Handling the Most Difficult 10

1. �Handling the Most Difficult 10%� Kevin Huckshorn & Janice LeBel Hogg Foundation for Mental Health Implementing Seclusion & Restraint Reduction: Sharing the Experience June 22, 2007

2. What We�ll Cover How to" Handle� Difficult People? What does it mean to �handle�? What information needs more focus? Literature on environmental triggers Who are the �Most Difficult?� What is �most difficult?� Who are the �most difficult�? Examples of challenges & strategies Conclusions & recommendations

3. �Handling� Difficult People? What does �Handling� connote? Webster (2001) defines �handle, handled, handling� as: a) a part of a tool; a vessel by which it is grasped or held by a hand; b) to pick up, touch, carry, or deal with; c) to manage, train or control; d) to deal or trade in, to perform in a particular way when operated�

4. Handling People Apologize for being provocative. But we must get a �handle� on our language Has anyone ever felt �handled� in a job, at home, in the community? I sure have�

5. 5 Handling People What did that feel like? Do you think that �handle�, or �manage�, are words that describe what we do when people come to us for service? I can only just ask you to think about language and how we all use it, daily in our work

6. The Challenge We initially approached conflict, violence, and the use of S/R, by first addressing the leadership, policy, and process issues that seemed to lead to these problems. We have noted that many of these challenges are solved when you work through the initial implementation issues.

7. 7 S/R Reduction Strategies Effective Senior Leadership Involvement on a daily basis S/R use data, graphed and posted on all units Workforce development that includes both training and HR involvement in orientation and performance S/R reduction tools that include assessments for violence, injury, trauma hx, safety planning and environmental changes Inclusion of service users and families in operations and as staff Rigorous analysis of events, with documentation and follow-up.

8. What is �Most Difficult� for you? There is no doubt that certain kids and adults on your units are presenting major challenges We have seen, over and over, that effectively implementing the strategies will change the environment and will provide you will needed skills for most of the clients My question is: Have you implemented the six strategies fully? What happened? What did not work?

9. 9 What is �Most Difficult� for you? Discussion

10. Emerging Workforce Information? We were not able to get your current data but understood that you are trying, as best you can, to reduce S/R use The following is a synopsis of a current review of the literature regarding practices in MH environments that lead to conflicts and the use of S/R

11. 11 Reducing S/R Use In late 2006, we went back to the literature The �prevention focus� caused us to re-think the priorities,as,did the struggles that folks were having in reducing in some settings We looked again at the MAJOR question� What causes coercion and violence to occur in inpatient settings, in the first place?

12. 12 Onsite Observations We looked at over 40 years of literature findings to see if any patterns emerged�we drilled down�we found patterns Seclusion, restraint, and trauma work has illuminated an �onion� of issues We have found complicated, systemic patterns of practice and workforce and leadership issues pervasive and often problematic

13. 13 The Importance of Workforce Development Workforce development is a core strategy in both implementing TIC and reducing violence However, workforce development mostly given short shrift in health settings Result: facilities have failed to realize the amount of attention required in this domain The work required to train our direct care workforce is huge, given the turnover and budgetary constraints But it is paramount, possibly 2nd only to leadership effectiveness

14. 14 Staff/Consumer Conflict + Hx = Violence, Trauma, Injuries + Deaths in Inpatient and Residential Settings These are the core factors that have brought us to this point in time We have struggled to deal with these issues Often have chosen control and coercion, not knowing what else worked These dilemmas characterize traditional practice

15. 15 Traditional Approaches to Violence in Mental Health Settings �Professionals� have mostly focused on the �patient� as the cause of violence, we were trained in this model The focus? Demographic & Clinical Characteristics Age, race, diagnosis, certain symptoms, substance abuse history, foster care or DJJ involvement, forensic involvement, medication compliance Result: We still cannot predict violence well, this approach has not reduced events, but this approach gave us a rationale to lean on � to explain violence�

16. 16 Internal Model of Violence The �Internal Model� is used for many reasons - including ease of research methodologies, lack of knowledge, and an insidious discriminatory paradigm The �them� not �us� focus is more comfortable and does not result in any changes in our own behaviors Is convenient but often inaccurate (Duxbury, 2002)

17. 17 External Model The �External Model� is another way to look at violence causal factors (has emerged from UK) (Duxbury, 2002) This approach takes another view of violence, by asking: �What is the role of the environment in violent events?�

18. 18 Institutional Cultures Unit �norms� included the need for physical restraint and �it�s not you we don�t trust� Roles for non-professional nursing staff included enforcing, policing, supermanning, and �putting on a show� New staff were introduced and coerced into compliance with these roles and were �punished� by peer staff if they did not (Morrison, 1989)

19. 19 Literature on Causes of Violence�The Present In 1985, Robert Okin, MD looked at a variety of psychiatric hospitals� use of S/R in one state alone, for 5 months He found that use of S/R varied significantly and differences could not be explained by patient demographics or pre-admit aggressive behavior He concluded that �factors related to the individual hospitals practices and conditions� were responsible for these different rates of use (Okin, 1985)

20. 20 Literature on Violence and S/R Fisher was concerned about injury rates resulting from S/R and noted that �staff training� was fundamental to safe use and must include (but did not): Informing staff about issue (S/R) �Attitude therapy� (for staff) Understanding the �patient�s perspective� Training on appropriate staff responses (Fisher, 1994)

21. 21 Recent Literature on Causes of Violence Petti, Mohr, & Somers performed another review in 2001 and found current studies inconclusive and focused on the �patient� as cause of restraint use. This study�s findings included: The medical record �jargon� did not adequately describe events, for instance, �aggressive�� could mean anything from cursing to spitting to hitting�

22. 22 Recent Literature on Causes of Violence A need for a more precise assessment on event antecedents instead of the repetitive rationale of �safety� An attitude change in staff, led by leaders, that valued and learned from the consumer�s experience, and The need to understand, better, why staff reported these events very differently than service users did (Petti, Mohr, & Somers, 2001)

23. 23 Core Issue: Shame and Humiliation Gilligan, in his prison research identified shame/humiliation as core element in violence Garbarino addresses the impact of trauma on boys & predilection to antisocial behavior by �regaining control� through aggression Denial of abuse and emotions Explosion with little provocation � hypersensitivity when not feeling respected (Gilligan & Lee, 2004; Garbarino, 1999) 1st bullet -Exquisite vulnerability to being demeaned and need to ward off vulnerability and replace with feeling of pride.. 2nd bullet - The boys deny the abuse and feel it is unsafe to have emotions and regain control through antisocial behavior and aggression as survival strategies.1st bullet -Exquisite vulnerability to being demeaned and need to ward off vulnerability and replace with feeling of pride.. 2nd bullet - The boys deny the abuse and feel it is unsafe to have emotions and regain control through antisocial behavior and aggression as survival strategies.

24. 24 Recent Literature on Causes of Violence Another study in 2004 studied 215 assaults in a 2-month time frame. Significant causal factors to violence were staff verbal directions, re-directions, and limit setting vs. service user age, history with DJJ, diagnosis, and gender. (Ryan, Hart, Messick, Aaron, & Burnette, 2004)

25. 25 Recent Literature on Causes of Violence D�Orio and colleagues (2004) found that addressing two factors led to the 39% decrease in the use of S/R. These factors were: Improved management of problematic behaviors by staff Improved monitoring by staff (D�Orio, Puselle, Stevens, & Garlow, 2004)

26. 26 Recent Literature on Causes of Violence Hinsby & Baker, published a study in 2004, by gathering data from service users and nurses using a qualitative approach. They found 5 themes describing violent incidents: loss of control by the service user; nurse role ambiguity between caring and controlling; a paternalistic model of care; an expectation to follow the rules; and an acceptance of violence as normative.

27. 27 Emergency Services Stefan (2006) interviewed hundreds of staff and service users of psychiatric emergency services and ED�s She found that most conflicts resulted from: Threats or use of force (security, weapons, mace, seclusion, handcuffs) before anyone asked what was wrong Disrespectful forced searches, by either sex Forced disrobing Refusal to allow companions, including animals to stay

28. 28 Emergency Services Forced Medication without consent Ignoring medical complaints, discrimination due to psychiatric labels Staff attitudes of contempt, derision, skepticism Lack of privacy or confidentiality Long delays Lack of translators, including signing Lack of understanding of Trauma

29. 29 So what does this mean? Where does this leave us?

