Keilman & Mishler | 70-81
The Power of Collaboration through Behavioral Assessment and Treatment
Stacey Keilman, LCSW, and Lindy Mishler, MS
Torrance State Hospital
(TSH) provides in-patient services for individuals with severe and persistent
mental health needs. This article presents the admission, assessment, and
treatment of a 55-year-old Caucasian man, referred to as DS with Intellectual
Disability, Schizophrenia, Chronic Paranoid Type, and Depression Not Otherwise
Specified (NOS). The initial assessment indicated significant trauma symptoms
in combination with undetected medical issues. However, treatments delivered at
TSH did not result in a clinically significant reduction in problem behavior. A
Functional Behavioral Assessment (FBA) was then completed to understand the
significance of DS's behaviors and provide strategies and supports that would
be beneficial to reduce the impacts of these actions, primarily in the hospital
setting. Direct and indirect data determined that the strategies resulted in a
significant decrease in behaviors while at TSH. Similar improvements occurred
in relationships with other patients and staff.
This article discusses the collaboration between State entities and the clinical implications of the assessments conducted.
Case Presentation
DS is a 55-year-old,
single, Caucasian male with a long history of admissions to community and State
hospitals. He was initially admitted to Torrance State Hospital due to
assaulting a nurse in a medical facility where he was seeking treatment for an
unknown medical issue. Upon admission, DS exhibited perseveration on thoughts
which included staff was going to cut off his testicles or people were
attempting to steal his items and keep them from him. He also showcased
significant anxiety due to not seeing his sister, with whom he previously had a
close relationship. He was then transferred to TSH's psychiatric unit due to
suicidal threats, self-injurious behaviors, and a significant regression in
self-care skills. Once on the psychiatric ward, staff described his behavior as
impulsive and physically aggressive towards other patients, staff, and
property. This included kicking, shoving, or charging at other patients; and
hitting, biting, or spitting at staff. He had also thrown food and drinks;
thrown or flipped tables; punched the walls; and often fell asleep laying on
the floor, preventing others from passing. DS also displayed self-injurious
behaviors such as hitting his head against something, scratching himself, and
throwing himself into a wall. In addition, staff observed DS becoming more
agitated after visits or phone calls with his sister. He would showcase refusal
behaviors with staff requests for taking medications or other task requests
during these times. During the initial presentation and throughout his hospital
stay, DS did not make staff aware if he was experiencing any pain, as evidenced
by his lack of expression when he experienced bleeding and lesions from extreme
jock itch, significant dental issues, and a corneal abrasion he received as a
result of a fight with another patient. Past medical issues included urinary
retention and acute renal failure, benign prostatic hyperplasia, GERD,
hypertension, kidney stones, hypercholesterolemia, and Chronic Obstructive
Pulmonary Disease (COPD).
Evaluation, Treatment, and Silos
Upon reviewing the referral information and prior records; it was identified that DS had a full-scale Intelligence Quotient (IQ) score of 56 from testing administered in early adulthood. This prompted consideration into potential involvement with other systems of care, triggering a conversation with DS's county mental health agency to identify historical information. This review identified that DS was involved with various community resources in the 1980s but was virtually unknown to the mental health/intellectual disability systems until 2006. Further, there was no agency involvement from 2006 to 2016. The mystery of how he maintained in the community for decades without involvement from the various human services systems required additional information since this could help develop strategies, supports, and resources to aid his discharge to community living.
Trauma
Shortly after hospital admission, a Torrance clinician conducted a comprehensive biopsychosocial assessment utilizing DS's sister as the primary source of information. The information gathered during this process uncovered medical issues and a significant change in his support system. Since his previous discharge in 2007, he lived with a caregiver for several years. During this time, he suffered some medical issues, including kidney stones. The arrangement with the caregiver ended, leading him to his psychiatric decompensation and hospitalization. This incident and the tragic loss of his mother in 2006 became two significant traumas affecting his stability.
Treatment
As a result of DS's self-injurious behaviors, he had been placed in several physical holds (a method of restraint with the outcome of purposely limiting physical movement), and a one-piece jumpsuit was ordered to be worn for his protection. His mood vacillated from withdrawn to irritable. At times, he was verbally and physically aggressive. He would become fixated on things and place himself on the floor when matters did not go as expected. He displayed the same perseverations as previously exhibited, and that he was going to die. He injured himself on three occasions by gouging at his wrists with a colored pencil, burning himself with a lighter, and attempting to cut off his genitals. He was an elopement risk during this time as well. The TSH Treatment Team had attempted various interventions to assist DS in gaining and maintaining safe behaviors, but he was not making significant improvements. The staff were demoralized over the lack of progress he was making, and DS expressed feelings of hopelessness. It soon became clear that the psychiatric interventions and strategies that TSH and staff had historically put in place were not effective on DS. Moreover, there was a need to consider other options.
