10 tips for responding to patients in an emotional or behavioral crisis

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The last several years have been difficult for many of us. The far-reaching physical, emotional and financial effects of the pandemic — combined with other societal risk factors like isolation, loneliness, and social media—have fueled a rising need for mental health services.

While our nation is experiencing this mental health crisis, 47% of the U.S. population is living in an area experiencing a mental health worker shortage. With nowhere else to go and limited resources, there has been an increase in behavioral health patients turning to their local emergency departments for treatment.

When an estimated 1 in 8 patients in emergency departments require mental health services, and 1 in 5 Americans experience mental illness each year, it’s clear this is a problem that needs immediate attention. People suffering from mental and behavioral health challenges can also experience trauma-informed reactions that may lead to escalating conflict responses and endanger those involved. The safety of everyone is of the utmost importance.

Though there may not be an overnight fix, there is hope through understanding person-centered, trauma-informed approaches to care. It’s an opportunity to learn how to recognize the individual in need of care, and the trauma they may be carrying or experiencing, so we can approach, interact with, and treat them the right way.

Short-term de-escalation techniques

We’ve all experienced a time where being overwhelmed, tired, or under significant stress has impacted how we respond to compounding situations. We also carry our own trauma and past experiences into every situation, and this informs our responses to stressful or dangerous circumstances. This can be especially true among health care workers who are stretched thin through overwork and increasingly demanding conditions.

The patients we care for, and their concerned loved ones, are no different than us. As we interact with them in the hospital or clinical setting, they’re likely under duress. Some may carry mental health concerns and past experiences that inform their reactions.

When faced with angry, hostile or noncompliant behavior, the key to avoiding physical confrontation is often within our own response to that behavior. Many of these things are hardwired into our brains, but by being conscious of it, we can help manage it. These 10 tips can help any employee safely de-escalate a situation:

1. Be empathetic and nonjudgmental. Center yourself on the person’s experience. It may be the most important thing in their life at the moment.
2. Respect personal space. If you enter someone’s personal space to provide care, explain your actions to reduce their anxiety and help them feel less confused or frightened.
3. Use nonthreatening verbal language. The more a person loses control, the less they hear your words — and the more they react to nonverbal communication. Keep your tone and body language neutral.
4. Avoid overreacting. Remain calm, rational, and professional. This person’s behavior is often communicating their anxiety, fear and/or an unmet need.How you respond can have a direct effect on whether the situation — and the individual’s emotional state — escalates or defuses.
5. Focus on feelings. How the person feels is the heart of the matter. Watch and listen carefully for the person’s real message. Supportive phrases like, “That must be scary,” or “That must have been hard for you,” can let them know that you’re listening.
6. Ignore challenging questions, but not the person. When a person challenges your authority, redirect their attention to the issue at hand.
7. Set limits. If the person is belligerent, defensive or disruptive, give them clear, simple, and enforceable limits, and lead with the positive choice.
8. Choose wisely what you insist upon. If you can offer options and flexibility, you may be able to avoid unnecessary altercations.
9. Allow silence for reflection. Silence is an important tool in allowing the person the mental space to reflect on (or process) what is happening and how he or she needs to proceed.
10. Allow time for decisions. A person’s stress rises when they feel rushed.

Long-term de-escalation techniques

Given the data, it’s likely your own facilities face increased mental and behavioral health patient needs. In response, de-escalation training for long-term benefit can prepare your staff to successfully, and safely, navigate even the most complex situations.

All employees are entitled to a safe workplace. Practicing person-centered, trauma-informed care can make a difference in your staff’s safety and well-being, especially when it becomes ingrained in your culture. This person-centered approach can be accomplished through two significant methods: verbal and nonviolent crisis interventions. Regardless of the employee’s role or risk level, the goal is to guide all employees toward peaceful resolutions in situations that might otherwise turn to conflict.

Verbal intervention can help employees:

• Recognize and respond to defensive behaviors. They learn to apply limit-setting strategies when verbally intervening to de-escalate defensive behaviors among patients.
• Understand what’s behind the behavior. Employees will better understand the effects of trauma and the psychology of the brain on the person in crisis.
• Address the needs of the individual. A person-centered focus helps ensure a consistently inclusive and culturally sensitive approach to the person displaying crisis behavior.

Nonviolent crisis intervention helps staff safely recognize and respond to everyday crisis situations that may involve more challenging behaviors. It can educate your staff on how to recognize micro-aggressions before they build to moments of violence, and provides skills to help manage the anxiety and frustration that can trigger trauma.

Just as employees learn through verbal intervention education, it provides employees the tools needed to recognize and respond to defensive behaviors. It explores the effects of trauma and the psychology of the brain on the person in crisis — as well as the responding individual.

It then takes verbal intervention a step further by teaching employees why and how to apply safety interventions and disengagement techniques for escalating risk behaviors.

Implementing organization- or facility-wide trainings for these skills makes an immediate impact throughout an organization, by enabling employees to quickly practice and pass on what they learn. This sparks adoption, and improves workplace interactions and work culture.

Together, these intervention skills create alignment among all employees across departments and facilities, so they can make the behavioral change needed for them to become a natural part of an organization’s work culture.

By learning verbal and nonviolent crisis interventions, health care organizations can build a positive workplace culture that helps employees feel safer, increases employee satisfaction, and aids in recruitment and retention. This helps reduce turnover, builds confidence in leadership, management, and colleagues, and improves patient care.

Together, we can create a peaceful workplace that is safe for everyone, especially at a time when patients need the best care we can offer them.

AlGene P. Caraulia is vice president, integration and sustainability at Crisis Prevention Institute