DNVC

Behavioral Crisis

Prevention and

Intervention The Dynamics of Non-Violent Care

Relationship is the single most important therapeutic modality for

ameliorating threats of violence, emotional crises, and the need

for restraint. Dr. Peter Breggin, Joint Commission on

Accreditation of Healthcare Organizations,

http://www.breggin.com/jcah.html

Draft Copy- Healthcare edition

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CONTENTS`

The Nature of Aggression ..................................................................................................................................................... 7

UNDERSTANDING VIOLENT BEHAVIOR................................................................................................................ 7

Recognizing Conflict ....................................................................................................................................................... 8

Recognizing Distress ....................................................................................................................................................... 8

Addressing Instrumental Conflict .................................................................................................................................... 9

What is violence? ........................................................................................................................................................... 10

Why do people act violently? ........................................................................................................................................ 10

What happens physiologically as aggression escalates? ................................................................................................ 11

Excited Delirium Syndrome .......................................................................................................................................... 12

What is the relation of trauma to violence and coercion? .............................................................................................. 13

What are risk factors (within the person receiving services) for aggression or violence? ............................................. 15

What factors in the care environment contribute to safety and dignity? ........................................................................ 17

Self Management ................................................................................................................................................................ 18

What are your values and beliefs in relation to conflict and aggression? ...................................................................... 18

How do you manage your own responses? .................................................................................................................... 18

STAGES OF DANGER (Lalemond) .................................................................................................................................. 22

Agitated/Aggressive Behavior Versus Non-Compliance ............................................................................................... 22

Professionalism along the continuum of care: ............................................................................................................... 24

Nonverbal skills .................................................................................................................................................................. 24

Proxemics: ..................................................................................................................................................................... 24

Kinesics (body Language): ............................................................................................................................................ 25

Paraverbals (Prosody): ................................................................................................................................................... 28

Nonviolent communication skills ....................................................................................................................................... 29

Principles of effective communication .......................................................................................................................... 29

Nonviolent Communications ......................................................................................................................................... 30

Empathy and Empathic Listening .................................................................................................................................. 30

Additional Verbal Skills ................................................................................................................................................ 33

―Heuristic Redirection‖ .................................................................................................................................................. 33

Applying the Principles of Social influence to De-escalation ........................................................................................... 34

Physical skills ..................................................................................................................................................................... 38

Personal Safety .............................................................................................................................................................. 38

General Principles .......................................................................................................................................................... 38

Physical Response Strategies ......................................................................................................................................... 38

Physical Holds ............................................................................................................................................................... 39

General Principles .......................................................................................................................................................... 39

Physical Response Strategies ......................................................................................................................................... 40

Debriefing ........................................................................................................................................................................... 41

Practical Steps ................................................................................................................................................................ 42

Additional Resources/Reading ........................................................................................................................................... 43

Ten Tips for Effective Verbal Interventions .................................................................................................................. 43

10 things we can do to contribute to internal, interpersonal, and organizational peace ................................................. 43

Information on Seclusion and Restraints ....................................................................................................................... 44

Reducing restraint related injuries and deaths ............................................................................................................... 45

Additional Communication Strategies ........................................................................................................................... 45

PHYSICAL TECHNIQUES checklist ........................................................................................................................... 47

Why Not Martial Arts-Based Techniques? .................................................................................................................... 51

De-escalation Preference Survey & Individual Crisis Planning .................................................................................... 54

What is included in this program and why..................................................................................................................... 57

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About this course

Why ―The Dynamics of Non-Violent Care‖?

Although the word ―dynamics‖ has a very specific technical definition in physics, in this context it

refers to the social and psychological forces and actions within an organization that create, maintain,

and reinforce an environment that is inherently non-violent, even when faced with violence on the

pat of service users.

While an important outcome is to establish effective techniques for de-escalating situations of

escalating and potential violence, and to deal effectively and safely with aggressive persons, this

course takes a broader scope approach. This course presents, but does not focus on techniques of de-

escalation, rather on the principles behind the techniques, and the broader context of interpersonal

and organization interactions. The broader outcome of creating an environment of ―non-violent care‖

becomes the context in which these techniques are taught.

Author‘s note:

Workshops in conflict resolution, de-escalation and management of aggressive behaviors (including

physical techniques, and stress management are available by the author.

For information on workshops contact: [email protected]

This course has been substantially revised as of 2010. This order version draft is provided for

informational purposes only. Please be advised that reader accepts that there are strictly no

warranties or conditions of any kind, regarding the use or performance of this material nor of any

advices or directions mentioned in this book. There are no warranties, expressed or implied, as to

infringement of third party rights, merchantability, or fitness for any particular purpose. The use of

this information is at the user's own risk. In no event will anyone be liable to you for any

consequential, incidental or special damages, including any lost profits or lost savings, or for any

claim by any third party.

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Behavioral Crisis Prevention and Intervention: Dynamics of Non-Violent Care (DNVC) is a risk

management, safety enhancement tool for organizations committed to creating a violence-free and coercion-

free care environment. It is based on principles drawn from evidence-based practice (to the extent it is

possible) and professional consensus, and tested in practice by various training programs.

DNVC emphasizes concepts that prevent incidents from occurring, or using de-escalation techniques to help

people manage their own behavior so staff members do not have to physically intervene to keep people safe.

It emphasizes the therapeutic relationship.

This program was designed, based on its developer‘s experience as a certified trainer of a nationally known

program, and trainer for in-house developed programs in long-term and acute care hospital, residential

treatment, psychiatric care facilities, and community based social service agencies. Experts in the fields of

law enforcement, emergency medical services, physical therapy, and mental health services were consulted in

its development. Additionally, the curriculum of several nationally offered programs were examined and

evaluated.

Unfortunately, no rigorous research exists in the field of the use of physical restraints, and research on de-

escalation techniques is sparse. Therefore, while rigorous evidence based practice is not possible numerous

guidelines and consensus are available. Chief among those used in the development of this program are:

The Recognition, Prevention and Therapeutic Management of Violence in Mental Health Care, A

consultation Document Prepared For The United Kingdom Central Council for Nursing, Midwifery and

Health, No Date

Behavior Support Management in Therapeutic Schools, Therapeutic Programs and Outdoor Behavioral

Health Programs: Addendum to the NATSAP Principles of Good Practice, National Association of

Therapeutic Schools and Programs

Comprehensive Accreditation Manual for Behavioral Health Care of the Joint Commission on Accreditation

of Health Care Organization (JCAHO) 1999-2000, 2001-2002, 2008 Chicago, IL.

Practice Parameter for the Prevention and Management of Aggressive Behavior in Child and Adolescent

Psychiatric Institutions, With Special Reference to Seclusion and Restraint

Journal of American Academy of Child and Adolescent Psychiatry, 2002, 41(2 Supplement):4S–25S

National Association of State Mental Health Program Directors:

Reducing the Use of Seclusion and Restraint: PART I, II and III 2000-2002

Creating Violence Free and Coercion Free Mental Health Treatment Environments for the Reduction

of Seclusions and restraints, Best Practices Symposium 2004

RESTRAINT AND SECLUSION: A Risk Management Guide 2006

Violence and Coercion in Mental Health Settings: Eliminating the Use of Seclusion and Restraint

Summer/Fall 2002

Copyright 2007,2008 Change Dynamics, John Lundholm

Contact: [email protected]

Permission is hereby granted to organizations participating in Dynamics of Non-Violent Care: De-

escalation and Personal Safety Training to reproduce these materials for internal distribution.

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De-escalation and Personal Safety

BASIC PHILOSOPHY

Maintain and maximize the dignity and safety of all involved throughout the continuum of

care.

Create relationships that are inherently nurturing, and free of coercion and violence

COMPETENCIES

Personal safety and the ability to effectively respond to situations of escalating aggression require a

hierarchy of emotional, cognitive, and physical skills that must be demonstrated in order to verify

initial competency. These skills must be practiced in order to maintain ongoing competency

Knowledge and Understanding

Participants will be able to describe the nature of aggressive behavior in terms of neuro-

physiological and psychosocial dynamics, and Trauma Informed Care models.

Participants will be able to describe components of a non-violent and non-coercive environment.

Participants will be able to demonstrate self-awareness and self-management skills in relations to

situations of escalating aggression.

Participants will be able to recognize and describe the stages of danger.

Participants will be able to describe their professional role along the continuum of care and in

relation to aggressive behavior.

Nonverbal Skills

Participants will be able to demonstrate the application of the principles of

Proxemics/positioning, Kinesics and Paraverbal skills in assessing, and responding along the

continuum of care.

Verbal

Participants will be able to demonstrate Empathic Listening using the Nonviolent

Communications model

Participants will be able to demonstrate Directive, Non-coercive communication using the

Nonviolent Communications model, and apply principles of Social Influence and Heuristic

Redirection.

Physical

Participants will be able to demonstrate non-violent techniques to maintain personal safety in

situations of physical aggression.

Participants will be able to demonstrate non-injurious physical holds that minimize risks to those

involved.

Participant Agreements

Learning

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Be responsible for my own learning.

As an adult, you are in charge of your learning, not the instructor. Take advantage of the class time,

practice sessions and the instructor's knowledge while you are in class.

Participate and be an active learner.

Learning is an active process! Ask questions, do the exercises, participate in the discussions, take

notes, help other class members, talk to the instructor, etc.

Be willing to make mistakes and learn from them.

Don't be embarrassed or frustrated when you make mistakes. Mistakes are learning opportunities for

you, the instructor, and the rest of the class. You learn more when you correct mistakes than if

everything goes perfectly.

Honor the time schedule and be on time for class and after breaks.

Time is money in a training class. If you are late, you are wasting not only your learning time and

money, but also the time and money of the rest of the class.

Give the instructor feedback throughout class if I have concerns, issues, or questions.

You are an adult, in charge of your learning. If you feel that the class is too slow/fast, or topics aren't

pertinent, convey this to the instructor during a break. Don't keep this all to yourself or complain to

your classmates. Most instructors will try to be flexible and see if they can address your concerns.

Take the time to complete the course evaluation and give honest, constructive feedback.

Take the time to give useful, pertinent feedback and offer suggestions, not just criticisms or smile

sheets with no meaningful comments.

Safety

Keep safety the top priority.

Understand that by their very nature physical interventions involve the risk of injury. Each

participant must be aware at all times of the potential effects of their actions on fellow learners in

regard to physical and emotional safety.

Respect the learning style and pace of fellow participants.

Gauge the comfort level of training partners with respect to physical ability and learning. When

practicing any physical technique be continually monitor the response of peers for their safety.

Cooperate, not compete.

In order to adequately prepare, it is beneficial for the practice of physical techniques to be as realistic

as possible with respect to speed and force. Realize, however, that there will be varying degrees of

physical ability and regulate your practice to respect the level of your training partner.

