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Meeting the Challenge: Crisis Services in the Community
by Ronald H. Hanson and Norman A. Wieseler
The deinstitutionalization of persons with intellectual disabilities or related conditions has produced dramatic changes in their lives. This is especially true for persons with challenging behavior, such as aggression toward others, self-injury, property destruction, public disrobing, sexual predation, and other behaviors previously managed within institutions. Behavior training programs and psychotropic medications have been the primary strategies for reducing the frequency and intensity of such challenging behaviors among individuals now living in the community. To sustain community living, specialized services are required. These crisis prevention and response services must include professionals with expertise in treatment of challenging behaviors utilizing positive behavior intervention and support.
For some individuals living in the community, psychiatric hospitalization has been the only treatment option available for behavior support or crisis response. But, it has come at a high cost, often proving to be disruptive and problematic for the individual, their family, and for the staff of the community residence and the psychiatric hospital unit. The hospitalized person with developmental disabilities can be vulnerable to exploitation by higher functioning psychiatric patients and must be closely supervised by hospital personnel. Hospital staff often have limited experience working with individuals with intellectual disabilities, and in some cases have requested that direct service providers remain at the hospital to care for the person. While such extra staffing may enhance care, it often reduces support for others living in the individual’s home.
Individuals with a mental health problem in addition to their developmental disability are frequently difficult to serve because they can “fall between the cracks” of services in the health care system. The system is usually organized to serve either the individuals with mental illness who have average intellectual abilities, or alternatively, individuals with intellectual disabilities who are well adjusted and do not evidence an emotional or psychological disturbance. Because of the concurrent mental health disorders often observed in this population, crisis services are often needed for individuals who range in age from childhood to those in advanced years of adulthood.
Key Features of Community Support
People with mental health disorders and developmental disabilities often benefit from a range of approaches, including the following:
- Psychotropic Medications. Psychotropic medication can be a beneficial adjunct to positive behavioral intervention. In the past 10 years, effective medications, specifically the atypical antipsychotics and the selective serotonin reuptake inhibitor antidepressants, have become available. For individuals with psychosis, depression, or other mental health disorders, the use of psychotropic medications in combination with positive behavior intervention and support procedures has been effective in the prevention of crisis occurrences. However, monitoring of the appropriateness and effectiveness of these and other medications on an ongoing basis must be part of any intervention using psychotropic medications.
- Supervision and Structure. In addition to the use of medication, vigilant supervision by care providers is necessary to ensure that individuals with challenging behaviors do not place themselves or others at risk. This means it is necessary to have funding for and access to residential and other settings with appropriate levels of staffing. In such settings, structure, through the daily scheduling of activities and tasks, is also an essential component in crisis prevention. This includes arranging the environment so positive behavior supports will reward both independence and prosocial alternative responses to challenging behaviors. An example of this structure building is through the scheduling of 15-minute increments of activities in which the individual will be involved during the day and evening hours until bedtime. The events may vary based on available opportunities and individual choice, but the creation of and adherence to the schedule is consistent.
- Staff Consistency. The therapeutic goals in responding to challenging behavior depend on direct service providers following specific training approaches and responding to the individual in a respectful and systematic manner. This is often referred to by treatment staff as the “consistency of program implementation.” Differences in both the expectation and the interaction with the individual among staff members create a more difficult learning environment. Without staff consistency, there will be varied staff responses to the person’s positive or challenging behaviors, and differing staff expectations concerning the individual’s level of independence. Inconsistent responding by direct service providers is often a setting event for challenging behaviors and can make the crisis situation even more serious. To achieve consistency, behavior support and crisis response service staff must work diligently to increase communication among all care providers. They must also assure that detailed, written treatment plans are developed and carefully taught to those expected to implement the specific practices. The many factors contributing to difficulties in recruiting, training, and retaining direct support staff have made the challenge of providing consistent staff response more difficult. High staff turnover, positions remaining unfilled due to the limited numbers and qualifications of interested candidates, and use of staff from temporary agencies all make establishing consistency a higher hurdle. Additionally, increasing numbers of direct support staff have no training or experience in participating in systematic analysis of behavior or implementation of behavior supports. As a result, highly specific training with frequent observation and ongoing support of staff are increasingly important for consistent and effective treatment.
