Hello and welcome. I am Jose Viruel, Clinical Director of Behavioral Health at Erie Family Health Centers and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Engage or Enrage? The Escalation Strategies for Mental Health Crisis, Part 2. Welcome back to those who are joining us after attending Part 1, and thank you to those who are joining us for Part 2. To those who missed Part 1, please note that the recording is available at smiadvisor.org. Also, the direct link will be posted in the chat. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinical community, our efforts have been designated to help you get the answers you need for the care of your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physician, one Continuing Education credit for Psychologist, one Social Work Continuing Education credit, and one Nursing Continuing Professional Development contact hours. Credits for participating in today's webinar will be available until April 14th of 2022. Slides from the presentations today are available in the handout area. Please select the link to download the PDF. And just like in Part 1, we included a helpful de-escalation handout, which can also be found in the handout area. Please feel free to access this resource to supplement the information from today's webinar. Also, please feel free to submit your questions throughout the presentation by typing them in the question area, also found in the lower portion of your control panel. We will reserve 10 to 15 minutes towards the end of the presentation for some questions and answers. Additionally, there's three points in the presentation where the speakers will ask the audience for responses to the discussion questions. Please feel free to use the question area to respond. And now, without further ado, I would like to introduce you to today's faculty's webinar, Mark Fagan and Brian Bean. Mark Fagan is the Vice President of Clinical Operations and Youth and Young Adult Services at Thresholds. Brian Bean is the Training Coordinator for Thresholds Youth and Young Adult Services. Both Mark and Brian work with comprehensive programs focused on transition-age youth with mental health needs and a history of complex trauma, child welfare, and juvenile justice involvement. Mark and Brian, thank you so much for leading today's webinar. All right. Thanks, Jose. Happy to kick it off. And thanks to all of you who are joining us live. So as Jose said, I'm Mark Fagan, and I'm hailing to you from Chicago, both of us are. And we work in an organization called Thresholds there, it's a large mental health organization working with various populations, all centered on folks with serious mental health conditions. And so I'm a psychologist by trade, certified in a handful of different de-escalation models and training that. And so a lot of what we're talking about today and what we talked about last time is sort of a weaving of those best practices, along with our years of experience across providing de-escalation tactics in residential care, in outpatient types of care, in individual therapy types of care, and other venues as well. Brian, you want to say a word as well? Yeah, not too much more, but happy to see folks today, even though I'm not seeing anybody because it's a webinar. But you work in Thresholds, the de-escalation techniques that we're going to be talking about today, I've been training for almost 20 years. And for most of that, I've also been practicing it. So this isn't just an academic exercise, but skills that we've used for over a decade, with the youth that we work with and some real intense crisis situations. And these sort of skills are hopefully some stuff that can be useful for folks engaging with dangerous crisis situations, wherever you are. All right. So no relationships or conflicts of interest related to the subject matter of this presentation. So took care of our disclosures. Let's talk a little bit about our learning objectives. So as you get through this, we're expecting that you'll have some strategies to get out of power struggles during times of escalation, that you'll learn a number of approaches to safely manage high level escalations and be able to gain some skills to debrief and support a person in crisis after that crisis is over. So as we said, during the first one, we usually do much longer training and also in person and you gain some skills by trying some of this stuff out and we're going to do our best to make it as live as possible during a webinar that you may be seeing live yourself or recorded. And there's a lot more to it, but I'm hoping that there will be some nuggets here, which we'll be able to take with you as you sort of get out of this training. So where have you been at our last webinar? Let's talk a little bit about what we got over there. And Brian, my understanding is that we broke SMI advisor with the last one. Is that about right? That's what I heard, yeah. So I think we had more than 1,500 people that have viewed the last one. Do we get a trophy for that? I'm not sure. I'm not sure, but it means it must be good. So if folks haven't checked it out, they should definitely go back and see what they missed. All right. We'll have to ask Jose about the trophy part. I'm sure there's like an SMI trophy out there somewhere. It's a t-shirt. Yeah. Would that be your favorite award, given like all your other awards that you've won in your life? Maybe. All right. Well, we'll see. So if you are interested in viewing the last one, here's a little bit of information on what we covered, and hopefully you won't be sorely disappointed with this one as a result. Last one, we talked a lot about the basics of crisis situations, a little bit about how crisis behavior is caused by an individual's inability to cope with difficult emotions or trauma responses, and that when we're responding to a crisis situation, the first thing that we really want to get into is what's going on with ourselves. We also then want to think about what's happening with the person in crisis and also what's happening with things around us in order to really prepare for a crisis situation. Talked a lot about how there's different degrees and levels of intensity there. And so for example, when somebody is saying, man, I'm really depressed, we don't want to be like, clear the room, everyone go. So we want to think about how crisis behavior has different degrees of emotional and behavioral intensity, and we illustrated that with the crisis volcano. We'll build on that today as well. We also talked a lot about self-awareness and how that's the key to ensuring that we're responding and not reacting, and that the way we communicate in crisis is essential. Active listening is a big part of doing that, and we talked about a number of keys in strategizing around active listening as we're getting into a crisis situation. We also talked about supportive strategies, those sorts of things that we can work on during those early stages of crisis to kind of keep things from getting to a really escalated level. So what we're going to cover today is providing you some strategies in these stages. And so the first one would be about fuming, and fuming is really where things are getting hot. There's verbal aggression, where there's threats, we're seeing some minor property destruction. We have folks that are appearing enraged and really trying to keep them from that erupting stage. And so that erupting stage is where violence is really directed at others or themselves, and the lava has really spilled out there, that safety is most important at that point. And then we're going to talk about cooling and how cooling can take place at any one of those other stages, and this is where we're helping the person in crisis kind of bring themselves eventually back down to