Presentation on theme: "De-Escalation Skills Law Enforcement Academy Asheville-Buncombe Technical Community College Asheville, North Carolina Crisis Intervention Team Training."— Presentation transcript:
1De-Escalation SkillsLaw Enforcement Academy Asheville-Buncombe Technical Community College Asheville, North Carolina Crisis Intervention Team Training September 27 – October 1, 2010
2Overview 1 ½ days (12 hours) Lots of role-playing practice in small groupsGoal is for you to feel very confident in your ability to de-escalateModel = E-LEAPE = engage (wed. pm)LEAP = listen, empathize, affirm, partner (thur. am)Specific strategies for consumers who are disoriented, intoxicated, suicidal, etc. (thur. pm)
3Wednesday PM What is de-escalation Effective communication Non-verbals Behavioral crisisEngagement
4What is verbal de-escalation? Verbal de-escalation is used during potentially dangerous, or threatening, situation in an attempt to prevent persons from causing harm to us, themselves, or others
5Goals of Verbal De-escalation Open up clear lines of communicationBuild trust and validate the consumer’s situationGet the consumer talking about his situationGathering the necessary information make a good resolution
6What is De-EscalationDe-escalation is less like a recipe or formula and more like a flexible set of options.No single set of de-escalation skills: we have tried to put together a effective set of skills by borrowing from multiple approachesDe-escalation will not always work
7What is de-escalationBoth officer and consumer safety always remain paramount concerns in a crisis involving a person with mental illness.Once officers become skilled in de-escalation, they do not simply abandon all the training and experience that came before it.De-escalation is another tool that officers have at their disposal to be judiciously applied in controlling a potentially volatile situation, rather than serving as a substitute for sound judgment and attentiveness to safety.
8Effective Communication 70% of communication misunderstoodEffective communication is defined as passing information between one person and another that is mutually understood
9Effective Communication Communication becomes more difficult when the person’s ability to understand what you are saying and/or their ability to express their own thoughts or needs are compromised by their symptoms.When they can’t express their needs, they become more angry and frustrated more quickly and more frequentlyYour ability to engage a consumer in conversation and successfully resolve a conflict often depends as much on how you say the words you choose as much as the words themselves.
10Barriers to Effective Communication Barriers to communication are the things that keep the meaning of what is being said from being heard:Pre-judgingNot listeningCriticizingName-callingEngaging in power strugglesOrderingThreateningMinimizingArguing
12Non-VerbalIt is very important to be able to identify exactly what you are communicating to others non-verballyYou may be trying to de-escalate the situation by talking to the other person, but your body language may be saying something else. The consumer will react to want you are saying with your body language
13Personal SpacePersons with mental illness often develop and altered sense of personal space. They require more space than usual to feel comfortable and feel intensely threatened when other people close in on them with no warning.Invasion or encroachment of personal space tends to heighten or escalate anxietyPersonal space in American culture is about 3 feetDo not touch a hostile person – they might interpret that as an aggressive actionAnnounce intention: “I need some space, so I am going to back up.”
14Eyes One eyebrow raised = sternness Eyes wide open = surprise A hard stare = threatening gestureClosing eyes longer than normal = I am not listening
15Body PostureChallenging postures that tend to threaten another person and escalate the situation include:Finger pointing may seem accusing or threateningShoulder shrugging may seem uncaring or unknowingRigid walking may seem unyielding or challengingUse slow and deliberate movements—quick actions may surprise or scare the other person
16Voice Tone - Usually unconscious Volume - A raised voice could create fear or challengesRate of speech - Speak slowly – This is usually interpreted as soothingInflection of voice - I didn’t say you were stupid
17FaceJaw set with clenched teeth shows that you are not open minded to listening to his or her side of the storyA natural smile is good. A fake smile can aggravate the situation
22What is a Behavioral Crisis? A crisis is a perception of an event or situation as an intolerable difficulty that exceeds the resources and coping mechanisms of the personUnless the person obtains relief, the crisis has the potential to cause severe behavioral malfunctioning.
23Behavioral Crisis?Crisis intervention is emotional first aid which is designed to assist the person in crisis to return to normal functioning.The focus of crisis intervention is what’s happening here and how!
