TCI 2011

CRISIS PREVENTION

What does TCI stands for?

Therapeutic Crisis Intervention

CRISIS PREVENTION

What does effective TCI implementation include?

Effective TCI implementation includes 

• leadership and programme support
• clinical participation
• supervision and post crisis response 
• training and competency standards
• documentation and incident monitoring and feedback

CRISIS PREVENTION

Describe conditions or settings that can affect behaviour

Anything that makes challenging behaviour more or less likely to occur

for example:

Organisational culture (e.g. control orientated, poorcommunication)

environment (e.g. hot, crowded)

Programme related (e.g. routine, staffing, activities)

Personal(e.g. illness, medication, trauma)

Relationship Based (e.g. excessive controls, “us versus them”, culture)

CRISIS PREVENTION

What constitutes a positive organisational culture?

a positive organisational culture:-

• Supports developmentally appropriate practice
• Provide opportunities children to participate successfully in activities
• Involves children, families, and staff members in decision-making
• Encourages relationship building activities
• Creates a learning organisation

CRISIS PREVENTION

Describe a calming physical environment?

a calming physical environment:-

• Makes good use of space of a personal public use
• Is clean, orderly, inviting
• Soft lighting and regional calming noise levels
• Is furnished and decorated a properly in the age group living there

CRISIS PREVENTION

What should Programmes, activities, and routines do?

Programmes, activities, and routines should:-

• Balance structure and flexibility to meet individual needs.
• Provide for thoughtful transitions.
• A consistent and satisfying.
• Have goals, structure, and be designed to help children develop skills.
• Be adequately resourced

CRISIS PREVENTION

With what should you treat each child as an individual with?

Treat each child as an individual with:-

• Individual baseline behaviour.
• Different strengths and abilities.
• Specific effects of trauma.
• Underdeveloped co-regulation and self-regulation skills.
• Possible physical discomfort (e.g., illness, medication)
• A need for individual crisis management plan (ICMP)

CRISIS PREVENTION

How would you encourage positive relationships?

Encourage positive relationships by:-

• Meeting children’s basic needs and building attachments.
• Building culturally competent staff members.
• Helping staff develop emotional competence and self-awareness.
• Teaching children relationship skills.
  Providing teambuilding experiences the staff members and Young people.

CRISIS PREVENTION

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What does emotional competence mean?

Emotional competence means:-

• Being aware of personal goals, values, beliefs.
• Understanding cultural differences and each other’s worldview.
• Demonstrating self-regulation skills.
• Knowing personal triggers.

CRISIS AS OPPORTUNITY

When does a crisis occur?

A crisis occurs when a young persons inability to cope results in a change in behaviour

CRISIS AS OPPORTUNITY

What are the goals of crisis intervention?

batchwood

SUPPORT: environmentally and emotionally to reduce stress and risk

TEACH: children better ways to cope with stress

CRISIS AS OPPORTUNITY

Describe the stress model of crisis

Pre-crisis date = baseline.
Triggering event.
Escalation phase.
Outburst crisis.
Recovery phase

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CRISIS AS OPPORTUNITY

What are the three levels of recovery of the recovery phase?

1. Lower (Abuser) – we end up yelling or threatening
2. No Change (Fire Fighter)
3. Higher ((Educateur) = We want to be/get here

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CRISIS AS OPPORTUNITY

Describe the skills building pyramid: self-awareness

Six levels.
LSI.
Crisis co-regulation.
Emotional first aid.
Behaviour support techniques.
Active listening crisis communication.
Self-awareness (the four questions)

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CRISIS AS OPPORTUNITY

What are the four questions we ask ourselves in a crisis situation?

1. What am I feeling now?
2. What is this young person feel, need, or want?
3. How is the environment affecting the young person?
4. How do I best respond?

CRISIS AS OPPORTUNITY

How do I best respond?

Provide environmental support by managing the environment to neutralise potential triggers.

Provide emotional support by engaging young person.

Exercise self-control over on feelings.

Knowing Ourselves

“What am I feeling now?”

Anger can undermine objectivity.

Anger is an emotional and physical state.

Cognitive abilities are reduced.

