TheMHS Mental Health Summer Forum: Tackling Aggression, understand, respond and prevent.
Speaker: Ron Diamond Medical Director of the Mental Health Centre of Dane County; Prof of Psychiatry at the Uni of Wisconsin and Consultant to the Wisconsin Bureau of Mental Health and Substance Abuse. Chair: Professor Maree Teesson
Maree: We have had to turn people away we have a packed room here today. We have international and local experts to tackle the issue, there is lots of time to ask questions today imagining those questions could be quite challenging. My pleasure to begin with Ron Diamond, leading force in this area. He has enormous background in this area and I invite him to stage.
Ron: Anger is a normal part of our emotional life we all have experienced anger – how do you know if I am angry, or someone else is angry? think about yourself how do you know if you are angry physiologically. Now think about what anger is for? it does get people to listen, someone will pay attention or backoff and distance themselves, give me space and gets people to respond.
What are the consquences of anger? it may get you attention but it gets people to stay away or be frightened. Who enjoys their anger? it makes us tired, blocks enjoyment, turns off extraneous information and we become narrow focused, we become more black and white and become less creative. It might help me win but we get into win lose mentality. We dont end up looking for middle grounds – we just want to win.
Think about your own experiences, what makes you angry ? it could be that you are not listened to, having people lie to you, etc Being tired and being drunk could also make us angry. Then there are the psychiatric elements psychosis with hallucinations and delusions, mania and depression.
Anger can be habitual, becomes a permanent way of being.
What do you want when you are angry? you want someone to listen, to be on your side, you want something to happen- you want action now – an emotional sense someone is with you.
Now thinking about your patient, maybe your clothes are taken away, you cant smoke, you get asked the same questions by police, nurse and psychiatrist? does this sound familiar. This is regularly what we do with our patients we tell them to calm down. Those patients are told you will be fine yet they make you wait and talk about you in a room where you cant here – and the patient is told they need to calm down.
How do we work with someone that is angry? you need to understand how you react with angry people, I need to understand myself we tend to get scared by anger, we need to be a calming influence with the person and not be part of the problem.
We need to over and under estimate the risk of violence based on stereotypes and stigma based on gender, size and larger body movements. For example someone with a cultural background that may use larger body movements and this can be interpreted wrongly, but there are cultural differences that we must understand.
If you cannot feel safe then you won’t listen effectively to your patients – you most consider both your own subjective responses and the objective risk. Listening is what we really need to do.
We want to make sure our reflection back is calming, the assumption is that everyone wants something, whaterver it is we all want something to improve the quality of our life – when we are dealing with person I need to be on their side, I dont want to be part of the problem.
Sometimes we cant give people everything that they want – once a person came into emergency and he was yelling, he came in voluntary and he talked to a triage asked questions and was asked to wait, asked triage nurse asked questions asked to wait, then saw a triage doctor (same thing happened) then he said he needed a smoke, they said no, he got agitated, he walked in voluntary due to the voices but then the hospital had now made it a problem.
If you cant change the situation, I could side with the patient, what part of what he wants can you do something about. Concentrate on areas of agreement rather than areas of disagreement. Make sure the patient feels heard.
Typically we ask the person to calm down first, we are supposed to be more flexible with them, our job is to begin the change process and make sure they feel heard.
We need to agree honestly and respectfully with them – the goal is to help the client reestablish control of him or herself and the need is to minimize risk of harm while the person is still out of control, risk cannot be eliminated some risk will always remain,
What does the client want? focus on what you can help with, what can we do that might help the client to reestablish control, what can we do to demonstrate good faith? too often we start by requiring the client to change first – that is not right.
Avoid unsolicited advice, empathize with the clients plight. The control should be back with the client. You cannot overdose with validation so validate feelings and attmept to cope with situation and validate any proactive behaviour, validate the degree of difficulty that is happening, do not say ‘calm down’ .
Pay attention to issues of power. who is the person trying to fight back, what tools is her or she is using, do we want to win or get out of the fight.
Why should patients feel one-down with us? Power is not the use of power its the potential. Clients are sensitive that the workers have the power over them.
It is oxymoronic to say that one person is not co-operating – it requires at least two people to no cooperate not just one.
We should understand our patients, clients and consumers are aware of the power relationship/heirachical situation – we want to reestablish control for them.
We need to remember to take our own pulse, we need to self reflect on how we deal with anger.
We need to actively listen, avoid being judgemental, give your undivided attention, focus on feelings what is being said and use silence- when to stop talking and use restatement.
Avoid Power Struggles: what does the client need, what do we need, what can we give in on and arrange for both sides to ‘win’.
He discusses how he got an assessment done in a carpark with a client, we want both sides to win.
Language to de-escalate: observe without blaming, use I statements rather than you statements.
Think long term/act in the moment. What does the person need now and how will this imporve the clients qulaity of life a year from now.
Respect the persons space, establish verbal contact, listen, agree or agree to disagree, be clear about limits, void being provocative and offer choices, respect personal space and think about using a gentle tone.
Identifying patients at risk for becoming assaultive: intoxication, drug or alchol withdrawal, other medical reasons
Differing Type of Threats
Hot Threat= anger
Cold Threats=attempt to control.
De-Escalation Key Points: use agreement, listen actively, be flexible, reflect empathy, gentle attitude and gentle tone.
Our job is to start the process not expect the client/consumer to do this.
Questions
1. Ron you addressed the notion of types of culture that we greet these patients into – some of the concerns the schematic approach where everyting involves control rather than engagement?
We need to think about what we are trying to accomplish, if i see my job and see that everyone is safe, we have a different job, at my centre we do a ‘walkthru’ we need to do it the same way that patients do, its amazing what you can learn about your own service, how well are we doing it? what has to change if you dont like what you see.
2. Can you give an example when you stuffed up tyring to de-escalate and what you have learnt?
If we try to calm the patient down and its not working, we have to ask ourselves how do we feel about it how did it go, my job is not to win, we must look at the sitatuion a few months down the track, are the patients now engaged.
3. We have recently lost our cigarettes – and our descalation skills have had to come to the fore. How are you managing it?
We do make nicotine available in other forms, we empathise with clients, it does increase annoyance but its a mixed bag.
4. Translating the information today for carers.
Discusses NAMI (Carers network in US) try to involve families as much as possible, reconnect with people in a social context, ask the consumer who they want to be involved with ie family members. We see families as very important and NAMI does run great courses in that area.
5.Curious how well non mental health staff have engaged with the mental health staff in the emergency dept?
Once mental health staff enter the emergency rule we do lose control, but the emergency rooms need our mobile crisis health services, so to some extent we have established a credibility which allows us to be listened to most of the time. We have worked very hard to overcome the split between medical and non-medical but yes sometimes its a struggle.
6. Do you find you have different approach /style depending on psychosis or intoxication?
If someone is actively intoxicated it is not useful to spend a lot of time with them. People with access to disorders that are hurting people with borderline disorder _ I am an optimist about dealing with them. If somone is feeling internal distress yes I can help them.
Speaker finishes