the dormant emotional stage. And we'll throw you a few strategies on how to work in that context as well. So let's start out here with power struggles, and Brian, I'll throw it over to you. Yeah, so when we're talking about intervening in crises at those higher levels of escalation, where there's the verbal threats or things are loud, maybe things are getting thrown away and we're thinking, hey, there might be violence. The first thing we want to be real mindful of is watching out for the kind of biggest hurdle that we can encounter that can make the situation worse, and that's falling into a power struggle. So power struggles in general is something that all of us have been through. And so while I'm talking through this slide, folks can go in that question box and type in, in your life, how do you know you're in a power struggle? Like anything you notice yourself, you've been in a power struggle, either at work or in a relationship or in the community, how do you know that you are kind of in a power struggle? And so what it is, power struggle is, you know that you're in it when you find yourself going back and forth with the person in crisis. So the person in crisis is yelling and you find that you're just pulling every time they pull and you're going back and forth. You know, that's when you're like the, hey, you need to leave the room. And they say, you know, no, and you're just like, you know, you leave the room, you find something that back and forth, you're not going anywhere, except you're actually making the stress of the incident itself and the crisis increase. Same thing as if you're arguing, and if you find that you're having to defend your authority or credibility, then you're in that stage in which you're actually making the situation worse. A lot of times we fall into arguing when we're kind of hooked by something that the person in crisis says, so if they say something provocative or that antagonizes us, like, you know, you're not good at your job or something like that, if our response is, well, yes, I am, we're trying to validate or defend our own ability, we're talking about ourselves and not about whatever it is that's the difficult situation, stressful event, or trauma reminder that is the reason why the person is in crisis. Another thing that happens that makes you know that you're in a power struggle is if you're issuing behavioral ultimatums or threats, you know, if you don't stop, I'm going to, you know, X. If you're in a program that has like consequences, issuing those or something horrible, like threatening to call the police, or the strangest one, when people issue kind of the hanging threats, if you don't stop doing this, you know, in two seconds, and then the person responds or you'll do what? And that's actually a question that I think can make the situation worse. And the last one is that if you'll notice you're in the power struggle, if you're feeling those angry, frustrated feelings with the person in crisis, and when you feel like you don't know what to do, when we talk about why crisis behavior is evident in a person you're dealing with, it's because, you know, the coping skills they had aren't working and the stressful situation is causing this changing behavior. It's the same thing for us. If we feel like our skills of intervening aren't working, or we don't have them, then we ourselves go into crisis. And that's how we can sort of lash out and by falling into a power struggle. So what we're seeing in the question box is exactly what I was hoping for, which is how people are recognizing power struggles within themselves. So you definitely picked up stuff from our last session, which is that you're feeling it in your body. You notice that your fists are getting clenched, maybe your teeth are clenched, or you're feeling hot. We got on here that, you know, somebody's angry and shaking and trying to get you to agree with them. Back and forth discussion, physical changes, increased stress. So really that body tension, really recognizing how you're feeling with it, but also understanding that like you continue to escalate your voice, the person you're with in crisis is escalating and things are starting to get a little bit hot. Yeah. Great. One other thing that maybe wasn't in the chat that I think is something to think about is I think being able to identify those, how your body sensations and the feelings are real important. I think also we can notice certain negative thoughts that are the sign that we're getting into it. The kind of like this again, or I can't believe they're not helping themselves, or these kind of negative thoughts. It also can be red flags that, hey, I'm beginning to fall into a power struggle, but really good suggestions. I'm glad people are paying attention to that self-awareness that really is kind of a core concept for being able to deescalate a situation. So power struggles, almost always it's going to end badly if you can't get yourself out of one. And the key thing about this is that we're going to fall into power struggles. Our goal of this training is not to say, hey, you can avoid all power struggles if you do these things, but being a skilled practitioner is being able to catch yourself before you get too far so that we don't make it badly. And the way that we make it worse is that what a power struggle does is that it means that our intervention, our presence in this stressful situation actually becomes the stressful situation. Our point of intervening is we want to figure out some way to lower the level of stress to co-regulate so that the person in crisis can regain some function of control. If we're getting in a power struggle, then we're making it worse by what we're doing in raising the situation further in a way that could have been avoidable. So if you find yourself in a power struggle, it's time to pull the escape hatch, catch it and then do something. And so how do we do that? So get yourself out of the power struggle. I blame Mark for the strange picture of this chick that has vanquished an egg in combat or is playing soccer with the egg. But I think what he's really going for is that the nature of getting out of power struggles is a bit of a chicken or the egg phenomenon in which identifying you're in a power struggle means you first have to identify you're in a power struggle. So this is why this self-awareness is key. Being able to get out of it means you have to realize that you're in it. And this foundational stuff of paying attention to how we're feeling, what sort of things trigger our own anger feelings, what values and worldviews we bring it into the situation that can possibly make us respond in a way that is reactive as opposed to responsive. So first pieces, you catch yourself, you realize, okay, I'm having these feelings. I got my fist clenched up or I got some negative thoughts. The first thing to do is take a deep, slow breath. And that may seem something that like is obvious, but is going to be something that isn't going to come automatically if you're stuck in it. And so taking a deep, slow breath regulates our default response to give us a second to kind of figure out what to do. It gives us that pause. Also, it helps our own blood pressure and pulse rate just moderate just a little bit. So that's the first important thing to do. It may seem obvious, but it's hard to do in the moment, but doing it is really impactful. So you take that deep, slow breath, allow yourself to get that little fraction of a space and then try to use some change self-talk. So as I mentioned before, this negative talk, these negative thoughts that fuel us responding as opposed to responding to the person in crisis can make us go deeper into the power struggle. And I think us being real cognizant about using positive talk