Module III De-escalation

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

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Factors Contributing to Aggression

• Internal factors

• External factors

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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

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Hostile vs. Instrumental Aggression
Multidisciplinary Responses to Mental Health
Crises
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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)

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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

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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?

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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
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Current Practices
Multidisciplinary Responses to Mental Health
Crises

• Restraint
• Seclusion
• Sedation (chemical restraint)

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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?

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De-escalation
Multidisciplinary Responses to Mental Health
Crises

• How would you define it?

What the . . . ?
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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)

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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)

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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 cant keep.
• Being firm but compassionate.
• Calm, lowered tone of voice.

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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
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Psychological De-escalation Strategies
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Physical De-escalation Strategies
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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.

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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)

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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.

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Thoughts and Questions?
Multidisciplinary Responses to Mental Health
Crises

• All behaviour is meaningful
• and can be understood
• Peplau
  (1952)

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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.