“Handling the Most Difficult 10%”

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

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

“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…

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…

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

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.

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.

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?

What is “Most Difficult” for you? Discussion

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

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?

OnsiteObservations • 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

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

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

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…

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)

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?”

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)

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)

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)

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…

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)

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)

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)

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)

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.

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

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

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

“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

“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

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)

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

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”

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…

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.

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

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.

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

Next, Janice will talk about people with challenging issues and what the literature indicates…

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

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

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

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

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).

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

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)

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)

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 délire, psychopathic inferiority, moral insanity, and moral imbecility. Retrieved on June 3, 2007 from http://www.cix.co.uk/~klockstone/spath.htm

“Handling the Most Difficult 10%”