Practice only the techniques presented.

The techniques presented are specifically chosen for application in a care setting. Techniques that

may be appropriate in other contexts may be discussed if there are questions, but are not to be

included in this training.

I agree to the above standards for this training. _______________________Date ________

signature

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The Nature of Aggression

Objectives: Participants will be able to describe the nature of aggressive

behavior in terms of neuro-physiological and psychosocial dynamics, and

Trauma Informed Care models.

UNDERSTANDING VIOLENT BEHAVIOR

Nonviolent care: care that is inherently therapeutic and minimizes forces that promote aggression,

and that responds to patient aggression and violence in a manner that maintains the safety and

dignity of all involved throughout the continuum of care.

One goal of the professional is to create environments and relationships that support therapeutic

alternatives to problem behaviors.

At its simplest level, all behavior is __Communication___

Whenever people use behavior, they are _Expressing what they are thinking, feeling

or wanting_

Aggression is not just a disruption that needs to be controlled, is a form of communication needing

understanding and interpretation.

A professional will conduct a range of assessments to determine the message of a person‘s behavior.

The professional then will support the person to find new ways to achieve his/her goals in ways that

are more appropriate, or that in the least do not cause harm or injury to themselves and/or others.

We do not shield people from the natural and social consequences of poor behavioral choices.

Sometime those consequences can be quite harsh, but in all cases, those consequences are applied

with the best therapeutic intentions, not in a spirit of retaliation or coercion.

People do not engage in problem behaviors because they have mental illness, conduct disorders,

developmental disabilities or other cognitive disabilities. There are lots of people with mental

illness, CD or DD who are not violent. These are certainly a factor, but there‘s more to it than

just that. They use behavior for specific reasons. People behave in ways that get what they want

or need, or to get away from something, someone or some place they do not want. They engage

in behaviors that have ―worked‘ for them in the past.

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Recognizing Conflict

Recognizing and resolving conflict early can prevent the escalation of aggression.

Whenever there are mutually exclusive interests of people involved in a process (such as a care

provider and a care recipient) there is conflict.

In considering the competing interests of the patient it is important to make a distinction:

Are the competing interests primarily

Expressive or instrumental_?

The experienced care provider will recognize that this distinction is not always a matter of either/or,

and that both can be occurring simultaneously. Still it is helpful to consider this, as it will direct the

care provider‘s approach.

Recognizing Distress

A problem exists when ever there are deviations from expected or desired processes or outcomes. When the source of

the problem is the mutually exclusive interests of people involved it the process we refer to it as conflict

It is tempting to consider the patient as the problem. After all, we are the experts, we know how things should be

done. We know what tasks need to be completed each day, and we know the best flow of activity. We know what

elements have to be in place to create a therapeutic environment. Patients disrupt the flow by asserting their interests.

In other words, is the conflict arising primarily because the person has unmet emotional needs, or is experiencing

unrelieved distress? Or, is the conflict primarily because of goal directed (instrumental) behavior on the part of the

person?

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Agitated distress arises from unmet physical or psychological needs. Agitation, simply stated, is

behavior indicating distress. Other conflict raising behaviors may indicate distress as well. A care

provider‘s primary responsibility is to address not only the behavior, but the distress underlying it.

Possible

Underlying

Distress

Possible Causes Interventions

Physical

discomfort

Constipation

Full Bladder

Need for reposition/unable to reposition self

Injury/pain

Hungry/thirsty

Tired

Fever

Physiological

Imbalance

Medication effects

Hypoxias

Cardiac/Respiratory

Metabolic

Fear Unfamiliar environment

OBS/Alzheimer‘s

Threats in environment

Displaced anxiety/fear

Boredom Unvaried routines

Lack of Socialization

Anger Displaced anger

Loss (freedom, health, etc.)

Psychological

factors

Depression

Psychosis

Addressing Instrumental Conflict

This includes criminal behavior, and in some cases, the behavior of patients with conduct or

oppositional defiant disorders. The behavior is not primarily an expression of distress, rather it is

goal directed.

In low levels this person resists or attempts to circumvent directives and imposed limitation.

At higher levels the person may be combative or assaultive.

This describes someone who may or may not be "confused," but is purposely attempting to cause harm to himself or

others. This is not an individual who is simply seeking to "escape" or "avoid contact with" others in a violent manner.

This is someone acting in a manner that suggests a purposeful intent to harm him self or others. When others

discontinue contact with him, a combative individual may continue attempting to harm him self or others.

The significance of this distinction is that you don‘t deescalate instrumental aggression, it‘s not a matter of

being supportive or empathetic; you have to take away the opportunity to act violently.

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What is violence?

Violence is any form of aggressive behavior intended to harm or injure another person against his

wishes. This includes shaming, frightening, and threatening.

Most acts of violence are the result of a wide range of interacting factors including instrumental

(goal directed) and emotional factors.

Even in an environment of nonviolent care, we are required to response quite aggressively at times

to a patient who is acting violently. To do less does not adequately protect ourselves or the patient

from harm.

Why do people act violently?

Violence is a behavior and follows all the principle of behavior, namely:

_Purposeful or expressive____

_Is learned in and maintained by the environment___

Environment is a primary determinant

Violence comes in many forms: verbal, physical, sexual; with or without a weapon; impulsive or

premeditated.

Despite the pervasiveness of violence, notable is the absence of a widely acceptable definition for

aggression across different contexts, or adequately validated scales for kind and severity of aggressive

acts. These can lead to confusion.

This means that behaviors that in one context are considered violent can properly be used with therapeutic intent.

These include: intimidation, coercion, and physical restraints.

Violent people are violent because their violence has been reinforced in their natural environment. One of the

most important things we do is provide an environment that no longer reinforces violence

A person brings in a lot of baggage in terms of personal history, mental and emotional disorders, a home environment

that reinforces violence, etc. As stated earlier, even when we do everything right patients can still act out; even so

there is much that we can do here to reduce aggressive behavior.

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What happens physiologically as aggression escalates?

When an person is confronted with a perceived danger – he or she reacts. The person will use as

many resources as needed, as much energy as possible - to deal with the threat.

In the face of danger, the body changes its inner-balance and priorities into a high physiological

arousal, to enable two functions, Fight or Flight.

A third response: _freeze__.

Physiological responses include:

Increased heart rate, blood pressure, and respiration.

Increased blood flow to the muscles, supplying more oxygen to the muscles, and the heart-

lung system.

Increased blood sugar, allowing rapid energy use, and accelerating metabolism for

emergency actions.

Sharpening of the senses. The pupils dilate; hearing is better etc., allowing rapid responses.

Prioritizing - increased blood supply to peripheral muscles and heart, to motor and basic-

functions regions in the brain; decreased blood supply to digestive system and irrelevant

brain regions (such as speech areas); this also causes secretion of body wastes, leaving the

body lighter.

Secretion of endorphins - natural painkillers, providing an instant defense against pain.

Secretion of adrenaline and other stress hormones - to further increase the response and to

strengthen relevant systems.

Thickening of the blood - increase in oxygen supply (red cells), enabling better defense from

infections (white cells) and to stop bleeding quickly (platelets).

Relevance of the physiology of aggression

The physiological response to threat follows a predictable pathway. The responses are both

simultaneous and sequential, meaning many of the responses occur independently of others, while

others are triggered or strengthened by previous responses.

The fight or flight is a pattern of physiological responses that prepares the organism to respond to an emergency.

When the external balance is disrupted, one‘s body changes its internal balance accordingly.

The manifestations of the flight or fight response are mainly through two channels: the sympathetic branch of the

autonomic nervous system (ANS) and the Endocrine system - both are closely interconnected. The ANS effects

many bodily functions instantly and directly, while hormones have slower yet wider effect on the body. Hormones

and neurons communicate with cells and create the delicate dynamic balance between the body and its surrounding,

through paired systems and feedback mechanisms.

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In some cases once a response is triggered, subsequent responses in the sequence are inevitable. The

response to the threat continues even after the threat has been removed.

The further along in the pathway a person reaches, the more difficult it is to de-escalate, as the

physiological response overshadows cognitive functions.

Excited Delirium Syndrome

Catecholamines are hormones produced in response to stress. Produced and secreted by the adrenal

gland, adrenaline and cortisol, the two primary stress hormones, are secreted as a direct reaction to

stressful situations. Their powerful effects are similar to those of the sympathetic branch of the ANS

(such as increasing heart rate, blood pressure, sugar-levels, muscle activity, etc.).

Besides its hormonal functions, adrenaline is also an excitatory neurotransmitter in the CNS

(indirectly controlling its own production). It is involved both in neural and hormonal processes and

its effects as a neurotransmitter are further reinforced by its hormonal function (a positive feedback

loop).

Adrenaline and cortisol are the most important hormones in regard to stress - taking a major role in

the stress reaction (and staying longer in the body than Autonomic Nervous System - [ANS]

processes).

Some researchers posit that the physiological cascade of responses can lead to a state of over release

of catecholamines, resulting in excited delirium syndrome. While the term ―Excited Delirium

Syndrome‖ is not a universally accepted medical term, it has been described by numerous clinical

researchers:

Delirium can alter sensation and render a person capable of extreme (abnormal) exertion

Can lead to cardiovascular collapse

Metabolic acidosis in cardiac arrest associated with use of restraint

Even though there is some controversy surrounding this concept, the import thing to be aware of is

that delirium defined as:

An acute, generally reversible, altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception, prominent hyperactivity, agitation, and autonomic nervous system overactivity.

Is a risk factor for harm when a person is violently agitated.

Normal body ph is 7.4. Autopsies of patients showed profound acidosis - 6.25

May be caused by a number of toxic, structural and metabolic disorders

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What is the relation of trauma to violence and coercion?

Until recently, trauma exposure was thought to be relatively rare (combat violence,

disaster trauma). Recent research has changed this.

One of the highest risk factors for experiencing trauma as a result of violence is a history of prior

traumatization.

Studies done in the last decade indicate that trauma exposure is common with 56 % of an adult

sample reporting at least one event in which they experienced trauma.

Exposure to trauma is even higher in the Mental Health Population:

90% of public mental health clients have been exposed

Most have multiple experiences of trauma

34-53% report childhood sexual or physical abuse

43-81% report some type of victimization

Current rates of PTSD in people with a diagnosed mental illness range from 29-43%

Majority of adults diagnosed BPD (81%) or DID (90%) were sexually or physically abused

as children

What is trauma informed care?

