“View from Mt Eliza”
Frederick Garling 1827
I would like to acknowledge the traditional Aboriginal and Torres-Strait Islander custodians of the lands and seas on which we work, the first people of this country. I pay my respect to them, their culture, and their Elders past, present and future.
Paul Dessauer Outreach Coordinator This presentation remains the intellectual property of Peer Based Harm Reduction WA. Content should not be used without permission.
OBJECTIVE: To develop participants’ attitudes, knowledge and practical skills in anticipating, preventing, and managing aggression and other challenging behaviour.
Theories of aggression. Risk; (awareness, assessment and management of risk).
Preventative measures; (behavioural and environmental).
De-escalation skills; (verbal and non-verbal).
Worst case scenario; (protective strategies and response to violent incidents).
This training may not increase your confidence
The relationship between knowledge, skill, and confidence doesn’t look like this…
…it looks like this;
Dealing with difficult or challenging behaviour; Prevention and Management of Aggression.
Any employer has a responsibility to;
Provide a safe workplace for employees, clients and visitors.
Develop policies and procedures designed to minimise the risk of aggression and violence in the workplace, and to provide suitable training for all relevant staff members in implementing these.
Ensure systems are in place to anticipate, identify, report and manage any risks.
Provide adequate guidance and support to staff at all levels of the agency. Any employee has a responsibility to;
Follow legal direction from employers. Be familiar with, and follow all policies and procedures.
Report all risks detected and any critical incidents, as per policy.
Take reasonable care to protect themselves and others, be aware of potential risks, and implement appropriate strategies to manage them.
What is “Reasonable Force” in self defense? Under WA law a person who has reason to believe they are threatened with physical assault may use “reasonable” force to protect themselves or others. Reasonable force is; Minimal (no more than necessary).
In proportion to the level of harm that is threatened. Open and accountable. To be defensible in a Court of Law, any use of force must be considered by a Magistrate to be; Legal, Proportionate, Accountable, and
Necessary to protect life and limb.
Violence and Aggression are different things; What is the difference?
The keys to avoiding confrontation are to be aware, to anticipate what might happen, respond appropriately to emerging threats, and adapt promptly to changes. Be aware of yourself and don’t respond emotionally to aggression.
“The most excellent General in the World is not the man who fights a thousand battles and wins a thousand battles… …the most excellent General in the World is the one who never fights any battles at all.” -Sun Tzu
The Stress Vulnerability Model as a tool for understanding mental illness and aggressive behaviour.
The Stress Vulnerability Model as a tool for understanding mental illness and aggressive behaviour.
There are an escalating series of psychological and physiological responses to environmental stressors.
Stress changes brain function. The neurochemical substrate of fear and aggression are both closely related.
Stress arousal responses – ‘Condition White’ to ‘Condition Black’…
Condition white = off guard, unaware. Slow response to the unexpected. Subject to “Normalcy bias” which may prevent recognition of a potential crisis. Vulnerable to ‘freezing’ in an unexpected emergency.
Condition yellow = relaxed but alert. Monitoring and actively aware of what is going on around you.
Condition orange = aware of a possible crisis developing. Pulse increases, stress level begins to increase. This is the time to recognise what is occurring and consciously formulate ‘action plans’.
Condition red = performance-improving stress. Adrenaline levels increasing. Complex motor skills, visual reaction times, and cognitive reaction times are at their peak. Fine motor skills degrade.
Condition grey = performance-degrading stress. Cognitive flexibility and complex motor skills suffer. Tunnel vision and loss of depth perception are common, and auditory exclusion may occur. Time-dilation effects, but also failure to recall significant details after the event, are not uncommon.
Condition black = catastrophic breakdown of physical and mental performance. Freeze response. Stress-related cardiac events.
The “OODA Loop”, (complex version). Situational awareness, and responding effectively to crises.
The “OODA Loop”, (simple version) Situational awareness, and responding effectively to crises. Emergencies typically involve rapidly changing situations. If you are not observant you will not be oriented to the emerging crisis, and unable to act appropriately or in time…
When a confrontation escalates to an assault it typically happens very quickly. If the aggressor is already acting, you have no time to observe, orient or decide. You will be ‘stuck in the OODA loop.’
If you are observant, and oriented to the situation as it unfolds, you can respond more effectively to any crisis. OBSERVE; • Remain in “Condition yellow”; (be aware and actively engaged with your environment). • Position yourself optimally.
