What to Say and Do: Response Training for Special Situations

1. What to Say and Do: Response Training for Special Situations Dr. Virginia Murphy Hershey Entertainment and Resorts Spring 2012

2. About the Presenter • Licensed Psychologist since 2005 • Has worked in the field of human services for 15 years at various levels of care (inpatient units, intensive outpatient programs, private practice, schools) • Currently employed as a Lead Psychologist at Milton Hershey School • Hershey Park Season Pass holder since 2008

3. Objectives • By the conclusion of this training, participants will be able to: • Verbalize a de-escalation plan for HE & R guests who present with behavioral or emotional concerns • Share strategies to assist lost children who have functional communication problems • Use a crisis intervention plan in response to acutely ill guests • Understand mandated reporting procedures and how to intervene in situations of suspected child abuse

4. Part I: Adult and Adolescent Guests with Mental Health Concerns

5. Mental Illness: Brief Overview • “Mental Illness” assumes a significant level of emotional and/or behavioral disturbance that interferes with daily functioning. The term covers a broad array of disorders and presentations, including: • Bipolar Disorder • Major Depressive Disorder • Schizophrenia • Acute Anxiety/Panic Disorder • Personality Disorders • NSSI – Non-suicidal Self-Injurious Behaviors • Dual Diagnosis (someone who has one of the above in addition to a Substance Abuse problem)

6. Mood Disturbances: Bipolar Disorder and Major Depressive Disorder • Bipolar Disorder: Presents as: • “manic” or hyper with extremely high energy • flight of ideas • rapid speech • inability to calm • can be extremely irritable/angry in response to minor stressors) • Major Depressive Disorder: Presents as: • low energy/fatigue • sad affect and presentation • unwilling/unmotivated to engage in pleasurable activities • crying, ruminating • ** less likely to be a HE & R guest, given condition, unless in suicidal state

7. Schizophrenia and Other Thought Disorders • Presents as: • Incoherent with loose associations, tangential speech • May describe visual or auditory hallucinations or delusions • May not have a clear understanding of where they are or what is happening around them • May present as paranoid – think that others are “out to get them” • Disorganized behavior (not goal-directed) • Can seem “not there” if responding to internal stimuli

8. Anxiety Disorders • Acute Anxiety/Panic Disorder: Presents as: • afraid or terrified • anxious to escape or leave current situation • can present with a “flight or fight response” • may say things like “I am going to vomit/faint/pass out/die of a heart attack” • physical symptoms include racing heart, elevated BP and pulse, shallow respiration

9. Personality Disorders • Personality Disorders: a large category of mental illness; most likely problematic presentation: • a high need for attention • interpersonal instability • perceived abandonment by others • presents as highly conflictual with others at times • may resort to dangerous behaviors to regain attention/sympathy – these behaviors can include self-injury

10. NSSI • NSSI – Non-suicidal Self-Injurious Behaviors – not a mental illness in itself, but is sometimes a behavior that accompanies a depressive disorder, personality disorder, or is present in a person who has survived a trauma (sexual abuse, physical abuse, etc.) • NSSI can take the form of cutting, burning, erasing

11. Dually Diagnosed Individuals • Individuals with both a mental health concern and a Substance Abuse problem • Signs to look for include: • Dilated pupils • Slurred speech • Trouble with gross motor movements (walking, etc.) ***If you suspect a Substance Abuse issue, DO NOT use the strategies we will discuss today. An intoxicated person will not be able to process the information you provide. Proceed with having them removed from the resort or park (review standard practice)***

12. Stress Model of Crisis • Typical phases of a situational crisis: • 1. Baseline or Pre-Crisis State • 2. Triggering Phase – where the first signs of abnormal behavior are evident (may be linked to the something in the environment, or may seem spontaneous and without warning) • 3. Escalation Phase – person becomes more and more upset and agitated. As the intensity of the agitation increases, the likelihood of the person responding to intervention decreases. • 4. Outburst Phase – person can be dangerous to self, others, the environment. Intervention at this phase must shift to safety/protection (not de-escalation) • 5. Recovery Phase – person begins to calm down and relax. The person is again more rational and able to respond to redirections.

13. Triggering Phase • The earlier the intervention, the greater the likelihood of a positive outcome. • The trigger may be a combination of the person’s underlying mental health concerns, combined with the stimulating environment. • What to do in this phase: • Provide a safe and predictable, calm environment (ie., suggest a short break in the safety/security office to calm down – give time and space)

14. Escalation Phase • At this phase, the person is showing signs of loss of control – may look like very loud talking, withdrawal, threatening words or behavior. • What to do in this phase: • Remove the audience if at all possible • Use specific de-escalation strategies (more to follow)

15. Assessing the Situation • There are four important questions to ask yourself when you enter a crisis or potential crisis, that will help you identify the most appropriate strategy: • 1. What am I feeling right now? • 2. What does this person feel, need, or want? • 3. How is the environment affecting this person? • 4. How can I best respond?

