Promoting Cultural Change with Words (#407)
Wednesday, August 29, 2007
Patrick Risser, B.A. (firstname.lastname@example.org) and
Pamela Trammell, M.A., M.S. (ALmom205@aol.com)
The will be up at:
within the next couple of weeks
Culture change means being open to willfully changing one's thinking, one's feelings and one's behavior. Crisis Intervention Training seeks to end the prejudice, discrimination and fear of people labeled with mental illness. CIT is dedicated to change from fear to people first. The heart of CIT is to use words, not weapons, to understand the situation of a person who is labeled with a mental illness. This presentation will focus on the development of policies and partnerships that promote a positive culture for law enforcement and those labeled with mental illness. Leadership by example will also promote the change necessary to make a difference in our culture.
Formation of CIT
In 1988, the Memphis Police Department joined in partnership with the Memphis Chapter of the Alliance on Mental Illness (AMI), mental health providers, and two local universities (the University of Memphis and the University of Tennessee) in organizing, training, and implementing a specialized unit. This unique and creative alliance was established for the purpose of developing a more intelligent, understandable, and safe approach to mental crisis events. This community effort was the genesis of the Memphis Police Department's Crisis Intervention Team. That's great but something's missing...
NOTHING ABOUT US WITHOUT US!
Violence and mental illness and stigma
Mad. Crazy. Insane. Demented. Deranged. Loony. Psycho. Dangerous. These are all words used by the public to describe people who are labeled as having a mental illness.
Unfortunately, the public believes those labeled as mentally ill are dangerous and need to be watched carefully. According to the National Institute of Mental Health, a recent survey conducted in California found that 83 percent surveyed believed those labeled as mentally ill are dangerous. In reality, though, less than 2 percent of those labeled as mentally ill people are dangerous, according to the institute -- a figure no higher than the incidence of violence in the general population.
Even more disheartening is the institute's finding that society holds ex-convicts in higher regard than people who've had a history of being labeled with mental illness.
Patients of no other set of medical issues are kept under such scrutiny by the public. Cancer patients who refuse chemotherapy are not taken to the hospital by the police and forced to get treatment. People are not locked up for not participating in treatment (refusing to use an inhaler or lighting up a cigarette) or failure to comply (eating a fast food hamburger while on a diet).
Laws that seek to curtail the rights of people labeled as mentally ill – the right to be left alone, the right to refuse treatment – are damaging to the dignity of those labeled as mentally ill. These laws only deepen the stigma and serve to drive the some people into hiding when they could be getting help.
People labeled as mentally ill face more obstacles in society than any other segment of the population. In many cases the prejudice and discrimination are far more disabling than the mental health problem itself. They find it difficult to find jobs and make friends. To further frustrate matters, those close to people labeled mentally ill are not likely to offer as much support as they would if the person had cancer or even AIDS instead.
How far has society come since the first mental hospital opened in Williamsburg, Va., in 1773? While the hospital was the first to cater specifically to the mentally ill, it was nothing more than a prison, with patients shackled and abused. Committal was virtually a life sentence.
Today the mentally ill aren't treated much better. A 1980 study found that a substantial number of mental health care professionals harbored resentment toward their patients. When a student in an upper-level psychology course recently mentioned she was an intern at Bangor Mental Health Institute, the student in front of her joked, "You wouldn't happen to be going there for treatment, would you?"
Yet nobody would joke in a similar way about heart disease.
In its brochure "The Stigma of Mental Illness," the NIMH says: "Historical physical abuse or neglect have been replaced by a less visible but no less damaging psychic cruelty. ... We no longer send (people labeled mentally ill) to a far-away asylum. Instead, we isolate them socially, a much more artful though equally debilitating form of ostracism."
The APA (American Psychiatric Association) has repeatedly stated that they are unable to predict dangerousness with any degree of certainty.
Similar "ism's" are:
Discrimination can be blatant but more often consists of:
1. Not powerful individually
2. hundreds, even thousands daily
3. cumulative effect over years
* Dr. Chester Pierce, an African-American psychiatrist and author writing about racism in the book, "The Black 70's", termed the multiple small insults and indignities directed at people "micro-aggressions."
Effects of Mentalism
… People internalize the negative attitudes
… People feel ashamed
… People blame themselves for their difficulties
… People feel worthless
… People feel hopeless about their future
… People lose confidence about their abilities
… People feel they must hide their histories
… People fear losing their job, their friends, their credibility
… People become demoralized
… People direct their anger and helplessness back upon themselves creating a worsening spiral downward
… Us vs. Them …
This black-and-white, all or nothing style of thinking is referred to in psychodynamic literature as "splitting."
