Kim J. Masters M.D.
Increasing Self-Determination through Advanced Crisis Management in Inpatient and Community Settings (ACM), Therapeutic Crisis Intervention System (TCI), and Satori Alternatives to Managing Aggression (SAMA) are three de-escalation programs that provide effective ways to prevent and manage aggression crises. Level 1 programs focus on skills necessary for preventing aggressive behavior before a crisis occurs and range from staff training to psychological advanced directives. Level 2 programs focus on skills to diffuse a crisis before seclusion or restrain is necessary. These skills include de-escalation techniques ranging from staff supported dialogs to self soothing talk. Level 3 programs teach how to safely carry out a seclusion or restraint.
Advanced Crisis Management in Inpatient and Community Settings (ACM)
ACM is essentially a Level 1 and Level 2 program. ACM focuses on creating “an advance crisis management component,” a psychological advanced directive which helps patients to determine personal stress triggers, and strategies that can be used to manage agitation or anger. The premise is that patients’ unique crisis management techniques can be used during hospitalization.
The non-violent crisis intervention component, developed by the Crisis Prevention Institute (CPI), is a Level 2 and 3 program and teaches staff members about factors that precipitate crises and non violent methods for managing aggressive behaviors, including the use of restraints (Jonikas et al. 2004). This program showed a decrease in the use of restraints up to 98% in an adult inpatient unit, an adolescent unit with patients ages 12–17, and a clinical research unit. It has been featured in several national initiatives that highlight successful approaches to reducing utilization of restraint and seclusion of adults and children with mental illness. ACM is taught via a manual and a video. CPI provides on-site staff training and ongoing supervision. Costs were not stated in the program materials I reviewed, but individuals interested in more information about the program should contact Jessica Jonikas, M.A. by email at JONIKAS@psych.uic.edu.
Therapeutic Crisis Intervention System (TCI)
TCI is a Level 1–3 program which is widely used in residential programs throughout the U.S. and in psychiatric facilities in England, Ireland, Israel, Canada, and Australia with children and adolescents. It is based on the Convention of the Rights of the Child adopted by the United Nations. The Convention was the result of a UNsponsored world summit for children held in 1991, which stressed the opportunity “to reverse the spread of disease and hunger brought on by poverty and war” (http://cartercenter.com/ doc1294.htm). The first right is, “Put Children First.” TCI was developed by Cornell University in the 1980s under a grant from the National Center on Child Abuse and Neglect. Its effectiveness was measured by positive changes in staff confidence levels, a decrease in the number of restraints, and an increase in the knowledge and skill levels of staff. The Hartford Courant reported on restraint deaths along with regulatory investigations, prompted a review of the program with emphasis on more careful attention to children’s complaints, and observed signs of respiratory and cardiac compromise. (Weiss 1998 a,b) (However, as far as I am aware, the program continues to employ prone restraint which is not permitted in New York State Mental Health Facilities.)
TCI emphasizes leadership and administrative support; clinical oversight in teaching how to individualize a crisis safety plan for each child, including a psychological advanced directive; and supervision to see that the crisis de-escalation techniques are effectively implemented. Review of critical incidents—meaning seclusion, restraint, and injuries resulting from the use of these interventions—are essential parts of this program. The program teaches individualized de-escalation strategies and when that fails, employs physical restraints (holds). The program does not appear to use seclusion. The cost of the program is not stated in the brochure I read. For more information, email Michael Nunno DSW, of the Family Life Development Center at the College of Human Ecology at Cornell University (firstname.lastname@example.org).
Satori Alternatives to Managing Aggression (SAMA)
SAMA developed as an alternative to the Prevention and Management of Aggressive Behavior Program of the Texas Department of Mental Health and Mental Retardation. It is a Level 2 and 3 program. It uses a study guide, videotapes, a manual, and a facilitator in its teaching, and it is used in both residential and inpatient facilities. It teaches “an Assisting Process for communicating with people (of all ages) who are at risk of becoming physically aggressive.” It emphasizes the following elements: Protection of Self and Others, Object Retrieval, and Containment.