The prevalence and risk of traumatization requires organizations and individual staff members to

recognize the high rates of PTSD and other psychiatric disorders related to trauma exposure in

people with mental illness. Some key features of trauma informed care include:

Early and rigorous diagnostic evaluation with focused consideration of trauma in people with

complicated, treatment-resistant illness such as DID, BPD

Use neutral, objective and supportive language

Develop individual care plans that incorporate flexible approaches

Are based on current literature, and are informed by research and evidence of effective

practice

Are inclusive of the survivor's perspective

Recognize that coercive interventions cause traumatization and re-traumatization and are to

be avoided

Trauma, like pain, has both objective and subjective components. Like pain, one can not judge the amount of trauma by

looking only at objective measures. For example, objective we can look at a situation and say this patient started the

conflict, he became increasing agitated when appropriate interventions were attempted, and he was the aggressor, so we

had to restraint him for his and our safety. That‘s the objective component. Subjectively the patient may still perceive

himself to be the victim

One must consider the persons involved and their experience and interpretation of an episode of violence.

The greater the escalation of aggression the greater the chance of retraumatization.

Furthermore, it is not just service recipients that experience trauma as the result of violence or coercion. Staff members

involved in an episode of violence are at risk for traumatization as well.

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Trauma Informed Care services are NOT designed to treat the specific symptoms related to the past

trauma or abuse. Rather they are providers of care whose primary mission is not the treatment of

trauma. They treat the ―person‖ who has special needs due to their trauma history in a sensitive,

caring, and welcoming way.

You‘re likely to hear the term ―trauma informed care‖ in relation to mental health service, if you haven‘t heard it

already. The concept of ―trauma informed care‖ is gaining increasing attention, especially over the last few years. But

if you look at this list of what it entails you‘ll see that we‘ve been doing this for years.

When you hear the term, know that we provide trauma informed care as part of our unusual stand of care.

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o Examples of previous violent behavior include: physical or sexual aggression, fire setting with the

intent to cause property destruction, planned, premeditated violent acts and group or gang violence

that is organized with other perpetrators. In addition, people who have been severely physically

abused as children and/or are sociopathic are at greater risk.

Objectives: Participants will be able to describe factors that make a person at risk for violence

What are risk factors (within the person receiving services) for aggression or violence?

Violence occurs as an interaction of a person and with the environment. In addition to attending to

the environment in which services are provided, it is important to be aware of individual factors in

service recipients.

A person experiencing increasing aggression or agitation is in distress. He/She is experiencing

hurt, fear, grief, anxiety, or some other distressing emotion. Aggression is his/her way of resolving

or distracting from that emotion.

A number of individual factors indicate a higher risk for violent behavior in response to distress.

What are some of the most serious violence correlates?

Previous violent behavior #1 individual risk factor for re-occurrence

Previous history physical or sexual aggression

Previous history of S/R use

Specific command hallucinations with intent to harm

Intoxication or detoxification

Delirium

Delirium may be causally related to a number of factors including neurological or metabolic conditions or

intoxication or withdrawal, also poses greater risk. Common to these conditions is the disruption to one‘s

cognitive processes, misinterpretation and paranoia along with greater impulsivity and disinhibition.

16

A consumer shared her experience in the

hospital. She approached a nurse who was

very busy and could not get the medication

that she needed at that moment.

The nurse told her in a heartfelt and

respectful way that she would have to wait:

―I‘m so sorry; I can‘t do this right now. I

know you‘re having a tough time; do you

feel like you can wait?‖

The power of an apology and real concern

made all the difference in terms of how this

interaction was experienced.

Objectives: Participants will be able to describe psychosocial factors within a care or service

environment that either contribute to or prevent aggression and violence

Violence in mental health settings has been blamed on the ―patient‖ for years.

Hundreds of studies have been done on patient demographics and

characteristics. Findings are variable and inconclusive.

More recently, studies have looked at the role of the environment in violence,

including staff. Situational factors refer to features or characteristics of the

environment in which they occur.

While acknowledging that patent characteristics is most often the single biggest factor in violence in

the care setting, it is also information to place focus on factors within the control of the care

provider. As was demonstrated in the famous Milgram

experiments of the 1960s, the environment is one of the most

powerful determinants of behavior. It is a factor care can

control.

Aggression depends on situational factors including the

social environment (example: status or to defend territory).

It is important to be aware of common

environmental triggers that lead to violence.

Triggering events leading to violence on a unit often

have to do with the way a person is treated in the most

basic of ways. Anger may be precipitated by the

enforcement of hospital policies, a sense of unfair treatment,

long wait times, or problems in the health care system.

Some factors in the care environment that can contribute to violence and aggression are:

Lack of structure/ Overly rigid rules and regulations

Institutional setting

Delays in care/ Understaffing

Unkempt setting, clutter, litter, disrepair

Poor temperature control

Spatial crowding

Limited or no staff training in conflict prevention and management

Younger staff with less experience

Consumers are labeled & pathologized as ―manipulative,‖ ―needy,‖ attention seeking

Misuse or overuse of displays of power - keys, security, demeanor

Culture of secrecy- no advocates, poor monitoring of staff

High rates of S/R & other restrictive measures

Poor management of medication: under or over medication

Little use of least restrictive alternatives other than medication

Institutions that emphasize ―patient compliance‖ rather than collaboration

Institutions that disempower and devalue staff who then ―pass on‖ that disrespect to service

recipients.

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Lack of/inadequate training in de-escalation or responding to aggression

Leadership and staff members within an organization have the responsibility to create an

environment of care that supports therapeutic relationships

What factors in the care environment contribute to safety and dignity?

Facilitate Empowerment of Service Users

Universal Screening for Trauma

Involve patient in treatment planning

Establish Safety for Patients

From the time of initial contact and throughout care communicate our commitment to

ensuring the physical, psychological, social and moral safety of patients.

Additional Factors

Non-institutional setting

Living plants

Cleanliness/organized work space

―Homey‖ environment

Use of comfort rooms/objects

Implement sensory rooms and sensory interventions

Manage overcrowding

We ask each patient questions, early in the admission process, to determine whether he or she has experienced

violence, abuse, neglect, disaster, terrorism, or war. These questions not only help to obtain the information

needed to plan an appropriate safety and recovery plan, but they also confirm to consumers/survivors that their

trauma histories matter.

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Self Management

Objective: Participants will be able to demonstrate self-awareness and self-management skills

in relation to situations of escalating aggression

What are your values and beliefs in relation to conflict and aggression?

Possible values/beliefs:

Avoid conflict at all costs

Never back down

My way or the highway

The ends justify the means

I‘m the boss

I know what‘s best

Speak softly and carry a big stick

I can‘t protect myself

Stick to the facts

The rules come first

How do you manage your own responses?

A person‘s state results from an interaction of physiological and cognitive processes. The

physiological response are largely automatic and non-specific (fight or flight response). The

cognitive processes primarily include self-talk (attribution and interpretation) and internal images.

Physiologically responses can not be addressed directly. A person must therefore self regulate self

talk and internal images. A third means of managing one‘s own state is to manage one‘s own

behavior.

Anticipation (What can go wrong?)

Risk assessment is an element of providing a safe and supportive environment; it is therefore a

professional responsibility to anticipate and plan for potential crisis situations.

This requires service providers to be aware of risk factors within individuals and within an

environment.

Risk assessment involves evaluating risk factors and intervening early so that we are able to prevent

aggressive behavior from occurring. We want to be able to identify early on, individuals in need of

assistance. We want to problem solve and address individual triggers, provide additional treatment

modalities, expand options and choices, and develop de-escalation preference plans in advance.

Response: Prevention/Preparation

The primary response to anticipated potential risks is prevention.

The primary means of prevention is to manage the environment to maximize therapeutic relationships between

service providers and service recipients.

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A secondary response is to prepare for the occurrence of crisis. This involves training in de-

escalation skills, physical interventions skills, and debriefing skills. Additionally it requires the

implementation of policies that govern the behaviors of care providers in the event of a crisis.

Expectation (What is likely to go wrong?)

Negatively, expectation of crisis can be an indication of inadequate prevention or preparation. It can

be an indication that the environment of care is lacking in therapeutic elements.

Positively, it can indicate a realistic assessment of a patient or situation that temporarily heighten the

possibility of violence.

Response: Practice

Practice involve the practice of both internal responses and external behaviors.

Internal behaviors (state management):

Fear prepares us to be mentally and physically ready to respond to a threat. Fear should be

recognized, acknowledged, and acted upon.

There is an effective three-step for managing fear.

1. Identify the threat

2. Dissect and de-mystify the threat

Fear, as with all emotions, must be managed indirectly. It‘s not enough to tell one‘s self, ―Don‘t be

afraid.‖ One must address the thoughts that maintain fear, both the internal dialogue and the images

one plays in one‘s head. Thought changing is an effective means of addressing one‘s fears. The time

to develop thought changing is not in the heat of the moment, but during times of deliberate practice.

In addition to attending to one‘s thought processes it is often helpful to practice mindfulness.

Over a long time period it can be stated that violence is to be expected. Short term there are times when the

potential for crisis is heightened due to the interaction of individual and environmental forces. Expectation in

this sense is more immediate than anticipation. If we expect violence to happen it can mean a number of things

This involves assessing the situation and all parties involved in an interaction. Effective interventions can only be

developed after knowing the factors in play. In de-escalation scenarios, it would be helpful to know who, what,

where, when and how a threat may present itself, both to you and to the patient.

Mindfulness draws on techniques commonly found in all spiritual traditions to help people maintain an open, nonjudgmental in-

the-present approach to everyday tasks. In the care setting the approach helps providers to be aware of how they are feeling and

how events in their own lives might be influencing how they react to service recipients.

A mindful approach helps one to stay flexible and adjust to constant changes in the care environment, to pay greater attention to

service recipients and treat them with respect.

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The most basic mindfulness practice is simply to be aware of one's own breathing concentrating on

breathing. As you bring your awareness to how you breathe in and out, you will also notice the

thoughts and feelings crowding your mind. Being acutely aware of what you're experiencing—the

racing heart, the tumbling thoughts—and accepting it without judgment, observing as it changes, has

a strong calming effect.

3. Prepare to deal with the threat.

As with most endeavors, there will be times when learning new techniques and honing previously

learned skills becomes necessary.

Detachment

Detachment is a type of mental assertiveness that allows people to maintain their boundaries and

their own emotional integrity when faced with the emotional demands of another. It is a positive and

deliberate mental attitude which avoids engaging the emotions of others.

What is it about the threat that makes it so frightening? Is it the fear of getting injured? Killed? Embarrassed? Those

are legitimate fears, but are they inevitable or only remotely possible? The solution to many fears is reality.

Analyze the current threat and try to determine how likely it is to occur, and what realistically is level of danger is

posed by the threat?

Additionally, one must be aware of one‘s own responses. How has the threat effected one‘s own behavior? How has

the threat effects one‘s own physiology?

