Using the Violence Risk Appraisal Guide (VRAG)

Introduction

The Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006) is a tool that can be used to estimate statistically the risk of recidivism. It is comprised of 12 items that are associated with a risk of re-offending and is completed with all available information. You can download the full VRAG in PDF format. The Sexual Offender Risk Appraisal Guide (SORAG) is reviewed in another article.

The VRAG is an actuarial risk assessment, involving a mathematical technique applied to determines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This approach eliminates the bias found in unstructured judgement.

The VRAG has been examined in over 40 studies, and has been found effective even with individuals who have a lower IQ. (Camilleri & Quinsey, 2011)

Completing the VRAG

The first step to completing the VRAG is to complete the Childhood & Adolescent Taxon Scale. Below, where a request for information relates to an “index offense” that is the one that led to the individual entering the Criminal Justice system

Childhood & Adolescent Taxon Scale (CATS) Worksheet

This scale includes 8 items that are scored from 0 to 1, based on the coding guidelines provided. These items are:

  1. Elementary School Maladjustment
  2. Teenage Alcohol Problem
  3. Childhood Aggression Rating
  4. More Than 3 DSM Conduct Disorder Symptoms
  5. Ever suspended or expelled from school
  6. Arrested under the age of 16
  7. Lived with both biological parents to age 16 (except for death of parents)

Conduct Disorder Symptoms

Next, the assessor will complete the list of Conduct Disorder symptoms, circling those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  • 1. Often bullied, threatened or intimidated others
  • 2. Often initiated physical fights
  • 3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  • 4. Was physically cruel to people
  • 5. Was physically cruel to animals
  • 6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  • 7. Forced someone into sexual activity
  • 8. Deliberately engaged in fire setting with the intention of causing serious damage
  • 9. Deliberately destroyed others’ property (other than by fire setting)
  • 10. Broken into someone else’s house, car, or building
  • 11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  • 12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  • 13. Before [age] 13, stayed out late at night, despite parental prohibitions
  • 14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  • 15. Before [age] 13, was often truant from school

Cormier-Lang Criminal History Scores for Non-Violent Offenses

This scoring form allows you to answer item number 5 below, the Criminal History Score for Non-Violent Offenses Prior to the Index Offense. This score is developed by counting the number of non-violent offenses and applying a weight to them. For instance, bank robbery is counted x7 while Indecent Exposure is counted x2. So an individual who has two instances of Indecent Exposure and 1 instance of Bank Robbery would have (2×2 = 4) + (1×7 = 7) = 4+7 = 11.

Violence Risk Appraisal Guide (VRAG) Items

Next are the 12 VRAG items. The tool provides detailed coding instructions for each of these:

  1. Lived with both biological parents to age 16 (except for death of parent):
  2. Elementary School Maladjustment:
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense):
  5. Criminal history score for nonviolent offenses prior to the index offense
  6. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release):
  7. Age at index offense
  8. Victim Injury (for index offense; the most serious is scored):
  9. Any female victim (for index offense)
  10. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  11. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  12. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
  13. (Technically 12b) bCATS score (from the CATS worksheet)

Scoring the VRAG

Determining Risk

Risk categories are provided in the VRAG manual. They are approximated here although more detail is available in the complete manual. For each score, if an individual is close to the next score you should list them as a combination of the two. For instance an individual whose score is -10, -9 or -8 would be listed as Low-Medium rather than just Low.

  • -24 to -8 is Low Risk
  • -7 to +13 is Medium Risk
  • +14 to +32 is High Risk

Determining Rate of Recidivism

The risk of recidivism is presented below, from the same manual (pages 283-286):

Probability of Recidivism
VRAG score 7 years 10 years
< −22 0.00 0.08
−21 to −15 0.08 0.10
−14 to −8 0.12 0.24
−7 to −1 0.17 0.31
0 to +6 0.35 0.48
+7 to +13 0.44 0.58
+14 to +20 0.55 0.64
+21 to +27 0.76 0.82
> +28 1.00 1.00

This is to be interpreted as a percentage. For instance a score of -10 is in the -14 to -8 category; therefore an individual would have a 7 year recidivism rate of 12% and a 10 year recidivism rate of 24%.

