Matthew is a client at the Healing Outpatient Clinic. All had been well for 8 months until he started missing his follow-up appointments. Four months after his last visit, Matthew arrived at the clinic, at 4:40pm, asking to be seen. His interactions with the front desk staff, his therapist, and psychiatrist were all “different” this time, threatening and immediately prompted a 911 call; Matthew began to resist, hitting two of the officers who were trying to get him to cooperate towards an emergent hospital admission. During the inpatient hospitalization, Matthew learned that he was being charged with aggravated assault (on a police officer). “I went to look for help, and now I am going to jail. What do I need to live for?” he said in anger to the medical student, conducting the initial interview. Two days later, Matthew was found tying the bed sheet around his neck. His roommate arrived soon enough, and he was placed on “one-to-one” monitoring for suicide watch. After discharge, Matthew found himself in jail, waiting for trial. Three days later, he was found once again, with his bed sheet around his neck, this time, unconscious.
Matthew’s case, however tragic it may sound, happens more often than most might be aware. However, for those who are rigorous enough to either do a root cause or a longitudinal-case analysis, for such agency related events, it will be discovered that Matthew’s story is more common than not.
From a root cause analysis standpoint, several contributing factors become obvious concerning this case. What is also palpable is the fact that Matthew must have escalated to the point where the front desk staff, the therapist and the psychiatrist were unable to de-escalate him. The outcomes lead to a mixture of emotions and ramifications for the clinicians, the agency, and importantly, the patient and, indeed, for the entire system. What should we do to understand such circumstances; is there anything at all we can do; what is our role as clinicians and as leaders; how should agencies and the health systems be better equipped?
Below are 6 reasons why learning, practicing, and mastering proper de-escalation skills, is essential.
From the Perspective of the Clinician and the Staff:
1. A Sense of Safety for the Clinician and Staff
Matthew’s case happened only three days after Stephanie, the same front desk staff, had to manage another client incident. Dina became very upset after she had been told to return to the clinic for an initial evaluation; she couldn’t be seen this time.
Dina was furious; someone else was also scheduled for the same clinician at that same time had arrived only a few minutes before Dina. “You are a B**, you know,” Dina screaming loudly to Stephanie, who delivered the news about rescheduling. “You have no idea what’s going on in my life. You are inhumane and you deserve to die.”
Stephanie was fearful for her life, and while still recovering from Dina, Matthew happened. She felt unsafe, her “reptilian” brain (amygdala and limbic system) and her survival mode kicked in and rightly so. Do we, as clinicians deserve a sense of safety while doing noble and challenging work with our patients and clients; as agency leaders, are we responsible to promote this sense of safety for all our staff?
2. Burn out Prevention
Eileen, Matthew’s therapist also had her share. “I don’t know what to do anymore. Two weeks ago, I called 911 for 4 clients, just in a space of 2 days. There was not even enough guidance available for me to know if I was doing the right thing,” uttered Eileen.
When Stephanie called Eileen’s office number to let her know of Matthew’s arrival to the clinic, Eileen was already managing a challenging client, trying to prevent escalation. By the time Eileen went to the front desk and saw Matthew, all she could think to recommend to Stephanie, “Enough with this. Just call 911.” Eileen had had enough; she was at the point of burn out and the right support, guidance, and skills were not readily available. Do you believe knowledge and skills empower and can help decrease the likelihood of clinician burn out?
3. Career Gratification Promotion
Dale is a child and adult psychiatrist, who believes in good results, good outcomes and recovery. After two decades of practicing in community settings, Dale has been wondering, “What have I done with these 14 years of education, hundreds of thousands of dollars in student loans, and years of sleepless nights?” When Eileen called Dale, to back up her order to the front desk staff to call 911, Dale’s depressing questioning about his career gratification was triggered. “Yes, that’s what I signed up for, call 911, send folks to the hospital, help create a revolving door, without really helping them recover.”
This was what Dale thought to himself before approving the 911 call, then walked towards Matthew and stated, “Why are you threatening the staff in order to be seen; and why have you been lost for 4 straight months?” This only further triggered Matthew, who then further escalated. Career gratification can be achieved when you are able to prevent fatal consequences. In Matthew’s case, two suicide attempts, a criminal record and time in jail were the ramifications. De-escalation skills do not automatically come with years of experience or years of education. These skills require conscious learning, and time spent in mastery. These are soft skills, which require critical thinking, problem solving abilities; and the feeling competent in these areas add to career gratification.