ÿ Behaviors of the power-down group are framed in pathological terms.
ÿ The same behaviors are excused or even valued in members of the power-up group.
A quiet client who causes no community disturbance is deemed "improved" ; no matter how miserable or incapacitated "they" may feel as a result of the "treatment."
"They" may be miserable but that's not the point.
"Their" misery doesn't matter. The only thing that matters is any inconvenience "they" may cause "us."
Labeling, diagnosis and other practices tend to decontextualize people.
Typically, when treatments are ineffective or unacceptable, the recipient is blamed. He or she is:
and, has therefore failed the provider rather than the other way around.
… Mentalism and Language …
There is NO such thing as a "side-effect."
There are only "effects" from taking drugs. Some effects are desired and others are undesirable.
Calling an adverse effect a "side-effect" obscures and minimizes the resultant pain, suffering and misery that can be caused by psychoactive drugs. This discounts our experiences and perceptions and thus denies our reality.
"Decompensating" is an us-them term
The demotion from "us" to "them" is a loss of one's designation as a person.
A person with a diagnosis can become:
"a schizophrenic" or
"a bipolar" or
CMI, SMI, SPMI, ADHD, etc.
… Myth of Compliance …
Nowhere in medicine are physicians more preoccupied with enforcing "compliance" than psychiatry. Most non-psychiatric physicians have come to accept that compliance itself is a myth.
ÿ Humans don't comply with anything (Studies of "compliance" with everything from diabetic diets to anti-hypertensive agents show that humans don't comply with anything. At least one third of people in these studies fail to follow their doctors' instructions and many studies have shown rates of "non-compliance" of over 50%.)
ÿ Best results are obtained when people are well-informed and in control of their treatment
ÿ Incarceration is used to contain the person who will not comply, though, because the incarceration occurs in a hospital, it is deemed to be "treatment"
ÿ Imagine jailing a diabeti c for having dessert or incarcerating a person having chronic bronchitis for lighting up a cigarette or forgetting his/her inhaler
… Mentalism and Trauma …
Mentalism can cause further difficulties for those who have a past history of trauma.
In the United States, a child is reported abused or neglected every 10 seconds.
Roughly 4 – 6% of our elderly are abused, primarily by family members.
70% of women who are homeless were abused as children. Nearly 90% of women who are both homeless and have been diagnosed as having a mental illness experienced abuse both as children and adults.
80% of incarcerated women have been victims of physical and sexual abuse. The majority of murderers and sexual offenders, who tend to be male, have a history of childhood abuse, neglect, maltreatment and trauma.
The majority of both men and women in substance abuse programs report childhood abuse or neglect.
Each year, 2,000 children die from maltreatment: 90% are under the age of five.
40-50% of males with mental health issues were sexually abused in childhood.
Actual numbers are uncertain due to differences in how data were collected (chart review vs. interview)
Instead of proclaiming, "What's wrong with you?" mental health professionals need to learn to ask,
"What happened to you?"
Mental Health Clients and Trauma
n 90% of public mental health clients have been exposed
(Muesar et al., in press; Muesar et al., 1998)
nMost have multiple experiences of trauma
n34-53% report childhood sexual or physical abuse
(Kessler et al., 1995; MHA NY & NYOMH 1995)
n43-81% report some type of victimization
n97 % of homeless women with SMI have experienced severe physical and sexual abuse - 87% experience this abuse both as child and adult
(Goodman et al., 1997)
nCurrent rates of PTSD in people with SMI range from 29-43%
(CMHS/HRANE, 1995; Jennings & Ralph, 1997)
nEpidemic among population in public mental health system, especially women
n74 % of Maine's AMHI C/S/X reported histories of sexual and physical abuse
nMajority of adults diagnosed BPD (81%) or DID (90%) were sexually or physically abused as children
(Herman et al., 1989; Ross et al., 1990)
The literature substantiates that:
nSexual abuse of women was largely under-diagnosed
nCoercive interventions like S/R caused trauma and re-traumatization in treatment settings
n"Observer violence" in treatment settings was traumatizing
nComplex PTSD, DID and related syndromes frequently misdiagnosed in treatment settings
nInadequate or no treatment was common
(Cook et al., 2002; Fallot & Harris, 2002; Frueh et al., 2000; Rosenberg et al., 2001; Carmen et al., 1996)
nPeople who are psychotic and delusional can respond reliably to trauma assessments if asked appropriately with one person sensitively asking the questions. (Rosenberg, 2002)
Courteous, Non-violent Help from Police
When you're in crisis, you hope for a helper who is just as compassionate and concerned as someone would be who was helping you out of some kind of physical danger.