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Brown, J. & Singh, J.P. (2014) Forensic Risk Assessment: A Beginner’s Guide. Archives of Forensic Psychology. 1(1). 49-59. Retrieved on January 20, 2017 from http://www.archivesofforensicpsychology.com/web/wp-content/uploads/2015/01/Brown-and-Singh1.pdf

Camilleri, J.A. & Quinsey, V.L. (2011) Appraising the risk of sexual and violent recidivism among intellectually disabled offenders. Psychology, Crime & Law. 17(1) 59-74

Cite this article as: MacDonald, D.K., (2017), "Using the Violence Risk Appraisal Guide (VRAG)," retrieved on May 29, 2017 from http://dustinkmacdonald.com/using-violence-risk-appraisal-guide-vrag/.
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Level of Care Utilization System (LOCUS)

Introduction

The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)

Parameters

The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.

Scoring

Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid

Research

Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.

References

American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on May 29, 2017 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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Language Learning for Social Service Workers

Introduction

An important part of cultural competency for social workers is the ability to speak a language understood by their clients. In the US and Canada there are significant populations of Spanish, French, and South Asian language speakers, and their ability to access social work support may be impaired by the lack of speakers of those languages.

The good news is that it’s not an insurmountable goal to learn a language, especially with new technologies. Many resources exist for free that help an individual learn their language of choice. Some people wonder about the time commitment, but luckily the US State Department has already answered this question.

The State Department operates the Foreign Service Institute (FSI), a language school for US Diplomats. Based on their extensive research and experience actually training complete beginners to speak a variety of languages, they’ve separated them into four categories. Each of these categories are listed below with some of the languages that fit into them:

Category I Language (languages closely related to English)

  • Danish
  • Dutch
  • French
  • Italian
  • Norwegian
  • Portuguese
  • Romanian
  • Spanish
  • Swedish

Category II Languages (languages similar to English)

  • German
  • Indonesian
  • Malay
  • Swahili

Category III Languages (languages moderately different from English)

  • Albanian
  • Amharic
  • Armenian
  • Azerbaijani
  • Bengali
  • Bulgarian
  • Burmese
  • Czech
  • Dari
  • Estonian
  • Farsi
  • Finnish
  • Georgian
  • Greek
  • Gujarati
  • Hausa
  • Hebrew
  • Hindi
  • Hungarian
  • Icelandic
  • Kazakh
  • Khmer
  • Kurdish
  • Lao
  • Latvian
  • Lithuanian
  • Macedonian
  • Mongolian
  • Nepali
  • Pashto
  • Polish
  • Russian
  • Serbo-Croatian
  • Sinhala
  • Slovak
  • Slovenian
  • Somali
  • Tagalog
  • Tajiki
  • Tamil
  • Telugu
  • Thai
  • Tibetan
  • Turkish
  • Ukrainian
  • Urdu
  • Uzbek
  • Vietnamese

Category IV Languages (languages significantly different from English)

  • Arabic
  • Chinese (Mandarin)
  • Japanese
  • Korean

For each of these categories the State Department prescribes how much time it will take for an English learner to reach a useful level of language knowledge. For Category I languages you must study for 600 hours, for Category II 750 hours, for Category III 900 hours and for Category IV 1100 hours. Of course, this may be an under-estimation because these individuals are in class for 30 hours a week, but it gives you a good idea.

Choose a Language

Choosing a language is a very personal choice, but there are a few things that might be able to help you decide: number of speakers (or number of speakers in your area), ease of accessing language material, career usefulness and closeness to your native language.

For individuals who choose a language based on number of speakers, here are the top 5:

  1. Chinese (Mandarin)
  2. Hindi
  3. Spanish
  4. English
  5. Arabic

Ease of accessing language material is hard to quantify but there are certainly many products available for the Romance languages (French, Spanish, Italian, etc.) as opposed to others.