You will need to master many skills if you are to be successful at your with dealing with persons throughout the

continuum of escalating aggression. Some of those skills are physical and require a certain level of proficiency.

However, there are many psychological skills that will be called upon much more often. Time spent on these areas

will pay big dividends in your interactions with potentially aggressive individuals. Managing fear is one of these top

skills.

Self preservation is a natural instinct; intentionally putting yourself in harms way is an unnatural act, but this is what

many roles require. Fear is a normal and necessary defense mechanism built into our DNA in order to preserve the

species. That being said, it is absolutely necessary to learn to work with, around and through fear if you are

effectively de-escalate a potentially violent situation.

Detachment is an important skill in dealing with conflict situation.

This detachment does not mean avoiding the feeling of empathy; rather it involves an awareness of empathetic

feelings that allows the person space needed to rationally choose whether or not to engage or be overwhelmed by

such feelings.

It can mean holding back from the need to rescue, save, or fix another person from being sick, dysfunctional, or

irrational, or the willingness to accept that you cannot change or control another person. A patient will make bad

choices regardless of what we attempt, and we have to respond to those choices. Positive detachment allows a

caregiver to approach the behavior of an angry, frightened or otherwise distressed person with an attitude of concern,

or even curiosity. An underlying principle for maintaining positive detachment is the recognition that short of

physically restraining someone, we can never fully control another person. We can influence others; we can provide

information; can make requests of others; but we can only control our own behavior.

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External behaviors:

External behaviors refer to all outward responses to an individual experiencing increasing

distress leading to aggression. This include verbal and nonverbal interactions. While one can not

always control one‘s internal responses, the care provider is absolutely responsible for his or her

external behaviors.

External behaviors will be examined in detail following a discussion of the stages of danger.

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STAGES OF DANGER (Lalemond)

A number of models to describe the escalation of aggression are in use by

various researchers, practitioners, and service providers. While there is

disagreement on the number of stages or levels, and how they should be

labeled, the consensus is that aggression or violence follows a continuum

of behaviors varying in intensity.

The Lalemond Behavior Scale offers staff a framework with which to conduct such an assessment. It

gives staff a common language in which five levels of danger are determined. This scale offers a

way to ―hear‖ second level messages and provide staff response options.

Agitated/Aggressive Behavior Versus Non-Compliance

Noncompliant behavior often precedes aggression, and it is often a sign of escalating aggression. It‘s

important, however, to be aware of the distinction between behavior that is merely non-compliant

(individual is merely not doing what we want him or her to do) and behavior of escalating

aggression.

Forms of non-compliance:

Reluctance—Individual does not believe that desired behavior is in his/her best interest. May be a

lack of motivation or understanding.

Reactance— Natural response to attempts to restrict behaviors/options

Resistance— Counter-behavior to deal with heightened anxiety

The model used is not as important as the fact that there is a specific model that all

staff members are using to describe the behaviors and stages.

While it is best to be as specific as possible when describing the behavior of those

being served and the staff‘s response, shorthand terms invariably become part of the

descriptions of incidents of escalating aggression. It is therefore important that all

staff members are in agreement when decoding what is meant by terms such as

―agitated‖, ―disruptive‖ or ―acting out‖.

It‘s only when there is agreement on a model, in terms of labels, the behavioral

components of each, and appropriate the responses to each level, that the model

becomes valuable as a means of communicating, and guiding staff members‘

responses in actual situations.

To label all noncompliance as aggression ignores the wider context in which behaviors occur. Staff response to

noncompliance is often the trigger for aggression.

The physical interventions that are appropriate in cases of violent or self-destructive behavior (for example: manual

holds, restraint/seclusion) are very different than those that are appropriate for noncompliance (for example:

escorting, leading).

Level

Behaviors Professional Role/Intervention

5. Threat of Lethal

This is the most dangerous but is actually seen the least.

Message: Stop me.

A very direct threat of suicide or serious aggression

Physical Intervention:

Personal Safety

Physical Control

4. Dangerous

Physical behaviors directed towards self or others. This

level usually includes gross motor movements and a loud

voice.

Message: I‘ve lost control

Threatening to hit someone with true intent, hurting

themselves or using a weapon such a chair or glass to hurt

someone else

Physical Intervention:

Personal Safety

Physical Control

3. Destructive

This typically involves some kind of physical behavior

directed towards property

Message: I‘m losing control

Pounding a wall and yelling, throwing clothing or even a

chair but not at someone

Personal Safety

Empathic listening

Problem solving

Diversion/Distraction

Presentation of options to reduce anxiety

and enhance self-control

Presentation of reality (benefits/risk;

choices/consequences)

Isolate/

Immediate assistance/intervention plan

―What else can this mean?‖

2 Disruptive

This is still a fairly early stage of upset but now involves

other people. This is often the stage at which staff over-

react, start to set limits, rather than offer support or

options, which may contribute to the process of escalation.

Message: Pay attention

Pacing in front of a TV, going into someone else‘s

bedroom, yelling at the nurse‘s station, interrupting the

behaviors of others, noncompliance

Empathic listening

Problem solving

Diversion/ Distraction

Presentation of options to reduce anxiety

and enhance self-control

Presentation of reality (benefits/risk;

choices/consequences)

Isolate

―What else can this mean?‖

1. Agitated

This, the lowest level, is often ignored because it is the

least disruptive. Trained staff understand that if

intervention occurs here, it is most likely to resolve.

Message: I‘m in distress

Early warning signs might include pacing, clenching fists,

teeth, hands, tremors or sweating. Other signs include

verbalization of distress, staring, hypervigilance, brooding

or plotting to hurt someone, noncompliance

Identify distress and relieve it:

Empathic listening

Problem solving

Diversion/Distraction

Presentation of options to reduce anxiety

and enhance self-control

―What else can this mean?‖

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Professionalism along the continuum of care:

General Principles:

Safety first

Find the distress, relieve the distress

Open up communication

Make others safe

Use least restrictive intervention that matches behavior

Professional versus Personal Response

If we want people to behave in a certain manner, we must set the stage and give them a cue. …

There is no telling how deeply a mind may be affected by the deliberate staging of gestures, acts and

symbols.

Eric Hoffer, The Passionate State of Mind

Stage Presence:

Educated response: A professional response is by definition one that is acquired through purposeful

education and training. The professional does not have the luxury of saying ―that‘s just how I am.‖

Doing what comes naturally is not only ―unprofessional‖ in a situation of aggression or violence it is

dangerous.

Skills For Professional Response

Nonverbal skills

Proxemics:

Competency: Care provider is able to identify and maintain appropriate personal space

through an interaction with a care recipient

Personal space 18-36 inches; includes personal items.

Safety considerations:

Once a person enters a professional role he or she must be able to suspend his or her ―natural‖ response and act in the

role which he or she has taken on.

While approximate one arms length is appropriate for

social setting in situations of increasing distress and

agitation/aggression safety considerations extend the

appropriate space to no less than two arms length (striking

distance).

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Other factors affecting personal space

Culture

Age

Gender

Size absolute and relative

Positioning (face-to-face versus side-by- side

Environmental constraints

Mood

Presence of risk factors

Kinesics (body Language):

Competencies: Care provider is able to correctly identify the possible underlying emotions

associated with common kinesic elements.

Care provider is able to demonstrate and purposely display kinesic elements that convey

support and safety.

Includes facial expressions, positioning, gestures and movements.

NONVERBAL BEHAVIORS and Kinesics

The meaning of nonverbal communication is highly dependent on context created by situational

(including parallel communications), and demographic elements.

Cultures and various ethnic groups maintain varying personal spaces, for example many European cultures generally

stand closer, while many Asian culture maintain a slighter greater distance

Very young and very old service recipients more closely approached

Research shows that people are generally poor judges of nonverbal cues. Misunderstanding and false conclusions are

common. The probability of error increases as people are under stress.

Adolescents and younger children are especially prone to false interpretations, with a tendency to interpret various

emotions, such as surprise, confusion, or worry as anger. Children with conduct problems are especially likely to

interpret nonverbal cues as anger, while those with Attention Deficit (with or without hyperactivity) are likely to miss

nonverbal cues altogether. Further confounding nonverbal communications is gender and culture.

For example, what is the meaning of extended eye contact? It could be friendly or threatening depending on who and

under what circumstances, and what other verbal and nonverbal messages are being communicated.

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Therefore it is important to consider any interpretation of nonverbal cues as provisional until it

is clarified, reflected, and verified.

More important, care providers need to be aware of the nonverbal messages they are sending, and

the effect they might have. The following is not intended as a guide to interpreting body language,

rather is help staff be more deliberate in their own body language.

By being aware of the following nonverbal behaviors staff member can be sure to convey the

message they intent.

Eye contact and gaze

.

Head tilt and movement

Figure A. Figure B. Figure C.

Figure A Figure B

Dictionaries of nonverbal language that present the ―meaning‖ of various elements of body language such as ―arms

crossed means person is unreceptive‖ have limited value. The most reliable gestures are the one that do not need a

dictionary to interpret. Less obvious gestures are too varied, as there are too many individual and environmental

factors that may be influencing a particular gesture.

Length of eye contact: Generally speaking 3-5 seconds is the maximum duration of eye contact before raising discomfort.

This can vary greatly based on cultural factors, and other facial expressions accompanying the eye contact.

While speaking to a person be aware of the difference between a ―business gaze‖ that focuses on the area of the triangle in

figure A, and a ―social gaze‖ that focuses on the area of the triangle in figure B. The ―business gaze‖ is appropriate when

being more directive, or as aggression escalates. Overuse can be taken as threatening. The ―social gaze‖ is appropriate for

conveying understanding or support. Over use can be taken as weakness, or even flirtatiousness.

When breaking eye contact, breaking downward communicates understanding, however, breaking contact in any direction

except as in figure C (right or left) is acceptable.

Rather than facing and maintaining eye-to-eye contact with both eyes, there appears to be an advantage in aligning one‘s

right eye to the right eye of the individual you are speaking with, so that you are primarily in that person‘s right visual

field. There is a tendency to be perceived as less threatening, and more supportive.

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Shoulders

Arms and hands

Pointing:

Hands in front: Openness, nonthreatening (nothing to hide). Also safer.

Hands Down: ―Pause‖ , ―This is important‖, ―Calm down‖

Palms Up: Can be taken as supportive and open or as submissive, depending on other factors

Hands on hips: Readiness, aggression

Arms crossed on chest: Defensiveness, closed to listening

Open palm: Sincerity, openness, innocence

Tapping or drumming fingers: Impatience

General movement and positioning

Matching/Mirroring:

Shifting weight:

A slight head tilt, forward and to the side, as in figure A can convey attentive listening (especially with a slight

leaning forward posture) and supportiveness. It can be taken as submissiveness if over used, especially as

agitation/aggression escalates. The chin up neck straight is more directive, but can be taken as coldness.

