Positive Alternatives Training

Rights, Choices, Professional Relationships & Positive Support

Introduction

As employees, we are dedicated to developing positive relationships with people who have disabilities. Sometimes people with disabilities will demonstrate difficult and confusing behavior, even dangerous behavior. (It is also true that people without disabilities will demonstrate difficult and dangerous behavior.) Our obligation is to use positive communication and positive methods of behavioral support so that both dangerous behavior and the need for physical restraints will be minimized. In fact, as an agency, Turning Point hopes to get rid of almost all restraints.

Understanding why people behave the way they do is important, and that includes why you behave the way you do.

Some Factors that influence how people feel and how they behave

Forces outside people can affect behavior, such as:

  • Past experiences – both good and not so good experiences influence how we may act
  • Cultural experience – our cultural background and beliefs frame how we think about and react to life experiences
  • Religion – what we believe shapes how we think and act
  • Education – what we know affects choices and feelings
  • Environment – feeling comfortable, anxious, or scared about where we are

Forces inside us can affect behavior too:

  • Health – our general health, especially pain, can influence behavior
  • Inherited personality traits
  • Inherited communication traits and obstacles
  • Inherited conditions that shape how we think about or understand the world, such as mental retardation and autism
  • Stress – excess stress and tiredness cloud thinking and blur emotions

What other people think is happening is more important than what you think is happening. As direct service employees, we must always respect the perspectives of other people. Try to listen and understand what the consumer is feeling and thinking. This task is complicated when people have difficulty communicating.

When people have disabilities, the way they think about their experiences, how they feel abut those experiences, and how they communicate those thoughts and feelings may be very different than the way you think and feel about things…..not better or worse, just different.

It’s your job to respond with respect, knowledge, and courtesy so that consumers feel safe and capable when they are around you. All people are much less likely to engage in dangerous or risky behavior when they feel safe and respected.

When you are at work, you must constantly be aware that what you do and say has an effect on everybody around you. If you are tense and rude, others will respond in the same way. If you are respectful, careful, and honest, you may be helping someone else to act that way, too. Always be aware of your own moods and behavior – your negative attitude, short words, rushing through tasks – can escalate bad feelings in someone else, too.

Health

How someone feels physically definitely has an impact on behavior. Pain, hunger, energy – all these contribute to our behavior in ways that we may not always be aware of. In the same way, these factors alter behavior in consumers, too.

If someone you are working with appears tense or distracted, or responds differently than most days, check out their health first. Have basic routines like sleeping and eating changed recently? Do you see symptoms of a cold or flu virus? How about coughing or sneezing? Is there a seizure disorder? Ask others who are familiar if routines have changed or if symptoms of an illness are evident. The point is – if you notice significant behavioral changes in someone who does not communicate directly, eliminate health issues first. Never assume that a “bad mood” is just a “behavior”.

Stress

Stress can cause short tempers, poor judgment, and bad decisions. Stress can also cause health problems. Stress persisting over a long time can cause lots of health problems, and we have just learned that health problems can also affect our behavior. Achieving a balance between the forces that stress us and the comfort routines we use to “protect” and soothe ourselves is vital to all of us. These are called risk factors and protective factors.

People with disabilities must cope with many risk factors – mental illness, health problems, a history of abuse or violence, weak support systems. But many people with disabilities have few communication and coping skills, and few opportunities to comfort and soothe raw feelings. A pressure cooker of emotions can heat up quickly.

Sometimes the stress in consumers hard to see. Our job is to interpret behavior as communication, and never to judge behavior as ‘good’ or ‘bad’.

Anger, Fear, and Other Strong Emotions

Strong emotions alter our regular behavior. We must understand that people with disabilities, because many have limited outlets for stress, may move into the “flight or fight” mode more quickly and more often than other people. Usually, when aggression happens, it means that stress, pain, and misunderstanding have gone beyond a person’s ability to cope, and the fight or flight response has taken control. Physically restraining someone in the “flight or fight” mode is tricky and potentially dangerous. Look for other responses to such situations.

Sometimes where a consumer is has a big impact on feelings and behavior. Space, noise, people, animals, temperature – all these are important to note. Solving this mood mystery quickly will help avoid strong emotions. Many such “place stressors” are described below.

