De-escalation and Crisis Intervention Principles.
By Dr. David Dawson for Home on the Hill De-escalation Training Nov 8 2017
A prerequisite for crisis intervention is that at least one person not be in crisis.
Someone needs to take the lead and be the only communicator. That someone must be calm and focused. To achieve this one needs to take a minute or five minutes to dispel all other preoccupations, to call home, to cancel other appointments, to clear the mind. This includes clearing the mind of prejudice, assumptions, and personal needs.
Things can be replaced.
Never intervene to protect property. If property is being destroyed wait until the man or woman has finished, is spent, has quieted. All property can be replaced. Your eye and his eye cannot.
True emergencies requiring immediate action are rare.
Slow down. The only time speed is required and time is important is on the rare occasion when one person is actually harming another. Not threatening. Actually harming now. Words are just words. This includes threat to jump or hurt oneself.
Time is on your side.
Slow down. There is no hurry. This may take all day. A good outcome is far more important than a speedy conclusion. Learn to ignore the pressures to intervene, to “get this over with.” These pressures come from inside, from supervisors, from colleagues, from bystanders. Ignore them. Accept that this may take a while.
There are rhythms and patterns to emotions.
Slow down. A man in a rage will eventually sate his rage. He will have moments of calm, of anxiety, of despair. Emotions wax and wane. Anger eventually dissipates unless repeatedly provoked.
Aggression is (almost always) a response to fear.
- Do not do or say anything that might be perceived as threatening.
This means monitoring boundaries: physical, interpersonal and emotional boundaries.
- Do not intrude on his or her space.
- Maintain a pleasant, non-threatening, but also not excessively expressive face and tone of voice. Maintain a neutral, patient, mildly empathic demeanor. Do not use the overly empathic and falsely understanding tone seen on good cop routines on television. This will trigger suspicion and fear.
- Do not touch. Do not gesture or reach out. Speak calmly and slowly. Move slowly.
- Use few words. Listen.
- Address this person formally. If you know the person’s name use Mr. Mrs. or Miss and the last name. That means even if the ward nurses have been in the habit of calling this man Joe, he is now Mr. She is now Miss or Mrs. If you do not know the person’s name he is now “Sir” and she is “Ma’am.”
- Introduce yourself with full name and title or job.
- Ask permission before doing anything, or moving. Wait for permission before moving, before entering a room, before sitting.
- Never block the door or his escape route with your body. If permission is granted to enter a room (seclusion room, bedroom, front door of house, or other room) enter and move to the side.
- Keep your distance. Large men should always sit on the floor or a chair if possible.
- If possible sit so you can converse in parallel fashion, e.g. side by side, rather than face to face.
- Women may ask if it is all right to bring in a chair. Always sit away from the door.
- Exercise stillness.
- If opportunity arises feel free to talk with the person about anything he wishes or is willing to talk about. It needn’t be about the actual situation.
- Be meticulously honest in your responses.
- Pay close attention to your own emotional responses.
- Do not argue with a delusion.
- Do not argue, period.
- Listen to the non-textual communication. Ignore verbal threats, denials, and refusals.
- But if you see increased agitation ask the person if he would like you to back up, stop talking, leave room, fetch a coffee….
Each situation and context defines your goal. It may be to have this man go peacefully with the police officers, or walk with you back to the ward, or walk with you back to a bedroom and to take a pill, or to assess for safety and be allowed to leave or not. He will know and understand your goal. You do not have to verbally insist upon it or even speak it. Ignore verbal refusals. Do not argue or give choices.
You have presented yourself as non-threatening, as empathic, as honest, as calm, sane, receptive. You have listened. At some point you will see by his demeanor, by his non-verbal communication, by his body posture, his facial expression, that he may now be receptive to your goal. At this time you may verbalize your goal, but quietly, not forcefully, and not in a way that implies anything but choice on his part. If you want him to take medication this can now be offered without words spoken.
A show of force and an authoritative command may work well when the subject for this is relatively calm and sane, and interpreting external information in a rational manner. It is often ineffective when the target is mentally ill, not interpreting information rationally, and it may exacerbate the situation.
Psychotic and paranoid (delusional)
- Don’t argue with a delusion
- You may be perceived as a foe, part of the delusion
- Apart from all the general principles, you may achieve the goal (go to hospital etc) by not directly saying or implying that the subject is ill, crazy, or mental.
- You may be able to interpret upward, meaning without colluding with the delusion, empathize with the feeling and general implications, and be perceived as an ally.
- Be very careful with physical and emotional boundaries.
- This person may feel invulnerable, powerful, and even immortal. He will be talking quickly. He may want to get his message to the world. Again the goal (take a medication, go to hospital, back to a ward) may be achieved by physically in timely manner offering these without overtly stating the need or the reason.
- Use few words. Do not argue.
- Be very careful with physical and emotional boundaries.
- Walk with, parallel conversation.
- Provide security without threat.
- Be prepared to repeat over and over what the situation is.
- Provide orientation (I am, you are, you’re here, this is…..)
- Do not react to the lewd and crude
- Help with a physical task (let me get that for you)
- Touch may be welcome, gentle arm touch eg.
- May be able to distract with activities that are routine.
- Calm, soothing words
- Safe environment (could mean outside, large room, hallway)
- Low stimulus
- Parallel sitting
- Instruction to breathe, focus, relax
- Routines of coffee, tissue