PowerPoint Presentation...6-wk course/7.5 contact hrs Offered quarterly First presentation airs on September 18th National Online Training Series Pre-recorded presentations air 1x/month

8/7/2020

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Institute on Disability/UCED, University of New Hampshire

© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCED© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCED

The Center for START Services

University of New Hampshire Institute on Disability/UCED

57 Regional Drive, Unit 8, Concord, New Hampshire 03301

Phone: (603) 228-2084 | Email: [email protected] | www.centerforstartservices.org

Joan B. Beasley, PhD

Director, Center for START Services

Research Associate Professor, University of New Hampshire

Director, National Research Consortium on Mental Health in IDD

David O’Neal, MS, LMHC, MHP,

Project Facilitator, Center for START Services

START Crisis Services Overview


© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCED

Welcome to day 3 of orientation

3 things to include in every meeting, forum, training, crisis encounter:

gratitude, kindness and hope

Recap: START methods/ humanism

Focus: Well being, PERMA

Positive medicine (bio)

Positive psychology (psycho)

Positive behavior support (social)

Integrated: Social work-strength based, bio-psycho-social: ecology

We ask that today you apply what we have presented to your participation, not the lens you usually use.



Poll: Take a moment please to share

your top strength1. Hope

2. Love of Learning

3. Creativity

4. Spirituality

5. Love

6. Prudence

7. Humor

8. Kindness

9. Appreciation of beauty and excellence

10. Social Intelligence

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http://www.centerforstartservices.org/

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Today’s Agenda

Eastern Pacific Topic

1:00-2:30pm ET 10:00-11:30am PT Crisis Assessment & Prevention

2:30-3:00pm ET 11:30am-12:00pm PT Crisis Intervention Part I

30 minute break

3:30-4:30pm ET 12:30-1:30pm PT Crisis Intervention Part II

4:30-5:00pm ET 1:30-2:00pm PT Wrap-up

Cross-Systems Crisis Prevention and Intervention

Joan B. Beasley, PhD, CSS Director, and David O'Neal, MS

Joan B. Beasley, Ph.D.



Poll

Why are most MH crisis service requests for people

with IDD precipitated by aggression?

a) Aggression is caused by IDD

b) It's what we all notice to ask for help

c) That's when the crisis team wants to be called

d) All of the above




Breakout: Juan Scenario 1

Juan was recently discharged from an in-patient psychiatric unit and sent back to his residential program. He is being referred to START because of his long history of in-patient stays. His staff members are reportedly tired of dealing with the aggression, report that Juan is manipulative and attention seeking. Juan has GERD, asthma and constipation, along with Severe ID and ASD, and ODD. Juan is 23 years old. He enjoys helping to prepare meals and listening to music. Juan very meticulously folds his clothes or anything else he can find to fold. He sometimes cannot move on to another activity so his folding has been limited in his behavior plan with a timer. Juan has been in his group home for three years, but they think he is not a good fit and would like to see him move. They state that Juan is a danger to the other residents, although there has never been an incident with other residents and Juan they know it is coming.

Discussion:

How can we "reframe" the goals of engagement with the information

presented here?

Tip: Think strengths, skills, interests… Bio-psycho-social


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We May Not Have All the Information




START Crisis Support Effectiveness:

The 3 A’s

Access (plan in place, response time, ease)(timely, available)

Appropriateness (expertise, CSCPIP, options)(matches real needs, provides tools)

Accountability (in person, back–up, outreach, follow-up, linkages)(responsiveness, engaging, flexible, creative)



Poll

As a START coordinator your first step is to:

a. Let people know that you have expertise in people like Juan and have a plan

b. It's always medical, just tell them to deal with the medical conditions

c. Set up a time to meet Juan and see him in his home

d. Provide training about the medical conditions he has

e. Set up an intake appointment, and develop a provisional crisis plan

f. A and D

g. None of the above


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Poll

You set up regular meeting with his team to discuss how to best understand and support Juan. The time of the meeting is convenient for you but does not allow for DSP engagement and Juan is not there. In order to address this issue you:

a. Get detailed data on how Juan is doing, monitor his aggression carefully and discuss at meetings

b. Provide direct and clear instructions as to how to train DSPs

c. This is not a problem, DSPs are not part of the planning

d. Schedule additional times to visit the program and get input from DSPs

e. Reschedule meeting; everyone should be represented and you need to spend some time with Juan before or after each meeting

f. Both a and b

g. Both c and d




• INSERT Einstein if I had an hour quote



Crisis Mental Health Assessment; What

is the presenting problem?

