Navigation and a Couple Tips for On-line Modules Navigation Instructions: Whenever you see words in this color and style in the module click on it for additional information De-escalation and Management of Aggressive Behaviors Module 3: Self-Management and Mental Preparation This module reviews key strategies for defusing agitation and managing verbally aggressive behaviors and focuses on the skill set of self management

It can happen in any work setting, any shift … You’re going about your duties. Taking care of what needs to be taken care of. The day, so far has gone well… It only takes one unhappy patient, one unhappy patient family member, one person in distress and wanting relief from that distress… NOW! To change your day. How do you respond?

Recall the Five Key Strategies for Effective Verbal De-escalation Situational Awareness and managing the stages of conflict Non-verbal Communication including approach and positioning Listening- Active and Empathic Assertive Verbal Communication Self-Management and Mental Preparation This module focuses on Self-Management and Mental Preparation, but first we’ll briefly review one or two points from the other key strategies, allowing you to test your recall of them.

What is Situational Awareness? Take a moment to think about your answer Then click here for an answer .

Situational Awareness - Stages of Conflict As you recall aggression follows a predictable pattern. The stage of conflict will direct your response. For the highlighted stage below click on the appropriate response to the right. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Defensive Supportive-Identify distress Supportive-Open communication Assertive

Situational Awareness - Stages of Conflict As you recall Aggression follows a predictable pattern. The stage of conflict will direct your response. For the highlighted stage below click on the appropriate response. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Defensive Supportive-Identify distress Supportive-Open communication Assertive

Situational Awareness - Stages of Conflict As you recall Aggression follows a predictable pattern. The stage of conflict will direct your response. For the highlighted stage below click on the appropriate response. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Defensive Supportive-Identify distress Supportive-Open communication Assertive

Situational Awareness - Stages of Conflict As you recall Aggression follows a predictable pattern. The stage of conflict will direct your response. For the highlighted stage below click on the appropriate response. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Defensive Supportive-Identify distress Supportive-Open communication Assertive

Situational Awareness - Stages of Conflict Correct. Re-open communication with the individual; again conveying support and your intent to help. Note that the stages are not necessarily linear, and each situation is unique, requiring you to maintain constant awareness. Baseline Anxiety Verbal Aggression Physical Aggression Resolution/Tension Reduction Defensive Supportive-Identify distress Supportive-Open communication Assertive

SUMMARY- Key principles and strategies   Non-verbal Communication including approach and positioning Pay attention to the nonverbal signs of distress along the stages of conflict. Manage the space around you and be deliberate in how you approach a person in distress Make sure your nonverbal behavior matches your verbal interventions and intentions. Consider this individual to the right, you can make a number of inferences from his facial expression, his gestures and his tone of voice. Before continuing, answer these questions: How would you describe your body language and your approach? What amount of distance would you keep?

SUMMARY- Key principles and strategies   Non-verbal Communication including approach and positioning Clearly this is an agitated, possibly verbally aggressive individual. Your approach would be at an approximately 45 degree angle—remember avoid the directly in front approach– your body language would best be described as calm, yet confident. For the verbally aggressive individual you would maintain a distance of about six feet. How did you do? Now think about what you would say to him. Assume you are meeting him for the first time. Before you continue, what might you say?

SUMMARY- Key principles and strategies  Listening and Assertive Communication. Possible responses: Hi, sir. My name is ________ I’m _(your title or role). Rationale: The use of names personalizes the interaction. You also identify up front your role. I’m sorry for this situation. I’d like know how I can help you. Rationale: Assertive communication is appropriate in the verbal aggression stage, you continue, however, to respond empathetically. This recognizes and puts into words his distress, and states your intent to help. Note: avoid referring to “a problem” or “your problem” I can see you how upsetting this is. Can you fill me in on what happened? Rationale: Empathic response acknowledges his feelings. The question then directs the individual to focus on facts.

In any situation keep in mind these key principles and strategies:   Situational Awareness and managing the stages of conflict Non-verbal Communication including approach and positioning Listening- Active and Empathic Assertive Verbal Communication Self-Management and Mental Preparation

“Be the change you want to see in the world.” Mohandas Gandhi While you are attempting to influence the behavior of a distressed person, you can only control how you respond. The flight or fight response reduces a person’s ability to act rationally. When faced with aggression your natural response is fight or flight. Self management is a set of skills that allows you respond in a professional manner. As stated in a previous module it all comes down to preparation, planning and practice. We’ll look at each of these in more detail now. Why Self-Management is key:

Preparation is building the base of knowledge and learning skills needed to respond to a behavioral crisis. This base of knowledge allows for effective risk assessment. It is a professional responsibility to anticipate and plan for potential crisis situations. This reinforces the importance of being aware of risk factors within individuals and within an environment.   Additionally, we want to be aware of risk factors within ourselves. Are you aware of any knowledge or deficits that prevent us from responding effectively to aggression? How are you addressing these? Can you quickly scan a crowd and determine who is mostly like to be difficult to deal with? While is important to be aware of risk factors, it is equally important to be aware of our pre-conceived ideas about people based on appearance, age, ethnicity or any other outward characteristic. We need be self aware of our attitudes and guard against them influencing our interactions with others. One particularly harmful prejudice is the report of other staff members. If you are told a patient is “a real pain in the ____,” that is a prejudice that may interfere with your interactions.