B. From the Perspective of the Patient or Client:
4. Enhance Clinical Outcomes and Prevent Iatrogenic Occurrences
“I went to look for help. Now I am going to jail.” As above, Matthew couldn't believe what was happening. In order for us to achieve the desired clinical outcomes, we need to reach our clients and patients where they are at; in order to reach them where they are at, we need to force ourselves to understand where they are coming from; and in order for us to understand where they are coming from, we need to do what it takes to prevent escalation or to properly de-escalate them. This is easier said than done, but if you keep the end in mind, the big picture of clinical outcomes enhancement, and learn and master the skills of de-escalation, what seems to be far from reach will become a reality. The outcome for Matthew is far from what any of us would wish for any of our clients and patients. We can stay away from iatrogenic occurrences (unintended ill effects or bad outcomes for patients and clients, directly related to the clinician’s intervention) and enhance desired clinical outcomes, by learning and mastering the right de-escalation skills.
5. A Sense of Safety for Patients and Clients
“I don’t go to the doctor, because they always find something wrong.” “If I tell you what I am thinking, you are just going to call the ambulance on me.” “I went to look for help and now I am going to jail.” Many of our patients and clients have an extensive history of trauma; they have a justifiable emotional response to authority, to being told “no” and they tend to overreact in the presence of authority or under similar circumstances. They are here, working with us, looking for help, willing to trust, trying to trust, and we have been called and are striving to be the promoter of this healing process, the witness of this transformation, and the bearer of this decree. Unfortunately, we at times, undo what we have started to work on, leading to further mistrust, treatment drop out and lack of engagement on the part of our patients and clients. We will be unable to help them heal from trauma, as long as the likelihood of exposure to micro-trauma remains high within our agencies. We can solve this dilemma and promote a sense of safety for our patients and clients through mastering de-escalation skills.
C. From the Perspective of the Clinician, Staff, Client, Patient, Agency, and the entire System:
6. Trauma Prevention
As agency leaders and health care decision makers, we are mandated to protect, as much as we can, our clinicians and staff from work related or other trauma. Of course, this involves ensuring a safe work place for them, help with preventing burnout, and promoting career gratification, which in turn will increase productivity and decrease number of sick days. As clinicians, we, too, are mandated to ensure that our agencies provide a place where our patients and clients feel safe, as stated above, and more importantly, it is our responsibility to prevent them from experiencing trauma and more trauma. For Matthew, calling 911, and putting him face to face with police officers caused further trauma, leading him to dissociate, hitting two officers, and making his full recovery even more challenging.
We all want to make a difference in the lives of others. This is one of the reasons why we are doing this work, one of the reasons why we are working with this population and one of the reasons why we are seeking to empower ourselves with knowledge, skills and tools, to be the most effective and efficient. De-escalation skills are essential, for us, as clinicians, as agency and system leaders, and also for our patients and clients. The proper de-escalation skills can help promote a sense of safety and career gratification, prevent burnout and trauma, and can help with desired clinical outcome achievements, improving show rate and increase productivity. De-escalation skills are therefore a “win-win” for all of us.
Dr. Sidor is quadruple board certified in psychiatry, with vast clinical, teaching, supervision, mentorship, and management experience. He also has extensive experience in public speaking, leadership, business, and research, in addition to a passion for program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past Medical Director and Chief Medical Officer for CASES (Center for Alternative Sentencing and employment Services), where he continues to see patients and consulting on challenging cases. He speaks and writes fluently in six (6) languages—French, English, Spanish, Portuguese, Creole and Italian.
Lazare A, Eisenthal S, Wasserman L. The customer approach to patienthood: attending to patient requests in a walk-in clinic. Arch Gen Psychiatry. 1975;32:553–558
Lindenmayer JP. The pathophysiology of agitation. J Clin Psychiatry. 2000;61((suppl 14)):5–10.
Nordstrom K, Allen MH. Managing the acutely agitated and psychotic patient. CNS Spectr. 2007;12((suppl 17)):5–11.
Holloman GH, Jr, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2011;13:1–2.
Livingston JD, Verdun-Jones S, Brink J, et al. A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff. J Forensic Nurs. 2010;6:15–28.
Farrell G, Cubit K. Nurses under threat: a comparison of content of 28 aggression management programs. Int J Ment Health Nurs. 2005;14:44–53.
Dupont RT. The crisis intervention team model: an intersection point for the criminal justice system and the psychiatric emergency service. In: Glick RL, Berlin JS, Fishkind AB, et al., editors. Emergency Psychiatry: Principles and Practice. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.
Elgin SH. Language in Emergency Medicine: A Verbal Self-Defense Handbook. Bloomington, IN: XLibris Corporation;; 1999.
Fishkind A. Calming agitation with words, not drugs: 10 commandments for safety. Current Psych. 2002;2011;1(4) Available at: http://www.currentpsychiatry.com/pdf/0104/0104_Fishkind.pdf. Accessed June 13,
Lazare A, Levy RS. Apologizing for humiliations in medical practice. Chest. 2011;139