Career usefulness can be looked at in terms of languages critical to US interests (just a few of the 60 languages listed:

  1. Arabic
  2. Chinese (Cantonese and Mandarin)
  3. Hindi
  4. Indonesian
  5. Korean
  6. Russian
  7. Turkish

For those interested in using their language in their Social Work career, knowing the number of US speakers may be important:

  1. English
  2. Spanish
  3. Chinese (Cantonese and Mandarin)
  4. French
  5. Tagalog

Measuring Fluency

If you had attended an FSI or DLI (Defense Language Institute – the military’s language school) course, you would be considered at a level useful enough to understand the language as spoken and to produce it yourself. But how do you know what that actually means, especially when compared to another individual? That’s where various proficiency tests and assessments come in.

Although I won’t go into detail about specific language-related tests (like the DELF tests for French), I will discuss two common standards, the Common European Framework of Reference for Languages and the Defense Language Proficiency Test.

Common European Framework of Reference for Languages (CEFR)

The CEFR is the worldwide standard for proficiency. It is grouped into 6 categories, A1, A2, B1, B2 and C1 and C2. A1 and A2 are beginner and low-intermediate levels of proficiency. B1 and B2 are considered intermediate users of the language who are independent, while C1 and C2 are advanced language learners. For each language you wish to take, there are CEFR assessments that match.

An FSI language course would place a learner at B1 at completion, enough to use the language independently, engage in conversations and understand the world around them.

Defense Language Proficiency Test (DLPT)

The DLPT is another proficiency test for languages. The reason that I list it, is that there are a lot of people using DLI language learning materials who might want to understand this test. After completing the DLPT, a learner is assessed a scale from 0-3, with 2/2 generally corresponding to B1, and 3/3 corresponding to C1. In each category, there are plus (+) options available to indicate a level of proficiency higher than the number.

Language Learning Resources

Language learning resources differ based on what language an individual is learning. Below are a few resources I’m familiar with a heavy influence towards French (the language I’m learning now), Spanish (a language I spent 3 years learning in high school) and Arabic (the next challenge I want to tackle.)

Duolingo

Available Languages: Spanish, French, German, Italian, Portuguese, Russian, Dutch, Swedish, Irish, Turkish, Danish, Norwegian, Polish, Esperanto, Hebrew, Ukranian, Vietnamese, Welsh (In Beta): Hungarian, Greek, Romanian (In Progress): Swahili, Czech, Hindi, Korean, Klingon, Indonesian

Price: Free

Description: Duolingo offers you a skills tree with all the information you need to reach approximately A2 (some people say B1) of your language, and learn about 2000 words in the process. It’s very intuitive and by working through the course you learn to translate between your native language and English while developing knowledge of vocabulary.

Pros: It’s simple and very fun. You get to see your progress and work your way to the end. You get a trophy when you finish!

Cons: The grammar instruction can be light in some areas which can be very confusing

Memrise

Available Languages: (Made by Memrise Team): English, Japanese, French, Spanish, German, Chinese, Korean, Italian, Russian

Price: Free

Description:  Memrise is like a flashcards program on steroids, but organized into courses. You do a lot of filling in the blanks or other exercises that teach you words and helps build your vocab.

Pros: Great audio narration accompanies the cards. There are courses for the most common languages that correspond to the CEFR Levels. For instance, French has 7 courses. French 1-3 correspond to A1, French 4-6 correspond to A2, and French 7 corresponds to B1.

Cons: There’s zero grammar instruction which means Memrise is not useable on its own. There’s also no indication on the number of words, and many of the smaller courses (not created by the Memrise team) are of varying quality.

Lingvist

Available Languages: French, German, Russian, Spanish

Price: Free

Description: Lingvist is a deceptively simple but very powerful program designed to build your vocabulary up to 5000 words. It uses an endless card interface that presents you with a “fill in the blank.” You can double click on the sentence or any word to get a translation to help you, and if you get it wrong you’ll get an opportunity to fill in the correct answer.