Nodding while listening emphasizes that one is listening. Nodding or shaking one‘s head while speaking can

reinforce the verbal message, ―This isn‘t a good situation for you [shaking head] and I can understand [nodding head]

why you would feel that way.‖

Raising (shrugging) one‘s shoulders while speaking can be disarming. It helps neutralize the sense of ―us-versus-them‖

by conveying that the speaker, while in control, does not have all the answers. It communicates that the speaker is

willing (within limits) to give options/control to the listener, or that the speaker is in the same position as the listener of

being up against the policy

Hand to chin/cheek: This conveys that you are thinking what is being said. Pausing

while using this gesture conveys a seriousness about what is said, rather than an

automatic response.

Hands on jugular communicates fear or defensiveness

Direct pointing at an individual is taken as aggressive or accusative. If you need to point towards

someone, it‘s better to use the back of an open hand.

Persons in rapport naturally develop synchronicity of movement. Research is equivocal , but suggests that when done

subtly, deliberate matching and mirroring of another person can help develop rapport, even in a conflict situation.

Frequent shifting weight from side to side can be interpreted as uncertainty or a sign of weakness.

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Paraverbals (Prosody):

Copyright 2005, Allison Barrows, Used with permission

Competency: Care provider is able to identify and display appropriate paraverbals

throughout interactions with care recipients

Defined as: the pitch, loudness, tempo, and rhythm patterns of spoken language.

This refers to all the parts of verbal communications, other than the words used. A technical

examination of these can be quite complex. For the purpose of effectively managing aggression the

most important elements are:

Tone. Significance signaled by pitch and other paraverbal distinctions

Volume. Loudness

Cadence. Rate, rhythm, duration, pauses

Inflection. Rise and fall of voice pitch over entire phrases and sentences

Communications is often the first intervention for managing aggressive behavior. While the words

used are important, equally (at some would argue, more important) is how it is spoken.

Too great of a mismatch between the paraverbals of persons in an interaction can hinder communication. Too gentle

or soft a response to an angry person can convey disregard for the person‘s feeling, or lack of importance. While it is

not appropriate to match the anger in a person‘s voice it is important to convey urgency or importance when

responding.

The cadence of a person‘s speech often reflects how a person processes information. Speaking too rapidly to a

person who speaks slowly or too slowly to a person who speaks rapidly can lead to confusion or raised anxiety. The

care provider can enhance communication by adopting certain aspects, at least initially, of the paraverbals of the care

recipient.

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Nonviolent communication skills

Participants will be able to describe the principles of effective communication

Participants will be able to demonstrate Empathic listening using the Nonviolent

Communications model

Participants will be able to demonstrate Directive, Non-coercive communication using the

Nonviolent Communications model

Principles of effective communication

Have a clear goal or objective, rather than merely reacting. Know what outcome you want to

achieve. Maintain initiative in setting the frame.

Be aware of verbal and the non-verbal communication that indicate whether you are moving

towards or away from your desired outcome.

Be flexible in approach, by having a wide repertoire of communication skills, and be willing

to used varied approaches to achieving your outcome based on above.

Respect the client as someone doing the best they know how (rather than judging them as

"broken")

Enjoy the challenges of difficult ("resistant") clients, seeing them as a chance to learn rather

than an intractable "problem" (positive detachment)

These are broad principles, that encompass multiple contexts.

An additional broad principles that is specific to the situation of interacting with an anxious of

aggressive person is:

Redirect rather than oppose or resist.

Nonviolent communication skills is one subset or model of communications skills. Before turning attention to it

specifically, it is important to take a broad look at communications skills, and to do so we‘ll look at the question,

what does it take to be an effective communicator? Stated in this matter the focus is not on specific communication

techniques, rather on broad principles or strategies for effective communication.

The questions of whether or not there are common traits that are shared by expert communicators within and across

varied fields – top therapists, top physicians, top nurses, top executives or top salespeople, etc., has been studied by

numerous researchers. The difficulty lies in sorting through the various terminologies used by researchers in varied

field, and varied distinctions between principles versus techniques or discrete skills. For example, is the use of open

ended questions a principle, or a specific skill?

Consequently, it is impossible to enumerate a definitive list of characteristics of effective communication. The

following is presented as guidelines for discussion:

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Nonviolent Communications

The process of NVC encourages us to focus on what we and others are observing, how and why we

are each feeling as we do, what our underlying needs are, and what each of us would like to have

happen. The primary skills of NVC are:

Make careful observations free of judgments.

Specify behaviors and conditions that are affecting us.

Identify our own deeper needs and those of others.

Identify and clearly articulate what we are wanting (requests) in a given moment.

These skills emphasize personal responsibility for our actions and the choices we make when we

respond to others.

Empathy and Empathic Listening

Violence is the language of the unheard

Martin Luther King JR.

Empathy involves two elements:

(1) the ability to accurately attribute mental states, such as beliefs, intents, desires, and affects to

others; and

(2) having an emotional reaction that is appropriate to the other‘s emotional state.

Definition: a process of attending and responding to another so that the person feels heard in a non-

judgmental way.

As the name implies, this approach to communication emphasizes compassion as the motivation for action rather

than fear, guilt, shame, blame, coercion, threat or justification for punishment. In other words, it is about getting what

you want that build relationship in the long run as well as short term or immediately.

These techniques allow you to make conscious choices about how you will respond whether you get what you want,

or not. It is definitely not about guilt tripping and tricking people into giving you what you want.

Empathetic listening is distinct from normal social conversation, in which friends or colleagues often compete to

speak and be heard. In empathic listening a person suspends his or her desire to heard (even when he or she has a

brilliant diagnosis or good advice to share), and focuses on allowing the other to express him or herself fully, and on

understanding the mental state of the other.

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Specific Empathic Listening Skills

Dangling questions

Repeating a key word or phrase

Requesting more information

Paraphrasing

Empathic sayings

Phrases to avoid include:

―I know how you feel.‖

―You should/shouldn‘t…‖

These are incomplete questions that allow the speaker to control the direction of communication. It is more open than

―open-ended‖ questions, in that the listener is not request specific information, as much as providing a spring board

for the speaker to explore more in depth.

Repeating a key word or phrase in the same tone of voice that has been used lets the speaker know we are following

and invites the speaker to further explore his or her own thinking.

There are numerous way to signal our desire to hear more. Simply saying, ―Tell me more, about that.‖ Or

―Interesting‖, invites further expression.

Restating or summarizing what has been heard and understood allows the speaker to clarify if necessary, and builds

rapport when it is accurate.

An empathic saying is a entry phrase to let a person know we are following them. Commonly used ones are:

―It sound like you‘re ________‖

―I can see you‘re (feeling) ____________‖

I can only imagine how __________ you must be feeling.‖

Used sparingly they convey empathy and can encourage the person to express him or her self more fully. Overly used

the seem artificial and insincere.

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NONVIOLENT COMMUNICATION SKILLS

Empathically receiving without blame or

criticism

Honestly expressing without blame or criticism

At every phase evaluations, interpretations, judgments, defensiveness, attempts to control,

blame, and avoidance of responsibility can block communication.

Observation

What concrete actions (including verbal

expression) am I observing in you?

What concrete actions I am observing--seeing,

hearing, remembering?

―When you…‖

―When I …‖

Feeling

How are you feeling in relation to these

actions?

How are you feeling in relation to these actions?

―Do you feel…?‖

―You‘re feeling….‖

―I feel…‖

Needs

What are the values, desires and

expectations that are creating the feeling?

What are the values, desires and expectations that

are creating the feeling?

―Because you are needing…?‖ ―Because I am needing…‖

Requests

What concrete actions would you like me

to take?

What concrete actions would I like you to take?

―And would you like me to…?‖

―And I would like you to…‖

That these are presented in this order is not to say that this is the ―proper‖ sequence or step-by-step

order to follow in communicating these four elements.

Adapted from Nonviolent Communication: A Language of Life

by Marshall B. Rosenberg, Ph.D.

Published by PuddleDancer Press

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Additional Verbal Skills

“Heuristic Redirection”

Definition: A set of linguistic tools for achieving a specific outcome by taking advantage of

cognitive biases in order to bypass reflexive resistance

Pacing and leading:

Sensory-based feedback:

Embedded commands:

Binds:

Displacement:

Presuppositions/Implications

(―Yes Set‖) Gaining agreement early on increases the likelihood of subsequent agreement, and reduces the risk for

escalation. Pacing refers to verbalizing statements that are easy to agree with. These can be aspect of the situation, the

person, or a restatement of what the individual has expressed, ―I‘m standing here talking to you…You‘re not

wanting to go now…and we need to come to an agreement about what happens next…‖ Accurate reflection

(empathy) is a form of pacing.

Leading follows pacing with a statement that is not self-evident, obvious, or as easily agreed with. If the pacing is

successful the listener is more likely (but there is no guarantee) to agree with the leading statement.

Sensory-based feedback is describing, without evaluation or labeling an individual‘s behavior. Use with pacing and

leading.

Commands (set apart tonally) as given within the context of a larger statement. The use of embedded commands

gives greater flexibility for communicating messages that might other wise be rejected. Embedded commands are

often used with one or more types of displacement.

(Equivalent choices) ― You can finish right away or you can just get it over with so you can have time to relax

afterwards…‖ Hint: to be more effective, follow up with a tangential question or statement, then quickly follow

which a question about what their preference is.

Disclaimer/ Negative commands. ―I don‘t expect you to just…, You don‘t have to …right away.‖, ―I know you don‘t

want to…‖

Quotes. ―I‘m not going to order you around like a drill sergeant, ‗you need to get that done right now‘, I want you to

think about what would be best.‖

Time - eventually, in the past, up until now, before, after, while. ―I don‘t know when you will soon begin to feel

better about all this.‖

Ordinals – first, second. ―Which would you like to do first…‖

Awareness — have you realized, noticed, understood. ―I don‘t know if anyone explained it to you so that you realize

that doing it this way works out the best for you.‖

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Applying the Principles of Social influence to De-escalation

In creating an environment that promotes pro-social behavior, it‘s important

to be aware of the principles of social influence.

Those six principles are:

Rule of Reciprocity

According to sociologists and anthropologists, one of the most widespread and basic norms of

human culture is embodied in the rule of reciprocity. This rule requires that one person try to repay

what another person has provided. The rule applies even to uninvited first favors.

Applications in a care environment:

Commitment and Consistency

In contrast to a lot of anecdotal, or pop-psychology information on persuasion and

influencing others, there is some actual scientific research that can inform our practice.

