De-Escalation in the WorkplaceA I D S U n i te d

S e n i o r P ro g ra m M a n a g e rAlicia Downes, LMSW

Welcome

Objectives

By the end of the webinar participants will:

1. Describe the causes and correlates of aggressive behavior among patients.

2. Increase knowledge of 7 Stages of Escalation

3. Demonstrate skills to evaluate and assess how to work with clients when they become aggressive

4. Identify ways to de-escalate situations to create safety for you and the client.

Addressing Aggressive Behavior

1. Describe the causes and correlates of aggressive behavior among patients.

OBJECTIVE

Definition and Types of Aggression

An aggressive patient is one who has the potential to harm or is harming themselves or others.

Aggression can be:• Physical

– hitting, kicking, biting, using weapons, and breaking things or other possessions

• Verbal– scolding, teasing, profanity, insults,

Traits and factors that may Trigger aggression

• Psychiatric illness

• Substance abuse

• Prior history of violence

• Highly stressful situations– Removal of children

– Involvement with DCS

– Court proceedings

– Compliance with services

– Termination of parental rights

• Ages 15-40, esp. males

• Certain feelings– powerlessness

– Fear

– Grief

– feeling of injustice

– Boredom

– humiliation

• Access to weapons

• Physical disability or chronic pain

• Personal history of child abuse

North Carolina Division of Social Services and the Family and Children Resource Program: Children's Services Practice Notes, vol. 3, 1998.

Causes of Aggression

• Confusion• Pain• Previous learning or lack thereof • Modeling and imitation• Medication• Loss• Environment• Frustration• Mental Illness (Delusions or hallucinations)• Sexual or physical abuse• Lack of internal control

OBJECTIVE

2. Increase knowledge of the 7 Stages of Escalation

7 Stages of Escalation

1. Calm – Person relatively calm / cooperative.

2. Trigger - Person experiences unresolved conflicts . This triggers the person’s behavior to escalate.

3. Agitation – Person increasingly unfocused / upset.

4. Acceleration - Conflict remains unresolved. Person FOCUSES on the conflict.

7 Stages of Escalation

5. Peak - Person out of control / exhibits severe behavior.

6. De-escalation – Vents in the peak stage, person displays confusion. Severity of peak behavior subsides.

7. Recovery - Person displays willingness to participate in activities.

Colvin, G., & Sugai, G. (1989). Understanding and Managing Escalating Behavior (ppt). Retrieved 22 January 2012 from http://www.pbis.org/common/pbisresources.

Visual of Stages of Escalation

Colvin, G., & Sugai, G. (1989). Understanding and Managing Escalating Behavior (ppt). Retrieved 22 January 2012 from http://www.pbis.org/common/pbisresources.

OBJECTIVE

2. Identify safe options to prevent and manage patient aggression.

Verbal De-Escalation is an intervention for use with people who are at risk for aggression.

It is basically using calm language, along with other communication techniques, to diffuse, re-direct, or de-escalate a conflict situation.

Verbal Interaction Guidelines

1. Show respect and model calm interactions2. Define your role and explain the rules3. Listen, take your time, restate your understanding of

the situation4. Do not allow yourself to be induced into their

emotional state5. Form an agreement with the client about the issue,

validate the difficulty6. Explore options7. Bridge to the next person or activity

Verbal Response Options

• Clarification– A question beginning “Do you mean that…” or “Are you

saying that…” plus a rephrasing of the patient’s message

• Paraphrase– Rephrasing the content of the client’s message

• Reflection– Reflecting the emotional part of the patient’s message

• Summarization– Two or more paraphrases or reflections that condenses the

patient’s message

Special Considerations

Physically Aggressive Situation

• Step back

• Use care in body language

• Be alert

• Get help

• Act defensively

BODY LANGUAGE55% OF COMMUNICATION IS NON-VERBAL

1. 4. Identify ways to de-escalate situations to create safety for you and the client.

