RECOVERY INSTITUTE OF SOUTH FLORIDA, INC.
VERBALLY DE-ESCALATING PATIENTS IN TREATMENT
TOTAL CE CREDITS: 2.0
VERBALLY DE-ESCALATING PATIENTS IN TREATMENT
The overall goal of this program is to familiarize the participant with aggression control and deescalation techniques.. The participant will develop skills to manage an aggressive client in a behavioral healthcare setting.
This self-study packet provides Aggression Control education for nursing, mental health, and addictions professional who are licensured and certificated.
- Participants will understand the concept of aggression control.
- Participants will understand the techniques for de-escalation.
- Participants will be able to employ communication and de-escalation skills to manage aggression and prevent violence from escalating as far as possible.
Hour One: Understanding Aggression Control
Hour Two: Techniques for Handling Aggressive Clients
Methods: Online study guide, posttest and evaluation.
Purpose: The purpose of this self-study program is to provide education for aggression control. Learners can expect to understand the concept of aggression control and learn safe techniques.
Managing aggressive and violent behavior has become an essential skill pertinent to all staff providing behavioral services. What was once a skill reserved for those who worked on locked psychiatric units, now is in demand for emergency room staff, outpatient counselors, educators, and security and law enforcement personnel. The need for safe, effective techniques to manage the potentially assaultive person is no longer limited to those who work with individuals who are mentally ill. The clerical admissions worker feels the same fear in today’s human service setting as does the security officer.
Yet, many human service providers do not have the technical skills necessary to manage violent behavior. This lack of skill and training produces normal reactions of fear and self-protection when confronted with violence. If one does not have the necessary skills to manage violence, he naturally reverts to instinctive responses. The challenge of managing violence in today’s workplace can be met only by a commitment from administration to firmly confront the problem with quality training on an ongoing basis. Human service providers need safe, effective behavior management training designed to maintain the Care, Welfare, Safety, and Security of all involved in the intervention process.
Aggression Control is a safe, non harmful behavior management designed to aid human service professionals in the management of disruptive and assaultive people, even during the most violent moments.
The program has several primary objectives:
- Training staff with the techniques effective in approaching and reducing the tension of an agitated person.
- Focusing on the alternatives if a person loses control and becomes violent.
- Instructing staff members in techniques to control their own anxieties during interventions and maintain the best possible professional attitude.
- Providing nonverbal, paraverbal, verbal, and physical intervention skills to allow the staff to maintain the best possible care and welfare, as well as safety and security, for all involved even during the most violent moments.
Two Forms of Aggressive Behavior
As a general rule, there are two ways a hostile person will vent his aggression or hostility: verbally and physically. This is one of the essential tenets of managing aggressive behavior which at first seems obvious, but upon closer examination is a critical key to intervening. Clarification of this point allows the staff member to begin formulating concrete guidelines regarding the procedure utilized during interventions.
These two types of “acting-out” behaviors often become somewhat muddled or confused and are not separated from each other. This leads to inappropriate actions on the part of the staff intervening in the situation.
For example, let us assume that we have an agitated person in an emergency room and his agitation escalates to the point of screaming at select staff who are present.
Occasionally, one will see staff overreact and attempt to use a “hands-on” (physical intervention) strategy in an effort to calm down the individual. Thus staff action may actually precipitate a “physical acting-out” episode. In attempting to use a hands-on approach, the staff has escalated the person’s behavior into a more difficult and more dangerous level. An appropriate analogy is running up to a fire and throwing gasoline on it in an attempt to put the fire out. It does not work, and makes matters more difficult to manage.
On the other side of the coin, we have the staff who may attempt to utilize verbal intervention to safely manage the physically acting-out person. Words are an ineffective means of intervening when a person is hitting, biting, or choking you. In many cases, the person’s auditory channels shut down and they cannot hear you during the peak of the violent outburst. The analogy here is attempting to use a squirt gun to douse a bonfire; it is ineffective.
Therefore, the first principle which must be established is: Avoid overreaction and under reaction. Use verbal intervention skills to intervene with a verbally acting-out person. However, when the aggression becomes physical, you must also have in your repertoire of skills, safe physical intervention techniques to control the physical acting-out behavior.
In any crisis development situation there are four distinct and identifiable behavior levels. The purpose of defining each level is to attempt to meet each level with the appropriate staff response to defuse or de-escalate the crisis development. The four levels model is not meant to oversimplify the complexities of the behavioral process, but rather functions as a workable guideline for the staff member who is intervening. Behavior is anything but neat and packaged. However, the following behavior patterns can be seen in most people who are escalating toward a potentially violent episode. For the purposes of this article, we will be using a typical example of a person waiting for a visitor in a waiting area of any human service setting. As we point out the four crisis development behavior levels, we will also be outlining the four staff responses or staff attitudes to each behavior level.