24Behavioral Crisis3 reasons that a consumer may be having a behavioral crisis:Medical conditionSubstance usePsychiatric condition: 1) thought disorder; 2) mood disorder; 3) anxiety disorder; 4) personality disorder
25Behavioral CrisisThe majority of encounters that you will have with consumers are because the symptoms of their illness are not under control. Most commonly, this occurs at the initial onset of illness, during a relapse (that can result for a variety of reasons) and when the person s using substances.The consumer’s behavior is usually a result of his or her illness, rather than being criminally motivated
26Consumers typically will have one of 3 feelings AngerFearSadness/depression
27Consumer’s Inner Experience What you may be seeing . . .Consumer’s Inner ExperienceHostility, evasionFearRisk-takingElationSelf-destructive behaviorDepressionOdd, dangerous behaviorConfusionVery odd behaviorPsychosisAttempts at self-treatment (e.g. drugs)Hopelessness, demoralization
28Behavioral CrisisGiven the low likelihood that emotional people in crisis can succeed in rationalizing alternatives, law enforcement responses to emotional people in volatile situations cannot rely on convincing people by making a rational proposal to think differently. Rather, responders need to create a stable and respectful environment within which emotional individuals can take comfort and relief.
29Engagement Be aware of your setting; personal safety first Move to a safe place if necessaryAllow plenty of spacePersons with mental illnesses often can be expected to process information slowly and to have difficulty remembering things. This includes understanding and remembering instructions given by a police officer.
30EngagementBe aware that a uniform, gun, and handcuffs may frighten the person with mental illness so reassure consumer that no harm is intended.Remain calmYou will likely have contact with the consumer again; how you treat him will be important for establishing trust
31EngagementKnow when to act: A person may be acting dangerously, but not directly threatening any other person or himself/herself. If possible, give the consumer time to calm down. This requires patience and continuous safety evaluation.Allow partner to de-escalate others on the scene as necessary
32Engagement“It is the wise officer who can, at times, conceal his or her combat-ready status.”-Lt. Michael Woody
33Avoid Maintaining continuous eye contact Crowding or “cornering” the consumerTouching the consumer unless you ask first or it is essential for safetyLetting others interact simultaneously with the consumerNegative thoughts (“God, this is another one of those homeless people.”)
34Avoid Expressing anger, impatience or irritation Inflammatory language (“You are acting crazy.”)Feeling as though you have to rush or feeling like you are stuck if it takes time to get the consumer talkingIntervening too quickly or trying too hard to control the interaction by interrupting or talking over the consumer.
35Avoid Saying “You need to calm down.” Shouting or giving rapid commandsArguing with the consumerTaking the words or actions of the consumer personally (They are symptoms of mental illness.)Lying, tricking, deceiving, threatening the consumer to get her to comply
36AvoidAsking why questions. Why questions are logic-based. Persons in crisis are not logical. Typically, what ever has worked in the past is not working now. Why questions put the consumer on the defensive. Ask open-ended questions.Forcing discussion
37AvoidMinimizing the consumer’s situation as a way to elicit conversation (“Things can’t be that bad, can they?”)Suggesting that things will get better; they may notMaking promises that you may not be able to keep
38AvoidCommands such as “drop the knife,” or “Get down on the ground” might seem to be straightforward and easy to understand. When dealing with people who live with mental illness, however, officers need to take into account the types of barriers to effective communication that the brain disorder might create.Telling the consumer “I know how you feel.”
39AvoidAsking a lot of questions of the consumer in the beginning. This is a natural tendency, however, this is generally not a good idea, especially early in the interaction. In de-escalation, encouraging the consumer to continue talking is more effective than asking a lot of questions. It will help continue the dialogue and will provide the consumer with opportunities to give information that will help to resolve the crisis.