• Practice situational awareness in every day life. “We don't rise to the level of our expectations, we fall to the level of our training” Archilocus 680 – 645 BC
ORIENT; • Establish “Baseline(s)” in any environment; (what is normal or expected mood, activity, manners, behaviours in this setting?)
• Identify Anomalies; (what causes someone or something to stand out in this setting?)
Have a plan based on what you observe
The “OODA Loop”, situational awareness, and responding effectively to crises. ORIENT; We use three Clusters of body language/kinesics to identify anomalies. • Dominant behaviour
versus
Submissive behaviour
violent ← aggressive ← posturing ← grandiose ← arrogant ← [confidently assertive] → calming → quiet → submissive → insecure → fearful → frozen
• Comfortable behaviour
versus
Uncomfortable behaviour
unresponsive ← sedated ← napping ← oblivious ← too relaxed ← [ calm but alert ] → fidgeting → nervous → agitated → emotionally upset → hysterical
• Interested behaviour
versus
Uninterested behaviour
delusional ← hyper-vigilant ← elevated/aroused ← excited ← [ alert and aware ]→ nonchalant → bored → distracted → daydreaming → oblivious
Monitor where others are positioned on these scales, but also be aware of where you are positioned on these scales. Aim to remain close to centre. You need to recognise when you are sliding away from centre. Controlling your own behaviour is essential in responding appropriately to the behaviour of others.
The “OODA Loop”, situational awareness, and responding effectively to crises. ORIENT; Practice maintaining awareness of self and others under stress.
• Remember the “Stress Arousal Response Scale”, (condition white to condition black). This can be used as a tool to improve your awareness. • Monitor where people you are interacting with (and any bystanders) are positioned on this scale and notice any changes. This will inform your behaviour and your response to the behaviour of others. Most people spend most of their time in ‘condition white’. Notice the people who are also in condition yellow; they are potentially allies or threats in an emergency. • Practice being aware of your own position on this scale. Remain in condition yellow. Don’t drift into condition white. Recognise when your own stress arousal levels are escalating to orange and beyond.
The “OODA Loop”, situational awareness, and responding effectively to crises. You need to practice observation and orientation (being aware) all the time. “ We don't rise to the level of our expectations, we fall to the level of our training ”
Be aware and actively observe what is around you while ‘acting normal’. You don’t have to look like a sticky beak to be observant. You do need to practice. Make a game of it in day-to-day life. Form an internal map of exits and entry points; line of sight and fields of view; any objects and potential weapons or hazards; and the other people in your environment.
If you consciously observe the people around you and consistently engage in active orientation in ‘normal’ activities, it will become will become something you do automatically.
Why do we have Fire Drills? If you are already ORIENTED when an emergency arises, decisions are easier. Good policies and procedures for dealing with crises that might occur in your work form the basis of ‘action plans’. Many decisions can be made before you need to act. Formulate simple action plans based on what you are observing; “What will I do if ‘x’ occurs now?”
When formulating action plans, aim for a ‘decision twig’ not a ‘decision tree’ Action plans should be short and simple. “If this, then that”, and “either/or” options
In a crisis, too many options will leave you paralysed in the ‘OODA Loop’
Any behaviour is a response to perceived stimuli. However, how any one person perceives and interprets any particular stimuli is a “black box” STIMULI something happens…
↓ PERCEPTION someone notices it…
↓ COGNITION they think something about it…
↓ RESPONSE they react to what they think is happening…
↓ NEW STIMULI how they behave changes what is happening…
You are not ‘seeing’ the world; what we think is happening…
You are not ‘seeing’ the world; what is actually happening… Light striking the retina causes a chemical signal which in turn sends an electrical signal via the optic nerve to the thalamus, and then on to the visual cortex (at the back of your brain). Information from this signal is sent via two different pathways (‘where’ and ‘what’) to the prefrontal cortex and other executive functioning areas of the brain.
This takes ~100 milliseconds (1/10 of a second). 90% of information transmitted from the retina follows the pathway via the visual cortex. The remaining 10% goes straight to the superior colliculus, bypassing the ‘higher’ brain functions. Responsible for following and orienting on objects, blind sight, startle response, etc.
~10 million bits of information per second are transmitted from the retina to the brain. Of this information, only ~40 bits per second actually register in your consciousness. 9/10s of the information you base your view upon is internally generated.
For every neural pathway that carries visual information ‘up’ to the cortex, there are nine which carry information ‘down’ to the thalamus. This ‘top-down’ information sorts, interprets, limits and filters data from the retina BEFORE it even reaches the visual cortex. Your previous experiences and expectations, a multitude of cues and images that are processed pre-consciously, your level of stress-arousal and your emotional or visceral responses colour all of your perceptions.