The Anxiety Level
One of the first behaviors one will observe in the crisis development sequence is the Anxiety Level. Anxiety has numerous definitions in the fields of psychology and psychiatry, but for our example we will simply define anxiety behavior as a noticeable increase or change in behavior which is manifested by a non-directed expenditure of energy.
Let’s assume the person is sitting in a waiting area and a visitor is due at 2:00 p.m. The person glances up at the clock and it is now 2:15. She proceeds to put down the magazine she was reading and begins to pace slowly back and forth, looking toward the window at the street outside the facility. Now the clock reads 2:20.The person goes back to her seat and begins going through the magazine a bit more vigorously. She’s not really reading, but using the magazine to expend some of her built-up energy. Another glance at the clock shows the time to be 2:25. Now she tosses the magazine aside and gets up again, this time pacing more rapidly, and she begins to wring her hands and mutter to herself. All of the previously described behaviors are classic examples of anxiety. It is the instance when one can tell by observing a person’s behavior that something is “different” about her. You may not know the source of the anxiety, but you can clearly tell that something is causing her to expend built-up energy and act differently than she normally would.
The Supportive Staff Response
During the Anxiety Crisis Development Level, it is generally most effective to use a supportive staff response. The Supportive Approach requires the staff to be empathic and actively listen to what is bothering the individual. In this mode of intervention, the staff member should avoid being judgmental and avoid dismissing the person as a “constant complainer.” The individual who is in the Anxiety Level does not need to be judged; she simply needs staff to listen.
Without even realizing it, here is where most potentially explosive situations are defused. As human service providers intervene on a daily basis, they become very adept at offering support. They also develop their own personal styles of conveying this support. It is important, however, that staff understand that although this may seem a routine interaction experienced daily, it is often the key to “nipping the crisis in the bud” and defusing the situation at the onset of crisis development. You don’t have to stretch your imagination too far to envision how a non-supportive approach at this point during the intervention can escalate the situation rapidly.
The Agitated Client
The staff member does not intervene with a supportive approach, the individual refuses to accept the staff’s support, or the staff member arrives too late during the crisis development, there may be the possibility of the individual escalating to the second level, the defensive stage.
The Agitated signifies the beginning stages of loss of rationality. At this point, the person begins to give you cues, verbally and nonverbally, indicating he is beginning to lose control. The Agitated Level is a highly volatile state and usually includes verbal belligerence and hostility. You will find the individual challenging you, your institution, and your authority. The defensive person begins to respond or cue on different modes of communication. Often, at the peak of his defensiveness, he no longer responds to the rational context of your words. Instead, he may be more in tune with other types of communication such as your tone of voice, your proximity to him, or your body posture.
Here is where we see power struggles and “button pushing” begin. Abusive language alluding to your race, weight, sex, and other sensitive areas is spouted.The person is testing you, and testing your limits. He may even solicit help with his verbal barrage from onlookers. Many times the verbal “acting out” strays far from the original issue that upset him, and staff may find themselves defending a completely different topic than originally precipitated the crisis.
This is an extremely critical time during the crisis development. At this stage, the staff can make or break the intervention. If the individual’s irrationality and “button pushing” affects the staff member to the point where he loses his professionalism and becomes irrational, he has little chance of defusing the situation. Irrationality breeds irrationality. If the person senses you are not in control of your behavior, it will serve as further fuel for the fire.
The perfect example happens many times in larger institutions. A crisis alarm or signal that alerts security to report to a particular area is sounded. When security arrives on the scene, they see two people in a heated shouting match, one more agitated than the other. Being a large institution, security’s first task turns out to be determining who is the staff and who is the client. The point here is that during the Defensive Level, it is very easy for the staff member to slip into his own crisis development. Ifthis occurs, no one is in control and the situation is almost sure to escalate.
The best staff response during the Agitated level is to begin Setting Limits, which entails setting behavioral limits for the individual. It is quite clear that a supportive, empathic approach is not very productive when a person becomes irrational and is testing limits. In many cases, support merely feeds into the irrational person’s defensiveness. The individual needs, and at times is actually seeking, structural limits to regain rational control.