16. Self-Awareness • Your own feelings about the situation can give you important data – use your own feelings as a barometer. • The person you are dealing with may be an astute observer of you – therefore, your feelings can have an effect on the outcome. • You cannot “not communicate”!! • Be aware of your feelings and make sure you are calm so that your emotions are not dictating your response.

17. The Needs, Feelings, and Wants of the Guest • This question leads to a discovery of what the person’s goals are, or what the person is seeking to achieve. Remember that usually, behavior reflects need. • Examples of what the person may need: • Need to feel safe (overwhelmed by own MH concerns) • Need to be treated fairly • Need for attention • Need to feel accepted or important • Need to be heard

18. Awareness of the Environment • Many times, a potential crisis can be averted by making modifications to the immediate environment. • Again, remove the audience when at all possible. • Attempt to have the guest move to a quieter, calmer, location with you. Have a room prepared that is calm, quiet, and has minimal objects in it. • If the guest is in conflict with a fellow guest, get them separated and out of eyesight.

19. Intervention Approaches • Based on your assessment of your own feelings, the feelings/needs/wants of the guest, and the environment, potential approaches include: • Managing the environment to neutralize potential triggers • Engage the guest and defuse acting-out behavior or contain dangerous behavior • Exercise self-control over the feelings the situation evokes.

20. An Important Note • The interventions discussed next are ideally used at the Triggering Phase or at the Escalation Phase. • If the situation is at the Outburst Phase (acute safety concern, either for the guest or for others) – immediately attempt to control the environment by vacating other guests from the area, and by contacting 911.

21. Guidelines for De-escalation • Never work alone – have at least one co-worker with you • Only one person (the lead) should talk with the guest. Too many voices can be confusing and stressful for the individual, leading to further escalation of symptoms • Speak calmly and clearly, and use short, declarative sentences (more on this later) • Attempt to have the guest accompany you to a relatively calm place with no audience (safety/security office, first aid building)

22. General Guidelines, cont’d • Structuring: provide a safe environment; be predictable and consistent; set clear expectations and repeat them • Listening: Identify feelings; be non-judgmental; use active listening techniques • Directing: Redirect behaviors; make clear statements about what behaviors are and are not acceptable; use rewards and punishments; establish control and order • Relating: Give personal attention and encourage any signs of de-escalation and regaining self control • Teaching: Hold person responsible for his/her actions and choices; when possible, provide forced-choices to reinforce self-control (i.e., “you can either go to X or you can rest here for a few more minutes.”)

23. Verbal Crisis Communication • Be aware that your tone of voice, body posture, and eye contact all send powerful messages. • Maintain eye contact without “staring” • Tone of voice should convey strength without being loud. Your rate of speech should be slow and deliberate. Resist the urge to talk louder in order to capture attention. Instead, talk slightly softer. • A word on space – do NOT touch the person without his/her permission unless it is an acute crisis where someone’s safety is at-risk. Provide enough personal space at all times.

24. “I didn’t say you were stupid.”

25. Verbal Crisis Communication • To reduce the volume of speech/words from the guest, ask closed questions (“Are you upset because your wife said something rude to you?”) – these questions require a yes or no response from the guest, and tend to slow things down. Other examples include: • “Do you feel safe in this space right now?” • “Would you like a cup of water?” • “Do you live nearby?” • “Do you take any medications?”

26. Verbal Crisis Communication • To get more conversation going, ask open questions (“How do you feel right now?” “What happened to get you upset?” “What do you think should happen next?”) • Avoid “why” questions because they often lead to defensive responses. • Reflect back what you have heard (“It sounds like you are saying that you were really angry and upset about X, and that led you to begin doing Y . ... Is that correct?”)

27. Verbal Crisis Communication • When you think you understand the concerns, summarize the conversation: • “Let me see if I have this straight. You were doing okay until X happened, then you became really upset. This led you to do Y. Now, what we need to do is . . . “ • Remember that in a summary, tie the feelings to the behavior, and then conclude with a tentative plan (or invite the person to discuss a tentative plan with you. You can also give a forced choice.)

28. De-escalation Strategies • I-ESCAPE* • I: Isolate the Conversation • E: Explore person’s point of view • S: Summarize feelings and content • C: Connect behavior to feelings • A: Alternative behaviors discussed • P: Plan developed • E: Enter person into plan

29. Practicing the Skills • Break into groups of 8-10 • Each group gets a scenario and a worksheet • Decide who is the lead • Decide who will record results on the worksheet • Implement the guidelines • Use the I-ESCAPE de-escalation strategies and the verbal crisis communication strategies

30. Reporting Out • General reactions to the practice • What was the easiest part? • What was the toughest part? • How often should you role-play to keep practicing these skills?