40DO Speak in a calm, slow, clear voice You may need to repeat; the consumer may be distractedBe patient; give the situation time; time is on your sideTry to reduce background noise and distractionsUse “and” instead of “but”Obtain relevant information from informants
41DO Allow the consumer to ventilate (“Tell me some more about that.” Use “please” and “thank you” oftenRemain friendly but firmAsk the consumer if she needs somethingOffer a cigarette, nutrition bar, warm clothingForecast: Announce your actions and movements
42DOAccept the consumer’s feelings, thoughts and behavioral; acceptance is not easy when a consumer is behaving in a bizarre or hostile mannerRespect the dignity of the consumer without regard to sex, race, age, sexual orientation
43Hot Buttons Consumers will sometimes push a hot button We all have themExample: The consumer calls you a “pig” or swears at you.This is NOT the time to demand respect
44Hot Buttons: Rationale Detachment Staying in control of your emotions during a crisis situation3 steps
451. Develop a PlanDecisions made ahead of time are more likely to be rationaleIdentify your hot buttonsStrategic visualization – practice what you would doHelps you gain confidence
462. Use Positive Self-Talk You are not the target of the outburstNever take anything personallyRemember that most of us have been irrational and said inappropriate things when we are under extreme stress
473. Recognize Your Limits Let someone else take over if necessary Set a limit with the person; use an “I” statement; “I really want to help you but I find it difficult because of your name-calling; could you help me and stop the cursing so that I can work on helping you. Thanks, I would appreciate it if you try.”
48The Logic of De-Escalation If you take a LESS authoritative, LESS controlling, LESS confrontational approach, you actually will have MORE control.You are trying to give the consumer a sense that he or she is in control.Why? Because he or she is in a crisis, which by definition means the consumer is feeling out of control. The consumer’s normal coping measures are not working at this time.
49Introduce Yourself An introduction promotes communication Hi, my name is Doug (or Deputy Smith). I am a CIT officer with the Sheriff’s Department.Can you tell me your name?State what you see/know (“I can see you’re upset.”)State or convey that you are there to help.Be prepared to explain the reason you are there(e.g., a neighbor called to say someone is upset)
50Introduce YourselfHow many of you can have someone tell you her name, and within a few seconds you have already forgotten itMake a point of immediately starting to use the consumer’s name; that will help you remember itUse the consumer’s name often
51Introduce Yourself “Get out of here you damn cop!” Don’t take the bait and turn confrontational
52Role-playing Scenarios Role-playing is a learning toolAllows us to try out new approachesExpect mistakes; they are an opportunity to learnYou can rewind and try again
53Role-playing Scenarios Everyone feels uncomfortable in role playFeedback will be constructiveScenarios are derived from real-life experiencesWe will be working as a team to assist one another in skill developmentSmall groups: 3 roles—Law enforcement, consumer, observer
54Thursday AM Listen Empathize Affirm Partner What Ifs 5 special strategies
55L = Listen Silent and listen are spelled with the same letters Listen twice as much as you talk; that’s why you have 2 ears and 1 mouthWhat is the difference between listening and hearing?
57Listen Listen for the total meaning Focus on what the consumer is telling youBlock out distractions
58ListenIt is important understand and remember that what the consumer is saying or believing may be real or imagined. Since mental illness is a brain disease, thinking is what is most affected by mental illness. Sometimes their thoughts are disconnected and you’ll hear this in their speech, which can be difficult to follow and make sense of.
59Techniques that Show You Are Listening Minimal encouragersReflectingAsk open-ended questions (“Can you tell me more about that.”
60Minimal EncouragersMinimal encouragers are brief statements that can be either nonverbal, such as a positive nod of the head, or simple verbal responses such as Okay, Uh-huh, I see, I am listening.Minimal encouragers demonstrate to the consumer that you are listening and paying attention, without stalling the dialogue or creating an undue interruption. Especially early in the encounter, consumers need these types of encouragers to feel that the officer is really attending to them and listening to what they are saying.
61ReflectingWhereas minimal encouragers provide initial confirmation that you are listening, reflecting adds another dimension to the communication. Here, you provide the consumer with evidence that you are listening by actually repeating what he or she has said. Often the reflecting response will simply consist of the last few words the consumer says. These statements should be brief and used in such a way as not to interrupt the consumer.
62Reflecting Repeat the last few words that the consumer said Example: “I am tired of everyone not listening to me and it make me angry.”“Jim, it makes you angry.”
63Open-Ended QuestionsOpen ended questions allow you to get more informationOpen ended questions enable us to assess the consumer’s level of dangerousnessOpen ended questions allow you to assess whether the consumer is in touch with reality
64Specific Questions That You May Want You Ask, When Appropriate Does the consumer need something (e.g., hungry, thirsty)Is the consumer receiving servicesWhere is the consumer receiving servicesDoes the consumer have a case managerIs the consumer taking medicationWhen did the consumer last take his or her medication
65Medication Mentioning “medication” must be given careful thought. In some cases, the topic is best left to mental healthcare providers after the consumer has calmed down.In other situations, the consumer may want to talk about his or her medication.Also, many consumers have had negative experiences with therapists and don’t want to talk about it their counselor.
