Behavioral Crisis Prevention and Intervention

The Dynamics of Non-Violent Care

Draft Copy- Healthcare edition

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

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

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 deescalation, 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. Authors 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: Lundholm@juno.com

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.

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 coercionfree 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 developers 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 deescalation 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):4S25S 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: Lundholm@juno.com

Permission is hereby granted to organizations participating in Dynamics of Non-Violent Care: Deescalation and Personal Safety Training to reproduce these materials for internal distribution. 4

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 neurophysiological 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

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

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.

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 theres 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.

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 persons 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.

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.
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 considering the competing interests of the patient it is important to make a distinction: Are the competing interests primarily Expressive or instrumental_?

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?

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 providers approach.

Recognizing Distress

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 providers primary responsibility is to address not only the behavior, but the distress underlying it. Possible Underlying Distress Physical discomfort Possible Causes Interventions

Physiological Imbalance

Fear

Boredom Anger

Constipation Full Bladder Need for reposition/unable to reposition self Injury/pain Hungry/thirsty Tired Fever Medication effects Hypoxias Cardiac/Respiratory Metabolic Unfamiliar environment OBS/Alzheimers Threats in environment Displaced anxiety/fear Unvaried routines Lack of Socialization Displaced anger Loss (freedom, health, etc.) Depression Psychosis

Psychological factors

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.
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.

In low levels this person resists or attempts to circumvent directives and imposed limitation. At higher levels the person may be combative or assaultive.
The significance of this distinction is that you dont deescalate instrumental aggression, its not a matter of being supportive or empathetic; you have to take away the opportunity to act violently.

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.
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.

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.
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.

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___

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

Environment is a primary determinant

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__.

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, ones 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.

Physiological responses include: Increased heart rate, blood pressure, and respiration. Increased blood flow to the muscles, supplying more oxygen to the muscles, and the heartlung 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 basicfunctions 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.

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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

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

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

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

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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
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. Thats 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.

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 13

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.
Youre likely to hear the term trauma informed care in relation to mental health service, if you havent 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 youll see that weve 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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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
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.

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

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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 A consumer shared her experience in the experiments of the 1960s, the environment is one of the most hospital. She approached a nurse who was powerful determinants of behavior. It is a factor care can very busy and could not get the medication control. that she needed at that moment. 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.
The nurse told her in a heartfelt and respectful way that she would have to wait: Im so sorry; I cant do this right now. I know youre 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.

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. 16

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
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.

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

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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 Im the boss How do you manage your own responses? A persons 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 ones own state is to manage ones 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.

I know whats best Speak softly and carry a big stick I cant protect myself Stick to the facts The rules come first

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A secondary response is to prepare for the occurrence of crisis. This involves training in deescalation 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.
Mindfulness draws on techniques commonly found in all spiritual traditions to help people maintain an open, nonjudgmental inthe-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.

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

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
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.

2. Dissect and de-mystify the threat Fear, as with all emotions, must be managed indirectly. Its not enough to tell ones self, Dont be afraid. One must address the thoughts that maintain fear, both the internal dialogue and the images one plays in ones head. Thought changing is an effective means of addressing ones 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 ones thought processes it is often helpful to practice mindfulness.

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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 ones own responses. How has the threat effected ones own behavior? How has the threat effects ones own physiology?

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 experiencingthe racing heart, the tumbling thoughtsand 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.
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
Detachment is an important skill in dealing with conflict situation.

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.
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 ones 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 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 staffs 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. Its 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.

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. Its 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.
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).

Forms of non-compliance: ReluctanceIndividual 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

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Level

Behaviors

Professional Role/Intervention Physical Intervention: Personal Safety Physical Control

5. Threat of Lethal This is the most dangerous but is actually seen the least. Message: Stop me. 4. Dangerous Physical behaviors directed towards self or others. This level usually includes gross motor movements and a loud voice. Message: Ive lost control 3. Destructive This typically involves some kind of physical behavior directed towards property Message: Im losing control

A very direct threat of suicide or serious aggression

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

Pounding a wall and yelling, throwing clothing or even a chair but not at someone

2 Disruptive This is still a fairly early stage of upset but now involves other people. This is often the stage at which staff overreact, start to set limits, rather than offer support or options, which may contribute to the process of escalation. Message: Pay attention 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: Im in distress

Pacing in front of a TV, going into someone elses bedroom, yelling at the nurses station, interrupting the behaviors of others, noncompliance

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? 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? 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?