30. 30 �Inconvenient Truths?� We �professionals� have been poorly prepared and expected to work from intuition; lacking sophisticated theory, philosophy, or best practice interventions to improve safety We have been conditioned, in some settings, to an acceptance of ineffective, often non-existent, leadership or supervision on best practice We have been inculcated to insidious, discrimination as evidenced in practices and language We have rarely or never been introduced to an understanding of role of institutional triggers in violence

31. 31 �Inconvenient Truths?� Our practices have not changed in any significant manner, over the last 30 years, as evidenced by: Many homogeneous treatment activities, one size fits all a lack of risk prevention a lack of individualized treatment planning or full use of assessment information the exclusion of service users/family members from service planning and a primary focus on �control� to manage

32. 32 Lessons Learned Seems we could be �missing the boat� in so far as addressing the causal factors leading to use of S/R As leaders we need to: Redefine our personal treatment philosophies, values, and desired outcomes including the elimination of coercion Understand how to assure for and measure adequate staff leadership, supervision, & training (Anthony, 2004)

33. 33 Lessons Learned We must acknowledge: That �we� may not have factored in our own contributions to institutional violence That some of our practices are discriminatory, in care settings And that we may be unaware or in denial about the outcomes of actual practices in the systems of care that we oversee

34. 34

35. 35 Next Steps S/R reduction has become for us �the outside skin of an onion�; its link is key to developing recovery oriented care If we are truly committed to reducing coercion, conflict, coercion and S/R for the people and families you serve, this shift will require Deep Change (Quinn, 1996) Kuhn said �paradigm shifts are revolutions�

36. 36 Deep Change Quinn says that change can be incremental or �Deep� and that the more familiar is the former (1996) Deep change requires more of us �on board� quicker It includes new ways of thinking, behaving, is discontinuous with the past, and irreversible once begun� �walking naked into uncertainty�� (p. 3) This is transformational change�

37. 37 A Thought to Ponder� Martin Luther King, Jr. said: �Violence is the language of the unheard� This seems to be a particularly germane statement regarding our problems with violence. We hope that this training will help you to go farther in this work.

38. 38 References Anthony, W. A. (2004, Fall) Overcoming obstacles to a recovery-oriented system: The necessity for state-level leadership. NASMHPD/NTAC e-Report on Recovery. Retrieved November 28, 2004 from http://www.nasmhpd.org/publications(http://www.nasmhpd.org/publications) D�Orio, B.M., Purselle, D., Stevens, D., & Garlow, S.J.(2004). Reduction of episodes of seclusion and restraint in a psychiatric emergency service. Psychiatric Services, 55, 581-583. Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9, 325-337

39. 39 References Fisher, W. A. (1994). Restraint and seclusion: A review of the literature. American Journal of Psychiatry, 151, 1584-1591. Garborino, J. (1999) Gilligan and Lee Morrison, E.F. (1989). The tradition of toughness: A study of the nonprofessional nursing care in psychiatric facilities. Image: The Journal of Nursing Scholarship, 22, 1, 32-38. Okin, R.L. (1985). Variation among state hospitals in use of seclusion and restraint. Psychiatric Services, 36, 648-652.

40. 40 References Petti, T.A., Mohr, W.K., & Somers, J.W. (2001). Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility. Journal of Child and Adolescent Psychiatric Nursing, 14, 3, 115-127. Quinn, R. (1996). Deep change. San Francisco: Josey-Bass, Inc Ryan, E.P., Hart, V.S., Messick, D.L., Aaron, J., & Burnette, M. (2004). A prospective study of assault against staff by youths in a state psychiatric hospital. Psychiatric Services, 55, 665-670. Stefan, S. (2006). Emergency Department Treatment of the Psychiatric Patient. New York: Oxford University Press Webster�s Dictionary. (2001). Random House, (4th Ed). New York: Ballentine Books

41. 41 Next, Janice will talk about people with challenging issues and what the literature indicates�

42. 42 Who are the Most Difficult? People with Intellectual & Developmental Disabilities? People with Sociopathy? People with Aggression & Violence?