Your perceptions and memories are internally generated interpretations of what your senses tell you, not recordings of objective reality.
There are at least three sides to any story; your perception, the other person’s perception, and objective reality.
If someone is suffering a brain injury or infection, or is intoxicated, in withdrawal, sleep-deprived, anxious, frightened, angry, or delusional, then how they perceive what is happening, and what they think it means, may be very different to your perception of the situation. STIMULI something happens…
↓ PERCEPTION someone notices it…
↓ COGNITION they think something about it…
↓ RESPONSE they react to what they think is happening…
↓ NEW STIMULI how they behave changes what is happening…
This is the most important thing you can ever learn about any kind of confrontation… You can never control another person’s behaviour. The only thing you can ever truly control is how you anticipate or respond to that behaviour. But when you learn to respond effectively, you begin to redirect the other person’s behaviour. The more skilled you can become at anticipating another person’s behaviour the easier it is to avoid trouble before it starts. But most importantly, the more skilled you are at controlling your own responses to an aggressive person’s behaviour, the more confident and effective you will be at avoiding, redirecting and diffusing that aggression. This type of awareness (of others and of yourself) is the essence of deescalation skills.
Warning Signs; violence rarely erupts without warning. Awareness, and early recognition of behaviour that “telegraphs” increasing risk, are key to anticipating and preventing a serious incident before it even arises. Changes in speech- becoming more rapid, loud, disrespectful, and repetitive. Increased muscle tension- clenching fists, arm muscles tensing, gritting teeth. Widened eyes, nostrils flaring, red face. Motor agitation- pacing, rocking, tremors. Self report of angry or violent feelings. Violence to property, “acting out”. Verbal threats or physical gestures. Invading personal space, eyeballing.
What is the “Assault Cycle” ?
The “Assault Cycle” describes the pattern of escalation and resolution typical of most violent episodes.
The “Assault Cycle” describes the pattern of escalation and resolution typical of most violent episodes.
What is “de-escalation”?
De-escalation strategies are designed to interrupt the “Assault Cycle” before the crisis phase is reached.
Preventative Measures involve designing and controlling both the physical environment and the behaviour of your staff to minimise the risk of a serious incident arising.
Protective Strategies involve verbal and non-verbal techniques that are used to de-escalate a threatening situation, and to protect your body should a violent assault occur.
De-escalation in it’s purest form involves strategies employed during a potentially dangerous situation which attempt to delay, divert or diffuse aggression in order to prevent a person harming you, themselves, or others.
Preventative Measures; Environmental.
Policies and procedures must be in place, known to staff, and followed at all times. The physical layout of the venue must be designed to limit the potential for incidents to arise, and to allow staff to assist each other or to evacuate the area easily should the need arise. Assistance and Duress alarms greatly increase safety for all staff, other clients and visitors. Assistance button;
Duress Alarm;
Specific policies and procedures are required for “outreach” or home-visit staff.
Site map showing which zones of the building consumers can access
Rear exit doors and the door to the shared toilets/corridor must be closed and locked at all times, unless in use. If you are in the rear alley to access the bins or to smoke, never walk out of line-of-sight of an unlocked door and never leave an unlocked door unattended.
When locking the door to the shared corridor/toilets, please slide the top bolt across so that others can see the door has been secured.
Preventative Measures; Environmental. When an incident does arise, you must already;
Have a plan, (but recognize quickly if it isn’t working, and be prepared to change tactic or run),
Be aware of entry and exit points, Be aware of objects that may be used as weapons, Be aware of safe distance and protective stances, Be prepared to run, to evacuate bystanders and/or to call for appropriate assistance.
Preventative Measures; Behavioural. Ensure staff are adequately trained, and all know policies and
procedures for responding to aggression and other incidents. If appropriate consider issuing duress pendant-alarms. All staff must know who to call or how to summon emergency
assistance. Any potentially dangerous incident must be reported. Critical incidents should be analysed to allow risk assessment and (if necessary) modification of policies, practices, or physical layout of the building to reduce unnecessary risks.
Best Practice involves treating all clients equitably. If staff are patient and polite, pay equal attention to all clients, are calm, reasonable and display empathy even to “annoying” clients, the risk of any incident is greatly reduced.
Preventative Measures; Behavioural.
Self awareness is key. Be aware of your tone of voice and manner at all times, and pay attention to how the person is responding to them. You are not expected to like every client you interact with. However, you ARE expected to be capable of hiding any distaste, disapproval or prejudice the person provokes in you. A professional should treat all clients consistently with the same level of care, respect and regard, not just the “likeable” or “deserving” ones.