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

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:
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.

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 thats 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:
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

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

Age
Very young and very old service recipients more closely approached

Gender Size absolute and relative Positioning (face-to-face versus side-by- side Kinesics (body Language):

Environmental constraints Mood Presence of risk factors

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
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.

The meaning of nonverbal communication is highly dependent on context created by situational (including parallel communications), and demographic elements.
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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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.

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 .

Figure A.

Figure B.

Figure C.

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 ones right eye to the right eye of the individual you are speaking with, so that you are primarily in that persons right visual field. There is a tendency to be perceived as less threatening, and more supportive.

Head tilt and movement

Figure A

Figure B

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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 ones head while speaking can reinforce the verbal message, This isnt a good situation for you [shaking head] and I can understand [nodding head] why you would feel that way.

Shoulders
Raising (shrugging) ones 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

Arms and hands

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

Pointing:
Direct pointing at an individual is taken as aggressive or accusative. If you need to point towards someone, its better to use the back of an open hand.

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
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.

Matching/Mirroring: Shifting weight:

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 persons feeling, or lack of importance. While it is not appropriate to match the anger in a persons voice it is important to convey urgency or importance when responding. The cadence of a persons 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
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 well 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:

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.

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Nonviolent Communications
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.

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 others emotional state. Definition: a process of attending and responding to another so that the person feels heard in a nonjudgmental way.
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
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

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.

Requesting more information

There are numerous way to signal our desire to hear more. Simply saying, Tell me more, about that. Or Interesting, invites further expression.

Paraphrasing
Restating or summarizing what has been heard and understood allows the speaker to clarify if necessary, and builds rapport when it is accurate.

Empathic sayings
An empathic saying is a entry phrase to let a person know we are following them. Commonly used ones are: It sound like youre ________ I can see youre (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.

Phrases to avoid include: I know how you feel. You should/shouldnt

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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? When you

What concrete actions I am observing--seeing, hearing, remembering? When I Feeling How are you feeling in relation to these actions? I feel Needs

How are you feeling in relation to these actions? Do you feel? Youre feeling.

What are the values, desires and expectations that are creating the feeling? Because you are needing?

What are the values, desires and expectations that are creating the feeling? Because I am needing

Requests What concrete actions would you like me to take? And would you like me to? What concrete actions would I like you to take? 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:
(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, Im standing here talking to youYoure not wanting to go nowand 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:
Sensory-based feedback is describing, without evaluation or labeling an individuals behavior. Use with pacing and leading.

Embedded commands:
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.

Binds:
(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.

Displacement:
Disclaimer/ Negative commands. I dont expect you to just, You dont have to right away., I know you dont want to Quotes. Im 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.

Presuppositions/Implications
Time - eventually, in the past, up until now, before, after, while. I dont 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 dont 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, its important to be aware of the principles of social influence.
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.

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.
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.

Applications in a care environment:

Frame communications as a concession Ill give you time to think about it Remind patient of privileges received

Commitment and Consistency 34

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.
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.

Applications in a care environment:

Remind patient of past positive behaviors Remind patient of previous agreements

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.
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.

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:

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Normalize resistance while conveying that peers make the positive choice. Example; A lot of patient feel upset, and dont want to do it, not until they realize that its better for you in the long run and then theyll do it.

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:
Be aware of patients response to authority and emphasize or deemphasize as appropriate

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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.
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.

