Crisis Intervention Training Program

Developmental Manual

Participants Workbook: 7TH Edition

 This training series was developed by:

Dr. Colin Pryor, Ph.D., C. Psych.

Dr. Bruce Linder, Ph.D., C. Psych., BCBA-D
Benj Wu, M.A.
Brandie Stevenson, M.A., C.Psych. Associate

Contents of this manual are the sole property of Safe Management Group Inc. All rights reserved.

form or by any means, electronic, mechanical, photocopying, recording or otherwise without the

Safe Management Group Inc.

1320 Cornwall Road, Suite 202
Oakville, Ontario L6J 7W5
Canada

Tel: (905) 849-0967 or 1-866-554-5001

Fax: (905) 849-8801
Email: [email protected]

Web Site: www.safemanagement.org

PLEASE READ CAREFULLY

Please be advised that some of these methods involve physical con-

tact and may include risk of injury. It is important that you follow the
Instructor.

is in compli-
ance
ity whatsoever for any bodily injury, loss, damage or any related claims caused by the misuse
as a

er or not such injury, loss, or damage is foreseeable.

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TABLE OF CONTENTS
Creating and Maintaining Safe Environments

INTRODUCTION Page
Mission/Overview 3
Aspects of the Program 4
Ministry Regulations 5
Organization of Program 6
Specialized Training Programs 7
Why SMG Training? 8
The Recovery Model 9
The Trauma Informed Care Model 10
RISK MANAGEMENT
Behavioural Crisis 12
Types of Risk 13
System/Organization Preparation 14
Intrusive Protocols 15
Family Preparation 16
Environmental Preparation 17
EnviroScan™ 19
Staff Preparation - Stress Management 24
Individual Preparation - Nutrition and Medication 25
RELATIONSHIP MANAGEMENT
Communication 28
Relationship Management Checklist 29
Power & Equity 30
Social Exchange & Reciprocity 32
Empathy, Caring & Acceptance 35
Genuineness & Openness 38
Reading & Responding to Emotions 40
Avoiding Coercion 44
Setting Limits & Interpersonal Boundaries 47
BEHAVIOUR MANAGEMENT
Environmental Planning 50
Functions of Behaviour 51
Anger Management Skills 53
Developing Plans 54
Developing a Behavioural Profile 55

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AGGRESSION MANAGEMENT PAGE

Aggression Escalation Continuum 62
Individual Behaviour - Escalation Continuum 63
Staff Response - Escalation Continuum 64
Individual Behaviour Exercise - Escalation Continuum 65
Staff Response Exercise - Escalation Continuum 66
Developing an Effective Crisis Intervention Team 67
Debriefing 68
When to Physically Intervene 71
Responding to Weapons 74
De-Escalation Checklist 76
PHYSICAL INTERVENTION CONCEPTS
Safe Management Group’s Teaching Approach 78
Safety for Individual 79
Safety for Participants 80
Positional Asphyxia 81
Protective Positions 82
Strikes 83
Wrist Grabs 84
Clothing Grabs 86
Hair Pulls 87
Chokes 89
Bites and Kicks 90
Escorts/Containments 91
Alternative Techniques 93
APPENDIX
Definitions 95
Bibliography 96
Crisis Intervention Test 100
Training Evaluation 105

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OVERVIEW
DEVELOPMENTAL PROGRAM

Introduction
Our Mission Research
Our mission is guided by our core principle, Safe Management Group Inc. continues to
“Caring for your safety.” We will provide research the effectiveness of its training programs
comprehensive, effective and proven training and the outcome measures are published. We
programs and consultation services to promote have partnered with various organizations on
individual and community safety through dignity these endeavours and will continue to do so.
and respect.
Initial studies suggest that Safe Management’s
Overview Crisis Intervention Training, together with
Trauma Informed Care, the Trauma Recovery
Safe Management Group’s Crisis Intervention
Model, and other system interventions, makes a
Training Program was initially developed in 1990
positive difference to both staff and the people
for staff working in agencies that serviced adults
they serve. These interventions reduce the need
with developmental disabilities. It was developed
for both physical and mechanical restraints,
by psychologists, behaviour analysts/therapists,
lower staff injuries, and reduce behaviour crises.
and physical intervention specialists to address
the unique needs and challenges posed by
Our ongoing study of the effectiveness of our
individuals with unsafe aggressive/violent
online vs. classroom training has shown that
behaviour. Clinical experience suggested that a
online training is highly successful in teaching
high proportion of this behaviour was predictable
course content, with a statistically significant
and, therefore, potentially preventable if
increase in knowledge to a score of 82% correct.
appropriate information was obtained and
used within a behavioural management system.
Experience also suggested that more extensive
physical intervention techniques were often
required to safely manage the aggressive
behaviour that was more commonly seen. All of
our training programs were designed to integrate
behavioural management principles, strategies,
and techniques with new, improved state-of-
the-art physical intervention techniques. These
techniques reflect the diverse professional
skills of the design team and the unique needs
of the individuals, while emphasizing the least
restrictive, least intrusive philosophy of care.

Our Crisis Intervention Training Program has

been recognized by the Ministry of Children
Community and Social Services since 2003
for agencies serving children, youth and
adults with developmental disabilities. Safe
Management continues to build partnerships
with organizations, community partners, and
Ministries in pursuit of maintaining and caring for
all levels of safety.
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Aspects of the Program

Safe Management Group’s Crisis Intervention Training Individual Specialized Consultation Process
Program involves training in Risk Management,
Behavioural Management, Relationship Management,
and Physical Intervention Skills. Individuals whose
aggressive behaviours require more complex physical
intervention techniques than are offered in the Crisis
Intervention Training require an “Individual Specialized
Consultation” by Safe Management Group personnel.
This consultation ensures that the techniques are
properly designed for the individual, the staff, and the
specific environment. The consultation also ensures
that specific professions (behavioural therapists and
psychologists) are involved to assist in the preventative
behavioural management programming and
environmental enhancement, which helps to ensure
that the techniques are used optimally for the individual.
Basis of Program
Safe Management Group’s Crisis Intervention Training
Program provides staff and instructor training. Our philosophical basis for all of our training programs
Accordingly, there are two manuals that accompany involves integrating principles, strategies, and
the program; a Training Workbook/Reference Manual techniques from the areas of:
for all training participants, and an Instructor’s Guide/
Advanced Manual for instructors. Knowledge and
performance testing of all participants is conducted
by the Instructors using specially designed Safe
Management Group tools. Trainer skills are monitored
by Safe Management Group on an annual basis.

Specialized Consultations result in an Individual

Specialized Consultation Report that includes an
updated behavioural and environmental assessment
of the individual and “photolog” of individualized
physical intervention techniques. Designated and
trained Instructors provide staff training and monitoring
of the staff’s skills in the techniques identified in the
consultation report.

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Ministry Regulations
Staff are employed by organizations from different incorporate the use of intrusive strategies. Accordingly,
Ministries – e.g., Education, Health Care, Corrections, approval is required by a Psychologist, Psychological
and Children Community and Social Services. Each Associate, a Physician, a Psychiatrist or Behaviour
Ministry has its own regulations and Policies/Procedures Analyst certified by the Behaviour Analyst Certification
regulating the use of physical restraint. A review of these Boards. Safe Management Group’s Crisis Intervention
policies indicates a common emphasis on the following: Training incorporates each of these areas, recognizing
their importance in the prevention and management of
• Preventing restraints. challenging behaviours.
• Using restraints only as a last resort and only for
reducing imminent risk to an individual.
• Using restraints only if approved by various
regulated health professionals, agency/organization
administrators, and by parents/ legal guardians/
substitute decision makers.

When “Ministry” guidelines are mentioned it is

In our opinion, the MCCSS document Services and the MCCSS Behavioural Standards and associated
Supports to Promote the Social Inclusions of Persons guidelines to which we are referring as a good standard.
with Developmental Disabilities Act (2008) contains the Safe Management Group Inc. makes no warranty or
most extensively developed standards for the regulation representation that the skills, techniques and methods
and use of restraints, especially when integrated with taught in this program comply with all local laws, rules,
preventative behavioural programming. The new regulations and ordinances that may be applicable
Quality Assurance Measures set out the criteria for to persons utilizing same. Safe Management does
the implementation, training and monitoring of all attempt to stay apprised of various Ministry regulations
Behaviour Support Plans. All individuals with challenging and standards and modify programs to address such
behaviours who are supported by a community agency changes. Safe Management Group Inc.’s Physical
require a Behaviour Support Plan. The Behaviour Intervention Techniques should be used in a manner
Support plan must outline a functional assessment that is in compliance with local laws and regulations.
and positive programming interventions, seek out
least intrusive effective strategies and be approved Safe Management Group Inc. assumes no liability
and monitored by a Psychologist or BCBA Behaviour whatsoever for any bodily injury, loss, damage or
Analyst. Safe Management Group’s Crisis Intervention any related claims caused by the misuse or incorrect
training incorporates each of these areas recognizing application of the skills, techniques and methods taught
its importance in the prevention and management of in the program, as a result of any undisclosed medical
challenging behaviours. Safe Management Group’s condition or by illegal or inappropriate use of same,
Crisis Intervention Training program was approved in whether or not injury, loss or damage is foreseeable.
2003 by the Ministry of Children Community and Social
Services/Ministry of Child/Family for use with children,
youth and adults. A further review was conducted
in 2011/12; which recognized Safe Management’s
program was in compliance with O. Reg 299, S18
(3c8). Regulation 299/10 sets out the qualifications of
those who can approve behaviour support plans that
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Organization of Program
The approach of our Training Program relies crises, with the idea that Predictable crises
heavily on the distinction between “Prevention” involve a higher degree of responsibility and
and “Management” of risky behaviours. liability for adequate prevention.
“Prevention” involves those techniques that
reduce the future probability of an aggressive The typical concept of risk is broadened to include
incident. the idea of “Organizational/Agency Risk”, which
allows for the consideration of Ministry and
“Management” refers to all those techniques Organization Policies in a truly comprehensive
used at the time of an incident to reduce its “Crisis Intervention” Training Program.
intensity and/or duration. Safe Management
Group places strong emphasis on prevention; Management Techniques are outlined in
however, when Management Strategies are the Aggression Management and Physical
required, we focus on the least intrusive Intervention Concepts. A four-level model of
strategies, while maintaining safety for both theescalating aggression, manifested in three
individual and staff at all times. domains of individual functioning, is introduced
as a basis for developing individualized
This training introduces the distinction between comprehensive management plans.
“Predictable” and “Unpredictable” behavioural

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DEVELOPMENTAL PROGRAM

Specialized Training Programs

Safe Management recognizes the unique needs of individuals. As such, we have developed a
number of certified training programs to address these needs.

Developmental/Adult
- Adult - Day/Residential Services
- Families/Caregivers

Children with Autism Spectrum Disorders/Complex Needs

- Children's Aid
- Autism Services
- Children/Youth - Day/Residential Services
- Families/Caregivers

Health Care
- Community Health Care/In-Out Individual Treatment Centres
- Long Term Care
- Mental Health/Forensics
- Acquired Brain Injury

Education
- Colleges
- School Boards
- Universities

Community
- Municipal Services
- Emergency Response Services
- Security/Corrections
- Private Service Sector

Elderly Care
- Long Term Care
- Medically Fragile

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Why SMG Training?

This training system was developed for people • It is rare for individuals with significant
providing services to populations who may, cognitive, developmental, or neurological
on occasion, demonstrate aggressive/violent deficits to respond in a logical, rational way
behaviours. Recognizing that such aggression can to verbal intervention. Therefore, the course
result from cognitive ability, previous history and/ covers a spectrum of communication
or current circumstances, implementers of the techniques.
program need to match their responses to the
particular incidents and intervene with timely, • Staff may be frightened and frustrated
practiced and specific techniques that ultimately: when dealing with repeated incidents of
aggression. Knowledge of early interventions
• Ensure the safety of everyone involved. can significantly decrease anxiety and
• Support the organization’s Policies & frustration.
Procedures.
• Adhere to all relevant Government Acts. By participating in realistic case studies and
directed role-plays, you will:
The approach is straightforward:
• Gain greater understanding of underlying
• Whenever possible, strive to prevent causes of aggressive/violent behaviour.
aggressive incidents before they occur. • Be able to recognize escalating behaviour
• If prevention is impossible, intervene with patterns and how to intervene.
the least intrusive measures possible. • Become more attuned to verbal, physical
• If physical intervention is absolutely and environmental cues.
necessary, employ the Safe Management • Expand your problem-solving abilities in the
techniques, which are firmly based in sound areas of awareness and physical intervention
physical intervention principles, so that skills.
response is swift and effective.

This course is designed with the following in

mind:

• Staff must match their responses to each

individual by carefully profiling and taking
into consideration critical elements of each
individual’s response style and history.

• Some individuals are not verbal; nor can

they respond to verbal intervention. Thus,
gestures, environmental cues and reference
to established routines all need to be
considered when establishing a framework
for intervention.

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OVERVIEW
RECOVERY MODEL

The Recovery Model

The Recovery Model of Care in mental health Safe Management Group Inc.’s comprehensive
services emphasizes recovery and hopefulness Crisis Intervention Day One Program was
for the future of those with significant mental designed to teach principles, strategies and
health issues. It has been heavily influenced techniques related directly to the Recovery
by the recent Positive Psychology and older Model, including the humanistic-inspired 7
Humanistic traditions in Clinical Psychology. Principles of Relationship Management, the
Six key principles govern this approach; some Behaviour Profiling of child’s, Environmental Risk
similar to the Trauma-Informed Care Model, Management, and the Collaborative Problem
such as Hope, Security, Supportive Relationships, Solving approach to Verbal De-Escalation.
Empowerment and Inclusion, Coping Strategies,
and Meaning.

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TRAUMA INFORMED CARE

Trauma Informed Care

As noted on the SAMHSA website “Trauma- Safe Management Group Inc.’s comprehensive
Informed Care is an approach used to engage Crisis Intervention Program focuses on strategies
people with histories of trauma. It recognizes the and techniques related directly to the objectives
presence of trauma symptoms and acknowledges of creating TIEs; including the humanistic-inspired
the role that trauma can play in people’s lives.” 7 principles of Relationship Management,
This approach has become important in all the Behaviour Profiling of individuals, the
mental health services areas, and the goal has Collaborative Problem Solving approach to
been to create trauma-informed environments Verbal De-Escalation and the skills of Reading
(TIEs) that facilitate mental health and recovery. and Responding to Emotions.

A Trauma-Informed Environment (TIE) includes four critical elements:

1. Respect for the individual
2. Being Informed about the individual’s individuality and uniqueness
3. Experiencing Connectedness with caregivers
4. Supporting Hopefulness about the future and recovery

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RISK MANAGEMENT
Section One

This section of the course outlines the Risk Management concepts of Safe Management Group Inc.
At the end of this section, participants should be able to:
1. Appropriately plan for Predictable Crises and respond accordingly to Unpredictable Crises.
2. Identify and mitigate risks that occur between individual and staff, staff and individual and
between staff.
3. Understand the legislative criteria for the use of intrusive protocols (physical interventions).
4. Understand how system issues influence aggression within agencies.
5. Identify and mitigate risks associated with the physical environment.
6. Understand the relationship between personal stress management and managing aggression in
others.

RISK MANAGEMENT PAGE

Behavioural Crisis 12
Types of Risk 13
System/Organization Preparation 14
Intrusive Protocols 15
Family Preparation 16
Environmental Preparation 17
EnviroScan™ Checklist 19
Staff Preparation - Stress Management 24
Individual Preparation - Nutrition and Medication 25

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One BEHAVIOURAL CRISIS

Behavioural Crisis
Definition: An
 escalating episode of emotional upsets involving anger and verbal threats, which
may lead to dangerous situations of self-abuse, environmental destructiveness and/or
physical aggression towards staff and peers.

