisis Communication Communicating with an individual in crisis can be challenging at best and may present the responding staff with a scenario that that were not prepared to address. Therefore, it is suggested that staff have an opportunity to discuss potential statements that may act as triggers when delivered by staff. Crisis communication is something that should be occurring all of the time when we are interacting with individuals. If we are trying to prevent situations from occurring, we need to be willing to see if our current communication style is effective- does it calm people down or does it generally upset people? Revision date 9/ CCM Trainer Manual

“Good communicators “They also know how to
Know how to listen.” “They also know how to Interpret and impact Their audience.” As communicators we need to realize that there is more to communicating than just talking. As a good communicator, we need to learn how to listen to the individuals that we are working with hearing their concerns and validating their thoughts. This should be done using active listening. A good communicator also realizes when the intervention that they are doing and the communication that they are using isn’t working. A good communicator is willing to change their communication style or their intervention style to meet the needs of the individuals we work with. Revision date 9/ CCM Trainer Manual

Effective Crisis Communication Strategies
Self assessment Previous experiences Trust and relationship Communication style (Verbal and Physical) Situational Alliance Switch lead if necessary Self assessment: Thinking about whether or not you are bringing any baggage with you to work and understanding that the stressors that we experience outside of work may have an impact on the work that we do. It is important to realize your professional limits as well as acknowledge compassion fatigue and burnout. Previous experiences with individual- realizing that past experiences with this individual are also going to shape/guide our intervention. If the individual had a pleasant experience with us before is going to be quite different than if that person did not have a good experience. Also, did they have a good experience with the facility, other staff, etc. Reflect back on the trusting relationship and realizing how this is a huge component to crisis communication. Looking at communication style- the tone of your voice, the words that you use (are they judgmental or parental in nature). During a crisis situation, this is not a time to get into a power struggle or to teach new skills. The goal of crisis communication is to allow the person to feel validated and create an atmosphere of safety so that change can occur. If we make the other person put up a wall and shut down, it might have seemed as though we won, but in reality we have lost. Can we practice having a calm presence, patience, inhibition, and speaking in language that the individual can understand us. Can we inform individuals why they can’t do something when we tell them they can’t do it, instead of not giving a reason. Also be aware of humor vs. sarcasm. For a physical communication style- are we active listening, what does our posture and physical stance communicate? Situational alliance– offer dignified choices and alternatives- using ‘we’ statements and does the individual feel that we are really there to help. Sometimes we need to realize that we may not be the best person to work with this individual and we need to have a ‘tap out’ system where we can put our pride/emotions aside and allow someone else to take the lead. Revision date 9/ CCM Trainer Manual