Applications in a care environment:

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

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

Focus on principles not techniques, and strategies not tactics General Principles Safety for all parties involved Maintain initiativeThe goals is never self-defense (reactive); rather your role is to control an aggressive situation Physical Response Strategies SpeedWhen 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: Momentumdirect the force of the attack/assault Leverageuse of natural range of motion, fulcrum points, body mechanics (elbow to elbow) Weak point use of natural escape paths 38

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

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.

Safety for all involved Efficacyineffective techniques endanger the care provider, and are therefore unsafe.
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.

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 39

Three person- minimum safe and effective number Maintain Initiative

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

Physical Response Strategies Control Speed/Momentum

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

. Control Space/Limit attack options

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

Control balance/body mechanics

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

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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)
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,

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

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

Practical Steps Make Debriefing Rigorous.

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.

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

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

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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. Dont 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.

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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 individuals 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.

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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 JCAHOs 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 causesinsufficient orientation and training, faulty communication, and insufficient staffing levelsare 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 dont 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. 45

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 individuals 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 adequacythe appropriate number and level of staff, trained and competent in alternatives to restraint and safe restraint useis 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.

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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 clients 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.

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Checklist Physical Response Strategies for Personal Safety Against Strikes SpeedWhen 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 Momentumdirect the force of the attack/assault Leverageuse 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 Aggressors Action Wrist grab

Clothing/hair grab

Front Choke

Rear choke

Headlock

Personal Safety Response Uses momentum of aggressor to move forward Moves hand/wrist in direction of aggressors weak point Moves elbow to elbow Maintains proper eye contact and exits Place both palms over aggressors knuckles Moves elbow to elbow Applies pressure and moves downward and toward aggressors body Pushes aggressors hand down and way Maintains proper eye contact and exits Raises arms overhead and against aggressors hands Rotates shoulders and hips away from aggressor Sweeps arms back and down Maintains proper eye contact and exits Raises arms overhead and against aggressors hands Rotates shoulders and hips away toward aggressor Sweeps arms back and down Maintains proper eye contact and exits Rotates chin to elbow to maintain airway Places hands on wrist and elbow 48

Bear hug

Pushes downward on wrist and upward on elbow Duck down and back to release head Releases aggressor while exiting Places hands over aggressive persons 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

Kicks

Dealing with armed assaults --Lethal

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 Raise forward foot straight up from ground while rotating towards aggressor Maintains proper eye contact and exits If immediate exit and safety shield not availableNon 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 aggressors body space Maintain eye contact deflect at aggressors wristnot 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 shieldpadded 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

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Peel weapon free with twisting motion towards weak point of hold Move to escort position or control position depending on aggressors 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. 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 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. Move close in and extend inside hand between arm and torso Grab own bicep of outside arm or bicep of aggressors opposite bicep, depending on size Place outside hand on shoulder (either depending on size) With wide base aggressor is pulled backward onto staff persons 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.) 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 persons side for support. Lower aggressor to floor by bending on one knee

Escorts

Holds

Use of a One-person hold

Use of a two-person team hold

Use of a threeperson team Use of a four-person

As per Two person hold Third person maintains control of persons legs

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team Use of a five-person team 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 Standing the patient Passive holding (escorts) while standing Seating the patient Negotiating doors Separating fighting patients Entry into/exit from seclusion

As per four person hold Fifth person maintains

Controls legs above the knee Forms barrier to movement, rather than pressing upon legs

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.

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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. Grossmotor skills are large, full body movements that tend to work better under stress than finemotor 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

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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 members attitude is far more important than any particular technique or tactic.

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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 Being touched Room checks Loud noises Large men Not having control Yelling Being stared at People too close Other (describe) Not being listened to __________________________________ Lack of privacy Feeling lonely Particular time of day/night___________ Darkness Particular time of year_______________ Being teased or picked on Contact with family_________________ Feeling pressured Other*___________________________ People yelling * Consumers have unique histories with Room checks uniquely specific triggers - essential to ask Arguments & incorporate Being isolated Identify Early Warning Signs

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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 Cant 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 55

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

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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 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 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 patients management and treatment

* Excluded from this program, unless specifically requested. Other components may be excluded as appropriate for specific organizations receiving training.

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