There are two types of Behavioural Crises:

• Expected behaviour pattern

Predictable • History of aggression
• Behaviours occur on regular basis

Unpredictable • An unexpected incident

• Someone who rarely aggresses

Effective Prevention of Behaviour Crises

Action: 

• Plan for “Predictable” crises, but know how to respond in “Unpredictable” behavioural crises.

Principles of Effective Prevention:

• Prepare/control the physical environment.

• Manage individual behaviour.
• Implement appropriate Policies & Procedures.

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Types of Risk
The Types of Risk section encourages you to use a Safe Management promotes working with
different perspective in approaching how to work aggressive/violent individuals from a “multi-
with individuals who have a history or recently factor” perspective. We train staff to manage
diagnosed pattern of physical aggression/ physical aggression using a system-wide
violence. The traditional approach usually views approach. A core concept is viewing physical
issues of working with physically aggressive aggression from a Risk Management perspective.
individuals from a “one factor” perspective. That
is, issues arise because there is insufficient and/
or inappropriate staff training.

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System/Organization Preparation
You should be prepared to deal with aggressive/violent individuals who have predictable behavioural
crises. It is important to consider the following legal and procedural requirements.

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Intrusive Protocols
Intrusive Protocols are behaviour plans that include restrictive physical interventions, such as
physically escorting someone against their will or using a physically restraining hold.
Ensure that Intrusive Intervention Procedures, such as physical restraints, are appropriately approved
and reviewed.

LAST RESORT STRINGENT ACCOUNTABILITY

Some plans may require staff to use Intrusive intervention procedures, such as
physical supports. Consider such supports physical restraints, are regulated, and MUST BE:
only under the following circumstances:
a) DOCUMENTED IN WRITING.
• It is determined that less intrusive
intervention would be ineffective. b) APPROVED PRIOR TO USE.

• There is a clear and imminent risk that c) MONITORED CAREFULLY, ON AN ONGOING

the individual will physically injure him/ BASIS, AFTER THEY HAVE BEEN APPROVED.
herself or others. In all plans that use physical support
•
The techniques are carried out using procedures, document the following:
the least amount of force necessary to • That the individual’s guardian(s) or
restrict the individual’s ability to move substitute decision maker(s) have provided
freely. consent.
• While under restraint, the individual’s • A method of reviewing and evaluating the
condition is continually monitored and procedures with appropriate personnel
assessed. (e.g., directors, supervisors, etc.) and other
• The restraint is stopped when there is specialists in behavioural consulting (e.g.,
no longer a clear and imminent risk that behavioural therapists, psychologists).
the individual will physically injure him/
herself or others. • Approvals from staff, supervisors and
other individuals or committees deemed
• The restraint is stopped when there is a important to the integrity of the plan (e.g.,
risk that the restraint itself will endanger a Behavioural Ethics Review Committee,
the health or safety of the individual. the individual’s physician). The physician’s
opinion is absolutely necessary before an
• The procedure is not used for the purpose intrusive technique can be implemented.
of punishing the individual.
• Training and evaluation of staff in the
• The procedures are appropriately physical techniques which have been
approved and reviewed. approved to manage a behavioural crisis.
• Regular monitoring of staff’s competence
in implementing approved physical
intervention procedures.

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Family Preparation
In the case of care providers implementing the Safe Management System who are not connected to
an Agency, preparation is somewhat different. There are no Agency Policies and Procedures related
to ensuring quality programming when physical intervention is required. The following steps are
important:

Preparation for Families

1. Access suitably trained professionals for help in designing and approving behavioural
management plans that include physical intervention techniques, e.g., behavioural
therapist, psychologist. Written plans with the signature of a registered or licensed
psychologist should be obtained.
2. Involve the individual’s physician in reviewing the proposed physical intervention plan
for whether the techniques are acceptably safe given the individual’s unique medical
status. Written opinion should be obtained. Regular follow-up medical assessments may be
required to ensure physical safety to the individual.

3. Use your local Public Guardian & Trustee (PG&T) for legal advice about the acceptability of
physical intervention techniques in the program plan. Written permission may be advisable
when the techniques must be used often and are significantly restrictive to the individual’s
freedom.
4. Remember to collect data about the use of physical intervention techniques for program
reviews with your behavioural specialist to ensure objective information is collected, and for
accountability.
Note: Safe Management Group’s techniques are considered acceptably safe for physically
normal individuals, but many individuals with developmental disabilities are at higher risk for
various physical problems (e.g., cerebral palsy, orthopedic and musculoskeletal problems, and
cardiac conditions) that may raise the risk of harm associated with the use of some of these
techniques. Only a physician is in the position to assess this type of risk.

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Environmental Preparation

Behavioural crisis can often be prevented by adequate preparation and planning. Environmental
Preparation is one type of preparation that has been found to be most effective in preventing
behavioural crises.

1. Room Furniture 2. Size of Rooms 3. Hallway Access & Size

(Type & Location)

• Ensure no sharp or hard • Large enough to allow safe • Easily accessible and wide
edges individual-staff interaction enough to permit staff and
• Height of furniture during a behavioural individuals to move easily
incident involving more from one room to another
• Locate against the walls so
than two people if physical intervention is
people are less likely to trip
required
or fall over them, and have
easy access to and • Provide sufficient room for
from the room staff to safely implement
any interventions

6. Amount of Space or
4. Decorations and Objects 5. Noise Levels Crowding

• Selected - recognizing • Monitored and reduced, • Ensure ample space for the
objects may be dangerous whenever possible (e.g., number of people in the
if broken and could be used suggest classical or easy environment
as weapons listening music) • In residential situations,
• Not breakable - (e.g., • If an individual has a use the entire house for
pictures should be dry preference for loud music, living and workspace
mounted rather than suggest using headphones • Engage people in various
framed with glass) • Stereos and Tvs should activities in different areas
• Secured - in some way if not be played at the same
they are large and heavy time and should be turned
(e.g., wall units may need off during meals and
to be secured to the wall) instructional times.
• Awareness of increased
noise levels

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Environmental Preparation

7. Air Quality 8. “Calming” Area 9. Enhanced Staff

• Ensure good ventilation in • Identify and reserve for • Note: Various intervention
all areas of the building, times when an aggressive techniques require
especially smoking areas outburst occurs additional staff to ensure
and areas where noxious • Make easily accessible to their safe implementation
or highly scented objects most areas of the house or • Use back-up call systems in
are used workplace (usually on the situations where staff are
main floor in multi-level working in different areas
buildings) • Organize call systems with
• Provide more than one staff from nearby houses or
area for a individual with buildings
frequent behavioural • Use “beepers” to activate
outbursts, especially in back-up calls quickly
multi-level buildings

10. Staff’s Room/Work Areas 11. First Aid Kits 12. Lighting

• Permit easy, on-going • Make readily available and • Providing appropriate

supervision of the properly equipped for staff levels of lighting ensures
individual by sight or to deal with emergency easy monitoring of
sound situations, including the physiological changes
•P  rovide easy, rapid access handling of blood • Psychologically, lighting
to an individual if an • Be familiar with all kit has an effect on mood and
incident occurs locations and contents mental well-being
• If ongoing individual • Recognize that for some
monitoring is required, individuals too much
consider developing staff lighting can be problematic
assignment systems for
room supervision
• If necessary, eliminate work
areas that restrict constant
individual supervision

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EnviroScan™

In settings where there are individuals who may display physical violence or aggression, an adequately
prepared physical environment can help lower the probability of injury to individuals and staff. The
Safe Management EnviroScan™ process helps staff ensure the safety of their physical environment.
Staff can use the Safe Management EnviroScan™ Guidelines to assess their home, special care
environment and/or long term care facility.

Exits Furniture Potential Weapons

• Doors that can be locked • Potential hazards • Fire Extinguishers

• Areas that can be sealed identified • Tools
off or isolated • Mobility blocks identified • Utensils
• Number of exits • Furniture positioning • Sports equipment
shows awareness of,
• Location of exits and planning for exits, • Dishes
• Hazards involving exits, escape/evacuation • Pictures
e.g., stairs routes
• Televisions
• Canes/Walkers
Escape Routes Secured Environment
• Hangers
• For staff • Movement flow to room • Finger/Toe Nails
completed • Books
• For individual
• Location and swing of • Wheelchairs
• Movement flow analysis
doors
completed • Phones
• Space for intervention
• Crisis evacuation routes considered • Keys
determined
• View for monitoring • Pens
• Procedures for crisis available • Etc.
available
• Potential hazards
• Practice frequency removed

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EnviroScan™ Checklist
Scan Caution Consider Check

Can a person be Placing furniture to

Height from the floor pushed through? block access
Windows
Composition Broken glass can Replacing glass with
cause injury other material

People could be Relocating

Method of attachment pushed into a mirror
Placing furniture to
Composition Could be broken block access
Mirrors/
Pictures Broken glass can Replacing glass with
cause injury safer material

Door opens inward/ Door could slam into Removing items

outwards from room you blocking the
doorways
How easily does the door Sole exit could be
open? blocked by individual Making necessary
or door that opens repairs to facilitate
How easy is it to unlock the wrong way the opening of doors
doors?
Doors/ Central poles in Pocket doors
Doorways How many exits from the double doorway
room? could cause injury Replacing lock with
easily opened lock
How wide/tall are doors? Staff could be locked
in/out Ensuring staff can
get in or out

Limited room for Removing potential

Width of hallway
movement obstacles
Unobstructed access?
Movements can Identifying potential
be blocked easily exits along the
Hallways by obstacles or hallway
individuals
Presence of monitors

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EnviroScan™ Checklist
Scan Caution Consider Check

Working condition Be aware of the Repairing all

phone nearest you phones

Location Could be used as Testing phones

weapon before shift

Phones Phone location can Positioning phones

Accessibility increase staff so calls can be
vulnerability made easily
Posting emergency
numbers near the
phone

Movement of high
Location Relocating buzzers
risk individuals not
to hard-to-reach
monitored
locations for
Buzzers Non-working individuals
Condition
buzzers allow
Testing buzzers
individuals to leave
regularly
the premises

Could mask pre-

aggressive clues Ensuring regular
inspection
Environment Noise Level Calls for assistance
Conditions may not be heard

Temperature Level Higher probability Immediate repairs

of aggression

Broken or damaged Repairing pathways

pathways
Ensuring weather
Slippery conditions safety procedures
Sidewalks
due to weather e.g., salt in winter
Exterior
Environment Yard ornaments Attaching yard
Grounds could be used as ornaments firmly
weapons into ground

Yard tools could be Locking up yard

weapons tools
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EnviroScan™ Checklist
Scan Caution Consider Check

Removing
Could be thrown
Composition
Ornaments Relocating to
Could be used as
Weight ensure difficult
weapons
access

Used as a weapon Installing locks on

Location
drawers
Meal Trays/ Serious injury could
Utensils Cutting edge
result against staff Relocating to
or individual lockable drawers

Could be thrown at Storing securely

Type of chemical
staff or others when not in use
Cleaning
Chemicals Type of potential
Could be used for Keeping only what
injury
self-harm is needed on hand

Lighting Sufficient lighting? Replacing with

brighter bulbs
Low ceilings could
Height of Ceiling cause injury from Ensuring bulbs
fixtures hung at low are working
heights appropriately
Hanging plants/
Ceiling Low fixtures could Using recessed
fans/lights
be weapons after lighting
being pulled down
Brighter paint for
ceiling

Raising low fixtures

How was it Can you trip over No-slip flooring

installed? exposed edges?
Carpets/Rugs Replacing
Condition/texture Rugs could be pulled
from under staff

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One ENVIROSCAN™

EnviroScan™ Checklist

Scan Caution Consider Check

How wide is the Could be pushed Keeping individual

staircase? from behind in front of you

Carpet/Bare Objects thrown from Installing higher

Stairs height railings

Could be slippery Redirecting

individual away
from stairs

Blocking movement Removing potential

Arrangement of
flow to exits obstacles
furniture
Location, can trip Rearranging to
Size of item
people allow full view
Shelves
Used as weapons
Attaching shelves
Furniture/ Could shelves be firmly to wall
Carts/Trolleys
tipped?
Readjusting height
Height of shelving - of shelves
injury to head, trunk
Rounded edges or
Blocking vision foam covers

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 SECTION Risk Management
One STAFF PREPARATION

Stress Management
It is essential that good communication is established between staff, family members, caregivers and
individuals to help identify stressful times and ensure additional support is available as required.
Since it is our interpretation of events which influences our behaviour, it is critical that staff are aware
of their own internal processes and use this knowledge when dealing with stressful situations. Staff
can decrease and control their anxiety by following the 3 steps outlined below.

Step ONE Step TWO Step THREE

Staff need to become Staff need to CHANGE what Controlling and slowing
AWARE of what they tell they tell themselves. The goal down one’s own breathing
themselves during a crisis here is to create statements can boost positive self
situation. This means that are calming and statements.
catching themselves and reassuring.
listening to what they are When people are anxious
saying. Positive self-statements such or frightened, they tend
as: to breathe quicker and
Statements such as: shallower. This type of
“Boy, this is a difficult breathing tends to escalate
“Oh my gosh, he’s really situation, but I’ve handled anxiety.
going to hurt me!” this kind of thing before” can
help maintain a sense of calm During a crisis, staff should
or and control and will help to monitor their breathing
“Oh no, what am I going to ensure that good decisions and ensure they are taking
do now?” are made. long, slow, deep breaths.
This is most easily done
or by breathing out in a long,
forced stream.
“Oh, I should never have
taken this job!” The long breath out will
trigger a deeper and longer
will tend to inflame the breath in. This will begin
situation, increase anxiety, to assist staff in calming
and likely result in an themselves and will help
undesirable outcome. them make decisions in a
calm manner.

Summary

These self-management strategies are important because they reduce the chance that staff will
act too quickly or impulsively. Deep breathing and positive self statements put staff in the right
frame of mind in case they have to act in a more direct or intrusive manner.

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One INDIVIDUAL PREPARATION

Nutrition and Medication

When supporting individuals, there could be a When possible, light physical exercise is a
number of problems with their diet that need to good way to burn off excess fat and keep the
be explored. metabolism in balance.
In general, people require a balanced diet Where available, Nutritionists, Dieticians,
consisting of a variety of healthy, fresh foods. Physicians, or Nutrition Services at Public Health
Departments may be able to offer assistance to
For these daily requirements, consult Eating individuals who require dietary suggestions or
Well with Canada’s Food Guide, available from management.
the Health Canada website. This guide indicates
percentages and quantities for the daily intake of
the various food groups in an easy-to-understand
format.
There are also several other problems that could
be related to food and dietary requirements.
Poor nutrition can affect behaviour in negative
ways, so dietary planning should be considered
for each person.

Consider the following:

1. D
 oes the individual have any developmental or medical problems that affect his/her diet,
e.g., seizure activity/epilepsy, diabetes, and/or eating disorders?
 oes he/she use medications that require dietary restrictions or counter the effect of other
2. D
medications?
3. Does the individual have a tendency to “cram” food, or choke easily?
4. Does the individual suffer from food allergies?
5. D
 oes the individual have access to snacks that are nutritious and healthy, rather than high fat,
salty, sweet or caffeine-loaded foods?
6. D
 oes the individual require education in proper eating and snacking habits, i.e., are they
aware that some foods are healthier than others?
7. Has the individual’s appetite changed, e.g., Never hungry, always hungry?

