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Help People in Crisis

People from various professions all over the world are trained to effectively de-escalate crisis situations. These crisis responders may include educators, mental health professionals, behavior analysts, healthcare professionals, correctional facility staff, security personnel and first responders. How frequent crisis responders receive training, the specific techniques taught, and how effective the training is depends on multiple factors such the crisis training program and the expectations set forth by the employer. One factor that appears to be consistent is the use of de-escalation techniques prior to using more intrusive techniques such as physical restraint.


Physically restraining a person should only be used when the person is in an emergency situation where they are in danger of hurting themselves or others. Once the threat of harm is over, the person should be released from the restraint. Crisis responders typically make every effort to prevent placing a person in a physical restraint by initially using de-escalation strategies as outlined below. People in a crisis need help, not force. The latter should only be used as a safety measure.



The only studies found to quantify and thus measure de-escalation skills are the studies on the De-Escalating Aggressive Behaviour Scale (DABS) and the English modified De-Escalating Aggressive Behaviour Scale (EMDABS). (The scale is available upon request). The seven recommended EMDABS skills are incorporated in the following section on De-escalation Strategies based on the model by Price and Baker (2012):


DE-ESCALATION STRATEGIES


STAFF SKILLS

  1. Characteristics of Effective De-escalators

  2. Open; Honest; Supportive; Self-aware; Coherent; Non-judgemental; Confident; Lack of Arrogance

  3. Express Genuine Concern; Appear Non-threatening; Non-authoritarian Manner; Gain Person’s Trust; Ability to Empathize and establish an empathetic connection

  4. Valuing the Client - genuine acknowledgement that the client’s concerns are valid, important and will be addressed in a meaningful way (EMDABS #1)

  5. Maintaining Personal Control

  6. Appear calm during a crisis, even when feeling anxious

  7. Remaining Calm - maintains a calming tone of voice and steady pace regardless of the client’s responses (EMDABS #6)

  8. Suppress anger; Do not take offense; Avoid personal feelings toward the person

  9. Verbal and Non-verbal Skills

  10. Calm tone of voice; Humor (if sensitive and appropriate),

  11. Body language should show concern for the person

  12. Effective communication; Active listening; Introduce or greet the person in crisis; Using “I” statements; Restating statements; Mirroring statements; Summarizing statements

  13. Be courteous with the person in crisis and say please and thank you

  14. Reducing Fear - listens actively to the client and offers genuine empathy while suggesting their situation has the potential for positive future change (EMDABS #2)

  15. Risky - maintains a moderate distance from the client to ensure safety, but does not appear guarded or fearful (EMDABS #7)

  16. Avoid entering personal space and giving too much direct eye contact

  17. Avoid ‘why’ questions as it may cause defensiveness

  18. Avoid speaking loudly


INTERVENING

  1. Engaging with the Client

  2. Establish rapport and remain connected during the crisis

  3. Assess for risk of violence

  4. Promote autonomy and avoid restriction

  5. Ask open-ended and closed-ended questions

  6. Show value and respect towards the person

  7. Inquiring about Client’s Queries and Anxiety - con communicate a thorough understanding of the client’s concerns, and works to uncover the root of the issue (EMDABS #3)

  8. Working out Possible Agreements - takes responsibility for the client’s care and concludes the encounter with an agreed-upon short-term solution and a long-term action plan (EMDABS #5)

  9. Providing Guidance to the Client - suggests multiple ways to help the client with their current concerns and recommends preventative measures (EMDABS #6)

  10. Avoid punitive or aversive approaches; A show of force can quickly escalate the situation. Time should be given to effectively de-escalate the crisis and not rush to use more force than necessary.

  11. When to Intervene

  12. Based on: Knowledge of the person; Function of behavior; Abnormal behavior for that person; Severity of Behavior; Impact on Others; Available Staff Resources

  13. Ensure Safe Conditions for De-escalation

  14. Assess the area for weapons and exits

  15. Prompt the person to move to a more safer area

  16. How much and what kind of support is necessary

  17. Always maintain safety

  18. Strategies for De-escalation - crisis interventions should be proportionate to the posed risk

  19. Autonomy Confirming Interventions

  20. Shared Problem Solving

  21. What is causing the person’s upset? Ask them! Ask them how you can help. Connect with the person and focus on helping them get what they want in an appropriate manner.

  22. Avoid arguing, sounding commanding, or engaging in power struggles.

  23. Facilitating Expression

  24. Encourage and reinforce the person for expressing their frustrations and feelings. This is where you can actively listen to them and validate their concerns.

  25. Offering Alternatives to Aggression

  26. Teach coping skills or calming strategies

  27. Offer choices of what they can do

  28. Offer time to calm down or cool off

  29. Be mindful of the person’s dignity and desire to ‘save face’

  30. Let them make the choice to calm down

  31. Positively reinforce appropriate calm behavior

  32. Limit-setting and Authoritative Interventions

  33. If the person is engaging in dangerous, violent, harmful crisis behavior, crisis responders may focus less on de-escalation techniques and more on making sure the environment, responders, and person is safe.

  34. The more limits that are set and authoritative approaches used, the more likely the situation will be exacerbated.

  35. If the De-escalation strategies are ineffective and the person is in danger of harming himself or others, this is when the team may decide to use restrictive procedures such as a restraint. However, focus should be put on making sure the person is safe during the restraint and if at any time the person says they cannot breathe or they appear to struggle to breathe, or are showing other signs of medical distress, the restraint should be ended immediately. Once the threat of harm is over, the restrain should be removed, and redirection or de-escalation strategies should be reinstated to help the person get back to their regular activity.


The sad reality is that physical restraints can be necessary to keep people safe during a crisis situation. However, de-escalation strategies must be used prior to restraining someone unless there is an immediate threat to someone’s safety. Additionally, staff should receive adequate training and frequent opportunities for feedback on the effectiveness of their de-escalation techniques. A quantifiable score should be given to staff based on their performance and additional training and guidance should be provided as necessary. For more information on the topic of de-escalation and the use of physical restraints, please refer to the resources below or feel free to contact me.


Sara Athman, MS, BCBA




Resources


Nau, J., Halfens, R., Needham, I., & Dassen, T. (2009). The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal of Advanced Nursing, 65(9), 1956-1964.


Mavandadi, V., Bieling, P. J., & Madsen, V (2016). Effective ingredients of verbal de-escalation: Validating an english modified version of the ‘de-escalating aggressive behaviour scale’. Journal of Psychiatric and Mental Health Nursing, 23, 357-368.


Oliva, J. R., Morgan, R., & Compton, M. (2010). A practical overview of de-escalation skills in law enforcement: Helping individuals in crisis while reducing police liability and injury. Journal of Police Crisis Negotiations, 10, 15-29.


Price, O. & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21, 310-319.


Verret, C., Masse, L., Lagace-Leblanc, L., Delisle, G., & Doyon, J. (2019). The impact of a schoolwide de-escalation intervention plan on the use of seclusion and restraint in a special education school. Emotional and Behavioral Difficulties, 24(4), 357-373.


Vollmer, T. R., Hagopian, L. P., Bailey, J. S., Dorsey, M. F., Hanley, G. P., Lennox, D., Riordan, M. M., & Spreat, S. (2011). The Association for Behavior Analysis International position statement on restraint and seclusion. The Behavior Analyst, 34(1), 103-110.


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