43. 43 Implicit Challenge to theMost Difficult �Difficulty� is in the eye of the beholder No one definition of what is �most difficult� No common description of who is most difficult Defies standard definition and eludes treatment algorithms and practice parameters

44. 44 People with Intellectual & Developmental Disabilities The Research: 70% - 85% of people with DD referred for psychiatric consultation have one or more untreated, under treated or undiagnosed medical problems influencing their behavior (Ryan and Sunada, 1997; Sundheim et al., 1998). Search for secondary medical conditions that contribute to /cause the apparent extreme behavior / psychosis (Szymanski et al., 1990). Retrieved on June 3, 2007 from http://www.intellectualdisability.info/diagnosis/psychosis_rr.htm

45. 45 People with Intellectual & Developmental Disabilities The Research: Individuals with developmental disabilities are at increased risk for abuse as compared to the general population (NCTSN, 2004; Gil, 1970; Mahoney & Camilo, 1998; Ryan, 1994) 60% and 100% (depending on sample) of individuals with DD have experienced trauma, usually repeated incidents of abuse (Sobsey, 1994) Retrieved on June 3, 2007 from http://www.intellectualdisability.info/diagnosis/psychosis_rr.htm

46. 46 People with Intellectual & Developmental Disabilities Data From NCTSN: (www.NCTSNet.org) Risk of abuse increases by 78 percent due to exposure to the "disabilities service system� alone (Sobsey & Doe, 1991). Sexual abuse incidents are almost four times as common in institutional settings as in the community (Blatt & Brown, 1986). Ninety-nine percent of those who commit abuse are well known to, and trusted by, both the child and the child's care providers (Baladerian, 1991).

47. 47 People with Intellectual & Developmental Disabilities Lesch-Nyhan Syndrome Rare genetic disorder, linked to recessive x gene Enzyme deficiency, neurological disorder, retardation, extreme self-mutilating behavior � particularly self-biting, head-banging Treatment of symptoms, no cure, early death Cornelia de Lange Syndrome Confirm by genetic testing, confused with FAS Possible developmental delay, aggressiveness, self-mutilation, a lack of interpersonal connectiveness, self-stimulation, repetitive motions, and rigidity of behavior Treatment: systemic / interdisciplinary Retrieved on June 3, 2007 from http://www.ninds.nih.gov/disorders/lesch_nyhan/lesch_nyhan.htm

48. 48 General Recommendations Slow down your speech Use visuals whenever possible to reinforce verbal messages: draw pictures & write down suggestions Present information one item at a time Ask for feedback after each item to ensure clear comprehension Be specific in making suggestions for change Practice different ways of handling tough situations the client is likely to encounter (Avrin, Charlton, Tallant, 1998)

49. 49 General Recommendations Format treatment / interventions so that several repeats of key information occur. Work on building coping skills rather than insight. Change will occur more slowly than with others. Measure change with a micrometer rather than a yardstick. Effective treatment for people must include a variety of support and education services for families and caregivers. (Avrin, Charlton, Tallant, 1998)

50. People with Sociopathy/Psychopathy This condition of missing conscience is called by other names, most often "sociopathy," or the somewhat more familiar term psychopathy. Guiltlessness was the first personality disorder to be recognized by psychiatry, and terms that have been used at times over the past century include: manie sans d�lire, psychopathic inferiority, moral insanity, and moral imbecility. Retrieved on June 3, 2007 from http://www.cix.co.uk/~klockstone/spath.htm

51. 51 People with Sociopathy/Psychopathy The Research: Sociopathy prevalence is approximately 4% of the population which is seemingly low until it is compared to: Schizophrenia prevalence which is approximately 1% of the population 20% of the prison population has sociopathy, but this group accounts for more than 50% of the most serious crimes (Stout, 2005) Retrieved on June 3, 2007 from http://www.uchc.edu/ocomm/newsarchive/news05/mar05/killers.html

52. 52 People with Sociopathy/Psychopathy The Research: Some neurological research suggests that socipaths process emotionally laden and neutral stimuli in a similar manner and do not distinguish the difference � which is consistent with their inability to process emotional experience (Stout, 2005; Intrator et al, 1997) Sociopathy is often comorbid with substance abuse. Research indicates: 75% sociopaths may be alcohol dependent 50% sociopaths may be addicted to other drugs (Regier et al., 1990) Retrieved on June 3, 2007 from http://www.uchc.edu/ocomm/newsarchive/news05/mar05/killers.html

53. People with Sociopathy/Psychopathy The Research: Quetiapine (Seroquel) was effective with Antisocial Personality Disordered-patients in a maximum security psychiatric hospital. Results included a decrease in: impulsivity, hostility, aggressiveness, irritability, and rage reactions. Typical dosage was 600 to 800 mg per day. Patients attributed their willingness to comply with quetiapine treatment to both the effectiveness of the drug and its favorable adverse-event profile. Retrieved on June 3, 2007 from http://ijo.sagepub.com/cgi/content/abstract/47/5/556

