The Art and Science of De-escalation: A 5-Step Formula

James is a patient and client at the HOPE Clinic. He is working, attending college, and planning his wedding. Two-years ago, when he first came to the clinic, through open access, things were totally different: “I am going to kill all of you. You are not here to help. All you care about is a pay check.” James yelled these words to Kellie, in the waiting area. JoAnn, Kellie’s supervisor, who was close by, heard the yelling, saw the situation, and quickly intervened.

In previous articles, I outlined reasons why it is critical to learn and master de-escalation skills, and I gave 5 reasons why patients and clients are likely to escalate. In this current piece, I am going to start delving into the how of De-escalation.

Below is a 5-step formula for you in your journey toward learning and mastering the skills of de-escalation.

1. An Overall Proactive Stance

When JoAnn heard James yelling at Kellie, she approached them both with a subtle presence, quickly asked Kellie to remove herself; and, she used the lowest tone of voice possible and stated, while looking at James and maintaining her distance:

“Something must have upset you. I don’t know what it is, but I would like to hear it from you; so, together, we can get to the bottom of it.”

James paused, starred at JoAnn in surprise, and then looked down. A few seconds lapsed before he, this time with a low voice, explained: “I have been here since this morning. No one came and told me anything. She now comes to me, telling me there are two more people in front of me. This is unfair.”  “This is unfair,” repeated JoAnn, with sincerity, while looking into James’ eyes; she was looking at the situation from his perspective, and he thought it was unfair. James looked back at JoAnn in surprise and once more lowered his eyes. He then agreed to sit in a less busy space with her, in order to continue their conversation.

An overall proactive stance means thinking about the top reasons why patients and clients are likely to escalate and intervening as quickly as possible by using the appropriate techniques: In JoAnn’s case, she used the technique of Validation (“This is unfair.”); of Silence (allowing James to collect his thoughts); of Humanizing (looking into James’s eyes); and that of Togetherness (“So, together, we can get to the bottom of it.”).  She also made sure to avoid the trap of Limited Listening while she used the technique of Modeling (Using a low voice, while still conveying a powerful message – “Something must have upset you. I don’t know what it is, but I would like to hear it from you; so, together, we can get to the bottom of it”).

An overall proactive stance allows us to avoid the top reasons why our patients and clients are likely to escalate, while incorporating the general principles and techniques of de-escalation. 

2. A Risk-Stratification System

James was new to the clinic. No one knew who he was, what his triggers were and how to best mitigate them. As JoAnn started to speak with him, Dimitri, a member of the HOPE Clinic DEST (De-escalation) team, had already started working on accessing James’ medical records, looking for the general risk and mitigating factors for violence, as part of their risk-stratification system. Upon review of Psyckes, the referral note, and the Rap sheet, James was found to have a history of two arrests for marijuana possession and for turnstile jumping, but no violent offenses. Given his verbal threat to Kellie that day, Dimitri and the team later agreed to flag him as part of their protocol.

A risk-stratification system is related to an overall proactive stance to help plan, prepare, prevent and, therefore, increase the likelihood of success at both preventing escalation and, if it does happen, effectively de-escalating. The specific design of a risk-stratification system is less important than having one that works and that can be adjusted accordingly. This also helps make clinicians and other agency staff feel much safer and empowered, knowing there is a system in place to guide them. Does your agency have a risk-stratification system in place? If so, how well does it work or inform the decision-making process around de-escalation?

3. An Agency Based Planning System

When JoAnn (a different staff) heard the words, “I am going to kill all of you…” she quickly responded, approaching James with subtle intervention, giving a time-out to Kellie, who immediately went to write down what happened, while the incident was still fresh in her mind.  Barbara, the front desk staff, also activated the discrete alarm system, which alerted Dimitri, as part of the DEST protocol.  When Dimitri arrived, Barbara pointed him to Kellie, as the best person to relate the story and provide context.  As Kellie related the story to Dimitri, he asked in reflex about risk stratification, but Kellie did not know, since James was there for the first time.  Dimitri knew exactly what to do, and he got to work.

Connor, also part of the DEST team, arrived immediately after Dimitri, went straight to observe the encounter between JoAnn and James.  He stood far enough away in order to avoid interfering with JoAnn’s therapeutic process and avoid overwhelming James, which might further escalate him.  He also knew he needed to stand close enough to understand what might be working well and what might not, and then decide if and when intervention was necessary.  Does your agency have an agency-based planning system?  If so, how well coordinated is it? And, if not, what will it take for you to help design one?

