5 reasons why patients and clients are likely to escalate
“How dare you tell me I can’t leave; who do you think you are? How dare you?” Harry spoke these words loudly and in anger to Nate, a forensic social worker, who was meeting with him for the first time, for an evaluation.
Throughout the assessment, Harry had been superficially cooperative, barely responding to questions, and Nate, an experienced evaluator, known for his thorough reports, was having quite a challenge trying to engage him. As everything else seemed to be failing, Harry looked at Nate and asked: “Are we done now? I need to leave.” To this Nate responded: “No, you cannot leave. We are not done yet.” When Harry heard that, his posture changed immediately, making a fist, starring at Nate, and asking him, “How dare you tell me I can’t leave; who do you think you are? How dare you?”
Human behavior is unpredictable at best. As clinicians, supervisors, managers and leaders, we often surprise ourselves with our own conduct, things we said and wish we could take back, actions we demonstrated later we just find unbelievable. And sometimes we send emails that we just wished we had used that 24-hour rule. Regardless of who, where and when, the human response can be dubious at best. Having said that, there are factors contributing to the likelihood of displaying a certain reaction over another. And in this regard, special attention has been given to aggression and escalation, the focus of this current article. Regardless of your experience, you can expect one or more of your patients and clients to escalate one or more times. What is also certain, you can decrease the likelihood that your patients and clients will escalate, and you can also become successful at preventing them from further escalating, by knowing the reasons why they are likely to do so.
Below are the top 5 reasons why.
In the above case, Harry told Nate he needed to go. However, Nate was too anxious about delivering the most thorough report possible that he failed to listen. During debriefing, Nate later on learned that Harry had made arrangements with his wife to help baby sit their three children. All he was thinking about was his promise to get back home. Harry was worried that his wife would once again miss her job interview because of him. “I was, indeed, not listening,” said Nate, during debriefing. “I was so focused on getting this report done, and I failed to do that one important thing—listening.” Listening is a simple word, but an essential skill that needs to be practiced every day, if it is to remain sharp.
Limited listening hinders the ability to fully validate. Nate was not listening; he had his own agenda - he was in his own head, worrying about getting the information he needed. He was unable, therefore, to validate, to ask Harry: “You seem to be in a need to leave. You must have someone or something important waiting for you.” This simple sentence might have opened up the opportunity for Harry to say more. Maybe Harry might have disclosed his need to be at home and voiced his worry and concern, “My wife may once again miss her job interview with no one at home earning an income, no one working, and it would be all my fault.” This was a missed opportunity. After a longitudinal case analysis, this was, in fact, what was going on in Harry’s head. He, of course, had difficulty articulating what he was thinking and expected Nate to initiate, to at least ask or take a step back to better understand what was happening. And rightly so. Patients and clients do come to us with all types of expectations, and we, as clinicians, must be aware of the need to understand them, listen, and validate. The next time you sit with your patient and client, strive to listen and strive to validate.
In two previously written articles on engagement, I described, (1) Focusing on the client or patient, and (2) Identifying barriers and problem solving, as some of the most effective ways of establishing engagement. As described above, Nate failed to focus on Harry, because he was too preoccupied with having the most complete write up possible, and this was at the detriment of engagement. Despite Harry being superficially cooperative, Nate violated principle #2, failing to identify barriers and offer problem-solving solutions. A simple statement like, “I am having some difficulty getting your attention at this time” might have gone a long way. Such a statement might be followed by a pause and then, if needed, could be supported by a simple question, “What might be your suggestion for me to get your attention, so we can successfully complete this evaluation?” This again may go a long way. Whenever I supervise clinicians, including those very experienced and knowledgeable, I realize how they often fail to state the obvious, to stay with the emotion; many fail to pay close attention to body language or to gently name the elephant in the room. Finding a way to avoid these failures and to incorporate these engagement strategies in your practice will help convey to your patients and clients that you are listening to them, that you do, or, at least, you are seeking to understand them. And with that, you are already eliminating three of the main reasons why patients and clients are likely to escalate.