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 NOTES

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RELATIONSHIP MANAGEMENT
Section Two

Relationship Management is a critical element in the creation and management of safe

environments. In many instances, outbursts occur because the individual is reacting to some aspect
of the quality of his/her relationships with others. Your personal interaction with the individual
can determine the outcome of such situations by the way you respond to unexpected crises.

This section describes 7 basic principles of Relationship Management with associated intervention
techniques. These principles are effective strategies for managing relationships with others, including
individuals, colleagues, professionals and family members. The principles must be reinterpreted
within the context of the individual’s particular developmental level and processing characteristics.
For some individuals this may involve a more concrete design of the strategy.
At the end of this section participants should be able to:
1. Identify the 7 Relationship Management Principles, implementation strategies and corrective
techniques.
2. Demonstrate a working knowledge of how the Relationship Management principles relate to
Verbal De-Escalation.

RELATIONSHIP MANAGEMENT PAGE

Communication 28
Relationship Management Checklist 29
Power & Equity 30
Social Exchange & Reciprocity 32
Empathy, Caring & Acceptance 35
Genuineness & Openness 38
Reading & Responding to Emotions 40
Avoiding Coercion 44
Setting Limits & Interpersonal Boundaries 47

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Two COMMUNICATION

Communication
Good communication is the foundation for any relationship. We communicate using much more
than words; many of our most effective and understood means of communicating are non-
verbal. The way we stand, our facial expressions, our hand gestures, our tone of voice and our eye
contact sometimes tell a much different story than the words we say, and they don’t stop once we
stop talking.

When communicating with a person, remember to do the following:

• Use the person’s name.
• Always introduce yourself.
• Always speak to the person in an age appropriate manner.
• Speak clearly and slowly and explain what you are doing, e.g., helping them get ready for a
bath.
• Use small words and simple sentences.
• Ask one question at a time.
• Make eye contact (when culturally acceptable).
• Try and use familiar words, pictures and/or charts to help them understand.
• Respect their physical space.
• Try not to rush them.

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Two CHECKLIST

Relationship Management Checklist

Principle Strategy Technique
Assess if the individual has
Provide greater choices in areas
Power & Equity sufficient self-determination
of insufficient self-determination.
in daily routines.

Assess if relationship is
Social Exchange & Create relationship balance
imbalanced with insufficient
by giving more positives and
Reciprocity positives and excessive
reducing unnecessary negatives.
negatives.

Use 'active listening' skills.

Communicate Empathy.
Demonstrate caring by putting
Empathy, Caring & Show Caring by responding to
the individual's needs before your
needs/wants.
Acceptance own.
Show Acceptance by
Include the individual in decision
respecting rights.
making.

Assess feelings towards the Disclose feelings, personal

Genuineness & individual and the degree of thoughts and information,
Openness sharing personal thoughts, while maintaining appropriate
feelings and experiences. professional boundaries.

Work through emotions with

Assess Emotions using target
active listening.
indicators.
Reading & Responding Problem solve by defining the
to Emotions Work through initial
problem, brainstorming, weighing
emotional expression, then
alternatives, and planning
facilitate problem solving.
implementation.

Identify Coercive behaviour. Don't 'give in' to coercion; re-

Avoiding Coercion direct by actively listening and
Avoid confrontation. problem solving.

Assess inconsistencies
Setting Limits Discuss specific rules and limits
between staff and between
with other staff; write them down
and Interpersonal various situations. Set limits,
to ensure consistency and review
Boundaries behavioural expectations and
follow-through.
rules.

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Power & Equity

Human beings have an innate desire to obtain as much power and control over their lives as
possible, striving for freedom, autonomy and independence. This highly adaptive instinct ensures
that we maximize our self-determination wherever we live.

Principle Strategy Technique

When freedom and control Identify the crucial Provide more

are repeatedly threatened, elements of the individual’s opportunities for him/
power inequities arise environment. her to make more choices
and conflicts ensue. regarding what he/she
While power inequities Assess whether the does and with whom.
are an inevitable individual has sufficient
element of human control over and access to Be flexible about the
interaction, continuous those elements. times and locations
power inequities breed If the individual does not where activities can take
discontent, frustration and have enough control, plan place.
anger. opportunities for the
individual to exert Identify what is hard or
Behavioural crises difficult for an individual
often result from the more control over their
environment by providing and identify ways for
expression of anger and them to move forward.
frustration with the power choices.
inequities in a individual’s
relationships.
Lack of choices can lead
to excessive behaviours or
lack of behaviour.

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Example:

Behavioural Problem:
Lisa is a 27-year-old woman with a moderate intellectual disability who lives in a group home
with three other individuals. Lisa has been in this home for two months. All residents in the house
are required to participate in a chore program which is scheduled and assigned by group home
staff. In the last 3 weeks, Lisa has begun to challenge staff about completing her chores. She has
refused to complete her chores on several occasions and, at times, has threatened to hit staff
when pushed on the issue.

Staff Response:
Staff have typically responded to this behaviour by redirecting Lisa to complete her chore or by
redirecting her to her room if/when she threatens others.

Assessment/Concept

Lisa’s behaviour was brought up at the following week’s staff meeting. Using the principle of
Power and Equity, staff discussed the chore program and acknowledged that Lisa (and the other
residents) had little to no choice on how the chore program was implemented.

Solution - Strategy/Technique:

Based on the strategies and techniques for Power and Equity the staff met with Lisa and
together came up with a chore program that would allow Lisa to choose a time frame for chore
completion. In addition, a rotating chore list was developed to ensure variety in the chores Lisa
had to complete. Lisa agreed to the new plan and immediately began to follow-through when
asked to complete her chore routine. Within one week of the change, the staff implemented the
new program for all residents in the home.

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Social Exchange & Reciprocity

Individuals are very sensitive to the number of positive and negative experiences they have with
other people.

Positive Reciprocity Negative Reciprocity

When we receive many positive When we receive a negative experience

experiences from someone, we are more from someone, we are more likely to
likely to respond or reciprocate with reciprocate with a negative experience.
another positive experience.
Example: If a staff member is forceful when
Example: If staff interact with an individual assisting an individual with dressing on
in a positive manner, the individual is one occasion, the individual may be more
motivated to return the positive experience motivated to return the negative experience
and may be more cooperative when doing by refusing to do a task when asked by the
an “unpreferred” or a less desirable task. same staff.

Positive and negative reciprocity are both examples of the methods we use to maintain a balance
between positive or negative experiences that we give to and receive from others - similar to a social
bank account.
This balancing process often operates at an unconscious level. We usually do not make conscious
calculations of the positives and negatives in each relationship; however, research indicates that
equality in positive and negative exchanges is well maintained in normal relationships.

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Social Exchange & Reciprocity

Principle Strategy Technique

Human beings are When dealing with an Review your relationship

motivated to maintain an individual who has had a balance with the individual
equal level of positive and behavioural crisis, do the and determine the following:
negative exchanges with following:
others - we give what we • Is the individual receiving
get. • Assess if the number enough positive
of positive exchanges experiences.
An individual in an with the individual
unbalanced negative have been adequate. • Is the individual receiving
relationship is likely to too many negative
display negative emotions • Review recent negative experiences.
such as frustration, exchanges that may
uncooperativeness and have motivated
the individual to If you decide the individual is
anger. You can also expect
behavioural crises to reciprocate negatively. receiving too many negative
develop. experiences, plan more
If you decide the positive experiences or
behavioural crisis occurred reduce unnecessary negative
as a form of negative ones.
reciprocity, do the
following:
• Plan more positive
experiences for the
individual.
• Reduce the
individual’s negative
experiences.

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Example:

Behavioural Problem:

Ted is an 18-year-old man with moderate Autism Spectrum Disorder. He attends an Educational
and Life Skills Day Program each day from 9:00am - 3:00pm. Each day as Ted gets off the bus at
the Day Program he is greeted by the Program Coordinator, Susan; at which point Susan directs
Ted to place his coat and lunch in his locker. Ted often responds by swearing at Susan and telling
her to shut-up.

Staff Response:

Susan will, at times, ignore the behaviour and re-direct Ted to his locker. When this is unsuccessful,
Ted is required to meet with a support staff prior to entering the Day Program.

Assessment/Concept:
Although Ted’s behaviour was not too extreme or disruptive, the staff were upset that he routinely
started his day in a negative mind-set. Considering the principle of Social Exchange and Reciprocity,
the staff team realized that Susan’s only interaction with Ted each day was when he first arrived.
Furthermore, the interaction only consisted of providing direction to place items in the locker.

Solution - Strategy/Technique:
Based on the strategies and techniques for Social Exchange and Reciprocity, the staff team and
Susan discussed Ted’s behaviour. It was agreed upon that Susan would find at least two other
opportunities throughout her day to interact with Ted during desired tasks and activities. It
was also decided that Susan would start each morning’s interaction at the bus with a positive
statement to Ted such as, “You look nice today”, or “It’s a beautiful day” prior to directing Ted to
his locker. Within one week, staff noticed a change in Ted’s behaviour. He began to swear less at
Susan upon arrival and appeared more content first thing in the morning.

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Empathy, Caring & Acceptance

Showing Empathy, Caring and Acceptance is important in preventing and managing crisis episodes.

Empathy Caring Acceptance

Communicating to Demonstrated by Occurs when an individual

someone else that accurately identifying the is respected and
you appreciate his/ individual’s needs, feelings welcomed, even though
her situation and inner and wants and responding current behaviour may
emotional experiences. promptly to them. be unacceptable to those
around them.

Principle Strategy

Communicating Empathy, Caring and When working with an individual who is

Acceptance is important for maintaining prone to episodes of behavioural crises, do
harmonious interpersonal relationships. the following:
The absence of emotional support can • Assess whether there are sufficient
create disharmony, discontent and signs of Empathy, Caring and Acceptance
interpersonal conflict (i.e. behavioural in the individual’s relationships.
crisis).
If these elements are lacking, do the
following:
• Review plans to increase these aspects
of the individual’s care.
• Provide training sessions to help staff
effectively communicate Empathy,
Caring and Acceptance.

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Two EMPATHY, CARING & ACCEPTANCE

Empathy, Caring & Acceptance

Actively listen when the individual attempts to Incorporate the following verbal and
communicate with you by doing the following: nonverbal cues:
1. Pay Attention • Make good eye contact.
Pay attention by looking at the individual and • Nod with understanding or agreement.
avoiding distractions. Listen intently to their • State the individual’s feelings by labelling
words and be aware of their non-verbal messages. them.
• Ask the individual to confirm your
2. Acknowledge understanding.
Acknowledge the individual’s feelings and repeat in • Ask the individual to tell you more.
your own words what you heard him/her say. • Wait until the individual has finished
3. Encourage talking before answering.
Encourage the individual to communicate more.
It is important, when using these strategies, that staff do not try to control the individual by providing
solutions to them or redirecting the conversation. Active listening shows Empathy, Caring and
Acceptance as the individual is encouraged to communicate more. Control strategies reduce the
chances that the individual will feel heard, validated and will want to contribute.

Caring Acceptance
Show you are responsive to an • Openly and honestly state what you
individual’s needs and wants by asking like about the individual.
the following:
• Respect his/her wishes, even though
• What do you need/want? they may represent an inconvenience.
• Do I correctly understand your need/
want? • Include the individual in decision
making, whenever possible.
• Can I provide for that need/want?
• When appropriate, clearly communicate
• What is the best way to address your
need/want? that a specific behaviour is unacceptable,
but that the individual is still accepted.
Note: A caring response includes
giving your time and attention at the
moment the individual’s need/want is
experienced. Delaying or waiting until
it is convenient for you to respond does
not demonstrate caring.
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Example:

Behavioural Problem:

Marcy is a 22-year-old individual living in a dual diagnosis residential facility. Marcy shares this
residence with 4 other individuals. During the evening, Marcy was on the phone to her parents. Staff
could notice that she was becoming upset. Eventually, Marcy started screaming and swearing on the
phone. She then threw the phone across the room.

Staff Response:

One of the staff members, Frank, immediately approached Marcy and told her that throwing the
phone was not appropriate; he then directed her to her room to calm down. Marcy escalated further
and began to scream and swear at Frank. When another staff member, Tim, entered the situation to
assist Frank, Marcy began to cry and ran up to her room.

Assessment/Concept:

Immediately following the incident, Frank and Tim briefly met to discuss what had just occurred.
Considering the principle of Empathy, Caring and Acceptance, Frank realized that redirecting Marcy
to her room after she threw the phone may not have conveyed empathy for her situation. Tim
respectfully suggested to Frank that trying to find out what was so upsetting about the phone call
may have been a better approach.

Solution - Strategy/Technique:

Based on the strategies and techniques for Empathy, Caring and Acceptance, Frank met with Marcy
after the phone incident and employed active listening skills. After paraphrasing what he heard Marcy
say and by encouraging her to talk more about her feelings, Frank was able to identify that Marcy was
upset because she had just been told that her parents were separating.
Frank agreed that the next time something similar occurred, he would ask to speak to Marcy in a
private area and would explore what may be causing the issue.

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Genuineness & Openness

Openness, Honesty and Self-disclosure are important elements in maintaining a positive relationship
with an individual, fostering closeness, friendly behaviour and camaraderie. Conflicts may develop
when these elements are absent.

Principle Strategy Technique

Openness, Honesty and Share appropriate feelings, If you have a conflict-ridden

Self-disclosure increase thoughts and information to: individual relationship with
the closeness of your • Improve the emotional frequent episodes of anger
relationships. bond you share with the and uncooperativeness,
individual. review the emotional
closeness of your
• Promote friendly behaviour
relationship.
and mutual caring.
• Decrease conflict and Consider the following:
emotional distance.
• How you feel about the
Assess the genuineness of individual.
your interactions with your
individuals. • How the individual feels
Is your non-verbal about you.
communication (body • Whether the individual
language, voice, tone, shares personal feelings,
volume, facial expressions) thoughts, and experiences
congruent with your verbal and whether you
message? reciprocate.
Important: When staff are
learning how and when to
share appropriate feelings, Note: The answers may
thoughts and information indicate too much or too
with an individual, ensure little closeness. Take the
that experienced care appropriate action.
providers supervise all
interactions.

Staff should be aware of professional boundaries when considering self-disclosure.

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Example:

Behavioural Problem:
David, a 17-year-old with a moderate developmental delay was admitted to a new day program.
As part of the admission process, David was asked several questions pertaining to his family, his
community, his medications and his behaviour. He was also asked to talk about his recent involvement
with the police. Although reluctant, David answered all the questions asked of him. Three days after
admission, David was working on a craft with his support staff, Mary. David asked Mary if she was
married and had any children. Mary immediately re-focused David on his craft and explained that his
question was inappropriate to ask. David became upset, stood up and told Mary that he didn’t want
to do the craft with her any longer.

Staff Response:

Mary responded by redirecting David to his “calming area”. David complied but after calming down
he would not continue working on his craft with Mary.

Assessment/Concept:
At the end of the day Mary met with her supervisor, Barb, to discuss the incident that occurred
with David. Mary and Barb discussed some possible reasons for why David had become so upset.
Considering the principle of Genuineness and Openness, Mary and Barb recognized that they had
asked David some very personal questions as part of the admission process. Mary hypothesized
that when she did not answer David’s personal question about her marriage and kids, it may have
inadvertently sent a message to David that she didn’t care enough about him to share this aspect of
her life.

Solution - Strategy/Technique:

Based on the strategies and techniques for Genuineness and Openness, Barb and Mary discussed
the importance of balancing professional boundaries with some self-disclosure. Barb helped Mary
realize that sharing some aspects of her personal life with David may help strengthen their rapport.
Barb assisted Mary to identify which aspects of her life could be comfortably shared with David
without jeopardizing professional boundaries. Mary began to use self-disclosure when appropriate
with David. David in turn responded favourably.

