De-escalation Techniques
08/04/2016
De-escalation
Prevents agitation from escalating using a
caring approach that incorporates
concepts of personal space and anxiety/
agitation reduction
reduction.
Can calm an anxious/agitated person.
Uses non-violent crisis intervention
techniques to prevent injury to the person
or others.
De-escalation Techniques
Liz Masanz
DON
Norwood Health Center
Katrina Czys
Legal Services/Crisis Supervisor
Wood County Human Services
2
Agitated Behavior
Progression to Violence
Severe Agitation
Can be present in anybody
Has many causes that vary from person to
person
May be directly related to a:
-- physical illness
-- mental illness
-- psychosocial issue
Vi l
Violence
!
Early Agitation/Anger
Anxiety
Can be very challenging to deal with!
3
Psychosocial Factors
Psychosocial Factors
Feeling violated
-- Touched
-- In “personal space”
-- Condescended
-- Put down
Stress
Lack of sleep
ETOH use/abuse and drug use
-- PCP
Loss of job
Loss of family
Antagonistic relationship
Dysfunctional family
Recent personal tragedy/loss
Basic needs threatened
Feeling “cornered”
Loneliness
5
CIP Training: Portage-Wood Counties
4
6
1
De-escalation Techniques
08/04/2016
Physical Illness
Physical Illness (con’t)
Most common medical causes of agitation:
-- Urinary tract infection
-- Delirium
-- Previous head injury
-- Electrolyte or vitamin imbalance
-- Dementia/Alzheimer’s
-- Hypoglycemia (low blood sugar)
-- Diabetic ketoacidosis
7
Medications
CVA (stroke)
Brain tumor
Liver failure
Infections (sepsis, late syphilis, AIDS)
Fever
Low cardiac output
Post anoxic state
Withdrawal
 Alcohol
 Psych and other medications
8
Physical Illness (con’t)
Side Note
Less common medical causes:
-- Myxedema (hypothyroid – low throid)
-- Thyrotoxicosis (hyper thyroid)
-- Hypertensive Encephalopathy,
-- Wernicke’s Encephalopathy
-- Huntington’s Chorea
-- Heavy metal poisoning/Bromide poisoning
Don’t assume that an agitated person with
a Mental Health history is agitated due to
his/her mental health condition.
The person needs to be assessed for an
underlying medical reason.
Remember, an early sign of illness is a
mental status change, especially in the
elderly.
9
How we can cause agitation
Ten Domains of De-escalation
Behaviors and attitudes that can cause agitation:
-- Our own fear
-- Apathy
-- Biases
-- Anger
-- Disgust
-- Ignoring the patient or faking attention
-- Body language
-- Argumentative
-- Insensitivity to cultural practices
-- Inconsistency
11
CIP Training: Portage-Wood Counties
10
Respect personal space
Do not be provocative
Establish verbal contact
Be concise
Identify wants and feelings
Listen closely to what the patient is saying
Agree or agree to disagree
Lay down the law and set clear limits
Offer choices and optimism
Debrief the person, other people involved.
12
2
De-escalation Techniques
08/04/2016
Dealing with the person who is
upset
Progression to Violence
https://www.youtube.com/watch?v=46JP5i
by7yM
Office interview about exercises
Severe Agitation
Violence!
Early Agitation/Anger
Anxiety
13
Assessing the situation
The Anxiety Factor
What is the person doing?
How are they acting?
What is the person saying?
How are they saying it?
What is their body language?
What is their facial expression?
Who else is involved?
Anxiety often precipitates agitation
-- Unfamiliar situation, setting or person
e.g. talking with a store clerk, librarian, clerk in office
15
De-escalation video
-- Pending surgery
-- Newly diagnosed illness or problem
-- Ill family member or recent death of a
someone close
-- PTSD
-- Getting bad news
16
Interventions for Anxiety
https://www.youtube.com/watch?v=pBe4A
32fpyI&feature=player_embedded
17
CIP Training: Portage-Wood Counties
14
Reduce stimulation – sounds, lights, activity
around them
Approach the person from the side, and in a
non-threatening
g manner when at all p
possible
Offer short explanations of your interaction
-- a procedure in a clinic or ER
-- a job interview, paying a bill at a window, purchasing something
Be consoling and compassionate
18
3
De-escalation Techniques
08/04/2016
About Communication
More Interventions for Anxiety
Assume they are listening and slowly
processing what is going on inside their
head and in the room.