Pros: Never-ending interface allows you to go much longer before you get bored or tired. Beautiful interface. 5000 words beats Memrise and Duolingo

Cons: No grammar instruction similar to Memrise

GLOSS (Global Language Online Support System)

Available Languages: Albanian, Arabic (Egyptian, Gulf, Iraqi, Levantine, MSA, Sudanese, Yemeni), Azerbaijani, Balochi, Chinese (Mandarin), Croatian, Dari, Farsi, French,German, Greek, Hausa, Hebrew, Hindi, Indonesian, Japanese, Korean (North and South), Kurmanji, Pashto, Portuguese (Brazilian and European), Punjabi, Russian, Serbian, Somali, Sorani, Spanish, Swahili, Tagalog, Thai, Turkish, Turkmen

Price: Free

Description: Created by the US military, GLOSS exercises are sorted into the 3/3 DLPT proficency areas and allow you to view real material in those languages and answer questions or complete exercises.

Pros: Lots of exercises available for lots of languages, native material means it’s very high quality

Cons: Not a language course per se

Headstart2

Available Languages: Amharic, Arabic (Egyptian, Iraqi, Levantine, MSA, Moroccan) Baluchi, Cebuano, Chavacano, Chinese (Mandarin), Dari, French, German, Hausi, Hindi, Indonesian, Italian, Japanese, Korean, Kurmanji, Malay, Pashto, Persian-Farsi, Portguese (Brazilian, European), Russian, Somali, Spanish, Swahili, Tagalog, Tausug, Thai, Turkish, Turkmen, Urdu, Uzbek, Yemeni

Price: Free

Description: Brought to you by the Defense Language Institute, Headstart2 provides you with approximately 750 words, and basic grammar with the goal of getting you to 0+ (memorized proficiency) on the DLPT.

Pros: For languages like Hindi, Arabic and Pashto that don’t use the Latin alphabet, Headstart2 is a great teaching resource

Cons: Vocabulary is very military-focused (if you consider that a con.) Will need to move on to other courses quickly.

Peace Corps

Available Languages: Albanian, Arabic, Armenian, Azerbaijani, Bambara, Bengali, Bulgarian, Chinese, French, Georgian, Hausa, Kyrgyz, Macedonian, Malagasy, Mongolian, Romanian, Moldovan, Russian, Siswati, Thai, Tswana, Turkmen, Ukrainian, Wolof

Price: Free

Description: The Peace Corps requires all individuals who deploy as volunteers to reach a certain level of language training. Although the Peace Corps uses a simple proficiency scale (Beginner, Intermediate, Advanced, with Low, Intermediate, High for each level.) Part of these training resources are available online.

Pros: Very audio-focused, with lots of survival phrases

Cons: Some languages have limited material; the accents can be challenging

Special Operations Language Training (SOLT)

Available Languages: IndonesianRussian, SerbianSpanishThai, many others (if active-duty military)

Price: Free

Description: Similar to the Peace Corps, members of the US Special Forces are required to reach a certain level of language proficiency (in their case 1/1 on the DLPT scale.) When completed in person, this 18 weeks (for Pashto) or 24 weeks (for Arabic); other languages are shorter.

Pros: Not a lot of “fluff”, courses get down to business quickly

Cons: Only a few courses are available online

Cite this article as: MacDonald, D.K., (2017), "Language Learning for Social Service Workers," retrieved on May 29, 2017 from http://dustinkmacdonald.com/language-learning-social-service-workers/.
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Manage Stress Like a Marine

Military members salute

Introduction

Nobody knows stress management like the US military. Stress management has been recognized as an important part of ensuring an effective fighting force since the First World War. The US Marine Coprs manual MCRP 6-11C, “Combat and Operational Stress Control” (2010) is one part of this program.

Bite-sized takeaway: Know yourself and your team (whether that’s fellow Marines in a military environment or family and coworkers in a civilian enivronment) and be alert for any sudden, persistent or progressive change in their behaviour

Combat Stress Reactions

A combat stress-reaction (CSR) is the military equivalent to acute stress reaction, the state of agitation seen as a response to combat or other stressful or traumatic situations. These symptoms, if not properly managed, can lead to Post-Traumatic Stress Disorder (PTSD.)

