Transcript HEAVEN’S HANDS COMMUNITY SERVICE INC.

HEAVEN’S HANDS COMMUNITY
SERVICE INC.
STRATEGIES for CRISIS INTERVENTION & PREVENTION - REVISED
(S.C.I.P-R)
7/20/2015
THE TESTING PROCESS
• At the end of the SCIP course,
certain student must demonstrate
knowledge of three physical
interventions of the instructor’s
choice, and pass a written test
consisting of 18 questions, 6 fill-ins
and 10 True or False questions. A
passing grade of 80% is required.
• If you see red you will see it again
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WHAT IS SCIP?
• SCIP is the acronym for Strategies for
Crisis Interventions & Preventions.
• SCIP focuses on proactive strategies to avert a
crisis. SCIP uses OPWDD approved techniques for
terminating situations where a danger of injury is
present, or a danger of significant property
damage may occur. At the onset of challenging
behaviors, or even before , during the early
warning signs, verbal and non- verbal techniques
should be implemented to end a crisis prior to it’s
actual beginning.
• SCIP is everything we do and say to an individual
receiving service.
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Knowing this, when was the last
time you used SCIP and why.
• You use SCIP on a daily basis.
• Think about the times you talk/interacted
with a someone.
• What did you say/do?
• Think about their reactions during and
after your talk to them.
• The best time to intervene with a
consumer is when they are displaying
appropriate behavior.
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Why do we need SCIP?
• Decrease the number of injuries to everyone
• Improve reactions of care providers when responding to a crisis
• Decrease incidents of abuse through awareness of the definition of
abuse
• Establish an effective and humane training program for addressing
challenging behaviors
• Fulfill the need for a “proactive” least restrictive approach
• Increases awareness of the negative effect of institutionalization:
– Depersonalization
– Modeling of violence
– Lack of freedom
– Regimentation
– Lack of stimulation
– Learned helplessness
– Lack of appropriate outlets for normal human emotions.
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Think of a Consumer
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Take a moment and think of
consumer you know.
List some of the behavior the
individual displays.
What is the common factor of
the behaviors?
REMEMBER: Individuals with MR
can become aggressive because it
serves a purpose for them
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Past Practices
• Prior to the Willowbrook Consent Degree, no positive
approaches to behavioral crisis were used. .
• Mechanical restraints such as straitjackets can cause injury
or death. Chemical restraints were used to control
individual’s behaviors as opposed to give control back.
Restraints are not proactive but are reactive. Restraints
may have been used as a replacement to active
programming or as a threat or convenience to staff.
• Non-programming responses, usually reactions learned by
staff through upbringing or previous experiences. These
may tend to personalize a situation.
• No method of intervention should ever be used as a
convenience to staff, intimidation, punishment or substitute
for proactive approaches
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Characteristics for Individuals
with Mental Retardation
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Poor Impulse Control
Low Frustration/Tolerance
Short attention Span
Lock in a Development Stage
Inability to Perceive an Idea/concept
Can’t Remember/Can’t Forget
Inability to Communicate a Want or Need
Inability to Perceive Time and Space
Relationships
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Survival Exercise
World War 3 has started and you are
chosen to run a shelter. Listed below
are 10 people, but you can only
choose 5 people to be in your shelter.
REMEMBER , if you take number 8
you must take number 9
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Survival Exercise
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20 yr old
40 yr old
17 yr old
36 yr old
75 yr old
34 yr old
30 yr old
drugs
8. 32 yr old
9. 30 yr old
10. 30 yr old
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black militant
prostitute
pregnant girl with questionable IQ
ex-cop indicted for brutality
Rabbi who loves everyone
violinist who is a homosexual
architect who is convicted for selling
law student and his &
wife who has leukemia
doctor whom has a hysterectomy
How staff attitudes affect
their actions
• BELIEFS: Opinions, Views and
conclusions (Generally internally
held)
• VALUES; Things or ideas of relative
worth (Generally reflected in words
or actions)
• ATTITUDES: Posture or positions
expressive of actions (Generally
based on knowledge)
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How staff attitudes affect
their actions continue…
»TRUE OR FALSE
• Providing knowledge and understanding
can lead to changes in Values and
Attitudes.
• Changes in Values and Attitudes can lead
to changes in behaviors.