67Empathy What is the difference between empathy and sympathy? Feeling sorry versus trying to understand what it is like to be in their shoes.Being sincere and real will convey understanding“To my mind, empathy is in itself a healing agent because it releases, it confirms, it brings even the most frightened person into the human race. If a person is understood, he or she belongs.” (Carl Rogers)It’s hard to stay angry and aroused when someone empathizes
68Emotional LabelingIn emotional labeling, you again take listening to a higher level by trying to help the consumer identify feelings.This is different from “telling” the consumer what he or she is feeling because your statement is based on what the consumer has been communicating through his or her words and behavior.If you have used your listening skills well, it will often be rather easy to provide an emotional label to assist the consumer.
69Emotional Labeling Examples You seem to beIt seems to me like you feelIf I were in your situation, I think I’d feel . . .
70ParaphrasingParaphrasing is similar to reflecting except that now you begin to communicate that you are trying to understand the consumer’s entire message by putting what the consumer has said into your own words.
71Paraphrasing Builds rapport between officer and consumer Helps the officer refine the assessment of the crisisProvides information that lays the groundwork for an eventual resolution of the crisisCommunicates that you are listening and understanding
72Paraphrasing Examples Consumer: I don’t know what I am going to do. My family doesn’t want me here.CIT Officer: You’re not sure where you can stay for awhile, but home doesn’t seem like the best place right now.
73Paraphrasing Examples What I hear you saying isIf I am hearing you rightLet me see if I understand what you are saying . . .These types of statements also summarize what has been said in the communication.
74A = Affirm You need to know what the consumer is upset about You may have a tendency to go to the solution step without really identifying what the issue is with the consumer. You should not assume that you know why the consumer is upset. You should ask and let the consumer tell you what the problem is before looking at possible solutions.After getting the information that you need, steer the conversation toward a resolution by affirming the consumer’s situation
75Affirm Example“Okay, let me make sure I understand you, You’ve told me that people are bothering you and that your case manager is not helping you. That your meds are hurting you because they make you feel sick. Did I understand you correctly.”
76P = Partner Also “plan,” “problem-solve” Goal is to find a resolution and return to pre-crisis state.You are looking to find the combination that will unlock the crisis.
77PartnerYou can ask the consumer what she thinks will resolve the problemLook for alternatives with the consumerTry to have 2 or more optionsEmpower the consumer to chooseIf one approach doesn’t work, “throw another lure”
78PartnerPutting yourself in the consumer’s shoes will help you find a solutionDon’t force particular points of discussionTry to get agreement on a course of action. Repeat what the plan is and what is expected.Meet reasonable demands when possibleReach for small concrete goalsIt’s never too late to reassess and change a plan
79PartnerIf repeated attempts fail, set firm limits and tell the consumer that you are worried about his safely and you want to help him.Ask if there is a family member you could talk to.State your expectations by linking to safety issue: I need to make sure that everyone stays safe.
80PartnerIn your attempts to resolve an escalating situation you may be tempted to use bargaining, deal-making, or saying/promising anything to gain compliance.They are not recommended as they ultimately violate trust—which is important in your repeated encounters with people.
81Resolution Can it be informally resolved? Is an evaluation needed? Are commitment criteria met?Was a crime committed?
82What Ifs What if the consumer asks you a long-term question? Say that you don’t know the answer but that you and the consumer can handle the immediate situation
83What If The consumer says that there’s nothing you can do to help? Say that you’re not sure what you can do, but that you want to work with the consumer to figure out something
84What IfThe consumer will not engage problem-solving and is distracted?Say “Stay with me, Frank. Let’s work on this together. I’d like for you to stop for a minute and take a deep breath with me. Like this. That’s good. Thank you, Frank.”
85What If The consumers moves too close you? Say “I need some space, Jim, so I am going to back up.”
86What If The consumer is talking so loudly it is disruptive? Drop the volume in your own voice and say, “Jim, I am having a hard time understanding you because of how loud your voice is.”