The leading researcher on social influence, Robert Cialdini, a Professor of Psychology at

Arizona State University, lists six basic social and psychological principles that form the

foundation for successful strategies used to influence others.

The decision to comply with someone's request is frequently based upon the Rule of Reciprocity. A possible tactic to

increase the probability of cooperation would be to give something to someone before asking for a favor in return.

The rule is extremely powerful, often overwhelming the influence of other factors that normally determine

compliance with a request.

Another way in which the Rule of Reciprocity can increase cooperation involves a simple variation on the basic

theme: instead of providing a favor first that stimulates a returned favor, an individual can make instead an initial

concession that stimulates a return concession.

One procedure, called the "rejection-then-retreat technique", or ―door-in-the-face technique‖, relies on the pressure to

reciprocate concessions. By starting with an extreme request that is sure to be rejected, the requester can then

profitably retreat to a smaller request--the one that was desired all along. This request is likely to now be accepted

because it appears to be a concession. Research indicates, that aside from increasing the likelihood that a person will

say yes to a request, the rejection-then-retreat technique also increases the likelihood that the person carrying out the

request will agree to future requests.

Frame communications as a concession ―I‘ll give you time to think about it‖

Remind patient of privileges received

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People have a desire to look consistent through their words, beliefs, attitudes, and deeds.

The key to using the principles of Commitment and Consistency to gain the cooperation of others is

held within the initial commitment. That is--after making a commitment, taking a stand or position,

or coming to an agreement people are more willing to agree to requests that are consistent with their

prior commitment. It is easier to request a small initial position that is consistent with a behavior

they will later request.

Applications in a care environment:

Social Proof

One means used to determine what is correct is to find out what others believe is correct. People

often view a behavior as more correct in a given situation--to the degree that we see others

performing it.

Social proof is most influential under two conditions:

Uncertainty--when people are unsure and the situation is ambiguous they are more likely to observe

the behavior of others and to accept that behavior as correct.

Similarity--people are more inclined to follow the lead of others who are similar.

Applications in a care environment:

Commitments are most effective when they are active, public, effortful, and viewed as internally motivated and not

coerced. Once a stand is taken, there is a natural tendency to behave in ways that are consistent with the stand.

Commitment decisions, even erroneous ones, have a tendency to be self-perpetuating. Those involved may add new

reasons and justifications to support the commitments they have already made. For this reason it is especially

important to avoid interactions that set up early resistance.

This principle of Social Proof can be used to stimulate a person's agreement with a request by informing him or her

that many other individuals, perhaps some that are role models, are or have observed this behavior.

Remind patient of past positive behaviors

Remind patient of previous agreements

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Liking

People prefer to say yes to individuals they know and like.

A number of factors contribute to this, but those most easily influenced are:

Praise -- praise produces liking. Generally, compliments most often enhance liking and can be used

as a means to gain agreement.

Increased familiarity -- repeated contact with a person or thing is yet another factor that normally

facilitates liking. But this holds true principally when that contact takes place under positive rather

than negative circumstances. One positive circumstance that may work well is mutual and successful

cooperation.

Applications in care environment:

Authority

In the seminal studies and research conducted by Stanley Milgram regarding obedience there, is

evidence of the strong pressure within our society for compliance when requested by an authority

figure.

Conversely, resistance to authorities can occur in a mindless fashion as a kind of decision-making

shortcut. Since authority can have a strong negative or positive effect in terms of agreement and

cooperation, it is important to know how the individual might respond before employing this

element.

Applications in care environment:

Normalize resistance while conveying that peers make the positive choice.

Example; ―A lot of patient feel upset, and don‘t want to do it, not until they realize that it‘s better for you in the long

run and then they‘ll do it.‖

Be aware of patient‘s response to authority and emphasize or deemphasize as appropriate

37

Scarcity

According to the Principle of Scarcity people assign more value to opportunities when they are less

available. When access to something is restricted, or threatened to be lost, it is more highly desired.

Things difficult to attain, or likely to be lost are typically more valuable. The availability of an item

or experience can serve as a shortcut clue or cue to its quality.

Applications in a care environment:

When something becomes less accessible, the freedom to have it may be lost. According to psychological reactance

theory, people respond to the loss of freedom by wanting to have it more. This includes the freedom to have certain

goods and services. As a motivator, psychological reactance is present throughout the great majority of a person's life

span. However, it is especially evident at a pair of ages: "the terrible twos" and the teenage years. Both of these

periods are characterized by an emerging sense of individuality, which brings to prominence such issues as control,

individual rights, and freedoms. People at these ages are especially sensitive to restrictions.

Remind a patient of the privileges he or she all ready has and frame the consequences as loss of those privileges

38

Physical skills

Participants will be able to demonstrate non-violent techniques to maintain personal safety

in situations of physical aggression

Participants will be able to demonstrate non-injurious physical holds that minimize risks to

those involved.

Personal Safety

Avoidance and evasion are the first choice always!

Focus on principles not techniques, and strategies not tactics

General Principles

Safety— for all parties involved

Maintain initiative—The goals is never self-defense (reactive); rather your role is to control

an aggressive situation

Physical Response Strategies

Speed—When action is required move quickly and without hesitation

Redirect rather than block or resist

Surprise— Unexpected actions interrupt the pattern, and buys time

Move the target- Keep moving until it is safe

Control space

Two ways a person can attack physically:

Strikes (punches, slaps, kicks, thrown objects)

Response (Strategy) is:

Deflect (parry)

Move

Grabs (grabs, hair pulls, chokes)

Response (Strategy) is:

Momentum—direct the force of the attack/assault

Leverage—use of natural range of motion, fulcrum points, body mechanics (elbow to elbow)

Weak point— use of natural escape paths

Even though this is not a self-defense or martial arts course there is an important lesson to be learned from these, namely,

39

Physical Holds

Physical hold are used when a person is violent or self destructive (danger to self or others), and all

other alternatives have been exhausted

Escort positions for a non-compliant person is not a physical hold. Staff members must be very

careful in approach a non-compliant person so as not to trigger aggression.

General Principles

Safety— for all involved

Efficacy—ineffective techniques endanger the care provider, and are therefore unsafe.

Anytime we intervene physically there are potential problems with:

• Airway Obstruction/Position

• Pressure

• Exacerbation of unknown or known medical disorders

One person- Greatest risk of harm to staff or service recipient only to be used in dire

emergency

Two person- High risk, only to be used in emergency

Two primary guiding principles for any

physical intervention are safety and

efficacy.

The two person control position shown

here has been widely used. Both safety and

efficacy are questionable. A number of

deaths of persons held in this manner have

been reported.

A number of state have enacted

regulations prohibiting its use, and the use

of face down holds, in care and

correctional facilities.

Certain techniques are effective, even highly effective, in controlling an aggressive person, but have a potential of

causing severe harm. These include joint locks, pain compliance holds, and pressure points. These are, therefore, not

an acceptable intervention.

40

Three person- minimum safe and effective number

Maintain Initiative

Physical Response Strategies

Control Speed/Momentum

.

Control Space/Limit attack options

Control balance/body mechanics

As with personal safety response, the goal is not self defense, rather it is to take control of a dangerous situation

Once a physical intervention has been decided upon it is necessary to move quickly and without hesitation

in order to minimize the risk of harm to both the aggressive individual and staff member. Furthermore, staff

members must control the direction of force

By positioning and controlling movement of limbs staff members limit the ways an individual can harm self

or others. Furthermore, staff members must control the distance between the aggressive person and self

The use of body mechanics to control balance and limit movement option is essential. The more strength is

used to control a violent person, the more potential there is for harm. Also the more techniques rely on

strength in order to be effective, the more limited they are in their applicability of all staff.

Go to Physical skills check off in back

41

Debriefing

Guiding Principle

“A debriefing should follow each episode of seclusion or restraint. The debriefing should include an

assessment of the factors leading to the use of seclusions or restraint, steps to reduce the potential

future need for the seclusion or restraint of the patient, and the clinical impact of the intervention on

the patient.” (American Psychiatric Association/American Academy of Child & Adolescent

Psychiatry/National Association of Psychiatric Health Systems Joint Statement of General Principles

on Seclusion and Restraint, May 1999)

A debriefing or psychological debriefing is a time-limited, semi-structured conversation with

individuals who have just experienced a stressful or traumatic event.

The purpose of debriefing is twofold:

1)

2)

Depending on organizational policies and standards debrief may include more elements, but

minimally it will include an analysis of:

Triggers,

Antecedent behaviors,

Alternative behaviors,

Least restrictive or alternative interventions attempted,

De-escalation preferences or safety planning measures identified and

Treatment plan strategies.

Two types of Debriefing Activities:

Acute - immediate post event response to gather info, manage milieu, assure safety

As with stages of aggression, there are several models. Organizations will favor a model which they teach their

volunteers and staff members. Various models differ in the number and type of phases (or stages). They all get at the

same basic elements to help people cope with the sights, sounds, smells, thoughts, feelings, symptoms, and memories

that are all part of a normal stress reaction to a traumatic event. Here we use the COPING model,

42

Formal - rigorous problem solving event with treatment team and consumer input, usually 24 hours

later

Practical Steps

Make Debriefing Rigorous.

Pay attention to both what was done correctly, and what can be improved.

Have a set format or template for debriefing (COPING). Use a standard format that is to be followed after every

incident of restraint or seclusion. Additional examples of debriefing forms are included in the appendix.

Debriefing is a teaching moment. Staff members are generally more comfortable with the former, yet an examination

of the latter is often more valuable.

43

Additional Resources/Reading

Ten Tips for Effective Verbal Interventions

Self-Management

1. Remain calm

2. Maintain the initiative

Non-confrontive communication

3. Be empathic

4. Clarify messages

5. Don‘t argue

6. Redirect challenging questions

7. Permit venting when possible

8. Keep messages short and simple

Non-threatening nonverbals

9. Be aware of position

10. Be aware of your paraverbal communications

10 things we can do to contribute to internal, interpersonal, and organizational peace

(1) Spend some time each day quietly reflecting on how we would like to relate to ourselves and

others.

(2) Remember that all human beings have the same needs.

(3) Check our intention to see if we are as interested in others getting their needs met as our own.

(4) When asking someone to do something, check first to see if we are making a request or a

demand.

(5) Instead of saying what we DON'T want someone to do, say what we DO want the person to do.

(6) Instead of saying what we want someone to BE, say what action we'd like the person to take that

we hope will help the person be that way.

(7) Before agreeing or disagreeing with anyone's opinions, try to tune in to what the person is feeling

and needing.

(8) Instead of saying ―No,‖ say what need of ours prevents us from saying ―Yes.‖

(9) If we are feeling upset, think about what need of ours is not being met, and what we could do to

meet it, instead of thinking about what's wrong with others or ourselves.