• Beliefs, Attitudes & Values may be
influenced by cultural or societal factors.
• Beliefs & Attitudes can change
• Our belief system is more likely to affect
our actions in dealing with persons with
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Developmental Disabilities.
TRUE or FALSE
• Each person is unique in his or her needs and
learning style?
• Positive expectations have a positive effect on
behavior of others?
• As staff we must be free as possible from
stereotyped notions of what persons with
developmental disabilities are like and what they
can and cannot do?
• Regardless of the severity of one’s handicap, all
persons can learn and grow?
• Each person is of equal human value and
deserving of respect?
• Expectations can either challenge or limit the
growth of individuals?
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Staff
• List 10 ways staff can cause a consumer to
become disruptive.
• The percentage a staff member causes a
consumer to become disruptive is…
•90%
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Timeline for Developmental Disabled
Population Philosophy and Treatment
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People believed to be possessed by devils.
Beating, starvation, and torture used to drive sprit
from bodies.
Middles Ages
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Dr. Philppe Pinel (French) and William Tuke (English)
pioneer more humane treatment.
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American Association on Mental Deficiency.
1876
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French psychologist, Alfred Binet and Theodore Simon
developed 1st intelligence test.
1905
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Willowbrook opens
1938
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Willowbrook Consent Decree
1975
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Late 1700’s
Timeline for Developmental
Disabled Population Philosophy
and Treatment
• B-MAC training program
1980
• Govenor Cuomo says “Willowbrook will be
closed.”
1983
• Willowbrook closed
1987
• SCIP Training Program replaces B-MAC
1988
• Positive Approaches for Behavior Changes
1991
• SCIP-R
1997
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Consumers would like us to
keep the following in mind:
I am not a client. I am a person
I am not a resident. I am a citizen
I am not a patient. I am an individual
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Peoples First Language
• People do not like to be labeled. Doctors
diagnosed developmental disabled
individuals as:
• Moronic
• Imbecile
• Idiotic
• The difference between the right word and
the almost right word is the difference
between lighting and a lighting bug.
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You and I
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Language of “Us and They”
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624/633 REGULATIONS
Abuse
• The maltreatment or mishandling of a
person receiving services which would
endanger the physical or emotional well
being of the person through the action or
inaction on the part of anyone, including
an employee, intern, volunteer,
consultant, contractor, visitor, or others,
whether or not the person is or appears to
be injured or harmed. The failure to
exercise one’s duty to intercede in
behalf of a person receiving services
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also constitutes abuse.
Categories of Abuse
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Physical Abuse
Sexual Abuse
Psychological Abuse
Seclusion
Unauthorized or Inappropriate use of Restraint
Unauthorized or Inappropriate use of Aversive
Conditioning
Unauthorized or Inappropriate use of Time-Out
Violation of Civil Rights
Mistreatment
Neglect
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If you witness abuse, you
must:
• First:
Intervene and Stop
the Abuse.
• Second:
Notify Your Supervisor
• Third:
Document Exactly
what you Observed
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Causes of Abuse
• Please list 10 causes of abuse.
• According to the list, what could be
done to prevent the cause of abuse?
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Possible Causes and
Prevention of Abuse
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Overworked/ too much overtime
Stressed
Not knowing what constitutes abuse
Not knowing individuals antecedents, etc
Personal Problems
Poor staff communication
Working 1 on 1 with an aggressive
individual
• Low staff morale
• Bringing personal problems to work
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Possible Preventions of
Abuse
• Know when to work overtime
• Dealing with stress appropriately,
knowing
• Knowing what constitutes abuse
• Knowing all individuals
• Dealing with personal problems
• Good staff communications
• Calling for assistance when required
• On going staff trainings
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Common Signs of Stress
Dealing with situations can be emotionally
and physically demanding. Stress can
easily take over. Some common signs of
stress are:
• Fatigue
• Change in eating habits
• Loss of interest in job
• Change in work performance
• Increased illness
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Do not personalize the
situation, always reframe it
• Keep in mind, habits of thinking need
not be forever.
• Take positive steps to problem
solving situations.
• Taking action is a primary way of
managing feelings of helplessness.