Knowing Ourselves

What are the effects of anger?

“When we after angriest, we are at our stupidest.”

As anger increases, cognitive functioning decreases

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Knowing Ourselves

Describe the Feelings, Needs, and Behaviors Iceberg

Feelings and Needs are under the water

and

Behaviors are above the water

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Knowing Ourselves

What does Assessing Behavior Mean?

1. All behaviour has meaning.
2. Behaviour reflects needs.
3. Trauma affects our children behave.

Knowing Ourselves

Pain-based behaviour includes?

Knowing Ourselves

Identifying a young person’s needs

MANAGING THE ENVIRONMENT

What would you examine the physical setting for?

MANAGING THE ENVIRONMENT

What questions should be asked about activities and routines?

Are they causing frustration, boredom or anger?
Are they in adequately resource so that children cannot fully participate?
Are they conducted in areas without enough space or equipment?
Do they build on children’s strength or point out their weaknesses?
Do they allow individuals (adult or child) to agitate others?

MANAGING THE ENVIRONMENT

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Agency policy and procedures should be?

Clearly written

Communicated

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Understood

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Applied

COMMUNICATION;

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Nonverbal techniques include?

Silence.

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Nods.

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Facial expression.

Eye contact.

CRISIS COMMUNICATION AND ACTIVE LISTENING

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What does MEANING in emotional communication equal?

Facial expression = 55%
+ Tone of voice = 38%
+ Words = 7%

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CRISIS COMMUNICATION AND ACTIVE LISTENING

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What are Encouraging and eliciting techniques?

• Tone of voice.
• Minimal encouragements: “uh-huh”, “go on”, “I see.”
• Door openers. “I’d like to hear more,” “tell me about that”.
• Close questions: “do you like your teacher ?”.
• Open questions: “how did you respond?” “What happened next?”

CRISIS COMMUNICATION AND ACTIVE LISTENING

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Understanding responses

Reflective responses:

“you feel uncomfortable when your friends talk about school.”
“You’re angry about your visit being counselled. I be upset, too.”

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Summarisation:

“here’s what I hear you saying, you felt good at first, but now…”

CRISIS COMMUNICATION AND ACTIVE LISTENING

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What is active listening?

Acting listening:-

1. Identifies and validates feelings.
2. Reduces defensiveness.
3. Promotes change.
4. Communicate that we care and understand.
5. It is an effective co-regulation strategy.
6. Help young people. “Talk out rather lacked out”

CRISIS COMMUNICATION AND ACTIVE LISTENING

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Active listening is not

1. Throwing up roadblocks.
2. Arguing or blaming.
3. Giving permission.
4. Giving advice or solving the problem to the child.
5. Necessarily time-consuming.

BEHAVIOUR SUPPORT TECHNIQUES

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What behaviour support techniques?

Behaviour support techniques are:-

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1. Managing environment.
2. Prompting.
3. Caring gesture.
4. Hurdle help.
5. Redirection and distractions.
6. Proximity
7. Directive statements.
8. Time away

EMOTIONAL FIRST AID

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Adults can help children by?

• Seeing the incident from the child’s perspective.
• Helping children see the connection between feelings and behaviour.
• Encouraging children to be responsible for their actions.

CRISIS COMMUNICATION AND ACTIVE LISTENING

What are the goals of emotional first aid?

1. To provide immediate help and support to reduce emotional intensity (co-regulation).
2. To resolve the immediate crisis.
3. To keep the child in the programme / activity

CRISIS COMMUNICATION AND ACTIVE LISTENING

What are the strategies are emotional first aid?

• Drain off emotions.
• Clarify events.
• Maintain a relationship and lines of communication.
• Remind a child of expectations immediate situation if necessary.

CRISIS COMMUNICATION AND ACTIVE LISTENING

What should the worker ensure that the child understands?

• That the child believes they have the ability to successfully participate in activity.
• But there will be time to talk again later if needed.

THE CONFLICT CYCLE

What are the four elements of the conflict cycle?

1. Stressful situation/incident.
2. Young Persons feelings.
3. Young person’s behaviour.
4. Adults response

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CONFLICT CYCLE

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How can we avoid a conflict cycle?