• Factors that bias clinicians

• Factors that impact diagnosis and treatment

• The lens we use in evaluation matters


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Guiding Principles that influence

START Crisis Assessment• Diagnostic Overshadowing (Steven Reiss, et, al 1982)

• Four aspects of IDD that can influence that MH

diagnosis and treatment (Hurley and Sovner, 1986)

• Multimodal functional model (Gardner & Sovner, 1994)




Diagnostic Overshadowing (Reiss)

Diagnostic Overshadowing refers to the process by

which a person with an IDD receives inadequate or

delayed treatment on account of the misattribution of their

physical or mental health symptoms to their IDD

However, it is a common problem in emergency settings,

(example)




Why Worry About Assumptions?

Diagnostic Overshadowing

• Common problem in MH crisis services

• Will most likely simplify the complex, or complicate the simple

• Attributed to what you "know" about the person i.e., they have "IDD"; they are on medication, etc.

• Overshadows the whole person approach to assessment

• Do we see the person or our bias about the person?


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Bio-Psycho-Social

approach (Engel, 1979)

considers the

biological,

psychological and

social strengths and

vulnerabilities

Gardner (1994), later

applied to analysis of

aggression in people

with IDD

Engel, G. (1979). The biopsychosocial model and the education of health

professionals. General Hospital Psychiatry, 1(2), pp.156-165.




Let's Discuss the Influences on IDD-MH

Crisis

• START is a closed system, why? (not magicians)

• MH diagnosis may take time; crisis interventions provide

stability and hope

• Expertise on assessment is not the same as expertise

about the person

• Sovner & Hurley: 4 factors to consider are imbedded in

our foundational practices




"Psychosocial Masking" (Sovner & Hurley)

Limited social experiences influence the content of

psychiatric symptoms (less colorful, therefore less evident)

• Why? Expression of MH symptoms may be missed

• Need to know the person when they are doing well

• Cultural competency


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"Cognitive Disintegration"(Sovner & Hurley)

Decreased ability to tolerate stress, leading to anxiety

induced confusion (can be misconstrued as psychosis) not

limited to IDD

Why? psychosis is not the same as panic. These are not

the same as attention seeking behavior…We need to

understand the role of trauma, genetics, stressors (we use

the RSQ)




"Baseline Exaggeration"(Sovner & Hurley)

Quantitative rather than qualitative changes in presentation may be indicative of mental illness(more common in IDD but not restricted to IDD)

Why does this matter?

• Need to know what a person is like when they are doing well, in order to know when they are not

• Do not assume that more of the same is the same as usual

• Not everyone has the resources to wear 5 hats at once




"Intellectual Distortion"(Sovner & Hurley)

"Symptoms can be masked by deficits in abstract thinking

and expressive language (patients unable to describe

experience)"

Why?

• The need for plain language engagement

• Cultural and linguistic barriers

• Fear, stigma

• Lack of time, listening…


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Crisis Intervention

Our job is to provide oxygen to the person and the people

around them.

Let’s welcome Dave


© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCED© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCED

The Center for START Services

University of New Hampshire Institute on Disability/UCED

57 Regional Drive, Unit 8, Concord, New Hampshire 03301

Phone: (603) 228-2084 | Email: [email protected] | www.centerforstartservices.org

David O’Neal, MS, LMHC, MHP

CSS Project Facilitator

Crisis Intervention



Poll

What is a crisis? (choose all that apply):

a) In the eyes of the beholder

b) A problem without the tools to address it

c) Lack of knowledge of how to use the tools

d) You always need the police

e) Something you cannot handle, ever

f) a-c


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A Crisis Is……Inconvenient

"There cannot be a crisis this week. My schedule is

already full."

-Henry Kissinger




Crisis Is a Subjective Experience

• It can be scary

• It is in the eyes of the beholder, definition of urgent need can

vary based on personal experience; defining crisis is key

• Problems can lead to crises when you do not have the tools

to address them and the knowledge of how to use those tools

• Crises do not necessarily define underlying cause




POLL: START CRISIS

RESPONSE

The residence calls START on call at 8PM to report that Juan has been out of control. He is running around the house screaming and opening and closing doors since early this morning. The on-call coordinator is tired after a long day and it is raining outside.

