Module III De-escalation

1. Multidisciplinary Responses to Mental Health Crises Module IIIDe-escalation

2. Module IIIVideo 1 Multidisciplinary Responses to Mental Health Crises Double click on the movie to start

3. Module III Outline: Multidisciplinary Responses to Mental Health Crises By the completion of this Module, students should be able to: • Discuss theories of aggression (including triggers). • Compare and contrast de-escalation with other forms of aggression management. • Discuss definitions, principles and specific strategies incorporated under the umbrella term de-escalation. • Apply learnt theory and strategies to a simulation.

4. Factors Contributing to Aggression • Internal factors • External factors

5. Aggression Multidisciplinary Responses to Mental Health Crises • Patient aggression in the pre-hospital setting may be associated with a wide range of pathologies including: • Organic disorders • Psychiatric illness • Substance abuse

6. Hostile vs. Instrumental Aggression: Multidisciplinary Responses to Mental Health Crises

7. Theories of Aggression: Multidisciplinary Responses to Mental Health Crises • HOT: Threats that are a part of escalation. Commonly caused by fear, frustration, confusion, etc. • COLD: Threats that are a part of manipulation and control, common in persons diagnosed with a personality disorder. Attempt to get needs met. (Maier, 1996)

8. HOT Episodes: Multidisciplinary Responses to Mental Health Crises More commonly seen in mental health. • Recognised in five-set behavioural assessment: • Minor movements(e.g. clenching fists) • Verbal abuse and threats • Major motor movements (e.g. pacing) • Aggression • Exhaustion

9. Perspectives on Aggression: Multidisciplinary Responses to Mental Health Crises With reference to readings provided: • Identify the consumer and staff perspectives on causes of aggression. • Do they differ? • WHY??? • Why is it important to identify possible discrepancies in perceptions?

10. The Assault Cycle Phase 3 Crisis Verbal or physical demonstration of anger/frustration. Phase 2 Escalation The ongoing aggravation resulting in unresolved frustration. Phase 4 Recovery Once the aggression/frustration has been vented, the person tends to settle with time. Phase 5 Post Depression Crisis Often, after the venting process, as the individual settles down further, recognise the upset they have caused and often regret their actions. Phase 1 The Triggering Event The sequence of actions that have irritated the individual. Baseline Level Adapted from Smith, P.A.R.T, 1983

11. Current Practices: Multidisciplinary Responses to Mental Health Crises • Restraint • Seclusion • Sedation (chemical restraint)

12. Current Practices: Multidisciplinary Responses to Mental Health Crises • Clinicians will generally use the technique they are more familiar with, despite the potential of the situation. • Control and restraint is preferred as an early option. (Lee, 2001) • RSS continue to be used in a reactive way. (Duxbury,2002)WHY????? • Potential problems with these practices?

13. De-escalation: Multidisciplinary Responses to Mental Health Crises • How would you define it? What the . . . ?

14. Definition: Multidisciplinary Responses to Mental Health Crises “(the) gradual resolution of a potentially violent and/or aggressive situation through the use of verbal and physical expressions of empathy, alliance and non-confrontational limit setting that is based on respect” Cowin, et al. (2003)

15. Principles of De-escalation: Multidisciplinary Responses to Mental Health Crises • Maintaining autonomy and dignity of the patient. • Using self-knowledge to achieve goals. • Being self-aware. • Intervening early. • Providing options and choice. • Avoiding physical confrontations. Distasio (1994)

16. De-escalation Strategies: Verbal Multidisciplinary Responses to Mental Health Crises • Allow time for person to respond if confused or disoriented. • Allocate one key person to communicate with consumer. • Active listening (addressed in Module II). • Ask carer/family for advice and strategies. • Calm, respectful language. • Open-ended sentences. • Avoid challenges and promises you can’t keep. • Being firm but compassionate. • Calm, lowered tone of voice.

17. Verbal De-escalation: Multidisciplinary Responses to Mental Health Crises COLD Threats Set clear, firm boundaries on behaviour and offer alternatives. Give less time to listening when person is acting inappropriately or being manipulative. HOT Threats Allow time for the person to cool down

18. Psychological De-escalation Strategies:

19. Physical De-escalation Strategies:

20. De-escalation strategies: Physical Multidisciplinary Responses to Mental Health Crises • HOT Threats • Open body language, eye contact • Show interest in what they are saying • Be respectful • Try to match levels • COLD Threats • Check centre of gravity. • Match levels with consumer. • Open body language if they engage in more appropriate. • Closed body language communicates disinterest in manipulation and threats.

21. Management: Multidisciplinary Responses to Mental Health Crises • Awareness of role and responsibilities in a mental health crisis (as per Module I) • Clearly articulated management plan (as per Module II) • Identified team leader (as per Module II)

22. Police and Mental Health Services Multidisciplinary Responses to Mental Health Crises • Police remain responsible for incident control and the safety of all persons present at the scene; mental health service personnel cannot act as negotiators.

23. Thoughts and Questions? Multidisciplinary Responses to Mental Health Crises “All behaviour is meaningful and can be understood” Peplau (1952)

24. References Multidisciplinary Responses to Mental Health Crises • Anderson, C.A. & Bushman, B.J. (2002). Human Aggression. Annual Review of Psychology, 53, 27-51. • Bell, F., Szmukler, G., & Carson, J. (2000). Violence and its management in in-patient mental health settings: a review of the literature. Mental Health Care, 3(11), 370-372. • Bushman, B.J. & Anderson, C.A. (2001). Is it time to pull the plug on the hostile versus instrumental aggression dichotomy? Psychological Review, 108(1), 273-279. • Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M., & Hoot, S. (2003). De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12, 64-73. • Distasio, C.A. (1994). Violence in health care: Institutional strategies to cope with the phenomenon. The Health Care Supervisor, 12(4), 1-27. • Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9, 325-337. • Haber, J., Krainovich-Miller, B., McMahon, A., & Price-Hoskins, P. (1997). Comprehensive Psychiatric Nursing (5th ed). St Louis: Mosby. • Kerrison, S.A. & Chapman, R. (2007). What general emergency nurses want to know about mental health patients presenting to their emergency department. Accident and Emergency Nursing, 15, 48-55. • Link, B.G. & Stueve, A. (1995). Evidence bearing on mental illness and possible causes of violent behaviour. Epidemiology Reviews, 17, 172-181. • Maier, G.J. (1996). Managing threatening behavior, the role of talk down and talk up. Journal of Psychosocial Nursing, 6, 25-30. • Paterson, B., Leadbetter, D., & McComish, A. (1997). De-escalation in the management of aggression and violence. Nursing Times, 93(36), 58-61 • Smith, P.A., Reid, G.V., Sheahan, C. & Sheahan, P. (2004). Professional Assault Response Training: Predicting, understanding and managing aggressive/assaultive behaviour. Ringwood: Professional Group Facilitators. • Stevenson, S. (1991). Heading off violence with verbal de-escalation. Journal of Psychosocial Nursing, 29(9), 6-10.