Situational Alliance Consistent and unconditional respect
Respond to needs and “demands” Active listening Ability to remain objective Empathy Honesty Situational Alliance: Creating situational alliance means working with the escalated individual so that they understand that they are not alone in this crisis and that you are there to help. The question to your participants should be; how are we getting the individual to understand that we are there to help them? Are there circumstances when we may inadvertently violate this concept, i.e. we are too busy to stop and talk or times when a show of force is unnecessarily used? Participants should understand that Situational Alliance includes active listening skills and the use of non-verbal cues. The goal is to make sure that the individual in crisis knows that you have heard them and that you are there to assist. Sometimes the barrier to this type of intervention is that the individual assumes or fears that staff members are there to harm them in some way. It is our duty to show the individual otherwise. The following characteristics are ways in to build situational alliance: Consistent and unconditional respect: Every effort must be made to show respect to the individual(s) involved in our intervention. As a trainer, you must make sure that your participants understand how they should display and show respect for the individuals in their care. For example, how do staff members show respect to an older adult suffering from dementia compared to how staff members show respect to an adolescent? This will be done in very different ways as people interpret respect differently. A few examples for use in class include: Make eye contact, Introduce yourself, Find out the what the individual would like to be called (and pronounce their name correctly), Address them appropriately, Ask before taking vital signs (or touching of any sort), etc. Respond to needs and demands: Every individual that we work with will have different thoughts about what is important to them and what services they want. How they put these thoughts out there and what they would like to have may come across in different ways. Sometimes they express this in a calm way about what they need. Sometimes the individuals do not feel as though they are being heard, they feel overly passionate about what is going on and it may come across more as a demand. Either way, our goal is not to take this personal. Our goal is to respond to what they need. It is never a good idea to start with what we can’t do for someone, rather, reframing and talking about what we can do to support their needs. Active listening: This should be a genuine effort of listening to what the person is saying while not being distracted by one’s own thoughts, activities or things going on around them. For example: checking your watch or answering a text on your cell phone as a individual is talking to you. Ability to remain objective: Some individuals in our care may have done things that we as staff are not morally ok with. It is not our job to judge but to provide treatment and remain objective as if this were another consumer. For example: we should treat someone who has a history of abusing a child the same way we would treat a consumer coming in for depression. Or we should provide the same services for a kid who doesn’t come to school clean and showered everyday the same as one of the star pupils. Empathy is the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another. Empathy and sympathy are quite different. Empathy is being able to think what it may be like to be in someone else’s ‘shoes’ and trying to see the world through their lens vs. feeling sorry for someone (sympathy). Honesty: When working on situational alliance it is important for the individual to feel and trust that we are giving them all of the information. When an individual is in the room we should be talking with them, not about them. We should be giving them the facts and presenting information in a way that is not to deceive the individual we are working with. When safety is involved, this may look a little different. Revision date 9/ CCM Trainer Manual

Situational Alliance Be careful of your approach
Offer dignified choices/alternatives Use of “We” statements to promote partnership Perception - are we really there to help? Be careful of your approach: This is a relatively simple concept, but difficult to practice. Essentially the idea here is that I have to juggle assessing myself as well as the other person to make sure what I am doing is reasonable, effective, workable, etc.. In other words, I’m trying to fit myself to the person, the situation, the need, to what I can or can’t do, to an almost endless variety of variables. I am attempting to have a positive outcome , so as the consumer or their behavior changes, I have to adapt what I say, what I suggest, how I appear, etc to keep the intervention moving to an acceptable outcome for all concerned. Offer dignified choices/ alternatives: Participants should be able to identify times in treatment or during a crisis situation when control can be given back to the individual in crisis. Offering control or the ability to choose is very important in allowing a person to have some sense of control. Are we battling over control issues? Allowing an individual to make dignified choices is very important to building trust during the delivery of treatment. An individual entering into treatment or any healthcare facility may experience a heightened sense of fear, anxiety, or a loss of control. This may be in part due to fear of a procedure or treatment. As fear and anxiety increase, the ability to think clearly and make rational decisions can be impaired. This is why staff members must look for opportunities to give some level of control back to the escalated individual. When a consumer has requests or desires that are inappropriate , unreasonable, or can’t be readily met, it behooves us to attempt to find a alternative that closely meets the consumers needs. Example: Consumers wants to punch someone who has made them angry. An alternative would be to punch a pillow, exercise briskly, etc and maybe meet with the person to talk out the feelings. Use of “We” statements to promote partnership: Telling someone what, when, where to do something is about control. Situational alliance implies a partnership and working together to resolve problems, meet a goal, make a decision, etc. Use of the word “we” is always a positive alternative to “you” or “I”. Perception-are we really there to help: Interactions aren’t just about what we say; instead, they should be about how we say something, how we present ourselves, and the effort we put into our interactions. If we are there to help, we should make every effort to show by our actions that we truly are there to help. Revision date 9/ CCM Trainer Manual

