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key point refresher leader’s guide

For Review of the Nonviolent Nonviol ent Cri Crisi siss Intervention® Training Program

care, welfare, safety, and securitySM

© 2005 CPI (reprinted 2011). All rights reserved. This work is protected by the copyright laws of the United States and other countries and remains the sole and exclusive property of CPI. This work may not be reproduced in any manner without the express written permission of CPI. Important information about your license to use teaching materials.

CPI hereby grants CPI Certiﬁed Instructors a perpetual, nonexclusive, and nontransferable license to use this work in teaching this program to staff within the Certiﬁed Instructor’s Base of Employment, as deﬁned in the Instructor Manual. This license is site-speciﬁc to the Certiﬁed Instructor’s Base of Employment and includes the right to distribute this work to program participants for use during this training. Any other use of this work is strictly prohibited and will be considered a breach of this license and a violation of applicable copyright laws. Certiﬁed Instructors are not agents (implied, apparent, or otherwise) or employees of CPI and do not have any authority to act for or on behalf of CPI. CPI®and Nonviolent Crisis Intervention®are registered trademarks of CPI.

Maintaining Safety in the Nonviolent Crisis Intervention Training Training Program ®

Remember the responsibility that we have as Certiﬁed Instructors to provide our participants with a safe learning environment. environment. Formal refresher trainings are an opportunity to role model the philosophy of Care, Welfare, Safety, and SecuritySM. Have your participants read the Due Care guidelines that are listed on page 2 of their Key Point Refresher Workbook. Be sure that these guidelines are followed during the training. • I will respect other participants participants as peers. • I am responsible for the safety of others others with regard regard to my actions. • I am responsible for gauging gauging myself with regard to any past/current past/current injuries injuries and my comfort level performing any given technique. If I have any concerns, I will see my Instructor at a break. • I will not engage in horseplay. • I will not teach other techniques. • In all role-plays/techniques, role-play s/techniques, I will act only on my Instructor’s Instructor ’s direction. • I will will cooperate, cooperate, not compete. compete. • I will take time to warm up and stretch stretch before performing performing any physical activity, activity, and I will drink plenty of ﬂuids throughout the day. • I will be conscious of the space around around me and always consider consider safety while practicing practicing physical techniques. I must remember that there are others who are practicing near me. • During physical physical exercises, any participant participant can ask to stop the activity activity at any time, for any reason. If, while practicing physical exercises, my partner asks me to stop the activity, I will take the request seriously and immediately discontinue the exercise. • I will inform my Instructor Instructor prior prior to class of any injuries injuries or limitations. • I will report all all injuries to my Instructor Instructor immediately immediately..

Please Read Carefully:

As a Certiﬁed Instructor of the Nonviolent Crisis Intervention®training program, you and your participants will be involved in practicing i ntervention strategies. You You should understand that some of these methods involve physical contact and include risk of injury. It is important that you remind participants of the Due Care guidelines of the program, as well as model them yourself. CPI makes no warranty or representation that the skills, techniques, techniques, and methods taught in this program comply with all local l ocal laws, rules, regulations, and ordinances that may be applicable to persons utilizing same. CPI’s C PI’s physical intervention techniques techniques should be used only in a manner that comports with local laws. CPI assumes no liability for any bodily injury, loss, or damage caused by the misuse or incorrect application of the s kills, techniques, and methods taught in this program, or by the illegal or inappropriate use of same, whether or not such injury, loss, or damage is foreseeable.

Introduction Formal refreshers are an essential step in the Nonviolent Crisis Intervention®Training Process. They provide opportunities for participants to: • Develop a greater understanding understanding of course concepts. concepts. • Problem solve and strengthen strengthen crisis intervention skills. • Receive additional supporting information. • Demonstrate ability ability and condence condence in applying applying course content content and skills to real-life work experiences. experiences. Formal refresher training courses should be scheduled to review and expand upon the Nonviolent Crisis Intervention®training concepts. It is recommended recommended that all participants review course content to refresh their skills every six to twelve months. The formal refresher course must be a minimum of three hours in length for training credits to be granted.

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The Minimum Content for a Formal Refresher Includes: • Pre-test.

Policy Discussions Discussion

Formal Refreshers Refreshers

• The CPI Crisis Development ModelSM. • All verbal verbal intervention information. • A review and practice practice of all CPI Classroom Classroom Model Personal Safety TechniquesSM. • A review and practice practice of all CPI Classroom Classroom Model Nonviolent Physical Crisis SM Intervention techniques if they were taught to staff in the original training. • Problem solving solving and role-playing role-playing based on staff needs. • Post-test. Planning and preparation are necessary for making formal refreshers a positive and valuable training experience for participants. The Instructor must keep in mind that staff st aff members returning to refresher classes will arrive thinking, “I already know this information.” Therefore, formal refresher training must be stimulating, challenging, challenging, and engaging. Customizing the refresher training to your participants’ needs and interests will make the training more meaningful and relevant to your participants.

Introduction Customizing Formal Refresher Training The importance of customizing formal refresher training to the needs of each group cannot be overstated. It requires creativity and exibility. While it may be necessary to do some formal lectures, participants generally appreciate a format that is highly interactive in these classes. Through discussions, exercises, and supplemental information, formal refresher trainings should be customized to meet the needs and interests of participants, as well as to build on the foundation laid in their original Nonviolent Crisis Intervention® training program. Speciﬁc information regarding the needs and interests of participants can be collected through feedback from supervisors and team leaders, incident reports, and pretraining surveys from participants. Pretraining surveys can be designed by the Certied Instructor to establish the objectives and focus of training. There are several ways to do a pretraining assessment; the following are just a few ideas: • In order to assess participants’ prior knowledge and retention from previous trainings, you might consider having participants complete the pre-test prior to the training. It will give you a good idea of which units you may need to spend more time on. • In order to determine how much time to plan for, specic content areas on which the greatest emphasis should be placed, and the type of supplemental information that should be presented, you might ask participants: • About their roles and how they use training on the job. • Topics that they would like to focus on. • If they have specic questions about applying the training to various situations. • How long it has been since their last formal refresher training and since their original training. • In order to identify areas of need, you may also consider asking staff members to rate: • Their perception of internal staff cohesiveness/teamwork. • Their level of condence on the job. • Their assessment of how safe they feel at work. This data can later be used to measure the ongoing impact of training. Input from questions such as these will be useful in customizing the training to meet the needs and interests of your participants and help them effectively apply skills to on-the-job situations. Additional options for customized formal refreshers are available to Certiﬁed Instructors after completing advanced training programs such as Autism Spectrum Disorders: Applications of Nonviolent Crisis Intervention®Training, Supporting Individuals With Dementia and Related Cognitive Challenges, Enhancing Verbal Skills: Applications of Life Space Crisis InterventionSM, Applied Physical TrainingSM, and Trauma-Informed Care: Implications for CPI’s Crisis Development ModelSM. The Teaching Notes throughout this Leader’s Guide will guide you through the basic content of the Nonviolent Crisis Intervention®Key Point Refresher Course. Be creative in your presentation. Challenge the group. Engage the group. Remember, they think they already know this information. Surprise them by showing them that there is more to learn and that their skills and conﬁdence can continue to grow. The goal is to inspire further learning, problem solving, and a renewed commitment to Care, Welfare, Safety, and SecuritySM. © 2005 CPI (reprinted 2011).