to get us out of it are real key. So you're going to do this by basically just saying something in your head to kind of counteract the negative talk. The one that I always use is this is not about me. It's almost like just using a mantra to kind of recenter yourself. If folks in the question tab can write in, what are some positive change talks that you guys use that are helpful? I think it's important to kind of think about this ahead of time, because again, when you're in the moment, when the adrenaline's flowing, we're feeling the feelings, it's not going to be an automatic thing that we're going to say, oh, wait a second, you got this, or this is not about me. But thinking about it ahead of time so that when you're feeling okay, I'm feeling I'm in the power struggle, and now I'm going to use the positive self-talk. Rob, do we get any good positive self-talks there in the chat? Yeah, I got a handful so far. So take it easy, leave the ego at the door, a couple of folks saying it's not about me, this is not personal, you got this, things around like I'm here to help others, I'm stronger than I think. Oh, I got one that's blue dolphin, I would love to hear more about that. Sometimes it's the imagery, right? That helps a lot too. And I tend to be more in terms of images than in words, and so I recognize, I sort of connect with that a little bit better too. So you just have a chick standing on an egg, Mark? That's right. I think about the chick on the egg all the time. Yeah, so think about that ahead of time, so you're prepared when you get in it, you kind of got your mantra there ready to go, and try to counteract some of these negative thoughts and negative feelings that are going to come when you're in a stressful situation. I got one that I hadn't seen before here, that really resonates with both of us probably, Q-tip, quit taking it personally. Oh, excellent, and I'm sure they're referencing this seminal tribe called Quest Artists as well. Yeah, we'll be playing some of that, I'm sure, during our next webinar. So getting yourself out of a power struggle depends most importantly on first knowing that you're in it, and then taking a second to just calm yourself enough to be able to think a little clearly, and then you got to do something. So next slide, Mark. So most importantly, after you have taken the words of the poet Ice Cube to heart and realize you have to check yourself so you don't wreck yourself, then you can use one of these techniques to try to get out of the power struggle. In talking about these, it's not that these techniques are going to de-escalate the situation. They're not going to bring the person in crisis back to their normal level of functioning. What they're going to do is give you something to do so you're not feeling like you don't have anything to do, and you're just being reactive to what's going on. It's a way to sort of hold on to something to get out of the power struggle. And so they're just tools in your toolkit to be able to have. So you find yourself going back and forth. You're arguing with the person in crisis. Then you can do one of these. You can say, okay, well, I'm just going to actively listen. So I'm just going to sit back and then focus on those things we talked about in part one. I'm just going to give those reflective responses. Seems like you're upset right now. I'm just going to give this empathic responses. Man, that's really hard. Asking some open questions like, okay, I don't know what else to do. I am just going to listen. Second thing to do is pay attention to your body language. If we're in a power struggle, our body has probably changed in ways that are unconscious to us that might be showing us feeling out of control or anger or other negative sort of affective qualities for the person in crisis. Check it. Pay attention to it. Where are you standing? Are your arms crossed? Are your fists clenched? Pay attention to your body language. Like, okay, well, I don't know what to do, but I'm going to adjust my body language. The other is give space and choices to the person and time for them to consider. So instead of arguing about whether or not someone needs to leave your office or not, you find yourself in the power struggle, you've taken your deep breath, you've said, you know, blue dolphin, and you want to say, okay, well, I'm going to step over here. When you're ready to leave my office, you just let me know or something like that. You just give the options for them to consider, give them the space to figure that out and the time to do so. Another thing you can do is appeal to the self-interest of the person in crisis. Hey, you know, if we can work through this together, maybe we'll be able to find some kind of solution. Don't make promises, but appeal to the self-interest. And then I think that sometimes you just have to let it go. If you find yourself going back and forth or arguing about some kind of expectation that's required, just letting it go, maybe what needs to happen where, you know, if the person is, you know, not leaving your office or is not doing a certain thing and fighting about that might inflame the situation even more, just forget about it. And at a certain point, if you find that you're making it worse by how you're engaging in this situation, at a certain point, you may have to step out, you know, you have to make sure you can do this safely, but if you need to step out, you got to step out. Right, so thanks Brian we talked a lot about getting out of the power struggles one of those strategies in reducing that human sort of end of the volcano and so we're going to spend a little time now shifting up. And what I mean by that is as we're talking more and more about that volcano of crisis and the lava sort of boiling further up. We now want to get into some strategies of when you're on the verge of eruption. And so these are those times where the where the lava is like at the cusp, where you know it could be spilling out and causing danger to everybody, or you have the opportunity to get back down. And so these are those times where that crisis situation is really on that cusp, really having that opportunity to engage or enrage for that last time. And during this opportunity. This is exactly when we need to be. Brian do I really need to say this. Yeah. Oh, fine. All right. This is what we need to be a smarty. Yes, that's right, a smarty. When we say smarty this is what we really mean we're talking about an acronym here self check, making space and being aware, and then responding to the individual, and we're going to talk in a little bit more detail on those areas, but thinking about smarty as you're going into these situations and that we know sometimes by by us ensuring that we are and also stay calm is really one of the best tools to calm a situation. So, the further we go into these sorts of situations, our goal is to really reduce the chances that it's going to become an eruption and dangerous to the person in crisis to yourself or anybody else that's around there. So, let's start with the first part. That's the yes, this is the self check, and this is going to really kind of throw us back to our first webinar that we did in kind of taking it taking an opportunity to look at what's going on with ourselves. First thing we want to do to get there, of course, is what we talked about in the power struggle, taking that deep breath. We already talked about how that regulates our default response, it really regulates us physiologically, helps with our blood pressure and pulse rate, but then also gives us that chance to decide how to respond. We always feel like we're rushing in a crisis situation and we do have to think fast and act fast, but it's important to be able to take that breath. So, from there, being able