De-escalation in Three Steps – Taking a Medical Approach

De-escalation in Three Steps – Taking a Medical Approach
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In my book, Talking to Crazy: How to Deal with the Irrational and Impossible People in Your Life, the underlying principle in calming highly agitated people down is to quickly connect with them emotionally and lead them away from rapidly increasing impulses and destructive actions and then get them past their racing thoughts towards being able to have a rational conversation with you.

I am a medical doctor and to help make the case for the above, you’ll need to excuse me as I borrow from some medical analogies.

The first analogy is dialysis.

With dialysis, a patient’s kidneys have stopped working and is hooked up to a dialysis machine which then proceeds to detoxify his/her blood in ways that functioning kidneys otherwise would. If a patient without functioning kidneys is taken off dialysis, he/she will rapidly develop a condition called uremia which can lead to death in a matter hours to days. Thus, in the first of the three steps to de-escalation that follow, you will see how the intervention is like connecting directly to an agitated person’s toxic impulses just before they explode into destructive actions that can also lead to death.

The second analogy is a skin graft.

When someone is badly burned, a skin graft can not only prevent infection, it can serve as a foundation upon which a healing process can proceed. Without that skin graft the likelihood of infection and escalation of a diseased state – including septic shock - is greatly increased. In the second of the three steps to de-escalation that follow, you will see how the intervention steps directly into the racing thoughts that are often fueling the impulses above.

The third analogy is the reciprocal relationship between cortisol and oxytocin.

When someone is stressed and even worse, in a state of distress, their cortisol becomes highly elevated. What worsens such moments is that people feel utterly alone and fully stuck in a survival mode. On the other hand, when someone feels emotionally connected, listened to, related to and talked with, their oxytocin goes way up, they feel less alone and their cortisol – and distress – goes down.

Years ago, I remember hearing a distinction between pain and suffering. Pain, or if you will stress, is just pain. Suffering, or if you will distress, is feeling absolutely alone in pain. When someone whose suffering and in distress feels less alone, suffering and distress they can’t tolerate or live with becomes pain that they can.

The following approach referred to as “De-escalation in Three Steps” helps to first, dialyze toxic –on-the-verge-of-violence impulses; second, calm racing thoughts that are fueling those impulses and third, increase oxytocin and therefore lower cortisol. With the combination of all three, impulsivity goes down and the possibility of listening to reason goes up.

1. Dialysis

When someone is yelling or venting at you, let them vent for approximately five to ten seconds, to allow them to get some of their upset off their chest. After all, they are using words which as upsetting as they are to hear are still safer than their resorting to hostile and belligerent actions. After the five to ten seconds have passed say to them, “Whoa” “Whoa” “Whoa” Whoa.” The reason for a fourth “Whoa” is to add a little extra icing to the cake which make up the first three “Whoa’s.” People are instinctively used to hearing things in three. Adding a fourth is a way of adding an extra bit of pacification in your conversation. This should also be accompanied by raising your arms and hands to chest height, half outreached with palms facing outward as if you are an orchestra conductor directing a section to play softer. The word “Whoa” is a universal expression towards anyone to slow down and is meant to intervene between their using their words and resorting to hostile action.

2. Mental Skin Graft

If done correctly, the agitated person will hopefully be slightly disarmed and confused and may the respond with, “Huh?” Their saying “Huh?” represents their pausing in the escalation of their taking some kind of destructive action. At that point, say, “Shhh” “Shhh” “Shhh” “Shhh.” This should also be accompanied by the same hand gestures above or alternatively using your left hand by itself (and if you’re a police officer, you can have them look at your left hand, while you blade your bodies with your gun side back). A left hand alone is less confrontational and felt as more conciliatory than both hands or a right hand alone. A right hand can indicate something that can quickly turn into a fist or grabbing something to throw. The purpose of saying, “Shhh” “Shhh” “Shhh” “Shhh” is to intervene in the agitated person’s thinking. In other words, it is a way to help them quiet their mind.

3. Raising Oxytocin and lowering Cortisol

If done correctly, the agitated person will hopefully be even more disarmed and confused – but not agitated - and may again respond with, “Huh?” If this works, you have calmed down both their impulse and slowed down their racing thoughts. At that point say, “Now tell me what happened that brought you to this.” They may not immediately be ready to engage with you in a conversation and may again respond with either, “Huh?” or “What?” If they say either, respond with, “Yes, something happened that led up to this, tell me what that was.” By responding in this way, you’re validating and appealing to the reasonable person inside and that something must have occurred that triggered their becoming so angry. You’re also causing them to feel listened to and talked with, both of which increase their feeling connected and their oxytocin.

Of course, every situation needs to be taken on its own and you’ll need to use your discretion whether to try and how to use the above approach.

However, at the very least, the three steps may offer an additional tool in your toolkit when attempting to de-escalate a situation that otherwise can have tragic consequences.

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