Merging the Silos
When examining the health needs of people in Pennsylvania, the State health system tends to categorize by the individual’s cognitive and psychological, medical, and physiological needs. These divided mental, physical, and behavioral health sectors often complicate thorough treatments as a result of each operating independently from one another. Furthermore, there is no system in place where they can adequately share information across territories. Although this is not a new issue, its complexities have increased over time, causing holes where treatments are concerned. To begin the initial steps in merging the silos, the Office of Developmental Programs started the Capacity Building Institute (CBI). Torrance State Hospital (TSH) staff were invited to join a select group of professionals to meet with the intended goal of sharing philosophies and treatments while ultimately braiding together the mental, physical, and behavioral health territories. During these meetings, case presentations became a joint exercise for staff to share their entities' experiences and successes. It also provided a forum where other groups could recommend treatments or strategies that may not have been previously considered to improve the patient's treatment and address system issues. DS was one of the cases TSH chose to share due to his medical, psychological, and behavioral complexities.
One of the presentations by the Bureau of Supports for Autism and Special Populations (BSASP) was about the process and benefits of Functional Behavioral Assessment (FBA). It was explained that FBA is an evidence-based practice comprised of data collection to understand and recognize the purpose of specific behaviors exhibited by an individual. Once identified, the treatment team can decrease triggers and develop tailored interventions to eliminate problematic behaviors. In addition, the FBA is versatile because it can be used with anyone, in any setting, for any behavior.
Although TSH did have staff trained in the process of FBA, the general practice was not completed routinely, since this approach differs from the typical psychiatric treatment that has long been in place at TSH. Although treatments in State hospitals can be successful1, their interventions historically focused on mental health treatments2 rather than routine use of behavioral interventions to identify and decrease problematic behaviors. Since mental health treatments for the acute population have a significant focus on behavioral reduction rather than teaching new skills, interventions tend to be reactive rather than proactive, leaving the hospital staff in a cycle of crisis rather than proactive mitigation. To help address this issue, TSH requested BSASP complete an FBA on DS. Simultaneously, they also encouraged their staff to be trained in the FBA process, challenging the historical belief of enacting the otherwise unconventional therapeutic strategy in the state hospital setting and breaking down potential cross-system barriers.
Functional Behavioral Assessment3
Two clinicians from BSASP were assigned to complete the FBA at TSH for DS. The first step was to gather information about DS's behaviors. This indirect and direct information was collected through rating scales, assessments, direct observation of DS, interviews with hospital staff and DS's relatives, archived incidents, as well as record reviews. TSH freely provided access to the necessary people and resources for the BSASP staff to obtain the necessary information to be as comprehensive and holistic as possible. Using the information gathered on observed target behaviors, BSASP clinicians designed a customized data sheet for staff to collect additional information. This included the behaviors identified with the most significant and what occurred before and after the behavior. For accurate data collection and consistency across staff, it is considered good practice to ensure that the staff collecting the data have a thorough understanding of the expectations for recording the information. To assist with this, all staff were trained in using the datasheet prior to doing so. However, during the clinicians' initial analysis of the raw data, it was identified that there were still variances in the data being collected. As a result, both BSASP and TSH staff met to discuss confusion and revised the data sheets to make sense to the hospital staff to ensure accurate data collection. These revisions were proven successful after the next data set was analyzed, as evidenced by consistencies across staff in the raw data reviewed.
After collecting enough data to accurately represent all variables, BSASP staff graphed and analyzed the data to create a visual story of what the staff had been seeing over the course of the data collection period. Once developed, the graphs were compiled into a report. Without presenting their own hypothesis, BSASP presented the report to TSH staff and prompted conversation while encouraging staff to develop their own hypotheses based on what they were seeing in the data. Ultimately, TSH staff were able to use the visual analysis to develop their own story of what was occurring with DS, aligning with what BSASP hypothesized before meeting with the team. These similar observations were the foundation necessary to develop individualized recommendations.
Strategy recommendations are supports, strategies, interventions, and treatment recommendations grounded in information gathered and analyzed through the FBA process. They are completely reliant on accurate data, thorough data analysis, and hypotheses developed. Due to the quality put forth in the aforementioned steps, BSASP staff were able to identify the contributing conditions to DS’s problematic behaviors, how they can be addressed, any skills that needed to be taught, communication and social skill barriers, and how the environment and people were responding to DS’s behaviors. This resulted in developing operational definitions of the target behaviors, hypotheses of the functions of those behaviors, behavioral outcomes, and ideas for antecedent (before the behavior), replacement (during the behavior), and consequence (after the behavior has been completed) strategies. Although the strategy recommendations were linked to the hypotheses formulated from the indirect and direct data collected, they were also developed based on the ability of staff to complete them. Thus, a collaboration between BSASP clinicians and TSH staff was essential in developing and solidifying the final recommendation section. These comprehensive recommendations were later revisited to ensure they were effective and produced the intended results.