Introduction How to Use the Key Point Refresher Leader’s Guide Page numbers are provided at the top of each Leader’s Guide page for easy reference to the participants’ Key Point Refresher Workbooks. Encourage participants to take notes. This will help with further retention. The information shown in this bold italic fontis the basic (minimal) information that should be addressed by discussion, visuals, exercises, etc. In addition, Teaching Notes are identied by a shaded box. You will notice that this Key Point Refresher Leader’s Guide is organized differently than the workbook. This allows the Certied Instructor exibility and the ability to focus participants on a broad view of crisis as it relates to the CPI Crisis Development ModelSM. The CPI Crisis Development ModelSMis the foundation of the Nonviolent Crisis Intervention®training program. All of the concepts discussed during training expand on the various levels of behavior and staff interventions. As such, the Key Point Refresher Workbook is designed to highlight this. For example: Page 6allows you to review the basic

Page 9presents an overview of how

behavioral levels and corresponding staff approaches along with their deﬁnitions. It is useful to engage participants in developing a list of examples of each behavior and approach.

Precipitating Factors and Rational Detachment affect the Integrated Experience that occurs within the CPI Crisis Development ModelSM.

Page 7expands on the Anxiety/Supportive

Page 10expands on the Acting-Out

level of the CPI Crisis Development ModelSM. The workbook is organized so that you can address how Proxemics, Kinesics, the CPI Supportive StanceSM, and Paraverbal Communication relate to both clients and staff members.

Person/Nonviolent Physical Crisis InterventionSMlevel of the CPI Crisis Development ModelSM. It focuses on the continuum of acting-out behaviors and the continuum of physical intervention strategies ranging from the least restrictive all the way to restraint as a last resort. Team intervention strategies are also included as a key aspect of this level.

Page 8expands on the Defensive/Directive

level of the CPI Crisis Development ModelSM. The CPI Verbal Escalation ContinuumSMis positioned along the client side because it represents a variety of defensive behaviors. Along the staff side, the appropriate interventions are discussed. Empathic Listening covers both sides because it is an active process that occurs between staff members and the individuals in their care.

Page 18 expands on the fourth level of

the CPI Crisis Development ModelSM: Tension Reduction/Therapeutic Rapport. The workbook and Leader’s Guide are designed to allow you to review the Postvention process as it relates to both clients and staff.

This Leader’s Guide can be used in conjunction with your Nonviolent Crisis Intervention ®Instructor Manual. Although the Leader’s Guide repeats base content from the core training, what i s most important is that you are able to discuss and apply this information at your facility. You are encouraged and authorized to spend more time on applying the content as opposed to simply reteaching it.

Notes:

Key Point Refresher

Pre-Test Introducing the Formal Refresher Training Craft a positive and concise welcome and introduction. Include: • Validation for knowledge, skills, and prior training. • An example of the positive impact ongoing training is having. • A reminder of the organization’s commitment to Care, Welfare, Safety, and SecuritySM. • An overview of training objectives (workbook page 3). • Logistics information (parking and lunch arrangements, breaks, emergency exits, requirements for successful completion of formal refresher training, etc.). • Pre-test.

The Pre-Test (workbook page 4) As with all pre-tests, this one provides the Instructor with information about the knowledge base of participants. It gets participants thinking about and remembering earlier training and their experiences implementing the training. Allow 7–12 minutes for participants to complete the pre-test (individually or in pairs), then discuss their responses. Each pre-test question is designed to foreshadow content that will be addressed within the training. Therefore, it is not necessary to examine each question in depth at this time. Bridge back to the pre-test questions and participants’ responses throughout the formal refresher training.

Workbook page 4

Key Point Refresher

Pre-Test Name__________________________________________________ Date __________________________________ Title __________________________________________________________________________________________ Facility _________________________________________________ Phone (______) _________________________ Facility Address ________________________________________________________________________________ City_________________________________ State/Province__________ Zip/Postal Code ___________________ Country ____________________________ Email _____________________________________________________ 1. What is the philosophy of the Nonviolent Crisis Intervention®training program? Care, Welfare, Safety, and SecuritySM

2. Complete the CPI Verbal Escalation ContinuumSMusing the terms below.

Intimidation

Questioning

3.Release 4.Intimidation

Tension Reduction

Refusal

Release 5. Tension Reduction

2.Refusal

1.Questioning

3. When should you use Nonviolent Physical Crisis InterventionSM? As a last resort.

4. Match each CPI model to the appropriate deﬁnition: a. The CPI Crisis Development ModelSM

c. This model is used to guide staff through the ____ process of establishing Therapeutic Rapport and staff debrieﬁng after a crisis incident.

b. The CPI Verbal Escalation ContinuumSM

____ a. This model assists staff members to recognize a client’s behavior level and intervene early and appropriately.

c. The CPI COPING ModelSM

b. This model demonstrates defensive behaviors ____ and staff interventions for each behavior.

This nal pre-test question reminds participants of the key models that will be discussed in the Nonviolent Crisis Intervention®Key Point Refresher training and serves as a smooth transition to the CPI Crisis Development ModelSM, which is discussed next. © 2005 CPI (reprinted 2011).