Preventative Measures; Behavioural. The ‘Three Hs’ for defusing confrontation; Honesty
Humility Humour (but if humour is not received well, don’t persist). Avoid confrontation by ‘being on their side’ and by; Treating everyone equitably Expressing genuine care and concern
Demonstrating that you are prepared to do anything you can do to help the person. If you do this consistently the people who access your service will notice the difference.
Preventative Measures; Behavioural.
It does not necessarily require a saint’s empathy to behave in this way. You can just as easily take pride in the fact that your manner remains professional even when you disapprove of, or feel superior to, the person you are talking to, as long as you are capable of behaving empathetically in a convincing and caring way. You can learn to manipulate any situation, maneuvering to be seen as a part of the solution to the person’s problem.
Do not do it to be nice to the person- do it because it is safer for everyone involved. If you succeed they will never direct their anger at you.
Managing stress-arousal Practice breathing exercises. “ We don't rise to the level of our expectations, we fall to the level of our training ” ‘Belly-breathing’ or ‘Box Breathing’, aka ‘Tactical Breathing’, aka ‘Warrior Breathing’
Slowly inhale a deep breath for 4 seconds. Feel your belly push out as your diaphragm pushes down. Hold the breath in for 4 seconds. Slowly exhale the breath for 4 seconds. Hold the empty breath for 4 seconds. Repeat until your breathing is under control. Simple.
What’s hard is having the discipline to do this when you start feeling stressed. Controlling your breathing sends calming feedback to your nervous system. The more you practice it, the more effective this technique becomes.
Managing your own emotional responses Remember that IT’S NOT ABOUT YOU! You are probably not the reason why the behaviour is occurring The problem is almost certainly not really about you. You are just the person the frustration is being vented at. Don’t get triggered and respond emotionally. Listen to understand the issue(s) that have provoked the incident, express your concern or empathy, then work in any way you can to help resolve the actual issue.
Remember that IT IS ALL ABOUT YOU! Your behaviour can dramatically influence what will happen next. How the incident escalates or is resolved will depend heavily on how you respond to the person and their behaviour. Stay calm and maintain your self awareness. If you can control your own behaviour you can usually side-step, re-direct, or diffuse most confrontational situations.
Protective Strategies; Verbal. Be aware of your voice and talk calmly, at a normal volume, pitch and tempo.
Be succinct but be polite. Use open-ended questions, and draw out information.
Use active listening to encourage client to elaborate useful responses. Use the person’s name if you know it. Agree with the person about anything you reasonably can. Do not get caught up in anything the person says that is provocative, offensive or upsetting. Don’t mirror their aggression. Your job is not to win an argument. Your job is to make sure no-one gets hurt.
Protective Strategies; Verbal. Explain why you can’t do what they want. (If necessary, you can empathise and expediently re-direct the blame).
Offer choices or alternatives. Remain assertive and establish limits. Don’t ask “why”. Ask “what”.
Keep returning the focus to the present and resolving the immediate situation. If possible, encourage simple compliance, (such as inviting them to sit down, come outside for a cigarette, or move to a quieter room). If the person is psychotic or delusional, do not confront delusions “head on”. Sidestep, distract or redirect. Don’t be afraid to allow the aggressor to save face.
Protective Strategies; Non-verbal. Maintain appropriate eye contact. Adopt a non-threatening posture.
“The Fence” (aka “Bouncer’s stance”, aka “steady on tiger”)
Indicate genuine interest. Be aware of your facial expression; a fixed smile is as bad as a sneer.
Be confident. If you can’t, then look confident. Use silence and give the person time to talk and time to process. If possible offer drinking water. Maintain a casual defensive stance and be aware of safe distance. Try not to look frightened or angry. Be alert to subtle non-verbal clues that the situation is deteriorating.
Protective Strategies; Non-verbal. Be aware of your;
“The Fence” (aka “Bouncer’s stance”, aka “steady on tiger”)
Proxemics; (personal space) General guide is to maintain one legs length (approximately 1 metre).
Kinesics; (body posture and movement) Stand side on, not square on. Keep hands in view, allow perceived escape route. Para-verbal communication; Tone, pitch and tempo of voice may be more significant than the content of what you are saying. Pay attention to your inflection. Be alert to subtle non-verbal clues that the situation is deteriorating.