There are several critical keys in setting limits. First, make sure that your limits are clear to the person. Don’t assume that she understands why the directive is being issued. Second, be sure that your limits are simple. Don’t make them overly complex. When a person is losing rationality, she does not need five or six options to process. The key is to ensure that any limits you impose are enforceable. For example, if you tell someone she must calm down or you will have to remove her from the area, think about whether or not this is something you are prepared-or authorized-to do. You can almost guarantee that any limits you impose will be tested.
Limit setting should be done as objectively as possible and should not be delivered in a threatening manner. Your goal is to make the person realize that the consequences of her behavior are up to her. The limits you impose on the individual should not merely be enforceable either; they have to be reasonable. Avoid getting yourself into a knowing situation by issuing limits which cannot be enforced.
Behavioral limits do not have to be issued negatively. The “do it this way or else” ultimatum can be the spark which ignites the dynamite in a volatile situation. Inform the individual of the positive consequences resulting from her compliance. Let her make the choice.
For example, if the person is getting too loud, the first step is to let her know why her behavior has to cease. A simple explanation of the fact that the noise is disturbing others can often be enough to calm her down. If it is not, there is no need to threaten the person into compliance. Instead, point out the fact that she can remain in the area if she quiets down. Also inform her that she will have to be escorted out of the area if she continues the behavior. Make the individual feel as though she has a choice; Le., the consequences of her behavior are determined by her decision. This approach will avoid getting you into a no-win power struggle. You must keep in mind that you are there to enforce the consequences of the individual’s choice and not to make the person choose one option or the other.
Limit setting is a skill which requires practice and a calm, professional approach. Verbal abuse by anyone can be frightening, not to mention insulting. It is critical, however, that you maintain your professionalism. A verbal loss of control at this moment may be the reaction that escalates a person into a total loss of control.
The Acting-Out Person
If you do not impose and enforce reasonable limits, the individual simply refuses to follow your directives, or you arrive too late during the crisis development process, you may encounter the third level of behavior-the Acting-Out Person.
This behavior level is defined as total loss of control which usually involves physical aggression. The individual is no longer able to control himself and verbal aggression turns into physical assault. The person may assault staff, other people, or even attempt to harm himself.
Verbal Deescalation – Aggression Control
At this point and no sooner, you must physically control the person’s behavior until he can regain control on his own. Aggression Control should be used only as a last resort. You have now reached the point where all verbal means of managing the situation have been exhausted. The person is no longer responding to reason, and he presents a danger to himself, staff, or other people in the area.
You want to avoid physical intervention for several reasons. First, there are the obvious legal implications of physically restraining someone. Also, physical intervention can be dangerous to the individual and staff. But equally important, you don’t want to use a hands-on approach until it is absolutely necessary because you run the risk of escalating a situation which might have been defused through verbal means.
Physical intervention should never be utilized as a punitive measure. Unfortunately, pain compliance techniques are still a part of the restraint technique repertoire in some agencies and institutions. Besides the ethical questions, pain compliance produces negative feelings between the individual and staff. When a person loses total control, he often does not remember what happened during his outburst. If the first sensation he experiences when regaining control is pain, he will remember that pain. This will lead to difficulty in managing the individual’s behavior during future interactions.
Staff must remember that losing control of one’s behavior is an unpleasant and frightening experience. It is sometimes difficult to keep this in perspective when the aggression or violence is directed toward you. However, most physical acting out in human service environments is not premeditated violence, but simply an explosion of pent-up energy. The staff are simply the object of the explosion because they happen to be present at the time.
The Deescalating is the fourth and final level in the control a crisis situation. Unfortunately, this final stage is often forgotten in many models of crisis escalation, but it may be one of the most important.
During the crisis build-up there is a tremendous build up of energy and tension within a person. At the third or “acting-out” level, a person experiences a total energy expenditure. Anyone who has had to restrain a struggling individual can testify to the fact that this is a total expenditure of energy. This cannot go on indefinitely; eventually there must be a Tension Reduction.
The De-escalation Stage is both physical and emotional. The person “comes down” from the peak of energy output. If you are restraining the person, you can actually feel the De-escalation Stage in the muscles of the body. Often, the individual is emotionally drained, as well.
Many times, the person who moments ago was aggressive and hostile now appears emotionally withdrawn. She may even feel remorseful and be apologetic. This change in behavior can often confuse staff members and they may even become distrustful of this aftermath of the violent episode.
The key point to remember in the De-escalation Stage is that this is the start of control, or a regaining of rationality. The individual who is experiencing De-escalation Stage has been through a very frightening and traumatic experience, some or all of which she may not remember. When she enters Tension Reduction, she may be at a very vulnerable emotional level. Fear, confusion, and remorse are typical emotions felt by the individual during this behavior level. Staff should remember that the act of “going out of control” is even more frightening to the individual than to the staff.