Verbal Intervention Goals
Providing Reassurance Assessing Calming Gaining Voluntary Compliance Informing Setting Limits Providing Reassurance: This does not mean that we are going to fix the consumers problem or making them feel better by saying “everything will be alright”. Instead, it does mean that we are and will be a resource and/or support to the person as they face their challenges and learn new ways to cope with their problems. Assessing: Verbal intervention doesn't just mean talking, it also implies that we are constantly looking at us and them and the interaction itself…we should be asking…is this working… are we getting anywhere…have I figured out what’s needed to help the person…have I done my best to eliminate control issues etc. My intervention needs critiquing and I have to do this while I’m interacting. Calming: I have to maintain a calming presence so I don’t escalate the tension of the interaction. I may need to seek the help of another staff to take over if I “lose control” Gaining Voluntary Compliance: One of my tasks is to establish a situational alliance with the person I am interacting with so that they are willing to work on the tasks and difficulties together. Informing: Another task is to keep the individual abreast of where we are from my prospectus. Words like…I think we were able to resolve “x” or it looks like we still have some work to do on “y” help to establish where we are or where we need to go . Setting Limits: If the interaction gets too far out of hand or I can’t provide what the individual is looking for, it’s my place to establish the limits of the interaction. Example: I know you want to continue yelling and verbalizing about your anger, but it’s scaring the people around you. Let’s go to your room to work on this. Revision date 9/ CCM Trainer Manual

General Communication Guidelines
One person speaking Anger = Distance x 2 Use of silence Timing should not be a factor Compassion fatigue vs. burnout Only One Person Should Be Speaking: During a crisis situation, only one person should be speaking. When more than one person is speaking, information tends to get lost and the verbal intervention becomes ineffective. For the most part, the person in crisis should be given every opportunity to talk. If possible, the escalated individual should do most of the talking. This allows the responding staff members to gather information that will assist in the de-escalation process. This may also allow the escalated individual the opportunity to calm themselves by verbalizing their problem and possibly dissipate some of their negative energy. Anger = Distance x 2: It is really important that as an individual is starting to get angry or agitated that we start to create space between us and the individual. The more angry they are becoming, the more space that should be created. This allows us to have more of a reaction time in case they turn towards a physical assault and it also allows us to see the individuals full body so we can start to recognize more agitation (clenched fist, heavier breathing, posturing, etc). This also allows the individual a little bit of space so that they are not feeling boxed or closed in. Recognize the Importance of “Silence” (e.g. The Ministry of Presence): There are times during crisis situations when the staff member’s ability to verbally de-escalate a person in crisis does not meet the level of severity of the situation. A person in crisis may be suffering to the point that any words used by the staff member(s) may not be effective enough. Many professionals in the disaster and crisis management field recognize that a show of support for a person in crisis may be effective through their presence alone. Staff members may need to be prepared to say nothing and simply listen or show support through their actions. As this may be new to some staff, it is a concept and intervention process that may take time to master. There are several experts writing about this topic. Please see the references page for locating additional information on “The Ministry of Presence”. Timing should not be a factor: During a crisis situation, we should not push our schedule onto the intervention. Example: If our shift is about to end in 10 minutes, we shouldn’t try to rush the situation or tell the individual that they only have 10 minutes to resolve this. Often times if we are patient, don’t appear rushed, and don’t make timing a factor we are able to calm the situation down in a short period of time and maybe only leave 5 minutes late. On the other hand if we appear rushed, we let the individual know that we are under time restrictions and cause the situation to worsen we could be with this intervention for much longer. Compassion fatigue vs. burnout: During an intervention it is important to realize if there is compassion fatigue or burnout. Often times people lump these two terms together, but they are quite different. Compassion fatigue is when someone is struggling being empathetic, compassionate or nurturing in that moment. Compassion fatigue can happen slowly over time and it can sneak up on you or it can happen in an intense intervention. Once they practice some self care, take a day off, etc. they are easily able to go back to their normal caring behavior. When someone experiences burnout, the only real solution for this is for them to find a different career path. It is important to realize that if either of these are going on that we switch the lead staff member so that the individual gets the best care possible. Revision date 9/ CCM Trainer Manual