(10) Instead of praising someone who did something we like, express our gratitude by telling the

person what need of ours that action met.

© 2001, revised 2004 Gary Baran & CNVC

The right to freely duplicate this document is hereby granted.

44

Information on Seclusion and Restraints

The use of restraints carries a significant risk. The risks of restraints are:

Injury to person served

Injury may be related to the process of placing a person in restraints, for example, improper body

mechanics, hyperextension of joints, or excessive force. It may also be related to improper the

application of restraint, such as, prolonged immobilization, or mechanical injuries.

Injuries to care provider

Persons served resist being restrained. Attempting to restrain another person always carries the risk

of injury due to a fight back response.

Death

The General Accounting Office and the Harvard Center for Risk Analysis have researched deaths

due to restraints and estimate that 50 to 150 people a year die because of restraint on the floor or

mechanical restraints.

Manual or Mechanical Restraints

If an individual‘s behavior has the potential to cause serious harm or injury, the professional should

only consider methods for manual or mechanical restraint that keep the person safe and free from

harm. Mechanical restraints are any type of restraint other than human contact, such as a belt, strap,

or sash.

Staff must administer manual restraint in a way that maintains the normal body alignment for that

person and causes no pain. Hyperextension of joints or use of pressure points is not an acceptable

component of manual restraint.

In order to minimize risk to both the person served and to staff members manual restraints should be

time-limited to one minute or less with a maximum time limit of five minutes. The goal of manual

restraint is to protect people from harm, not to restrain people until they are ―calm‖.

Manual restraints of all four limbs or mechanical restraints of any part of the body are highly

intrusive procedures that should be used only in cases of immediate danger to the safety of the

individual and/or others.

Several states have prohibited restraint on the floor. For example, Minnesota regulations go so far as

to prohibit any restraint on the floor in community-based programs.

45

Seclusionary Time-out

Seclusionary time-out (placing an individual into an area from which they cannot leave until others

decide they can) is another highly intrusive procedure. This procedure should only be used as a last

resort where there is a risk of immediate danger to others.

The use of seclusionary time-out should always be prohibited in cases of self-injurious behavior.

Reducing restraint related injuries and deaths

Data from JCAHO‘s Sentinel Event Database indicate that restraint-related injuries and death

represent approximately 5% of the total number of sentinel events (incidents resulting in significant

injury or unexpected death) reviewed by JCAHO.

The top six root causes identified by organizations that experienced restraint-related sentinel events

were:

Insufficient orientation and training

Inadequate patient assessment

Faulty communication

Unsafe equipment or equipment use

Inadequate care planning

Insufficient staffing levels.

Although the majority of the events occurred in psychiatric hospitals, general hospitals, and long

term care facilities, restraint use poses a danger for all organizations that provide human services.

Strategies for addressing three of the top root causes—insufficient orientation and training, faulty

communication, and insufficient staffing levels—are applicable to health care, education, and social

service settings.

Additional Communication Strategies

To achieve high quality, timely, and effective care that minimizes restraint use and ensures safe

restraint use when use is absolutely necessary, staff, those served, and families must communicate

effectively. Effective communication is complete, accurate, timely, and unambiguous.

Enhance communication with those served and their families. Effective communication can reduce

the need to use restraint in order to maintain treatment goals, address aggressive behavior, and

prevent falls.

In the medical setting, confused or agitated individuals who don‘t understand why an IV line, an

endotracheal or nasogastric tube, a catheter, or other indwelling devices are in place can be their own

worst enemies. They can act to disrupt their therapy or remove the devices or dressings necessary to

meet their needs.

46

Speaking slowly and in a calm manner, using simple statements, and listening attentively to what the

individual and family say are recommended by experts. Involving the individual in conversation

often provides needed reality orientation. If an agitated or aggressive individual responds well to a

particular staff member, that staff member can be asked to help redirect the individual.

TIP When restraint is needed for behavioral reasons, staff should promptly notify the individual‘s

family of restraint initiation. Communication with the family is required if the individual consented

to have his or her family informed about his or her care and if the family agreed to be notified.

TIP When restraint is needed, designate one staff member to direct other staff and communicate

with the patient during the application of physical restraints. The staff member should explain to the

patient in understandable and nonpunitive terms the procedure, purpose, and time period for the

intervention and the behaviors necessary for its termination.

Staffing Strategies

Staffing adequacy—the appropriate number and level of staff, trained and competent in alternatives

to restraint and safe restraint use—is critical to the safety of those served.

TIP Ensure that the staffing level and assignments in the organization minimize circumstances that

give rise to restraint use and that maximize safety when restraint is used. Leaders should base

staffing levels and assignments on staff qualifications, the physical design of the environment, and

diagnoses, co-occurring conditions, acuity levels, and age and developmental functioning of

individuals served.

TIP When restraint must be used, adjust staffing numbers to make allocations for the necessary

number of clinical staff to provide care and frequently assess the condition of individuals in

restraints. Monitoring and assessing individuals in restraints, as outlined in the PC standards, can be

carried out simultaneously by the same staff member.

TIP Inform supervisors of unsafe staffing levels. Staff should be encouraged to report unsafe staffing

levels to supervisors. Leaders might wish to revise the staffing model and develop a pool of trained,

competent volunteers who can sit with those at risk for restraint use. These volunteers can provide

one-on-one observation while reading to the individual or offering music or other therapies.

Using physical restraints is potentially dangerous. Staff in all care settings can reduce the likelihood

of restraint-related injuries or deaths by using alternatives to restraint, whenever possible, and by

ensuring proper training, enhancing communication, and maintaining appropriate staffing levels.

47

PHYSICAL TECHNIQUES checklist

Guiding Principles for physical techniques

Use of physical interventions is restricted to justifiable self defense, protection of

others, protection of property, and prevention of escapes. The amount of force is

limited to that minimally necessary to control the situation. Restraints- manual,

mechanical, or chemical - are restricted to temporary control of a person who is violent

or self-destructive.

Physical intervention is not used as punishment.

Staff are prohibited from using techniques of physical restraints that unduly risk serious

harm or needless pain to the client. These techniques include:

Restricting respiration in any way, such as applying a chokehold or pressure to a

client‘s back or chest or placing the client in a position that is capable of causing

asphyxia;

Using any method that is capable of causing loss of consciousness or harm to the

neck;

Pinning down with knees to torso, head and/or neck;

Slapping, punching, kicking or hitting;

Using pressure point, pain compliance and joint manipulation techniques.

Modifying restraint equipment or applying any cuffing technique that connects

handcuffs behind the back to ankle restraints;

Dragging or lifting of the client by the hair or by any type of mechanical restraints;

and

Using other clients or untrained staff to assist with the restraint.

48

Checklist

Physical Response Strategies for Personal Safety Against Strikes

Speed—When action is required move quickly and without hesitation

Surprise— Unexpected actions interrupt the pattern, and buys time

Move the target

Control space

Physical Response Strategies for Personal Safety Against Grabs

Momentum—direct the force of the attack/assault

Leverage—use of natural range of motion, fulcrum points, body mechanics (for

example, elbow to elbow)

Weak point— use of natural escape paths

Physical Response Strategies for Holds

Control Speed/Momentum

Control Space/Limit attack options

Control balance/body mechanics

Aggressor‘s Action Personal Safety Response

Wrist grab Uses momentum of aggressor to move forward

Moves hand/wrist in direction of aggressor‘s weak point

Moves ―elbow to elbow‖

Maintains proper eye contact and exits

Clothing/hair grab Place both palms over aggressor‘s knuckles

Moves ―elbow to elbow

Applies pressure and moves downward and toward aggressor‘s

body

Pushes aggressor‘s hand down and way

Maintains proper eye contact and exits

Front Choke Raises arms overhead and against aggressor‘s hands

Rotates shoulders and hips away from aggressor

Sweeps arms back and down

Maintains proper eye contact and exits

Rear choke Raises arms overhead and against aggressor‘s hands

Rotates shoulders and hips away toward aggressor

Sweeps arms back and down

Maintains proper eye contact and exits

Headlock Rotates chin to elbow to maintain airway

Places hands on wrist and elbow

49

Pushes downward on wrist and upward on elbow

Duck down and back to release head

Releases aggressor while exiting

Bear hug Places hands over aggressive person‘s hands and presses down

(inward)

With quick motion bends at waist and throws hands outward and

forward

Maintains proper eye contact and exits

Or:

Brings arm up and crossed under aggressors arms and toward own

chest.

Rotates arms out and down.

Punches Step towards and outside aggressor

Deflects, rather than blocks force of assault

Raises open hands in upward sweeping motion

Maintains proper eye contact and exits

Kicks Raise forward foot straight up from ground while rotating towards

aggressor

Maintains proper eye contact and exits

Dealing with armed

assaults --Lethal

If immediate exit and safety shield not available-

Non projectile – Outside authorities contacted immediately

Request aggressor to place weapon on ground (never in hands)

Maintain distance outside reach of weapon

If aggressor attacks- move into aggressor‘s body space

Maintain eye contact deflect at aggressor‘s wrist—not weapon

Projectile (gun)- Outside authorities contacted immediately

Request aggressor to place weapon on ground (never in hands)

Keep aggressor talking, defer to outside authorities

Dealing with armed

assaults -Non-Lethal

Obtain safety shield—padded soft surface

Request aggressor to place weapon on ground (never in hands)

If non-cooperative:

Approach aggressor with shield directly in front

Secure aggressor with weapon against nearest wall

Capture arm with weapon above the wrist

Drop Shield and second team member captures other arm

Team member with captured arm rotates inward towards aggressor

and hold arm with weapon against hip

50

Peel weapon free with twisting motion towards weak point of hold

Move to escort position or control position depending on

aggressor‘s response

Defending oneself

while on the ground

From kick: rotates body to present feet to aggressive person

From choking or punches: Lift either hand to back of own neck

(forming acutely bent arm)

Quick twist upper torso in direction opposite arm.

Escorts Escort are not holds- They are to be used for non-compliant

persons who are not an immediate danger to self or others.

Verbalize to patient intentions before physical contact is made.

Move close in slightly behind person

Place outside hand lightly on elbow with palm turned

upward/outward

Place inside hand behind shoulder with open palm with light

contact

Maintain elbow and shoulder in same plain

Guide aggressor toward designated location

Holds The use of holds with fewer than three people is to use only in

cases of extreme emergency, when escape is not possible, or

escape would place other persona in danger.

Use of a One-person

hold

Move close in and extend inside hand between arm and torso

Grab own bicep of outside arm or bicep of aggressor‘s opposite

bicep, depending on size

Place outside hand on shoulder (either depending on size)

With wide base aggressor is pulled backward onto staff person‘s

side for support.