54. People with Sociopathy/Psychopathy Sobering Recommendations: Can an adult with sociopathy or psychopathy change? �Usually not. It seems that if you don't develop a conscience early, it's hard to get one." Nick DeMartinis, MD, U.Conn (2005) Strategies �If you recognize a sociopath, the best way to protect yourself is to avoid him or her. Psychologists do not usually like to recommend avoidance, but in this case, I make a very deliberate exception." Martha Stout, Ph.D., The Sociopath Next Door� (2005) Retrieved on June 3, 2007 from http://www.uchc.edu/ocomm/newsarchive/news05/mar05/killers.html

55. People with Sociopathy/Psychopathy Sobering Recommendations: Higgins: �Sociopaths think they're always right and will normally resist attempts at therapy.� If they do agree to therapy they will try and subvert the process, particularly in a group context. You can't negotiate or bargain with psychopaths." Retrieved from http://www.cix.co.uk/~klockstone/spath.htm

56. People with Sociopathy/Psychopathy The Dilemma: No consensus about terminology: psychopathy v. sociopathy Diagnosis often mis-used Likely reflects early history of family turmoil, & comorbid substance abuse No consensus about treatment approaches No consensus about treatment benefit or efficacy No consensus about outcomes

57. People with Aggression & Violence Defining the Issue Some Research Suggested Resources Successful Strategies

58. 58 What is aggressive?What is violent? Defining assaultive, aggressive behavior is an extraordinary challenge. It has been likened to �taking a stroll through a semantic jungle� (Bandura, 1973) and stymied international leaders for years. A case in point: In 1923, the League of Nations established a committee to define what constituted aggressive acts. Fifty years later, they finally submitted their 350-word report to the United Nations and ultimately left the task of definition to the United Nations Security Council. (LeBel, 1988; Cairns, 1979).

59. 59 Types of Aggression Different Types Different Dimensions Instrumental Verbal Hostile Physical Relational Written Territorial Indirect Fear-induced (internet, stalking) Predatory Maternal / Paternal Irritable

60. 60 People With Aggression & Violence The Research: Research indicates that, at best, trained mental health professionals alone can predict the potential for violence somewhat better than chance (53%). (Mossman, 1994; Lidz, Mulvey & Gardner, 1993; Janofsky, Spears, Neubauer, 1988) The capacity to predict violence increases when multiple sources of data are used. (Heilbrun, 2003; Mossman, 1994; Lidz, Mulvey & Gardner, 1993; McNeil & Binder, 1991)

61. 61 People With Aggression & Violence Previous violent behavior #1 individual risk factor for re-occurrence Previous history physical or sexual aggression History of homelessness or Trauma Previous history of S/R use Command hallucinations Intoxication or detoxification Planned Aggression vs. Spontaneous

62. 62 People With Aggression & Violence The Research: �Anti-prison� model created by James Gilligan, M.D. Reduced recidivism 83% in CA pilot programs �Far from deterring violent behavior, punishment is by far the most powerful stimulus of violent behavior that we know. Today's prisons treat humans like animals, and then we are surprised when prisoners act like animals." Retrieved on June 3, 2007 from http://www.nelmh.org/page_view.asp?c=6&fc=009025&did=2575

63. 63 People With Aggression & Violence The Research: One of the most effective programs to reduce recidivism is a college education. In Massachusetts, after 30 years, only 1% of prisoners who had received a bachelor's or master's degree while in prison were returned to prison for a new crime. In contrast, the usual rate of repeat offenders is 65% within the first 3 years following release from prison. In the 1990s, Congress repealed Pell grants for prisoners. In the name of being "tough on crime," the most effective program discovered for reducing crime and violence was eliminated.

64. 64 People With Aggression & Violence Other Effective Strategies: Cognitive skills training CBT DBT Inclusion of family members Retrieved on June 3, 2007 from http://www.nelmh.org/page_view.asp?c=6&fc=009025&did=2575

65. 65 People With Aggression & Violence The Research: Clozapine has proven superior to haloperidol and risperidone and at least equivalent to olanzapine in the management of violent behavior among patients with thought disorders. Compared with placebo, patients in a study who received Seroquel demonstrated significantly greater improvements in symptoms of aggression and hostility in all areas measured by the study protocol. http://www.medscape.com/viewarticle/501527 http://www.medicalnewstoday.com/medicalnews.php?newsid=26328

66. 66 People With Aggression & Violence The Third Side: Part of the Global Negotiation Project at Harvard http://www.thirdside.org Taking the Third Side means: Seeking to understand both sides of the conflict Encouraging a process of cooperative negotiation Supporting a wise solution that fairly meets the essential needs of both sides and the community

67. 67 What is the Third Side? Who are the Thirdsiders? We are.