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Dealing with Stress
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Reframe the situation
Express feeling and emotions
Seek social support
Use physical exercise
Use relaxation, deep Breathing, Meditation
Try Humor (But be careful)
Distract yourself/escape
Learn new skills in applicable areas
Focus on the here and now
Go to your supervisor for assistance
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Emotional and Physical
reactions may:
• Influence how staff perceives a situation.
What we believe about why the behavior
is occurring.
• Influence our performance
• The higher level of emotional involvement,
the lower the rational response
• Learn to identify signs of stress and
burnout
• Learn coping strategies and how to
reframe a situation
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• Seeking support when needed
Why do individuals exhibit
certain behaviors?
• Problem behaviors are largely learned through a
history of interactions between the person and
the environment.
• In general, problem behaviors are seen as
purposeful to the individual exhibiting them.
• Problem behavior may communicate an unmet
want or need.
• Behavior is more likely change when the
environment changes.
• To decrease a problem behavior, teach a
substitute skill to take the place and serve the
function.
• An individual’s problem behavior may be
maintained by more than one factor or
mechanism.
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• A group of behaviors may members of a single
Behavior Control vs. Behavior Support
• Behavior Control
Behavior Support
Goals is to reduce frequency of negative
Behavior
Goals is to meet people’s needs and to
give people the skills to meet their own
need so the negative behavior will not
occur
Frequency of negative behavior is starting
point of plan
Function or cause of negative behavior is
starting point of plan
Frequency of negative behaviors is
reduced by staff use of negative
consequences
Function of negative behavior is replaced
by assisting the person to meet needs in
socially acceptable fashion
Plans are primarily reactive in that they
go into effect after the negative behaviors
occurs.
Plans are primarily proactive in that they
focus on meeting needs and training skills
before negative behaviors occurs.
Reinforces/Punishers may be
unrelated to the behaviors
Attempts are made to use “Natural
Consequences”
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Side Effects of Punishers
• Negative self-image
• Dislike/avoidance of staff
• Learning to avoid circumstances in which
punishment occurs rather that changing the
behavior.
• Depression
• Reliance on external rather than internal control.
• Frustration resulting in displaced aggression
• Treating others negatively may come to be seen
as acceptable by both staff and individuals.
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The Four Functions of
Behaviors
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Sensory: Provides input into one or more sensory-perceptual pathways.
Looks, Sound, Feel, Smell, or Taste good or otherwise produces pleasure
for the person (e.g. A certain form of repetitive movements such as
rocking, head weaving or finger flicking.)
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Escape: Avoidance of a demand, task or activity. (e.g. a person not
performing a task because he of she perceives the task to be too difficult.)
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Attention: To get another person to attend or spend time with them.
Attention can be verbal, physical, social, or related to proximity (distance
of a person). The length of time may vary. (e.g. The adolescent in the
classroom who makes snide remarks during the class while the teacher
responds in a socially disapproving manner).
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Tangible: Want or access to an item, service, food or activity. . (e.g. a
child in the supermarket checkout aisle who picks up a piece of candy and
tantrums until the parent purchases it.)
Behaviors can occur using one of a combination of any or all four
functions.
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Group Exercise Worksheet
What may be the function of the
behavior?
• John enjoys going shopping. He has a history of periodic
difficulties on such trips. While at a large department store last
Tuesday, John became upset when he walked into the store past
the service counter and “concession area”. What might be the
function of his behavior in this particular incident?
• Tangible
• Mary lives in an IRA with three other people. She has a well
developed relationship with Susan, one of the staff persons
working evenings on the weekend. Mary has a history of
interrupting her peers in order to engage Susan in conversation
about her week at work. On this particular weekend her friend
Joan is ill with stomach pains. Susan is busy dealing with Joan’s
condition. Suddenly, Mary becomes upset, stamping her feet and
screaming. What might be the function of Mary’s behavior in this
particular situation?
• Attention
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Group Exercise Worksheet
What may be the function of the
behavior?
• Francis is sitting in the living room of her home. She often likes
to sit and slowly rock back and forth. She can often be found
finger flicking and making others repetitive hand movements in
front of her face. This behavior is difficult to interrupt or redirect
when she is engaging in it. What might be the function of
Francis’ behavior in this commonly occurring situation?