The fourth and final staff response during the individual’s De-escalation Stage is the Therapeutic Relationship, or communication. This is one of the best times to attempt to talk with the person. Surprisingly enough, many times the person is actively seeking communication.
When dealing with potentially violent people, one cannot stress enough the importance of nonverbal communication and its impact on whether the situation escalates. When someone is losing rationality, he tends to focus on nonverbal cues more than on rational communication, such as the context of words. At certain times during the intervention, it seems as if nonverbal communication is the only form of communication that gets through to the irrational individual.
The proximity or distance between you and a possibly violent person is one of the most critical elements in defusing a potentially explosive situation. Even though you may have the best of intentions in moving close to the individual, you must realize that he may not feel the same. Your proximity can be perceived as a threat.
We all have an area surrounding our body which we consider an extension of our physical self. Any “invasion” or encroachment into that area tends to be perceived as a threat, or at least makes us feel uncomfortable. This is commonly known as our “personal space.” Personal space varies with each individual. The critical distance for most people is about 11/2 to 3 feet. Even in non~threatening social situations, we can become uneasy when a person is closer than 2 to 3 feet.
Be sure that you inform the individual what the sequence of events will be. If you are going to move her, let her know where she is going. Tell her why she is being moved. This is a good time to form a verbal contract with her and let her know that if she remains can, you will not need to restrain her again. Within safe judgment, allow the person to “make her own choices” while staff still maintain full control, should another violent outburst occur. The more therapeutic communication you initiate, the quicker she will regain total rationality.
Frequently, as we near a potentially violent person, we tend to forget that his personal space may be much larger than ours. “Stay out of my face!” is a commonly used slang expression. Interpreted, it usually means: “I feel threatened by you because you are coming too close to me.”
When approaching the potentially violent individual, stay in tune with his nonverbal behavior. He will often signal (by nonverbal means) the fact that you are getting too close. Clenched fists, tightening of the facial muscles, and movement away from you as you draw near are very common nonverbal signals. Give him as much space as you can. If the person feels threatened by your proximity, you increase the chances of the situation escalating and his behavior may progress into a level which is much more difficult to manage.
Body posture and motion
How you position your body can also have a significant impact on the nonverbal message you send to the potentially violent person. A face-to-face, shoulder-to-shoulder position is generally perceived as a “challenge position.” You may be speaking to the individual with calm, reassuring words, but if your body is positioned in a challenging mode, you may be delivering a mixed message.
Standing in front of Client
First, you do not encroach on personal space, nor do you present a confrontational position. Second, you offer the person a perceived “escape route,” so he doesn’t feel trapped. Finally, you allow at least one leg-length (about three feet) as a personal safety margin.
Another element of body posture is the positioning of your hands. Many times the individual will be focusing much of his attention on your hand placement. Avoid concealing your hands behind your back. This can be perceived as a threatening pose, but more importantly, the irrational person can imagine you have something dangerous behind your back. It is not unlike the irrational thought process to imagine that you’re holding a gun or knife. Also, keep your hands out of your pockets. They will not do anyone any good resting inside your pockets if the individual escalates and becomes physically aggressive. Keep your hands out in plain view, at your sides if possible.
Communication experts seem to agree that only a minor portion of the messages we send comes through our words. The major part of our communication comes through our nonverbal communication, as well as our paraverbal communication.
Paraverbal communication involves three components: the tone, volume, and cadence of voice. These three components make up most of the context of any message we deliver. Take, for example, the sentence, “Is anything bothering you?” By altering the tone, volume, and rate of speech, we can give this sentence various meanings. It can be a gesture of support or it can be an insulting and sarcastic message. One only needs to alter the inflection to convey a completely different message.
Inflection becomes very critical when intervening with the potentially explosive or violent individual. Staff must be consciously aware of how they are speaking to the person (the paraverbal message), as much as they need to be conscious of what they are saying (the words they use). The best way to monitor your communication with someone is to focus on her feedback. Do not automatically assume that the individual has received the message you intended to deliver; rather, listen to her response.
De-escalation and Interpersonal/Communication Skills
Before anything else happens staff should seek to defuse the situation. A person who is out of control will be under the influence of the adrenal cocktail. Staff should aim to do nothing to escalate their state of mind whilst being prepared to defend themselves if necessary.