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Reading & Responding To Emotions

Misconception Functions of Emotions

One of the biggest misconceptions Emotions are highly adaptive, physical

about human emotions is that they are events that induce quick, adaptive action.
irrational.
Each emotion evolved biologically because
Very intense emotions can blind us it helped human beings adapt to certain
to certain facts about a situation and situations over time. All emotions are
prevent us from understanding other important in the management of human
points of view. Emotions can also play relationships.
a positive, helpful role in our daily
experiences.

The following table examines some basic emotions, their common indicators and their function.
Fear/Anxiety Anger Sadness Joy
• Tense body • Tense body • Tearfulness • Smiling
• Clenched jaw/fists • Clenched jaw/ • Crying • Energized body
• Scowling fists • Slumped • Laughing
• Tight facial • Intense eye shoulders/body • Quick
expression contact • Soft voice movements
• Averted gaze • Showing teeth • Verbal • Verbal
Indicators • Tears when talking expression of expression of
• Greater physical • Loud verbal euphoria,
disappointment,
distance  behaviour happiness
resignation,
• Shaky limbs • Less physical
hopelessness or
• Nausea distance
• Frequent • Waving arms regret
urination • Shakiness

• Alerts the body • Alerts the body • Alerts the •A

 lerts the body
that something to a threat or body that that something
dangerous or possible harm something of self-beneficial
harmful is going to • Motivates value has has occurred
happen reaction to been lost or •M
 otivates
Function • Mobilizes defend against, cannot be repetition of
reaction to flee, or attack, the attained instrumental
avoid or withdraw source of the • Motivates actions for
from the situation threat (e.g., reaction of further self-
defending rights) withdrawal benefit

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Reading & Responding to Emotions

Basic human emotions are highly evolved biological mechanisms that promote adaptive action. Each
emotion has an adaptive function and motivates an adaptive action, such as fear -> withdrawal,
anger -> self-defense, sadness -> accepting the unattainable, joy -> instrumental action. Several
principles, strategies and techniques are helpful in using emotions to effectively solve problems.

Strategy for Effective Problem Solving

Phase One Phase Two

Working Through Initial Emotions Facilitating Problem Solving

Ensure that the individual’s emotions are: • Guide and motivate to resolve the
emotion.
• Being heard and understood.
• Gently direct the individual through
• Not being questioned, challenged or problem solving.
judged.
• Help the individual identify the problem.
• Respected and that his/her feelings
are validated. • Brainstorm with the individual about
options that might solve the problem.
• Weigh the suitability of the options with
the individual.
• Develop a plan with the individual to
implement the solution.

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Techniques for Reading & Responding to Emotions

Phase One Phase Two

Allow the individual to express emotions Engage the individual in these four steps
naturally and adaptively. Instead of of problem solving:
interrupting the individual during this
process, which can make the individual 1. Identifying the problem
angry and intensify the problem, use 2. Brainstorming solutions
the active listening skills described in
the “Empathy, Caring and Acceptance” 3. Weighing options
portion of this section.
4. Implementing the plan
Active Listening involves these skills:
Phase Two techniques should only be
• Looking at the individual and listening implemented after the initial intense
carefully to the words they use. expression of emotion in Phase One is
clearly over. Any effort to prompt and
• Paraphrasing what has been said, with support rational problem solving too
special emphasis on emotions, early will only interrupt the individual’s
(e.g., “You felt put-down and emotional expression, resulting in anger.
embarrassed”).
• Encouraging complete communication
by prompting the individual to
communicate more. Ask questions
(e.g. “Can you tell me more about why
this situation was so embarrassing for
you?”).

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Example:

Behavioural Problem:

Staff member Tammy met Cathy at her bus drop off area at the end of the school day. Cathy exited
the bus appearing to be very angry and ignored Tammy’s presence. When Tammy attempted to
greet Cathy, Cathy proceeded to throw her backpack in Tammy’s direction and then ran towards
the residence screaming “I hate you, leave me alone”.

Staff Response:

Staff Tammy proceeded to follow Cathy into the residence and informed Cathy that she needed
to go back outside and pick up her backpack. Tammy also told Cathy that, after she retrieved her
backpack, she needed to apologize. Cathy started yelling “I’m not doing anything you tell me to
do” and then proceeded to move closer to Tammy in an intimidating and threatening manner.

Assessment/Concept:

Tammy realized that she needed to review the principles of Reading and Responding to Emotions
as Cathy started to display more aggressive behaviours and was becoming more angry.

Solution - Strategy/Technique:

Based on the strategies and techniques for Reading and Responding to Emotions, Tammy
proceeded to focus on Actively Listening to what Cathy was saying by paying closer attention
to her verbal and non-verbal communication, by acknowledging and validating what Cathy was
saying and lastly encouraging Cathy to continue to communicate through asking questions (Phase
One Techniques). As more information was received, Tammy and Cathy were able to identify
that Cathy was scared and sad because she learned that her teacher was leaving the classroom.
Tammy and Cathy were then able to use Reading and Responding (Phase Two Techniques) once
they were able to identify Cathy’s fear and sadness. They proceeded to brainstorm solutions,
weigh out the options and then implement a plan to support Cathy.

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Two AVOIDING COERCION

Avoiding Coercion

Coercion occurs when we threaten to punish or withdraw privileges from someone, unless that
person cooperates and does what we want them to do.

Coercion Coercive Interactions

You are being coerced when the following Coercive interactive cycles are personal
occurs: interactions in which coercion is involved
and both individual and staff receive
• A
 n individual begins unacceptable reinforcement for their behaviour.
behaviours in response to something
you have done that the individual does Example: A staff threatens to punish an
not like. individual or withdraw privileges when the
individual behaves unacceptably. When the
• The behaviour only terminates when individual stops their behaviour, it reinforces
you provide whatever it is the individual the staff’s threatening behaviour. As a result,
wants. threatening the individual may become a
When the above behaviour happens, habit.
negative reinforcement occurs (where Note: The individual may also receive
avoidance and escape behaviour are reinforcement of coercive aggressive
reinforced). behaviour in those situations where the
caregiver “gives in” to the “demands” of the
individual in order to stop the aggressing. This
too can become a habit. These interlocking
behaviours are called interactive cycles.

Coercive Interactive Cycles

During a behavioural crisis, it is not uncommon for staff to try and escalate their demands through
threats of punishment or the withdrawal of privileges. In the past, this approach has been
negatively reinforced by the cessation of inappropriate behaviours. However, because many
individuals often respond to threats with more intensely aggressive behaviour (this response has
also been strongly reinforced in the past), punishment/withdrawal strategies can quickly trigger a
coercive interactive cycle, leading to greater risk for both people.

One of the best ways to avoid becoming trapped in coercive interactive cycles is to use the
strategies and techniques described in the “Reading & Responding to Emotions” section.

Know and implement the policies and codes of conduct fairly and consistently.

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Two AVOIDING COERCION

Avoiding Coercion

The following are guidelines for dealing with coercion-based situations:

Principle Strategy Technique

People often unknowingly Be aware that an individual Below are the most useful
respond to behavioural may be engaging in coercive techniques for avoiding
crises with escalating
behaviour. interactive behaviour confrontation:
When either or both of the
This type of response can: following occur: • Ignore the behaviour

• Become part of a • His/her behaviour • Actively listen

coercive interactive escalates when
cycle.
confronted with • Problem solve
• Raise the risk of harm to something undesirable.
both the individual and Note:
the staff. • He/she only exhibits a These techniques can
willingness to stop if the be used in combination
situation is changed in to successfully redirect
Attack his/her favour. escalating behaviour toward
a more successful outcome.
In order to break the cycle,
Defend Defend
actively avoid confrontation.

Counter
Attack

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 SECTION Relationship Management
Two AVOIDING COERCION

Example:
Behavioural Problem:

While driving in the program vehicle, Glen becomes escalated if he is unable to sit in the front
seat area. If this request is denied or another resident is in this seat, Glen will often refuse to get
in the van and will begin screaming. Due to the safety of Glen within the community, and the
other residents becoming frustrated, staff have allowed him to access the seat in order to return
him and the others home safely.

Staff Response:

Typically, when Glen does not respond to staff’s direction to sit in the back seat of the van, they
become increasingly frustrated and annoyed by Glen’s behaviour and inform him that he will lose
all community outing privileges with the group. When this occurs, Glen proceeds to threaten that
he will run away if outings are taken away from him. Knowing the increased risk of Glen in the
community on his own, staff often withdraw and allow Glen to sit in the front seat.

Assessment/Concept:
Reviewing the principle of Avoiding Coercion the staff team reviewed the situation and recognized
that Glen has learned that staff will give in to his request if he threatens elopement, thus increasing
safety concerns. Staff also began to identify that Glen would comply with their request to get in
the van if they did not follow through with an identified consequence. A Coercive Interactive
Cycle had been developed.

Solution - Strategy/Technique:
Based on the strategies and techniques of Avoiding Coercion, staff reviewed ways to be
preventative and plan community outings with Glen, including reviewing the expectations
with him prior to the activity. When doing this, staff will focus on using Active Listening Skills
(Phase One - Pay Attention, Acknowledge and Encourage) to identify what is contributing to his
behaviours and then staff will support him through the Problem Solving (Phase Two - Define the
Problem, Brainstorm, Weigh Options and Implement Plan).
Staff also reviewed their role within the Coercive Interactive Cycle and identified that they
needed to ignore Glen’s undesirable behaviours versus becoming frustrated and reactive; which
has resulted in contributing to the cycle. They will stay calm and use the same techniques as
identified above in Phase One and Phase Two.
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 SECTION Relationship Management
Two INTERPERSONAL BOUNDARIES

Setting Limits & Interpersonal Boundaries

Some individuals will engage in escalating aggressive behaviour in order to determine the limits of a
staff’s tolerance.

Principle Strategy

Teach individuals the boundaries of When managing behavioural crises, it is

acceptable behaviour and help them important to ensure the following:
effectively access needed or wanted
objects and activities. • Set consistent limits regarding what is
considered acceptable social behaviour.
At all times, provide a consistent
response: • Set the degree of acceptable freedom
around certain objects and activities.
1. In different situations. • Establish greater consistency in how all
2. From all staff on the same issue. staff implement the established limits.

Techniques

• Review your own unstated rules about behaviour and be aware that you are using some type
of rule.
• Write down the rules you think you are using and communicate them to the individual.
• Frequently and regularly review and communicate with other staff about their rules
surrounding different daily situations.

• Negotiate and compromise with other staff on less important rules to ensure all staff are
following the same rules.

• Record staff rules and have everyone read and sign them to ensure awareness and
consensus.
• Do not accept that a staff’s description of the rules is actually how the rules are being
applied. Instead, arrange for staff to observe each other in selected situations, so staff can
see if the stated rules are being practiced.
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Two INTERPERSONAL BOUNDARIES

Example:

Behavioural Problem:
Staff member, Tom, supports Steven every other weekend and when Steven is asked to do his
chore at the scheduled time of 10:00am, he starts yelling threats at Tom while also stating “you’re
the only one that makes me do it.” He also attempts to leave the residence and damages property
by throwing items. As part of Steven’s care plan, his Behaviour Therapist has identified that staff
need to be consistent with Steven’s programming schedule; therefore, Tom continues to request
the chore be completed at the scheduled time, resulting in ongoing incidents of aggression.

Staff Response:
Tom reviewed case notes from other weekends and found that staff at times either negotiate
or allow Steven to refuse doing his chores on the weekend. During a team meeting Tom asked
the other support staff why this happens, and they responded by stating “since it’s the weekend
sometimes it’s easier if we let him pick when he wants to do it”.

Assessment/Concept:
Reviewing the principle of Setting Limits and Interpersonal Boundaries the team reviewed
how staff’s inconsistent approach to following Steven’s programming schedule is resulting in his
aggressive behaviours and an increase of incidents involving specific staff members.

Solution - Strategy/Technique:

The team reviewed the strategies and techniques of Setting Limits and Interpersonal Boundaries
and identified that their inconsistent approach was contributing to Steven’s behaviours. The
Behaviour Therapist reviewed the care plan and why staff consistency was needed to best support
Steven. Staff identified that they needed to review the expectations once again with Steven so
that he understood his chore schedule was the same on the weekend. At first Steven had a
difficult time when all staff followed his program, but as staff remained consistent he adapted
well.

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BEHAVIOUR MANAGEMENT
Section Three

There are many important questions to answer when planning preventively. This section provides
a worksheet, with a systematic set of questions and issues to address, to help with planning, e.g.,
knowing how the individual learns best, how the individual uniquely communicates his/her wants and
needs and how the individual expresses his/her aggressive behaviour in response to specific triggers.
Knowing early warning signs of frustration and agitation and developing specific intervention strategies
are critical elements.

At the end of this section participants should be able to:

1. Identify and understand the importance of the essential elements or pre-requisites of a nurturing
supportive environment/milieu.

2. Understand behaviour from the Antecedent, Behaviour and Consequence, the (ABC) perspective.

3. Demonstrate a working knowledge of the various Functions of Behaviour.

4. Develop a Behaviour Profile for an individual.

5. Develop a Behaviour Plan based on an individual’s functions of behaviour and behaviour profile.

6. Identify and apply anger management strategies to help individual’s cope with anger and frustration.

BEHAVIOUR MANAGEMENT Page

Environmental Planning 50
Functions of Behaviour 51
Anger Management Skills 53
Developing Plans 54
Developing a Behavioural Profile 55

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Three ENVIRONMENTAL PLANNING

Environmental Planning
Individual welfare can be improved with the help of medical and psychiatric assessments and
treatment. You should also develop a written plan to help prevent predictable and recurring incidents
of violence/aggression. Consider the three pre-requisites for programming discussed in the MCSS
“Standards for Behavioural Programming for Facilities for the Developmentally Handicapped” (1986),
Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities
Act, 2008, and Ontario Regulation 299/10 - Quality Assurance Measures.

Environmental Prerequisites for Programming

Development of Alternative
Functional Activity Attention
Behaviour
Remember: Remember: Remember:
Aggressive behaviours are Friendly, reinforcing Demonstrations of appropriate
reduced when boredom communication helps prevent behaviour, such as positive
and under-stimulation are loneliness, social isolation, interactions with others and
minimized. withdrawal and attention complying with staff requests,
seeking behaviour. need to be reinforced.

Therefore, ensure individuals Therefore, ensure individuals Therefore, ensure individuals

have meaningful functional receive adequate levels are taught how to access
activities and leisure activities of positive reinforcement meaningful, social and material
that are scheduled and through social interaction with reinforcement from their
planned. other individuals and staff. environment (e.g., how to
turn on the television, listen to
music, talk to other individuals/
staff, or travel to the park).
If such skills are difficult to
learn or would take too long,
ensure the individual receives
adequate reinforcement for
engaging in activities that
involve positive interactions
with others.

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Three FUNCTIONS OF BEHAVIOUR

Functions of Behaviour
By examining the specific functions or underlying meaning of an individual’s behaviour, you will learn
how to avoid negative behaviour and encourage more appropriate social behaviour.
Most recurring behavioural outbursts fit a pattern.

Observe and Assess all inappropriate and aggressive behaviour in order to understand possible
functions of behavioural outbursts.

Develop plans relating to the functions that specific behaviours serve for the individual.

A particular behaviour may serve common functions such as:

• Establishing and maintaining social interaction with another person.

• Avoiding or escaping tasks or activities that the individual dislikes.

• Obtaining special stimulation (e.g., going for a walk, listening to music).

• Communicating to others about something the individual desires or wants.

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Three FUNCTIONS OF BEHAVIOUR

Functions of Behaviour
Antecedent Behaviour Consequence Function

An individual is The individual starts One staff says it’s ok Escape

watching TV when he to cry and stomp his to miss dinner. The
is asked to come for feet. crying stops and the
dinner. individual continues
watching TV.

