De-escalating the Acting-out individual

1. De-escalating the Acting-out individual

2. What do you do? • 1) You ask a individual if they need help, He pushes a chair, swears, walks to the other side of the room and yells, “Leave me alone. • 2) An individual is complaining about not seeing the Doctor, The more he talks the more angry he is getting. Seeing the Doctor is not an option, since the Doctor is not in. • 3) You ask an individual to leave the room.  He does, but on his way out he turns off your lights and states,”I’ll make sure you all go to hell.” • 4) A individual becomes increasingly upset in session with his wife, now he is becoming more argumentative and starting to yell.

3. Sources of individual Stress • Social life, dating, friendships, harassment • Self Image issues • Life circumstances - divorce, unemployment, • D&A abuse, legal issues • Work stress • Physical health • Life circumstances, • Mental functioning • Emotional health

4. Possible causes of acting out • Frustration or Anger Reaction (over desires or needs not being met) • Retribution (directed towards individual, staff or institution) • Loss of Control ( medical issue, insufficient coping skills, social conditioning) • Displaced Aggression • Low tolerance for boredom, no patience • Stressed, rushed, confusion, • Full Moon (if you are in the field long enough, you just might believe it) • Bio-physiological reasons- meds, hormonal changes, physical conditions, pain

5. Precipitating factors • Being aware of precipitating factors can strongly influence the successful interaction with an escalated individual. • Although you don’t have control over anothers precipitating factors, you can become one yourself. • Issues like, hunger, lack of sleep, weather, staff changes, holidays, attitude,

6. What are the ways a person can act out. • Verbally - refusing, defiance, anger, verbal assault/aggression, • Physically- striking, destroying property, biting,choking,etc. Many of the problems that end up with a physical outcome, could have been maintained to the verbal realm.

7. Intentional - deliberate, motivated, goal directed, for status, revenge, disruption, etc. CD,ODD, Some Axis II Dx. Reactionary- not deliberate, not controllable (yet), escape, avoid, fight or flight condition. PDD, ADHD,Intermittent Explosive Disorder Two types of aggressive person

8. a noticeable change in mood, behavior Verbal defiance, beligerant, yelling Physical acting out- slamming, shoving, Reduction in physical and emotional energy calming down Be supportive, non-judgemental talk Be directive, control by setting limits Insure safety of all, physical restraint if trained. Re-establish communication, become the individual’s “nurse”- get water, tissue, etc. Most situations will progress from one step to another, it’s possible that you can manage a crisis by addressing the level appropriately.

9. Examples of the Intentional • The individual who becomes argumentative as a way of getting people to give in • individual who acts out due to being disrespected, “brushed off”, • individual who feels their “rights” have been violated in some way. • Individual who has a rational or irrational reason for retribution, revenge, settle the score.

10. How to handle the intentional • Verbal de-escalation, the person usually retains the ability to think, reason, weigh consequences at least to some degree. • Remain in control, but assertive, it may be necessary to slightly “heighten” your emotional state- not to argue, but to “join” with the individual’s state of being. • Forced choices, to allow a conversation, the first choice positive, the second with a consequence. • “We can sit down and see what we can do, or if you choose to continue to (yell, swear, disrupt others) we will be forced to (have you leave, call security, etc.)

11. How to handle the intentional • Often times the “acting out” individual simply wants to be heard. Other times, they require some kind of action to be satisfied. • Don’t operate on a “must win the battle” or you will likely lose • Finding some accommodation or middle ground will help defuse the situation quicker than, “sorry that’s against policy” attitude.

12. Examples of reactionary. • Autistic individual who is unable to engage in their ritualistic behaviors, due to (schedule change, new staff, ) • Knee jerk reaction to physical contact- read by the individual as aggressive in nature • “Melt down”- emotional outburst with no apparent cause or triggering event.

13. How to handle the reactionary • Remove stimulus and audience if possible • allow for it to play out, insure individuals safety, limit maneuverability if necessary • Once venting has started, need to let it happen • Wait for tension reduction, offer water, wet wash cloth, tissue, etc. • delay verbal processing of incident • Look to antecedents for future prevention.