The CPI Crisis Development ModelSM Teaching Notes (workbook page 6) This page allows you to review the basic terms in the CPI Crisis Development ModelSMbefore you begin to expand on each. Please review all basic deﬁnitions and have participants provide workrelated examples of how each pertains to their work experience. Encourage them to come up with examples of observable behaviors and staff approaches based on their observations and experiences since their last training. Sample discussion questions:

• What is the Integrated Experience? What is its signicance during crisis development? • Do individuals always exhibit the behaviors in the order of the model? If not, what is the value of the model? • In small groups, participants may prepare and present role-plays that demonstrate individuals escalating in the order of the model/not in the order of the model. Are both types of escalations realistic? • Can you think of examples of situations in which behavior levels have overlapped? • Are there circ*mstances that make the behavior levels easier or harder to identify?

Workbook page 6

The CPI Crisis Development ModelSM

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety

1. Supportive

Deﬁnition:A noticeable change or increase in

Deﬁnition:An empathic, nonjudgmental

behavior.

approach.

Examples: pacing, withdrawal, tapping

Examples: listening, offering reassurance

2. Defensive

2. Directive

Deﬁnition:The beginning stage of loss

Deﬁnition:An approach in which a staff member

of rationality.

takes control of a potentially escalating situation by setting limits.

Examples: challenging authority,

becoming belligerent

Examples: explaining options and

consequences to the individual

3. Nonviolent Physical Crisis InterventionSM

3. Acting-Out Person Deﬁnition:The total loss of rational control

Deﬁnition:Safe, nonharmful restraint positions to

that results in a physical acting-out episode.

control an individual until he can regain control of his own behavior. Used only as a LAST RESORT.

Examples: presenting a danger to self or others

by hitting, biting, kicking, throwing objects, etc.

Examples: CPI Children’s Control PositionSM, CPI Team Control PositionSM, etc.

4. Tension Reduction

4. Therapeutic Rapport

Deﬁnition:A decrease in physical and

Deﬁnition:An approach used to re-establish

emotional energy.

communication.

Examples: showing signs of relaxation, normal

Examples: listening, showing interest and

breathing

See Also

CPI Pages 1-50 - Flip PDF Download

concern

Level

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety 2. Defensive

1. Supportive 2. Directive

3. Acting-Out Person 4. Tension Reduction

3. Nonviolent Physical Crisis InterventionSM 4. Therapeutic Rapport

Teaching Notes (workbook page 7) Explain to participants that you will now begin to expand on each level of the CPI Crisis Development ModelSM, beginning with an examination of the Anxiety/Supportive level. The workbook and Leader’s Guide are organized so that you can address how each key concept relates to both clients and staff members. For example: Proxemics: Discuss the relationship between anxiety and a client’s need for personal space as

well as what a staff member can do to be supportive. Kinesics:Discuss kinesic signs of anxiety that may be visible in an individual and supportive

kinesics that can be used by the staff member. CPI Supportive StanceSM:Discuss how staff members can use the stance and why it is

advantageous. Paraverbal Communication:Discuss how crisis situations can affect the paraverbal

communication of both clients and staff and what staff members can do to maintain a more supportive environment through the use of their voice. Nonverbal and paraverbal communication are concepts that can easily be understood but are sometimes forgotten during a crisis situation. As staff members develop a greater appreciation for their signiﬁcance, they are less likely to be forgotten. Encourage participants to remember that all of these concepts extend to all levels of the CPI Crisis Development ModelSMand should be utilized in all their interventions. Involve participants in a discussion that will help them become more attentive to nonverbal and paraverbal communication. Sample discussion questions:

• Can you think of an individual you work with who communicates more with nonverbals and paraverbals than with words? • Can you think of a time when you gave mixed messages? What happened? • What have you done (or could you do) to become more attentive to nonverbal and paraverbal communication?

Workbook page 7

Level 1

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety

1. Supportive

Proxemics: Personal space. An area surrounding the body, approximately 1.5 to three feet (depending on the context of the situation) in length. Personal space is considered an extension of self, and invasion can escalate anxiety. Individual Discuss reasons why an individual may want more or less personal space. Disregard is likely to cause escalation.

Staff Member Must try to respect/accommodate personal space needs. Discuss ways staff can do this.

Kinesics:The nonverbal message transmitted by the motion and posture of the body. Individual Fidgeting, glaring, head down, worried look, muscle tension.

Staff Member Open body posture, interested facial expression, nonthreatening gestures, and eye contact.

CPI Supportive StanceSM: Body positioned at least one leg-length away and at an angle. Reasons for using: 1. Respect (honors personal space). 2. Nonthreatening. 3. Safety.

Paraverbal Communication: The vocal part of speech, excluding the actual words one uses. Three key components are tone, volume, and cadence of speech. Individual Tone may be angry, aggressive, sarcastic. Volume may be loud. Cadence may be choppy, fast at times.

Staff Member Tone should be calm, reassuring. Volume should be controlled, appropriate for the setting. Cadence should be smooth.

Level

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety 2. Defensive

1. Supportive 2. Directive

3. Acting-Out Person 4. Tension Reduction

3. Nonviolent Physical Crisis InterventionSM 4. Therapeutic Rapport

Teaching Notes (workbook page 8) This page expands on the Defensive/Directive level of the CPI Crisis Development ModelSM. The CPI Verbal Escalation ContinuumSMis positioned along the client side because it represents a variety of defensive behaviors a client may exhibit. Along the staff side, the appropriate interventions are discussed. Empathic Listening covers both sides because it is an active process that occurs between staff members and the individuals in their care. Many staff members have a great deal of experience responding to verbal escalations, and yet verbal escalations can still be uncomfortable and frightening. Facilitate participation in this part of the formal refresher course to allow staff to practice verbal strategies and receive feedback from others. This team approach to learning can strengthen individual conﬁdence. Sample discussion questions:

• What is the difference between setting limits and threatening an individual? Give examples. • What is our organization’s policy with regard to responding to threats? • What have you done (or could you do) to build condence in your verbal intervention skills? Use creativity in presenting the section on Empathic Listening. Encourage participants to focus on applying the skills in real-life work situations. Feel free to create an activity that allows staff to discuss strategies for Empathic Listening. One way to do this is to divide participants into small groups. Assign each group one of the Empathic Listening skills (e.g., providing undivided attention) and ask each group to discuss: • Why the skill is important. • What might happen if staff members do not use that skill. • Strategies/ways that staff members can implement the skill. • Examples of situations in which NOT listening to an individual caused a problem to worsen. Have the small groups present their thoughts to the full group.