31. Part II: Assisting Children with Functional Communication Problems

32. Functional Communication Problems in Children • Most often, children with functional communication problems will fall into one of three categories: • Autism Spectrum Disorders • Mental Retardation • Selective Mutism • Physical problems (deafness)

33. Autism Spectrum Disorders • Hallmarks of this set of disorders include: • Difficulty in social interactions (this includes eye contact, verbal communication, and emotional connections with others) • Difficulty in communication (delay – either partial or total – in the development of spoken language. If language is present, it is often impaired – ie., the child cannot sustain a conversation, may use repetitive language) • Repetitive motor mannerisms (hand flapping, body rocking), preoccupation with very narrow interests • Cognitive and behavioral rigidity – can become very agitated when routine is changed, or when environment is too stimulating.

34. Communication Issues with ASD Children • Can exhibit echolalia (repeating same words over and over) • Cannot adapt their responses to the statements of others (therefore, previous slide re: verbal crisis communication will not work) • Avoidant of communication with others; avoidant of eye contact • Unable to read non-verbal cues

35. Key Points to Remember • Provide a calm space for the child • Do not be alarmed by repetitive movements (hand-flapping, spinning, etc). Allow the child to perform these movements as long as they are not self-injurious. • Do not become frustrated by lack of communication – it is likely that the child does not have the ability to communicate effectively.

36. Be Prepared • Have a functional communication board or paper: • This device should illustrate with simple words and pictures the following: • Are you with your mom, your dad, or someone else? • Can you write your name? • Can you write how old you are? • What are you feeling right now? (feelings faces) • What do you need right now? (a snack, a drink, to write or draw, etc) • **Note that this visual aid can be used with any child who has functional communication problems – not just ASD kids.

37. Example of Functional Communication Helper

38. Functional Communication Helper Are you here with … Mother? Father? Or someone else? Can you say or write your name? ___________________________________________ Can you say or write how old you are? ______________________________________ How are you feeling right now? Circle one: Angry Happy Scared Snack Drink Rest

39. What do you need right now?

40. Provide the following simple statements (both verbally and in writing) • 1. We will help you to find your parents/caregivers. • 2. We will keep you safe until your parents/caregivers get here. • 3. We will give you a drink, and a place to rest/relax.

41. Other Issues to Note • Kids with ASD are often tactile defensive – different textures can be intolerable to them. • They also can be hyper-sensitive to sounds (so keep things soft and calm) • Note that kids with ASD benefit from knowing what will happen next - so convey that even if you are not sure that they understand (“Now we are going to find your parents and tell them where you are so they can meet us here. Until they come, you can draw or play with these toys.”)

42. HE & R Plan for Lost Children • Make sure all staff know the two locations lost children are taken to, in order to assist parents smoothly. All staff includes all ride operators, ticket takers, refreshment stand workers, vendors, and safety/security.

43. Part III: Response to Suspected Child Abuse

44. Mandated Reporting Laws in PA • As employees of HE & R, you have a legal and ethical responsibility to report suspected child abuse to appropriate authorities. • Your role is to report suspected abuse, not investigate the abuse or interpret the law.

45. Definitions of Child Abuse • Child abuse is defined as any recent act or failure to act that causes physical injury, mental injury, sexual abuse, sexual exploitation or physical neglect of a child under 18 years of age. • Imminent Risk (newest category- added to law in 1995) • Child abuse also occurs when an individual places a child in imminent risk of serious physical injury or sexual abuse or exploitation.

46. The Laws in PA will be changing. . . • In the aftermath of the sexual abuse scandal at Penn State University, PA legislators are planning on revising the Child Protective Services laws to ensure better compliance with reporting, including expanding the reporting requirements. • PA Senate and House have created a Joint Task Force On Child Protection – report to be submitted by November 30, 2012 • Data analyses reveals that PA does poorly in identifying child abuse. PA has the lowest reporting rates in the nation (8 reports per 1,000 children, vs. 40 per 1,000 nationwide). PA also has the lowest rate of identified child abuse in the nature (1.3 identified victims per 1,000 children compared to an average of 9.2 per 1,000 nationwide).

47. Steps in Mandated Reporting • Step 1: Assure that the child victim gets medical assistance and is safe. • Step 2: Internal Notification: Notify supervisor (or designated point person) of the suspicion • Step 3: Obtain basic information (child’s name, address, age, parents’ names if possible) • Step 4: Contact PA Childline (1-800-932-0313) and Derry Township Police (534-2202) and make report of suspicion. Also seek guidance re: next steps. • Step 5: Documentation: Have a system by which you consistently record all suspicions of child abuse, your response, and final outcome. Also identify where such documentation will be kept.

48. Questions/Discussion

49. References • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. • Cohen, D. J. & Volkmar, F.R., Editors (2005). Handbook of Autism and Pervasive Developmental Disorders, 3rd Edition, Volumes 1 and 2. New York: Wiley & Sons, Inc. • The Family Life Development Center (2001). Therapeutic Crisis Intervention, 5th Edition, Cornell University, New York. • Myles, B. S. & Southwick, J. (1999). Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns. Shawnee Mission, Kansas: Autism Asperger Publishing Company. • Pennsylvania Department of Public Welfare (2010). Annual child abuse report. Harrisburg, PA. • U.S. Department of Health and Human Services (2010). Child maltreatment 2010. Washington, DC.