Police uniforms are designed to look threatening and intimidating.
When you, as a police officer, get involved in matters related to my mental health (e.g. transporting me to the hospital, checking on me at my home, etc.), please take care not to treat me in ways which could make me feel like a criminal.
Please tr y talking with me first, before reaching any decisions about me or choosing to apply handcuffs.
If you are a police officer, please gently explain why you need to do anything which feels threatening, humiliating, or unjustified to me.
Please understand that to a trauma survivor the following activities are extremely traumatizing: frisking, handcuffing, authoritarian behavior, unexpected or unwanted physical contact, rough handling, provocation, verbal abuse, physical assault, being transported in the back of a police car. These experiences can be terrifying and can trigger former traumatic experiences.
Since I may already be in crisis, and remembering people who harmed me in the past, please speak to me and relate with me in ways that do not provoke my fear, anger, or anguish.
Since police officers usually arrive in numbers, it helps greatly if they do not close in and surround me.
Please do not stand too close
to me, since it threatens my sense of safety and self.
Thoughts, moods, feelings and emotions are NOT an illness, disease or disorder!!
We need to learn to listen to people's stories.
It is important to understand that, due to the power differential between staff and recipients, many psychiatric interventions trigger or retraumatize the survivor.
Triggers and retraumatization can occur in both the physical and interpersonal environments.
Examples include spread-eagle restraint of a rape victim or disbelieving the history given by a survivor of incest.
u u u
Because powerlessness is a core element of trauma, any treatment that does not support choice and self-determination will tend to trigger individuals having a history of abuse.
People may re-experience the helplessness, hopelessness, pain, despair, and rage that accompanied the trauma.
They also may experience intense self-loathing, shame, hopelessness, or guilt.
Mentalist thought tends to label these negative effects of treatment in pejorative terms that blame the survivor: "He's just acting out," "She's manipulating," "He's attention-seeking."
These labels are often communicated through the attitudes and language of staff, and become re-traumatizing in themselves.
Mentalism, like racism or sexism, is abuse.
The system's biological approach reduces human distress to a brain disease, and recovery to taking a pill. The focus on drugs obscures issues such as housing and income support, vocational training, rehabilitation, and empowerment, all of which play a role in recovery.
Stigma has to be adopted by the person to be shamed.
Stigma is consumer inaction in the face of oppression.
It doesn't exist without the collusion of the target person.
The whole stigma, anti-stigma issue is primarily about marketing mental health services, shifting responsibility for a system in shambles, from the system to the would be service user, who doesn't ask for help because of 'stigma.' Mental health clients, just like the general public, have been convinced by "Big Pharma" marketing.
We are the victims. Stigma is not 'our' behaviors; it is behavior of those who learn it in school, law enforcement, media, and the general public.
The proper words are prejudice and discrimination. One is social, the other legal. They are legally actionable!
Stigma is a stigmatizing word in itself, why have a different word for prejudice against mental health consumers than for prejudice against other groups?
ACTIVE LISTENING SKILLS
In recent years, the FBI and a growing number of law enforcement agencies have used active listening to resolve volatile confrontations successfully. These positive results have led the FBI to incorporate and emphasize active listening skills in its crisis negotiation training. The following seven techniques constitute the core elements of the active listening approach the FBI teaches.
ÿ Minimal Encouragements
ÿ Emotion Labeling
ÿ Open-ended Questions
ÿ "I" Messages
ÿ Effective Pauses
ACTIVE LISTENING SKILLS
In recent years, the FBI and a growing number of law enforcement agencies have used active listening to resolve volatile confrontations successfully. These positive results have led the FBI to incorporate and emphasize active listening skills in its crisis negotiation training. The following seven techniques constitute the core elements of the active listening approach the FBI teaches. Together, these techniques provide a framework for negotiators to respond to the immediate emotional needs of expressive subjects, clearing the way for behavioral changes that must occur before negotiators can resolve critical incidents.