to do a quick awareness scan of ourselves in this situation that involves those questions of what's going on with me, am I in a position where I can take care of this? Am I having such a rough time right now that my emotions are getting to me and causing power struggles and could potentially enrage, and if I have other teammates with me, maybe I want to tap out to have them work in my stead for a minute as well? Or am I in a position where I can take a deep breath, give myself some confidence, use that positive self-talk and get in there? So, finding out what's going on with me, am I ready to be able to deal with this? Of course, the next one is what's really going on with that person in crisis? What do they need? What are they trying to convey to you? What is happening that's really sparking it now that maybe hadn't sparked things before? And taking a good look at what's around me, where are my exits, which we'll get into, any kind of things that might be used as weapons. So, getting a good sense of what's going on around me that might also be contributing to the stress here. So, that's the S part, really kind of throwing back to that. Next part is the MA, right? So, making space and being aware. So, making space is also about stepping back. So, in the question box, go ahead and throw in there what are some things that stepping back might demonstrate to the person in crisis? What might stepping back demonstrate to that person in crisis? We'll get back to that one. The second idea here is that the physical space that you're in is important. It promotes safety. And so, the idea is if you're in a cramp-tight space, we talked about this in the first webinar, that can really continue to amp up what's going on. You know, heat that may be going on, really, really cold spaces, loud spaces, the trigger still being in that area if it's another person. So, really being able to think about your physical space and where you are within it. Allowing the individual to have exit paths. You want the person in crisis to be able to see exits. So, you want to be thoughtful about exactly where you're positioning your body, and Brian will talk about that in just a little bit. But making sure that the person in crisis can see where their exits are, that they can see beyond where you are, that they can see the room that they're in and where the door path might be. That's going to be important because we know that, similar to us, if we feel like we're trapped, we're going to be doing everything we need to to lash out. And that's going to happen not just consciously, but also subconsciously, that will really amp it up. Allowing the individual time to process what's going on. So, again, we want to slow things down, really want to kind of take some time to slow it down as much as possible. So, using silence will be really helpful here. So, we got some things back in the question, Mark, about what stepping back demonstrates. And so, it does depend on the situation. We got some of that, right, that it can depend on the situation. Sometimes it can show that maybe we don't care if we're doing it in a body language phase that's demonstrating us walking away. Other times it can demonstrate a respect for their space. That we're not trying to control them, that we're not getting in their boundaries, that we're giving them the opportunity to take a look at what's going around, to move around if they need to. That we're not trying to hold them in. All those other things. So, the restriction is what we want to get around. One other piece here, too, is just being aware, right? And so, we want to be aware of our surroundings here and that we want to maintain vigilance, take a look at what's going on, right? Luckily, physiologically, our adrenaline has kicked in, typically, and our response to stress heightens as a result of it. And so, these are sort of the sensors that we can tap into and be more vigilant with what's going on. We want to look for weapons. We want to see if there's anything that could be used for a weapon. And maybe slowly maneuver away from it or sort of try to move it away from where you are, the person in crisis might be, right? So, we want to assess the situation non-verbally. We're going to be able to really look around, keep an eye on what's happening, keep an eye on the exits for ourselves. There's times where you may be with a person in crisis and you need to kind of pivot around so you know how you can get to an exit in case this does get to an exit. So, a couple of tools to think about in terms of your spacing. So, let's go into the next part over here. Brian, you'll take that. Yeah. So, you know, we talk about spacing. I think that it's important to remember that whatever words we say are going to be way less impactful and communicate less than our body language and our voice tone. So, when things are very heightened and they're kind of on the knife's edge and maybe violence, it's real important that we are very, very conscious into how we're standing and how we're holding our body. And so, we want to make sure that we're standing in a way that is completely non-threatening and doesn't trigger any counteraggression. Along with that, we want to make sure that we're staying, you know, at an angle. So, what that means is that we're not kind of squared off with the person where our shoulders are directly at them. It's non-threatening. We're giving that sort of space to move past and just being very attentive to everything that we say. You want to keep your distance. You want to stand at minimum six to eight feet away if you can. I always try to be a little bit more than that, you know, 10 to 15 feet if you can. You know, you don't want to be completely weird with it, but at the same time, you don't want to make it easy for them to think, okay, I'm going to be aggressive with this person and give you that space to move further away if you need to. You're going to be standing in a way where your feet are apart and you're on the balls of your feet. This is going to allow you to be mobile. As a person in crisis, it's usually me moving around, and it's going to be up to you to be able to kind of negotiate moving in space that maintains that distance in a way that also doesn't communicate, I'm like afraid of you or I'm running away. So sort of being able to keep your feet about shorter width apart and be on the balls of your feet allows you to be able to make that movement in a way that isn't jerky or jumping or can be provocative to the person in crisis. All throughout, we want to be relaxed, but alert. We're paying attention to everything, the space, the body language of the person in crisis, but as much as you can, trying to communicate a certain degree of being relaxed, even if you're not. That deep breath is going to do a lot to try to help you kind of regain some sense of control, but you're trying to demonstrate being relaxed, even if you're not. Your hands, you want them to be visible. You don't want to draw attention to what's going on with your hands, but you want to make sure they're down. I think sometimes people have an instinct to kind of hold their hands up, like in a protective type way. They get a little bit too high and it looks like you're trying to box or do kung fu with someone. So keeping it kind of down around your waist, visible, palms open so that if you need to be quick to be able to deflect anything or move out of the way, they're there, but similarly responsive and down. Your face, as much as possible, demonstrate that calmness, trying to show that you are both calm and relaxed in this moment without being impassive or too cold. You also want to be responsive. They're telling you something about their life that is sad, angry, whatever. You want to sort of show that we're listening