Role Play Examples (There is a role play examples handout) Role Play Examples for Crisis Communication General guidelines: *Will need 2 trainers for this activity *There are two 3-5 minute role plays *As trainers are role playing, the group will be making a list of positive and negative communication styles that they see. They will also list anything that they see that is concerning or things that they see that has been done well Role Play #1: Trainer 1(T1) will be a staff at your facility (teacher, counselor, technician, etc.) You can set up what type of staff that they are. This staff member will sit furthest away from the door. This staff member should appear busy and frustrated, it’s the end of their workday and they are ready to go home. Trainer 2(T2) will be the individual (patient, client, consumer, student, etc). This individual wants to get a need met. What do people struggle with at your facility? Examples: extra meal, discharged, not wanting to transition, medication, etc. T2 will approach T1 to ask for help. At first they will politely ask for what they are looking for. T1 should ignore, act annoyed with, appear more busy and then T2 will then demand what they are looking for. Goals for this role play is to show things that you see happen currently or that could happen in a negative manner. Staff member should appear that she is needing control. Themes that often occur during this section could be: **Public reprimands **Power struggle (refusing to back down) **Physical response (taking off jewelry, bracelets, arms crossed, etc) **Impatient **Intervention is all about you and not the individual **Sarcasm Role Play #2: Trainer 1(T1) will again be a staff at your facility (teacher, counselor, technician, etc.) You can set up what type of staff that they are. This time the staff member will sit closest to the door. This staff member should appear open and welcoming, it’s the end of their workday but understand that the individuals still need them until it is time to go. Trainer 2(T2) will be the individual (patient, client, consumer, student, etc). This individual wants to get a need met. What do people struggle with at your facility? Examples: extra meal, discharged, not wanting to transition, medication, etc. You can use the same need as above. T2 will approach T1 to ask for help. This time have the individual demand what they would like. T1 should not own the feelings of T2 and power struggle with them. No matter what T2 says we want T1 to remain empathetic, supportive and ready to help. Goals for this role play is to show things that you see happen currently or that could happen in a positive manner. Staff member should appear that she not personalizing the interaction and is focused on helping the individual. **Empathy **Active Listening **Positive physical stance (open and non threatening) **Patient **Empowering individual **Trying to understand what the individual is upset about and a positive resolution Revision date 9/ CCM Trainer Manual

Environmental & Personal Safety
This slide is to help the staff start a discussion around their safety at work. We should start this section out by asking “How do you keep yourself safe when you are at work?” Different things that often come up are: wearing a body button, not letting people behind them, being aware of their own surroundings, knowing how to contact security, not sitting in a crisis situation, allowing other staff to know when they are going to secluded parts of the building, wearing ID when they are in the community, limiting potential weapons in their work environment, etc. Revision date 9/ CCM Trainer Manual