In order to shift the
staff’s responses from reacting to a crisis to being proactive and mitigating
risks, a Crisis Intervention Plan (CIP) was also developed. Using the
information gathered through the FBA process, BSASP staff were able to
recognize the situations that could be triggers for DS and precursor behaviors.
As a result, a CIP was developed that included triggers to a crisis, details to
assist in delineating the settings in which DS would be in and identify
de-escalation techniques for the TSH staff to implement.
The FBA process not only is designed to develop a list of strategy recommendations and CIP, but it can also be a means for identifying information otherwise undiscovered through its in-depth data collection and assessments. During the completion of DS’s FBA, interviews with DS and his sister identified that he had experienced more severe trauma than previously known. Some traumatic events included the deaths of multiple loved ones, including both of his parents and two close friends. He also experienced severe physical abuse from his previous girlfriend's children. Therefore, a Trauma-Informed Care (TIC) approach was critical to helping DS recover. Without the FBA, the central information regarding trauma would have continued to be missed and not addressed.
Conclusion
Following the FBA, TSH’s
treatment team began to see DS’s progress in maintaining safety. His mood
significantly improved, and he did not present any self- injurious behaviors
over time. In addition, his sister was actively involved in his treatment planning,
including providing historical information that assisted in medication
adjustments. Over the last few months at TSH, DS had gone on day passes with
his sister which had gone well and demonstrated that he was ready for
discharge. DS was ultimately discharged to a group with supports in place to
assist him in maintaining stability in the community.
It was not only DS that had benefited from the CBI’s collaboration. TSH staff experienced benefits as well. Through the FBA process, a data-driven, detailed, and thorough set of recommendations and strategies was made available to support the direct care staff. Torrance leadership supported staff to work with DS, setting a standard for staff to work towards and providing emotional support in times of stress and pressure. CBI became a champion for TSH and partners to come together, without the previous barriers and silos, to identify what DS needed to regain stability and return to his life in the community. The outcome for DS was a great success and demonstrated a complex culture evolution within the State hospital environment from the long-standing pure psychiatric treatment to eventually, total immersion with a data-based behavioral approach. Not only does this experience show the evolution and treatment progress of TSH, it also reflects the importance of collaboration from various stakeholders to meet individuals' complex and unique needs to ensure their long-term success.
1. Grossi PhD L, Osborn PhD L, Joplin MME, MT-BC K, O’Conner MS B. Clinical Interventions in State Psychiatric Hospitals: Safety and Logistical Considerations. Journal of Forensic Psychology Research and Practice. 2020;21(2):152-170. doi.org/10.1080/24732850.2020.1843105
2.
Geller
JL, Shore H, Grudzinskas AJ, Appelbaum PS. Against the Grain? A Reasoned
Argument for Not Closing a State Hospital. Psychiatric Quarterly.
2005;76(2):177-194. doi:10.1007/s11089-005-2338-y
3. Office of Developmental Programs. Functional Behavior Assessment Training. MyODP. https://www.myodp.org/course/view.php?id=1644
Biographies:
Stacey K. Keilman, LCSW: Stacey has been working in
the field of human services for 17 years. Her experience has
been focused in the areas of substance abuse and mental health treatment.
Her various roles have included assessment, treatment
planning and intervention, crisis de-escalation, case
management, social work administration, community discharge
planning, forensic administration, and hospital
administration. Stacey has held several leadership positions at Torrance
State Hospital including Social Work Supervisor, Social Work Manager, Forensic
Unit Director and is currently the Chief Executive Officer (CEO). Stacey
is a strong advocate for the individuals served at Torrance State
Hospital and embraces the Recovery Model.
Lindy Mishler, MS began working as a Clinical Consultant for the Bureau of Supports for Autism and Special Populations, Office of Developmental Programs in 2014. Lindy started her career as a Therapeutic Staff Support (TSS), where she discovered her passion working with children with autism. Since then, she has worked in a variety of positions, including direct support professional, vocational development, and has overseen Pennsylvania’s waiver programs in multiple agencies. Through these experiences, she has been able to expand her knowledge and experiences into other populations including adults with autism, traumatic brain injuries, other physical disabilities, and Mental Health diagnoses. She has a master’s degree in Psychology with a concentration in Applied Behavioral Analysis.
Contact Information
Stacey Keilman
Torrance State Hospital
Chief Executive Officer, LCSW
724-459-4511
Lindy Mishler, MS
Office of Developmental Programs, Bureau of Supports for Autism and Special Populations
Senior
Clinical Consultant