During negotiations with a subject, negotiators must demonstrate that they are listening attentively and are focused on the subject's words. Negotiators can convey these qualities either through body language or brief verbal replies that relate interest and concern. The responses need not be lengthy. By giving occasional, brief, and well-timed vocal replies, negotiators demonstrate that they are following what the subject says. Even relatively simple phrases, such as "yes," "O.K.," or "I see," effectively convey that a negotiator is paying attention to the subject. These responses will encourage the subject to continue talking and gradually relinquish more control of the situation to the negotiator.
Paraphrasing consists of negotiators' repeating in their own words the meaning of subjects' messages back to them. This shows that negotiators are not only listening but also understanding what the subject is conveying.
For example, the subject might say, "What's the use in trying to go on anymore. I've lost my job of 18 years, my wife has left me for good, I have no money and no friends. I'd be better off dead." In response, the negotiator might express understanding by paraphrasing the subject's words, "You've lost your job and your wife, there is no one to turn to, and you're not sure if you want to go on living."
Because expressive subjects operate from an almost purely emotional framework, negotiators must address the emotional dimensions of a crisis as the subject sees them. Emotion labeling allows negotiators to attach a tentative label to the feelings expressed or implied by the subject's words and actions. Such labeling shows that negotiators are paying attention to the emotional aspects of what the subject is conveying. When used effectively, emotion labeling becomes one of the most powerful skills available to negotiators because it helps them identify the issues and feelings that drive the subject's behavior.
A negotiator might say, "You sound as though you are so angry over being fired from your job that you want to make your supervisor suffer for what happened." In response, a subject might agree with the negotiator's statement and thereby validate the assessment. Or, the subject could modify or correct the assessment: "Yes, I'm angry, but I don't want to hurt anyone. I just want my job back." Either way, negotiators have learned something important about the subject's emotions, needs, and contemplated plans.
By mirroring, negotiators repeat only the last words or main idea of the subject's message. It serves as both an attending and listening technique, as it indicates both interest and understanding. For example, a subject may declare, "I'm sick and tired of being pushed around," to which the negotiator can respond, "Feel pushed, huh?"
Mirroring can be especially helpful in the early stages of a crisis, as negotiators attempt to establish a non-confrontational presence, gain initial intelligence, and begin to build rapport. This technique allows negotiators to follow verbally wherever the subject leads the conversation. Consequently, negotiators learn valuable information about the circumstances surrounding the incident, while they provide the subject an opportunity to vent.
This technique also frees negotiators from the pressure of constantly directing the conversation. Under stress, negotiators may find they are unsure of how to respond to the subject. Mirroring enables a negotiator to be a full partner in the conversational dance without having to lead. Using this skill also helps negotiators avoid asking questions interrogation-style, which blocks rapport building.
By using open-ended questions, negotiators stimulate the subject to talk. Negotiators should avoid asking "why" questions, which could imply interrogation. When the subject speaks, negotiators gain greater insight into the subject's intent. Effective negotiations focus on learning what the subject thinks and feels. If negotiators do most of the talking, they decrease the opportunities to learn about the subject. Additional examples of effective open-ended questions include, "Can you tell me more about that?" "I didn't understand what you just said; could you help me better understand by explaining that further?" and "Could you tell me more about what happened to you today?"
By using "I" messages, a negotiator ostensibly sheds the negotiator role and acts as any other person might in response to the subject's actions. In an unprovocative way, negotiators express how they feel when the subject does or says certain things.
For instance, a negotiator might say, "We have been talking for several hours, and I feel frustrated that we haven't been able to come to an agreement." This technique also serves as an effective response when the subject verbally attacks the negotiator, who can respond, "I feel frustrated when you scream at me because I am trying to help you."
While employing this skill--and all active listening techniques--negotiators must avoid being pulled into an argument or trading personal attacks with a subject. An argumentative, sarcastic, or hostile tone could reinforce the subject's already negative view of law enforcement and cause the subject to rationalize increased resistance due to a lack of perceived concern on the part of the police. Use of "I" messages serves to personalize the negotiator. This helps to move the negotiator beyond the role of a police officer trying to manipulate the subject into surrendering.
By deliberately using pauses, negotiators can harness the power of silence for effect at appropriate times. People tend to speak to fill spaces in a conversation. Therefore, negotiators should, on occasion, consciously create a space or void that will encourage the subject to speak and, in the process, provide additional information that may help negotiators resolve the situation.