with some of those minimal sort of facial expressions that show that we're there. We're trying to attune with them, even if they're in a real escalated state of crisis. As much as possible, you want to lower your profile, and so what I mean by that is, especially if you're someone who may be taller or larger than the person in crisis, making sure that you're kind of lowering the whole profile of your body by sitting down, if you can, with enough distance that can be safe. I always like to kind of lean against a wall enough where I can still move if I need, if the distance becomes too narrow, but showing again, I'm not kind of standing up and sort of bucking up against you, but trying to sort of lower the profile of the space that I'm taking up in the room can ensure that we're not going to accidentally kind of create any counteraggression by any moves that we make, and that all is about kind of putting it all together, is that our body language is going to say way more in the situation than whatever words that we're going to choose to use, but eventually we're going to say something, and so we want to train ourselves when we're in those crisis situations to, before we start speaking, to do that self-check, to make that space and be aware and pay attention to your body first. That stuff that is not going to come natural, we're going to be cognizant about doing that first, but eventually you're going to want to say something, and that's what we're going to use to try to engage the person, and this is where the active listening skills that we talked about in the first part are really going to come into play. Throughout all, use of silence is still very, very important. We want to create that space. It's an active thing. We want to give them the space to try to kind of vent out and talk their feelings, but at the same time, you know, using our other skills to kind of draw them into that space. You want to make the space by using silence, but really using these reflective responses and empathic statements. The, you know, I can see you're really angry. I know that's really hard. You must be scared. Using these reflective responses and empathic statements help to validate the other person's experience because it shows you're listening, but it also helps them name the feelings, and that's why we talk about naming feelings, tames feelings. When someone's in crisis, they experience their feelings as sensations, not as words, and the sensations flood the body. They're part of that survival brain, activating fight, flight, freeze responses, and so if you can name the feelings by using those reflective responses, that actually helps them gain a little bit of the core control of them, activates the thinking part of the brain, and can be a really important part of them trying to sort of calm down, so you naming those feelings helps the person in crisis tame them. Use their name, if you know it, as much as possible, attempts to connect, so when you're saying, hey, why don't we step out right now and go talk about this, you know, preface that with, hey, Mark, I know you're really angry right now. Why don't we go talk about this? As much as possible, you saying the name kind of brings them back into the present and demonstrates an attempt to connect that's really impactful. On top of that, if you have a relationship, remind them of that. We've got through this before. I know we can do this. I really care about you. These little things you throw out when the person is on the cusp of violence can help just dampen and minimize and provide emotional support in ways that can kind of keep it from tipping fully over the way, and then all throughout everything you say, making sure that we're speaking low in volume and slow in speed. That is going to do two things. It's going to help keep you calm, which is really important, and it's going to be helpful to call them. Ideally, they'll might mirror that. They'll need to sort of pause and be able to hear you, and so just going and continuing to speak lowly and slowly with whatever we're saying is real key, and then in the end, you want to offer a way out. We're giving our reflective responses. We're validating what they're saying. We're speaking low and slow, giving that silence, but we also want to suggest something that they can do that will help them calm down, so some typical ones is like, hey, let's take a deep breath. Let's go take a walk and talk about this. Let's have a seat. Let's put down the chair. Whatever you think is a way out to be able to engage them and talk about it further is really key, and one thing I like to think about this is that you're not going to ever tell a person who is upset or in crisis to calm down, because remember, they're in crisis because they can't calm down. Something happened, and they're unable to handle, and so when you're offering a way out, you're giving them a suggestion of some things that would calm them down a little bit without having to say, hey, calm down, because that's going to blow back in their face. All throughout, you don't want to make promises you can't keep. You want to try not to bargain. You're not going to be problem-solving when the person's on the cusp of violence, but you want to encourage them, hey, I can find some solution. You figure something out without jumping to I'm going to do this or that, especially if it's something that we don't want to do or that we want to reinforce, kind of using crisis behavior to just kind of get things, and all throughout, I think your watch words are validate, validate, validate. Validate their experience, how difficult it is, and naming those feelings. Remember, them being unable to handle the feelings, the stressful situations, or the trauma reminders are why we're seeing the crisis behavior. Validate that as much as possible. Provide the emotional support to allow them to kind of use your calmness to be able to allow them to calm themselves down. So we're now going to watch a little video of Mark and I doing a demonstration of doing a little bit of crisis de-escalation. And so in the video, pay attention, because we're going to ask some questions afterwards about what I did and how you know that I was kind of using the SMART-E technique, what looks like it worked well. Also, because I'm speaking quite low, make sure you turn your volume up. Mark will be quite loud because he'll be role playing the person in crisis. But make sure you turn the volume up and really pay attention to what I'm saying, even though I'm really trying to speak quite lowly, lowly and slowly. And last, I think Mark might use a little bit of adult language, not too bad, you know, to keep this thing PG-13. So there's that, there's that disclaimer. And so Mark, why don't you roll the video and folks pay attention to what we do and how we do it. Okay, here we go. Mark, I can see you're really angry right now. Feeling pretty overwhelmed? I know it's really hard. Hmm. I'm going to kick your ass. I'm done. I'm done. So done. Man, I know what to do. I know exactly what to do. I'm going to kick your ass. I'm so done at this point. It's total bullshit. This whole thing. All of it. You're fed up? Totally fed up. Completely. It's all bullshit. Mark, I can tell you're not really knowing what to do and you're feeling a little pissed off. Do you want to try to sit down and just tell me what's going on so I can hear you better? No, man. Like, I, like, I am so, I'm so full of it right now. I'm so done. I've so had it. Seems like nothing's working. You have no idea, man. Every time this goes on. Every time with her. Every. Damn. Time. And you don't know what to do. Mark, I know this is really overwhelming. Maybe I can help you find some kind of solution. Man, I don't know. Nobody's able to help. Looks like no one's