We can avoid a conflict cycle by:-

• Using positive self talk.
• Listening and validating feelings.
• Managing the environment (e.g. removing others).
• Giving choices and the time to decide.
• Redirecting young person to another positive activity.
• Appealing to young persons self-interest.
• Dropping or changing the expectation

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MANAGING AGGRESIVE BEHAVIOUR

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What are the 2 Types of Aggressive Behaviors?

MANAGING AGGRESIVE BEHAVIOUR

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What is Reactive Aggression mean and what does it look like?

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1. Affective or expressive aggression
2. Loss of control and emotional flooding
3. Emotions are dominant

MANAGING AGGRESIVE BEHAVIOUR

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What is Proactive Aggression and what does it look like?

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1. Instrumental or operant aggression
2. Goal Oriented
3. Cognitions are dominant (Thinking is dominant)

MANAGING AGGRESIVE BEHAVIOUR

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What are the features of reactive aggression?

Facial features;;;;;;;;;; wide-eyed red-faced (pale if afraid).
Actions;;;;;;;;;;;;;;;;;; ;;;;;;;;;;;;;;;;;;;;;;;;; disorganised, impulsive

Tone of voice;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; angry, loud, shrill

Emotions;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; ;;;;;;highly aroused

MANAGING AGGRESIVE BEHAVIOUR

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What are the features of proactive aggression?

Facial features;;;;;;;; ;;;;; impassive staring smiling or smirking Actions;;;;;;;;;;;;;;;;;;;;;;;;;;; ;;;;;;;;;;;;;;;;;;;;;;;;; deliberate, methodical

Tone of voice;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; firm, calm, menacing

Emotions;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;apparently controlled

MANAGING AGGRESIVE BEHAVIOUR

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what are the immediate response priorities reactive and proactive aggression?

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REACTIVE;;;;;;;;;;;;;;;;;;;;;;;; PROACTIVE

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safety;;;;;;;;;;;;;;;;;;;;;;;;;safety

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understanding and support;;;;;;;;;;;;;;;;;;;;;; containment and negotiation

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remove or reduce stimulus;;;;;;;;;;;;;;;;;;;; ;engagement and reasoning

MANAGING AGGRESIVE BEHAVIOUR

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what are the ongoing response priorities reactive and proactive aggression?

REACTIVE;;;;;;;;;;;;;;;;;;;;;;;; PROACTIVE

Teach coping skills;;;;;;;;;;;;;;;;;;;;Teach appropriate

;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; thinking,;values, and social

;;;;;;;;;;;;;;;;;;;;;;;;;;; skills

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teach self regulation skills;;;;;;;;;;;;;;;;;;;;;;;;reward sociallyappropriate

;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;behaviour, not antisocial

;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; behaviour

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;;;;;;;;;;;;;;;;;;;anger management;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;

MANAGING AGGRESIVE BEHAVIOUR

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What is an individual crisis management plan?

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Functional analysis of high risk behaviour.

Strategy intervening tailored to the young person.

Periodic review and update

MANAGING AGGRESIVE BEHAVIOUR

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ELEMENTS OF A POTENTIALLY VIOLENT SITUATION

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What are the elements of a potentially violent situation?

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• A potential triggered violence.
• A target.
• A weapon.
• Level of stress or motivation

ELEMENTS OF A POTENTIALLY VIOLENT SITUATION

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How do you remove the potential triggered violence?

• Never touching and angry and potentially violent person.
• Avoiding any aggressive moves and provocative statements.
• Avoiding the conflict cycle and counter aggression.
• Removing others who might trigger the violence.

-; BODY LANGUAGE IS CRITICAL –

ELEMENTS OF A POTENTIALLY VIOLENT SITUATION

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Remove the target by

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• Asking the targeted person to leave.
• It’s you, reminding young person of your relationship only when the situation and asking a “neutral” staff to manage incident.

– THE TARGET MAY SHIFT DURING THE EPISODE –

ELEMENTS OF A POTENTIALLY VIOLENT SITUATION

How would you avoid the weapon?