Safety Ideas Safety Factors Dress Instinct Community Safety
Physical Position Dress Safety Ideas After the discussion, there is just a general guideline of things to do while you are at work to help maintain safety. Below are just some suggestions. Physical Position: Do Not Remain Seated During a Crisis Situation: In order for a staff person to put themselves in the safest position, it is important they immediately stand and move once a crisis has started. It is also important that staff understand that movement is always recommended when a situation becomes unstable. For example a staff can move to a position behind a table across from the escalated individual in order to be in a better defensive location. This allows the staff person time to move or flee from the area should the need arise. Trainers should instruct participants that they should always place themselves in a position to move freely and not be confined. Don’t Isolate Yourself with an Agitated Person: This may sound fairly basic however; staff members must understand that this places them at serious risk for injury. Even if the staff member knows the escalated individual very well, they should never assume that they can be alone. Staff members should always alert others to potential crisis situations. Always Give Yourself an Exit: Any time there is a potential for a crisis situation, staff members should consider where they are positioned. Whether it’s sitting at a desk, or responding to a crisis call, staff should always have a clear route for escape. This may take some planning or assistance from property management as many office areas are not designed appropriately. Something as simple as turning a desk or eliminating obstacles could mean the difference in keeping people safe. If staff members respond to individuals in the community, they should be instructed not to go too far into the residence or meeting area and always be able to see an opportunity for escape if problems arise. Instinct: Don’t Ignore Cues or Behaviors: Participants should understand that there are times during treatment when individuals in our care exhibit certain cues or behaviors that indicate that they are having a problem. It is important for participants to make note of any behavior that falls outside of an individual’s daily routine. For instance, if a person that is usually very social and active becomes withdrawn from the group and quiet, staff should make note of this behavior, alert others and prepare to intervene. Staff members can not assume that situations such as this example are nothing to be concerned about. Don’t Assume Anything: For the most part the various environments where we are employed are safe and free from crisis situations. However, staff members must always be prepared to respond and should never assume that they will not be involved in a crisis situation or the de-escalation of an escalated individual. It could be potentially dangerous to ignore these warnings and assume that everything will be OK. Trusting Your Instincts: This is an important component to crisis management. Often times we dismiss that uneasy feeling that we experience and never truly trust what our “gut” tells us. Your participants should know that over time that “uneasy feeling” is an important indicator that may help us to respond to an individual long before a crisis situation takes place. Participants are encouraged to always respond to that “uneasy” feeling (i.e. instinct) in some way. Whether it’s by telling a co-worker about their feeling or stopping and thinking through a situation, staff members should never ignore that feeling. Dress: (There is an activity in participant workbook for this) Dress for Safety: Participants should be instructed to consider their attire prior to the start of their shift. Staff members must give consideration to such things as footwear, ties, stethoscopes around the neck, provocative dress, clothes that limit mobility, or carrying pens in their front shirt pocket. These are either inappropriate or may place the staff at risk. Don’t Wear Expensive Clothing or Jewelry: This could be a problem for a number of reasons. First, it could make a person a target if they wear valuable items. Second, if these items are damaged or stolen while on duty, often times these items will not be replaced by the organization. Lastly, wearing these items could potentially set the staff member apart from their client/patient and make it more difficult to connect with them. Building Safety: Know How to Contact Security / Assistance: Staff working in any environment should always know how to get help to their work area. Whether it’s for assistance with an escalated individual or for medical emergency, participants should understand such things as: *How to contact help *Who will respond to them *How long it will take for help to arrive *How many responders will arrive This information is important for staff and should be posted in work areas. Staff members should never have to wonder if help will show up during a crisis situation. For staff working in the community, they should be aware of the local police department and medical emergency phone numbers. Participants are encouraged to have those phone numbers pre-dialed into their phone for one touch access. Know the Individuals in Your Area: This should include knowing the individuals in your care and fellow co-workers. Staff members should have some background information about an individual’s recent history, whether it’s for medical purposes or to inform staff members about any crucial crisis related information. Also, staff members should know their co-workers strengths and weaknesses. For example, knowing which staff members have good verbal skills is very important. Knowing which staff members have therapeutic relationships with certain individuals could be valuable information if a crisis situation occurs. Wear Identification (*If Appropriate): For the most part, all staff members must have proper identification and be easily identified. It is important that participants follow their organization’s policy and procedures with regard to photo identification. In addition, it is important that participants be comfortable with questioning any person that appears to be out of place within their work area. If staff members are not comfortable with confronting a stranger, they should be directed to contact security or assistance. Assess the Needs in Waiting Areas: Waiting areas for any type of services (medical or behavioral) have traditionally been problematic for any number of reasons. For the most part, waiting for services creates problems because of the length of waiting, lack of activities to pass the time, over-stimulation, or the nature of the illness or reasons for seeking services. Staff members should spend some time evaluating the needs of any waiting area to help keep crisis situations to a minimum. Potential considerations could be given to items such as: Magazines, TV, refreshments. Children’s Rooms, area for children to play away from the waiting area. Remove any potential item that could be used as a weapon. Staff members should check in frequently with those waiting for extended periods of time. Waiting rooms are excellent areas to post volunteers. Volunteers can help meet minor needs that individuals may have while waiting for treatment. This is an excellent prevention option that does not tap the resources of the treatment area. Community Safety: Locking up belongings before going into the building/home: It is important that staff aren’t putting their purses or personal belongings in the trunk of the vehicle as they are outside of the building that they are going into. It allows other people to recognize that you are putting valuables in the trunk and opens one up to being robbed. Being aware of the parking lot: It is important to stay focused and pay attention when walking through the parking lot of the place that you work. If you notice anything suspicious making sure to notify security or the proper people at your facility. Being aware when going into homes: A lot of this goes back to trusting your instincts. The goal is to make sure that we don’t allow complacency to set in. We need to be aware of the surroundings and aware of the homes that we go into- scanning their yard, their house, etc. It is also important to know if other people are in the house and if they have any pets that may cause problems. Instinct Community Safety Building Safety Revision date 9/ CCM Trainer Manual

