5 De-escalation Principles to Master

“What are you laughing about; why are you laughing at me?” Castro asked these questions during his visit with Jack in the ER. He started to raise his voice, then he got up, made a fist, and as the situation escalated, he ended up in restraints.

 This is the fourth in a series of articles on De-Escalation. After an overview of the reasons why it is critical to master the skills of de-escalation, the reasons why patients and clients are likely to escalate, and the 5-step formula for the art and science of de-escalation, and the 7 steps to follow when de-escalating, it is now time to introduce to you the principles of de-escalation.

Here are the 5 principles to master:

• Self Management:

“What do you mean by what I am laughing about; who is laughing at you?” Jack responded to Castro, with a high-pitched voice and a frowning face. Castro added, “You see; you are lying. I can’t trust you,” his voice raising, and his posture and position changing.

Jack, the clinician, failed to manage himself appropriately; his response to Castro’s accusation, and his statement, and his body language all needed better self control. He failed to manage his emotions, the tone and pitch of his voice, and he reacted instead of responding. In order to adequately respond, Jack would first need to do some active listening, while taking himself out of the equation, before reacting to Castro’s assertion. Castro was actively hallucinating. He was brought to the ED after found wandering the streets, thanks to a search initiated by his residence. Staying calm and managing himself would have allowed Jack to listen with the “third ear,” and, at the same time, before reacting, seek to understand what might be going on. This might then have allowed him to empathize, avoid any type of argument and “respond” instead of “react.”

• Grabbing the Attention:

You are calm and managing yourself; you are now ready to adequately use the second principle, “grabbing the attention.”  You do this by using a calming and understanding statement and demeanor.  For example, Jack could have told Castro, “Let me see if I understood what you just said.”  This is an example of a powerful way to grab someone’s attention.  You will see that they will stop talking and start paying attention, which will then allow you to continue using the principles of effective de-escalation.

Once you grab the attention, you can then ask an open-ended question, like, “Is there anything I can say in order to improve things a bit right now?”  With this, you convey the message that you are seeking to understand, that you do care and you are here to help without having to be explicit. Once you grab the attention and ask an open-ended question, it is essential that you use this opportunity to actively listen, using the art and the power of silence, before you offer validation.  This will then make it easier to be reflective, to humanize, and to separate the person from the actual behavior and situation.  With this foundation, it would have been easier for Jack to respond to Castro’s claim, to acknowledge him and better problem solve.

• Establishing and Maintaining Safety:

Establishing and maintaining safety is essential for you, your co-workers, and your clients and patients.  As in the previous article, The Art and Science of De-escalation: A 5-Step Formula, JoAnn went to complete her conversation with James in a place that was less crowded, quieter, and safer for everyone.  She made sure to provide a line of egress, ensuring that she was not in James’s way, should there be a need for him to walk out.  Few factors can be triggering to our patients and clients than a perceived inability to leave.  JoAnn also quickly determined the best place to position herself, while Connor stood around, monitoring the situation.

Establishing and maintaining safety also means avoiding a power struggle, remaining trauma informed, and striving to reach the clients and patients where they are. Further, it is essential to consider the trigger and respect personal space.  JoAnn made sure to stand alongside instead of directly in front of James.  She knew when to give a time out to Kellie and how to tell James that she might also need a time out, should her team members think it was the right thing to do.  Lastly, and importantly, establishing and maintaining safety may also include setting limits, as needed.  You can do so effectively, if you keep in mind the other de-escalation principles and steps previously outlined.

• Getting to “Yes”:

You are calm and managing yourself; you have grabbed the attention of your client and patient, and you have established and maintained safety.  Now that you have set the tone, you are ready for the next step, which is to get to a common ground with your client and patient – you are ready to work towards getting to “yes.”  You are able to get to “yes” by making your client and patient part of the team.