• Discreetly removing objects.
• Manoeuvering away from weapons.
• Staying a safe distance away

ELEMENTS OF A POTENTIALLY VIOLENT SITUATION

How would you decrease the level of stress or motivation?

• Usual relationship.
• Actively listen to identify feelings.
• Remove the audience.
• Using co-regulation strategies (reactive aggression).
• Offering alternative, nonaggressive ways to achieve goals (pro active aggression)

HELP ME HELP MYSELF : CRISIS CO-REGULATION

What is the objective of crisis co-regulation?

HELP ME HELP MYSELF : CRISIS CO-REGULATION

What should I think (self-awareness)

Ask yourself the four questions

HELP ME HELP MYSELF : CRISIS CO-REGULATION

What should you do? (non-verbal strategies)

• Take a deep breath.
• Use protective stance.
• Step back.
• Give the situation time.
• Sit down if appropriate.

-remember the importance of body language and facial expression-

HELP ME HELP MYSELF : CRISIS CO-REGULATION

What should you say? (Verbal strategies)

• “I can see….” (validate feelings.)
• “When you….” (encourage positive behaviours).
• “I know we…” (emphasise desirable outcomes).
• “I am sorry…” (offer an apology).

– remember the importance of tone of voice –

HELP ME HELP MYSELF : CRISIS CO-REGULATION

What to do when it’s over

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• It’s over when the………….
• Prepare to discuss the situation in an LSI

THE LIFE SPACE INTERVIEW

The life space interview (LSI) is?

A therapeutic, verbal strategy to intervene with the young person.

“The clinical exploitation of life events”

– Fritz Redl

THE LIFE SPACE INTERVIEW

What are the goals of the LSI?

1. Return the young person to normal functioning.
2. Clarify events.
3. Repair and restore the relationship.
4. Teach new coping skills.
5. Reintegrate young person back into the programme.

THE LIFE SPACE INTERVIEW

What are the steps to the LSI

 I  – Isolate the conversation.

E – Explore young person’s point of view.
S – Summarise the feelings and content.
C – Connect feelings to behaviour.
A – Alternative behaviour is discussed.
P – Plan developed/practice new behaviour.
E – Enter young person back into the routine

THE LIFE SPACE INTERVIEW

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I verbiage in I ESCAPE

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“I’d like to talk to you” or “Lets go ….and sit down….”

THE LIFE SPACE INTERVIEW

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The verbiage for E in I ESCAPE:

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E = “What was happening?” “And then what happened?” “So you felt….” I was worried when….”

THE LIFE SPACE INTERVIEW

The verbiage for S in I ESCAPE:

“Let’s make sure I got this straight.”

THE LIFE SPACE INTERVIEW

The verbiage for the C in I ESCAPE

“So, when you feel….. you….?”

THE LIFE SPACE INTERVIEW

The verbiage for the A in I ESCAPE:

“Let’s think of some different ways you could….”

THE LIFE SPACE INTERVIEW

The verbiage for the P in I ESCAPE:

“You’ve got some good options.”
“Let’s make a plan.”
“Let’s now practice/rehearse”

THE LIFE SPACE INTERVIEW

The verbiage for the last E in I ESCAPE:

“Here’s what’s happening now…”
“Do you think you are ready to go back?”

SAFETY INTERVENTIONS

Options to handle physical violence are? (5)

1. Eliminate one of the elements of the violent situation.

2. Make a directive statement that clearly communicates that the violence must stop

3. Use releases and maintain a safe distance with a protective stance

4. Leave the situation and get assistance

5. Employ physical restraint techniques (if indicated on the ICMP)

SAFETY INTERVENTIONS

What is the goal of physical intervention?

To ensure safety

SAFETY INTERVENTIONS

What is the definition of Physical Restraint?

Physical Restraint: The use of staff members to hold a young person in order to contain acute physical behavior

Acute Physical behavior: Behavior likely to result in physical injury

The young person, other clients, staff members, or others are at imminent risk of physical harm

SAFETY INTERVENTIONS

 physical restraint should only be used when?

Physical restraint should only be used when: (all criteria must be met)

1. Agency policies and state regulations approve restraint

2. The young person’s ICMP indicates it

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3. Our professional judgement indicates it

SAFETY INTERVENTIONS

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Physical restraint is not used to?

