BRIEF REPORTS programs

CRISIS INTERVENTION IN A STATE INSTITUTION FOR THE MENTALLY Philip

S. Pierce,

drug

overdose;

seen

in a general-hospital

traditionally has such as suicide

various

accidental

Crisis

intervention

located health phone care of abled,

teams

and

been used prevention

crises

emergency

that

married becoming

centers

in and

might

room;

crises, including getting or finishing school, or

and

be

devel-

or divorced, a parent.

usually

have

have

not

attempted

to use

this

reorganized

units

based

dents,

in on

nine

crisis

December

the

intervention

1973

levels

were

team

specially

under

the

and

for a

understaffed

areas

consultation

service

at

four of

major the

resi-

selected

direction

the

for

for of

residential

a

a psy-

problems

facility, in

boarding

homes, nursing homes, and other community and for the families of the retarded. Since

the

catchment

as the entire approximately almost

25

dealing

with

Dr.

Pierce,

director nal,

Maine S.

Psychiatric

per

L.

cent

crises.

formerly

of the

area

for

state of Maine, one million, of In

their

of

center

which has the team time

addition,

director

psychology

the

the

department

in

facilities, was

the

of spent

community and

intervention

at the

defined

a population members

education crisis

Pineland

training

team, Center,

is now Pow-

04069. Schwartz, Quarterly,

“A Vol.

Review 45,

of Winter

Crisis 1971,

of

community the

social

retarded.

work-

We

also

Intervention pp. 498-508.

Programs,”

intervention,

62

requests

for

behavior

modifica-

tion programming, 48 requests for holding and respite care, 171 calls for help from areas in the institution that were understaffed, and 20 calls for inservice training-a total of 566 requests for service. Of those calls, 25 per

tion,

chologist. A hotline was maintained 24 hours a day, seven days a week. Immediate services were offered, including therapeutic intervention for the acutely disturbed, behavior modification programming, a floater service

to staff, parents

came

from

the

community.

total of 132 retarded persons at the institution and 68 retarded persons from the community received an individualized therapeutic program for a mean number of 50 days. The programs included behavior modifica-

model.

into

developmental

employees

offered and

A

However, the use of a crisis intervention team at the Pineland Center in Pownal, Maine, is an example of the successful use of the model in a state institution for the mentally retarded. After the 650-bed residential facility was

peutic

cent

been

in community hospitals and community mental centers and have used walk-in clinics and telehotlines.’ State institutions for the residential the mentally retarded, the developmentally disthe mentally ill, and court-committed offenders

usually

were

teachers,

provided a six-bed respite-care and holding service for boarding homes and families in the community. In the first year of operation, the crisis intervention center received 265 requests for various types of thera-

RETARDED

Ph.D.

#{149}Crisis intervention psychiatric emergencies

opmental entering

ers,

counseling,

reality

therapy,

play

therapy,

and

so

on. Thirty-nine persons from the community and 19 from the institution were admitted to the six-bed respite facility. All requests, except 61 of the calls from understaffed areas, were answered immediately. The most frequent requests from the community were in the following three categories: destructive behavior, temper tantrums, and uncontrolled nonaggressive behavior (29 per cent); acting-out, stealing, running away, and disruptive behavior (19 per cent); and physical aggressive behavior (13 per cent). The requests from within the institution most frequently concerned physical aggressive behavior (17 per cent); general eating problems (14 per cent); and self-abusive behavior (10 nity concerned

per

cent). self-abusive

No

requests behavior

from the or general

commueating

problems. In general, the crisis intervention team members use the following approach in crisis situations. The team member goes to the site of the crisis to evaluate the problem and develop a course of action. He stays until another team member relieves him or the problem is solved. The team member then returns to the crisis center and writes a report of the problem and the action taken; he includes suggestions for prevention of such crises in the future. Follow-up contacts are made twice a year for as long as it is possible to maintain contact. The

crisis

intervention

model

could

be

(Continued

VOLUME

28 NUMBER

1 JANUARY

1977

used

in other

on page

18)

9

(Continued state volving

from

page

institutions physical

9)

such as aggression,

in

prisons psychotic

during episodes,

crises or

insui-

cide attempts. It could also be used in state institutions for delinquent minors or the emotionally disturbed. Maine is considering the use of crisis intervention in a mental health institute and the state prison because of its demonstrated versatility, mobility, low-cost efficiency, and effective use of an institution’s more experienced and competent staff.#{149} TRUSS: A CONTINGENCY CONTRACT TO MAKE SURE THE UNIT PHYSICIAN DROPS BY ONCE IN A WHILE John Davis, MA. Sheridan Williams, Va! Baker, RN.,

MA. BA.

lOne day the staff of the research unit at Camarillo State Hospital turned the tables on the unit’s physician. The physician is an expert in the field of behavior therapy and had been instrumental in developing the unit’s treatment and research programs to a high level of efficiency. However, the staff generally found that he was

spending

far

too

little

time

on

the

unit

to

provide

optimum assistance with strictly medical problems. Since the unit was far above average in all other respects, it was not acceptable to settle for average medical

care.