Workbook page 8

Level 2

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

2. Defensive

2. Directive

The CPI Verbal Escalation Continuum SM

Interventions: 1. Questioning Information-seeking: Give a rational response.

Challenging: Redirect; avoid a power struggle.

2. Refusal: Set limits. 3. Release

3. Release • Allow individual to let off steam. • Remove audience. • State nonthreatening directives. • Use an understanding, reasonable approach. • Enforce any limits you set.

4. Intimidation

2. Refusal

4. Intimidation • Seek assistance. • Wait for team. • Avoid individual intervention.

5. Tension Reduction • Establish Therapeutic Rapport. • Re-establish communication. (This stage is expanded upon later in the course.)

5. Tension Reduction

1. Questioning

Setting Limits: The result of recognizing that you cannot force individuals to act appropriately. Effective limit setting means offering choices, stating the consequences of those choices, and stating the positive choice ﬁrst. Keys

1. Simple and clear 2. Reasonable 3. Enforceable

Empathic Listening: An active process to discern what a person is saying. 1) Be nonjudgmental. 2) Give undivided attention.

3) Allow silence. 4) Use restatement to clarify.

5) Listen for underlying messages.

Integrated Experience

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety 2. Defensive

1. Supportive 2. Directive

3. Acting-Out Person 4. Tension Reduction

3. Nonviolent Physical Crisis InterventionSM 4. Therapeutic Rapport

Teaching Notes (workbook page 9) This page presents an overview of how Precipitating Factors and Rational Detachment affect the Integrated Experience that occurs within the CPI Crisis Development ModelSM. You may wish to review the deﬁnitions of the key concepts prior to discussion. Note how Precipitating Factors (light gray) are more dominant in a client during crisis situations—but that staff members are affected by Precipitating Factors as well. Also note how Rational Detachment (dark gray) is largely the responsibility of st aff members. Notice how the balance between these concepts affects the overall Integrated Experience. Lead a discussion on how Precipitating Factors and staff members’ ability to rationally detach impact the Integrated Experience and the crisis situation as a whole. Sample discussion questions:

• Can you think of real-life examples of Precipitating Factors that impacted the Integrated Experience of a crisis situation? • What are real-life examples of positive outlets that staff members use to rationally detach and keep the Integrated Experience balanced? • Imagine if the graphic were tilted, and staff approached a crisis situation with a lot of Precipitating Factors and little ability to rationally detach—how might that affect the Integrated Experience and the result of the crisis situation? • Can you think of any real-life examples of crisis situations that would have resulted differently if the balance between Precipitating Factors and Rational Detachment was different? • How does staff fear and anxiety affect the Integrated Experience? • How can staff members stay rationally detached if an individual becomes physically aggressive?

Workbook page 9

Integrated Experience Integrated Experience—

the concept that behaviors and attitudes of staff impact behaviors and attitudes of individuals, and vice versa.

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

Examples: • Loss of personal power

• Fear

c a F

• Displaced anger, etc.

• Examples from your group

a t

Examples:

• Take a deep breath

• Get a good night’s sleep

c e

• Examples from your group

c h

e n

Precipitating Factors—internal or

Rational Detachment—the ability

external causes of an acting-out behavior over which a staff member has little or no control.

to stay in control of one’s own behavior and not take acting-out behavior personally.

Level

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety 2. Defensive

1. Supportive 2. Directive

3. Acting-Out Person 4. Tension Reduction

3. Nonviolent Physical Crisis InterventionSM 4. Therapeutic Rapport

Teaching Notes (workbook page 10) This page expands on the Acting-Out Person/ Nonviolent Physical Crisis InterventionSMlevel of the CPI Crisis Development ModelSM. It focuses on the continuum of acting-out behaviors and the continuum of physical intervention strategies, ranging from the least restrictive all the way to restraint as a last resort. (Note the graphic explanation along the right side of the page.) • Begin the discussion by reviewing the denitions and examples of strikes and grabs (along the client side of the CPI Crisis Development ModelSM), as well as the CPI Personal Safety TechniquesSM(along the staff side). • Because restraint is a last resort, discuss alternative strategies staff members might use prior to the use of Nonviolent Physical Crisis InterventionSM. List these alternatives in the right-hand column (staff side). (Examples of alternatives to restraints may be using a pull-through, clearing the room, removing unsafe objects, using verbal intervention, etc.) • Involving other team members may also help prevent the need for physical intervention. Furthermore, if physical intervention does become necessary, it is important that team members are in place and ready to assist. Discuss essential elements of team intervention with your participants. • Develop examples of behavior that may constitute a need for physical intervention (along the left side). Discuss whether the examples given would truly be a “last resort.” Note:If you teach only Units I–VII and X, you may still wish to review alternatives to avoid

restraint and discuss team intervention strategies. • CPI Personal Safety TechniquesSMand Nonviolent Physical Crisis InterventionSMprinciples and dynamics can be best understood and reinforced by reviewing and practicing the CPI Classroom Models illustrated on pages 19–25 in this Leader’s Guide (workbook pages 11–17). You may want to consider competency-testing your participants on their ability to demonstrate each of the CPI Classroom Models. • Before practicing the CPI Team Control PositionSM, review the Control Dynamics on page 23 of this Leader’s Guide (workbook page 15). • CPI also recommends that you discuss the Risks of Restraints information on pages 32–35 of this Leader’s Guide (pages 22–25 of the Key Point Refresher Workbook). Sample discussion questions:

• Who is on the Crisis Response Team that responds to escalating behaviors in your area/ department? How has that worked? • Who decides when it is necessary to use physical intervention? • Has our organization’s approach to the use of physical intervention changed over the past three years? Five years? Ten years? How and why? • How have we (or could we) improve our team interventions? 17

Workbook page 10

Level 3

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

3. Acting-Out Person

3. Nonviolent Physical Crisis InterventionSM

Strike:A weapon coming in contact

with a target.

1. Block (or deﬂect) the weapon.

Examples: punch, kick

2. Move the target.

Grab: An attempt to control and/or

1. Gain a physiological advantage by using: a. The weak point of the grab. b. Leverage. c. Momentum.

destroy a part of one’s anatomy. Examples: hair pull, choke

l e a s t r e s t r i c t i v e

P e r s o n a l S a f e t y

2. To gain a psychological advantage: a. Stay calm. b. Have a plan. c. Use an element of surprise or distraction. Team Intervention:

• Benets of a team approach. • Choosing a team leader. • Team leader duties. • Auxiliary team duties.