Silence also is an effective response when subjects engage in highly charged emotional outbursts. When they fail to elicit a verbal response, subjects often calm down to verify that negotiators are still listening. Eventually, even the most emotionally overwrought subjects will find it difficult to sustain a one-sided argument, and they again will return to meaningful dialogue with negotiators. Thus, by remaining silent at the right times, negotiators actually can move the overall negotiation process forward.
In combination, active listening skills can help negotiators demonstrate that the negotiation team sincerely wants to help the subject out of a difficult situation. No set formula exists for using these skills, however. The application of some or all of the skills should depend upon the specifics of the situation confronting negotiators.
Negotiators should look at these skills as tools to be applied as deemed appropriate during a crisis situation. Like all tools, they should be used only to perform the jobs for which they are intended.
THE CHANGE PROCESS
The application of active listening skills helps to create an empathic relationship between negotiators and the subject. Demonstrating this empathy tends to build rapport and, in time, change the subject's behavior. This approach to crisis intervention represents an effort over a relatively short period of time to stabilize emotions and restore the subject's ability to think more rationally.
However, when dealing with expressive subjects, negotiators should avoid the standard law enforcement inclination to resolve the problem as rapidly as possible. Even the most well orchestrated negotiations take time.
People tend to listen to and follow the advice of individuals who have influence over them. Negotiators generally achieve peaceful resolutions only after they demonstrate their desire to be nonjudgmental, non-threatening, and understanding of the subject's feelings. By projecting that understanding, negotiators show empathy and lead the subject to perceive them, not as the enemy, but as concerned individuals who want to help.
Applying active listening skills and showing empathy establish a degree of rapport between negotiators and subjects that can lead to the discussion of nonviolent alternatives to resolve incidents. The rapport creates an environment where negotiators can suggest various alternatives that the subject previously could not see or would not consider.
Subjects who turn to negotiators and say, "I'm so confused and scared. What should I do to get out of this situation?" have reached a point where, due to the rapport-building efforts of negotiators, they are ready to accept advice on the best way to resolve the situation. Such a query provides an opening that negotiators can use to influence the actions of the subject by suggesting alternatives and offering solutions.
Crisis negotiators must respond to critical incidents involving individuals who display a variety of behavioral traits. However, during the majority of critical incidents, negotiators confront subjects who manifest predominantly expressive behavior.
Expressive subjects are in a state of crisis that blocks their normal coping mechanisms for handling stress. Their thinking becomes highly constricted and disorganized, making it difficult for them to deal logically with their problems and exercise good judgment. Skilled and patient negotiators can significantly influence such a subject's behavior by being supportive and non-confrontational.
By applying active listening skills, negotiators demonstrate that they are not a threat to the subject and that their goal is to help rather than harm. When negotiators demonstrate empathy and understanding, they build rapport, which, in turn, enables them to influence the subject's actions by providing nonviolent problem-solving alternatives. In short, by demonstrating support and empathy, negotiators often can talk an expressive subject into surrendering largely by listening.
Four Steps to Effective Crisis Intervention
Step #1: Listen
* Elements of Listening
* Establish rapport and trust.
* Identify precipitating problems.
* Help the person deal with, identify, and diffuse feelings.
* Techniques for Listening
* Use first names, ask if it OK to use the person's first name.
* Use content questions.
* Ask or use feeling questions or statements.
Step #2: Assess
* Elements of Assessing
* Determine the severity of the crisis.
* Assess potential lethality or physical harm to the person or others.
* Identify coping patterns, strengths and resources
* Techniques for Assessing
* Find out if the person is suicidal, homicidal, or both.
* Find out to what extent the crisis has disrupted the person's normal life pattern. Are daily routines with family, friends, work, etc. affected?
* Find out if the level of tension has distorted the perception of reality.
* Find out how the person deals with anxiety, tension, or depression. Have they been proactive?
* Find out what coping methods were used in the past. Do they have a variety?
* Find out if family and social resources are potential resources. Are the resources positive or negative?
* Find out what the person used as support systems in the past. Are they present, absent, or exhausted? Can the combine or use the systems in a new way?
Step #3: Develop an Action Plan
* Elements of Developing an Action Plan
* Selectively choose and use appropriate approaches to action planning.
* Assist in modifying previous inadequate coping skills.
* Negotiate a contract or action plan.
* Select appropriate referral resources.
* Plan for immediate action and implementation.
* Techniques for Developing an Action Plan
* Use three basic approaches:
1. Start by being non-directive.
2. Be collaborative by working together on a joint plan.
3. Be directive if the person does not or will not make a plan.
* When making an action plan, keep it simple and manageable.