If it’s a procedure in a clinic/hospital or waiting:
– Allow 11 sec between what yyou say.
y
– They have to reset and start processing
words all over again each time someone says
something even if it is the same sentence.
 Allow a comforting family member, friend or clergy to
be present – offer to call someone
 Allow the person to engage in relaxing activities such
as listening
li t i tto music,
i reading,
di
watching
t hi TV
Use sentences of 5 words or less
Use ‘reverse yelling’ (talk quieter)
19
Reduce Arousal / Anxiety:
Deep Breathe
Other techniques to reduce arousal
 If they are still nervous, tense, anxious, suggest
another physical activity that can make them feel more
centered, calmer.
“Before we go any further, let’s take a
minute to just take a few breathes. Let’s do
it together.”
“Let’s

Let s take 3 deep breaths like this”;
this ;
– Breathe in (count 4), hold (count 4), blow it out
(Count 4), repeat.
– “It’s ok to make a sound as you breathe in and
blow the air out”
Repeat 3-4 times.
21
– With the hands at their side, have them clench their
fists 4-5 times
– Cross their arms over and tap
p the opposite
pp
shoulder
about 20 times.
– Feel their toes, wiggle them, move their foot, (go up
the leg to the knees etc if they need more
guidance/support)
– Drink some water
– Count all the dots or red items in the room
– Name 2 things they see in the room, touch 2 things,
name a smell, name a sound
– Take a minute – touch something soft, listen, smell,
taste
22
Building Trust and Rapport –
cont.
Building Trust and Rapport
Be genuine, open, honest and consistent.
Use “I” statements – take responsibility for
what is happening. Explain what you are
trying to do, why.
 Avoid the temptation to interact in a way that
ultimately may violate trust
– Examples: don’t make a promise you can’t keep,
bargain or make a deal you can’t keep
 “I’m not going to…”
 “You
You won’t
won t be put in the hospital
hospital.”
 “You won’t go to jail”
– “II am trying to make sure that you are safe and
that you get the help that you need”
– “I’m concerned that you will …. “
– “I would like to …. because….”
 Stay in the ‘here and now’ - defer long term
questions
– If they are wandering in conversation, bring it back
to the situation at hand
– e.g. what is it they need, why are they in the
store/library, do they hurt, are they having pain,
where is the pain
Use ‘and’ instead of ‘but’ and use ‘please’ and
‘thank you’ often
23
CIP Training: Portage-Wood Counties
20
24
4
De-escalation Techniques
08/04/2016
Examples of What to Say:
Continued…
 Paraphrase
– “Okay, let me make sure I understand you, You’ve told
me that people are bothering you and that your case
manager is not helping you. That your meds are hurting
you because they make you feel sick. Did I understand
you correctly?”
Other examples of responses:
– “What I hear you saying is . . . . “
– “If
If I am hearing you right . . . . “
– “Let me see if I understand what you’re saying
...“
– Person: “I don’t know what I am going to do. My family
doesn’t want me here.”
 RESPONSE: “You’re not sure where you can stay for
awhile, but home doesn’t seem like the best place
right now.”
 If you ask questions, focus on ‘what’, ‘how’ - and the ‘here
and now’
– Avoid ‘why”
– Instead: “Can you tell me more about that?”
25
26
Set Limits
Empower Through Choice
Empower the person to choose
– Try to offer choices – only 1 or 2.
– Examples:
* Explain exactly what behavior is inappropriate
 Would you like to sit here or there?
 Do you want help to lie down or can you do it
yourself?
 I need to take your blood pressure, would you
prefer your right or left arm?
* Explain
E l i why
h b
behavior
h i iis iinappropriate
i t
* Allow time to respond
– If one approach doesn’t work, try another
* Enforce the consequences
27
28
Example –Set Limits
Examples – Setting Limits
“It looks to me like you are pretty upset, and I
want to help you. But I am afraid someone is
going to get hurt by those stones you’re tossing.
So I’d like you to stop tossing them and step up
here on the curb so I can talk to you and try to
understand what is going on with you today.”
“Joe, I want you to stop throwing the stones or, if
you prefer, step over here with me on the grass
and throw them in the grass while we talk. What
is best for you?”