George is sitting at a For no apparent The staff ask him to Sensory

computer. reason he starts stop but he doesn’t.
rocking.

Mike’s roommate had Mike said he was not His roommate got Tangible/Escape
prepared dinner. “eating that stuff.” angry. Staff said Mike
could make his own
dinner.

Sue is in her bed Staff try giving her an Sue says she is feeling Attention
moaning about antacid to calm her better and refuses to
stomach pains. stomach. It seems to go.
work while they stay
with her, but gets
worse when they try
to leave her to rest.
Staff inform her they
will have to take her
to the doctor.

While on a Staff physically escort Rachel eventually Sensory/Escape/

community outing, her to the van where calms down but Attention
Rachel starts to cover they close the door refuses to join the
her ears and shriek. and sit with her rest of the group
trying to verbally again.
de-escalate her.

An antecedent is an event that regularly precedes (triggers) a target behaviour.

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Three ANGER MANAGEMENT SKILLS

Anger Management Skills

Individuals with frequent aggressive behaviours often have deficits in emotional self-control.
Depending on the cognitive function of the individual, teaching the following skills might be
considered when developing a comprehensive behaviour plan (see Goldstein, Glick, Gibbs, 1986
for these and other ideas):
• Knowing one’s own unique physical and behavioural signs of impending anger.
• Using physical relaxation and deep breathing techniques to control physiological components of
anger.
• Using positive self-calming talk when upset.
• Focusing on pleasant imagery and positive visualization when trying to calm down.
• Thinking about short and long-term consequences of aggression.
• Looking at the situation in objective terms, from other’s point of view.
• Taking a “time-out” from the situation until calm.
• Verbally negotiating with others when in conflict (“talking the problem out”).
• Double-checking the validity of angry thoughts and beliefs about others.

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Three DEVELOPING PLANS

Developing Plans
Develop program plans based on information from the functional analysis of an individual’s behavioural
pattern. You should match a plan to each function served by specific behaviours.

Positive and Preventative Methods

Try to develop positive and preventative ways of dealing with the functions of inappropriate
behaviours.

Consider the functions you have identified and attempt to accomplish the following:

• P
 rovide structured attention and social stimulation to the individual on a regular basis, even
if it is for a short period of time.
• Minimize the individual’s frustration while doing required tasks.
• Choose tasks/activities the individual enjoys and minimize disliked tasks/activities.
• Structure the environment so desired leisure activities are more readily available.
• Teach more adaptive ways of expressing negative emotions.
•U
 se augmentative communication techniques or explicit instruction to better communicate
requests.

Augmentative Communication Methods

Balanced plans should include teaching the use of alternative or augmented methods of
communication. Here are some examples:
• Picture exchange training.
• Talking machines.
• Picture schedules of daily activities.
•P  hotos of daily special events in which individual participated (review photos for
orientation).
• Sign language.
• Idiosyncratic functional signing.
• Functional object pointing.
• Symbolic communication and conceptualization.
• Picture symbols.
•  T he development of individual communication profiles and developmental wants and needs
(include verbal expression of such wants and needs).
• Any combination of the above.

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Three DEVELOPING A PROFILE

Developing a Behaviour Profile

A Behaviour Profile is a biographical essay presenting an individual’s most noteworthy
characteristics.

Develop a profile when supporting an individual who is:

• New to your organization, has a history of aggressive behaviour and shows a recent High-Risk
behaviour pattern. (This alerts staff to use the appropriate De-Escalation strategies, should the
individual demonstrate aggressive/violent behaviour in the new setting).
• Currently with your organization and is not currently aggressive/violent, but has an aggressive/
violent history.
• Regularly aggressive/violent and/or has poor anger management and communication skills.
Include:
• Concise information about the individual’s unique behavioural patterns.

• Antecedents/triggers to inappropriate behaviours.

• Strategies and intervention techniques to manage behaviours that are escalating towards
being aggressive.

Update After:
• The first incident of physical aggression or self-injurious behaviour.

• Each subsequent incident, if necessary. Include new information, including any strategy changes
required and increase in frequency or intensity of behaviour.

Share:
• Updated profile information with all other staff who deal with the individual.

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Three DEVELOPING A PROFILE

Developing a Behavioural Profile

The following worksheets provide an outline for developing a Behavioural Profile.
The staff most familiar with the individual (sometimes more than one staff) should complete the
following pages. Be as operational as possible in your descriptions.
Familiarity Index:
1. I have some idea about the individual’s behavioural patterns, but am not sure of my accuracy.
2. I am quite familiar with the individual’s behavioural patterns in some situations.
3. I am extremely familiar with the individual’s behavioural patterns in most situations.
4. I know the individual’s behavioural patterns in all situations.

Name of Person(s) Completing Form Familiarity Index

Circle appropriate familiarity index 1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

Creating a Behavioural Profile

1. How does the individual best learn?
• Establish personalized teaching
strategies for the individual.
• Identify opportunities for choice-
making and power-sharing.

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Three DEVELOPING A PROFILE

2. How does the individual best Remember: Data should be collected

communicate?
• Establish personalized communication
strategies for the individual.
• When in doubt, request an assessment
or consultation with a speech
pathologist who can clarify the
interactions between the individual’s
communication and behaviour.
• It is important to understand the
relationship between the individual’s
style of communication and
corresponding aggressive episodes.

3. What aggressive/violent/excessive
behaviours, does the individual exhibit?
• Identify all problematic behaviours and
categorize them as:
• Common Occurrence
• Sporadic Occurrence (occasional)
•W
 hen documenting behaviours of
serious concern that rarely occur,
describe them as “highly infrequent”
or “reported in the past” but not seen.

4. What are the typical antecedents An antecedent is an event or set of

(triggers) for the individual? circumstances that immediately precedes
(triggers) the behaviour.
• Identify the antecedents and alter
them, if possible, to reduce the
likelihood of the individual having a
similar aggressive episode.
•W
 atch for environmental factors that
you can also alter.

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Three DEVELOPING A PROFILE

5. What are the early warning signs

indicating that the individual’s
behaviour is escalating?
• Identify the initial behaviours that
may signal something is wrong.
• Use the Aggression Escalation
Continuum (described later).
Early warning signs may include:
• Increased movement, demands and/
or verbalizations.
• Decreased interaction with others
(withdrawal).

6. Describe current De-Escalation

strategies.

• Identify initial De-Escalation strategies

for calming the individual.
• Verbal De-Escalation strategies
should be attempted prior to physical
intervention strategies.

7. Which behaviours can be monitored

from a safe distance?
Consider requirements and
prerequisites such as:
• Throwing soft objects.
• E nvironmental destruction such as
punching walls, overturning furniture.
•O
 ther venting types of behaviour.
Consider when these behaviours may
require intervention.

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8. Which behaviours require physical

intervention?
List all behaviours that result in imminent
or actual physical harm to the individual
or others.

• Different types of strikes.

• Different types of kicks.

• Different topographies of strikes.

9. Describe the interventions. Remember: Data should be collected

Outline all intervention strategies that
have been approved for staff to use with
the individual during a behavioural crisis.
This outline should include:

• Which strategies have worked

successfully with the individual in the
past.
• The roles of various team members when
intervention is required.

10. D
 escribe the minimum monitoring
requirements for staff.
Consider requirements and
prerequisites such as:
• Time.
• Skills required, such as physical
intervention skills, clinical skills,
awareness of physical abilities.
• Minimum program monitoring
pre-requisites and review.

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 NOTES

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AGGRESSION MANAGEMENT
Section Four

Aggression usually does not just happen suddenly and without warning. Aggression often occurs
over time and through different phases. This section of the program describes how to assess this
development in terms of four phases (subtle changes, escalating, imminent, and physical aggression)
in three response domains (verbal, physiological, and gross motor) and how to incorporate the
findings into an understandable “Escalation Continuum.”

At the end of this section participants should be able to:

1. Demonstrate a working knowledge of the phases of aggression and appropriate staff responses.

2. Apply Behaviour Profile information to the Aggression Continuum.

3. Relate the importance of effective team work and communication to De-Escalation and Crisis
Management.

4. Understand the elements and importance of Debriefing following crisis episodes.

5. Identify and demonstrate knowledge of Verbal De-Escalation strategies and when physical
intervention is required.

6. Identify when external supports, such as police should be accessed.

AGGRESSION MANAGEMENT PAGE

Aggression Escalation Continuum 62
Individual Behaviour - Escalation Continuum 63
Staff Response - Escalation Continuum 64
Individual Behaviour Exercise - Escalation Continuum 65
Staff Response Exercise - Escalation Continuum 66
Developing a Crisis Intervention Team 67
Debriefing 68
When to Physically Intervene 71
Responding to Weapons 74
De-Escalation Checklist 76

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Four AGGRESSION ESCALATION CONTINUUM

Behaviour
• Hitting/Kicking
• Scratching/choking
• Use of objects as weapons
Behaviour • Pulling hair, biting and
other physical
• Speaks explosively, swears and aggressions
CLIENT BEHAVIOUR uses obscenities
• Intense physiological signs,
(i.e. very red face, fast and heavy
breathing)
• Accompanies verbal with
threatening gestures,
(i.e. pretending to throw objects
and/or hitting people)
• Moves towards staff with
visibly higher agitation
PHYSICAL
AGGRESSION
Behaviour
• Increase in questioning of staff
• Verbal retorts/challenging of staff
• Increase in rate or volume
of speech
• Resistance to instruction
IMMINENT
• Physical tension

Response
• Do not physically intervene if no
immediate danger
• Employ active listening skills
and problem solving
de-escalation strategies
Behaviour
ESCALATING Response
• If part of a coercive cycle, state
known contingencies
• Change in social interaction style • If client is aggressive use
• Manner of speaking • Remove others from immediate
release methods
• Language used area
• Remove client from the area
• Energy level change • Alert other staff to the situation
• Monitor situation, but do not
• Allow client to vent, listen for
intervene
clues to identify the underlying
primary emotions
• Avoid making counter threats
• Remind them of previously
agreed-upon contingencies
Response
SUBTLE • Assume protective position
• Ensure client has a clear
exit route
• Direct client to a private area
(free of distractions but
not isolation)
• Communicate in a
non-confrontational manner
• Implement de-escalation
strategies
Response
• Employ active listening skills
• Review the behaviour profile,
alter any antecedents STAFF RESPONSE
• Stay out of client’s personal
space
• Ensure there is a clear exit route
• Utilize problem solving skills
• Indicate you are available to
discuss any problems

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Four INDIVIDUAL ESCALATION CONTINUUM

STAGE INDIVIDUAL BEHAVIOUR

Social interaction style
Verbal Manner of speaking
Language used

SUBTLE Change in energy level

Physiological
Regular behavioural patterns show change

Lethargic or manic actions (mood change)

Gross Motor
Increased pacing or limb movements

Increased questioning
Verbal Verbal challenges
Change in rate, volume and tone of voice

Physical tension
ESCALATING Physiological Faster breathing
Flushing of face or neck areas

Jerky movements (observable agitation)

Gross Motor
General increase (or decrease) of movements

Language directed towards staff

Verbal
Threats or warning of harm

Extremely fast or heavy breathing

Physiological
IMMINENT Very red face and neck area

Moves towards staff

Gross Motor Threatening gestures (showing fist, pretending to
throw).

Verbal All verbal behaviour accompanying aggression

Similar to imminent signs, possibly more

PHYSICAL Physiological
AGGRESSION intense

Kicking, slapping, throwing items, scratching.

Gross Motor Note: Describe the aggression (i.e. slaps with open
hands, strikes with up and down motion).

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Four STAFF RESPONSE CONTINUUM

STAGE STAFF RESPONSE

Note changes in behaviour

Verbal Identify triggers/problems
Problem solve with individual if possible

Deep breathing
SUBTLE Physiological Remain calm
Present “open stance”
Stay out of individual’s personal space
Ensure that there is a clear exit route
Gross Motor Have individual problem solve if able; otherwise, staff
may need to assist
Implement known De-Escalation strategy
Verbal Non-confrontational communication
Active listening for emotional indicators

Deep breathing
ESCALATING Physiological Remain calm
Provide eye contact

Assume protective position out of individuals’ space

Gross Motor Ensure that there is a clear exit route
Direct individual to private area (not isolated)

Alert others in area, allow individual to vent

Verbal State boundaries in positive manner, actively listening
Do not threaten, remind of agreed-upon contingencies

Deep breathing and remain calm

IMMINENT Wait for pauses in individual’s behaviour to problem
Physiological solve
Present in a supportive manner

Assume protective position out of individual’s space

Gross Motor Remove others from area and clear exit routes

Alert others in area, allow individual to vent

Verbal Prompt for required back-up
Wait for lulls in individual’s behaviour to problem solve

PHYSICAL Physiological Deep breathing and remain calm

AGGRESSION Assume protective position out of individual’s space

Clear others from immediate area

Gross Motor Remember to use an approved physical intervention
only if the behaviours present imminent danger
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Four INDIVIDUAL BEHAVIOUR EXERCISE

STAGE INDIVIDUAL BEHAVIOUR

Verbal

SUBTLE Physiological

Gross Motor

Verbal

ESCALATING Physiological

Gross Motor

Verbal

IMMINENT Physiological

Gross Motor

Verbal

PHYSICAL Physiological
AGGRESSION

Gross Motor

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Four STAFF RESPONSE EXERCISE

STAGE STAFF RESPONSE

Verbal

SUBTLE Physiological

Gross Motor

Verbal

ESCALATING Physiological

Gross Motor

Verbal

IMMINENT Physiological

Gross Motor

Verbal

PHYSICAL Physiological
AGGRESSION

Gross Motor

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Four INTERVENTION TEAM

Developing an Effective Crisis Intervention Team

This process is not something you can choose to switch on and off as the need dictates. Safety is
at stake when you intervene with an individual who is engaged in aggressive behaviour. In these
situations, team members must have:

1. Trust in one another;

2. Confidence in the skill levels of the other team members;
3. The same expectations;
4. Regular practice sessions; and
5. Knowledge of each team member’s strengths, skills, and triggers.

Communication Prerequisites:
Your team must consistently implement mutually agreed-upon communication procedures before,
during and after behavioural incidents.

Always remain focused on understanding what others are saying to you and
making yourself understood.
It is important to discuss the following:
Before • Common expectations
• Individual’s needs
• Prevention strategies
• Intervention plans: non-alarming code words
• Team leader and support member roles

Identify the team leader according to pre-established criteria.

Determine specific code words or gestures to determine when to:

During • Approach and/or begin intervention

• Abort a procedure during a physical intervention
• Request assistance

Check on each other’s physical and emotional well-being

After Decide who will check on the individual’s physical and emotional well-being
Implement the debriefing process

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Four DEBRIEFING

Debriefing
Debriefing with individual(s) and staff should occur following a behavioural crisis or episode. Individual
debriefing should be done once the individual is calm and able to engage in the process. The process
should be seen as an opportunity to listen and reflect on the incident with the individual.
Debriefing should not involve lengthy dialogue sessions, but rather focus on providing individuals,
staff and management with support and functional information.
Debriefing enables team members to:

 eview how they’ve been coping since the incident occurred.

1. R

2. Vent and share feelings about their involvement in the incident.

3. Identify strategies the team used and determine which worked well and/or need to be revised.

4. Identify any system issues that might assist the team in working more smoothly together.

When debriefing with staff, Safe Management recommends that stages of Coping and Venting
Feelings be discussed first and at a separate time from Identifying Strategies and System Issues.
It is important that staff have an opportunity to vent their feelings and share how the incident
impacted them emotionally. Trying to problem-solve ineffective strategies and system concerns too
soon can sometimes feel like criticism or blame.