The most common combat stress reaction symptoms include:

  • Slow reaction time
  • Difficulty with tasks and prioritizing
  • Excessive concern with minor issues
  • Indecision
  • Focus on familiar tasks
  • Loss of initiative

It can be hard to recognize when something is a normal reaction to battle or something that requires more intense medical or psychological support. One example given is that mild shaking while being fired upon or mortar rounds are incoming is very normal. On the other hand, intense shaking post-battle can be incapacitating and will require additional support.

Normal reactions to battle can include:

  • Perspiration
  • Chills
  • Nausea
  • Vomiting
  • Loss of appetite
  • Abdominal distress
  • Frequent urination
  • Incontinence

Dreams and flashbacks are one area that are commonly associated with PTSD. MCRP 6-11C notes that vivid battle dreams are a totally normal part of working through and processing combat experiences. Additionally, flashbacks are normal as long as they are recognized as flashbacks. These may become part of PTSD if the acute stress reaction is not managed but can be treated.

Some issues that may require more intensive support are stress-related blindness/deafness or partial paralysis. These can improve with reassurance from comrades, unit medical personnel or the batallion physician. As well, a reaction known as a panic run, where the service member rushes about without self-control or awareness (US Army, 1950) also requires evacuation for treatment.

Managing Combat Stress Reactions

If you need to, remove a soldier’s access to his weapon if he is experiencing combat stress reactions and you’re not sure he can keep himself safe. Additionally, give him simple tasks to do when not sleeping, eating, or resting. Strategies to manage combat stress reaction include:

  • Treating the service member close to the front (better outcomes happen when the service member is out of danger but still in theatre)
  • Utilize the BICEPS Model of Combat Stress Control
    • Brief (they should be out of the field no more than 3-4 days)
    • Immediate (treatment should be identified and started quickly)
    • Centrality (they should be treated out of hospital but close to the front)
    • Expectancy (the chain of command should have faith the service member will recover)
    • Proximity (keep the service member close to the rest of their unit so they can offer support)
    • Simplicity (the treatment should focus on the member’s return to duty)

Sleep Deprivation

Night time is the time to retain or gain the initiative, so it is common for operations to occur then. This increases the chance that sleep deprivation affects military member abilities to manage combat stress. Increasing circulation through activities like moderate exercise or drinking hot beverages may shorten start-up time after a short time sleeping.

After 36-48 hours of complete sleep loss, a minimum of 12 hours of sleep will be required to regain functioning. Keep watch for sleep drunkenness, which is the opposite (reduced functioning as a result of sleeping too much.)

Grief and Death

One area that many military members struggle with is grief and death. So-called open grieving, talking about grief and loss with comrades can help alleviate anxiety, whether this is a fear of the military member’s own death or survivor guilt from having lost friends and fellow military members on the battlefield.

Stress Management Techniques

It’s recommended that each service member know two stress management techniques: a slow or long one that can be used for deep relaxation and a quick one that can be deployed on-the-job.

Psychological Stress Management

Confidence is one of the strongest defences against stress. “If men can’t fight back, fear will overtake; as long as they can return fire they will not fear.”

Cognitive exercises include positive self-talk, visualization, rehearsal and meditation. Positive self-talk involves telling yourself that things will work out for you, rather than assuming and thinking the worst. Replacing bad self-talk with good self-talk can help increase your resilience.

Visualization is a cognitive technique that involves imagining good things. When you remember something that made you angry, your body reacts the same (your blood pressure rises and constricts), and you’re “right back there” mentally. By visualizing happy things, your blood pressure reduces and you find yourself more able to cope.

Rehearsal is similar to visualization but specifically involves yourself going over the tasks in your mind that you are about to perform. This helps to give you more confidence that you’re able to perform these tasks. Finally, meditation is a form of deep breathing and relaxation to improve one’s emotional state.

Physical Stress Management

Good nutrition and hydration is important. Remember the acronym HALT, the four items that make regulating our emotions more difficult (HALT is “Hungry, Angry, Lonely, Tired.”) If the service member only drinks when they are thirsty, they’ll become dehydrated.

Increasing your aerobic fitness increases your ability to handle stress

Mastering relaxation techniques allows you to reverse the combat stress process. Physical stress management techniques include deep breathing, and progressive muscle relaxation.

