Community Mental Health &
Substance Abuse Services
of St. Joseph County
Operating
Procedure
Subject:
Clinical Practice
Behavior Treatment Committee
Application:
35.16
All Departments
Effective
8/23/88
Reviewed
10/19/04
Revised
6/5/06, 3/13/08
4/12/10, 4/7/11
12/2/13
Approved
I. Purpose
To establish and operate a Behavior Treatment Committee, whose appointment, duties, and
functions are intended to safeguard the rights of individuals served, and whose purpose is to
prevent unnecessary application of aversive, intrusive, restrictive techniques or psycho-active
medication for behavior control purposes. Such techniques will be used only when less
restrictive techniques have been adequately implemented and documented to have failed, or
when failure to implement such techniques would result in physical harm to the client or to
others, and only in conjunction with an accompanying positive reinforcement procedure.
II. Policy
It is the policy of the Community Mental Health and Substance Abuse Services of St. Joseph
County to develop a behavior treatment plan, where needed, by developing a person-centered
planning process that involves the individual served. The approved behavioral plan shall be based
on a comprehensive assessment of the behavioral needs of the individual. Review and approval (or
disapproval) of such treatment plans shall be done in light of current research and prevailing
standards of practice as found in current peer-reviewed psychological/psychiatric literature.
Acceptable behavioral treatment plans are designed to reduce maladaptive behaviors, to maximize
behavioral self-control, or to restore normalized psychological functioning, reality orientation, and
emotional adjustment, thus enabling the individual to function more appropriately in interpersonal
and social relationships. Such reviews shall be completed prior to the individual’s signing and
implementation of the plan and as expeditiously as possible.
It is further the Board's policy to incorporate standards prescribed by the Michigan Department of
Mental Health, as agreed to in the master contract that further delineate the acceptable standards of
practice for this sub-specialty.
III. Definitions
A. Applied Behavior Analysis: means the organized field of study which has as its objective
the acquisition of knowledge about behavior using accepted principles of inquiry based on
operant and respondent conditioning theory. It also refers to a set of techniques for
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modifying behavior toward socially meaningful ends based on these conceptions of
behavior. Although this field of study is a recognized sub-specialty in the psychology
discipline, not all practitioners are psychologists, and such training may be acquired in a
variety of disciplines.
B. Aversive Techniques: Those techniques that require the deliberate infliction of
unpleasant stimulation (stimuli which would be unpleasant to the average person or
stimuli that would have a specific unpleasant effect on a particular person) to achieve the
management, control, or extinction of seriously aggressive, self injurious or other
behaviors that place the individual or others at risk of physical harm. Examples of such
techniques include use of mouthwash, water mist or other noxious substance to
consequate behavior or to accomplish a negative association with target behavior, and use
of nausea-generating medication to establish a negative association with a target behavior
or for directly consequating target behavior. Clinical techniques and practices established
in the peer-reviewed literature that are prescribed in the behavior treatment plan and that
are voluntary and self-administered (e.g., exposure therapy for anxiety, masturbatory
satiation for paraphilias) are not considered aversive for purposes of this technical
requirement. Otherwise, use of aversive techniques is prohibited.
C. Behavior Management: means the exercise of general control of behavior to achieve
therapeutic objectives through the use of a variety of recognized techniques including
shaping, positive reinforcement, and other techniques based on general behavior theory,
verbal directions, physical guidance, physical management, medications, restraint and
seclusion.
D. Behavior Modification:
means the systematic application of principles of general
behavior theory to the development of adaptive and/or elimination of maladaptive behavior
consistent with therapeutic objectives.
E. Critical Incident: A Critical Incident is a relatively brief occurrence involving injury,
loss, conflict, discovery or change of significant proportion, usually unscripted and
unanticipated. Critical incidents are usually traumatic, threatening the bonds of trust
between a consumer, staff and stakeholders that left unaddressed may have adverse
consequences. If repeated, a critical incident may become a sentinel event.
F. Intrusive Techniques: Those techniques that encroach upon the bodily integrity or the
personal space of the individual for the purpose of achieving management or control of a
seriously aggressive, self-injurious, or other behavior that places the individual or others
at risk of physical harm. Examples of such techniques include the use of a medication
that is not a standard treatment or dosage for the individual’s condition. Use of intrusive
techniques as defined here requires the review and approval by the Committee.
G. Peer-reviewed Literature: Scholarly works that typically represent the latest original
research in the field, research that has been generally accepted by academic and
professional peers for dissemination and discussion. Review panels are comprised of
other researchers and scholars who use criteria such as “significance” and “methodology”
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to evaluate the research. Publication in peer-reviewed literature does not necessarily
mean the research findings are true, but the findings are considered authoritative evidence
for a claim whose validation typically comes as the research is further analyzed and its
findings are applied and re-examined in different contexts or using varying theoretical
frameworks.
H. Physical Management: A technique used by staff to restrict the movement of an
individual by direct physical contact in order to prevent the individual from physically
harming himself, herself, or others. Physical management shall only be used on an
emergency basis when the situation places the individual or others at imminent risk of
serious physical harm. Physical management, as defined here, shall not be included as a
component of a behavior treatment plan. The term “physical management” does not
include briefly holding an individual in order to comfort him or her or to demonstrate
affection, or holding his/her hand. Physical management involving prone
immobilization of an individual for behavioral control purposes is prohibited under
any circumstance.