68. 68 The Third Side Violence Schemata Retrieved on June 14, 2007 from http://www.thirdside.org/overview.cfm

69. 69 Use Tools & Resources Use Tools Nobully.com Bullyonline.org The Broset Violence Checklist: http://home.no.net/bvc2/ The McArthur Violence Risk Assessment: http://macarthur.virginia.edu/risk.html Blueprints for Violence Prevention: http://www.colorado.edu/cspv/blueprints/ Violence Institute of NJ http://www.umdnj.edu/vinjweb CDC http://www.cdc.gov/ncipc/dvp/dvp.htm Surgeon General�s Report http://mentalhealth.samhsa.gov/youthviolence/

70. Example of Successful Intervention Mr. Weeks A very large 40 year old man with Psychotic & Anti-social DO in a forensic hospital for assaultive behavior. He is not able to verbally process but does admit to �bad thoughts.� Due to a history of and reliance upon extensive restraint use, Mr. Weeks would precipitate situations in which he was restrained and seemed to rely on such containment.

71. Example of Successful InterventionMr. Weeks Effective Strategy: Staff made a deal with him to use a �vibrating pillow� in exchange for restraints. Mr. Weeks liked the softness, buzzing sound and motion of pillow. He couldn�t identify warning signs but would ask staff to use pillow if needed. Historical Experience: One of the highest �users� of restraint and considered �untreatable.�

72. Example of Successful InterventionJulissa A 13 year old young woman with intellectual disability (FS IQ 60) and a severe trauma history including abuse, neglect, abandonment, and rape by a family member. She has been hospitalized > 20 times, placed/tossed from specialized residential placements in 3 states, and considered �impossible to treat.� When distressed she urinates spontaneously, yells, �flaps� her arms and hands, bites and severely self-injures herself and staff who try to stop her.

73. Example of Successful Intervention Julissa Effective Strategy: Brought in experienced OT, analyzed behavior, and created flexible, sensory-based interventions: Built a cardboard box �her house� to have nearby to create her own physical containment on her terms Gave her �chewlery� to wear and bite on when distressed Created oral intervention sessions w/oral massagers to teach proprioception & biting modulation Anticipated need with crunchy fruits/vegetables at �peak� times

74. Example of Successful Intervention Bruce A 17 year old young man with history of physical abuse by father, neglect, and social victimization / bullying at school. Hospitalized forensically on multiple counts of animal cruelty, mutilation and homicidal threats to peers. Socially withdrawn, preoccupied with death, unwilling to participate in programming, threatening to kill if �forced� to attend groups. Efforts to get Bruce to school/groups consistently lead to violent restraints and severe injuries to staff.

75. Example of Successful Intervention Bruce Effective Strategy: Program Director �dumped the rules� - allowed Bruce to isolate in his room. Staff told to keep hands-off. As relationship developed with therapist, trust led to change. School work brought to him, slow movement out of room, outdoor time started in evenings and progressed to day time, OT identified weighted item preference, once willing to try group activities, he wore a weighted vest underneath shirt to feel supported - �no one knew� - no restraint/seclusion occurred.

76. 76 Example of Successful Intervention Eva A 59 year old woman who was dropped off and �raised at a State Hospital� from 12 � 55 yo. Eva was placed in an adult group home and �bounced� from hospital to hospital. She was �black listed� by most ERs. When admitted to a local hospital, staff threatened to quit, and some walked out rather than �deal with Eva again� and her chronic screaming, disrobing, smearing, sexualized response to restraint and nightly chanting, �Frankie stole the cherries.� The hospital took a �fresh look,� met with the family repeatedly and ultimately confirmed, Eva had been repeatedly raped as a child by her brother at night. She was a horrifically traumatized, trauma-survivor.

77. 77 Example of Successful Intervention Eva Effective Strategy: The hospital began to: create choice, control and safety (what time to go to bed, if she wanted to be in groups, night light in bedroom, closing the door) name and identify her rage and what helped to soothe her. Her greatest comfort as a child � when her Irish grandmother sang to her. Staff started to sing to Eva at night to help her fall asleep. It worked. The screaming/chanting/smearing stopped. Eva was given a choice of where she went next. She chose a nursing home. She stayed and was not readmitted to the acute unit again.