“Jack, I understand that you are upset and
that you feel like no one is listening to you or
doing enough to help you. But you and I
need to let these people get back to work
here, so we are going to have to get out of
this waiting room. I’d like you to walk with
me down the hallway to an empty room so
you and I can talk.”
29
CIP Training: Portage-Wood Counties
30
5
De-escalation Techniques
08/04/2016
Early Signs of Agitation
Talking quickly or suddenly getting quiet
Talking to self
Sweating
Attitude
Early anger
Person in store – becomes
upset/confused/anxious
-- If an intervention is not done at this
point, the person’s agitation may escalate
31
32
Interventions for Early Agitation
Interventions for Early Agitation
 Non-threatening communication
-- Ask the person questions like:
“Are you alright?”
“Is there something bothering you?”
-- Make observations about the person:
“Y llook
“You
k angry””
“You look upset”
-- Offer assistance:
Ask, “What can we do to help you?” and follow
through, or if you cannot help the person, try to find
someone who can
 Non-threatening communication
-- Pick your battles – Agree to disagree
-- Meet reasonable requests
 Other interventions
-- Allow the person time to verbally vent
-- Offer quiet time or a “time out”
-- Ask the person what they need to remain in control of
their emotions
 Other options – depending on your setting (e.g. jail, NH)
-- Offer diversionary activities– ask the person
what they like to do to relax (music, reading,
TV, visiting family/friends)
-- Offer and give medications
33
Interventions for Early Agitation
Interventions for Early Agitation
Have your hand in plain view and have
them open and at your sides
 Non-threatening body language
 Stand at an angle towards the patient
– The Crisis Prevention Institute calls this the
– This prevents the person from fearing that you
are going to harm them in some way
“Supportive Stance”
– Allows you to stay out of their personal space
space—at
at
least a leg’s length away (their leg, not yours)
– Allows the person more room to move, which
decreases their feeling of being “trapped”
– Allows you room to lean back or back up should the
person strike out and still maintain your balance
In general, be as non-threatening as
possible
Assume that the person has a real
concern and LISTEN
35
CIP Training: Portage-Wood Counties
34
36
6
De-escalation Techniques
08/04/2016
Interventions for Early Agitation
 When communicating with an agitated person:
Interventions for Early Agitation
By approaching the person in a nonthreatening, caring manner, it
communicates to the person that they are
safe.
safe
It can often prevent them from escalating
Preventing full-blown agitation is much
easier than dealing with a highly agitated
person.
Video – man in movie theater
– Be firm, but kind
– Set limits
– Stay calm and do not yell (Talking loudly may be necessary,
however)
– Do not threaten the person
– Do not put them down
– Do not laugh at the person
– Do not challenge the patient
– Do apologize if you did or said something that inadvertently
upset he patient.
37
What to do if …
38
Examples
 The person seems to be hearing voices or is
talking/having a conversation with ‘someone’ OR
 The person believes something is happening that you
don’t see
Demons in the cell phone
CODE - example in Corrections Facility
– Someone is reading their mind or sending messages by TV, cell phone
or FBI or CIA or someone is trying to harm/kill them or snakes are in the
room
 How to respond
– Ask - Are you hearing people talking or voices? What are they
saying? Are they telling them to do something?
– Avoid a discussion about what they are telling you details about
what they are seeing or believe is happening
– Do not try to explain it away or say that you see/hear it too.
– Speak to the emotions behind it
 Listen for their words about their feelings about it
 If they don’t tell you a feeling, what would be a reasonable
emotion if it was happening?
39
40
What if things escalate…..
Signs of Severe Agitation
Should the person escalate to severe
agitation, the same above principles apply.
However, specific interventions are
necessary to protect yourself and others.
others
Yelling
Cursing
Name calling
Posturing
Pacing
-- Intervention is required at this point to
prevent the person from becoming
violent
41
CIP Training: Portage-Wood Counties
42
7
De-escalation Techniques
08/04/2016
Monty Python shows us how not
to argue
Moyers Types of Aggression
Instrumental Aggression-Not driven by emotion
– Used as a technique to get what they want.
Fear Driven Aggression
– The p
person wants to avoid being
g hurt.