The on-call person does the following first:a) Tells the residence to call the police, then calls admin on call to let them know.

b) Pulls up the crisis plan and sees where they are in the process, calls admin on call.

c) Makes arrangements for an in person visit the next day, most of these situations can wait. Let's START team know next day.

d) Provide step by step instructions for the staff over the phone. They clearly have no idea about that they are doing. Calls admin on call.

e) Over the phone, creates a safety plan, determines they can wait for arrival, then provides an in-person or video evaluation. Calls admin on call to discuss prior to arrival.


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The Story of Juan

• Dr. Beasley shares the story of Juan

• What happened at the crisis pre-screen?

• Who helped?

• What did we learn?




Components of a Crisis Experience

• Precipitating events

• Person's vulnerabilities or context vulnerabilities

• The actual crisis event/active crisis state

• Stabilization

• Recovery




Positive Psychology in Crisis Planning and

Evaluation

• When conditions to promote wellness are undermined, problem presentations may occur

• When was this person at their best?

• The frequency and quality of interactions with others during the course of the day needs to promote a wellness approach rather than behavior management

• Health/Mental Health – identification and understanding behavior in the context in which it occurs includes an evaluation of biomedical and mental health issues as vulnerabilities that perpetuate challenging behavior

• PERMA, conditions in the person's life that promote or undermine wellbeing


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Trauma Informed Crisis Intervention

• People with IDD experience trauma at higher rates

o Increases risk of MH conditions

o Increases risk of emergency service interface

• Actual crisis events are traumatic in and of themselves

START methods

• Why coordinators are on call.

• Why we are mobile (or video)

• How we use the crisis plan




START Acute Crisis Experience

1. The cross systems plan (mapping a strategy)

2. The actual crisis event/active crisis state (the call for help)

3. START to action: Stabilization (O2 phase)

4. Address (review crisis plan)

• Precipitating events/vulnerabilities (bio-psycho-social-stressors),

MH-IDD Dx, system of support

• Knowing what helps: Observing and reassuring (strength

spotting)

5. Follow-up linkages revisited

6. A revised plan




Planning

• Preliminary plan begins on the first day (Provisional

Crisis Plan) and continues

• Planning is the process of discussion, practice and

review

• The goal is to rely upon the use of primary intervention

strategies whenever possible (avoid higher levels of

intervention)

• Getting there is a process: it takes time and

collaboration


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The START Cross-Systems Crisis Prevention

and Intervention Plan

• Who is the author?

• Instructs: Action-oriented based on consensus amongst partners in the systems

• Relies on mutual definitions of how to reach a goal

• Ongoing interaction is needed to review and modify as we learn more about how to respond

• Clear, concise, relevant

• Must easily and accurately communicate relevant issues/results

• Is a tool to foster communication and service linkages

• IS a systemic intervention and owned by the system!




The START CSCPIP Format Includes:

• Demographic information

• Mental health/health diagnoses

• Strengths, skills and interests

• General patterns of behavior

• Vulnerabilities and factors that increase the likelihood of

crisis

• Interventions that incorporate knowledge of person and

treatment modalities into crisis intervention stages




If It's Just Another Form, Forget it

• The plan will not have value without cross-system

collaboration

• Requires revision, debriefing and training

• Talk, talk, talk, talk

• The plan should be written in a way that anyone can use

o Use bulleted statements; avoid long prose

o Use positive, solution focused language; how would you like

others to describe you?

o What information would be needed in order for anyone to be

helpful during a crisis event?


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Emergency On-Call Supports

• 24/7 in fully operational teams

• Immediate Telephone Access

• In-Person Response (or Telehealth) within 1- 2 hours

(wherever that person might be)

• Next day follow up



Enhancing the Existing Crisis Supports

• Working with current mental health emergency system

• Linkage and partnerships!

• Collaborate and assist with stabilization, interventions

and dispositions, and prescreening for inpatient

admissions.

• Connect with follow up



Key Elements of a Usual MH Evaluation

• Show up!

• Examination of the person

• Review of the chief complaint and history of the presenting problemo Symptoms

o Clinical course, history

• Medical and physical assessment

• Mental Status Exam

• Case formulation and diagnostic hypotheses based on all of the above data sources including CSCPIP

• Plan based on above


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Breakout Session

• What are the things that get in the way at the time of

crisis?