Environmental Stressors

Factor Impact Try This
Space Crowding or isolation Arrange space for greatest comfort, create open space
Health Pain, fatigue, the blahs Watch for signs of illness, inform other people, pursue treatment
Time Peak and weak times of day for focusing Ask or discover the best times to accomplish certain tasks
Transitions Abrupt changes cause confusion and stress Understand transition rituals (ask family, friends, your QP) and make sure plenty of time is available for changes from one activity or environment to another
Fatigue Low energy, reduced attention, quicker to anger; fatigue also increases pain Schedule activities at person’s best time of day, ask about sleeping patterns, assure rest periods if necessary, allow for transitions
Weather Individualized – temperature, light, wind, and noise (thunder) affect people differently Know and understand an individual’s reaction to weather patterns, maintain an awareness of weather changes
Sound Excites, overwhelms, or soothes Be aware of noise and its effects on individual consumers
Work practices Changes center of focus from consumer to procedure Maintain steady focus on consumer and your job, assure rights training
Respect Creates opportunities and acknowledges differences Discover and understand comfort routines, listen, support options and opportunities for choice

Preventing Crises

People with disabilities often have limited options for discharging such stress. They often also have limited opportunities to use release stress. A lack of control over individual choices also causes stress. These choices may be as simple as when to take a bath, or as complex as who to marry. I know I would be frustrated and angry if I did not have control over these decisions. For each of us, including people with disabilities, having the freedom to make (what others may see as) mistakes is a part of life. In fact, it is so important that as individuals, societies, and nations, we are willing to fight for the right to choose.

When we see “non-compliant behavior”, anger, stubbornness, or aggression, we must always ask – is this a communication? Have I missed an earlier warning? Did I step on somebody’s toes by overlooking a preference or choice? Have I not listened well enough to notice a headache or sinus infection?

So what am I supposed to do, you may be asking?

Three things are most important:

  1. Be aware of your own stress levels, emotions, and health, and how these may alter your feelings and behavior.
  2. Be aware of the stressors, emotions, and health of the person you are supporting, and how these things can alter his/her feelings and behavior.
  3. Know the consumer’s methods for reducing stress and calming down – then assist the consumer to choose such options by offering opportunities to do so. Remember those two critical factors – options and opportunity.

When people are forced through circumstances to relentlessly suffer pain, stressors, or strong emotions without comfort or release, eventually the flight or fight response will emerge. “Translating” all forms of communication is important, including speech, behavior, and body language.

Communication

For our purpose here, remember that if things with a consumer seem confusing, and maybe are leaning toward becoming tricky or dangerous, you do not need to be alone. Communicate immediately with your supervising Q, or anyone else in the local office. Communicate your thoughts to others around you if they have a stake in the support system for the consumer (family, treatment team member, etc.). Try to rally support before behavior escalates to another level.

SO THE BIG QUESTION – WHAT AM I SUPPOSED TO DO WHEN A CONSUMER IS GETTING UPSET?

Communication techniques are critically important if behavior is escalating toward dangerous possibilities. Using your “soft” power can be very effective.

  • A low tone of voice, confident stance, reassurances, and praise for every positive choice or action (”thanks for talking to me about this”) will help de-escalate many situations.
  • Stay relaxed, make sure people have plenty of personal space, and gently prompt the use of coping or relaxation skills. (But always be sure to practice relaxation or anger management skills when people are relaxed and happy.)
  • As soon as possible, redirect the individual to positive activities.
  • Do not threaten, plead, whine, or beg – a matter of fact tone and relaxed posture is reassuring.

Last but certainly not least, the Qualified Professional helping you become a successful employee will review the service plan and other information about the person you will be supporting. During this training (client specific competency), you will learn individual preferences, routines, and health factors as well as proven methods for avoiding crises for the individual you will be working with.