– Do not use a ‘show of force’.
https://www.youtube.com/watch?v=kQFKtI
6gn9Y
Irritable Aggression
– 1st type: Their boundaries are violated. The person
feels cheated, humiliated, or wounded emotionally
– 2nd type: Chronic angry person.
43
Instrumental Aggression
 They give no reason for their anger.
 Looking for a reason to go “Off”
44
Fear Driven Aggression
Not driven by an emotional response
Use unspecified counter offers
“If I can’t leave right now I’m going to hurt
someone”
Are they feeling attacked? Paranoid? or
psychosis?
Give the fearful person space.
Do not have a ‘show of force’.
– Response: “ I don’t think that’s a very good
idea”
– This may escalate the individual
Do not intimidate or make him feel
threatened.
“Why not’?”
– Response: “ There will be consequenses you
would have to face for that”
45
Fear Driven Aggression
Irritable Aggression
Match the person’s pace
Repeat reassurance
1st form-patient feels humiliated, cheated.
Patient is trying to regain his self-worth
and integrity
W t to
Wants
t be
b heard
h d and
dh
have hi
his ffeelings
li
validated (even if he is not right) Identified
by patient telling you what made him
angry.
Set conditions for patient being heard.
– They are safe
– You will stayy with them ((or find someone else
who will be there)
– Decrease the verbal tone.
47
CIP Training: Portage-Wood Counties
46
48
8
De-escalation Techniques
08/04/2016
Irritable aggression
Example
 2nd form- Chronically angry at the world
–
–
–
–
Looking for an excuse to “GO OFF”
They give no reason for their anger
They want to release the constant pressure from their world view
They make erratic and unrealistic demands, may be happy about creating fear
and confusion and may feign attacks to intimidate others.
 How to respond/interaction
–
–
–
–
Do not react in a startled or defensive way
way, they are looking for an emotional response from
anyone who is an audience.
Remove others and the “audience” if possible
Use emotionless response
Use the broken record response and set clear limits
 Let him know you are willing to work with him only when he cooperates.
 Set firm limits to protect the person
 May do exactly the opposite and test the limits and end up in more
restriction situation
49
50
Interventions for Severe Agitation
Interventions for Severe Agitation
If you feel the situation is escalating to
severe agitation, call 911 – or have
someone else call
Keep yourself safe:
 Do not let yourself be cornered!
 Always keep yourself between the agitated person
and the door.
 This gives you an escape route if necessary
 Do not turn your back on a potentially violent
person
 Back out of the room if you leave
 Never go “hands on” by yourself
51
Interventions for Severe Agitation
Interventions for Severe Agitation
Always protect other people
Do not let others form a crowd
Above all: NEVER strike out at a person
or threaten them
-- This will agitate the person more
-- This can also cause serious legal
ramifications
 This can cause agitation to escalate
 It can also cause others to become agitated or
anxious
Options:
 Take the person away from the audience
 If you can’t do that – have someone take the
audience away from the person (or you can ask them
to ‘move on’ - leave the area)
53
CIP Training: Portage-Wood Counties
52
54
9
De-escalation Techniques
08/04/2016
Signs of Violence
Interventions for Severe Agitation
 Sometimes family members can be helpful in
de-escalation
Hitting
Kicking
Biting
Spitting
Punching
Damaging property
 This can also be emotionally traumatic for some
families, especially if this is not “normal” for their
loved one
Sometimes family members are the “cause” of
the agitation
55
Self protection: General Guidelines
56
Self protection: General Guidelines
Things that can be used as weapons:
-- Scissors
-- Pens/pencils
-- Eating utensils (even plastic), plates, plate warmers,
water pitchers
-- Vases, anything glass or ceramic, pictures
-- Furniture
-- Belts, robe ties
-- Tubing (IV, O2, etc.)
-- Sheets, pillowcases, gowns
-- Hemostats
Always be aware of the following:
– Bad lanyards that are not “break-away”
– Long necklaces
– Dangling earrings
– Long hair—always pull back
– Neck ties or stethoscopes around your neck
57
Available Recources
58
Discussion
Mental Health Support and Education
Team
Mental Health information on Intranet
C
Consultation
lt ti S
Service
i
CPI Training
Calling the Mental Health Unit
Article Verbal De-escalation of the agitated
patient “Janet S Richmond” Taft university
59
CIP Training: Portage-Wood Counties
60
10