A Smaller person may be held in standing position from this hold;

a larger person may have to be lowered to the ground in side

position by going to one knee (closest to aggressor.)

Use of a two-person

team hold

Approach in unison

Each person moves close in and extend inside hand between arm

and torso

Grab own bicep of outside arm

Place outside hand on closest shoulder

With wide base aggressor is pulled backward onto staff person‘s

side for support.

Lower aggressor to floor by bending on one knee

Use of a three-

person team

As per Two person hold

Third person maintains control of persons legs

Use of a four-person

51

team

Use of a five-person

team

As per four person hold

Fifth person maintains

Use of more than

five people to

restrain

Different roles

within the team

Taking the patient to

the ground (face

down)

Taking the patient to

the ground (face up)

Turning the patient

over on the ground

Control of the legs Controls legs above the knee

Forms barrier to movement, rather than pressing upon legs

Standing the patient

Passive holding

(escorts) while

standing

Seating the patient

Negotiating doors

Separating fighting

patients

Entry into/exit from

seclusion

Why Not Martial Arts-Based Techniques?

This is a question a number of participants in de-escalation programs have raised.

Behind the question is the misperception that learning marital arts skills might be valuable in a

service environment.

An observation of the skills used in this course may be mistaken for martial arts

techniques. While some overlap in principles may be unavoidable, there is an important

distinction. The techniques taught in this course are based on body mechanics, not martial arts.

The reason techniques based on martial arts are not taught is simple. It is a question of

proficiency.

Many of the techniques used in personal safety courses are based on non-offensive

martial arts systems (e.g., Jiujutsu, Aikido). These techniques can do more harm than good.

This is not a critique of these arts, since there are numerous valid martial arts systems that can

enable even a much smaller person to overcome an attack from a bigger, stronger opponent.

They have the benefit of being less injurious to assaultive persons.

52

A practitioner of Aikido or Jiujutsu, who trains diligently over several years, is a force

to be reckoned with. The problem is few, if any, staff members in a care setting will ever attain

the degree of skill required to effectively execute many of these types of techniques under the

stress of a real life or violent confrontation.

Many martial arts-based techniques work well in the training environment, when the

partners are cooperative and react to the pain stimulus. In such an artificial context the

techniques seem to be effective. When staff members employ these techniques on a person

who does not respond the way their training partner did -- because the person is under the

influence or alcohol, drugs, or is impervious to pain for any number of reasons -- the training

proves ineffective. In a sense, learning these martial arts-based techniques can actually

endanger care providers by fostering a false sense of security.

Gross Motor and Body Mechanics Based Tactics

Staff members need to be taught gross-motor skills to control violent situations. Gross-

motor skills are large, full body movements that tend to work better under stress than fine-

motor skills. There are adequate therapeutic and legal issues that preclude the use of techniques

such as joint locks and pressure point manipulations. That these are fine motor skills that

―degrade‖ under stress is just an additional reason to exclude these.

The degradation of fine-motor skills can be attributed to the fight-or-flight response,

which triggers a number of physiological reactions in the body. During the stress of a

potentially violent situation, blood is transferred from relatively non-essential areas such as the

brain and other organs to the large muscle groups such as the arms and legs. As a result, the

body becomes stronger and faster but significantly less coordinated. This phenomenon is what

makes it so difficult to perform complicated techniques during a physical intervention.

Furthermore, techniques that rely on superior strength are doomed to failure in a large

proportion of cases. Techniques must therefore be based on principles that allow a smaller

person to effectively respond to a larger aggressor. These considerations point to techniques

based on body mechanics as the logical option.

Commonality of Technique

Care providers need to be equipped with relatively few techniques, based on relatively

few principles that can be applied in a multitude of scenarios. Research on response times

demonstrates that having two responses to a stimulus rather than one increases reaction time

by as much as 58%. Therefore, learning multiple ways to react to multiple punches reduces

effectiveness with each technique taught..

A more logical concept would be to teach staff members to deal with any type of punch

by using their arms to form a cage to protect their head while deflecting the energy of the

attack.

This tactic could be used to negate jabs, crosses, hooks, and straight punches thrown

with either hand. This prevents the staff person form having to make a split-second decision as

to the specific type of punch and then recall and execute the block designed specifically to

negate that punch.

Emphasis on High Threat Level Responses

53

Certain types of assaults are more likely to occur and require specific training in

dealing with them. For example, despite the fact that it's not uncommon for an aggressive

person to tackle or knock a staff person to the ground before continuing to assault, no other

nationally offered training program includes training to prevent being taken down.

Considering the recent explosion in popularity of televised mixed martial arts events, this type

of attack may become even more common.

Emphasis on Principles and Strategies

Techniques are a specific application of principles. The applications may vary but the

principles remain. They are a means to an end. The ultimate goal of any use of physical

intervention is to establish control in a manner that maintains the safety of all involved,

including the aggressor. As stated, some techniques are better suited for use by care providers

than others. But, the staff member‘s attitude is far more important than any particular technique

or tactic.

54

De-escalation Preference Survey & Individual Crisis Planning

A Crisis Prevention Plan is an individualized plan developed in advance to prevent a crisis and

avoid the use of restraint or seclusion. It is also:

A therapeutic process

A task that is trauma sensitive

A partnership of safety planning

A collaboration between consumers and staff to create a crisis strategy together

A consumer owned plan written in easy to understand language

Also known as:

Safety Tool

De-escalation Preference Tool

Advance Crisis Plan

Individual Crisis Plan

Personal Safety Plan

Personal Safety Form

Safety Zone Tool

Purpose:

To help consumers during the earliest stages of escalation before a crisis erupts

To help consumers identify coping strategies before they are needed

To help staff plan ahead and know what to do with each person if a problem arises

To help staff use interventions that reduce risk and trauma to individuals

Essential Components

Triggers [Avoid the term “trigger” when speaking with patients]

What makes you feel scared or upset or angry and could cause you to go into crisis?

Bedtime

Room checks

Large men

Yelling

People too close

Not being listened to

Lack of privacy

Feeling lonely

Darkness

Being teased or picked on

Feeling pressured

People yelling

Room checks

Arguments

Being isolated

Being touched

Loud noises

Not having control

Being stared at

Other (describe)

__________________________________

Particular time of day/night___________

Particular time of year_______________

Contact with family_________________

Other*___________________________

* Consumers have unique histories with

uniquely specific triggers - essential to ask

& incorporate

Identify Early Warning Signs

55

A signal of distress is a physical precursor and manifestation of upset or possible crisis. Some

signals are not observable, but some are, such as:

Restlessness

Agitation

Pacing

Shortness of breath

Sensation of a tightness in the chest

Sweating

(“What might you or others notice or what you might feel just before you get really

upset?”)

Clenching teeth

Wringing hands

Bouncing legs

Shaking

Crying

Giggling

Heart Pounding

Singing inappropriately

Pacing

Eating more

Breathing hard

Shortness of breath

Clenching fists

Loud voice

Rocking

Can‘t sit still

Swearing

Restlessness

Other ___________

Identify Strategies

Strategies are individual-specific calming mechanisms to manage and minimize stress.

[ Not all these are appropriate in all care setting. Do not present alternatives that are not an

option]

(―What are some things that help you calm down when you start to get upset?’)

Time alone

Reading a book

Pacing

Coloring

Hugging a stuffed animal

Taking a hot shower

Deep breathing

Being left alone

Talking to peers

Therapeutic Touch, describe ______

Exercising

Eating

Writing in a journal

Taking a cold shower

Listening to music

Talking with staff

Molding clay

Calling friends or family (who?) ______

Blanket wraps

Lying down

Using cold face cloth

Deep breathing exercises

Getting a hug

Running cold water on hands

Ripping paper

Using ice

Having your hand held

Going for a walk

Snapping bubble wrap

Bouncing ball in quiet room

Using the gym

Male staff support

Female staff support

Humor

Screaming into a pillow

Punching a pillow

Crying

Spiritual Practices: prayer, meditation,

religious reflection

Touching preferences

Speaking with therapist

Being read a story

Using Sensory Room

Using Comfort Room

56

Identified interventions:____________

Preferences in Extreme Emergencies (to minimize trauma or re-traumatization)

Medication

by mouth

by injection

Preferred medication ______________

Prefer women/men

Hold my hands, do not restrain my body

Consider racial, cultural, and religious factors

57

What is included in this program and why

While there are numerous guidelines for the management of behaviors, there are no widely distributed

guidelines for what should be included in training. One notable exception is The Recognition, Prevention and

Therapeutic Management of Violence in Mental Health Care, A Consultation Document Prepared For The

United Kingdom Central Council for Nursing, Midwifery and Health , by Professor Kevin Gournay CBE and

a team from the Department of Health Services Research Institute of Psychiatry and South London and

Maudsley NHS Trust, LONDON.

The document contains 15 Components of Theoretical Training, all of which are included in this

program. Additionally it recommends 32 components of Practical Training, 28 of which are included in this

program. Those excluded are excluded for either reasons of safety (example: Figure four leg lock) or limited

application (Example: Dressing the patient)

THEORETICAL TRAINING

Possible causes of violence

The prevention of violence

Legal and ethical issues in the management of

violence

Verbal de-escalation of potentially violent

situations

Dealing with language barriers

[Age and ]Cultural sensitivity

Sensitivity to gender issues

Dealing with sensory impairments

Patients with physical disabilities or health

problems

Protection of airway

Risk of sudden death through positional asphyxia,

excited/agitated delirium, etc

Observation/monitoring of sedated patients

Review of incident both with restrained patient

and staff members

Documentation of the incident for audit purposes

Post-restraint review of the restrained patient‘s

management and treatment

PRACTICAL TRAINING

De-escalation strategies

Dealing with space, place and physical distance

factors

Non-verbal social skills

Verbal strategies

Breakaway techniques (personal safety)

Escaping holds

Blocking punches

Blocking kicks

Advice on dealing with armed assaults

Defending oneself while on the ground

Restraint techniques

One person restraining hold

Use of a two-person team

Use of a three-person team

Use of a four-person team

Use of a five-person team

Use of more than five people to restrain

Briefing on practice of different roles within the

team

Taking the patient to the ground (face down)

Taking the patient to the ground (face up)

Turning the patient over on the ground

*Control of the legs (figure four lock)

Control of the legs (other)

Standing the patient

De-escalation of holds and passive holding while

standing

De-escalation of holds and passive holding while

seated

De-escalation of holds and passive holding on the

floor

Seating the patient

*Dressing/undressing the patient

*Negotiating stairways

Negotiating doors

*Entering/exiting vehicles

Entry into/exit from fixed objects

Separating fighting patients

Entry into/exit from seclusion

* Excluded from this program, unless specifically requested. Other components may be excluded as

appropriate for specific organizations receiving training.

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