Interpreting Body Language*

Domain Positive Cues Negative Cues
Eyes Looking at you, sustained eye contact, normal blinking Looking down or up, avoiding eye contact with you, rapid blinking
Head Turning towards you or towards the task at hand Turning away
Face Smiling, relaxed Frowns, grimaces, blank expression
Arms Reaching towards you, loose at sides Stiff at sides, crossed (tightly)
Torso Shoulders are level and relaxed, back is straight Shoulders are stiff, back is arched
Muscle Tone Relaxed Jerky movements
Hands Held open with relaxed fingers Clenched fists, pointing at you or something else
Speech Soft, even speech pattern Loud, whining, angry, threatening
Overall Relaxed posture, even movements Jerky movements, moving away from you, tension

* adapted from “North Carolina Interventions: Prevention/Alternatives Workbook”

Consumer Rights

Sometimes people with disabilities may become angry or confused because they do not enjoy the full exercise of the various rights and privileges as other citizens. Here are a few of the most important.

  • All people with disabilities have the right to dignity, privacy, humane treatment, and freedom from physical punishment, abuse, neglect and exploitation.
  • People with disabilities have the same privilege to make mistakes as anyone else.
  • All consumers retain the same rights as any other citizen unless a court has declared them incompetent. Incompetence is often strictly defined, meaning that people with guardians still have most of the rights and privileges the rest of us do. For adults, this includes the right to vote, marry, work, have kids, and make decisions about daily life. No Turning Point Services employee may interfere with the full exercise of a consumer’s rights.
  • All consumers have the right to state any complaints they have about services received from Turning Point Services, Inc. without fear of reprisal or termination from services.

Reporting Abuse, Neglect or Exploitation of a Consumer

As an employee of Turning Point Services, Inc., you are required by law to immediately report any alleged or suspected instances of abuse, neglect, or exploitation of a consumer. Request assistance from (in order of contact) your supervising Qualified Professional, the Clinical Director (828-433-4719), or the CQI Director (828-443-2982). They will assist you in making reports to the local Department of Social Services (DSS). If you are unable to contact any of these folks, and have direct evidence of abuse, neglect, or exploitation, make the report directly to the local county DSS via telephone.

Search & Seizure

Search and seizure of a consumer or his living area shall be made by a Turning Point Services employee only under the following emergency condition – when the life and/or well-being of the consumer and/or persons within direct proximity to the consumer are known or suspected to be at risk due to the known or suspected possession of a weapon or materials which could be used to inflict harm or injury.

If possible, staff should consult with their immediate supervisor prior to conducting a search of a consumer or his living area and request the supervisor’s presence and/or assistance.

Restrictive Intervention Definitions and Procedures

The policy of Turning Point Services is to provide services using the least restrictive and most effective positive treatment methods. Turning Point employees will make every effort to prevent the need for physical restraints and/or any other form of restrictive intervention. Emergency Restrictive interventions (emergency restraints) are to be used only when danger is close or damage is just about to happen. Then, only restrain the consumer long enough to pass through the danger.

The use of emergency restraints is limited to emergency situations defined as the need to stop a behavior that places a consumer in imminent danger of abuse or injury to self or other persons, or when substantial property damage is occurring to such a degree that probable injury to self or others seems likely. Physical restraint shall only be used as a last resort; shall never be employed as retaliation or for the convenience of staff; shall not be used in a manner that causes harm or abuse.

Planned restrictive interventions are used only after there is a formal written behavior plan developed and overseen by a psychologist, then approved by the Human Rights Committee, and after the psychologist or designee trains TPS staff on implementation of this behavior plan.

All Turning Point Services employees are trained in Positive Alternatives at Turning Point Services (such as this training). We will also include in this training individual, person-centered training to prevent restraints as delivered to you by the supervising QP.

Most people with developmental disabilities will never need a restraint of any kind at any point in life. Using the tools of communication as found in this training, we can help assure that almost all consumers never need to be physically restrained. Our goal at Turning Point Services is to do just that, eliminate all physical restraints. The fact is, however, that this is not always possible, and a very few consumers may need physical restraints to stay safe.

Any staff that are required to use restraints (as written into a behavior plan) must also be trained in Parts A and B of North Carolina Interventions (NCI). Or, if a consumer’s treatment team can predict the need for emergency (meaning rare and unplanned) restraints, the TPS employee must complete the NCI course also.

At Turning Point Services, the use of simple ‘time out’ and/or ‘exclusionary time out’ must be used only when less restrictive interventions such as positive reinforcement, training, redirection, verbal prompting, and de-escalation techniques have failed. We also require that the use of any “time out” must be described in an approved treatment plan before you can use it. Simple Time Out means the removal of a person from positive reinforcement and from other people to another space within the same activity area. The length of time out should be specified in the treatment plan, but should be no longer than 15 minutes for anyone, and less than that for younger children. Exclusionary Time Out is the removal of a person to separate area or room from which the exit is not barred. In all cases, exclusion must be less than 15 minutes long, even less for young children.