I. Positive Behavior Support: A set of research-based strategies used to increase quality of
life and decrease problem behavior by teaching new skills and making changes in a
person's environment. Positive behavior support combines valued outcomes, behavioral,
and biomedical science, validated procedures; and systems change to enhance quality of
life and reduce problem behaviors such as self-injury, aggression, property destruction,
pica, defiance, and disruption.
J. Practice or Treatment Guidelines: Guidelines published by professional organizations
such as the American Psychiatric Association (APA), or the federal government.
K. Restraint: Any physical or mechanical device, material or equipment that immobilizes or
reduces the ability of the recipient to move his or her arms, legs, body or head freely, for
the purposes of the management, control, or extinction of seriously aggressive, selfinjurious or other behaviors that place the individual or others at risk of physical harm.
This definition excludes anatomical or physical supports that are ordered by a physician,
physical therapist or occupational therapist for the purpose of maintaining or improving
an individual’s physical functioning. The definition also excludes safety devices required
by law, such as car seat belts or child car seats used while riding in vehicles. The use of
physical or mechanical devices used as restraint is prohibited except in a state-operated
facility or a licensed hospital.
L. Restrictive Techniques: Those techniques which, when implemented, will result in the
limitation of the individual’s rights as specified in the Michigan Mental Health Code and
the federal Balanced Budget Act. Examples of such techniques used for the purposes of
management, control or extinction of seriously aggressive, self-injurious or other
behaviors that place the individual or others at risk of physical harm, include prohibiting
communication with others to achieve therapeutic objectives; prohibiting ordinary access
to meals; using the Craig (or veiled) bed, or any other limitation of the freedom of
movement of an individual. Restrictive techniques include the use of a drug or
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medication when it is used as a restriction to manage, control or extinguish an
individual’s behavior or restrict the individual’s freedom of movement and is not a
standard treatment or dosage for the individual’s condition. Use of restrictive techniques
requires the review and approval of the Committee.
M. Seclusion: The placement of an individual in a room alone where egress is prevented by
any means. Seclusion is prohibited except in a hospital or center operated by the
department, a hospital licensed by the department, or a licensed child caring institution
licensed under 1973 PA 116, MCL 722.111 to 722.128.
N. Sentinel Event: Any unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a person or persons, not related to the natural
course of the patient's illness. Sentinel events specifically include loss of a limb or gross
motor function, and any event for which a recurrence would carry a high risk of a serious
adverse outcome.
O. Special Consent: Obtaining the written consent of the recipient, the legal guardian, and
the parent with legal custody of a minor child or a designated patient advocate prior to the
implementation of any behavior treatment intervention that includes the use of intrusive
or restrictive interventions or those which would otherwise entail violating the
individual’s rights. The general consent to the individualized plan of services and/or
supports is not sufficient to authorize implementation of such a behavior treatment
intervention. Implementation of a behavior treatment intervention without the special
consent of the recipient, guardian or parent of a minor recipient may only occur when the
recipient has been adjudicated pursuant to the provisions of section 469a, 472a, 473, 515,
518, or 519 of the Mental Health Code.
IV. Procedure
A. Committee Standards
1.
The Committee assists CMHSAS-SJC and its providers to provide services in
the most positive, strength-based and least restrictive and intrusive manner
possible.
2.
The Committee ensures that plans incorporating intrusive and/or restrictive
interventions are used only to treat, manage or extinguish behaviors that are
seriously aggressive, self-injurious or place the individual or others at risk of
harm.
3.
The Committee ensures that less restrictive or intrusive interventions have been
researched, attempted and have failed prior to proposed use of intrusive and/or
restrictive interventions.
B. Committee Membership
1.
The Committee shall consist of at least three individuals, minimally including:
a. A licensed or limited licensed psychologist who has had at least one year
of experience in applied behavior analysis, following formal, documented
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2.
3.
4.
5.
6.
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training at an accredited college or university.
b.
A licensed physician/psychiatrist
A representative of the Office of Recipient Rights shall participate on the
committee as ex-office, non-voting member.
Other non-voting members may be added at the Committees discretion, and
with the consent of the individual whose plan is being reviewed.
Membership shall be appointed by the Executive Director of CMHSAS-SJC or
his/her designee and meet at least quarterly, but generally as often as necessary at
the call of the chair.
The Committee and Committee chair shall be appointed for a period of not more
than two years. Members may be appointed to consecutive terms.
Any Committee member who has authored a behavior treatment plan to be
reviewed by the Committee shall recuse themselves from the final decisionmaking.
C. Committee Roles and Responsibilities
1.
The Committee shall approve only Behavior Treatment Plans that do not
contain interventions prohibited by law or regulations including:
a.
Aversive techniques
b.
Physical management
c.
Seclusion
d.
Restraint
2.
The Committee shall review all Behavior Treatment plans proposing to use
intrusive and/or restrictive techniques. Approve or disapprove Behavior
Treatment Plans presented.