got your back. It's going to be a scary feeling. What? Just sit down and tell me what's going on. I want to be able to hear you. Man, seriously? I, I, like, I'm so done. I'm so done with her. I'm so done with all of it. You have no idea. So start from the beginning. All right. The Academy Award goes to Mr. Brian Bean. Very impressive. So let's go into your question box and throw a couple things in there in regards to these few questions. What did you see in that video? How did Brian make space and stay aware? How do you respond to the individual in crisis? And what about what seemed effective? And, of course, the other things are what about it maybe didn't seem effective that you would have liked to see differently. So. In terms of what we're trying to do here is be able to demonstrate a little bit of how this stuff goes on. Right. And the crisis takes place in many different forms and in many different ways. And so I'm seeing a couple of things in here about him trying to keep some distance. Right. And that you and that moving the chair over for safety. And so at the beginning, you would see him kind of moving the chair over. And part of it was just so he had space to be able to move around. Part of it also was in order to just kind of demonstrate some level of safety and what was going on. Kept his calm voice. His voice was low. It was calming to the point where, you know, it makes it a little bit hard to hear sometimes. But when you're there live, it definitely can make a big difference because you're almost forced to bring your own voice down when you are a person in crisis at the time. So you seated. It went down to a lower place. Wasn't asking why he wasn't trying to get details on this. And that's an important point that he wasn't trying to get there. He didn't want to find out information till I was ready to sort of sit down. And you notice that he didn't completely sit right. That he was sort of on the arm of the chair that he was nimble to the point where he could move and get up if he needed to. And so there's a lot of validation that went on at that time. I felt completely taken care of. He's really great. Kept his distance. He was also sort of maneuvering. You could see that like he was giving me angles. But he also was making sure that he like kind of moved closer and further away as maybe I was getting a little bit more, you know, getting a little bit more aggressive at that time. The key was that he also eventually asked me to sit. Right. And so you kind of know when we're moving past this because we're in a position where he was having me sit at that point. And that's where you know that you sort of have that person in crisis at a place to be able to work with them. We'll get into that in just a second too on how to deal with that. Brian, do you want to say a word about touch? There's a lot of thought about, you know, do we give an encouraging touch to somebody in crisis if you have a relationship with them? Yeah, I think, you know, touch can be a real positive element of an emotional support when the person is in those lower levels of crisis, when we're just kind of like steaming before we're at to the point in which we have the yelling and the threatening and all that. And so I think even if hypothetically, I had a good relationship with Mark in the video, you know, at the level of arousal that he was at where he was throwing a chair, I think the element of touch can be actually quite provocative and could trigger some sort of counteraggression. So I think that, you know, some sympathetic touch when the person is just triggered and in that sort of lower levels of crisis can be really effective. I think we're gonna be really careful and avoid using touch when we're on the cusp of violence in that fuming interruption stage. What you weren't able to see in the video quite as well is Brian sort of maneuvering toward an exit, right? That like behind him was where one of those exits were. So as he came closer to where I was in that demonstration, you know, he was getting a little bit further from where his exits would be. And so as I got a little bit more aggressive and was throwing things, he would move a little bit further back there. So there's a little bit of that back and forth that goes on too. Eventually to the point where he was relaxing his body, that had an effect on me relaxing my body too. So we know that we are kind of in that cooling phase, which is, you know, when the person in crisis, you can see it in their body start to get to more of a calming, less agitated posture. You're also gonna see that you've successfully got that person to kind of connect with you and be able to talk with you. So in this instance, I asked, or Brian had asked me to sit down and I did that. Sometimes it might be come take a walk with me or let's go outside for a little bit or whatever that thing might be. And once that person in crisis is willing to do that, you know that they're taking a step toward their thinking brain activity. They're sort of responding in a way where there may be able to connect back on up. And so we know that the cooling phase is not automatically you're back to dormant, right? That's why cooling is its own phase. And it doesn't just go straight from fuming or eruption to dormant. Cooling is a progression. It takes time and you sort of are going there in steps. And so even though you aren't all the way to dormant, this still is the right time to be able to continue to decrease that emotional intensity. And it's also really an opportunity to promote learning. You can learn a little bit about what happened in that situation. So you know how to then help that person in crisis a little bit more in this situation. The person in crisis is learning then also how to manage their high level emotions perhaps differently when this goes on another time. So just talking a little bit more detail about it, we want to attune our active listening skills and that this of course is essential as we get into it. So the cooling off process really is around moving that conversation first to a less stimulating location if possible. And so if there was a big sort of fuming or eruption that took place, want to be able to move that to a less stimulating location if possible. On top of that then, you want to kind of put on your journalist hat. So Brian's next stage in the video would have been him putting on a journalist hat. And I'm a journalist major before I went into psychology. And the idea around here is how do you get that full story out? What happened at the beginning? What caused the situation to start? Then what was the big emotion that really kind of triggered the next thing to happen? Then what led all the way up to me kind of stepping in as the helper in this situation as well? We want to validate that all the way through. The biggest piece is how can we get to that underlying emotion? Clearly the person in crisis is angry or pissed off or mad, but what's underneath that? Remember at first when we talked about those feelings of disappointment, jealousy, all those things that really kind of go on underneath. And so can we get to that big emotion? And if we can, can we link how that big emotion is what really caused a lot more of that fuming to take place in that situation? Then we can finally move into coping strategies. And coping strategies aren't what are you going to do now in this situation? Or what would you do next time you blow up? It's really all about like, what can you do next time you feel disappointed or you feel let down, or you feel jealous about something? How can you do something different with that big emotion? That's what we want to really try to get into here. And as we're talking about that and hopefully building some coping skills, then we want to repair