Behaviors that may require physical intervention as a LAST RESORT:

• Hurting self or others. • Engaged in dangerous behavior and not responding to verbal intervention. • Risks of continued behavior are greater than the risks of restraints. • Ask participants to describe speciﬁc examples.

Nonviolent Physical Crisis InterventionSM is used as a last resort.

Alternatives: (Examples) • Continue verbal intervention. • Clear the room and remove unsafe objects. • Use the pull-through. • Generate a list of alternatives with your group.

C N r io s i n v s i o I n e l t e n r t v e P n h t iy s o i n c Sa M l

l a s t r e s o r t

Caution

These CPI Classroom Model diagrams are intended as a point of reference and only represent a snapshot of the process required to execute the technique. Accordingly, these techniques should only be learned and practiced under the supervision of a Nonviolent Crisis Intervention ®Certiﬁed Instructor. Attempting to learn these techniques from the diagrams or descriptions may result in injury.

CPI KICK BLOCK

CPI ONE-HAND WRIST GRAB RELEASE

In any strike situation, you can remove the target or deect the weapon by placing an object between the weapon and the target. The act of blocking or shielding is based on your natural response—a primal reex to protect yourself from a strike. In this example, the bottom of the staff member’s foot is used to shield or block the oncoming kick.

Gain a physiological advantage by using leverage and momentum to pull away from the weak area of the wrist grab (between the thumb and four ﬁngers). You can increase your momentum and leverage by maintaining a balanced stance and using your body position to enhance your physiological advantage. At the same time, you can gain a psychological advantage by using a verbal distraction or an element of surprise.

Attempt to move out of the way to maintain safety.

Release and attempt to move out of the way to maintain safety.

CPI TWO-HAND WRIST GRAB RELEASE

CPI ONE-HAND HAIR PULL RELEASE

Gain a physiological advantage by using leverage and momentum to pull away from the weak area of the wrist grab (between the thumbs and four ﬁngers). You can increase your momentum and leverage by using your free hand to assist in pulling away from the grab, maintaining a balanced stance, and using your body position to enhance your physiological advantage. At the same time, you can gain a psychological advantage by using a verbal distraction or an element of s urprise.

Immobilize this grab by securing the person’s hand to your head. By using one or both of your hands to immobilize the person’s hand, you can prevent further grabbing of hair and minimize injury. Move your head toward the person, leveraging the arm position to a 45-degree angle. The grip of the hair pull is levered backward, reducing the strength of the grip and opening up the weak point of the grab at the ﬁngers. At the same time, you can gain a psychological advantage by using a verbal distraction or an element of s urprise.

Release and attempt to move out of the way to maintain safety.

As your hair is released, attempt to move out of the way to maintain safety.

Caution

These CPI Classroom Model diagrams are intended as a point of reference and only represent a snapshot of the process required to execute the t echnique. Accordingly, these techniques should only be learned and practiced under the supervision of a Nonviolent Crisis Intervention ®Certiﬁed Instructor. Attempting to learn these techniques from the diagrams or descriptions may result in injury.

CPI TWO-HAND HAIR PULL RELEASE Use both of your hands to immobilize the person’s hands on your head. By securing the hands to your head, you can prevent further grabbing of hair and minimize injury. Move your head toward the person, leveraging the arm position to a 45-degree angle. The grip of the hair pull is levered backward, reducing the strength of the grip and opening up the weak point of the grab at the ﬁngers. At the same time, you can gain a psychological advantage by using a verbal distraction or an element of surprise. As your hair is released, attempt to move out of the way to maintain safety.

CPI FRONT CHOKE RELEASE Raise your arms straight up for leverage. (This may also create a distraction.) Lean away to extend the individual’s arms; this will weaken the grab. Create momentum by turning your shoulders and arms in a rotating motion away from the individual. Your shoulders will act as a lever while your momentum will assist in releasing the grab. Increase your psychological advantage by using a verbal distraction or an element of surprise. Attempt to move out of the way to maintain safety.

CPI BITE RELEASE CPI BACK CHOKE RELEASE Raise your arms straight up for leverage. (This may also create a distraction.) Lean away to extend the individual’s arms; this will weaken the grab. Create momentum by turning your shoulders and arms in a rotating motion away from the individual. Your shoulders will act as a lever while your momentum will assist in releasing the grab. Increase your psychological advantage by using a verbal distraction or an element of surprise. Attempt to move out of the way to maintain safety.

Avoid pulling away from the bite. Instead, lean into or “feed” the bite, using the minimum amount of force necessary to cause the jaw of the person to open. You may also want to use your ﬁnger in a vibrating motion to stimulate the person’s upper lip. This vi brating motion may result in a parasympathetic response that causes the mouth to open. At the same time, you can gain a psychological advantage by using a verbal distraction or an element of surprise. Once the bite releases, attempt to move out of the way to maintain safety.

Notes:

Caution

These CPI Classroom Model diagrams are intended as a point of reference and only represent a snapshot of the process required to execute the t echnique. Accordingly, these techniques should only be learned and practiced under the supervision of a Nonviolent Crisis Intervention ®Certiﬁed Instructor. Attempting to learn these techniques from the diagrams or descriptions may result in injury.

Note: For more information on the risks of restraints, see pages 32–35.

Figure B

Figure A

CPI CHILDREN’S CONTROL POSITIONSM The CPI Children’s Control Position SMis designed to be used with children. You should consider using this position only with individuals considerably smaller than yourself. Gain control of the child’s arms from behind and cross the arms in front of the child. The arms should be positioned high on the child and secured by locking one arm under the other. This will prevent the child from slipping through and will minimize any pressure on the child’s chest or abdomen. (Fig. A) Position yourself behind the child while maintaining close body contact and st anding to one side. This position allows you to maintain a balanced stance while managing the child. (Fig. B) The auxiliary team member(s) will monitor for safety and assist, if needed.

Caution

Figure B Figure A

CPI TEAM CONTROL POSITIONSM

The CPI Team Control Position SMis used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: •

Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual.