Protection of Self: 19 procedures that cover protection at a distance and on the ground and protection from wrist grasps, life threatening grasps, hair pulls, and bites are listed in the program materials, which include a study guide, manual and video. The facilitator teaches and reviews the procedures.
Object Retrieval: This is a catch-all term for any object—cutting, blunt, or piercing—that an individual can use to cause harm to himself or others. Based on my conversation with Larry Hampton, CEO of Satori Learning Designs Inc., the program teaches how to use the Assisting Process to retrieve the object if the person is threatening harm or harming himself or others. (Personal Communication, Larry Hampton).
Containment: This process focuses on limiting a person’s movement, instead of immobilizing him, for reasons of protection. It uses elbow to hip containment. The Assisting Process teaches how to contain the person on the ground and then release him. This eliminates the need to move the patient or force him into a sitting or standing position.” Seclusion is not mentioned as a treatment modality. According to the web site, www.satorilearning.com, the program training costs $950. For more information about SAMA, see the web site or email email@example.com.
At the risk of being seen as unfairly critical, particularly in the face of impressive restraint and seclusion reduction data, I want to raise the following issues about the three programs:
All of these de-escalation programs essentially help institutions adapt to the personalities and needs of individual patients. None of them present any data to suggest that the patients are any better equipped to manage stresses when they leave the facilities or that their psychiatric illnesses have been improved by these interventions. This is important information for several reasons. First, in England from the 1830–80’s, attempts were made to reduce the use of seclusion and restraint by the Lunacy Commission without any apparent impact on the course of mental illnesses of patients or reduction of patients requiring inpatient services. This led to neglect of research on these interventions for a century.
Second, aggressive children and adolescents with conduct problems misperceive and distort communication from others, which may promote misdirected aggression (Dodge 1995). These distortions may be part of other mental illnesses, particularly mood and psychotic disorders and are likely to undermine a patient’s ability to be successful after discharge. It is not enough then, to help patients navigate the vagaries of the inpatient experience without falling afoul of a seclusion or restraint. We, as child mental health professionals, should also try to actively teach ways to challenge and cope with these misperceptions. These programs do not discuss using CBT training with patients or promoting patient role-play practice sessions to change disabling coping strategies. These readily available and inexpensive strategies seem missed opportunities which ultimately might set the stage for another round of neglect of patient concerns.
Finally, another déjà vu from the 19th century restraint controversy is that physicians, particularly psychiatrists, appear to have been marginalized in their input or involvement with deescalation programs. Although a few notable Academy members are active in this work, I could find no evidence that physicians play any role in the development or management of the three de-escalation programs described here. Yet in all of them, a physician is required to order the procedures and do face-to-face interviews!
Even in the articles that I was able to track down about these and many other similar programs, the absence of physician input into governance, advice, written articles, and performance improvement is a pervasive problem that I believe endangers the welfare of children and the long term survival of these aggression management programs. Perhaps the AACAP could have an initiative to get more involvement of child and adolescent psychiatrists in this arena?
Dr. Masters is Chief Medical Officer of ABS Hope Treatment Centers and Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior.
Dodge KA, Petit GS, Bates JE, Valente F (1995) Social information processing patterns partially mediate the effects of early physical abuse on later conduct problems. J Abnorm Child Psychol 104:632–43
Jonikas J, Cook J, Rosen C Laris A Kim Jong-Bae (2004) A Program to Reduce Use of Restraint in Psychiatric Inpatient Facilities, Psychiatric Services 55: 7 818–820
Weiss, E (1998, a) A Nationwide Pattern of Death, Hartford Courant, Oct. 11
Weiss, E (1998, b) Patients Suffer in a System without oversight, Hartford Courant, Oct 13