87What If You think the consumer might become aggressive? If possible, bring in another trained person.There is less chance of aggression if two people are talking to one person.
88What IfThe consumer will only respond non-verbally, like with a head nodRespond positively
89What If The consumer remains unresponsive? Simply validate the consumer by stating what you observe about their situation“You look really sad; you must be really hurting right now.”
90Five Special Strategies Assertive InterventionCorrective ActionReducing StimuliReducing ArousalPro-active (as opposed to reactive) engagement of consumers
911. Assertive Intervention Can be used when:The consumer is uncooperative or unresponsive to directives that they are expected to follow.The consumer is violating rules which serve to maintain security
92Three Step Assertive Intervention Empathy statement: A statement that lets the consumer know that you understand where he or she is coming from and how he or she likely feels.Conflict statement: A statement that describes to the consumer that you have a conflict that needs to be addressed.Action statement: A statement that lets the consumer know what you want him or her to do. This statement can be in the form of a request.
93Examples“Jack, I understand that you are upset and that you feel like no one is listening to you or doing enough to help you. But you and I need to let these people get back to work here, so we are going to have to get out of this waiting room. I’d like you to walk with me down the hallway to an empty room so you and I can talk.”“It looks to me like you are pretty upset, and I’m here to help you. But I am afraid someone is going to get hurt by those stones. So I’d like you to stop tossing them and step up here on the curb so I can talk to you and try to understand what is going on with you today.”
94Choice If possible, offer a choice: Joe, I want you to stop throwing the stones or, if you prefer, step over here with me on the grass and throw them in the grass while we talk. What is best for you?This helps the consumer “save face.”Everyone reacts better to a choice versus being told what to do.
952. Corrective Action: AAA If you make a mistake (and you will) and the consumer escalates:Acknowledge: “Jim, I can see that mentioning your medication is a real sore point.”Apologize: “I’m sorry to have upset you. I didn’t mean to.”Try Again: “I want to help, not upset you, so let’s try something else.”
963. Reducing StimuliRemove the audience or move the consumer to a private spaceTurn off flashing lights
974. Reducing ArousalEncourage the consumer to take 3 deep breaths; you can do this with the consumer. “Let’s take 3 deep breaths like this”; then demonstrate and do it with the consumer.
985. Pro-active Engagement of Consumers Many of you will interact with the same consumer on repeated occasions so you will get to know him or her. If you talk to a repeat consumer on a good day, you will have much better information to base an assessment come the bad day. That information will provide greater options for resolving conflicts.
99Pro-active Engagement of Consumers Drop by the consumer’s residence. Ask if there is anything you can do to help. (e.g. call the case manager to try to access a resource for the consumer.)If you see the consumer in the community, acknowledge him or her. Stop to say hello if it would not embarrass the consumer.Get to know some of the providers (e.g., case managers) who serve your consumers.
100Thursday PMVerbal Intervention Strategies for People who are Suicidal, Homeless, Delusional, Hallucinating, Confused, Agitated, Intoxicated, Having Flashbacks, Manic
101Review of TermsThought Disorder = usually a reference to a psychotic disorderPsychotic = out of touch with reality; often experiencing delusions or hallucinationsDelusion = false beliefHallucination = false sensory perception (most common is auditory)Mania = A manifestation of bipolar disorder (manic depression), characterized by profuse and rapidly changing ideas, exaggerated sexuality, gaiety, or irritability, and decreased sleep
102SuicideAsking about suicide: “Sometimes when people have been feeling down for a long time, they begin having thoughts that they would rather be dead, are you having any feelings like that?”“Have you ever tried to hurt yourself before?”“When and what did you do?”“Do you have a plan now?”“Do you have any weapons that you could use to hurt yourself?”Show support and interestBe non-judgmental and acceptingOffer help that is availableAssess availability of supports
103Suicide: Threatening Harm Focus on the anger or fear that is causing the threatsRepeat that you are here to help and keep everybody safeGet the names of significant others (even pets), as a way to make a personal connection and keep the consumer grounded
104Suicide AttemptVerbal communications should focus on providing hope for the consumer during a time when he is feeling hopeless.Generally, helpful comments to make during questioning include: These feelings will not last forever, even though it may seem like it now. There is help available. Many other people have felt this way and have gotten better.