OBJECTIVE

Variables to Control

• Yourself

• The aggressive client

• Other people

• The environment

Yourself

• Self-care

• Calming and grounding techniques

• Knowing your limits, strengths, resources

• Understanding of trauma

• Clothing and appearance

• Body language and movement

The Client

• History of past aggression

• Demographics (including body size and strength)

• History of past trauma

• Type of drug used

• Mental health status

Other People

• How does witnessing aggression affect others

• Is it possible to have them relocate

• Are witnesses causing

aggression to escalate

Environment

• Layout, lighting, access to exits

• “Could that be used as a weapon?”

• Staffing levels

• Availability of back-up or security staff

• Trauma-informed (physical, emotional, psychological, and social safety)

Phases of an Aggressive Incident

• Preparation

• Intervention

• Documentation

• Processing

• Monitoring

Preparation

• The best way to reduce aggression is to prepare

• Know yourself (self care assessment and plan)

• Know your client (calming solutions form)

• Know your resources

Intervention

• Body language

• De-escalation

Intervention: De-escalation

• Simply listening

• Distracting the other person

• Re-focusing the other person on something positive

• Changing the subject

• Use humor (sparingly) to lighten the mood (be very careful with this!)

• Motivating the other person

• Empathizing with the other person

• Giving choices

• Setting limits

Intervention: De-escalation

• Communication Barriers:

– Pre-judging

– Not Listening

– Criticizing

– Name-Calling

– Engaging in Power Struggles

– Ordering

– Threatening

– Minimizing

– Arguing

Teamwork

Working in Teams

• Teams of two to three people works best. One person working alone is at a major disadvantage. Teams larger than three may cause additional confusion.

• Procedures for working as a team include non-physical and physical elements.

Working in Teams

Non-Physical Elements

• Male-female teams work best• Get help whenever possible• Negotiate, don’t give in, but go half way• Don’t make promises you can’t keep• Don’t lie to the person• Avoid plays for power and control• Distraction and redirection are good options• Communicate• Agree to disagree

Working in Teams

Physical Elements:

• Establish a leader

• Prepare environment, know your exits

• Stay out of close range

• Keep your stance (T Stance)

Almost Done!

Summary

• Violent behavior is common in mental health and health care settings

• Incidents of aggression put you and the patient at risk

• Preparation is the best defense

• Good self-care and a trauma-informed environment can help manage the impact and reduce aggressive incidents

• Maintaining good verbal and physical communication skills will help reduce the likelihood pf aggressive incidents and decrease the risk of injury when they do occur

References

Occupational Health & Safety Agency for Healthcare in BC (2005). Preventing Violent and Aggressive Behaviour in

Healthcare: A literature review. Vancouver, BC.

Tardiff, K ., Marzuk, P.M., Leon, A.C., Portera, B.A, & Weiner, C. (1997). Violence by patients admitted to a

privatepsychiatric hospital. American Journal of Psychioatry, 154(1), 88-93.

Tateno, A., Jorge, R., & Robinson, R. (2003). Clinical correlates of aggressive behavior after traumatic brain injury.

Journal of Neuropsychiatry, 15(2), 155-160.

El-Badri, S.M., & Mellsop, G. (2006). Aggressive behavior in an acute general adult psychiatric unit. Psychiatric

Bulletin,2006(30), 166-168.

Carvalho, H.B., & Seibel, S.D. (2009). Crack cocaine use and its relationship with violence and HIV. Clinics, 64(9),857-

866

Soyka, M. (2000). Substance misuse, psychiatric disorder and violent and disturbed behaviour. British Journal of

Psychiatry, 176, 345-350.

Amore, M et al. (2008). Predictors of violent behavior among acute psychiatric patients: Clinical study. Psychiatry and

Clinical Neurosciences, 62, 247-255.

Colvin & Sugai, 1989 Understanding and Managing Escalating Behavior. Center on Positive Behavioral Interventions and

Supports

Thank You!

To my colleague David Stanley Jr for sharing some of his resources.