System Planning
When developing behavior support and crisis response services, system planning must ensure that services will be comprehensive and coordinated. This may begin with agencies or local governments developing services individually or collaborating with other agencies or governments to provide services regionally. In rural areas, agencies and local governments may form regional cooperatives to develop and oversee crisis services. State agencies are an important part of crisis service programs because of funding and regulatory requirements. But in many instances, state involvement may extend to service delivery, as well. State employees who have had extensive previous experience with individuals with challenging behavior while they were living in state institutions can be an important component of state involvement in providing community behavior support and crisis services. Private contractors can also be hired by state and local government or private authorities to provide core behavior support and crisis intervention services.
An important design feature for crisis prevention and response is the provision of services where the individuals actually live and work. Thus, in practice, behavior analysts, nurses, and other behavior support and crisis service personnel travel to settings where the person’s challenging behaviors actually occur. Staff visit the residence, day program, employment, or school setting to observe the interaction between the individual with challenging behaviors and others in his or her environment. This naturalistic observation differs from the traditional office-based counselor-client psychotherapeutic approach. This orientation requires mobility of the crisis service staff member and the capability of being in numerous settings each work day. Anticipation of transportation needs and costs for the mobile work-force must be considered during development of crisis services. Using modern technology such as laptop computers to quickly generate treatment reports from the field or cell phones to keep in touch on the road also ensures responsiveness and timely assistance to the referring agency and other team members.
Knowledgeable behavior analysts are, of course, the essential ingredient in successful behavior support and crisis response services. The most effective are those who have the maturity, experience, and communication skills to advise a diverse range of direct service providers in a sensitive and credible manner. Usually this implies a well-trained behavior analyst with excellent skills in functional assessment and positive behavior support, who has at least two or more years of experience in program development in residential, vocational, and school or day treatment settings. An extensive knowledge of mental health, developmental disability, and other relevant community resources in their region is also a very helpful.
The collaborative relationships among crisis response staff, psychologists, psychiatrists, and psychiatric nurses are important. The psychologist brings skills in intellectual and behavioral assessments as well as providing insights regarding the dynamics of the living and working situations. The psychiatrist can provide skill in medication management and may recognize physical conditions contributing to behavioral disturbances. Broad case consultation among behavior analysts, psychologists, psychiatrists, psychiatric nurses, and when necessary, individuals from other disciplines (e.g., speech therapy, dietetics, physical therapy, occupational therapy, clinical pharmacy, and other related specialities) provides a broad foundation on which to make treatment decisions.
Summary
The systematic and comprehensive provision of crisis prevention and response services allows many people with developmental disabilities, severe challenging behavior, and/or mental health disorders to remain stable members of the community. The delivery of behavior support and crisis services in the community benefits the individual, their residential settings, and the social service system by enhancing the person’s independence and self-determination, and avoiding costly and disruptive psychiatric hospitalizations.
Ronald H. Hanson is a consulting psychologist with Mount Olivet Rolling Acres, Victoria, Minnesota. He may be reached at 763/475-9614 or by e-mail at rhanson@mninter.net. Norman A. Wieseler is a Licensed Psychologist with Eastern Minnesota Community Support Services, Faribault, Minnesota. He may be reached at 507/333-2093 or by e-mail at norman.wieseler@state.mn.us.
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Citation: Hanson, R., Wieseler, N., & Lakin, K. (2000). Impact: Feature Issue on Behavior Support for Crisis Prevention and Response, 14(1) [online]. Minneapolis: University of Minnesota, Institute on Community Integration. Available from http://ici.umn.edu/products/impact/141/. __________ Hard copies of Impact are available from the Publications Office of the Institute on Community Integration. The first copy of this issue is free; additional copies are $4 each. You can request copies by phone at 612-624-4512 or E-mail at icipub@umn.edu, or you can fax or mail us an order form. See our listing of other issues of Impact for more information. The print design version (PDF, 448K, 28 pp.) of this issue of Impact is also available for free, complete with the color layout and photographs. This version looks the most like the newsletter as it was printed. The University of Minnesota is an equal opportunity employer and educator.