Worst Case Scenarios; Protective Strategies. When push comes to shove… Activate duress alarm. Call co-workers, police or security as appropriate. Avoid the danger zone, maintain safe distance. Escape the situation. Use any available barrier to place an object and/or distance between you and the aggressor.
Protect your body, especially head, neck, and midline.
Worst Case Scenarios; Protective Stances. “Dart” stance
“The Fence” (aka ‘Please don’t hurt me.’)
Ranbou shinaide kudasai
Always maintain safe distance. Safe distance required depends on reach (of the aggressor) and stance (both your stance and the aggressor’s).
Less safe distance is needed if there is an effective barrier between you and the person.
Be aware and don’t get cornered. Workplaces accessible by clients should always have a clear exit for staff. Be aware of where you are in relation to the aggressor, your safe exit, and other staff, clients or visitors. As long as you can move you can minimise injury until you can maneuver to escape. Getting backed into a wall or pushed to the ground will make you helpless.
Reporting critical incidents is important to reduce risk to you and your colleagues; it helps ensure you are as safe as possible in your role, and also reduces liability (for you and your employer) should legal action arise.
Critical Incident reports should be written immediately by all staff involved or witnessing the incident, while memories are fresh.
Potentially dangerous incidents that resolve well, and other ‘near misses’ should always be reported. Your line management cannot put measures in place to mitigate potential risks without someone making them aware of the potential risk.
Critical Incident reports should always be analysed to identify possible changes (for example, to the layout of the room, to policies and procedures, or to individual worker’s practices), that could reduce the risk of a reoccurrence. The object is not to find someone to “blame”, but rather to improve safety for everyone.
It is a normal consequence of being in a flight-or-flight situation to “crash” afterwards.
It is very common for people to perform calmly during a crisis, and then collapse, cry, shake uncontrollably, or get embarrassed, angry, anxious or depressed once the danger is passed.
This frequently surprises and embarrasses the person; especially if they think of themselves as being ‘good’ at dealing with crises or confrontations.
This is the aftermath of adrenaline and cortisol and the other chemicals released as part of the fight or flight response. It may occur anytime from several minutes to an hour or more after an incident. It will typically pass within 30 minutes or so as hormone and neurotransmitter levels normalise.
Do not allow someone to drive home immediately after any incident; talk to them and wait at least 30 minutes to ensure they are okay to drive.
It is normal for people who usually respond appropriately and effectively to emergencies to sometimes unexpectedly find themselves weak, shaking, overwhelmed by fear or shock, and suddenly losing all confidence in their ability to deal with an unfolding crisis.
Response to extreme stress varies greatly from person to person, but also at different times or in different situations for the same person.
Previous experience does not always protect against being overwhelmed by the fight-or-flight response. This frequently surprises and embarrasses the person; especially if they think of themselves as being ‘good’ at dealing with crises or confrontations.
It is important that people experiencing such responses are reassured that this is normal; it is simply one of the ways your body may respond to a potentially dangerous situation.
Regardless of how someone says they feel, debriefing should always be offered immediately follow an incident.
Experiencing or witnessing a violent assault or other acutely stressful incident can have long lasting psychological effects. Repeated exposure to stressful situations, and repeated exposure to ‘vicarious trauma’, can take a toll over time. It is important that front-line workers have good self-care practices and that management and senior staff provide good support to any staff who may be affected in these ways.
Your employer should have an Employee Assistance Program, (EAP), including independent, confidential counseling services available for staff. In some cases this extends to your family members who may be impacted.
Seriously stressful situations can induce long term psychological problems in perfectly healthy people. If you have been in a situation that disturbed you, and it bothers you for more than a few days, be open to the idea that talking to an experienced, confidential counselor may be beneficial and may also be better for your friends or family as well.
Relevant and Related Peer Based Harm Reduction WA Documents;
Peer Based Harm Reduction WA Critical Incidents Policy
(aka Responding to Disruptive Incidents)
Peer Based Harm Reduction WA Critical
Duress Alarm Document Peer Based Harm Reduction WA
Peer Based Harm Reduction WA Outreach
Peer Based Harm Reduction WA Managing
Peer Based Harm Reduction WA
WANADA Crisis Referral Tool
Incident Report form
Outreach Safety Policy & Procedures Risk Assessment Form
Clients with Psychosis Policy & Procedures Occupational Health and Safety policy (aka Principles of Crisis)
Peer Based Harm Reduction WA. “Peer Based Harm Reduction WA- Because sometimes, what you don’t know CAN hurt you…”
(08) 9325 8387 Paul Dessauer, Outreach Coordinator. 0418946706
[email protected] 