TREATING AT-RISK BEHAVIORS AT
THE ACQUIRED BRAIN INJURY (ABI)
UNIT AT EASTERN STATE HOSPITAL
LINDSEY JASINSKI, PH.D.
ABI PROGRAM DIRECTOR
OBJECTIVES
• Provide an overview of the new ABI unit at ESH
• Discuss approaches to management of at-risk behaviors at ESH
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Staff Training
Unit Structure
Environmental Management
Medical Interventions
• Future Goals and Directions of ABI Unit
MISSION AND VISION
• Promote the highest level of functioning and quality of life through a
systematically applied and comprehensive set of empirically supported
medical and therapeutic rehabilitative interventions
• Provide individualized, holistic, and compassionate post-acute brain injury
rehabilitation in a safe environment
• Focus on learning or re-learning new skills to improve functional
independence, and transition to a lower level of care, including the community
OVERVIEW
• 17 beds
• Locked, secure unit
• Private & Semi-private rooms
• 24-hour nursing care
• Licensed as a Long-Term Care Facility
• Anti-ligature hardware, focus on resident safety
• Opened in late Fall 2014
ADMISSION CRITERIA
INCLUSION CRITERIA
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Age 18+
History of Acquired Brain Injury
Current Axis I diagnosis
Meets nursing level of care, unsuccessful in less
restrictive care
• PASSR Level II
• Rancho V or higher
• Able to participate in at least 3 hours of
therapy/day
EXCLUSION CRITERIA
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Active felony for violent offense
Primary substance abuse dx
Any injury without known ABI (e.g. spinal cord)
Dx of progressive dementia
Psychiatric dx with no known ABI
Intellectual disability or developmental
disorder w/o etiology to ABI
ADMISSIONS PROCESS
• Referral
• Review by the Admissions Committee Team
• In Person visit
• PASRR Level 1 and 2
• Scheduled admission date
OUR TEAM
ABI SPECIFIC TEAM
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Medical Director, Board Certified in Neurology/Psychiatry
• Physical Medicine/Rehabilitation Specialist
ESH SERVICES
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Music Therapist
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Art Therapist
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Registered Dietician
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Chaplain
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Quality Control
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Infection Control
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Neurologist
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Neuropsychologist
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Business Services
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Clinical Psychologist
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Utilization Review
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Clinical Social Worker
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Medical Supply
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Safety/Environmental Services
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Security
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Laboratory
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Health Information Management
• Behavior Analyst
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Physical Therapist
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Speech/Language Pathologist
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Occupational Therapist
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Information Systems
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Recreation Therapist
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Pharmacy
• Registered Nurses
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Radiology
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Risk Management
State Registered Nurse Aids
TREATMENT TEAM APPROACH
Multidisciplinary
Interdisciplinary
Transdisciplinary
EXPECTED LOS 3-12 MONTHS
Admission/Transition
(goal development,
motivation/engagement)
Intensive Rehabilitation
(PT, OT, SLP, Psy)
Increased Community
Integration Focus
(Outings, expanded
therapy)
Transition to Community
with Supportive Services
AT RISK BEHAVIORS
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Aggression/Violence
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Toward self: self-harm, suicidal ideation, suicide attempts
Toward others: residents and staff
Sexual Acting Out
Personality Change/Irritability
Emotional Lability
Therapy Refusal
Elopement attempts
Other behaviors that interfere with progress in therapy or functional independence
ESH PHILOSOPHY/MODEL
Risk
Need
Responsivity
TARGET AREAS
FACTORS OFTEN CONTRIBUTING TO
AGGRESSION & AT RISK BEHAVIORS
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Decreased structure
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Environmental triggers
Staff attention less available
Difficulty with communication and/or
coping
Poor task persistence/motivation
Staff inexperience/ineffective
ESH RESPONSE
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Highly structured daily schedule
Low staff to resident ratios
Intensive Group and Individual Therapy
Behavioral Support/Level System
Errorless Learning, Goal Attainment
Feedback Loop