Although every Ministry and agency/organization has their own specific Polices and Procedures
regarding debriefing after an aggressive episode, the following debriefing questions/objectives are
offered as possible guidelines:

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Four DEBRIEFING

Debriefing for Staff

DEBRIEFING QUESTIONS OBJECTIVE
What support would be most Identify what level of support staff require immediately as well
helpful for you at this as several days following the incident.
moment? What about one
week from now?

Is there someone in particular Identify with whom the staff person feels comfortable
you’d like to talk to about the debriefing. It may be a supervisor, a colleague or an agency
incident? Trainer.

What was the impact of the Identify the degree to which the staff was affected by the
incident on you? incident.

What was the impact of the Obtain the staff person’s perception on how well the team is
incident on your co-workers? coping with the situation.

Is there anything that can be Determine what, if anything could be changed to prevent
learned as a result of this similar situations from occurring again.
incident?

Can you describe the situation Allows the staff to explain the situation without blame or
from your perspective? assumptions.

What did you do well in when Identify what actions and strategies were effective at
managing the situation? de-escalating or managing the situation.

If you could snap your fingers

and start this shift over again, Identify, without blame what, if any, factors contributed to the
is there anything you would situation.
adjust or modify about the day
(routines, actions, decisions)?

How do you feel about working Assess the staff’s state of mind and ability to function
your upcoming shifts? productively and effectively at work over the next few shifts.

What do you think the team Determine next steps to ensure the team is healthy and
needs at this point in time? functioning as a cohesive unit.

When is a good time for me to Allows the staff the opportunity to receive additional
check-in with you again? check-ins and support as required.

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 SECTION Aggression Management
Four DEBRIEFING

Debriefing for Individual

DEBRIEFING QUESTIONS OBJECTIVE

Were you injured as a result of Provide an opportunity for the individual to identify any
the incident? If so, do you require injuries and the emotional aspects of their injury. Staff
medical attention? Describe your should support and encourage the individual to talk about
experience of the situation. their experience.

What did you do well in when Have the individual identify what they feel they did well in
managing the situation? What managing the situation, what strategies were effective, and
strategies worked? what helped them calm down.

What could you have done to Have the individual identify areas where they could improve
better manage the situation? in their responses to the situation.

Have the individual identify areas where he/she felt that

Is there anything that your the staff team could have responded differently and would
support team could have done have been more successful in assisting the individual in de-
differently? escalating.

What did your support team do Have the individual identify what strategies the staffing
that was helpful? team used that he/she found helpful.

Was there anything that you feel Have the individual identify any environmental conditions/
made the situation worse? antecedents that further escalated the situation.

Were physical interventions Have the individual identify the reasons why physical
required? If yes, why? interventions were used.

How can physical interventions be Assist the individual in exploring strategies that could have
avoided? been used to prevent the use of physical interventions.

What would you do differently Facilitate problem solving by having the individual consider
in the future if a similar incident alternative strategies and responses to similar situations in
were to occur? the future.

Discuss the individual’s intervention plan and determine

if changes need to be made in the individual’s plan.
Do you feel changes in your Encourage the individual to take an active role in reviewing
support plan need to be made? their current intervention plan and discuss areas for
change/revision.

Support the individual in reviewing and determining

Do you need any additional whether he/she feels they require additional supports
services/supports? or services, e.g., counselling, anger management, social
supports. Provide resources and information to the
individual based on identified needs.
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 SECTION Aggression Management
Four WHEN TO PHYSICALLY INTERVENE

When to Physically Intervene

NEVER
Rush into a situation.

ALWAYS
Walk in calmly and slowly while evaluating the situation to determine what role you should assume.

When arriving on scene, consider the following:

Has someone assumed the crisis leadership role?

Is the staff in the leadership role in control emotionally and physically?

If not, who is the best person to assume this role?

Have support staff been called?

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Four WHEN TO PHYSICALLY INTERVENE

When to Physically Intervene

Does 911 need to be called?

Has injury occurred to anyone involved? If so, is medical attention required?

Are others in the area at risk. Can they be moved out of harms way and
monitored?

Can the individual involved in the crisis be monitored from a safe distance?

Are too many staff escalating or overwhelming the individual?

Are there properly trained staff available and ready to assist?

Are there weapons, or any items that could be used as potential weapons in
the immediate area? If so, can they be safely removed?

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Four WHEN TO PHYSICALLY INTERVENE

When to Physically Intervene

Once you have acquired self-protection skills, you need to learn WHEN to use physical intervention
and WHEN to refrain from using it.

Always refer to an Individual’s Behavioural Profile.

Ask Yourself:

• Does the situation or the individual’s behaviour meet the threshold of Imminent Risk of Harm
to Self or Others?
• Can I monitor the individual’s behaviour from a safe distance?
• Can I, or have I, given the individual adequate time to calm down on their own?
• Can I, or have I, allowed the individual to vent; have I actively listened to their concerns?
• Have I considered the 7 Relationship Management principles and have I tried to correct any
imbalances?
• Have I attempted any verbal de-escalation strategies?
• Is there another staff available that has a better rapport with the individual?
• Am I calm?
• Am I letting my emotions negatively influence my actions?

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 SECTION Aggression Management
Four RESPONDING TO WEAPONS

Responding to Weapons
Dealing with crisis can be challenging, unpredictable and anxiety producing. One of the most
volatile and stressful situations staff can experience is an aggressive individual with a weapon. Safe
Management Group DOES NOT RECOMMEND that staff intervene physically in an attempt to remove
a weapon from an aggressive individual. Safe Management does not endorse, promote or train the
use of physical interventions when weapons are involved. Most importantly, the risk of injury to staff,
the individual and others is far too great.
In all cases where weapons are involved, the use of Police intervention is encouraged. The Police
have a different mandate and specialized skills and tools to deal with weapon use.
Where possible, staff should utilize the RESPOND acronym until police arrive.

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Four RESPONDING TO WEAPONS

Weapons “RESPOND” Approach

Power & Equity - Respect the person and the severity of the
situation – At this moment, the aggressive individual has
the power. They need to know that they are in control and
you are only there to help.
Empathy Caring and Acceptance – Actively listen to the
individual’s needs. P.A.E. (Pay Attention, Acknowledge,
Encourage).
Genuineness and Openness – Ensure your words and non-
verbal messages are communicating a genuine sense of
wanting to help.
Relationship Management Responding to Emotions – Assess and gauge the intent
behind the action. Is the weapon a fear-based response? Is
there real intent to harm others? What does the individual
need or want? Can you meet those needs?

Call 911. Clearly state that a weapon is involved. This

will assist dispatch in assigning a higher level code to the
Emergency Response
situation and will influence the Police response. Initiate
internal crisis response protocol.

Your calm approach will influence the aggressive individual.

Stay Calm Speak softly and slowly. Focus on diaphragmatic breathing.

Assume Protective Position and increase the distance

between you and the aggressive individual. If possible,
close doors and contain the individual in a room or area that
Protective Position allows for observation.
Manage others in the vicinity. Staff, individuals, family
members, etc. may exacerbate the situation. If necessary,
remove others. Too many staff may threaten the aggressive
Others individual and lead to the weapon being used. Other
individuals may encourage weapon use or may be fearful,
which only adds to the intensity of the situation.
Keep the individual focused on you. Ask questions like, “How
can I help?” or “What do you need?” Answer “yes” to as
Negotiate many questions from the aggressive individual as you can.
The more “yes” answers, the more probability the person
will De-Escalate.
Attempting to physically intervene when a weapon is
involved puts you, others and the individual at risk of severe
Do Not Physically Intervene injury.
r
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 SECTION Aggression Management
Four DE-ESCALATION CHECKLIST

De-Escalation Checklist
A. GENERAL BEHAVIOUR
□ Do not crowd the individual
□ Be aware of environment (noise level, location of others, escape routes, etc.)
□ Be aware of Aggression Escalation Continuum and use it effectively
□ Determine objectives to be achieved during discussion
□ Maintain eye contact, when appropriate
□ Be firm and assertive, as required
□ Implement follow-up, as discussed with individual

B. CALMING BEHAVIOURS
□ Use simple words
□ Voice is soft, slow and clear
□ Face and body are relaxed
□ Ask brief, open-ended questions
□ Listen carefully to what the individual is saying (aphasia can lead to misunderstanding)
□ Report (paraphrase) what you hear the individual is saying
□ Concentrate on one issue/topic
□ Allow the individual to finish what he/she is saying
□ Identify/clarify the individual’s feelings
□ Use silence appropriately - allows the individual to initiate - elderly people will take longer
□ When appropriate, use distraction to focus the individual’s attention on another task (drinking
water, breathing exercises, washing face, etc.)
□ Summarize/clarify your understanding of the individual’s perception of the problem
□ End discussion when De-Escalation has occurred (not necessarily when problem is actually
solved). Problem solving can occur at another time when the individual is calmer

C. DEFUSING BEHAVIOURS - Use all of the general and calming behaviours listed above, as well
as the following:
□ Reinforce signs of De-Escalation (energy drops, breathing slows down)
□ Work as a team, if other staff are available
□ Leader gives clear directions to team members
□ Let the individual know that others are there to assist him/her, not to confront
□ Give the individual more space if needed
□ Use concrete words
□ Encourage the individual to engage in alternate behaviour
□ Remind the individual of consequences by stating facts, not threats
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PHYSICAL INTERVENTION CONCEPTS
Section Five

This section provides preliminary information relevant to learning the Safe Management Group’s
Physical Intervention Techniques. We review MCCSS requirements for training and implementing
emergency physical interventions. These requirements offer a set of quality control guidelines that
should be considered in all settings.

At the end of this section participants should be able to:

1. Understand Safe Management’s teaching approach.

2. Understand how physical intervention, based on biomechanical technology, is integrated into

Safe Management Group’s curriculum.

3. Identify methods of guaranteeing safety for individuals learning and practicing Safe
Management Group’s Physical Intervention Techniques.

4. Have a strong knowledge and concrete implementation of self-protection and physical

containment techniques.

PHYSICAL INTERVENTION CONCEPTS PAGE

Teaching Approach 78
Safety for Individual 79
Safety for Participants 80
Positional Asphyxia 81
Protective Positions 82
Strikes 83
Wrist Grabs 84
Clothing Grabs 86
Hair Pulls 87
Chokes 89
Bites and Kicks 90
Escorts/Containments 91
Alternative Techniques 93

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 SECTION Physical Intervention Concepts
Five TEACHING APPROACH

Safe Management’s Teaching Approach

Our approach in teaching advanced physical All manuals use a patented method of integrating
intervention methods, such as physical restraints, text with photographs. This approach is illustrated
focuses on safety in training and safety in in our Instructor/Advanced manual, in the section
implementation. To this extent, different titled “Physical Techniques”.
quality assurance tools have been developed
to help agencies maintain a high level of Risk These pages illustrate the basic escort,
Management and staff competency across time. containment and restraint techniques that
form the basis of most of Safe Management’s
Advanced vs. 2-Day Training Advanced Physical Intervention methods. We will
Advanced physical intervention methods are provide, upon request, a more detailed example
not taught as part of Safe Management’s Crisis of a customized Advanced Physical Intervention
Intervention Training. They are only taught reference manual.
to staff who work with severely aggressive/
violent individuals and who have attended Technology
Safe Management’s Crisis Intervention two day The physical intervention technology is a
Training. Many advanced physical intervention biomechanical technology designed to teach
methods are often misunderstood by laypersons. people how to execute body movements
Before any front-line training takes place, efficiently and effectively, in order to prevent
senior consultants work closely with an agency/ injury. It refers to the application of concepts
organization’s management-level representatives related to angles, movement recognition, body
to explain our training approach and methods. control, aggression topography profiling and
The training requirements for physical restraints aggression response styles.
and other advanced physical intervention
techniques are very complex and must be Developing cutting edge self-protection and
customized to each individual. As a result, not containment techniques, based on martial
all advanced methods are taught to each agency. arts biomechanical technology, does not
The Safe Management best practice process for necessarily make the techniques dangerous or
developing physical restraints is illustrated in the unacceptable. The way these techniques are
Individual Specialized Consultation Technique developed, taught and applied (a multi-factor
Development Process. approach) determines whether they are
dangerous or safe.
For example, a “general restraint” technique
would not adequately address the unique To be safe and effective, physical intervention
aggression topographies of each individual. techniques must be designed, taught and applied
All advanced intervention techniques must be within a properly developed and monitored
customized to reflect specific implementation agency infrastructure. To this extent, Safe
angles, body part placement, branching Management’s approach involves training needs
procedures and the physical ability of the staff. assessments and careful customizing of training
During the real-life simulation component of our packages to meet your short and long term
training, we draw extensively on the Behavioural needs. Safe Management’s physical techniques
Profile and physical aggression topography do not place pressure on joints, hyper-extend
analysis of the individual to enhance the value joints or use pressure points.
and impact of the training process.
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Five SAFETY FOR INDIVIDUAL

Safety for Individual

Consideration to implement physical intervention techniques with an individual should be based on
the following safety critical information. Appropriate Risk Management must be the core focus of any
procedure involving physical intervention techniques.

Physical Well-Being Clinical Information Operational Factors

• Individual has no medical • A Behavioural Profile • Information related to
conditions that preclude should be completed on the physical well-being
the use of physical the individual. of staff, who will be
intervention procedures. implementing physical
Such medical conditions • Depending on interventions, needs
may include, heart an individual’s to be available, (e.g.,
condition, history of back diagnosis, appropriate recent injuries, fitness
problems, respiratory professionals should be level, physical/medical
problems, bone density consulted on the role limitations, etc.)
issues. of psychiatric illness
and/or neurological • Has staff taken necessary
• Possible physical risk factors related to the training?
conditions should be individual’s physical
listed, (e.g., overweight, aggression. • Is there information
asthma, hay fever/other available on the
allergies, easily bruised, • Obtain information level of competency
etc.) related to possible demonstrated by staff
antecedents. during training?
• Recent physical injuries
should also be noted as • Topographical • Is the location staffed
well as severe injuries or analysis should also appropriately for safe
surgeries experienced in be completed on the implementation of
the past. individual’s physical physical intervention
aggression techniques, procedures? (e.g., is
• Medication’s impact e.g., the dominant hand there a large difference
on safety of physical the individual uses to between the individual’s
interventions should strike or which type size and strength and that
also be addressed with a of strike the individual of that staff members?
physician. most uses. Is there an appropriate
staffing ratio to safely
• A physician should • Physical aggression carry out physical
provide written “success ratio” needs to intervention procedures?
documentation on be determined as part Are the same staff
whether there are of the risk assessment. consistently on?
existing medical
conditions preventing • PRN, evacuation and 911
safe implementation of procedures in place?
physical intervention
techniques.
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Five SAFETY FOR PARTICIPANTS

Safety for Participants

The following safety critical procedures are necessary to ensure safety for participants during
training sessions in physical intervention techniques.

Physical Well-Being Clothing/Environment Training

• Participants must have • Participants must • Always follow the Model,

no medical conditions not wear jewelry or Explain, Imitate, and
that prevent them from have any extra items Consolidate teaching
participating fully in the attached to their approach:
training sessions (e.g., clothing (e.g., pens,
heart condition, history keys). Model - slowly demonstrate
of back problems, each movement in a physical
recent fractures, recent • Participants technique.
leg sprains). should wear loose, Explain - articulate and
comfortable demonstrate each technique
• The course instructor clothing. at least three times.
must be told of all Imitate - have participants
medical conditions • Participants should
wear appropriate, slowly imitate the
before the training movements.
sessions. flat-heeled, non-slip
soled shoes. Consolidate - have
• Participants need to participants practice slowly,
have opportunities • When training in a then with increasing speed,
to drink fluids once carpeted room, as coached by the instructor.
every half hour during participants should
extended intense be regularly reminded • Consistently implement
training sessions to lift their feet when a shaping procedure to
involving intense they move. help participants acquire
physical exertion. a skill.
• Furniture must be • Consistently maintain
•  indows and doors
W moved well away structure and discipline
must be opened in from participants. (e.g., discourage doing
non-air conditioned techniques at high
rooms. speed without instructor
approval, discourage
•  articipants must
P horseplay).
always stretch and • Use the “Paired entity”
warm-up when learning approach. Participants,
physical techniques. A when paired together,
cool down period at the learn to give feedback
end of physical activity and reinforce each
should also occur. other’s learning.