* Keep the action plan short-term, 24 hours to three days.
* Keep the action plan achievable and focused.
* Plan for follow-up provisions.
Step #4: Close
* Elements of Closing
* Review completed action plan.
* Do anticipatory planning for building new ties with resources.
* Plan and provide follow-up.
* Keep the action plan achievable and focused.
* Plan for follow-up provisions.
The following "10 tips for Crisis Prevention" were adapted by Yale University Libraries from those provided by the National Crisis Prevention Institute:
1) Remain calm and be empathetic.
… Try to show respect.
… Do not be judgmental.
Try not to be judgmental of your client's feelings. They are real—even if not based on reality—and must be attended to.
2) Clarify messages.
… Make sure you understand what is being said.
… Repeat your request if necessary.
Listen to what is really being said. Ask reflective questions, and use both silence and restatement.
3) Respect personal space.
… Don't stand too close for comfort.
Stand at least 1 ½ to 3 feet from the acting-out person. Encroaching on personal space tends to arouse and escalate an individual.
4) Be aware of body position.
… Don't stand straight in front of another person or appear to block his/her avenue of escape.
… Keep your nonverbal cues non-threatening.
… The more an individual loses c ontrol, the less the person listens to your actual words.
Standing eye to eye, toe-to-toe with the client sends a challenge message. Standing one leg length away and at an angle off to the side is less likely to escalate the individual.
5) Permit verbal venting where possible.
… Let the angry person blow off steam.
Allow the individual to release as much energy as possible by venting verbally. If this cannot be allowed, state directives and reasonable limits during lulls in the venting process.
6) Set and enforce reasonable limits.
… State what you will permit.
… Offer a choice of actions or alternatives if you can.
If the individual becomes belligerent, defensive or disruptive, state limits and directives clearly and concisely.
7) Avoid overreacting.
… Strive to remain calm, rational and professional.
… Avoid the use of humor, sarcasm or personal remarks.
Remain calm, rational and professional. How you, the staff person, respond will directly affect the individual.
8) Avoid using physical techniques (pushing, grabbing, etc.) except when personal safety is at risk. Use physical techniques as a last resort.
… Physical techniques can only make things worse, and may lead to subsequent lawsuits.
Use the least restrictive method of intervention pos sible. Employing physical techniques on an individual who is only acting out verbally can escalate the situation.
9) Ignore challenging questions.
… Do not respond to challenges to your authority, training, intelligence, policy, etc.
… Do not argue with outrageous statements.
When the client challenges your position, training, policy, etc., redirect the individual's attention to the issue at hand. Answering these questions often fuels a power struggle.
10) Be a team member when confronting a disturbed patron.
… Get help and do not try to handle the situation alone.
… Give support to another staff member who has had to confront a disturbed patron.
… Alert other staff members when strange behavior occurs. 
10) Keep your nonverbal cues non-threatening.
Be aware of your body language, movement, and tone of voice. The more an individual loses control the less he listens to your actual words. More attention is paid to your nonverbal cues.
Do the Following:
ÿ Remain calm and avoid over-reacting.
ÿ Provide or obtain on-scene emergency aid when treatment of an injury is urgent.
ÿ Follow procedures indicated on medical alert bracelets or necklaces.
ÿ Indicate a willingness to understand and help.
ÿ Speak simply and briefly, and move slowly.
ÿ Remove distractions, upsetting influences, and disruptive people from the scene.
ÿ Understand that a rational discussion may not take place.
ÿ Recognize that the person may be overwhelmed by sensations, thoughts, frightening beliefs, sounds ("voices"), or the environment.
ÿ Be friendly, patient, accepting, and encouraging, but remain firm and professional.
ÿ Be aware that a uniform, gun, handcuffs, etc. may frighten the person with mental illness, and reassure the person that no harm is intended.
ÿ Recognize and acknowledge that a person's delusional or hallucinatory experience is real to him or her.
ÿ Announce actions before initiating them.
ÿ Gather information from family or bystanders.
ÿ If the person is experiencing a psychiatric crisis, ask that a representative of a local mental health organization respond to the scene.
Do Not Do the Following:
ÿ Move suddenly, giving rapid orders or shouting.
ÿ Force discussion.
ÿ Maintain direct, continuous eye contact.
ÿ Touch the person (unless essential to safety).
ÿ Crowd the person or move into his or her zone of comfort.
ÿ Express anger, impatience, or irritation.
