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