What Navy SEALs Know   In an earlier module we talked about how Navy SEALs train for stressful situations. Let’s review each of their strategies Arousal Control via proper Breathing The mind becomes reactive and the primal instincts take over under stress. In any stressful situation arousal control is key. 4x4 breathing requires you to breathe in for 4 seconds, exhale for 4 seconds. Be sure to breath from your diaphragm. This forces you to get your mind off the stress and focus on your breathing, clearing the mind for solutions. This is a form of mindfulness that reduces your own flight or fight response. Deep breathing in response to stress is a learned behavior and requires practice. Repeated practice allows you to respond in even the most stressful situations in a controlled manner. Close

Mental Rehearsal is how we prepare, plan and practice for a crisis Role play and simulations are ways to practice verbal de-escalation skills, and physical training allows for some practice in physical skills, but what happen in between training? Skills rapidly decay if not used. The more you mentally rehearse effective responses to situations with an aggressive person (either verbally of physically) the better your response will be if and when it occurs in real life. Most situations are resolved without aggression, but you can use those situation to think through and mentally plan and practice “what if it had escalated?” Visualize as vividly as possible crisis scenarios, and your responses in those scenarios. Important: when mentally rehearsing, always visual a successful outcome. Mental rehearsal is used by top performers in every field.

Positive Self Talk is being purposeful about what you say when you talk to yourself. Recall from an earlier module the 2 questions to address negative beliefs: 1. Do I know this belief or negative self talk to be 100% true? and 2. ”What do I know that contradicts this negative self talk or belief?”. For example: “I’m no good at dealing with angry people.” Question 1: Is this 100% true? “I don’t know maybe, maybe not…..” Question 2: What do I know that contradicts this question? ”I have trained to de-escalate these types of situations, I did okay with that last situation, I’m challenging my negative self talk, so I must have learned something.” A participant in de-escalation training shared this “personal cheerleader” technique she found helpful:   When you are in a stressful situation think of someone who encourages you when you feel defeated or depressed. It could be whoever you wish. Mentally bring that person into that situation. When you start to panic, have your mental cheerleader give you a little pep-talk. “You can do it! I believe in you.” It doesn’t matter which of these techniques you use, or if there is another one, what’s important is that you address negative self-talk.

Short term goals is about being in the present moment. Set your sights on an immediate, easily-reachable goal and then take one step after another until you get there. Then set a new goal. For a SEAL trainee, their internal dialogue might go something like this…   “Just gotta make it until lunch, then I can rest.” And after lunch, “Just gotta make it over the next hundred yards of beach.” and then, “Just gotta swim this last 200 yards.”   The entire day is broken up into a series of individually manageable steps.   You can do the same when managing a crisis situation…”I just want him to lower his voice… I just want him to unclench his fists…” the interaction is broken up into manageable steps. This technique is deceptively simple, but it’s powerful and proven. It helps concentrate your efforts not on what you can’t do, but on what you can. Make eye contact Get his name Get him to lower voice Get him to talk about what happened Get permission to help resolve the issue The process of de-escalation can be broken down in a number of steps, each step a discrete short term goal

Three additional concepts in self-management: Once a person enters a professional role he or she must be able to suspend his or her “natural” response and act in the role which he or she has taken on. A professional response is by definition one that is acquired through purposeful education, training and practice. The professional does not have the luxury of saying “that’s just how I am.” Doing what comes naturally is not only “unprofessional” in a situation of aggression or violence it is dangerous. Without practice in the face of stress people revert to instinctual responses. Practice is the means of transforming learned responses into automatic responses. Rational Detachment Stage Presence Educated response

Rational Detachment Detachment is a type of mental assertiveness that allows people to maintain their boundaries and their own emotional integrity when faced with the emotional demands of another. It is a positive and deliberate mental attitude which avoids engaging the emotions of others. This detachment does not mean avoiding the feeling of empathy; rather it involves an awareness of empathetic feelings that allows the person to rationally choose whether or not to engage or be overwhelmed by such feelings. It can mean holding back from the need to rescue, save, or fix another person from being sick, dysfunctional, or irrational, or the willingness to accept that you cannot change or control a person, place, or thing. Positive detachment allows a caregiver to approach the behavior of an angry, frightened or otherwise distressed person with an attitude of curiosity. In order to maintain an attitude of both concern and detachment, an important question to consider when face-to-face with aggressive behavior is, “What else can this mean?”

Prepare, plan and practice Healthcare serves those in their most vulnerable state. Inevitably you will interact with individuals in distress and conflict. A knowledge base is only one element. How you prepare, plan for and practice the application of your knowledge, how you develop your skills, and how you manage your attitudes will make the difference when you are face to face with that one patient, one family member, or one person who wants relief from distress…NOW… Because the only thing you can truly control is your self and your own responses.

Self management is important because once we can control our own responses, then we can control others. F The fight or flight response effects staff members as much as it does patients. T When mentally rehearsing a scenario it is important to visual both successful and unsuccessful outcomes, and learn from both. F Practice is the means of transforming learned professional responses into automatic responses. T Detachment means guarding against empathy when the distressed person is in the wrong. F It is an important for safety to not let an aggressive person know your name. F Once a person turns verbally aggressive it is important to not respond empathetically. F It is possible to indirectly modify physiological response (flight or fight, for example) by changing one’s thinking or behavior. T