Intervention No we will start to look at what happens with situations that we were not able to prevent or situations that although we attempted to prevent didn’t turn out the way that we had hoped. Revision date 9/ CCM Trainer Manual

Least Restrictive Treatment Model (McGonigle 2000)
Challenging Behaviors Dangerous Behaviors Least Restrictive Treatment Model: Is a series of actions that we as staff can take to lessen the possibility of having to restrain or seclude our individuals. This model shows a process for intervening during crisis situations. We must think of every other possibility before more restrictive means are used. This model is not all-inclusive, but is an example of ways to intervene from the initiation of the challenging behavior up to the most restrictive form of crisis intervention. Once a challenging behavior begins, are there possibilities in the immediate area that we can change? For example, if two patients start fighting, by removing one of the patients, you will probably stop the action. That is an example of an environmental adaptation. Communication adaptation can be viewed a couple different ways. First, can we ask our individuals instead of telling them? This is essentially being respectful, however, we often wonder how much more information we can get from someone if we changed the way we communicate with them? Second, if you are working with a non-verbal individual, are there other avenues of communication open for this person? It is very preventative to deliver information in a way that a person can understand. Communication devices are helpful tools when working with a non-verbal individual. Helping an individual in this way will lessen the person’s frustration and ultimately the chances that they will act out, because their needs can be communicated. Distraction is a way of diverting the individual’s attention away from the behavior by introducing alternative activities. These activities more often are those that the individual prefers. Interruption and redirection are basically stopping an individual’s actions and redirecting them back too their original task. This often involves tasks that were not preferred by the individual. For example, if you have a child that is acting out in a classroom, you will stop this action and direct the child back to the schoolwork. Relaxation techniques can be applied to a situation if these skills were introduced prior to the individual acting out. Breathing exercises, counting, music, etc. are different techniques to think about, but don’t try to teach something new to an individual in crisis! This is a good place to get examples from the class. Verbal de-escalation should exist during this entire process. It is listed here in the model so that it can be discussed during class, and so that the class can see that it should always be a part of the process. Blocking can exist in a couple different forms. First, if you are attempting to stop an individual that is self-abusive. This does not always require restraint or seclusion. Blocking can also be using your own body to stop someone from injuring another. Depending on the situation, removal to a calming area can come in the form of a physical prompt or a verbal command. For example, if you have two individuals arguing, you can physically prompt them to separate areas. The last part of this process is crisis intervention, which includes restraints and seclusion. A few things should be noted about this last piece. The crisis intervention should be the last resort. You should encourage your staff to think of other possible least restrictive means that are appropriate for your facility. Also remind your class that there is not always a particular order to follow here. A crisis situation can start at the challenging behavior and go directly into a restraint if safety becomes the overwhelming factor. Finally, if your facility has a restraint free policy, think about what types of interventions are restrictive. This could be calling the police or moving an individual from their residence into a higher placement of care. Revision date 9/ CCM Trainer Manual

