Writer’s Guide for Developing an Individualized Discharge ...



• Individualized Crisis Safety plans can be updated anytime without holding a full POC. They should be written or revised when the following occurs:

➢ Within the first week of meeting a family; sooner if needed.

➢ Within 24 to 48 hours of a major crisis.

➢ Whenever a youth or family moves to a new residence, placement or school.

➢ When a new team member joins the team and will be part of the crisis intervention plan.

➢ When the youth or family experience a major life event; such as the death of a loved one, divorce, witnesses or is part of a violent act, pregnancy, birth, etc.

➢ When a youth has run away.

➢ When youth has had new charges filed against him/her.

➢ When new safety concerns arise (even if a crisis hasn’t occurred).

• What helps me relax:

This section should include the activities and approaches that the youth responds best to or enjoys engaging in when they are calm. The activities and approaches should cover all environments to be used at home, school, and/or in the community with various people. The focus on what helps someone relax gives the person responding in crisis an opportunity to utilize strategies and interventions that the youth enjoys and is more likely to respond to. These activities and approaches should be used to create the response strategies in the plan.

➢ Consider resiliency or protective factors: relationships, spirituality, and connections to people/places that feel safe.

➢ Identify current coping skills, even if they are disruptive (i.e. running or ripping up assignments) in order to provide opportunities for them to be used in safer ways (going for a jog together, ripping up a phone book).

➢ Include interests and hobbies as well as ways the youth likes to be approached

• It helps the people who support me when:

This section highlights what the caregiver can do to calm so they are able to assist the youth to get to a de-escalated state in a process of co-regulation. If the adults are not calm and in a safe emotional and physical state, it is difficult for the youth to relax. The “caregiver” in this section should include anyone who is responsible for providing care to the youth, and could include the parent, teacher, placement providers, or relatives who are involved in the response process.

Consider the caregiver’s trauma history and triggers, i.e. a DV history with the youth’s father who looks and sounds just like the youth when upset. It is also helpful to consider concerns related to the caregiver’s ability to respond to crisis; such as physical or cognitive limitations, mental health, or substance abuse, or supervision limitations. The strategies listed in this section should be steps the caregiver can use when a crisis occurs to role model calming for the youth, and to get to a calmer state in order to best support the youth. They may also be steps others can take to support the caregiver.

Questions to ask the caregiver:

➢ What’s helpful for you to do, or not do, when a specific crisis occurs? How can we support you in crisis?

➢ When past crisis situations have occurred, what has worked for you?

➢ When your child is struggling to control his or her emotions and behavior, what do you normally do? Have you noticed if that makes the situation better or worse?

➢ What helps you stay calm in a crisis?

➢ Who do you contact to help you through a crisis?

• People need to know I don’t like it when:

This section is used to identify triggers for crisis. Consider triggers associated with people, places, and events. The youth can identify situations that are likely to lead to crisis, which can include ways that people engage with them, tone of voice, statements, or situations. Encourage the youth to think about the things that “set them off” in the home, school, and community.

➢ Include precipitating events, triggers or warning signs that lead to an escalation of the crisis. Trauma triggers can include: people (facial expressions, body language, tone of voice, power difference, unfamiliar or unpredictable relationships) and places (rooms with reduced supervision or access to potentially harmful items, areas of the city that are linked to adverse experiences such as houses, streets, parks, schools, etc.). Youth may also experience flashbacks that are related to traumatic experiences, which can lead to crisis.

➢ Consider life changing events such as death, divorce, marriage, removal of a family member, new place to live, new baby, domestic violence, loss of employment, etc. The anniversary of events can also be a trigger.

➢ Intense fears; such as being in the dark, closed spaces, being touched, etc. may be triggers. Fears may have been generalized from a specific experience.

➢ Consider potentially dangerous affiliations; such as gangs, peer influences, or bullying.

➢ Include behaviors that could trigger or lead to a crisis, i.e. youth pacing the floor, keeping things bottled up, inconsistent sleeping patterns, etc. Trauma impact can significantly affect eating, sleeping, and stress patterns.

➢ Consider risks or triggers related to court ordered supervision and safety requirements (for example, adjudicated sex offenders cannot be around children under the age of twelve, or a youth who has been adjudicated for carrying a concealed weapon cannot possess or be around any firearms or weapons). On-going events such as court ordered visits, court hearing, testifying, etc. can also be a trigger.