78. 78 Example of Successful Intervention Juan A 31 year old man with mild-moderate intellectual disability and mental illness and an extensive history of impulsive assaults and property destruction. Juan was hospitalized in an acute unit, floridly psychotic, and intermittently agreeing to take his medication. In a paranoid rage, he picked up the unit television, carried it to the nurses� station and was about to hurl through the safety glass partition.

79. 79 Example of Successful Intervention Juan Effective Strategy: The fast-thinking Nurse Manager jumped up, took a stress ball out of her pocket and offered to trade items with Juan ... He traded ... without incident. Staff created an OT plan and made sure he (and they) had stress balls and soft hand-held items. As long as Juan was holding something � he wasn�t throwing or hitting.

80. 80 Conclusions Paradoxic Clarity in the Challenge: These challenges are not new and have defied easy answers from experts for many years Challenges declare themselves through manifest crisis that usually impacts more than one person These challenges test the organization and treatment culture No easy answers No uniform interventions Require clinical �due diligence�

81. Conclusions Solutions: Creative & inspirational Seldom simple, typically multi-faceted Tap the best of staff ingenuity Create situations and lessons learned that people remember Can lead to new competence & learning Can create organizational change and staff growth

82. 82 Recommendations Rule out medical problems first, even if previously assessed Do not rule out trauma � presume it and implement TIC practices Go back to the past, history gets lost FAST � obtain and review earlier information, retest/reexamine as indicated Based on history, is there reasonable perspective on the current challenge? Is the perspective driven by data or legend and lore?

83. 83 Recommendations Essential Strategies: Transparency: Admit challenge Gather the Group: More minds the better Gumby Factor: Flexibility in process & solutions Do not personalize. Look at the behavior. What�s the meaning? Involve Consumers & Families Share Success

84. There will always be people with exceptional challenges who we will not have all the answers for. It is not the difficulty they present rather, what we do in response to that difficulty.

85. 85 Sage Words for New Staff In the midst of the movement and chaos, keep stillness inside of you Deepak Chopra Your role as a helper is to be things, not to do things Nar-Anon

86. FINAL THOUGHT: OUR RESPONSE TO THE �MOST DIFFICULT� I�ve come to the frightening conclusion that I am the decisive element in the classroom. My personal approach creates the climate. My daily mood makes the weather. As a teacher, I possess a tremendous power to make a child�s life miserable or joyous. I can be a tool of torture or an instrument of inspiration. I can humiliate or humor, hurt or heal. In all situations, it is my response that decides whether a crisis will be escalated or de-escalated and a child humanized or dehumanized. Haim Ginott, Psychologist & Teacher (1965)

87. DISCUSSION

88. 88 References Avrin, S., Charlton, M., & Tallant, B. (1998). Diagnosis and treatment of clients with developmental disabilities. Unpublished manuscript, Aurora Mental Health Center. Baladerian, N.J. (1991). Sexual abuse of people with developmental disabilities. Journal of Sexuality and Disability, 9 (4): 323-335. Blatt, E. R. & Brown, S. W. (1986). Environmental influences on incidents of alleged child abuse and neglect in New York state psychiatric facilities: Toward an etiology of institutional child maltreatment. Child Abuse and Neglect, 10 (2): 171-180

89. 89 References Facts on Traumatic Stress and Children with Developmental Disabilities (2004). National Child Traumatic Stress Network, www.NCTSNet.org Gil, D. G. (1970). Violence against children: Physical abuse in the United States. Cambridge: Harvard UniversityPress Mahoney, J. & Camilo, C. (1998). Meeting the needs of crime victims with disabilities. (Draft). Crime Victims Compensation Program Mental Health Treatment Guidelines Task Force. Patrick, C.J. (Ed.) (2005). Handbook of Psychopathy, Guilford Press, New York

90. 90 References Ryan, R. (1994). Posttraumatic stress disorder in persons with developmental disabilities. Community Mental Health Journal, 30 (1): 45-54. Sobsey, D. & Doe, T. (1991). Patterns of sexual abuse and assault. Sexuality and Disability, 9 (3): 243-259. Stout, M. (2005). The Sociopath Next Door: The Ruthless versus the Rest of Us, Broadway Books, New York