Although

the

staff

did

not

take

measurements,

they guessed that the physician spent an average of only ten minutes a day on the unit. The solution was simple: apply standard behavior modification techniques to reinforce his time on the unit and to punish his excessive absence. To implement the program the following memo was issued: To: All Unit Staff From: Unit Charge Subject: Our Unit Beginning

Monday

Nurse Physician a new

program

for

Dr.

A called

TRUSS

(Timetable to Regulate Unit Support from Sawbones) will begin. Dr. A’s behavior to be modified is lack of time spent on the unit. In an attempt to modify his

behavior,

we

(the

nursing

contingency contract with Dr. A’s responsibilities 1 ) He is to give the unit between

be counted

0800-0900

Monday

service)

him

have

negotiated

a

as follows:

30 minutes through

of his time Friday.

Time

daily will

only

from the point at which he has made the charge nurse aware of his presence and until he has walked out of the unit door. la) He must pay the unit 50 cents for each minute At the time this paper was written. Mr. Davis and Mr. Williams were on the staff of the clinical research unit at Camarillo (Calif.) State Hospital. lhev are now graduate students at the University of Washington and Stanford University, respectively. Ms. Baker is head nurse th titit. Ek-aimr Ramirez, RN., and Charles Wallace, Ph.D., also I)articipated in the preparation of this be addressed t) Dr. Wallace, supervisor Hospital, Box A, Camarillo, California

paper. Correspondence of the unit, at Camarillo 93010.

should State

short of the goal at the end of each pay period. Pay periods will average five days, but can vary from one to ten days. ib) Time short of the goal must be made up before the end of each pay period. Nursing service responsibilities 1) A graph of the time Dr. A has spent on the unit will be posted. The graph will be maintained by the am. shift. la) For each two time periods completed with no time deficiencies, the charge nurse will make him a batch of fudge. Both Dr. A and the charge nurse signed the contract, and the first week started with everyone wondering if it would work. Because the physician never knew when the pay period would end, it behooved him to try to keep ahead of the game rather than trying to make up deficiencies later. The first day of the contract the physician spent 50 minutes on the unit. The second day he spent 40, the third 20, and the fourth 15. That was a tremendous improvement. As it turned out, the fourth day was the end of the first pay period, and he had reached the goal by

spending

day.

The

an

average

program

of 31

continued

minutes for

on

seven

the

pay

unit

periods.

each The

average number of minutes in attendance for each succeeding pay period was 43, 41, 56, 40, 16, and 38. During the sixth pay period the physician fell short of the goal. The preprogrammed schedule had called for a two-day period, and he had averaged only 16 minutes for those two days. He had to pay $14 to the unit improvement fund, which was gleefully accepted. The contract was terminated after the seventh pay period 35 days after the project began. The measurements of time spent on the unit were continued for what would have been an additional three pay periods, in order to check the earlier estimate that Dr. A usually spent only about ten minutes a day there. It was found that he spent 13, four, and 22 minutes on the unit during these three noncontracted periods. Thus his daily average esti mate.

of 13 minutes

was

not

far

from

the

initial

The program was initiated and carried out in a playful mood. But the effects made the staff take the program more seriously. The differences between the contracted and the noncontracted periods were so great that the contract was renewed again later after months of suffering without it. The new arrangement is simpler, the rules are implicit, no records are kept, and the reinforcement is praise and good fellowship. But all parties are aware of the new arrangement: that two days

a week

evaluate Many situation.

Dr.

Professional

clan, psychologist, sometimes hard

unit

A is scheduled

VOLUME

find

back-up,

social worker, to find. The staff

implemented

mutually services

to make

the unit’s problems. nursing staffs may

beneficial are there

28 NUMBER

a quick,

easy,

themselves whether

in a similar

relatively

1977

to help

it is by a physi-

or any other of the clinical

program to make when needed.U

1 JANUARY

rounds

person, is research

painless,

sure

that

and

support

13

Crisis intervention in a state institution for the mentally retarded.

BRIEF REPORTS programs CRISIS INTERVENTION IN A STATE INSTITUTION FOR THE MENTALLY Philip S. Pierce, drug overdose; seen in a general-hospital...
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