•

Keep their inside legs in front of the individual. (Fig. A)

•

Bring the individual’s arms across their bodies, securing them to their hip areas. (Fig. B)

•

Place the hands closest to the individual’s shoulders in a C-shape position to direct the shoulders forward. (Fig. C) Control Dynamics

1. Reduce upper-body strength by controlling the arms as weapons. a. Turn palms up. b. Raise arms above shoulders. c. Anchor arm to your body (hip area). 2. Reduce lower-body strength by controlling the back incline. a. Lower shoulders below hips. 3. Reduce mobility by close body contact. a. Move hips close to individual’s body (hug in). b. Move individual’s center of gravity forward onto toes (balls of feet).

Figure C

Caution

These CPI Classroom Model diagrams are intended as a point of reference and only represent a snapshot of the process required to execute the t echnique. Accordingly, these techniques should only be learned and practiced under the supervision of a Nonviolent Crisis Intervention ®Certiﬁed Instructor. Attempting to learn these techniques from the diagrams or descriptions may result in injury.

CPI TRANSPORT POSITIONSM The CPI Transport PositionSMwill assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual’s shoulder. Reach under the individual’s arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. It is not recommended to transport an individual who is struggling. If necessary, return to the CPI Team Control PositionSMif the individual’s and/or staff’s safety is at risk.

Caution

Figure A

Figure B

CPI INTERIM CONTROL POSITIONSM The CPI Interim Control PositionSMis a temporary control position that allows you to maintain control of both of the individual’s arms, if necessary, for a short time. Starting from the CPI Transport PositionSM, maintain control of the individual’s arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. (Fig. A) If the individual attempts to strike, use your free arm to block, and safely move away. (Fig. B)

Notes:

Level 4

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

1. Anxiety 2. Defensive

1. Supportive 2. Directive

3. Acting-Out Person 4. Tension Reduction

3. Nonviolent Physical Crisis InterventionSM 4. Therapeutic Rapport

Teaching Notes (workbook page 18) This page expands on the fourth level of the CPI Crisis Development ModelSM—Tension Reduction and Therapeutic Rapport. The workbook is designed to allow you to review the Postvention process as it relates to both clients and staff members. Postvention is another concept that may be easy to understand and accept as important, yet staff often lack condence in its execution. Consider providing your participants with opportunities to practice (and receive feedback from) being involved in debrieng with staff and re-establishing communication with the individual. A role-play is strongly recommended to reinforce the skills participants have learned and also to provide a lead-in to the discussion of the CPI COPING ModelSM. Remember that role-playing in front of the whole group may be intimidating. Participation in small groups for this exercise may make it a less stressful and more meaningful experience. Sample discussion questions:

• How soon after an incident can you debrief with staff? How soon after an incident can you re-establish communication with the individual? What factors should be considered in deciding when these things should take place? • Since your last training, who has had an experience in which Postvention has had a positive outcome? Ask for examples that involve both debrieng with staff and re-establishing communication with the individual. • What have we done (or could we do) to improve our Postvention efforts?

Workbook page 18

Level 4

Crisis Development/Behavior Levels

Staff Attitudes/Approaches

4. Tension Reduction

4. Therapeutic Rapport

A decrease in physical and emotional energy.

Individual must be back in physical and emotional control. Establish the basic facts regarding what happened. Listen to the individual. (Be nonjudgmental.) Look for patterns of behavior. (What triggers the behavior?)

Investigate alternatives to the inappropriate behavior. (What could help in making behavioral changes?) Aim for reaching an agreement about future behaviors and consequences. (Be sure the individual understands alternatives to inappropriate behaviors.) Return control to the individual. Give responsibility, along with support and encouragement.

An effort to re-establish communication between the individual and staff.

Control

All staff must be back in control before discussing the incident.

Orient

Establish basic facts regarding what happened. Exchange information and perspectives. Document.

Patterns

Investigate

Review the intervention. Are there patterns in the ways staff respond to crisis situations? (Which interventions are most/least effective?) Look for ways to strengthen future interventions. (Explore ways to prevent similar situations from occurring.)

Negotiate

Agree to changes that will improve future efforts to prevent and respond to crises.

Give

Offer support and encouragement to each other. Express trust and respect.

Why is Postvention important for the individual?

Why is Postvention important for staff?

• To teach/learn. • To strengthen the relationship. • To have closure.

• To teach/learn. • To strengthen the team. • To have closure.

Key Point Refresher

Post-Test Teaching Notes (workbook page 20) Be sure to have everyone complete and submit a post-test/evaluation to you. If participants are anxious about taking the post-test, you may want to do a brief review of content highlights. Alternatively, you may give participants a few minutes to read over their notes. After collecting the post-tests/evaluations, close the training by providing the post-test answers. Remind participants that the best learning occurs as part of an ongoing Training Process. Thank them for their time, their participation, and their commitment to Care, Welfare, Safety, and SecuritySM. Review all completed post-tests/evaluations. Fill out a Training Roster Form and send it along with all original post-tests/evaluations to CPI for documentation of your training hours. Please do this within 30 days of your formal refresher training.

Key Point Refresher

Post-Test

Workbook page 20

Name_________________________________________________________________ Date_____________________________ Title____________________________________________________________________________________________________ Facility________________________________________________________________ Phone____________________________ Facility Address__________________________________________________________________________________________ City____________________________________________ State/Province____________ Zip/Postal Code________________ Country __________________________ Email_________________________________________________________________

1. Match each behavior level of the CPI Crisis Development ModelSMto the corresponding interventions and CPI models recommended at each level of behavior. a. Anxiety/Supportive ____ d The CPI COPING ModelSM b. Defensive/Directive c. Acting-Out Person/ Nonviolent Physical Crisis InterventionSM d. Tension Reduction/Therapeutic Rapport

c CPI Classroom Models of CPI Personal Safety ____ TechniquesSMand Nonviolent Physical Crisis InterventionSMas a last resort

____ a Proxemics, Kinesics, CPI Supportive StanceSM, Paraverbal Communication ____ b The CPI Verbal Escalation ContinuumSMand Setting Limits

2. Match each level of the CPI Verbal Escalation ContinuumSMto the recommended staff responses for each level. 3 Remove audience from area; allow individual to let off steam. ____ 1 Provide a rational response and avoid power struggles. ____ 4. ____ 2 Set limits. ____ 5 Re-establish communication and Therapeutic Rapport. ____ 4 Seek assistance from team and avoid individual intervention.