ÿ Assume that a person who does not respond cannot hear.
ÿ Use inflammatory language, such as "crazy," "psycho," "mental," or "mental subject."
ÿ Challenge delusional or hallucinatory statements.
ÿ Mislead the person to believe that you or others on the scene think or feel the way the person does.
If the person is acting erratically, but not directly threatening any other person or him-or herself, such an individual should be given time to calm down. Violent outbursts are usually of short duration. It is better that the officer spend 15 or 20 minutes waiting and talking than to spend five minutes struggling to subdue the person.
Verbal De-escalation Techniques (Staff)
The staff member who assumes control of the situation should explain to the service user what they intend to do. This will involve:
The staff member who assumes control should ask for facts about the problem and encourage reasoning. This will involve:
The staff member should also ensure that their own non-verbal communication is non-threatening. This will involve:
What is Verbal De-escalation?
ßVerbal De-escalation is the use of techniques designed to reduce physical contact injuries.
ßVerbal De-escalation is what is used during a potentially dangerous situation to attempt to prevent a person from causing harm to themselves or others.
ßIn many places it is the philosophy that when maintaining control of the environment and the clients, to make every attempt to verbally de-escalate any situations before resorting to the use of physical force.
ßIn many places it has the force of being policy, and is taught to all employees.
Using Verbal De-escalation
ßTactics are non-physical skills used to prevent a potentially dangerous situation from escalating into a physical confrontation.
ßTactics have four main categories
… Tactics that you use to prevent a potentially dangerous situation from escalating.
… Tactics you use to de-escalate the situation.
… Tactics that you use to evade or escape from an attack.
… Tactics that you use in conjunction with techniques during a confrontation to insure your safety.
ßSome Tactics are:
… Distracting the person
… Re-focusing the person on something positive
… Changing the subject
… Making jokes/lightening the mood
… Motivating the person
… Simply listening
ßTo verbally de-escalate a person you must open as many clear lines of communication as possible.
ßBoth you and the person must listen to each other and have no barriers.
ßBarriers to Communication are those things that keep the meaning of what is being said from being heard.
ßList of Barriers:
… Engaging in Power Struggles
… Not Listening.
ßThree Main Listening Skills:
… Attending: Giving your physical attention to another person.
… Following: Making sure you're engaged by using eye contact, un-intrusive gestures (such as nodding of your head, saying okay or asking very infrequent questions).
… Reflecting: Paraphrasing, reflect back using the feelings of the person (empathetically).
ßPhysical force is used as the last resort and only when all tactics have failed.
ßTechniques: are physical actions taken against another person in order to subdue, control or restrain him or her.
ß93% of our communication is non-verbal. It is very important to be able to identify what we are communicating non-verbally.
ßIt is important to understand the non-verbal cues from a person who has the potential of escalating.
ßYou may be trying to de-escalate the situation by talking to the person but your body language may be showing a willingness to get physical.
ßWhile de-escalating a person you should be positioned in a non-threatening position.
… Becoming emotionally involved, control your emotions at all times.
… Engaging in power struggles.
… Becoming ridged in your process.
… Promising rewards for good behavior.
… Telling the person that you "know how he or she feels."
… Raising your voice, cussing, making threats, and giving ultimatums or demands.
… Aggressive language, including body language.
Verbal De-Escalation Techniques for
Defusing or Talking Down an Explosive Situation
- prepared by NASW's Committee for the Study and Prevention of Violence Against Social Workers
When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation techniques are appropriate.
There are two important concepts to keep in mind:
1. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible.
2. De-escalation techniques are abnormal. We are driven with adrenaline to fight or flight when scared. However, in de-escalation, we can do neither. We must appear centered and calm even when we are terrified. Therefore these techniques must be practiced before they are needed so that they can become "second nature."
A: The Worker in Control of Him/Her Self
1. Appear calm, centered and self-assured even though you don't feel it. Anxiety can make the client feel anxious and unsafe which can escalate aggression.
2. Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
3. If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you see the client (not in front of him/her)
4. Do not be defensive-even if the comments or insults are directed at you, they are not about you. Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
5. Be aware of any resources available for back up. Know that you can always leave, tell the client to leave or call the police should de-escalation not be effective
6. Be very respectful even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. We want him/her to know that it is not necessary to show us that they should be respected. We automatically treat them with dignity and respect.