Breathing Techniques

Deep Breathing involves slow, deep inhaling. Deep breathe for 2-5 seconds, then exhale slowly over 2-5 seconds
Perform this exercise 5 times for a quick mind-clearing, or continuously at night to promote sleep. Diaphragmatic breathing (which is deep in the chest, as opposed to shallow) is especially helpful for stress control

Muscle Relaxation is a special form of relaxation where you concentrate on one muscle group at a time, tensing and relaxing your limbs in order to relax your entire body. The quick version involves tensing all your muscles simultaneously, holding this state for 15 seconds, letting your body relax, and shaking out all the tension.

The long version involves starting in your feet and working up, body part by body part until you reach your head, tensing and then relaxing the limbs.

Pre and Post-Deployment Reactions

New members to a unit are more likely to become casualties than experienced members. Keeping this in mind, experienced members can help mentor new ones to build resilience and support. “Startle reactions to sudden noise
or movement, combat dreams and nightmares and occasional problems with sleeping, and feeling bored, frustrated and out of place” wee all identified as being common after deployment, as the service member re-integrates into their community.

References

US Army. (1950) TM 8-240 Psychiatry in Military Law. Washington, DC: Department of the Army and the Air Force.

US Marine Corps. (2010) MCRP 6-11C, “Combat and Operational Stress Control”. Retrieved on September 5, 2016 from http://www.marines.mil/Portals/59/Publications/MCRP%206-11C%20%20Combat%20and%20Operational%20Stress%20Control.pdf

Cite this article as: MacDonald, D.K., (2017), "Manage Stress Like a Marine," retrieved on May 29, 2017 from http://dustinkmacdonald.com/manage-stress-like-marine/.
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Preventing Burnout on Crisis Lines

Introduction

Burnout is defined as a state of ineffectiveness comprising “emotional exhaustion, depersonalization, and reduced personal accomplishment.” (Maslach, 1982) It is a pervasive and frustrating state, accounting for a large portion of the turnover experienced in mental health services, including volunteer and paraprofessional organizations like crisis lines.

There are a number of models of burnout, but one stage model is presented below from Cherniss (1980) and reproduced in Kinzel & Nanson (2000):

Stage 1: Stress

Stress is the first stage of burnout, when an individual is functioning at a level that exceeds their optimal operating conditions. This could be because of internal factors (like wanting a promotion or being intensely devoted to work), external factors (like being given a larger caseload due to budget cuts) or interpersonal factors (like a negative relationship with a colleague or supervisor.)

Stage 2: Strain

When a person experiences strain, they have now operated in a state of stress long enough that they are reaching a point of emotional exhaustion. Their coping begins to be maldaptive and they often experience negative somatic or physical complaints like headaches.

Stage 3: Defensive Coping

In the final stage of burnout, an individual’s burnout begins negatively impacting their ability to take calls or otherwise perform their helpline work. There is a lack of empathy or concern for the callers and this may be accompanied by blaming the callers or detachment from the situation. At this stage

Causes of Burnout

There are a variety of causes of burnout. Some listed by Kinzel & Nanson (2000) include:

  • Nature of crisis calls
  • Negative emotions experienced during the calls like anger or guilt
  • Countertransferrence (being triggered by one’s own experiences while supporting another)
  • Repeat or regular callers creating a feeling of powerlessness or ineffectiveness
  • A lack of effective coping skills

Additionally Kinzel & Nanson note studies that revealed the presence of magical thinking (assuming the situation would get better on its own) and escape-avoidance coping skills were associated with an increase in burnout, along with detachment and personality responsibility.

Paradoxically, workers who were too involved (taking personal responsibility for callers) were more likely to experience burnout as were volunteers who were detached. The least likely to experience burnout is the crisis line worker who stays emotionally connected to a caller but also recognizes that their life is their life and it is not the worker’s responsibility to change it. (Mishara & Giroux, 1993)

Assessing Burnout

The Maslach Burnout Inventory (MBI; Maslach, C., Jackson, S.E., & Leiter, 1996) is the most common measure for assessing burnout. It is a 21-item scale that produces scores on three subscales: Emotional Exhaustion, Personal Accomplishment and Depersonalization.