• Calming Rooms, Outdoor Space
• P.E.A.R.L, CPI, GIV program
DAILY SCHEDULE
7:25a
8:00a
8:30a
8:45a
9:00a
9:30a
10:00a
10:30a
10:45a
11:00a
11:25a
12:00p
12:30p
1:00p
1:30p
2:00p
2:30p
3:00p
3:30p
4:00p
4:30p
5:00p
5:30p
6:00p
6:30p
7:00p
7:30p
8:00p
8:30p
9:00p
9:30p
10:00p
10:30p
Monday
Breakfast
Tuesday
Breakfast
Wednesday
Breakfast
ADLs
ADLs
ADLs
Yoga/Stretch
Yoga/Stretch
Yoga/Stretch
Goals Group
Goals Group
Goals Group
Chaplain Group
Chapel
Lunch
Lunch
Lunch
Mobile Library
Mindfulness
Gift Shop
Thursday
Breakfast
ADLs
Library
Yoga/Stretch & Goals
Saturday
Breakfast
Sunday
Breakfast
ADLs
Relax/ADLs
Relax/ADLs
ADLs
ADLs
Yoga/Stretch
Yoga/Stretch
Goals Group
Goals Group
Lunch
Lunch
Mindfulness
Mindfulness
Gym and Reel Life
Gym and Reel Life
Dinner
Dinner
HW/Relax/Visitation
HW/Relax/Visitation
Wrap up Group
Wrap up Group
ADLs/lights out
ADLs/lights out
Yoga/Stretch & Goals
Music/Art Therapy
Gift Shop
Cooking Group
Mindfulness
Weekly Outing
Shopping/Meal Plan
Friday
Breakfast
Lunch
Communication Station
Retrain your Brain
Healthy Living Group
Check in Group
Double Trouble/Drug Ed
Family Ties Group
Feelings Group
I am a Survivor Group
On unit exercise
Mindfulness
Recreation Therapy
Gym/Exercise
Recreation Therapy
Gym/Exercise
Dinner
Dinner
Dinner
Dinner
HW/Relax/Visitation
HW/Relax/Visitation
Gym/Exercise
Gym/Exercise
Wrap up Group
Wrap up Group
Wrap up Group
Wrap up Group
Wrap up Group
ADLs/lights out
ADLs/lights out
ADLs/lights out
ADLs/lights out
ADLs/lights out
Dinner
HW/Relax/Visitation
HW/Relax/Visitation
AA Group
Gym/Exercise
GROUP & INDIVIDUAL THERAPY FOCUS
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Distress Tolerance, including Anger Management and Safe Coping
Social Skills Acquisition
Emotion Regulation
Mindfulness
Communication Skills
Family Support and Education
Development of Specific Goals related to psychiatric symptoms and coping
Promote insight into triggering events, emotions
Process incidents and use modified behavior chain analysis to explore alternatives
REPETITION!!!
Role Plays, In Vivo Training, In the moment coaching to use skills
LEVEL SYSTEM
• Begin on Level 1/2 at admission
Level Privileges
5
Able to have personal computer, cell phone, Ipad use
for 90 mins, Home visits
4
All outings (therapy/activity), Ipad use for 60 mins, able
to use Wii
3
Therapeutic outings, soda and all snacks
2
Able to go off unit in hospital (e.g. gift shop), Level 1
snacks, no outings
• 100 points = move to next level
• Must maintain 20 points per day to remain on level 5
• -10 points in a day = drop 1 level
• Behaviors (e.g. aggression, elopement, threatening, SAO, etc) =
automatic drop to level 0 for safety
1
0
Able to have soda & level 1 snacks, can have radio,
restricted to unit
No technology (computer, cell phone), No outings,
restricted to unit, level 0 snacks
• Points awarded for therapeutic and daily functional activities:
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Meal behavior and clean up
Therapy – groups and individual
Homework completion, if applicable
Housekeeping
ADLs
• 2 points for full participation and appropriate behavior, 1 for partial, 0
for excused absence, -4 for refusal
P.E.A.R.L. (MCMORROW, 2005)
Positive
Early
Reinforce
All
Look
P.E.A.R.L. CONTINUED…
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Purpose: “encourage a different approach to influencing the lives of persons who are
considered disabled, one that emphasizes the interaction between people as the
basis of all human existence.”
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Proactive Treatment Interaction—every interaction is a “social exchange” intended to
promote greater autonomy
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Teaching, ways to invite greater participation
Can take place anywhere, anytime
Can occur regardless of level of functioning
Promotes an ongoing interaction
POSITIVE
• Interaction is:
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Inviting
Physical characteristics: warm tone, expression, posture
Looks interested
Upbeat, makes request (not command) and encourages interaction
• Not a new skill, but reinforce in our staff, becomes self-reinforcing
• Expectation of 2 positive/neutral statements for every 1 request
EARLY
• Have a social exchange before emotional/behavioral upset
• Not just a “good idea” but rather a job expectation
• Providing support and problem-solving early, prior to a difficult situation
develops
• Paying specific attention to antecedents for each individual
• No behavior occurs in a vacuum
• Learning (i.e. coping skills) is most likely to occur at low levels of arousal
ALL
• Use all components of PEARL, with all people, in all settings, all the time
• Comprehensive approach to interactions, idealistic, inclusive
• “Consistent reminder that we are interested in developing more powerful,
mutually reinforcing relationships in our lives”
• Based on mutual reciprocity, helps refocus staff
• Sounds easy but in fact most individuals in our setting are there because of
behaviors that are unacceptable in the community/home setting making the
likelihood that “attack-attack reciprocity” will develop much higher
REINFORCE
• “Interact in a way that acknowledges more independent or autonomous
behavior and is intended to result in increased future use of this behavior.”