Ask him or her, “What usually helps you when you are upset?  What do you need right now, and what can we do to help?”  These questions serve multiple purposes. They demonstrate that you do care about them and they also allow you to engage and establish rapport. In order to get to “yes,” you also need to take yourself out of the equation and keep the end-game in mind. Part of this entails formulating the problem, which means both you and your client and patient will be able to agree on what the specific situation is, what may have been the trigger, which will then allow both of you to get to an agreed solution.  Some reframing may also be necessary, but remember to do so while empathizing and avoiding anything that might lead to an argument.

JoAnn and James agreed that his verbal threat to “kill all of you” resulted because he had never been acknowledged or told that he would have to wait “that long.” While this may sound a small trigger to such a big threat, remember that the purpose here is to find a common point of agreement, leaving out your ego, and focusing on the goal at hand.

• Knowing What to Say, What Not to say and How to Best Interact

All the principles, techniques, steps, and tips I have discussed so far may be futile without mastering this current and last principle – know what to say, what not to say and how to best interact. Your interactions need to be supportive at all times, and you need to keep your words to the minimum.

“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.”  JoAnn articulated this to James then she paused.

If there is one instance where the phrase “Less is more” applies, it is during de-escalation. The more you say, the higher the likelihood you will state something that might further escalate your client or patient.  Therefore, strive to say no more than necessary, to use reflective statements and to continuously maintain rapport. Knowing what to say, what not to say, and how to best interact also entails “Choosing your battles,” and that can be accomplished by always keeping the end-game in mind.  Focus more on feelings and less on facts, do not confront, and, avoid disagreeing, touching or staying too close. It is also essential that you stay away from interrupting, unless absolutely necessary, and, too, from being defensive. Do not label or judge; do not play neither the victim nor the villain; do not smile inappropriately, and do not ignore the expressed feelings and emotions.

As I mentioned in the second principle, use open-ended questions and minimize closed ended questions, as much as you can. Because many clients and patients may have some challenges with trust, instead of saying “I am here to help you” simply show that you are by following the above principles. Overall, “Show-don’t tell.”  And avoid the words, “Calm down; you cannot leave; sit down,” and the like.

“What are you laughing about; why are laughing at me?” was the question Castro asked Jack, who innocently reacted, using natural, instead of tactical, language. He did not know that he needed to stay calm and manage himself; grab Castro’s attention; establish and maintain safety; get to “yes;” and, know what to say, what not to say, and how to best interact.

You have just read these principles, learned about Jack’s mistakes and now you have the tools to not only avoid the same faux pas, but also to feel empowered to effectively de-escalate. Of course, there is more about de-escalation skills. However, the above principles can be a great foundation as you work toward mastering this crucial skill.

References:

1. Key components of de-escalation techniques: a thematic synthesis. Price O1, Baker J.Int J Ment Health Nurs. 2012 Aug;21(4):310-9. doi: 10.1111/j.1447-0349.2011.00793.x. Epub 2012 Feb 16

2. De-escalating aggression and violence in the mental health setting. Cowin L1, Davies R, Estall G, Berlin T, Fitzgerald M, Hoot S. Int J Ment Health Nurs. 2003 Mar;12(1):64-73.

3. An exploratory account of registered nurses’ experience of patient aggression in both mental health and general nursing settings. Duxbury J1. J Psychiatr Ment Health Nurs. 1999 Apr;6(2):107-14.

4. De-escalation and limit-setting in forensic mental health units. Roberton T1, Daffern M, Thomas S, Martin TJ Forensic Nurs. 2012 Jun;8(2):94-101. doi: 10.1111/j.1939-3938.2011.01125.x. Epub 2012 Jan 6.

5. Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory.Daffern M1, Day A, Cookson A. Int J Offender Ther Comp Criminol. 2012 May;56(3):401-19. doi: 10.1177/0306624X11404183. Epub 2011 Apr 24. J Psychiatr Ment Health Nurs. 2009 Sep;16(7):661-9. doi: 10.1111/j.1365-2850.2009.01454.x.

6. Aggressive behaviour in adolescent psychiatric settings: what are risk factors, possible interventions and implications for nursing practice? A literature review. Hage S1, Van Meijel B, Fluttert F, Berden GF.