105Suicide AttemptUnhelpful comments include clichés such as, There’s a silver lining in every cloud, or comments about all that they have, You have a nice home, family who loves you, who will take care of your kids. And finally comments about yourself, I felt the same way once or a friend of mine felt this way once. These types of unhelpful comments only elicit more profound feelings
106Homelessness 40% of homeless persons have a mental illness The ways in which homeless people dress may seen bizarre to other peopleMental health professionals may refer to a homeless person’s choice not to take medications as noncompliance, but to a homeless person the decision not to take sedating psychiatric medications may make good sense.
107Thought DisorderThe 3 possible responses to a person who loses contact with reality, and are either hallucinating or delusional, are:Agree with themDispute them, orDefer the issueWhich is the appropriate response: A, B or C?
108Thought DisorderThe engagement goal is to validate the consumer’s situation and how frightened and anxious he must feel without agreeing with their hallucinatory/delusional experience.It is OK to indicate that you do not hear or see what he is seeing/hearing but that you believe he does.Persons who are psychotic develop an altered sense of personal space and require more space than usual to feel safe.Remember to maintain a safe “reactionary” distance of from the consumer.Use friends and family members to get information if they are available and their presence is not escalating the consumer.
109DelusionsParanoid delusions can lead to dangerous behavior because they cause a great amount of fear. This is especially true if the delusion includes a belief that one’s thoughts are controlled by external forces.Convey your acceptance—but let the consumer know that you are not experiencing it and reinforce reality.“I can see that you are scared that someone is out to get you, but I don’t know of anyone who is trying to hurt you I’m here to keep you safe.”Don’t argue about the delusion—no one will win this argument
110HallucinationsAsk if they are hearing voices: “When people are stressed or scared, they may hear or see things, is that happening to you.”Ask, “are the voices telling you to do something, what?”People who are abusing substances or are in withdrawal may see things or feel things crawling on them
111HallucinationsIndicate that you understand that those experiences are real and frightening for the consumer.You can attempt to calm the person by letting them know that voices may “quiet” if you can help the consumer lessen their stress and get help.You may have to repeat a reassuring message many times before the consumer can respond to it. Repeat: I’m here to help; I am not going to hurt you.
112HallucinationsHallucinations/voices that are command oriented involving religion, good versus evil, or are declaring self-harm are higher-risk than non-religious, non-confrontational hallucinations.This can lead to dangerous behavior because many persons will obey the command.
113Confused/Disorganized Speech People with a variety of mental illnesses may experience confusion: schizophrenia, bipolar, neurological disorders, traumatic brain injury, people who are actively using or withdrawing from substancesKeep interactions brief and to the point
114Confused/Disorganized Speech When it is difficult to understand the consumer, say so and ask for clarification. If the consumer is rambling nonsensically, comment periodically that you realize that he must be frightened and that you are there to help.Drop the volume in your speech and say, “I am having a hard time understanding you because of how loud your voice is.”
115Agitation, Anxiety, Fears Encourage 3 slow deep breathsIf this is difficult for the consumer, ask him to look at you and do it with youReassure and converse calmly
116People Who Are Intoxicated Remember, substance use, especially alcohol is a significant risk factor associated with violence. Do not let your guard down (“She is only drunk.”)Keep statements brief and to the pointAvoid engaging in argumentsPoint out that it is difficult to understand what is being said
117PTSD FlashbacksSome people with post traumatic stress disorder experience flashbacks. During a flashback, the person is experiencing the traumatic event. So all the senses and thoughts are in the moment. It is really important to maintain personal space and avoid touch during a flashback.Orient and ground: My name is today is you are (describe where), it’s our job to keep you safeProvide simple directives and reassurance softly and slowly
118Rapid Speech / ManiaSome people talk rapidly when they are stressed or scared. People who are manic often talk very rapidlyEncourage the person to slow down, take deep breathes.“I want to understand what you are saying, but you are talking really fast. Let’s take some deep breaths together.”
119AcknowledgementsThis material was adapted from numerous sources, including:Memphis CIT CurriculumSam CochranRandy DupontGeorgia CIT CurriculumResponding to Individuals with Mental Illness by Michael Compton and Raymond KotwickiConnecticut State Department of Mental Health and Addiction ServicesFindlay/Hancock County CIT
120Thank you for going the extra mile to help people with mental illness!