De-escalating the Acting-out individual

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De-escalating the Acting-out individual
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• 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,Ill 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.

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Sources of individual Stress

• Social life, dating, friendships, harassment
• Self Image issues
• Life circumstances - divorce, unemployment,
• DA abuse, legal issues
• Work stress
• Physical health
• Life circumstances,
• Mental functioning
• Emotional health

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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

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Precipitating factors

• Being aware of precipitating factors can strongly
  influence the successful interaction with an
  escalated individual.
• Although you dont have control over anothers
  precipitating factors, you can become one
  yourself.
• Issues like, hunger, lack of sleep, weather,
  staff changes, holidays, attitude,

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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.

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Two types of aggressive person

• 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

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Most situations will progress from one step to
another, its possible that you can manage a
crisis by addressing the level appropriately.

• 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
  individuals nurse- get water, tissue, etc.

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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.

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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
  individuals 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.)

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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.
• Dont 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
  thats against policy attitude.

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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.

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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.

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When confronted with non-compliant behavior

• Dont 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.
• Dont get trapped in a power struggle with the
  individual

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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,

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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.
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Supportive Stance

• Remain a bit more than one leg length (of
  theirs) away
• Stand sideways, dont 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.

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Keys to Setting Limits

• Simple directives 2 choices
• 1 positive, 1 less positive
• Reasonable within individuals ability
• Enforceable, dont use a consequence that you
  cant follow through with.

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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.

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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.

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• 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.

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Summary- Ask yourself

• What was my original goal?
• What might be the individuals 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?

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• Establish Rapprt- when in a crisis, the
  individual tends to feel no one understands his
  concerns.
• Dont say I understand, or you need to calm
  down, You shouldnt let this get you so upset
• Remember they are likely upset because as of yet,
  they dont 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,
• Id 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 dont we see if
• Lets see about
• You have very quickly joined with them, validated
  their present mood, and are working on it
  together.

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• Give them a reasonable amount of time and space.
• Invite them to tell you more, lets find a place
  where we can talk. Lets sit down and see what
  we can do.
• Listen to their concerns, dont 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 whats going to happen from there.

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• Explore possibilities and options,
• Next time you feel that, Id like you to get a
  hold of me.
• While we cant go back and undo it, we can try
  to insure that doesnt happen again.
• What can we do, to help prevent such frustration
  again?
• Dont say If you would have only this tells
  them that it was all their fault, it wont help
  the current situation.

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• Dont take things personal, it is likely the
  individual is venting to you as a representative
  of what they are frustrated with.
• Dont 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.

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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 its 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.