De-escalating the Toxicologically Altered Aggressive Individual

Toxicologists when reviewing cases are often faced with a subject in question that had altered mental status as a consequence of the effects of illicit substances.  In this setting, dealing with aggressive patients can make a big difference in outcome. Patient death or injury resulting from the use of restraint and seclusion is an increasing concern in the field and in prison. Excessive and inappropriate TASER use has also been associated with sudden death.  A well-known 1998 article documented 142 restraint-related deaths nationwide over a decade, 40% of which were attributed to unintentional asphyxiation during restraint. Restraint not only poses a risk for patient harm but also is physically and emotionally traumatizing for staff involved in the incident. Many have pointed out that high restraint rates are now understood as evidence of treatment failure. Since the Joint Commission began tracking sentinel events in 1996, it has reviewed the deaths of 20 patients who were physically restrained. Since then, the Joint Commission has advocated standards based on prevention as an intervention and the use of restraint as a last resort only after the least restrictive measures are exhausted.

Most communities have a protocol to call for team assistance when a psychiatric patient begins to display aggression or when an ordinarily calm individual becomes agitated while on excitatory drugs such as methamphetamine, cocaine, or phencyclidine. Law enforcement often believe that there is power in numbers, which can be true in certain situations. However, the increased external stimuli of gathering more police officers can also have untoward effects on the patient. The show of force may contribute to the escalation of combative behaviors.

Evidence points to a direct correlation between a high level of anxiety or perceived powerlessness on the patient's part and ensuing aggression. The underlying cause of the behavior should be readily identified and handled accordingly. For instance, patients can become angry as a result of hallucinations, external provocation, or physical discomfort.

The Third-Person Approach

Although restraint may be necessary in emergency situations for patient and first responder safety, physical confrontation can usually be averted if de-escalation techniques are implemented before the patient gets out of control. De-escalation using a third-person approach, if implemented judiciously and cautiously by first responders, can be very effective in managing patients in the early stages of anger and aggression.

The third-person approach is similar to hostage crisis negotiation, in which a third party is brought in to negotiate a solution. Usually, it is much easier for the third person to take a neutral stance and to allow space for the angry person to step down. All other things being equal, an outside third party has a greater chance than an insider of successfully mediating and resolving a difference. The third person is not an arbiter trying to decide right from wrong, but a nonjudgmental facilitator of communication.

A "third party" or "third person" is a trained crisis interventionalist, often a first responder paramedic or a specially trained "situation handler" who was not present at the start of the dispute or conflict. A person who was involved in the conflict may be perceived, from the patient's standpoint, as being part of the problem. The ideal third person is someone who knows the patient well and with whom the patient has a certain degree of rapport.

The value of a therapeutic relationship has been a known and established fact for many decades. Research suggests that ineffective interpersonal relationships and interactions are major factors in escalating the aggressive behavior of a volatile individual. Irwin concludes that intolerable environments and ineffectual interactions are far more likely to influence behaviors than are psychiatric symptoms alone.

Use of the Third Person in De-escalation

Whenever an outburst is anticipated, the audience should be removed immediately. If team assistance is called in accordance with standing policy, it may be better for the team members to stay in the background, ready to provide support when needed, but allow a single, third person from the care team to approach the patient. This less-than-expected response, or "under-reaction," can promote de-escalation. The Pennsylvania Patient Safety Authority suggests shifting the method of intervention from "a show of force to a show of support." A 3-month study on the use of least restrictive interventions found that patients commonly select "verbal warning or talking things through" as the most valuable tool of anger management. In short, the men (and women) in blue need to put their guns away and back off. Crisis intervention teams will have greater success at de-escalating any situation, and there will be much less risk of injury to the patient and to law enforcement.

The third person should maintain a calm and supportive demeanor and use therapeutic communication skills. Avoid arguing with the patient or getting into a power struggle, and listen with empathy; the Greek Stoic philosopher Epictetus said that we have 2 ears and 1 mouth, so that we can speak less and listen more. In addition, state everything in clear, simple language: As anger escalates, the patient's perceptual field becomes limited; he or she probably cannot understand complex reasoning or process what you are saying. Tell the patient that you want to help, but he or she needs to calm down first. It is appropriate to say something like, "I would like to help you, but I can't hear you if you are screaming and yelling." Do not react to verbal attacks from the patient. Be aware of your own feelings of countertransference.

Staff members who take on the role of third person should have proper training in various techniques of nonviolent crisis intervention. The third person must also practice safety precautions, such as standing beyond arm's reach of the patient, positioning himself or herself for easy escape, and avoiding displays of body language that may be viewed as provocative to the patient.

Sometimes patients act out because they feel threatened. Assure the patient that he or she is safe, then set firm but nonthreatening limits. Offer choices to gain the patient's cooperation, and present positive reinforcement first. Positive reinforcement does not have to be a material reward; it can be praise and encouragement, or earning a certain privilege. In Rosenheck and Neale's 6-month study of 40 Veterans Affairs Assertive Community Treatment Program teams, clients with violent behavior who were exposed to negative limit-setting interventions typically had poorer outcomes.

First responders have an obligation to maintain the safety of the patient and others in the environment. If restraint is deemed necessary, it should be used only when all measures of de-escalation have failed. In reality, no rigid policy or clinical guideline can spell out each and every scenario when physical restraint is the lesser of 2 evils. Crisis intervention workers have to rely on their own clinical judgment to weigh the risks and benefits of the measures they are considering. When to initiate physical restraint is a situation that depends on circumstances.

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