Morse et. al. (2012) notes example cut-off scores for the three scales as follows “emotional exhaustion scores of at least 21, depersonalization scores of at least 8, and personal accomplishment scores of 28 or below” but with the caveat that those scores may be lower than necessary, artificially inflating the presence of burnout in mental health professionals.

Helpline managers will need to take the lead in determining whether their workers are experiencing symptoms of burnout. This may be witnessed in the quality of listened calls, in the comments made on call reports, or contacts that occur off the lines. For instance, volunteers who:

  • Started giving more advice to callers
  • Talked to staff about frustration with non-suicidal callers “wasting” distress line time
  • Missed shifts because of not being emotionally capable

These may be situations where you would recommend burnout prevention activities. Potential treatments for burnout are discussed more in-depth below, but in the helpline environment a leave of absence (LOA) from the lines for a while, increased self-care or decreased activity (e.g. limiting hours weekly or monthly) can help avoid burnout.

Treatments for Burnout

Smullens (2013), writing for Social Worker magazine notes a number of strategies including:

  • Stimulus control and counterconditioning. Stimulus control involves active decisions like not choosing to eat lunch at your desk or bringing a plant into the office while counterconditioning involves physical exercise, hobbies, or other diversions
  • Mental health treatment. Therapists should seek their own therapy when their personal issues interfere, and someone who is experiencing or worried about experiencing burnout is certainly under that category
  • Diversify. This refers to the idea of changing your responsibilities to give you non-clinical activities that help to refresh and restore you. For many social workers, this involves teaching, conferences, or other activities, but for heplline workers it can also involve becoming a leadership volunteer, serving on a non-profit Board or another form of volunteerism

Oser et. al. 2013) added to this with burnout prevention strategies including:

  • Coworker support. Being able to vent to colleagues who have a sense of what you’re going through and understand your organizational culture can be very helpful. Feeling like (or being) isolated without anyone to discuss concerns with can exacerbate feelings of ineffectiveness. This applies to helpline workers as well, who can make frequent use of debriefing
  • Clinical supervision. Supervision can also help reduce feelings of isolation and ineffectiveness by giving individuals an opportunity to identify maladaptive coping strategies or other issues that may lead to burnout

Research is continuing so hopefully in the future we have specific therapies designed for burnout and options; a number of individuals leave the helping professions each year because of burnout, which is obviously not ideal.

References

Bowden, G. E., Elizabeth Smith, J. C., Parker, P. A., & Christian Boxall, M. J. (2015). Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service. Clinical Psychology & Psychotherapy, 22(6), 488-501. doi:10.1002/cpp.1912

Cherniss (1980). Staff Burn-Out. Job Stress in the Human Services. Sage Publications.

Kinzel, A., & Nanson, J. (2000). Education and debriefing: Strategies for preventing crises in crisis-line volunteers. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 21(3), 126-134. doi:10.1027//0227-5910.21.3.126

Maslach, C. (1982). Burnout: The Cost of Caring. New Jersey: Prentice-Hall, Inc.

Mishara, B.L., Giroux, G. (1993). The relationship between coping strategies and perceived stress in telephone intervention volunteers at a suicide prevention center. Suicide and Life Threatening Behavior, 23(3).

Maslach, C., Jackson, S.E., & Leiter, M.P. (1996) Maslach Burnout Inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.

Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Administration and Policy in Mental Health, 39(5), 341–352. http://doi.org/10.1007/s10488-011-0352-1

Smullens, S. (2013) What I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession. Social Worker. Retrieved on December 28, 2016 from http://www.socialworker.com/feature-articles/field-placement/What_I_Wish_I_Had_Known_Burnout_and_Self-Care_in_Our_Social_Work_Profession/

Cite this article as: MacDonald, D.K., (2017), "Preventing Burnout on Crisis Lines," retrieved on May 29, 2017 from http://dustinkmacdonald.com/preventing-burnout-on-crisis-lines/.
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