Please consider: Imminent danger Risk vs. Risk Weapon Medical response
When going to physical intervention Please consider: Imminent danger Risk vs. Risk Weapon Medical response Safety of environment Assess for Imminent Danger: During a crisis situation, responding staff members must asses for or identify if imminent danger is present. For the purpose of this course, imminent danger is present when an individual in crisis takes action to further any threat of violence or aggression towards another person. Therefore, staff members may not have the option to wait until an assault occurs before they respond. In order to make this concept easy to understand (especially during tense moments), the authors define imminent danger as a time where if responding staff did not take action to stop the crisis situation, another person would be injured. (i.e. “If I don’t act right now, someone will get hurt right now”). Consider “Risk vs. Risk”: The concept of Risk vs. Risk is extremely important and must be given as much time as possible. This concept addresses the moments during crisis situations when the risk of an individual’s behavior becomes greater than the risk of the team’s intervention (i.e. Emergency Safety Interventions). This philosophy requires that the team work together to make the decision to intervene. Responding staff must always consider this prior to any physical intervention. *Import Note to Trainers A physical intervention is always the last resort under any circumstances. The risk for injury to responding staff members or the individual are high any time a physical intervention is necessary. It is extremely important that participants understand why this course spends most of the time on prevention rather than on intervention. A physical intervention should only occur as a last resort if the individual is physically aggressive towards themselves or others. As a CCM trainer, you should make every effort to discuss this topic so that the participants are clear on this concept. Included in this process is the consideration given to the number and skill level of the responding staff members as well as the medical condition of the individual in crisis. Discuss potential scenarios if necessary so that staff members feel more comfortable making the decision to respond. If a Weapon is Presented, Evacuate and Call the Police/911: Under no circumstances should staff members risk injury to themselves or others by intervening with an individual holding a weapon. A staff person’s responsibility should only be to evacuate the area and ensure their own safety. Once they are safe, staff members should call 911 and assist the responding law enforcement agency with their response. Assess the Need for a Medical Response: A staff member should be assessing the individual for any injuries or otherwise medical problems. Those facilities falling under the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) and the Pennsylvania Department of Public Welfare regulations must have an “observer” present during an emergency safety intervention (i.e. restraint) to assess the physical safety of the individual. As this is considered best practice, we also believe that during any crisis situation, staff should always assess for any medical conditions and be prepared to call for a medical response. Safety of the Environment: Responding staff members should assess the area to make sure that any potentially dangerous items are removed. This could mean furniture is moved, bystanders are evacuated, pens and pencils or other potential weapons are removed, etc. This can be conducted by any present staff member. Revision date 9/ CCM Trainer Manual

Intervention Approaches
Team approach Monitor the staff Call for additional assistance Attend to others Utilize the Team Approach The Team Approach is always the safest way to intervene initially. Essentially this requires a fast and effective response by staff members either assigned to a crisis response team or already working in the area of the crisis. Depending on the situation, staff members can decide if the team has enough responders to effective and safely manage the situation, or choose to send responding staff back to their work area. This is typically done to limit a “show of force” and not create further escalation. If participants work in an area where they are alone, they should be instructed to leave any situation that becomes escalated. It is not considered safe for one staff person to respond to an escalated individual alone. Monitor the Staff: During a crisis situation, responding staff members should not only monitor and assess the escalated individual, they should also monitor the staff member performing the verbal intervention. This is done to ensure that the intervention does not cause more escalation. If the individual is not responding well to the staff member performing the verbal intervention, other staff should be prepared to relieve the initial responder and attempt a verbal intervention. Some organizations have considered using the “Tap Out System”. This process is utilized during a verbal intervention and allows for the lead staff member to be “Tapped Out” or removed from the verbal intervention to allow other staff the opportunity to intervene. The goal here is to allow for the “right match” of responding staff member with the escalated individual. *It is important to note that some level of training and potentially role playing should occur prior to the use of this system. It can be effective as an intervention process if conducted appropriately Call for Additional Assistance: One staff member should be in a position to make a call or signal for additional staff members if necessary. Attend to Other Individuals, Patients, Visitors, etc.: Responding staff members should be prepared to respond to any other individual in the area of the crisis situation. This could include moving visitors from a waiting area, checking in with other patients in the area, or assessing other individuals in the area. Revision date 9/ CCM Trainer Manual

