Verbal De-escalation

No paramedic should need to be told that they constantly face the potential for violence.  That violence can come from bystanders, family or from the patient themselves.

We have all been on a call that later we thought to ourselves: “That got out of hand fast!”  Sometimes the patient doesn’t want us there (i.e. the sicidal patient that family/friends wanted to surprise with our visit).  Sometimes family and bystanders feel that they know how to do our job better than we do and get angry when we don’t follow their intructions to “Just give them somthing!”

The violence that ensues does not necessarily need to the brandishing of a knife or firearm.  A simple strike or push backwards that causes you to lose your balance and fall hurting your back, twisting your knee, tearing your rotator cuff etc. are more than enough to potentially end your career.

Before the violent episode or confrontation happens there are always warning signs or cues that the situation is escalating.  As a paramedic, you should be a keen observer of character and as your years on the job progress so should your ability to “read people”.  When you feel that your scene is starting to get out of hand you need to act quickly.  It is imprtant to recognize the cues that tell you a person is escalating towards violence and act on them.

I cannot stress how improtant it is that we be able to de-escelate a potentially volotile situation before it becomes physical, for so many reasons.

When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation is 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 to fight, flight or freeze when scared. We need to change this mindset. We must appear centered and calm even when terrified.  Therefore, these techniques must be practiced before they are needed so that they can become “second nature.”

There are 3 parts to be mastered in verbal de-escalation:
A: THE WORKER IN CONTROL OF HIM/HER SELF

• Appear calm, centered and self-assured even though you don’t feel it. Relax facial muscles and look confident. Your anxiety can make your aggressor feel anxious and unsafe which can escalate aggression.
• Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
• Do not be defensive, even if the comments or insults are directed at you.  Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
• Know that you have the choice to leave, tell your aggressor to leave or call the police (or even 10-200 if necessary) should de-escalation not be effective
• 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 must be respected.  We automatically treat them with dignity and respect.

B: THE PHYSICAL STANCE

• Never turn your back for any reason!!!!
• Being at the same eye level helps de-escelate the situation but you need to aware of your vulnerability to physical violence from this position.  Encourage the client to be seated, but if he/she needs to stand, you stand up also.
• Allow extra physical space between you – about four times your usual distance.  Anger and agitation fill the extra space between you and your client.
• Do not stand full front to client. Stand at an angle so you can sidestep away if needed.
• Do not maintain constant eye contact.  Allow the client to break his/her gaze and look away.
• Do not point or shake your finger.
• DO NOT smile. This could look like mockery or anxiety
• Do NOT touch, even if some touching is generally culturally appropriate and usual in your setting.  Cognitive distortion in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
• Keep hands out of your pockets, up and available to protect yourself.  It also demonstrates non-verbal ally, that you do not have a concealed weapon
• Do not argue or try to convince, give choices i.e. empower.
• Don’t be defensive or judgmental.

C: THE DE-ESCALATION DISCUSSION

• Remember that there is no content except trying to calmly bring the level of arousal down to a safer place.
• 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.
• Respond selectively; answer all informational questions no matter how rudely asked.  DO NOT answer abusive questions.
• 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 in a calm manner or should we have the police join us?)
• 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 partner.)
• Do not solicit how a person is feeling or interpret feelings in an analytic way.
• Do not argue or try to convince.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?
• Give the consequences of inappropriate behavior without threats or anger.
• Represent external controls as institutional rather than personal.
• Trust your instincts.  If you assess or feel that de-escalation is not working, STOP! You will know within 2 or 3 minutes if it’s beginning to work. 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 genuine interest in what the person wants to tell you, of calmness, and of respectful, clear limit setting in the hope that the client actually wishes to respond positively to your respectful attention.  Do not under any circumstances try de-escalation when a person has a knife or a gun.  In that case, simply comply.