Isolation Time Out and Seclusion are NEVER to be used by Turning Point Services personnel.
Isolation Time out is the removal of a person to a separate room from which the exit is barred by staff but not locked and where there is continuous supervision by staff for the purpose of modifying behavior. Seclusion means to isolating a person in a separate locked room for the purpose of controlling behavior.

Physical Restraint

Physical Restraints (see definitions below) are the only restrictive interventions ever used by TPS employees. Physical restraint must be used only by people trained in NCI, and each restraint must be less than 15 minutes long.

Physical Restraints are used ONLY:

  1. in case of emergency, that is, if there is IMMINENT danger of someone being hurt or when substantial property damage is occurring, and always as a last resort; or,
  2. when there is a formal written behavior plan developed and overseen by a psychologist and the psychologist or designee trains TPS staff on implementation of the behavior plan.

You must call your immediate supervisor anytime you use a restraint. The only two physical restraints approved for use by Turning Point employees are defined below.

  1. Physical restraint: a temporary physical intervention that restrains movement for any duration. Physical restraints are executed ONLY by those with current NCI or comparable certification, utilizing approved techniques.
  2. Protective devices: A form of physical restraint utilizing a device (strap, splint, collar, bandage, etc) that is applied for a period of time. Protective devices must be ordered by a physician (M.D.) and used with the intent of controlling unacceptable behavior, defined as behavior that causes injury.

These procedures should NEVER be used:

  • Corporal punishment
  • Substances administered that would induce painful bodily reactions.
  • Electric shock therapy (excluding medically administered electro convulsive therapy – shock therapy).
  • Insulin shock
  • Unpleasant tasting foodstuffs.
  • Administration of unpleasant (noxious) substances such as excessive noise, bad smells, or splashing with water.
  • Any potentially painful procedure, except when medically or therapeutically ordered by the appropriate professional.
  • As an employee of Turning Point Services, Inc. you are prohibited from knowingly causing pain or injury to a consumer. This includes not only physical pain, but also psychological distress, harassment, or the intentional arousal of anxiety or fear.
  • You may not borrow, sell, or take money or possessions from a consumer.

Any violations of the preceding rules governing restrictive interventions may constitute abuse, and will be treated and reported to authorities as such.

Confidentiality Rules

Confidentiality is an outcome of respect. As an employee of Turning Point Services, Inc. you will be required to sign an Acknowledgement of Confidentiality form. All employees who have access to consumer information are bound by strict confidentiality rules as specified by the state of North Carolina. Confidential information is any information that you learn, either written or verbal, that relates to a consumer and that was obtained in connection with the performance of your duties as an employee. As such, this information is not “yours,” and is not free for you to share with others.

Any consumer information you obtain in your duties can only be shared with those employees who also have a role in that consumer’s care and treatment; this includes the case manager, your employer, and other care providers directly involved with the consumer’s care. This does not include care providers who previously worked with your assigned consumer or fellow employees of Turning Point Services, Inc. who work with other consumers.

As much as you may be tempted to do so, do not go home and discuss your work in any way that might identify consumers. You should not discuss consumers in public when you are not working. You never know who could be listening or who may know the consumer and his/her family or friends.

Unauthorized release/disclosure of information by a Turning Point Services employee can result in disciplinary action, including termination of employment, and/or a misdemeanor charge with a $500.00 fine for a first offense and up to $5,000.00 for a subsequent offense. Due to confidential material, consumer records should be handled with care. This includes data sheets, progress notes, timesheets, or any document that contains the consumer’s name. Any information pertaining to a consumer shall be kept safe and confidential. All transported documents (such as your documentation) should be securely contained within an unlabeled folder, envelope, or briefcase to prevent exposure of sensitive material. Finally, Direct Care Employees may NEVER make a decision regarding the disclosure of information. Consult with your assigned Qualified Professional before releasing or sharing any confidential information.

Please click on the link below to open the competency quiz. You can complete the quiz on the computer and then print it out once you have finished.

Positive Alternatives Training Quiz