4. An Individualized Based Approach

JoAnn went and sat with James to emphasize that she would be speaking with him alone for now, but she also informed him that she worked as part of a team, and he should expect other staff to come and speak with him, should there be a need.  JoAnn then paused and said: “We want everyone, including you, who comes here to have the best experience possible.  We just failed today, and we want to correct that.”  She then invited him to speak at length and used active listening to learn about his triggers and what usually works for him.

JoAnn explained to James that she would be speaking with the team to be sure the information he provided was used to make the visits here the most therapeutic for him, as much as possible. “I am sorry. I overreacted. I do that a lot. I got expelled from school because I had told my teacher that I was going to kill her.  Of course, I would never do that, but when I am upset, I just lose it, and I say stupid things that I later on regret.  I am so sorry.”  James spoke these words in a low voice and with tears in his eyes. “You are in the right place at the right time. You and our team are going to work together, in order to help you reach your goals,” replied JoAnn, who thanked James, telling him, in an apologetic tone, that there was unfortunately a wait, but that he would be seen as soon as possible.  James understood and agreed to wait.  An individualized based approach is part of an agency based system, but it also conveys to each patient and client that he or she matters as a person, and that understanding the specific situation of the patent or client is a priority, in order to provide the most tailored care possible.  What triggered James was not the wait, but the time it took for Kellie to tell him that he would be waiting “that long.”  He was not acknowledged.

When an individual feels seen and special, the likelihood of escalating decreases tremendously.

5. A Stepwise Approach

Part of having a system is to have a stepwise approach. The system can be seen as a work plan while the stepwise approach can be seen as a checklist that everyone needs to become familiar with.  Further, you can start using this stepwise approach while waiting to build a system at your agency.  Elaborating on each of these steps is not the objective of this article.  Nonetheless, as part of your de-escalation skills toolkit, you can start familiarizing yourself with the following 7 steps, as a foundation, for you to master the additional and essential de-escalation skills.  This will help you increase success with your patients and clients, provide you with career gratification, prevent burnout, and decrease liabilities for your agency:

• Who am I dealing with?

Ask yourself: What are the risks and related mitigating factors?

• What’s the trigger?

What may have been either the apparent or the non-apparent trigger; what can be done and how can further escalation be prevented?

• What may I have done incorrectly that I need to correct?

Which of the top reasons of de-escalation did I fail to pay attention to; which of the principles did I violate, and what can I do to correct that?

• When do I time out?

When and how do I know to signal a request for help from my team member?

• What do I do now?

What now; is there anything else my team and I should be doing; did we exhaust all internal resources and interventions?

• When do I call 911?

Is it now time to call 911; how do I do that in the safest way possible; and how do I minimize the related ramifications?

• Debriefing and next step:

Why did this happen; why were we unable to prevent it from happening; what could we have done differently; what are the lessons learned and what is going to be our plan of correction?

Start familiarizing yourself with these steps.  This may be a daunting task at first, but if you dedicate yourself to master it one step at a time, you will be pleased with the outcome.  Furthermore, you can start to be proactive now.  Set some time aside to practice these steps ahead of time so they are handy and natural when you need them the most.  You can start with the patients and clients listed on your high-risk roster.  You can then team up with your co-workers and practice together.  Like that, you will be supporting each other and slowly lay the groundwork for an agency based system.

The team at the HOPE Clinic did not initially know James, but they had a system in place that allowed them to quickly find out. JoAnn knew when it was time for Kellie to have a time out, as she sought to understand the triggers, what may have gone wrong on their part and how to quickly correct it. Because of their proactive stance and their agency-based system, they were able to de-escalate without having to resort to a 911 call.  They then debriefed, supported each other, and conducted a root cause analysis, followed by a corrective and implementation plan.

The team did all this without passing any judgment, understanding that “we are all in this together.”  They also started a longitudinal-case analysis, and, now, two years later, James is still attending the clinic, working, attending college, and planning his wedding.

I have discussed the benefits of de-escalation skills, the top 5 reasons why our patients and clients are likely to escalate and a 5-step formula on how to de-escalate. De-escalation skills include principles, techniques, the do’s and the don’ts, and they require practice and additional tools.  I hope these series of articles are able to lay the foundation for you to master these additional and essential competencies.

References

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• Dupont RT. The crisis intervention team model: an intersection point for the criminal justice system and the psychiatric emergency service. In: Glick RL, Berlin JS, Fishkind AB, et al., editors. Emergency Psychiatry: Principles and Practice. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.

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