• What are you worried about when you think about going

out or conducting a crisis assessment?



Initial Interview Considerations

• Cultural Competence

• Bias

• Plain Language

• Time to Process

• Answer in their own way “voice” is important

• Make people comfortable and build rapport

• Observe and listen



Defining Changes

• The key is in the changes! That is where we get our

clues! The departure from typical is what we are looking

for

• What status has changed and why?

• Needs “coping skills” ask your self coping with what?


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Who is this Person?

Know Their Character Strengths

Evaluation of changes from ordinary day is important

• When was the last time the person was doing well?

• What puts the person in "flow"?




What's the "Problem"

• The ”diagnosed problem" is often different from

what is seen or reported problem event, i.e.,

"aggression"

• Problem definition requires accurate context,

history, information

• Need to develop a "common language"

• Problem definition requires collaboration




Real Life Cases & FindingsSame Patient, Same Problem, Different Day

Presenting Problem

• Aggression

• Aggression

• Aggression

• Aggression

• Aggression

• Aggression

• Aggression

• Aggression

• Aggression

Major Influencing Factor

• Constipation

• EPS and sedation

• Reflux

• Depression

• Agitated friend

• Boredom

• Family stress

• Impacted wisdom tooth

• Psychosis


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Attention to Stress (RSQ)

• Medical (primary medical, neuro, dental, medication)

• Changes in routines

• Changes in family, friends, supports, job, home

• Emotional upsets

• Onset of MH symptoms




Why is this part of the START service?

Well trained staff on developmental considerations in the

biopsychosocial model: executive and adaptive functioning

that are typical to the person

• "Differences in symptoms, or core features, of

disorders often vary as a function of development."

• "Clinicians need to be familiar with the varied ways

in which development can affect the presentation of

many disorders" (Charlot)




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© 2020 Center for START Services – University of New Hampshire Institute on Disability/UCEDDavid O’Neal, MS, LMHC, MHP



September START Virtual Orientation Sessions

Registration opening soon

Date/Time Topic(s) Presenters

OPEN TO ALL

September 15

1:00-5:00 pm ET

BREAK: 3:00-3:30pm ET

Community of Practice Jill Hinton, PhD

Keynote: Cultural & Linguistic

Competency

Tawara Goode, MA

START TEAMS ONLY

September 16

1:00-5:00 pm ET


Session 2-CSS Training Methods Joan B. Beasley, PhD

Beth Grosso, MSW

START TEAMS ONLY

September 17

1:00-5:00 pm ET


Session 3- Evidence-Informed

Practice: Research, Evaluation &

Fidelity

Andrea Caoili, LCSW


Luke Kalb, PhD

Karen Weigle, PhD

Ann Klein, MA



Date/Time Topic(s) Presenters

OPEN TO ALL

October 27

1:00-5:00 pm ET


Keynote: Trauma Informed Care Karyn Harvey, PhD

Jill Hinton, PhD

Anne LaForce, PhDSession 1- Application of Trauma

Informed Care

START TEAMS ONLY

October 28

1:00-5:00 pm ET


Session 2- Systems

Linkages/Working with Families


Andrea Caoili, LCSW

Jill Hinton, PhD

START TEAMS ONLY

October 29

1:00-5:00 pm ET


Session 3- Putting it Into Practice

& And Now We Have Hope

(START Film)

Jill Hinton, PhD

October START Virtual Orientation

Sessions

Registration opening soon

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CSS Training Calendar

Start Date Title Details

September 14 Mental Health Aspects of IDD Course for Care Coordinators & Case Managers

6-wk course/7.5 contact hrsOffered once annually

October 6 MH IDD for Mobile Crisis Responders Webinar Training Course

6-wk course/7.5 contact hrsOffered quarterly

First presentation airs on September 18th

National Online Training Series Pre-recorded presentations air 1x/month (Sept-April); Join a live Zoom group discussion on air date

January 2021 Mental Health Aspects of IDD Course for Direct Support Professionals

More details coming soon

Spring 2021 Positive Psychology Master Class w/ Dr. Dan Tomasulo

More details coming soon

Learn more and register at www.centerforstartservices.org (select the ‘Expert Training’ tab)

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Documents

PowerPoint Presentation...6-wk course/7.5 contact hrs Offered quarterly First presentation airs on September 18th National Online Training Series Pre-recorded presentations air 1x/month