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1 at 480. Demonstrate authority

2. Enforce compliance

3. Inflict harm or pain

4. Punish or discipline

SAFETY INTERVENTIONS

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What are the basic principles of physical intervention?

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A maximum amount of caring and a minimum amount of force with the goal of de-escalating the situation by reducing stimulation

SAFETY INTERVENTIONS

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What is the letting go process in a physical restraint?

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1. Is a gradual test of a young person’s self-control

2. States what is expected of the young person

3. Is directed by the team leader

4. Is supportive of the young person

LIFE SPACE INTERVIEWS

What are the Poential Pitfalls of an LSI?

1. Person refuses to talk

• convey calm support and sanction silence.
• Ask a focused question
• reschedule LSI

2. Young person gets off subject

• allow exploration and relate it to incident.
• Focus on issue at hand

3. Worker or young person wants to just “fix it”

• don’t interrupt a young person’s thought process.
• Don’t develop a plan for young person.

SAFETY CONCERNS

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Do not use physical restraint when?

1. We cannot control young person safely.
2. We are not in control or are too angry.
3. Sexual stimulation is the motivation.
4. We are in a public place.
5. Young person has a weapon.
6. Young person’s medical condition prohibits it.
7. Young person has emotional problems risking retraumatisation.
8. Young person is on medication is perfect his or her system

SAFETY CONCERNS

What are the definitions of asphyxia?

Asphyxia: the deprivation of oxygen to living cells

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Positional asphyxia: fatal respiratory arrest, in which the ability to breathe is compromised by the position of the body in relationship to its immediate surroundings

SAFETY CONCERNS

What are the predisposing risk factors of asphyxia?

• Obesity.
• Individuals under the influence of alcohol or drugs.
• Prolonged violent physical agitation.
• Underline natural disease (ie, enlarged heart, asthma, sickle cell trait, high blood pressure, diabetes).
• Hot humid environments.
• Individuals taking certain types of medication.

SAFETY CONCERNS

What are the warning signs of asphyxia?

Due to neck compression:

Goes limp and ceases to breathe spontaneously

Due to respiratory interference:

States he or she can’t breathe.
Restoration is laboured, rapid or abnormal.
May make grunting noises.
Vomiting or turning a dusky purple colour, especially of the face.
Goes limp and ceases to breathe

SAFETY CONCERNS

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What should you monitor during a restraint?

• Position of child and staff (appropriate restraint being applied).
• Skin colour.
• Respiration (no breathing problems).
• Level of consciousness (is responsive).
• Level of agitation (overexertion).
• Range of motion and/or swelling in extremities.

SAFETY CONCERNS

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What are the;recommendations to reduce the risk of injury or death?

• Never place weight a young person’s chest or back.
• Never put pressure on the young person’s neck.
• Never placed a head in a position because of a neck to be compressed.
• Never allow young person to stay in the prone or supine position once he or she is no longer a safety risk-get person up and in a seated position.
• Never place a young person’s arms behind his or her back when that person is in a prone position.
• Never bend, a child forward in the small child or seated restraint.
• Never place anything over or near the young person’s face, mouth, or knows that can be inhaled or conform to the contours of the face.
• Never ignore any of the warning signs appending asphyxia. Never failed to take immediate action if there is a need for an emergency medical treatment.
• Never restrain a child in the prone position on a mattress or surface that can conform to the contours of the face.
• Never use these restraint techniques on children under five years of age.

SAFETY CONCERNS

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Following a restraint what documentation should be kept?

• Who, what, when, where?
• What were the antededents?
• What did staff do to de-escalate situation?
• If physical contact, who did what (be specific)?
• How long did the restraint last?
• Staff/child injuries? Medical attention?
• What plan was developed in the Life Space Interview?
• Debriefing of staff?
• Was follow-up needed? What is the family notified?

MANAGING AGGRESIVE BEHAVIOUR

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All of the physical intervention techniques used in TCI are based on the priniples of ?

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(a) a maximum amount of caring with minimum amount of force

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(b) the goal of de-escalating the situation by reducing stimulation