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 SECTION Physical Intervention Concepts
Five POSITIONAL ASPHYXIA

Positional Asphyxia
Positional asphyxia, also known as postural asphyxia, is a form of asphyxia which occurs when an
individual’s physical position prevents them from breathing adequately. Research has suggested that
restraining a person in a face down position is more likely to cause greater restriction of breathing
than restraining a person face up.
Safe Management Group Inc. recommends staff only consider physical restraints if;

• It is determined that less intrusive intervention has been attempted and has been ineffective;

• There is a clear and imminent risk that the individual will physically injure themselves or
others;
• T he techniques are carried out using the least amount of force necessary to restrict the
individual’s ability to move freely;

• While under restraint, the individual’s condition is continually monitored and assessed;

• T he restraint is stopped when there is a risk that the restraint itself will endanger the health or
safety of the individual;

• Physical restraints have been integrated into a Behaviour Support Plan;as

• Staff have received training regarding the safe use of the physical restraint intervention.

Signs of Distress
It is imperative that an individual is monitored while in a physical restraint. Risk factors such as
obesity, prior cardiac or respiratory problems and how an individual is restrained can add distress to
an individual.

The following are some signs that an individual is in distress:

• Rapid, shallow breathing
• Panting
• Grunting
• Blue tinge to nail beds and/or around the mouth
• Nasal flaring
• Sudden slowing of breath

Safe Management’s Physical Intervention Techniques ensure the following conditions DO NOT
occur:
• Severe pressure or weight on chest, sternum or diaphragm areas.
• Methods causing severe chest compression (i.e. positional compression).
• Positional configurations causing breathing distress.
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Five PROTECTIVE POSITIONS

Basic Position
Used at all times
• Keep a step and a kick length away from the individual
• Body at a 45 degree angle to individual
• Feet shoulder width apart
• Hands up and above the waist in a non-threatening
manner

Protective Position
Used when individual is in the imminent phase
• Increase distance from individual
• Maintain Basic Position
• Forward arm matches forward leg; other hand up
• Arms at 90 degrees
• Arms are appropriate distance from core
• Hands are open, palms turned slightly out in a
non-threatening manner (fingers and thumb together,
ensuring clear sight lines)
• Ensure hands do not block vision

Movement
• Awareness of environment and exits
• Maintain Protective Position
• ‘Train Track’ concept.
• Shuffle Step - front foot pushes off for backward
movement; back foot pushes off for forward movement
• Pivot Step - pivot on ball of foot (door hinge concept)
• Maintain balance throughout movement

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Five STRIKES

Straight
Used for redirection/deflection/blocking
• Avoidance Strategies
• Mirror image (ideally), arm and body move as one unit
• Palm turned out, fleshy part of arm exposed
• Pivot on balls of feet
• Deflect the strike between wrist and elbow; do not push
• Maintain a visual of individual/Awareness of further aggression

Two Handed Lunge

Used to prevent chokes/grabs/hair pulls/shoves
• Similar to straight strike
• Pivot to either side. Let environment dictate

Roundhouse
Used for blocking strikes from the side
• Avoidance Strategies
• Block first, move only when safe
• Mirror image
• Arm at 90 degree angle with palm turned out
• Meet the strike, do not push
• Awareness of further aggression

Overhead
Used for blocking strikes coming from above
• Block first, move only when safe
• Mirror Image - ideally
• Forearm in front, above head at 45 degree angle
• Palm turned up and out, fleshy part of arm exposed
• Absorb impact with lower body (knees bent)
• Reinforce with other hand, palm to the back of hand if
necessary
• Awareness of further aggression

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Five WRIST GRABS

One on One
• Least intrusive first (e.g., “Please let go”)
• Step in; set feet up in direction of weak point
• Tuck - your elbow to your waist/trunk
• Turn - your wrist to the thinnest profile
• Reinforce or block with other hand, if necessary
• Twist - your whole body towards the weak point
(feet, hips, arms and shoulders move as one unit)

Two Hands on One Wrist

• Least intrusive first (e.g., “Please let go”)
• Step in and tuck elbow; set up feet for rotation;
arm and leg match
• Make a fist and grab it with the other hand
• Raise hands enough to clear individual’s forearms
• Pull up through weak point, rotating towards back leg
• Do not pull hands up towards your face

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Five WRIST GRABS

Two on Two - from the Front

• Least intrusive first (e.g., “Please let go”)
• Step in and tuck elbows
• Thrust your palms up and out
• Do not pull hands towards your face

Two on Two - from the Back

• Least intrusive first (e.g., “Please let go”)
• Step back
• Place your fists on your waist
• Elbows must be out to the side, not pointed back
• Step forward and straighten arms out to the front

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Five CLOTHING GRABS

Managing Clothing Grabs - from the Front

• Avoidance Strategies (Proximity/Positioning/
Appropriate clothing)
• Least intrusive first (e.g., “Please let go”)
• Contain clothing between individual’s hand and staff’s body
with the appropriate hand
• Cup with your free hand close to individuals fingers
• Elbow tucked
• Guide/Rotate through to release

Managing Clothing Grabs - from the Back

• Grab your clothing from the front at appropriate height
• Tighten the clothing by pulling your clothes forward
• Take a step forward and pivot towards the individual to release
clothing

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Five HAIR PULLS

One Hand or Two Hands from the Front

• Avoidance Strategies (Proximity/Positioning/
Appropriate hair style)
• Contain the individual’s hand(s) to your head
(hand-over-hand; no pressure on the knuckles)
• Step back (away from individual)
• Widen stance to lower body
(back straight, knees bent)
• Keep elbows in (for strength and protection)
• Call for assistance

Worm Release
• Help to contain the individual’s hand(s)
• Remove staff’s hands (as required) to expose
individual’s thumb
• Worm thumb in
• Lever up
• Block during release
• Communicate exit directions to staff

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Five HAIR PULLS

From the Back - One Hand

• Contain the individual’s hand(s) to your head
(hand-over-hand; no pressure on the knuckles)
• Elbows in (for strength and protection)
• Call for assistance
• Determine which hand the individual is using (feel for thumb)
• 3 steps – inside leg steps back and beside the individual,
step parallel, lower your body as you turn and face the side of
the individual’s leg (in line with seam of individual’s pants)
• Raise up slightly to lift the individual’s arm to 90 degree angle

Straight Hair Ponytail

• With one hand, contain the base of the ponytail
• With other hand, grasp above the individual’s hand and slide
it down
• Gather hair into containment hand, if necessary
• Repeat until free

From the Back - Two Hands

• Contain the individuals hand(s) to your head
(hand-over-hand; no pressure on the knuckles)
• Keep elbows in (for strength and protection)
• Step back towards the individual in a balanced stance
• Roll shoulders forward in a controlled manner
• Do not hyper-extend individual’s elbows
• Call for Assistance

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Five CHOKES

Chokes - from the Front

• Avoidance Strategies (Proximity/Positioning)
• Tuck Chin
• Raise both arms (elbows higher than individual’s forearms)
• One foot steps back
• Twist towards back leg/your core

Chokes - from the Back

• Tuck Chin
• Raise both arms (elbows higher than individual’s forearms)
• ‘Mark’ with one foot back
• Rotate on toes towards marked foot

Forearm Choke
• Cup over forearm
• Pull down and drop body weight if needed
• Tuck chin inside of individual’s forearm
• Step back with leg closest to the individual’s hand
• Turn head in towards individual’s body
• Continue to pull head free

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Five BITES & KICKS

Bites
• Avoidance Strategies (Proximity/Positioning/PPE)
• Contain back of head
• “Feed the bite”
• Call for assistance
• Release (“J-roll”) when bite loosens
• Seek medical attention immediately

Kicks
• Avoidance Strategies (Proximity/Triangle concept)
• Turn body 90 degrees to the individual
• Lift front knee straight up - foot is parallel to the floor
• Arms up to protect core
• Block the kick with the bottom of your foot
• Landmark on or near the top of the individual’s foot
• Do not kick out
• Reposition to maintain balance once kick is blocked

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Five ESCORT

Stage One Escort

Used to support/guide a non-resistant individual
• Line up shoulder behind individual’s shoulder
• Position hand on the individual’s arm, just above the elbow
• Tuck your arm to the front of your body to avoid swatting
• Other hand to support or block as required

Stage Two Escort

Used to support/guide an individual presenting low to
moderate resistance
• Grasp individuals wrist with outside hand (underhand grip)
• With inside arm, reach through and overtop individual’s
forearm; grasp your own wrist
• Prompt arm back into your armpit
• Move slightly behind individual
• Prompt individual forward with upper body

Stage Three from Stage Two

Used to contain or guide an individual presenting moderate to
high resistance
• Outside hand continues to secure individual’s wrist
• Prompt individual’s arm back
• Inside arm dives in and wraps around the individual’s waist
• Pull in at individual’s waist
• Walk forward or remain stationary
• Be aware of possible head butts

Stage Four from Stage Three

Used to safely manage an individual presenting severe
resistance
• Inside leg moves behind the individual’s knees, legs overlap
• Maintain a balanced stance
• Staff turn slightly towards each other, hips tight
against individual
• Tuck elbow to prevent bites and head butts as needed
• Tilt hips forward, if needed, to reduce individual’s strength

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 SECTION Physical Intervention Concepts
Five STANDING CONTAINMENT

Stage Four Containment (Alternate Approach)

Used to contain an individual displaying behaviour that
requires immediate intervention to manage clear and
imminent risk of harm to self or others

• Communicate approach with partner

• Move in at 45 degree angle in Protective Position
• Block on upper arm/shoulder
• Slide one hand down to wrist
• Prompt individual’s arm back
• Inside arm dives in and wraps around individual’s waist
• Inside leg moves behind the individual’s knees, legs overlap
• Maintain a balanced stance
• Staff turn slightly towards each other, hips tight
against individual
• Tuck elbow to prevent bites and head butts as needed
• Tilt hips forward, if needed, to reduce individual’s strength
• Third staff as barrier if necessary (do not hold individual’s
head)

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 SECTION Physical Intervention Concepts
Five ALTERNATIVE TECHNIQUES

Modified Escort
Must meet the threshold of imminent risk of harm to self or
others
• Communicate approach with partner
• Grasp individual’s wrist with outside hand
• Slide inside hand up to individual’s armpit (fingers facing
forward with thumb up)
• Apply upward pressure into individual’s armpit while pulling
down slightly on individual’s arm
• Line up shoulder behind individual’s shoulder (closed stance)
• Escort in a swift and controlled manner
• DO NOT RAISE OR PULL BACK ON INDIVIDUAL’S ARM
Wall/Corner Containment One (from Modified
Escort)
Must meet the threshold of imminent risk of harm to self or
others
• Communicate approach with partner
• Grasp individual’s wrist with outside hand
• Using Modified Escort, move individual to a wall or corner,
free from obstacles
• Use least amount of force required when placing individual
against wall
• Maintain the same arm position as the Modified Escort
• Place inside leg between individual’s legs (ideally)
• Compress the individual against the wall using hips
• ENSURE INDIVIDUAL’S SAFETY IF HEAD-BANGING ON WALL
• DO NOT RAISE OR PULL BACK ON INDIVIDUAL’S ARM
Wall/Corner Containment Two (from Modified
Escort)
Used to contain an individual who cannot be safely managed
using Wall Containment One
• Communicate approach with partner
• Using Modified Escort, move individual to a wall or corner,
free from obstacles
• Use least amount of force required when placing individual
against wall
• Wrap outside arm in-front and around individual’s arm, staff
join arms together behind individual’s back
• Inside hand secures individual’s wrist
• Staff turn inward to face each other with inside leg directly
behind individual - hips tight against individual
• ENSURE INDIVIDUAL’S SAFETY IF HEAD-BANGING ON WALL
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APPENDIX
Section Six

APPENDIX PAGE
Definitions 95
Bibliography 96
Crisis Intervention Test 100
Training Evaluation 104

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 SECTION Appendix
Six DEFINITIONS

Aggression
Verbal or physical acts such as loud yelling or threatening, hitting, kicking, punching, biting, etc.
Agitation
 n emotional state of heightened arousal and anxiety that often occurs in the early stages of an aggressive
A
escalation.
Arousal vs. Anxiety
 rousal involves a heightened physical state caused by the release of adrenaline characterized by
A
autonomic nervous system responses such as muscle tension, increased respiration rate, increased heart
rate, pupil constriction, etc. Anxiety is a more intense state of arousal also involving panicky feelings and
worry about catastrophic events.
Biomechanical Problem Solving
T eaching potential trainers how to identify the types of injuries that could occur in improper implementation
of basic self-protection skills and containment / restraint techniques.
Confine
To place an individual into an enclosed area from which escape is not permitted.
De-Escalation
A process of reducing a individual’s level of arousal during an aggressive escalation.
Entity Concept
Safe Management views a group of training participants from an “entity” framework. Two participants
make up an “entity”. Seasoned Safe Management instructors can instruct groups of 10 “entities”.
Participants in an “entity” acquire skills in working with each other, e.g., picking up cues on what their
partner did correctly or incorrectly. Participants also learn to provide positive and constructive feedback
during practice with each other.
Intrusive
Interventions that involve confinement or physical restraint.
Physical Restraint
Using a holding technique to restrict an individual’s ability to move freely.
3-Section Body Calibration
 articipants training to be trainers are taught how to help workshop participants problem-solve difficulties
P
in acquiring new physical techniques. A basic problem-solving skill is the ability to observe if any incorrect
or problematic physical movement is occurring in the following body sections, bounded by the following:
• Top of the head to the bottom of the neck.
• Shoulders to hip area.
• Bottom of the hip to the bottom of the feet.
Inappropriate movements in each section are corrected one section at a time.
Topography
The form which behaviour takes, e.g., hitting, spitting, running, biting.

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 SECTION Appendix
Six BIBLIOGRAPHY

Clinical Resources:
Bandura, A. (1951). Social Learning Theory. General Learning Press, Morristown, N.J.

Bandura, A. (1973). Aggression: A social learning analysis. Englewood Cliffs, NJ, Prentice-Hall.

Berkowitz, L. (1989). “Frustration-Aggression hypothesis: Examination and reformulation.”

Psychological Bulletin, 106(1):59-73.

Bell, J.L., Traumatic event debriefing: service delivery designs and the role of social work.
Social Work, January 1995.

Bradley, J. Valerie & Bersani, Hank A. (1990). Quality assurance for individuals with developmental disabilities –
It’s everybody’s business. Paul H. Brookes Publishing Co., Baltimore, Maryland.

Caraulia, A. and Steiger, (1997). L. Nonviolent Crisis Intervention: Learning to Defuse Explosive
Behaviour. CPI Publishing:Brookfield, Wisconsin.

Cooper, J.W. Managing disruptive behavioural symptoms: today’s do’s and don’ts. Nursing Homes, January/
February, 1994.

Cornell University’s Residential Child Care Project Newsletter, Refocus, vol. 7, 2002.