• Sensory
• Kenny enjoys brief interactions with those persons he like. Kenny
does not interact much with others. He is even known to interact
with persons he is frequently social with. Ed approached Kenny at
his Day Habilitation site to see how his night out went. Kenny
immediately avoids eye contact and quickly walks away. What
might be the function of Kenny’s periodic behaviors?
• Escape
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What is a Functional
Analysis?
• A “Functional Analysis” is the process of
looking at the relationship between the
behavior and the environment.
Conducting a “Functional Analysis will help
determine the cause of the behavior, or
what the expected outcome of the
behavior is.
• There are four requirements to conduct a
functional analysis which must be followed
to determine why a behavior occurs.
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What is a Functional
Analysis?
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Challenging behaviors are specifically defined. Fully
described what the person is doing. (e.g. The person got upset
would not be specific enough. “Hitting others with fist” or
“throwing furniture” would be more specific and operational.)
Events are identified that predict when the behavior is
likely and not likely to occur. What events occurred prior to
the negative behavior? What are the antecedents? (Positive or
Negative) These events and stimuli are important because they
may increase the probability of the behavior occurring again.
Changing these events and stimuli will reduce the probability
that the behavior will occur.
Hypotheses or ideas are developed as to the function of
the behavior. Why is the behavior occurring, what is the
behavior attempting to communicate? Identifying the function
of the behavior will aid in developing a functional strategy for
dealing with behaviors.
Data is collected. Events that predict the behavior are
accurate. Hypotheses about the function of the behavior are
correct. This may include Antecedent-Behavior-Consequence
(ABC) charts, Scatter Plot Data Collection, etc.
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A.B.C.’s
• Do you know your ABC’s?
• Antecedents: (What was the
consumer doing before the behavior
occurred?)
• Behavior: (What type of behavior did
the consumer display? How intense
was the behavior?)
• Consequence: (What intervention
did the staff use?)
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What will increase the likelihood of
a behavior reoccurring
• When you reinforce a negative
behavior it is likely the behavior
can/will reoccur
• Example will be to continuously
talking about the behaviors.
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Internal and External
Antecedents
Antecedents are those occurrences
prior to a behavior, or what triggered
the behavior.
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Internal Antecedents
(Think Medical)
• When a new behavior occurs, or an existing behavior
increases, an attempt must be made to find out what
changed for the individual. Pain should immediately be
ruled out. This hold especially true if the behavior is paired
with crying… Other internal antecedents may be…
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Signs and symptoms that have occurred before
Waxing or warning signs or symptoms
Disability specific conditions
Signs or symptoms common to the individuals syndrome or
disorder
Age related conditions
Trauma related conditions
Medication related conditions
Hunger or thirst
etc
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External Antecedents
(Think Environmental)
May be caused by any factor. Common external antecedents are:
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Noise
Temperature
Crowds
Fear
Being threatened or assaulted
Chaos in the environment
Being caught doing something wrong
etc
• Almost anything has the potential to be an external antecedent.
There are Positive as well as Negative antecedents. Staff must
identify both so it may be possible to eliminate the negative and
introduce more of the positive into the individual’s lives.
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Important Beliefs and
Attitudes about Behaviors
• People can change even over learned
behaviors
• People can make their own decisions
about behavioral changes.
• A major staff role is to help people solve
their own problems
• Staff does not always have to control
behaviors of others
• Idleness, boredom leads to behavior
problems
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What happens to you when
you are in a crisis?
• What crisis have you been involved in during your
lifetime? Think of how you felt emotionally and
physically.
• List so common physical reactions during a crisis.
(What happen to your body?)
• List some common emotional reactions during a
crisis (How did you feel?)
• “The Fight or Flight Response”: is important
to understand. Everyone experiences this in some
degree, emotional and physical reactions may
influence how a staff person perceives a
situation.
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During a time of Crisis
• Remember to:
• Display competent self –assurance
• Maintain calmness
• Know yourself and your limitations
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The Four Phases of
Behavior Escalation
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The Setting Event: Setting events may occur
hours, days or even week’s prior to the actual
crisis. These events are events which may
sensitize and individual to their environment.
Setting events are not immediately triggered.