3. 2.

3. Why should a team approach be used? Safety, professionalism, litigation

4. When should you use Nonviolent Physical Crisis InterventionSM? As a last resort

5. Match each component of the Postvention process with the appropriate description. ____ 1. Reach agreement on changes. 4 Control ____ 2. Establish basic facts. 2 Orient ____ 3. Provide support and encouragement. 5 Patterns ____ 4. Be sure everyone is calm and rational. 6 Investigate ____ 5. Look for trends. 1 Negotiate ____ 6. Look for alternatives. 3 Give 6. What is the philosophy of the Nonviolent Crisis Intervention®program? Care, Welfare, Safety, and SecuritySM © 2005 CPI (reprinted 2011).

Notes:

Understanding the Risks of Restraints

Understanding the Risks of Restraints The Nonviolent Crisis Intervention®training program focuses on crisis prevention and the creation of restraint-free environments through a commitment to Care, Welfare, Safety, and SecuritySM. While considered a last resort, physical intervention procedures are taught as part of the program to provide staff with skills and conﬁdence to safely manage emergency situations. Any physical intervention should be used only when all other options have been exhausted and when an individual is a danger to self or others. Even in those moments, an assessment is still necessary to determine the best course of action to maintain the Care, Welfare, Safety, and SecuritySMof all.

There may be times when other strategies, such as continuing verbal intervention, removing dangerous objects, using Personal Safety TechniquesSM, and calling for further assistance would precede and possibly prevent any physical intervention. Remember that there are risks involved in any physical intervention. Therefore, physical intervention should be considered only when the danger presented by the acting-out individual outweighs the risks of physical intervention. Speciﬁc laws or regulations may govern use of restraints. Be sure to check your facility’s policies and procedures for applicable rules.

Dangers of Restraints The events leading up to a crisis situation and the struggling that occurs during a restraint can result in a lot of stress for the individual being restrained. This negative stress is sometimes called distress. Consequently, it is not unusual for a restrained individual to show signs of distress, both physically and emotionally. Always keep in mind that the acting-out person might have health problems. Therefore, everyone being restrained should be considered at risk. It is also important to understand that in some cases, restrained individuals have gone from a state of no distress to death in a matter of moments. Policies and procedures should reﬂect how staff can monitor these signs of distress and identify what protocol should be followed. There is also a psychological danger in using restraints. Being restrained can be a frightening— even traumatic—experience. Restraints can interfere with the relationship between caregivers and the person being restrained. In fact, if people are restrained too often, they may begin to feel that they have no control over their lives.

For these reasons and others, restraints should be used only when a person’s behavior is MORE dangerous than the danger of using restraints.

Some restraints are more dangerous than others. For example, facedown (prone) oor restraints and positions in which a person is bent over in such a way that it is difcult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxiaoccurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart.

Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person’s ability to breathe. This includes sitting or lying across a person’s back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact that person’s ability to breathe effectively.

Examples of High-Risk Positions for Restraint-Related Positional Asphyxia

Illustrations based on information from various individuals and resources. See Additional Resources and References on page 37.

All of these positions may interfere with a person’s ability to breathe. While they are different, these positions share a common factor: When forcefully maintained, each of them could prevent the diaphragm (the largest muscle of respiration) from working. If the diaphragm is not allowed to move down into the abdomen, breathing is seriously restricted. In fact, when a forcefully maintained

position hinders both chest and abdomen movement—the result can be fatal. When confronted with an emergency situation, always consider the option of disengaging. If the person is not a danger to self or others while on the ﬂoor, staff may make the decision to move away and give a clear directive.

Reducing the Risks of Restraints There are ways to minimize risks involved in any physical intervention. The very best way to avoid injury is to avoid the need to restrain in the rst place. Get to know the people in your care. Be aware of changes in their behavior that can be warning signs of anxiety. Intervene early. Learn to set limits effectively. Avoid being drawn into power struggles. Work as hard at learning verbal intervention skills as you do at learning physical intervention skills. Treat everyone with dignity and respect. Staff members should be trained in and regularly practice safer ways of restraining. The physical intervention procedures taught in the Nonviolent Crisis Intervention®training program are designed to maximize safety and offer a safer alternative to techniques that involve the ﬂoor to restrain an individual. A physical restraint is an emergency procedure comparable to CPR or ﬁrst aid. As with any emergency response procedure, staff members need to practice these skills on a regular basis. Educate yourself and others on the risks and dangers of using restraints. Some restraints are more dangerous than others. By choosing safer restraint techniques, you and your facility can reduce the possibility of serious injury and even death. In particular, you should avoid positions that can lead to restraint-related positional asphyxia .

CPI’s Nonviolent Physical Crisis InterventionSM techniques are designed for safety and allow for a Therapeutic Rapport to be re-established with the individual who has lost control. Key elements of Nonviolent Physical Crisis InterventionSM responses include: • No element of pain is involved. • The intent is to calm the individual. • The individual is not restrained on the oor, thus reducing risks of restraint-related positional asphyxiaand other injuries. • Team interventions are used when necessary. • Nonviolent Physical Crisis InterventionSM is used only as a last resort when someone presents a danger. • Nonviolent Physical Crisis InterventionSM is used to protect—not to punish. The goal is for staff to continually assess for signs of Tension Reduction and identify opportunities to re-establish a Therapeutic Rapport with the individual. Remember, the best way to eliminate the dangers of restraints—to you and to those in your care—is to eliminate the need for restraints at all.

Glossary of CPI Terms Acting-Out Person–the total loss of control, which results

Nonviolent Physical Crisis Intervention SM–used only as a

in a physical acting-out episode. It is the third level in the CPI Crisis Development ModelSM. Individuals in this level are presenting a danger to themselves or others.

last resort when a person is a danger to self or others. This involves the use of safe, nonharmful control and restraint positions to safely control an individual until he can regain control of his behavior.

Anxiety–a noticeable increase or change in behavior. A

nondirected expenditure of energy; e.g., pacing, nger drumming, wringing of the hands, or staring. It is the ﬁrst level in the CPI Crisis Development ModelSM.

Paraverbal Communication–the vocal part of speech,

Challenge Position–a body position in which one individual

Precipitating Factors–the internal or external causes of an

is face-to-face, toe-to-toe, and eye-to-eye in relation to another individual. This position is often perceived as a challenge and tends to escalate a crisis situation.

acting-out behavior over which a staff member has little or no control.

excluding the actual words one uses. Three key components are tone, volume, and cadence of speech.