• Specific crisis situation

I need support when I feel/experience (unmet need) and react by (specific behavior)

Behavior comes from unmet need and is a byproduct of the actual crisis; it can be thought of as an external display of an internal crisis that lets others know something is going on. The definition of crisis for the youth is typically the need not being met, i.e. if the need is to feel heard, the crisis may be feeling ignored or misunderstood. The crisis for the adult is generally related to the behavioral response to the youth’s crisis. For example, if the youth is feeling ignored and leaves without telling Mom where she is going, Mom’s crisis may be fearing for the safety of her child or feeling disrespected. The behavioral response should be specific and accurate vs. a general label; i.e. yells at his mom and hits is brother vs. becomes verbally and physically aggressive; or throws things on the floor vs. destroys property. This helps to keep the plan accurate and person centered rather than labeling, blaming, and shaming the youth.

Steps to resolve the crisis

The intervention steps should be written in order of use starting with the trigger and sequentially going through debrief. They are written in order of least restrictive or intrusive (most normalized) to most restrictive or intrusive (formal system interventions). The debrief should outline how the team will learn from the situation and share those lessons, as well as efforts to repair and reconnect if relationships or trust was damaged in the process.

Also consider fight, flight, and freeze survival responses and the function of the behavior to help identify viable replacement behaviors or reduce triggers. Discuss the function of the defined crisis behavior so the team understands how the youth benefits from it and can aim to meet the need in safer ways. For example, if the function of fighting is self-protection, what can the team create as a replacement behavior that is equally protective.

Strategies should detail who is going to do what, and specifically how so that the youth, family and team know what to expect when someone is called to intervene. Rather than state interventions like “help them calm down”, indicate what they will do to help them calm, such as play music and dance for 3 songs, take a 20 min. walk before asking what happened, offer encouragement by telling the youth that they want to understand so they can be a better support next time. If the strategies are specific and detail how people will intervene, it is easier for the team to determine what works.

Account for the fact that we all lose the ability to think rationally and futuristically, control impulses, and creatively problem solve when we are in high emotional or stress states. Generally, non-verbal communication and sensory based activity are more powerful tools to promote calming than words in high stress states. Mutual engagement in calming activities (breathing, dancing, singing, drawing, drumming, etc.) is beneficial for all parties involved and promotes a connection between the adult and youth around safety and calming that strengthens the relationship.

What specific steps should we use?

➢ Clear steps to take for each specific crisis situation identified

For example:

A. When youth needs to separate himself from others and cusses at his teacher to create distance:

1. Step 1 starts at the trigger and outlines who will respond and how to help the youth feel better. Name, phone number, action

2. Step 2 Name, phone number, action

3. Step 3 Name, phone number, action

4. This continues through the crisis escalation and de-escalation process, including debrief to outline how the team will repair and reconnect after crisis to strengthen relationships and learn from the event.

B. When youth feels overwhelmed and uses marijuana to clear his head:

1.

2.

3.

C. When youth is embarrassed at school and creates a distraction by throwing things around the room:

1.

2.

3.

General guidelines:

➢ Crisis plans are written in the 1st person from the youth’s point of view.

➢ Prioritize relaxing activities at regular intervals throughout the day for a few min. at a time. Also, identify what feels safe for the youth and family and prioritize those types of interactions, routines, and activities to enhance safety and security to prevent crisis or resolve it quickly.

➢ Steps have to be realistic in a crisis situation and focused on crisis response. Prevention strategies are outlined in the POC.

➢ Include steps for caregivers/adults in all environments – school, home, placement and community. This provides accountability and helps clarify individual responsibility. The crisis response will be different in different places where different people are involved.

➢ Family and team members must agree to the steps and feel confident using them. For example, the police may not be seen as a helpful, supportive, or available resource by the family or a responding team member may not have the ability to co-regulate.

➢ Practice drills might be necessary to help people become comfortable carrying out their strategies and to understand where there are gaps in the plan.

➢ All steps should prioritize the utilization of the activities and approaches listed in the “what helps me relax” section of the plan, and be based on functional strengths of the family and team.

➢ Provide consistency and structure as much as possible while allowing flexibility to respond to the person’s emotional state and safety needs.

➢ Allow choices and options as often as possible to help the youth and family feel in control of their environment and interactions.

➢ Consider the developmental age of the person and base interventions and expectations on the developmental age instead of chronological age. For example, a 15 year old, under stress, may demonstrate and emotional and behavioral response similar to a much younger child; respond to the person’s developmental needs rather than expect them to “act their age”.

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