that relationship. We want to connect with them and talk about being on their side and how can we help them with that next step, which really leads to what are we doing now? And sometimes that next step may be repairing the relationship with somebody they're in crisis with. Maybe the next step is to clean up some destruction that had taken place as a result. Maybe the next step is going to the hospital because they continue to be in psychiatric crisis. So agreeing on what those next steps are in a position at this point during cooling. And so here are a couple of tips to be able to kind of use as you're sort of moving out of that crisis phase. All right. So Brian, I'm going to throw it back over to you. Sounds good. So to sum up what we've talked about today, in these moments where you have the high intense crisis situations, where you have the verbal aggression, the fuming up to the eruption of out and out violence, I think we wanted to talk about how the potential danger and a common one is power struggles. So catching yourself when you fall into one, being able to have that self-awareness and realize, hey, I'm in a power struggle, I've got these feelings and thoughts and using a strategy to get out of it is one of the most key things you can do to make sure that you don't feed into and fuel and needlessly escalate a situation that is becoming dangerous. So that's the first bit. The second is at those moments of behavioral eruption, where we're kind of from the point where there's, aggression to out and out violence, we want to talk about how using that smarty can be helpful to keep yourself calm and knowing that us keeping ourselves calm is one of the most important things we can do to calm the situation and to engage the person in crisis. And that smarties, of course, that self-check, that quick scanning of yourself, the person, the environment, deep breath, positive self-talk to make space and be aware and make sure we step back, mindful of the environment, how our body language is communicating and doing what it's doing in the situation. And then lastly, using those phrases to be able to respond to the individual with silence being important, using those reflective responses, those empathic statements, using the name to connect, being encouraging, and then trying to encourage a way out for them to talk further and engage with you more. And then you can go on to the last piece we talked about today, which is you get that engagement. They do that one thing that makes you realize, okay, I can start actually talking about the situation. We use that cooling off period to engage more, to help the person return to their sort of normal dormant functioning. And hopefully you and them can learn something about the situation, about how they can cope better with the feelings, the stressful situations, and the trauma reminders that provoke the crisis in the first place. So hopefully that's helpful. And I'll turn it over to Jose for some questions. We also dropped our emails in there too if folks want to email us any questions or consulting or anything like that. Turn to you Jose. Thank you so much guys for such an interesting and practical presentation. Like always, I love the energy, the humor, the creativity. Before we shift to questions and answers, I want to take a quick moment and let everyone know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit your questions directly to our team of SMI experts. Download the app now at smiadvisor.org forward slash app. Okay, so we have a whole bunch of interesting questions in the chat. The first question I'm going to field is causing the power struggle. Someone said, what are phrases that I can say to the person in crisis to get out of the power struggle? Hmm. I mean, I think that some phrases that are helpful is if you catch that you're in the power struggle, I think naming and acknowledging that can be real impactful. Like to be like, okay, sorry, I started on this wrong. Let's take a step back. Like kind of acknowledging that you kind of got into it can clear the way to talk about it more. And so I think that that's a really important thing too. Like apologizing when you note, hey, I'm in the power struggle. You've taken your deep breath and you sort of backed away is a real good way to do it. I think other statements that you can use, like we mentioned before, I think as much as possible appealing to the self-interest of the person in crisis is real important. Like, hey, if we can do this, I know that you'll be able to achieve this thing that you want. If we can sit down and figure something out, we can probably get through this in a calm way or something like that. And then similarly, I think as far as same as you can say, leaning back on those reflective and empathic statements are real important. Like if you don't know what to say, reflect back an emotion, you know, I know you're feeling really back to your corner right now. I can tell you're just completely angry. You're feeling hopeless. I think those are real important things you can say that avoid you kind of falling for those hooks and like arguing and going back and forth. And so I would say, you know, apologize and acknowledge if you've been in the power struggle. I think appealing to the self-interest as much as possible and then really leaning into those reflective responses and empathic responses are real important things you can do to get out of it. It sounds like you have to be specific and keep it nice and short for the person in crisis to understand you. Thank you, Brian, for that answer. So I have a follow-up question to that. Someone's asking, if I gave a person an ultimatum because I was scared, do you suggest changing that expectation? Yeah, and I can take that. And very similar to what Brian is saying, there's lots of times that that goes on. I mean, in my own family, I can think about times where I said to my daughter, if you don't do this, you can't go out with your friends later. So it definitely happens. And what we need to know about anytime we're in a power struggle like that, there's always the opportunity to pull the escape hat for you to be able to say, all right, I'm sorry about that. I'm overreacting a little bit. You're really stressed right now. I'm really stressed right now. Let's see if we can figure something out. Always okay to be able to do that. I think the one thing that you wanna keep in mind is about what your expectations are. If there's something going on where you do have an expectation, you have to decide, are you willing to let go of that expectation and reduce the crisis level right now, but knowing that you're still gonna get back to talking about that. You still will get back to talking about that in a cooling phase at some point. So, changing the expectation will come up, but knowing that you don't wanna completely let it go, because then you're reinforcing that there are heightened escalation will result in you backing down. Instead, you wanna be able to pull that escape hatch and then know that you're gonna get back to talking about other ways to manage. Thank you, Mark. So, I remember a few years back, I was working in a residential setting and I remember seeing a peer completely engaged in a power struggle. And I remember telling him, hey, you have a call from our supervisor in efforts of helping him realize that he was in the power struggle. His response to me was like, don't worry about it. Tell him to leave a message and I'll get back to them. So, the question for you both is this, how do you help a peer become aware that he or she are in a power struggle in the midst of it? Yeah, I think that the thing that I most commonly do is just trying to figure out some way to have your peer to step away and kind of regain their composure. You