Emergency Safety Interventions
Used as a LAST RESORT Only for Imminent Danger Applied Only By Trained Staff Must Consider Individual’s Medical Status Can’t Be Applied as Punishment or for Staff Convenience Applied for the Briefest Amount of Time Possible We will go in much further detail about the Emergency Safety Interventions this afternoon but we use this as an introduction about the Emergency Safety Interventions. This is very important for staff to understand. Emergency Safety Interventions should only be used as a last resort and only when involving imminent danger (see previous trainer slides). This should only be applied by trained staff. Even the observer needs to be a staff that is trained in Comprehensive Crisis Management. When doing Emergency Safety Interventions we need to always look at the individuals medical status before deciding which Emergency Safety Intervention works best. We should also be discussing this with a doctor if possible. And as a reminder, making sure that we are following our own agencies/state requirements about restraints. We do not use Emergency Safety Interventions for staff convenience or punishments. Those are old thoughts and ideas about how to make the individuals that we work with comply. We want to make sure that these are only used for safety purposes (imminent danger). Lastly, we want to only use the Emergency Safety Interventions for the briefest amount of time possible. Revision date 9/ CCM Trainer Manual

Postvention The Post Crisis Debriefing(PCD) or Postvention: Is a process created so that staff members involved in any type of crisis situation would have an opportunity to share views, process, debrief, and learn from each intervention. Revision date 9/ CCM Trainer Manual

Post Crisis Debriefing
Formal Processing Attended by Staff and Individual Highlights Learning Points Helps Avoid Future Problems Aids In Eliminating Future Need for Restraint Promotes Communication Addresses Inconsistency The Post Crisis Debriefing (PCD) should follow any type of crisis situation. Remember that crisis situations don’t always include physical aggression. There is plenty to learn from a good verbal intervention! The PCD was designed so that only those present would be involved. This is primarily due to the fact that only those present will have first hand knowledge of what possibly triggered the event. There are times when various staff members will have differing view points on the same crisis situation. It is important for those present at the time of the incident to share that information so that everyone understands why an intervention was selected. Following the PCD, any vital information can be shared with other staff members. The PCD should highlight learning points from the situation. Every intervention has something useful that staff can learn. This is especially helpful for new staff members. Remember that not all staff has advanced experience with crisis management. This process should allow for all staff present to share information and ask questions. This leads to the next point. Everyone present should have a voice during this process. Try not to have the most experienced staff person conduct the PCD and conduct the entire process. The newest staff member should have an opportunity to share information as well. It is important to note that this process DOES NOT replace any debriefing process required by the regulatory bodies governing healthcare. The PCD is truly a brief learning process designed to allow staff members to share information, learn, promote communication, build team cohesion, and eliminate any inconsistencies between staff members. If time does not permit for staff members to discuss this information as a group immediately following a situation, those present should attempt to make time as soon as possible. Revision date 9/ CCM Trainer Manual

Post Crisis Debriefing
Questions to Consider What Triggered the Event? What Interventions Were Attempted? What Part of the Response Went Well? Could the Situation Have Been Prevented? What Could Have Been Done Differently? How Can We Work Together Next Time? Finally, the Post Crisis Debriefing (Questions to Consider slide) highlight basic questions that staff members can address following their intervention. These questions are only listed to serve as a guide. Once participating staff members are comfortable with the process, they should feel free to share this information in whatever format works best for the group. Revision date 9/ CCM Trainer Manual

Questions? Revision date 9/ CCM Trainer Manual

Comprehensive Crisis Management

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