• Early Warning Signs (EWS): When an
individual begins to act differently, this may
very well be a sign that a crisis is on the
horizon. It is important to Know Your
Consumer in order to recognize the EWS. The
EWS may be displayed by, withdrawal, cursing,
increased pacing, threats, or any other change
or increase in behavior. Staff should
immediately attempt to meet unmet wants and
needs. Offer a preferred environment or
activity, use active listening and calming
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techniques.
The Four Phases of
Behavior Escalation
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Crisis: This crisis phase occurs when all
attempts have failed to calm an
individual. This is where the staff must
allow the SCIP Gradient and go from the
least restrictive to the more restrictive
intervention.
• Recovery: The amount of time for
recovery will again vary from individual
to individuals. Trying to rush through
this fourth phase of a crisis could start
the crisis again. Know Your
Consumer and how they calm down.
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Use a teachable moment.
Early Warning Signs
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Early Warning Signs may manifest in the
following ways:
Increase tension (e.g. Jaw clenched)
Agitation (e.g. pacing)
Verbal Outburst (e.g. cursing)
Threatening looks
Any Behavior Changes (e.g. withdrawal)
Person – Specific Signs
KNOW YOUR CONSUMER
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Escalators
• Escalators are the opposite of calming
techniques in that they typically increase
tension and the potential for crisis. Staff
should therefore be able to identify
“escalators” and consciously avoid them
when dealing with people showing early
warning signs. There are several types of
responses that may be initially perceived
as verbal calming, but which really
function as escalators. When using verbal
calming staff should be aware of potential
negative impact of the following types of
statements:
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Escalators
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Planting the suggestions of misbehavior. (e.g.
“Don’t hit me…”)
Threatening the consequences of a behavior.
(e.g. “if you throw that I will wrap you”)
Presenting commands in the form of a question.
(e.g. “Are you ready to get in the van now?”)
Restarting confrontation by immediately
demanding emotionally difficult actions. (e.g.
“You hit Marla, now apologize to her.”)
Rehashing the incident within hearing range of
the individual. (e.g. “Did you hear what Olga
did lasts night?...”)
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Approaches Used to
Support an Individual
• Proactive: The pre-fix “pro” means
before in time. Thus proactive
interventions are those which
address people’s needs before
problem arise. If proactive
interventions are effective,
challenging behaviors should become
rare.
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Approaches Used to
Support an Individual
• Active: If needs are not met,
problems begin to bubble up as
warning signs. Active intervention
are designed to help calm so that
needs may be addressed. NOTE:
Although active interventions involve
calming, in order to truly resolve
problems, people needs (which are
currently met through challenging
behaviors) must be addressed.
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Approaches Used to
Support an Individual
• Reactive: The prefix “re” means back in
time. Reactive interventions are those
which deal with challenging behavior as
they occur. We must wait for the person
to calm and go back to a point where it is
possible to address needs (proactive and
active interventions) Reactive
interventions include, but not limited to
personal interventions. They might also
be spoken reprimands, lost of privileges,
etc. The goal of proactive approach is to
reduce the need for any reactive
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intervention.
The Five Elements of MultiComponent Approach to Positive
Behavior
The following should be used in conjunction with
a treatment plan.
• 1 Lifestyle Enhancement: Helping individuals
experience a wide range of positive choices and
opportunities that will assist them in developing
adaptive self image and a sense of personal
control.
• 2. Environmental Changes: Always try to
eliminate non –supportive aspects of the
environment for the individual.
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The Five Elements of MultiComponent Approach to Positive
Behavior
• 3. Consequences to Behavior: Stress that “Natural
Consequences” are more likely to assist in maintaining an
individual at a higher level of self-control as opposed to
artificial consequences, which have little or no relationship
to the behavior.
The “Interrupt > Ignore> Redirect>
Reward” sequences is an example of use of consequences
in the Positive Approaches model.
• 4. Teach Substitute Skills: By conducting a “Functional
Analysis” and including “Positive Approaches” the idea is to
teach the individual more socially acceptable means of
getting the same results as the challenging behavior.
• 5. Teaching General Alternatives: This would include
teaching relaxing techniques, communication skills selfconfidence, problem solving and coping skills. When
appropriate positive behavior supports are integrated into a
person life, incident of crisis intervention are often reduced
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to zero, or near zero.
The SCIP Gradient
• The SCIP Gradient tells us to use the least
intrusive intervention first.
