De-escalation Skills: A Summary of the Why’s

“I went to look for help, and now I am going to jail. What do I need to live for?” said Matthew, angry, while in the inpatient unit. Once discharged from the hospital, he would go to jail, because he had struck two police officers, as they were trying to take him to the hospital. Matthew’s treatment team had difficulty managing his threatening behavior and called 911 as a result.

Later, Matthew was discovered in his hospital room, trying to hang himself. When placed in jail, he succeeded in hanging himself and was found unconscious. Matthew’s story introduced our first article on the De-escalation Skills series, entitled, De-escalation Skills: 6 Reasons Why. It was a tragic case, as I explained in that article, and they happen more often than any of us would like to believe. In that article, I then outlined the following six (6) reasons why it is crucial for all of us—clinicians and non-clinical staff—to master proper de-escalation skills:

1. To establish and maintain a sense of safety for the clinicians and staff;

2. To prevent burnout;

3. To promote a meaningful career ;

4. To enhance clinical outcomes and prevent iatrogeny;

5. To establish and maintain a sense of safety for our patients and clients; and

6. To prevent trauma or re-traumatization.

In the referenced article, I revealed that Matthew’s case occurred only three days after Diana, also a patient, had told Stephanie she deserved to die. Stephanie was the front desk staff who not only managed Diana but when dealing with Matthew, her emotional response was still lingering and she reacted and had no time to properly respond. De-escalation skills need to be acquired and honed through Education-Beyond-School, continued practice and eventual mastery, so they are readily available and become automatic, even in the most acute situations. Matthew’s therapist, Eileen also had her share of challenges, “I don’t know what to do anymore. Two weeks ago, I called 911 for 4 clients, in just a 2-day span. There was not even enough guidance available for me to know if I was doing the right thing.” A lack of support and consistent supervision, and limited training will prevent clinicians from making the best-informed and objective decision. This then leads to iatrogeny, burnout, limited meaningful career, and a lack of a sense of safety, for both clinicians and patients and clients.

Based on the above, mastering the skills of de-escalations is “win-win” for the clinician and advocate, the patients and clients, and the agencies, and the police officers, and system, as a whole. De-escalations skills give us the right language and tools to use with our patients and clients, the right principles and techniques to apply, the steps to take, and the do’s and don’ts to ensure everyone remains safe in the process.

As I often mention, many of the patients and clients we serve in the public sector have an extensive history of trauma; they do not like to be told “no,” and they tend to overreact. When I facilitate workshops on Dealing Effectively with Inappropriate/Maladaptive Behaviors, I always pose the question, “How much different would we be from our patients and clients, if we were to show their maladaptive behaviors the same way they do. As mental health professionals, we prove our expertise by the way we engage our patients and clients, especially during their hardest moments. This expertise and skill can be honed through regular training and proper supervision.

“How dare you tell me I can’t leave; who do you think you are? How dare you?” Harry said to Nate, the clinician who was evaluating him for the first time. Nate wanted to be as thorough as possible, making sure he covered everything; however, he neglected to pay attention to Harry’s body language, to what he was not saying, or to attending to his needs. Harry’s scenario, not an uncommon one, starts the first paragraph of the second article of the series on De-escalation Skills, entitled, 5 Reasons Why Patients and Clients Are Likely to Escalate. From a problem-solving perspective, attempting to solve a problem without an understanding of the root cause may lead to choosing a solution that creates more problems. And from a root cause analysis standpoint, the ability to effectively de-escalate entails a deep understanding of why our patients and clients are likely to escalate. This deep understanding will also help us decrease the likelihood of escalation, following a prevention approach. In that second article, I described the five reasons patients and clients are likely to escalate as follows:

1. Limited listening;

2. Limited validation;

3. Limited engagement;

4. Limited language sensitivity; and

5. Limited cultural sensitivity.

Harry had made arrangements with his wife to help baby sit their three children, so his wife would not miss a second job interview. “I was, indeed, not listening,” said Nate.

How often do we pay attention to our body language, to that of our patients and clients, to the language they use, as well as the language we use? How competent do you feel about properly de-escalating or more importantly about minimizing the likelihood that your patients and clients will escalate?