Proxemics–personal space. An area surrounding the body,

CPI Classroom Model–a standardized way of demonstrating

personal safety and Nonviolent Physical Crisis Intervention methods in order to show the application of basic principles.

CPI COPING ModelSM–a model that staff members can use

to guide them through the process of establishing Therapeutic Rapport with an individual after a crisis incident. The CPI COPING ModelSMcan also be used as a way to structure a staff debrieﬁng. CPI Crisis Development ModelSM –a series of recognizable

behavior levels an individual may go through in a crisis, and corresponding Staff Attitudes/Approaches used for crisis intervention. Defensive Level–the beginning stage of loss of rationality.

At this stage, an individual often becomes belligerent and challenges authority. It is the second level in the CPI Crisis Development ModelSM. Directive Staff Attitude/Approach–an approach in which

a staff member takes control of a potentially escalating situation by setting limits. It is the recommended Staff Attitude/ Approach to an individual at the Defensive level. Empathic Listening–an active process to discern what a

person is saying. Integrated Experience–the concept that behaviors and

attitudes of staff impact behaviors and attitudes of individuals, and vice versa. Kinesics–the nonverbal message transmitted by the motion

and posture of the body.

approximately 1.5 to three feet in length, which is considered an extension of self. Rational Detachment–the ability to stay in control of one’s

own behavior and not take acting-out behavior personally. Supportive Staff Attitude/Approach –an empathic,

nonjudgmental approach attempting to alleviate anxiety. It is the recommended Staff Attitude/Approach to an individual at the Anxiety level. CPI Supportive StanceSM–the suggested body position for a

staff member to maintain when intervening with a potentially out-of-control or acting-out individual. The CPI Supportive StanceSMis maintained by keeping a distance of one leg-length from the person and by remaining at an angle. Tension Reduction–a decrease in physical and emotional

energy that occurs after a person has acted out, characterized by the regaining of rationality. It is the fourth level in the CP I Crisis Development ModelSM. Therapeutic Rapport–an approach used to re-establish

communication with an individual who is experiencing Tension Reduction. Training Process–a format for identifying ongoing learning

opportunities to ensure training concepts expand upon course content through practical application. In addition to initial training, components include Formal Refreshers, Reviews, Policy Discussions, Practice, Situational Applications, and Rehearsals/Drills. CPI Verbal Escalation Continuum SM–a model demonstrating

Limit Setting–a verbal intervention technique in which a

person is offered choices and consequences. Limits should be clear, simple, reasonable, and enforceable.

a variety of defensive behaviors that are often seen when individuals are in the Defensive level of the CPI Crisis Development ModelSM. This model includes suggested staff interventions for each behavior.

Nonviolent Crisis Intervention ®Program–a safe, nonharmful

behavior management system designed to aid staff members in maintaining the best possible Care, Welfare, Safety, and SecuritySMfor agitated or out-of-control individuals even during their most violent moments.

Additional Resources and References Allen, D., & Tynan, H. (2000). Responding to aggressive behavior: Impact of training on staff members’ knowledge and conﬁdence. Mental Retardation, 38(2). Allen, J. D. (1997). Who’s driving this bus anyway? Em powering drivers. School Business Affairs, 63(1). American Academy of Family Physicians. (1997). Use of physical restraints in children. American Family Physician, 55(6). Bair, B., Toth, W., Johnson, M. A., Rosenberg, C., & Hurdle, J. F. (1999). Interventions for disruptive behaviors: Use and success. Journal of Gerontological Nursing, 25(1). Chou, K., Kaas, M., & Richie, M. (1996). Assaultive behavior in geriatric patients. Journal of Gerontological Nursing, 22(11). Cooper, A., Anthony, R., & Saxe-Braithwaite, M. (1996, June). Verbal abuse of hospital staff. The Canadian Nurse, 92(6). CPI. (2006). Instructor manual for the Nonviolent Crisis Intervention ®training program. Milwaukee, WI: Author. Dattillo, F., Beck, A., & Freeman, A. (Eds.). (2000). Cognitive-behavioral strategies in crisis intervention(2nd ed.). New York: Guilford Publications. Everly, G., & Mitchell, J. (1999). Critical incident stress management (CISM): A new era and standard of care in crisis intervention. Ellicott City, MD: Chevron Publishing Corporation. Fletcher, K. (1996). Use of restraints in t he elderly. AACN Clinical Issues, 7(4). Leger-Krall, S. (1994, March). When restraints become abusive. Nursing 94, 24(3). Maier, G. (1996). Managing threatening behavior: The role of talk down and talk up. Journal of Psychosocial Nursing, 34(6). Miller, C. D. (2002). Silent killer: Death by restraint. Milwaukee, WI: CPI. Miller, L. (1999). Workplace violence: Prevention, response, and recovery. Psychotherapy, 36(2). Nelson, J., et al. (1999). Positive discipline A–Z: From toddlers to teens, 1001 solutions to everyday parenting problems (2nd ed.). Rocklin, CA: Prima Publishing. Noesner, G., & Webster, M. (1997, August). Crisis intervention: Using active listening skills in negotiations. FBI Law Enforcement Bulletin, 66(8). O’Halloran, R. L., & Frank, J. G. (2000). Asphyxial death during prone restraint. American Journal of Forensic Medicine and Pathology, 21(1), 39–52. Patterson, B., Leadbetter, D., & McComish, A. (1998). Restraint and sudden death from asphyxia. Nursing Times, 94(44). Pitcher, G. D., & Poland, S. (1992). Crisis intervention in the schools. New York: Guilford Publications. Pollanen, M., Chiasson, D., Cairns, J., & Young, J. (1998). Unexpected death related to restraint for excited delirium: A retrospective study of deaths in police custody and in the community. Canadian Medical Association Journal, 158(12). Reak, K. (1996, June). Cocaine, restraints and sudden death. The Police Chief. Reay, D. (1996, May). Suspect restraint and sudden death. FBI Law Enforcement Bulletin, 65(5). Weiss, E. M. (1998, October 11–15). Deadly restraint: A nationwide pattern of death. Hartford Courant. Wright, S. (1999). Physical restraint in the management of violence and aggression in in-patient settings: A review of issues. Journal of Mental Health, 8(5).