14. When confronted with non-compliant behavior • Don’t lose sight of your goal. • Remember that the only behavior you can directly control is your own. • Stop thinking in terms of “giving in” or showing who is boss • Look for ways around the hurtle that the individuals behavior is causing. • Don’t get trapped in a power struggle with the individual

15. Be Aware of Body language (individuals and yours) • Posture, arms crossed, stance, swaying,eye contact, hand gestures, facial expressions, speed of approach- all carry a message • Reading body language is a two way street, make sure your body is conveying the information( tone, mood) that you want it to. • Supportive stance, sideways, hands at side,

16. When approaching a conflict situation, think about… What is happening - What am I walking into, what is the danger level Who is involved?- Is the individual angry with someone or something? Have I worked with them before, what is the status of the relationship? What do I know about them? Triggers, issues, if past history, types of behavior, spits, swears, bites.

17. Supportive Stance • Remain a bit more than “one leg length” (of theirs) away • Stand sideways, don’t square off shoulders, • Tilt head slightly to the left or right, signifies concern and attempt at understanding • Arms at side, waist level, palms up, as if they were going to hand you something.

18. Keys to Setting Limits • Simple directives 2 choices • 1 positive, 1 less positive • Reasonable within individual’s ability • Enforceable, don’t use a consequence that you can’t follow through with.

19. Managing a Fight scene • Make a quick assessment, consider disputants, weapons, likely level of assistance • Call for help/back up, use phone, radio, individual or yell, (organization should have a code word) • Attempt to defuse situation- model calmness, talk assertively and slow, use individuals names if known, • Cause a distraction-kick trashcan, pound locker, toss water on them, you are trying to get their attention off each other an onto you.

20. Controlling a fight scene • Control crowd, block doorway, tell individuals to leave area, “anyone watching will receive a consequence” • Avoid empty threats, ridicule, screaming • Only attempt to separate individuals if you have been trained to do so, and have the help and support you need. If you do it is usually more effective to assess who is the one losing the fight and drag them backwards, if you chose correctly, the winner will often be satisfied and the loser will be given an “out” of a losing situation.

21. Allow the combatants to de-escalate, keep them out of sight and preferably out of ear shot. • Interview separately, or have them write down what they feel happened. • Debrief any bystanders, coworkers often can be shocked by the physical nature of the conflict, let them talk about their reactions.

22. Summary- Ask yourself • What was my original goal? • What might be the individual’s motivation for the behavior? • Will traditional interventions (warnings, punishments, exclusion and orders) work now or do they make the situation worse? • What can I do to adjust my behavior right now to meet my original goal? (offer help, planned ignore, involve the individual) • What type of follow up is needed to teach the individual new skills so he/she can learn socially acceptable ways to express themselves?

23. Establish Rapprt- when in a crisis, the individual tends to feel no one understands his concerns. • Don’t say “I understand”, or “you need to calm down, You shouldn’t let this get you so upset” Remember they are likely upset because as of yet, they don’t feel understood, the other two responses are telling them something they should or need to do, taking control away, • Say things that help you join with them, I’d certainly be upset too.,I can see why this is frustrating, I can see this is big concern. and then add, “How about if we… “Why don’t we see if… Let’s see about… You have very quickly joined with them, validated their present mood, and are working on it together.

24. Give them a reasonable amount of time and space. • Invite them to tell you more, let’s find a place where we can talk. Let’s sit down and see what we can do. • Listen to their concerns, don’t allow phone calls or interruptions if you can help it, convey to them that they are important, and you are willing to listen. • Active listening, clarification questions, mirroring back what you hear are their concerns. • Jot down notes, helps convey that you are taking their concerns seriously. • Summarize their concerns back, and when possible tell them what’s going to happen from there.

25. Explore possibilities and options, • “Next time you feel that…, I’d like you to get a hold of me.” • “While we can’t go back and undo it, we can try to insure that… doesn’t happen again.” • “What can we do, to help prevent such frustration again?” • Don’t say “ If you would have only …” this tells them that it was all their fault, it won’t help the current situation.

26. Don’t take things personal, it is likely the individual is venting to you as a representative of what they are frustrated with. Don’t hold grudges, or you will be ineffective with that individual Disapprove of their behavior not the actual person. At a future time, ask how a potential concern could be handled differently by them and you.

27. Intimidation, Threats • Most attempts at intimidation are designed to get at a “goal” • Threats need to be taken seriously, no matter what the mental state, (manic, psychotic) • Get witness ASAP, keep any email, phone, written threats • Inform supervisor, co-worker, determine if follow up with police is warranted. • Remember, most threats occur in the “heat of conflict” and once it’s over, you will usually “mend fences”, however if the threat is threatening to you, make sure your supervisor follows up with a reaction that you can live with.