• Focus on what reinforces more functional behavior: verbal praise, touch, eye
contact, tangible rewards
• Also focus on what the desired outcomes are do we want this behavior to
continue?
• Reinforce-reinforce exchange: what part of the person’s behavior can you
acknowledge?
LOOK
• Identify opportunities to teach as they arise, encourage independence and
increase participation in the social community
• Goes against the idea that “teaching” is specific to a particular type of
interaction (i.e. didactic), specific discipline (e.g. psychology, SLP, OT, PT) or in
a certain setting (e.g. group therapy).
• Engages all staff to focus on what each interaction can produce, rather than imposing an
agenda on the resident
• “developing good therapy habits”  as important for future functioning as the content of
the session or interaction
ERRORLESS LEARNING
• Teaching method minimizing errors
• Contrasted to Trial and Error Learning
• Longer learning acquisition time
• Used for cognitive retraining, but also for learning coping skills, ADLs, engaging in
rehabilitation, etc.  doesn’t allow for guessing or mistakes
• Empirically supported for moderate to severe cognitive deficits after TBI
• Improves learning, reduces depression/frustration/lack of motivation/anxiety associated with
error correction process
• Increased opportunity for positive reinforcement
• Enhances engagement in rehabilitation process, develop good therapy habits, and improves
rapport in early stages of intervention
ERRORLESS LEARNING, EXAMPLES
• Cognitive retraining:
• Learn phone number for therapist  number is 8167  the number is 816_  the
number is 81_ _  the number is 8_ _ _  the number is ______
• Refusing rehabilitation:
• Comprehensive task breakdown, points awarded for increasingly completing the steps
over a period of time
GOAL ATTAINMENT FEEDBACK
• Daily goals group to start the day—maintains focus
• Written on footprint as visual cue
• Feedback given at lunch and dinner on level system and goals
• Wrap up group in evening—process goal attainment
• Visual cues also in binder relevant to other goals (e.g. cognitive goals, ADLs,
etc.)
CPI (NONVIOLENT CRISIS INTERVENTION)
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Crisis Prevention and Intervention
Focus on De-escalation, Process each incident to re-focus on future
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C: Recognize lack of control
O: Orient to the facts
P: Identify patterns
I: Investigate alternatives
N: Negotiate, give choices
G: Give back empowerment
Physical interventions are a LAST resort to managing a crisis situation
Staff highly training on staying calm, de-escalating the situation
CPI, CONTINUED
Anxiety
Supportive
Defensive
Directive
Acting
Out
Nonviolent
Physical
Intervention
Tension
Reduction
Therapeutic
Rapport
CALMING ROOMS
• In development, hospital-wide
• Transdisciplinary approach with Psychology and OT
• Focus on sensory and distraction tools for calming
GIV PROGRAM
• Individualized plan for giving the right patient, the right medication, at the right time.
• Verbal de-escalation always attempted first, prompt to use effective coping
• Effective and efficient utilization of PRN medication
• Initial evaluation includes:
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Safety Crisis Management Assessment (SCMA)-triggers and coping
What medications work and what dose?
What route works best?
At what point should medication be administered? Behavioral symptoms documented.
• Benefits:
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Safe environment for everyone
Decreased symptom burden
Decreased number of incidents, including staff, peer, and resident injuries
Allows staff to humanely intervene and respond effectively to a behavioral emergency
SAFETY CRISIS MANAGEMENT ASSESSMENT
Restraint Hours
1.6
1.4
1.38
1.28
1.13
1.2
1
0.84
0.8
0.56
0.6
0.31
0.4
0.2
0
-0.2
-0.4
Actual
3PMA
3PWMA
Exponential
jul
1.16
1.11
1.38
1.23
Actual
aug
1.02
1.36
1.28
1.28
3PMA
sep
0.61
1.33
1.13
1.24
3PWMA
oct
0.35
1.19
0.84
1.17
nov
0.17
0.93
0.56
1.01
Exponential
dec
0.11
0.66
0.31
0.81
Linear (3PWMA)
SUMMARY
• New unit: environment, culture and milieu very flexible, with solid foundation
• Approach to managing at-risk behaviors is multifaceted
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Staff training through P.E.A.R.L. and CPI
Highly structured therapeutic environment
Focus on behavioral and environmental supports
Maximize psychotherapeutic and medical interventions
LOOKING FORWARD…
• Continue clarifying our mission and vision, while meeting the needs of the
community
• Meet unit capacity, while maintaining highest levels of care and staffing ratios
• Integration of ESH services with other providers, continuum of care
• Research: What interventions have the biggest impact for what individuals?
• Opportunities for additional research & training
QUESTIONS???