Best Practices for Managing Resident Crisis and Creating Safe Environments

1. Best Practices and Helpful Practices From the Fidelity Reviews Paul Smits, LCSW Senior Policy Analyst University of South Florida M. Scott Young , PhD Research Assistant Professor University of South Florida

2. Overview • Managing Resident Crisis • Safe Rooms and Safe Lounges • Safety Practices • Amnesty Boxes • Peer Support • Evidence Based Practices • Getting Staff Buy In • Incident Reviews

3. Managing Resident Crisis • Have safety plan in place • Shift your approach from a sanctions based approach to an engagement based approach • More TX isn’t always better –find the right counselor, right groups and programs • Work collaboratively with the resident to resolve problems • Only ask Veterans to leave who pose a safety risk

4. Provider Innovation: Safe Rooms and Sober Lounges Why Were They Created? • Response to aggressive behavior at the facility • Effort to minimize disruptions • Alternative to police involvement / Deterrent to police contact • Motivation of program staff and administration • Desire to increase retention rates

5. What is Their Purpose? To ensure client safety To monitor client health and behavior To provide private area for recovery from substance use, medication effects, or unmanageable emotional distress To provide a private space for any client needing it

7. Typical Operation of the Safe Room • Staff direct residents who are escalating to the Safe Room. • Resident is instructed to spend 15 minutes in the Safe Room. • Staff are able to observe residents in the Safe Room through a window on the door to the room. • If a resident falls asleep in the room, staff make sure that resident is in a recovery position. • Resident is offered food and non-alcoholic beverages by staff. • At the 15 minute mark, staff re-evaluate the resident and determine if the Veteran is appropriate to re-enter the community. • If resident falls asleep, the resident is allowed to stay in the room for additional time if appropriate.

8. Encountering Resistance • Many sites have noted resident resistance to using the Safe Room • If resident is resistant to entering or staying in the Safe Room, he or she is allowed to take a 15 minute walk in the community instead • Possible techniques to manage resistance: • Prior to Safe Room use, remind Veteran that the facility is a calm, therapeutic environment • Ensure Veteran of the need to observe them for their safety • Encourage Veteran to think how their behavior affects their fellow Veterans • Create a comfortable environment in the Safe Room (comfortable furniture, food and drink) • If resistance to staff direction continues, police may be contacted in those instances

9. Safety Practices • Contraband policy • Bag and locker searches • Sign in / Sign out (staff observation) • Curfews • Amnesty boxes For additional information, see: Safety Practices for Low Demand Programs available at https://www.va.gov/HOMELESS/nchav/gpd-ta/GPD-LD.asp

10. Amnesty Boxes

11. Use of Amnesty Boxes • Amnesty boxes should be located in the entrance to the facility where anonymous disposal can occur • The container should be of sturdy, steel construction and be locked • The container must be attached in a way that cannot be removed • The container should be constructed in a manner that does not allow residents to remove items, and only staff should have access to the keys for the purpose of removing items • Residents should not face discipline or sanctions for use of the amnesty box • The program should maintain written polices for confiscation of contraband from the amnesty boxes • Weapons taken from the amnesty boxes should be disposed of in accordance with local law enforcement policy

12. Peer Support • Low Demand Programs can maximize retention by involving residents in helping roles, including incentivizing chores • Find out each resident’s skill sets and interests • Give residents recognition and rewards for their helping roles • Involve senior residents in peer orientation to program

13. Giving Residents a Voice • Hold routinely scheduled community meetings • Encourage resident participation and input • Encourage Veterans to give feedback and discuss community improvements that they would like • Have Veterans set up and coordinate some activities • Use the Shared Decision Making Model • Discuss reasonable options Veterans can pursue regarding their recovery, and then support their choices

14. Use of Evidence Based Practices • Stages of Change http://www.psychotherapy.com.au/fileadmin/site_files/events/pdfs/APPLYING_THE_STAGES_OF_CHANGE_JOHN_NORCROSS.pdf • Motivational Interviewing https://www.integration.samhsa.gov/clinical-practice/motivational-interviewing • Seeking Safety https://www.treatment-innovations.org/seeking-safety.html Trauma Informed Care https://www.samhsa.gov/nctic/trauma-interventions • De-Escalation Techniques / Crisis Response https://www.crisisprevention.com/Blog/June-2011/De-escalation-Tips?lang=en-US https://store.samhsa.gov/product/Core-Elements-for-Responding-to-Mental-Health-Crises/sma09-4427

15. Getting Staff Buy In • Review the core values of the model often • Help staff practice harm reduction strategies • Use real life scenarios to help staff practice the model • Reward staff who show they are adopting the model

16. Incident Reviews • Involve staff in incident reviews (The Morning Huddle) • Brainstorm on effective interventions • Help staff model engagement with the resident, and use sanctions only as a last resort • Be patient with staff as they learn harm reduction strategies

17. Questions? / Discussion