Limited language sensitivity
Language sensitivity does not refer to just those who speak a foreign language. It refers to the tone of voice, the facial expressions, the posture, and the direction your patients and clients set their resting feet, when sitting or standing. It also refers to your choice of words and the timing, among others. I do appreciate that these may not be necessarily discussed in traditional schoolings or teachings, but as we strive to help our patients and clients, we have no choice but to find ways to master these skills. This is more important when we know that limited language sensitivity is one of the reasons why our patients and clients are likely to escalate. During debriefing, Nate was encouraged to reproduce, as much as he could, Harry’s cues during the encounter. (A.) Harry had told the front desk staff: “I want to be in and out. I can’t stay long;” (B.) Harry had never removed his jacket, hat and sunglasses despite having had done so during his pre-intake visits; (C.) He had failed to elaborate on any of the questions; (D.) He had had his arms crossed for part of the interview; and (E). The direction of his resting feet was toward the door. Any of these verbal and non-verbal communications seem far from significant, especially when isolated and if not contextualized. However, a combination of any of them is an invitation to all of us to pause and show language sensitivity by trying to understand what may be going on and what we may be missing. Please keep this in mind, that addressing any of this need to be in the least confrontational or accusatory way possible, or you run the risk of the paradoxical effect of escalating your patients and clients.
Limited cultural sensitivity
Similar to limited language sensitivity, limited cultural sensitivity is another reason why patients and clients are likely to escalate. And, as with language sensitivity, I am not just referring to understanding a foreign culture. Do you have any patients and clients who have a substance use disorder, who are or have been part of a gang, who have been in jail or prison, or who have been raised in an impoverished neighborhood, by a single parent? Each of these circumstances and lifestyles confers a form of subculture to which we all need to be sensitive, and this in turn will help us be successful at decreasing the likelihood of escalation. As we strive to remind our patients and clients that their identity is not simply limited to their circumstances, let us continuously remind ourselves that the process takes time to complete. Just like 21-year-old Jay, described in our article, 5 tips to help engage your patients and clients, “Now that I don’t use, and I don’t hang out with my old friends, I don’t know who I am anymore. I don’t feel like I belong anywhere, because all I knew was being an addict, since using when I was 14.” Subcultures are real and strong. Sensitivity to these conveys to our patients and clients that we are listening to them; we are continuously working on engaging them and reaching them where they are at. This also helps decrease the likelihood that they will escalate, since they are more likely to trust us. Follow this principle or pay the price. In the case of Harry, he had recently been released from prison and was in early remission of opiate use disorder. He also had been part of the “Bloods” gang. Harry could not stand being ignored. He had already told the front desk staff that he “wanted to be in and out;” he kept on his coat, cap, and sunglasses. After all this failed, he asked for permission to leave and that, too, was ignored. Nate not only ignored all cues from Harry, he also defied him, telling him, “No, you can not leave.” That, indeed, was the last straw, and Harry did escalate. One way to show language and cultural sensitivity is to know which language to use and what to avoid when meeting with our patients and clients.
I look forward to describing the additional 5 reasons why our patients and clients are likely to escalate. Meanwhile, here is a challenge for you: select one of these 5 reasons described in this current article and turn it around. For example, instead of “limited listening” practice active listening and become more conscious of it. The next time you meet with one of your most challenging patients or clients, implement this, and then please tell us how different the session was when compared to previous ones.
Thank you for the opportunity to be on this journey with you and until soon.
Your friend and colleague,
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 Medical Director and Chief Medical Officer for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (6) languages—French, English, Spanish, Portuguese, Creole and Italian.
Learn more, practice differently, and feel confident
- Knutzen M, Mjosund NH, Eidhammer G, et al. Characteristics of psychiatric inpatients who experienced restraint and those who did not: a case-control study. Psychiatr Serv. 2011;62:492–497
- Moyer KE. Kinds of aggression and their physiological basis. Commun Behav Biol. 1968;2:65–87.
- DeLacy L, Edner B, Hart C, et al. Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health. American Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems, and American Hospital Association Section for Psychiatric and Substance Abuse Services; 2003. [19 January 2015
- Muralidharan S, Fenton M. Containment strategies for people with serious mental illness. Cochrane Database Syst Rev. 2006;(3) CD002084. Epub: 2006/07/21
- Azeem MW, Aujla A, Rammerth M, et al. Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. J Child Adolesc Psychiatr Nurs. 2011 Feb;24(1):11–5. Epub: 2011/01/29
- Sears M. Humanizing Health Care: Creating Cultures of Compassion With Nonviolent Communication. Encinitas, CA: Independent Publishers Group; 2010.
- Keski-Valkama A, Sailas E, Eronen M, et al. Who are the restrained and secluded patients: a 15-year nationwide study. Soc Psychiatry Psychiatr Epidemiol. 2010 Nov;45(11):1087–93. Epub: 2009/10/22
- Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. J Clin Epidemiol. 2012 Feb;65(2):163–78. Epub: 2011/10/01
- Hermanstyne KA, Mangurian C. Behavioral strategies to mitigate violent behavior among inpatients: a literature review. Psychiatr Serv. 2015 May 1;66(5):557–8. Epub: 2015/05/02