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The staff of residential facilities must learn how to identify, assess, and manage these situations, preferably before these situations escalate. TDMHMR utilizes a program known as the Prevention and Management of Aggressive Behavior (PMAB). It is designed to prevent and manage aggressive behavior in persons with mental illness and mental retardation. PMAB plays an essential role in ensuring that the facility is a safe place to be - both for staff and clients. The PMAB program is designed not only for the prevention of certain aggressive behaviors, it also provides training in physical interventions in which aggressive persons are controlled and the harm that they may poise is contained. It is of course beyond the scope of this document to review those physical techniques. However, it may be of benefit to discuss the verbal intervention techniques.
There are many reasons for aggressive behavior. For example:
Helping people find their appropriate ways for managing aggression and preventing it, is a major responsibility for staff members. Staff, who develop a caring, respectful relationships and show kindness and consideration in every contact with those they serve, are helping to prevent these kind of problems.
As employees display these qualities, they become more open and available to the persons that they serve. The person begins to see the staff member as a resource for helping them solve their problems. As an employee remains available, those in his or her care do not need to resort to negative actions such as aggression to meet their needs.
Even if a person becomes aggressive, an employee who has built a relationship with that person is more effective. Because of their relationship, the person trusts the staff member and knows the staff member will help.
The behavior modeled by employees has a tremendous impact on the relationships with people served. People respond according to actions towards them. Because of this, employees should understand how their actions impact others. The PMAB program is based upon four principles that provide guidance in interacting with the people served. These principles provide employees with a consistent approach for dealing with crises.
A person in crisis may be in a state of extreme emotional stress. They may use strong words or resort to physical aggression that could lead to the situation escalating. Use the principle of direct by yielding to work with, and not against, the person served. If the person is using forceful energy to explain their point of view, join the person in their effort to be understood. Listen fully to what the person in their effort to be understood. Listen fully to what the person has to say before offering an opinion. Listening non-judgmentally can help the person express their feelings and open the way to resolving the concerns.
Humans react to the world around them both emotionally and behaviorally. When something happens to a person, internal reactions may cause him or her to have certain feelings. For example, people often feel sad when they hear of tragedy. They may feel frustrated when things do not go their way.
Reactions to events can also trigger certain behaviors. For example, a sad person may cry. They may say things when frustrated that they later regret. Each person's internal and external reaction to an event is unique.
When applying the action-reaction principle, employees should become aware of how personal actions affect others. For instance, an employee should consider how personal behaviors affect what they are trying to achieve when working with a person. If the employee attempts to control a person, a typical reaction could be increased resistance or aggression. Allowing a person freedom of movement or choice can encourage calm and/or cooperation.
Tone of voice can invoke a positive or negative reaction in a person depending on the circumstances. If the person is hostile and using strong words, applying the action-reaction principle by listening and responding calmly will likely cause the person to react by becoming calm as well. Speaking calmly indicates that the employee is willing to assist.
Consistent behaviors and actions toward a person enable that person to react consistently as well. When an employee's reaction do not cause a desired reaction in the person served, the employee should consider changing actions to get a more favorable reaction.
Do things one-step at a time. Do things one-step at a time until they become automatic? First when a person becomes agitated, employees learn to recognize behaviors that indicate agitation in that person. It is best to detect them as early as possible. Second, the employee should communicate these observations to the person and assist them in working out a peaceful solution. Third, should the person become physically aggressive, the employee must act to prevent injuries.
The principle of 0 to 100 guides the amount of speed and strength used to manage aggressive behaviors. An employee must be able to respond to a situation in a moment's notice. It is the notion of the right amount of action at the right time. While the 0-100 principle chiefly apples to the application of physical force to control a situation, this principle can also be applied when speaking to a person in crisis. Employees must become aware of the volume and tone of their voice when managing such a situation. An employee can be firm and direct without using excessive verbal energy and should act as a counter balance to the person in crisis.
All persons served have rights. Employees have the responsibility for protecting these rights even if it causes an inconvenience for the employee. For example, if a person causing a disruption is unwilling to move to a quiet area, employees must find an alternative plan of action rather than forcing the person to move. The employees may decide to assist other people to move away from the person causing the disruption.
Employees must honor the rights of persons served unless the safety of the person is at stake. If the person is making a choice that could lead to injury unless action is taken, then employees have an obligation to ensure the safety of the person despite a possible violation of the person's rights.
Instances like these might be rare, but employees must ensure that both the rights and safety of the persons served are protected.
Many Community Mental Health and Mental Retardation Centers are happy to assist residential service providers in providing the highest quality of care for persons with mental illness. All community centers operate 24-hours-a-day, seven-days a week crisis telephone hotline, often staffed by volunteers. (See "Crisis Hotline Numbers"). Ask if your staff can attend the volunteer training. Ask local law enforcement if they can meet with employees, tour the facilities, and discuss an action plan to handle crises. Other sources of help may be other residents and neighbors. The key is to solicit help before a crisis occurs.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 1995. American Psychiatric Association. Washington, D.C.
PMAB, 3rd Edition, Texas Department of Mental Health and Mental Retardation, 1999. Austin, TX.
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