(From the Spring 2013 issue of Everything Matters: In Patient Care)
Ericka Bruns, MS, Ed, PCC-S, Crisis Program Clinical Coordinator
A common theme tends to arise each time I lead a presentation for medical providers about de-escalation strategies for individuals in crisis: agitated and aggressive behavior is unacceptable and we need to do something about it. The starting point of this change may be surprising. It is not a matter of changing the individual in crisis. It is a matter of changing our own reactions and behaviors. How do we respond to our patients and their family members who may be in a state of crisis or emotional instability?
We need to continue to hold others accountable for their behaviors, but we cannot always rely on them to change their behaviors. The only person we can truly control is our self. Therefore, the more we stay in control of our thoughts, emotions and behaviors, the more likely we are to keep ourselves and others safe.
It is important to gain insight into the worldview of a person in a state of emotional crisis. To them, the problem at hand feels unmanageable because regular coping skills have been exhausted and unsuccessful. Thoughts and expectations become irrational and illogical. Emotions can become angry, anxious, scared or frustrated. With all of this distress going on within the person, medical providers often become the target of the negative behavioral response. It is very common for a person in distress to subconsciously transfer his or her emotions onto another person. This is where the medical provider’s reaction to that transference can either help or hinder the situation.
It is easy to get caught up in power struggles, to take insults personally, to respond defensively toward accusations, to mirror the emotions of the person in crisis, to become overly authoritative and demand different behaviors and to quickly judge and negatively label the person in crisis. These responses will typically hinder the outcome and further escalate a person in crisis. In order to reduce these responses, medical providers first have to reframe their thinking about the person in crisis. Changing thoughts from, This parent is being rude and nasty to This parent must be scared for his/her child or This parent may think the only way to get his/her needs met is to yell will make our attempts at intervention more effective. The goal is to attach a more empathic thought to the person’s behavior instead of a negative or blaming thought. It takes practice but once this skill is attained and we learn to control our thoughts, our emotions and behaviors follow suit.
Approach is essential. A technique that can be highly effective is taking the one-down approach. In this method, the medical provider is not taking or giving up control. They are removing the negative momentum from the communication. An example is: [Patient] “You don’t even care about me. You’re just doing this because it’s your job!” [Provider] “I’m sorry if I’ve done anything to make you feel that way. I want to do a better job and understand how I can help you.” In this case, the provider took the one-down by apologizing and diverting the negative momentum that the patient was attempting to use as a power struggle. The provider in this example also allowed the patient to feel more in control and, as a result, decreased his or her discomfort and anxiety.
Using distraction techniques intermittently is vital in changing the escalated person’s frame of thinking. Changing the subject, paying a complement, asking open ended questions, offering food or drink, using something that creates a noise/sound with a younger person and using humor, if appropriate, are all examples of distraction techniques. Lastly, when the above techniques are ineffective, boundary setting with the escalated person should be used as a means to give him or her a choice as well as information about what will occur if the escalated behavior continues. Boundaries should be presented in a way that still yields the outcome of de-escalation as opposed to making the person feel threatened. Boundaries need to be reasonable, clear and enforceable. An example is: [Provider] “You have every right to be upset and if you choose to talk to me about it, we can work together to get your needs met. However, if you choose to continue to kick the chair and yell, I will have to call Security.” If the person chooses to de-escalate, engage with them immediately to demonstrate appreciation and respect. If the person continues with the escalating behavior, the boundary needs to be followed through immediately to demonstrate consistency for the purpose of safety.
The goal of de-escalation is an acute prevention of physical and psychological harm in the moment. It is not going to change generational patterns or psychopathology in others. A successful outcome is more likely to occur with the practiced, calm, confident and empathic medical provider who stays emotionally in control of his or her own reactions to the situation. Utilizing the methods outlined above can increase the likelihood that the escalated individual will respond in a manner that promotes safety and cooperation.