B: The Physical Stance
1. Never turn your back for any reason
2. Always be at the same eye level. Encourage the client to be seated, but if he/she needs to stand, you stand up also.
3. Allow extra physical space between you – about four times your usual distance. Anger and agitation fill the extra space between you and your client.
4. Do not maintain constant eye contact. Allow the client to break his/her gaze and look away.
5. Do not point or shake your finger.
6. Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Cognitive disorders in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
7. Keep hands out of your pockets, up and available to protect yourself. It also demons trates non-verbally, that you do not have a concealed weapon
C: The De-escalation Discussion
1. Remember that there is no content except trying to calmly bring the level of arousal down to a safer place.
2. Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Speak calmly at an average volume.
3. Respond selectively; answer only informational questions no matter how rudely asked, e.g. "Why do I have to fill out these (g-d forms?" This is a real information-seeking question). DO NOT answer abusive questions (e.g. "Why are all social workers ass holes?) This question should get no response what so ever.
4. Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both alternatives are safe ones (e.g. Would you like to continue our meeting calmly or would you prefer to stop now and come back tomorrow when things can be more relaxed?)
5. Empathize with feelings but not with the behavior (e.g. "I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff.)
6. Do not solicit how a person is feeling or interpret feelings in an analytic way.
7. Do not argue or try to convince.
8. Wherever possible, tap into the client's cognitive mode: DO NOT ask "Tell me how you feel. But: Help me to understand what your are saying to me" People are not attacking you while they are teaching you what they want you to know.
9. Suggest alternative behaviors where appropriate e.g. "Would you like to take a break and have a cup of coffee (tepid and in a paper cup) or some water?
10. Give the consequences of inappropriate behavior without threats or anger.
C: The De-escalation Discussion (page 2)
11. Represent external controls as institutional rather than personal.
12. Trust your instincts. If you assess or feel that de-escalation is not working, STOP! Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the police.
There is nothing magic about talking someone down. You are transferring your sense of calm, respectful, clear limit setting to the agitated person in the hope that he/she actually wishes to respond positively to your respectful attention. Do not be a hero and do not try de-escalation when a person has a gun. In that case, simply cooperate.
How to manage verbal abuse & threatening behavior
Researchers found that reaction to a verbal attack can seriously affect the outcome. When faced with someone shouting abuse or just staring silently, a number of physiological changes take place.
Increased heart rate, raised blood glucose levels and increased adrenalin among other changes cause an instinctive 'fight or flight reaction'. The most common reaction is TO FREEZE which may appear as aggressive.
You must signal non-aggression at an early stage in the interaction.
* Control your breathing rate. Inhale deeply and exhale slowly. This helps to increase a feeling of inner calmness and reduces panic and fear signals.
* Adopt a relaxed posture. If standing, stand with your legs slightly apart, one foot slightly behind the other.
* Use open hand language. Hold your hands down, either at your sides or gently clasped in front of you. Occasionally, stress what you say with a slow, open hand gesture.
* Listen actively. Reinforce you listening with occasional verbal affirmation 'hmmm/yes/ah, ha' and head nods.
* Sit down. This is not always easy to do, particularly if the aggressor is looming over you. However, by sitting down in a controlled manner you are indicating a willingness to stay and therefore stressing the importance of what the aggressor has to say.
* Keep you voice low and steady. This is not always easy, particularly when your vocal cords are tight and your throat dry.
* Show you are interested and concerned. This is the time to ask the 'How?' questions not the 'Why?' ones. 'How can I Help you' not 'Why are you like this?'
How to manage verbal abuse & threatening behavior (page 2)
* Empathize with the aggressor. 'That sounds bad' or 'I'd be angry too if it happened to me'. Do this only if you are being sincere. Insincerity will be picked up and will escalate the situation.
* Ask for permission to make notes. This helps to slow the aggressor down and stresses the importance of the information the aggressor has. This is a defusion technique as it moves from the act of aggression being expressed to what the aggressor has to say.
* Use eye movement. Occasionally meet the aggressor's eyes to stress of acknowledge a point will help, but always avert you eyes before a staring match develops.
Most of the time, the person doesn't really want to die. They usually just want the pain (often emotional pain) to end.
Acknowledge the person's painful feelings but assure them that even though they may be experiencing painful feelings, they don't have to act on those feelings in a way that would be harmful to themselves or others.
CIT needs to be studied.
What worked and what didn't under what circumstances?
Critical incidents need to be reported.
Damage and deaths caused by Taser's and other "non-lethal" weapons needs to be reported, tracked and researched.