don't want them to like lose face with whoever you're dealing with and be like, hey, you're in a power struggle, get out of here. But everything from like, hey, go take a break for a second or I'll handle this. Or even saying, you got a call in the office. Like if you kind of make something up to be able to kind of get them to break out of that tug and more back and forth, I think that's a fine thing to do. So, anything you can do to get them just like tap out for a second and get out of the situation allows them to kind of have that space that ideally they can recognize more so. With that said, I think if you find that you have a peer who's in it, if you need to say, hey, step away for a second, I'll handle this. It seems like you're kind of angry right now. That's what you have to say to diffuse the situation and make sure it doesn't erupt into violence. That's what you gotta do. And I've had to do that in the past for sure. Yeah, and to build on that as well, ideally that would be one way to go. And even further ideally is that you and your teammates are talking ahead of time and could potentially even have a safe word, have some sort of word or some sort of a look or some sort of tap that the other person knows that they're gonna step in and that you have a level of respect across your peers that like if somebody else is stepping in that you can manage to step out because a lot of times we have a hard time stepping out when somebody's trying to step in for us. So, it's a level of respect that goes a little bit deeper than just in the moment. And then also sometimes some planning ahead of time how you would manage that. Of course, that doesn't always happen. And so you might be working with somebody new or somebody that you don't have as much of a connection for. And so Brian's tips are really right on for some of that. Thank you, Mark and Brian for that response. I have another question here. If you identify the need or want with the person in crisis, do you share that with them in the moment? Yes, definitely. I think that's like a well-used reflective response is you trying to kind of guess what those needs and feelings that are undergirding or cause the crisis are. And so if you can reflect that back to them, that can give them more illumination of what's going on. So I think if you can say, hey, I know you're real pissed that you missed the bus or I know that you really want your SSI check or whatever it is, if you can sort of reflect that back, I think that allows for a level of insight. And really like you allowing them to drain off the emotions is based on three things. Like you naming the feeling of the need, you validating the feeling of the need and you normalizing the feeling of the need. So if you're able to sort of reflect that back to them, what is really going on and it's for real, then you're focusing on the cause, you're focusing on the trigger. And that's gonna change, I think, the dynamic of the crisis de-escalation radically. So I would totally do that. Thank you, Brian. So we have time for one more question. During the journalism stage, how do you help the person connect their feelings that they're experiencing during the crisis with their actions? Yeah, great question. I can take that one. And so, it kind of reflects back a little bit to what Brian was just talking about that. Sometimes you are doing some of those reflective responses where it's like, so it sounds like when you were throwing the chair, that's especially when you felt insulted by me or whatever that might be. And you're gonna have the other person respond and they may say yes or no, or F you or something else like that. The idea is that like you might be taking some educated guesses at it. And the person you're working with may not be able to access that deeper feeling that's going on. But by you naming it, it gives them the opportunity to talk those things out rather than act those things out a little bit more. Even if it's not for the time right now in crisis, maybe down the road to be able to consider that that's really what was going on that was different this time when they were angry. And so being able to do some of that can really be helpful in those situations. And I think another thing is if you have a relationship with that person that's in crisis, sometimes don't forget that usually you're in the cooling phase here and they're a lot more likely to access their thinking part of the brain. So they can think a little bit more about what you're saying. And if you have a relationship where you're able to help sort of demonstrate a little bit of a pattern where it's like, so I've noticed from time to time that when you are disappointed by something, that's especially when you rage out. And I've seen it here and I've seen it a couple other times. Have you noticed that before? And so I think that's a way to really kind of get at that because then you can go into, okay, so I think maybe we can talk a little bit about what might be a couple strategies that you can use next time you feel disappointed by something. Can I add something to that? Yeah, I think your tone when you're being a journalist is that you wanna kind of facilitate them telling you what's going on. And you wanna see it as a process of kind of self discovery you're engaging in with them. And so you can kind of adopt a kind of fake naivete about like, oh, so you were feeling embarrassed or betrayed as a way to kind of test the waters and have them confirm that. And so in the example of the video that Mark and I showed you, if I was doing the cooling off with Mark, as soon as he sits down, he's engaged, I'm gonna say, okay, tell me how it's going on. He would tell me some kind of backstory about whatever conflict he had with this person that provoked the thing. And after we've explored that all the way through, then I might say something like, okay, so when you were feeling like betrayed by your friend, then you threw things. And so that's how you're gonna kind of like piece it together after you get kind of all the information that the person in crisis is able to tell you. All right. Yeah, that's really powerful because the person is understanding the emotion and can transfer it over to other settings, which will help them actually digest it. Okay, so I'm gonna move on here. Do you have any final comment, Brian? No. No, okay. So if anyone has any follow-up questions about this or any topic related to evidence-based care for SMI or clinical experts are now available for online consultation. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and completely confidential. SMI Advice is just one of many SAMHSA initiatives that are designated to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Centers. These initiatives cover a broad range of topics, from school-based mental health to the opioid epidemic. To claim credit for participating in today's webinar, you will need to have met the required attendance thresholds for your profession. Verification of attendance may take up to five minutes. You will then be able to select Next to advance and complete the program evaluation before claiming your credit. And last but not least, please join us next week on February 25th of 2022 as Dr. Michelle Sawyers joins us in presenting Evidence-Based Strategies for Addressing Burnout and Enhancing Well-Being for Mental Health Providers. Again, this free webinar will be February 25th, 2022, from 12 to 1 p.m. Eastern Standard Time. Thank you all for joining us today, and until next time, take care.

Engage or Enrage? The Escalation Strategies for Mental Health Crisis

de-escalation tactics

power struggles

active listening

body language

SMARTY acronym

non-verbal communication

crisis de-escalation techniques

Q&A session

supportive environment