3.
The Committee shall review all Behavior Treatment Plans containing intrusive
and/or restrictive interventions at least quarterly, or more often when more
intrusive and/or restrictive interventions are used frequently.
4.
The Committee shall assure that inquiry has been made about any medical,
psychological or other factors that the individual has that might place him/her at
risk of death, injury or trauma if subjected to the intrusive/restrictive
intervention included in the Behavior Treatment Plan.
5.
The Committee shall ensure that written records of all committee meetings are
kept.
6.
The Committee shall collect data on the use of intrusive and/or restrictive
techniques, including:
a. Number of current Behavior Treatment Plans containing intrusive and/or
restrictive techniques
b. Types of intrusive and/or restrictive techniques included in plans.
c. Data related to reduction of use on intrusive and/or restrictive techniques.
7.
The Committee shall review data collected on the use all emergency physical
management each quarter. The data shall include:
a. The number of times emergency physical management techniques
employed.
b. Number of individuals with whom emergency physical management was
employed.
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8.
c. Number of individuals with whom emergency physical management was
employed more than one time during the quarter.
The Committee may advise and make recommendations to CMHSAS-SJC
regarding the needs for staff training, acceptable interventions to be used and
provide specific case consultation.
9.
The Committee shall:
a. Review and approve (or disapprove), in light of current research and
prevailing standards of practice, all behavioral programs utilizing aversive
techniques, the generalized use of token economies if the contingent
removal of tokens is a planned part of the program and prescribing psychoactive medications for behavior control purposes.; such reviews shall be
completed as expeditiously as possible.
b. Provide decisions, in writing, to the responsible staff person with an
indication of appropriate appeal process to the CMH Board in the event of
continuing dispute.
c. Abstain from decision making with respect to programs prepared by them
or under their specific direction.
d. Be familiar with all litigation involving the use of behavioral techniques at
Community Mental Health and Substance Abuse Services of St. Joseph
County, in the Michigan department of Mental Health, and in other states to
the extent it is available.
e. Types of individual treatment programs requiring review by the BTC are
specified in the "Procedural Hierarchy."
f. Consider the following factors when evaluating the program:
i. The frequency and severity of the targeted behavior(s), sufficiently
documented.
ii. The risks and benefits to the individual served and others of allowing
the targeted behavior(s) to continue.
iii. The thoroughness of the functional analysis of the target behavior(s) and
analysis of the client's history, including data indicating that the selected
target behaviors solve the identified problem, are appropriate for the
functional level of the client, and promote the quality of life of the
client.
iv. The criteria, in defined, behavioral measures, for determining the
effectiveness of the program.
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v. Evidence indicating less aversive or restrictive techniques were reliably
implemented for the targeted behavior(s) and found ineffective.
vi. Evidence/literature on the effectiveness and efficiency of the proposed
techniques and their appropriateness with respect to the targeted
behavior(s) and the client's level of functioning.
vii. The risks and benefits to the client and others of the proposed program.
viii. The plan for minimizing and monitoring the risks and side
effectiveness of the procedure.
ix. The adequacy of the accompanying positive program and the degree of
integration of the positive program with the proposed program and all
other aspects of the client's treatment program.
x. The level of expertise of the staff available, and/or the training plan to
ensure reliable implementation of the program.
xi. The availability of the resources required to implement the procedure to
ensure the likelihood of the successful outcome.
xii. The plan for monitoring progress and approving continuance of the
program or modifying the program based on specific behavioral criteria.
xiii. The adequacy of the data collection system considering the frequency,
intensity, and duration of the targeted behavior(s), the ability of the staff
available to collect data, and the design of the program.
g. Any restrictions or limitations of the recipient’s rights or any aversive or
intrusive behavior treatment techniques shall be reviewed and approved by
a formally constituted committee of mental health professionals with
specific knowledge, training, and expertise in applied behavioral analysis.
Any restriction or limitation shall be justified, time-limited, and clearly
documented in the plan of service. Documentation shall be included that
describes attempts that have been made to avoid such restrictions as well as
what actions will be taken as part of the plan to ameliorate or eliminate the
need for the restrictions in the future.
V.
Monitoring and Review
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A. The KCMHSAS/PIHP Network Quality Assurance Committee shall evaluate the data
on the use of intrusive and restrictive techniques as reported to the Committee.
B. Annually, the effectiveness of the Behavior Treatment Plan Review Committee shall be
evaluated by stakeholders, including individuals who had an approved plan, family
members and advocates.
VI. References and Legal Authority:
MDCH Technical Requirements for Behavior Treatment Committee Review
The Michigan Mental Health Code. Public Act 258, of 1974.
Standards for Intermediate Care Facilities for the Mentally Retarded.
Accreditation Council for Mental Retardation and Developmental Disabilities Standards.
Standards of the Joint Commission on the Accreditation of Hospitals.
Guidelines for the practice of behavior modification in community settings, by
the Institute for the Study of Mental Retardation and Related Disabilities.
Medicaid Provider Manual, Chapter III.
Review Responsibility
This procedure will be reviewed annually by the Behavior Treatment Committee
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