Doresey, M.F., Iwata, B.A., Reid, D Davis, P. (1982). Protective equipment: Continuous and
contingent application in the treatment of self-injurious behaviour. JABA, 17, 217-230.

Elliott, P. (1997). Violence in health care: What nurse managers need to know. Nursing Management, 28 (12), 38-
42. World Wide. Web:http//www.springnet.com/ce/m712a.htm.

Favell, J.E., McGimsey, J.F., & Jones, M. (1978). The use of physical restraint in the treatment of self-injury
and as positive reinforcement. JABA, 11, 225-241.

Feldman, M.A. (1990). Balancing freedom from harm and right to treatment for persons with
developmental disabilities. In Repp & Singh, Pp. 261-271.

Forster, J. and Wheildon, D. The psychiatric emergency: heading off trouble. Individual Care,
November 15, 1994.

Greenstone, J.L. and Leviton, S.C. (1993). Elements of Crisis Intervention: Crises and how to respond to them.
Brooks/Cole Publishing Company: Pacific Grove, CA.

Holden, M. and J. Levine-Powers (1993). Therapeutic crisis intervention. The Journal of

Emotional and Behavioural Problems, 2: 49-52.

Kaplan, S. G. and E. G. Wheeler (1983). Survival skills for working with potentially violent individuals. Social
Casework: The Journal of Contemporary Social Work.

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 SECTION Appendix
Six BIBLIOGRAPHY

Maier, G. Managing threatening behaviour: the role of talk down and talk up. Journal of Psychosocial Nurs-
ing, 1996, (34)6.

McCowan, R.J. and D. P. Weganast (1997). Embedded training evaluation: Blending training and
assessment. Buffalo, SIC-Buffalo.

Meichenbaum, D. (1977). Cognitive Behaviour Modification: An Integrative Approach. Plenum Press, New
York.

Miller, D., M.C. Walker, et al. (1989). “Use of a holding technique to control the violent behaviour of
seriously disturbed adolescents”. Hospital and Community Psychiatry, 40(5):520-524

Ministry of Community and Social Services. (1992). Staff training program for secure custody/
detention facilities. Toronto, Ontario.

Nunno, M., M. Holden, et al. (1998). Implementing and evaluating Therapeutic Crisis Intervention:
A crisis prevention and management program. Ithaca, Family Life Development Center, Cornell
University.

Parad, H.J. (1965) Crisis Intervention: Selected readings. New York, Family Service Association of
America.

Paterson, B. (2000). Standards for violence management training, vol. 13 no. 4, pp. 7-17.

Ratcliff, N. (1988). “Stress and burnout in the helping professions”. Social Casework: The Journal of Contem-
porary Social Work, March:47-154.

Schiller, W.I., Ditman, W.F., Olvera, D.R. (1983). The aggression management training series.
University of Illinois at Chicago, Chicago, Illinois.

Shulman, Lawrence. (1984). The skills of helping – individuals and groups. Illinois, F.E. Peacock
publishers Inc.

Seth Allcorn, (1994). Anger in the Workplace: Understanding the Causes of Aggression and
Violence.

Singh, N.N., Winton, A.S., & Ball, P.M. (1984). Effects of physical restraint on the behavior of hyperactive mentally
retarded persons. American Journal of Mental Deficiency, 89, 16-22.

Sulzer-Azaroff, B. & Reese, E.P. (1982). Applying behaviour analysis: A program for developing staff
competencies. New York:Holt, Rinehart & Winston.

Thackery, M. (1988). Therapeutics for Aggression: Psychological/Physical Crisis Intervention.

New York: Human Sciences Press. Inc.

Tharp, Roland G., Wetzel, Ralph J., (1969). Behaviour Modification in the natural environment.
New York: Academic Press.

Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008;
Ontario Regulation 299/10 Quality Assurance Measures.

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Signs, Vital. (1996). Standard First Aid student notebook. Vital Signs Inc., Ontario.

Willams, M., & Robertson, K. (1997). Workplace violence: Prevalence, prevention and first-line
interventions. Critical Care Nursing Clinics of North America, 9 (2), 221-8.

Wonderly, D. and S. Rosenberg (1988). Understanding aggression in treating emotionally disturbed youths.
Assaultive youth: Responding to physical aggressiveness in residential, community and health care settings.
J.K.R. Monkman, New York, The Haworth Press:29-48.

Physical Training Intervention Resources:

Annett, J. (1994), The Learning of Motor Skills: Sports science and ergonomics perspectives.
Ergonomics: The official publication of the Ergonomics Research Society, 37, 5-15

Baskind, Eric. (1993). Defend yourself: The official book of the british self defense governing body. Pelham
Books.

Crisis Intervention Instructor’s Manual (1986). Adult Occupation Center,. Edgar, Ontario

Hughes, C. (1985). Physical intervention: Planning and control techniques. Pointer, 29, 34-37.

Jay, Wally. (1981). Dynamic Jujitsu – Small circle theory. Masters publications. Canada.

Justice, Department of. (1995). Positional asphyxia – sudden death. National Law Enforcement
Technology Center Bulletin, National Institute of Justice, Rockville, MD.

Safe Use of Physical Restraint Devices, July 1992. FDA Backgrounder: Current & useful information from the
Food & Drug Administration. Web:http//www.fda.gov/opacom/backgrounders/safeuse.html

LaHaie, R. (2000-2002). Self-defense Newsletter. Protective Strategies, Winnipeg, Manitoba.

St. Thomas Psychiatric (1976). A program for the prevention and management of disturbed
behaviour. St. Thomas Psychiatric Hospital, St. Thomas, Ontario.

Tedeschi, Marc (2002). The art of holding – Principles and techniques. Weatherhill Publishing.

Warren-Holland, D., Rossell-Jones, D., Stewart, R. (1987). Self-Defense for Women: Learn to be alert and
Protect yourself. Hamlyn Publishing.

Relationship Management Resources:

Power & Equity

Alcock, J.E., Carment, D.W., & Sadava, S.W. (1994). A Textbook of Social Psychology. Scarborough, Ontario:
Prentice-Hall Canada Inc.

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 SECTION Appendix
Six BIBLIOGRAPHY

Equity Theory

Noller, P. & Fitzpatrick, M.A. (1993). Communication in Family Relationships. Englewood Cliffs,
New Jersey: Prentice Hall.

Social Exchange/Reciprocity

Jacobson, N. & Margolin, G. (1979). Behavioural Marital Therapy: Strategies Based on Social
Learning Theory and Behavior Exchange. New York: New York: Brunner/Mazel, Publishers.

Empathy/Caring/Acceptance & Genuineness/Openness

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of
Consulting Psychology, 21, 95-103.

Hill, C.E. & O’Brien, K.M. (1999). Helping Skills: Facilitating Exploration, Insight, and Action. Washington,
D.C.: American Psychological Association.

Reading/Responding to Emotions

Greenberg, L.S. & Paivio, S.C. (1997). Working with Emotions in Psychotherapy. New York, New York: The
Guilford Press.

Listening Skills

Faber, A. & Mazlish, E. (1980). How to Talk So Kids Listen & Listen So Kids Will Talk. New York, New York:
Avon Books.

Hill, C.E. & O’Brien, K.M. (1999). Helping Skills: Facilitating Exploration, Insight, and Action.
Washington, D.C.: American Psychological Association.

Working Through

Hill, C.E. & O’Brien, K.M. (1999). Helping Skills: Facilitating Exploration, Insight, and Action.
Washington, D.C.: American Psychological Association.

Coercive Interactive Cycle

Patterson, G.R. (1982). Coercive Family Process. Eugene, Oregon: Castalia Publishing Co.

Communicating Interpersonal Boundaries

Gordon, T. (1989). Discipline that works: Promoting self-discipline in children. New York: Plum Press.

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Test marks to be submitted To Safe Management Group Inc.

SAFE MANAGEMENT GROUP - BASIC CRISIS INTERVENTION TEST

Name: Agency:

Contact Number: Date:

Email Address: Percentage/Score: /26

1. A “Predictable Crisis” involves an incident of aggression:

a. By an individual who rarely, if ever, has any aggressive outbursts.
b. In which medical and organic factors play a primary role.
c. By an individual with a well documented history of aggressive behaviour.
d. In which the individual verbalizes intent to aggress.

2. When interacting with others, it’s important to consider both verbal and non-verbal communication.
In this course it was identified that non-verbal communication (body language, facial expressions,
voice tone) makes up ______% of communication, while words make up _____%.
a. 90; 10
b. 93; 7
c. 80; 20
d. 60; 40

3. The best way to correct an imbalance of power in a relationship is to?

a. Assess the number of positive versus negative interactions.
b. Provide more opportunities for choice and autonomy.
c. Use Active Listening.
d. Ensure that consistency between staff is maintained.

4. When considering the four stages of the Aggression Escalation Continuum, where should staff attempt
to focus their intervention attempts?
a. Physical Aggression Stage
b. Subtle Stage
c. Imminent Stage
d. Escalation Stage

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5.  The Relationship Management principle of “Reading and Responding to Emotions” promotes 2 distinct
phases. Phase one involves Active Listening. Phase two involves the Four Stages of Problem Solving.
These stages are:
a. Identify the problem; Brainstorm ideas; Weigh options; Implement the plan
b. Listen; Gather; Respond; Direct
c. Label feelings; Actively listen; Plan; Take action
d. Consider options; Explore solutions; Negotiate outcomes; Activate the plan

6. The Active Listening acronym promoted in this course is P.A.E. The E stands for:
a. EXPRESS emotions
b. ENCOURAGE more conversation
c. ELICIT a response
d. ENFORCE expectations

7. In addition to describing a client’s stages of escalation, the Aggression Escalation Continuum should
also be developed to describe:
a. Recommended staff responses to each of the client’s escalation stages.
b. What the client should not do in each of the escalation stages.
c. The number of hours staff are required to work.
d. None of the above.

8. The most successful approach in developing a Safe Environment is to focus on:

a. Admitting non-violent clients
b. Providing staff training in the most effective containment methods
c. Prevention
d. Developing an Aggression Escalation Continuum for the client and applying graduated intervention
techniques.

9.  The Aggression Escalation Continuum identifies levels of aggression using 3 response domains. These
domains are:
a. Verbal, Psychological and Physiological
b. Gross Motor, Physical Aggression and Body Language
c. Words, Emotions and Actions
d. Verbal, Physiological and Gross Motor

10.  Verbal De-Escalation Techniques are an effective initial strategy to help prevent an escalation in an
individual’s behaviour. Please choose the answer that best describes Verbal De-Escalation Strategies.
a. Providing staff implement De-Escalation Strategies effectively, they will work on all individuals.
b. Staff must be ready to use a variety of De-Escalation Strategies dependent on the person and the
behaviour.
c. Staff should become proficient in two or three effective De-Escalation Strategies and use them
consistently.
d. When all else fails, humour may be the best strategy to attempt.
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11. Threatening an individual with additional consequences in an attempt to gain compliance is an

example of ________________.
a. Effective De-Escalation
b. Consistency
c. Coercion
d. Establishing guidelines

12. An effective Behavioural Crisis Intervention Team must have TRUST in one another, CONFIDENCE in
each other’s skills and abilities, the SAME EXPECTATIONS, KNOWLEDGE of each member’s strengths
and potential triggers and __________________.
a. Camraderie
b. Cohesiveness
c. Regular practice sessions
d. Physical size

13. When we say that a behaviour serves a function in the client’s environment, we mean:
a. The behaviour occurs because of internal biological functional factors.
b. The behaviour is maladaptive and, is therefore, dysfunctional.
c. The behaviour occurs to get the client something they want or need.
d. The behaviour can be altered by changing the environmental contingencies.

14. From a functional perspective, aggressive behaviours can be reduced:

a. When staff ignore small behaviours that may escalate.
b. When boredom is minimized.
c. W
 ith appropriate profiling of clients.
d. When clients are given more free time.

15. When arriving in a situation where another staff member is dealing with an escalated individual, one
should:
a. Rush in and immediately offer assistance.
b. Walk in calmly to assess risk and next steps.
c. Immediately call the Police for assistance.
d. Immediately yell for help.

16. A Physical Restraint procedure is terminated when the client:

a. Says he/she is calm.
b. Indicates remorse for the inappropriate behaviour.
c. Stops resisting and agrees to staff’s expectations.
d. Is no longer a clear and imminent risk of harm to self or others.

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 Section Two: True or False
Please indicate the correct answer, by circling the “T” - True or “F” - False.

Safe Management Group promotes the “RESPOND” approach when dealing with an
1. T F
individual with a weapon. The “D” in RESPOND stands for “DISTANCE”.

Prior to using physical restraint, staff must be able to articulate that other, less intrusive
2. T F
interventions were first attempted.

An individual who speaks explosively, or swears and uses obscenities, accompanied by

3. threatening gestures is more likely in the Imminent Phase of the Aggression Escalation T F
Continuum.

An individual who aggresses in response to an undesirable demand or task may be

4. T F
engaging in coercive behaviour.

5. Safe Management takes responsibility for incorrect use of its procedures. T F

Participants in Safe Management training must share with their manager and/or trainer if
6. they have any physical limitations that might prevent them from fully participating in the T F
training.

The Relationship Management Principle of Empathy, Caring and Acceptance promotes

7. T F
that staff use the skill of active listening.

An individual who is truly in the PHYSICAL AGGRESSION phase of the Escalation

8. T F
Continuum is still able to be rational.

When an individual displays anger, it is imperative that staff use assertive language to
9. T F
gain control of the situation.

When debriefing with staff, it is important to deal with preventative strategies prior to
10. T F
allowing the staff the opportunity to vent and cope with the situation.

PLEASE READ CAREFULLY

As a participant in the SMG Crisis Intervention Training Program, you will be involved in practicing
intervention strategies. Please be advised that some of these methods involve physical contact and
may include risk of injury. It is important that you follow the exact directions of your Instructor.

Safe Management Group Inc. makes no warranty or representation that the skills, techniques, and
methods taught in this program comply with all local laws, rules, regulations, and ordinances that
may be applicable to persons utilizing same. Safe Management Group Inc.’s Physical Intervention
Techniques should be used in a manner that is in compliance with local laws and regulations.
Safe Management Group Inc. assumes no liability whatsoever for any bodily injury, loss, damage
or any related claims caused by the misuse or incorrect application of the skills, techniques, and
methods taught in this program, as a result of any undisclosed medical condition or by illegal or
inappropriate use of same, whether or not such injury, loss, or damage is foreseeable.

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 SAFE MANAGEMENT TRAINING EVALUATION
Please take a few minutes to answer the following questions about our Crisis Intervention Training.
Your feedback is important and will aid us in the future development of our training products.

Please rate the following: 1=Strongly disagree 2=Disagree

RATING
3=Neither agree nor disagree 4=Agree 5=Strongly agree

The instructor presented the information in a clear and concise

1 2 3 4 5
manner?

The workshop stimulated my learning? 1 2 3 4 5

The training materials used complemented the presentation? 1 2 3 4 5

The length of time to complete the training was sufficient? 1 2 3 4 5

Participation and interaction were encouraged? 1 2 3 4 5

The Instructor was helpful and engaging? 1 2 3 4 5

I gained valuable skills that I can apply to my work setting? 1 2 3 4 5

The presenter was knowledgeable and answered questions

1 2 3 4 5
satisfactorily?

The most valuable aspect of this workshop was:

The least valuable aspect of this workshop was:

Additional Comments:

Name (Optional): Role:

Training Program: 1/2-Day 1-Day 2-Day

Years of service: <1 Year 1-5 Years 5-10 Years 10-20 Years >20 Years
Have you taken previous Crisis Intervention Training? YES NO
Which program? MOAB NVCI UMAB PMAB Other:

Thank you!
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