Staff should seek to:
- Appear confident
- Displaying calmness
- Create some space
- Speak slowly, gently and clearly
- Lower your voice
- Avoid staring
- Avoid arguing and confrontation
- Show that they are listening
- Calm the person before trying to solve the problem
Staff should adopt a non-threatening body posture:
- Use a calm, open posture (sitting or standing)
- Reduce direct eye contact (as it may be taken as a confrontation)
- Allow the person adequate personal space
- Keep both hands visible
- Avoid sudden movements that may startle or be perceived as an attack
- Avoid audiences – as an audience may escalate the situation
NEVER THREATEN: Once you have made a threat or given an ultimatum you have ceased all negotiations and put yourself in a potential win lose situation.
Explain your purpose or intention
- Give clear, brief, assertive instructions, negotiate options and avoid threats.
- Move towards a ‘safer place’, i.e. avoid being trapped in a corner.
Encourage a reasoning (for their behavior)
- Encourage reasoning by the use of open questions and enquire about the reason for the aggression.
- Questions about the ‘facts’ rather than the feelings can assist in de-escalating (e.g. what has caused you to feel angry?)
- Show concern through non-verbal and verbal responses.
- Listen carefully and show empathy, acknowledge any grievances, concerns or frustrations. Don’t patronize their concerns.
Ensure that your non-verbal communication is non-threatening
- Consider which de-escalation techniques are appropriate for the situation.
- Pay attention to non-verbal clues (i.e. eye contact). Allow greater body space than normal.
- Be aware of your own non-verbal behavior, such as body posture and eye contact.
- Appear calm, self controlled and confident without being dismissive or over-bearing.
Verbal De-Escalation Techniques for
Defusing or Talking Down an Explosive Situation
When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation techniques are appropriate.
There are two important concepts to keep in mind:
1. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible.
2. De-escalation techniques are abnormal. We are adrenally driven to fight or flight when scared. However, in de-escalation, we can do neither. We must appear centered and calm even when we are terrified. Therefore these techniques must be practiced before they are needed so that they can become “second nature.”
It is essential that the Worker Stay in Control of Him/Her Self
1. Appear calm, centered and self-assured even though you don’t feel it. Anxiety can make the client feel anxious and unsafe which can escalate aggression.
2. Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
3. If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you see the client (not in front of him/her)
4. Do not be defensive-even if the comments or insults are directed at you, they are not about you. Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
5. Be aware of any resources available for back up. Know that you can always leave, tell the client to leave or call the police should de-escalation not be effective
6. Be very respectful even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. We want him/her to know that it is not necessary to show us that they should be respected. We automatically treat them with dignity and respect.
The Work should practice the Physical Stance of:
1. Never turn your back for any reason
2. Always be at the same eye level. Encourage the client to be seated, but if he/she needs to stand, you stand up also.
3. Allow extra physical space between you – about four times your usual distance. Anger and agitation fill the extra space between you and your client.
4. Do not maintain constant eye contact. Allow the client to break his/her gaze and look away.
5. Do not point or shake your finger.
6. Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Cognitive disorders in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
7. Keep hands out of your pockets, up and available to protect yourself. It also demonstrates non-verbal ally, that you do not have a concealed weapon
The De-escalation Discussion with the Client:
1. Remember that there is no content except trying to calmly bring the level of arousal down to a safer place.
2. Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Speak calmly at an average volume.
3. Respond selectively; answer only informational questions no matter how rudely asked, e.g. “Why do I have to fill out these (g-d forms?” This is a real information-seeking question). DO NOT answer abusive questions (e.g. “Why are all social workers ass holes?) This question should get no response what so ever.
4. Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both alternatives are safe ones (e.g. Would you like to continue our meeting calmly or would you prefer to stop now and come back tomorrow when things can be more relaxed?)
5. Empathize with feelings but not with the behavior (e.g. “I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff.)
6. Do not solicit how a person is feeling or interpret feelings in an analytic way.
7. Do not argue or try to convince.
8. Wherever possible, tap into the client’s cognitive mode: DO NOT ask “Tell me how you feel. But: Help me to understand what your are saying to me” People are not attacking you while they are teaching you what they want you to know.
9. Suggest alternative behaviors where appropriate e.g. “Would you like to take a break and have a cup of coffee (tepid and in a paper cup) or some water?
10. Give the consequences of inappropriate behavior without threats or anger.
11. Represent external controls as institutional rather than personal.
12. Trust your instincts. If you assess or feel that de-escalation is not working, STOP! Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the police.
There is nothing magic about talking someone down. You are transferring your sense of calm, respectful, clear limit setting to the agitated person in the hope that he/she actually wishes to respond positively to your respectful attention. Do not be a hero and do not try de-escalation when a person has a gun. In that case, simply cooperate.