Once an escalation happens, how do we de-escalate? Let's discuss.
The patient is angry and yelling. What do I do?
The one thing you don't do, ever, is get angry and yell back at the patient. Never raise your voice. Never match their intensity.
A sure sign of an unprofessional counselor is one who is unable to de-center themselves during live conflict. A professional counselor should always remember that unless you've said something deliberately disrespectful to the patient (and you should never do that either), the escalation is likely happening because the patient misunderstood what was said, or misinterpreted the circumstances. When this happens, it's time to go into de-escalation mode.
Using JADE
In addition to my experience in healthcare, I spent a lot of time in business in customer service roles as a rep, an analyst, a supervisor, a manager, and an owner. I dealt with A LOT of angry customers. I learned that if you've been respectful and professional with a customer or patient, and they become angry, it's usually because they're angry at the situation that they perceive as unfavorable for them. They're usually not angry with you, you're just in their immediate line of fire.
During these times, JADE can be a very effective approach. JADE is an acronym to remind us to never:
Justify
Argue
Defend or
Explain during an escalation.
Using this approach prevents the counselor from entering an emotional back and forth with the patient, as that will only fuel the outburst.
Using Emotional Neutrality
The use of emotional neutrality is a technique in which the counselor removes all emotional content from their voice, verbal expressions, facial expressions, gestures, and posture. Further, when using this technique the counselor keeps their responses exceptionally short, calm, and objective. This approach starves the interaction of the emotional conflict the patient may be seeking.
While this method can be effective, be aware that if the patient has reached a point of physical threats, it can actually exacerbate their anger. So make sure you're paying close attention to what the patient is saying. If it reaches a level where threats of violence have been made by the patient, it's time to alert security (hopefully your desk is equipped with an alert button) and/or quickly leave the room and find a safe place to call for help.
Being Understanding
Remember, you're not angry with the patient. You care about your patient, and all you want to do is help them return to a calm state so you can treat them. You don't have to internally agree with the reason that the patient is angry. You only need to understand that the patient has the right to their emotion. Rather than arguing, using just a simple phrase such as "I understand" can really help. It shows an effort to communicate understanding of the patient's right to feel the way they do.
Setting Boundaries
An escalation can reach a point where the patient is just belligerent. In these situations, a patient could be both cursing and yelling. As a counselor, this isn't a time to flex an authoritative tone. Instead, the phrasing you use needs to be directed toward assistance in a non-threatening manner. Here is a sentence I've used with great results while speaking in a calm voice with a normal volume:
"I want to help you, but I need you to speak to me without cursing or yelling so we can fix this together."
This accomplishes several things. It shows the patient that you're interested in helping them find a solution. It identifies what the patient is doing (cursing or yelling) that is preventing you from helping them. Using the term "together" shows the patient that you have a share in the matter, and that you have a mutual interest in resolving it.
Using Silence
One old friend of mine was an avid reader of the Tao Te Ching. He often talked about the importance of understanding the power of acting without acting, and how action and inaction have a symbiotic relationship. In a nutshell, while it's important to act in certain situations, sometimes by doing nothing you act by allowing things to unfold naturally. Using silence is an example of this.
One important purpose of using silence during an escalation with a patient is to allow space for the emotional intensity in the room to decrease. It also allows space for the patient to recognize that there is a lack of conflict coming from your side. It is the ultimate display of "action in inaction." Used with proper timing, you'll often see its positive effect on the patient's volume and tone.
As healthcare professionals, we have to remember that de-escalation begins with us. When we remain calm, respectful, and professional during moments of conflict, we are modeling that behavior for our patients. By doing so, we create the conditions that allow our patients to do the same.
The Next Session
Your ultimate goal is to help the patient abstain from the use of harmful substances. The escalation that took place in the prior session has passed. It's over.
In a new session, don't refer to the escalation directly or indirectly unless it's clinically necessary. Stay away from any words or phrases that you believe may have been the antecedent to the escalation in the prior session. If the patient brings up or apologizes for their past behavior, treat it all as water under the bridge. Thank the patient for being open with you, and move onward and upward with your patient toward their goal of abstinence.
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In a future piece, we'll discuss dealing with escalations when multiple patients are involved. In another, we'll discuss de-escalation when patients are dealing with mental health issues or a mental health crisis.