• The emphasis of staff working with a person
who displays challenging behaviors should
always be to assist the individual in
developing self control.
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Verbal and Non-Verbal
Calming Techniques
Non- Verbal
• Re-Direct to Another Activity: Starting a
person on a different activity especially one that
is motivating may serve to defuse the situation.
• Eye Contact: Making eye contact often helps
people to regain control by reminding them of
their personal relationship with staff. Note:
many people with autism may become more
agitated in response to attempted eye contact.
• Close Proximity: Standing close to people may
make them feel more secure, but it may also
seem threatening.
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Verbal and Non-Verbal
Calming Techniques
Non-Verbal
• Touch: Some people may find light physical contact
reassuring, and supportive.
• Effective Use of Space: Try to position yourself and
the individual in the area to both insure safety and
relieve tensions.
• Body Posture: Try to convey a calm, in control mood
by adopting relaxed, non-threatening stance and
gestures.
• Planned Ignoring: This is used to “extinguish”
negative attention seeking behavior and should be
used only as part of a treatment plan. It involves not
giving people attention for mildly disruptive behaviors.
(This will not work if the function of the person
is attention.)
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Verbal and Non-Verbal
Calming Techniques
Non- Verbal
• Facial Expressions: As with body
posture, relaxed and friendly facial
expressions tend to be calming.
Provide access to preferred
objects and environments.
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Verbal and Non-Verbal
Calming Techniques
Verbal
• Ventilation: Allowing a person to air
their concerns while listening to the
concerns in a non-judgmental way
may help the person to regain control.
• Use Active Listening: Repeat back to
the individual so they know you
understand.
• Distraction: Asking questions related
to peoples interests may serve to
distract them from the situation. You
might also make a “help me” request.
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Verbal and Non-Verbal
Calming Techniques
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Verbal
Reassurance: Let people know that you are
there to help them to deal with problems.
Understanding: Acknowledge that the person is
angry or upset without judging the individual or
the reason why the person is angry.
Modeling: Control your tone of voice, speaking
softly in short, simple sentences.
Humor: The use of positive, good natured humor
can alleviate tension in some cases. Never use
sarcasm or ridicule.
KNOW YOUR CONSUMER.
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Verbal and Non-Verbal
Calming Techniques
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VERBAL
One -to-One: Talking in private may help by providing
people with needed attention and removing them from the
source of tension. Make sure that other staffs are available
if needed.
Encourage Alternative Coping Strategies: Remind the
individual of the skills they already possess.
Remind the individual of the “Natural Consequences”
Try to do this in a positive, non-threatening way, focusing
on people’s positive motivations and your concern for them.
Use Positive Language: Even if you have to set limits,
use of positive language is an effective calming strategy in
that supports individuals self esteem.
Facilitate Relaxation: Move the individual to a quiet
place.
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The 6 step calming
sequence
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Identify: be sure to correctly identify the
problem and the individual feelings.
Reflect: Reflect your understanding of the
emotion/problem back to the individual.
Reassurance: Give a concrete example that
shows you understanding how the individual is
feeling.
Re-Direct: assist the individual in transferring
their energy to another task or object.
Praise: Respond positively to any steps the
individual makes to regain control.
Follow- up: Use teachable moments to work
on relevant skills.
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Positive Environment
Checklist
• Positive environment is one that is both
functional and supportive and needs to be
accessible.
• Physical Setting
• Social Setting
• Activities and Instruction
• Scheduling & Predictability
• Communication
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NOTE!!!
• Immediately release an individual from a
physical intervention if they become
unresponsive, start vomiting, or go into
seizure.
• Other special considerations are helmets,
and frail, recently eaten.
• Personal intervention techniques should
NEVER be used on the elderly, syndrome,
recent surgery.
• Guidelines for use of restrictive physical
intervention: A restrictive intervention may
only be utilized to terminate a truly
dangerous situation.
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BANC
• Breathing: Monitor the individuals breathing,
listen for signs of distress.
• Ability to move: Monitor individual for
unresponsiveness. Never be so rigid that there is
a risk of isometric injury to the individual.
• Noise: Listen for breaking/snapping sounds,
wheezing or other signs of distress.
• Color (or cyanosis) : Monitor the skin color as
changes could indicate too much pressure and
lack of circulation to that body part.
7/20/2015