So, welcome. Thank you all for being so timely and joining us today. This training today is sponsored by the Opioid Response Network. The Opioid Response Network is fully funded by the Substance Abuse and Mental Health Services Administration. Opioid Response Network, we've been in existence for over six years now, and our mission is to assist states, territories, tribes, organizations in providing education, training, consultation regarding opioid use disorders, stimulant use, and treatment of those disorders. We have consultants that are fully vetted throughout the U.S. and the U.S. territories that specialize in the areas of harm reduction, treatment, recovery, and prevention. In addition, we have an extensive repository of evidence-based materials and resources. Everything we do is based on the research, on the evidence. To submit a request, anyone can submit a request, any individual, organization, state, community can submit a request. Just simply go to our website, opioidresponsenetwork.org. There is a big red submit button on the upper right-hand corner. Just go in there. If you're not sure quite what you're looking for, the most important thing to do is just fill in your contact information, and we'll reach out to you within 24 hours. We'll have a conversation about your needs, and we'll move forward in meeting those needs. Without further ado, I'm going to turn it over to one of our consultants, Kristen Aja. Kristen, I'll allow you to introduce yourself. Good morning, everyone. My name is Kristen Aja. I'm excited to be here with you today, joining you from the sunny state of Florida. As Karen mentioned, this training is funded by SAMHSA, and the approach is to build on existing efforts to enhance, refine, and fill in the gaps when needed. We're avoiding duplication and not reenacting the wheel. Karen did touch on the mission, which is to provide training and technical assistance via local experts to enhance prevention, harm reduction treatment, especially medications like buprenorphine, naloxone, and methadone, and recovery efforts across the country addressing state and local specific needs. Our training objectives today is we're going to define trauma, trauma-informed care, traumatic brain injury, and explain their relevance in harm reduction settings, identify key preventative safety measures to reduce the risk of escalation, apply effective communication and de-escalation strategies when interacting with the person served, recognizing warning signs of escalating situations, differentiate between reactive and intentional responses, and then understand the importance of incident debriefing. My slides have a meaning of their own here. Let me go back. So sorry. I will cut this out, Karen. I don't know why I'm going in the opposite way here, and I appreciate your patience. It's April's getting up. Yeah, we're getting up pretty early. It's April's getting up. Yeah, we're getting a preview. Geez, I like it skipped all the way ahead, way ahead. Okay, back to our training objectives. The last one, understand the importance of post-incident debriefing, emotional processing, and self-care. So we're going to look into understanding trauma and traumatic-informed care. This is the definition of trauma according to SAMHSA. Trauma is an event or series of events that is physical or emotionally harmful or life-threatening. It has lasting negative effects on a person's mental, physical, emotional, social, and spiritual well-being. Trauma is based on perception, which is traumatic for one person but may not be for another. So when we break it down a little bit further and looking at common behavioral impacts of trauma, trauma can significantly shape an individual's thoughts, emotions, and actions. Its effects vary depending on type, severity, and duration of traumatic experience, as well as personal and environmental factors. Fight, flight, freeze response. Let's dig into that a little bit more. Trauma triggers survival instincts, leading to aggression, fight, avoidance, flight, or shutting down, freeze. Individuals may react with anger, fear, emotion, or numbness. Let's dig into hyper-vigilance and anxiety a little bit more, which is a constant state of alertness, even in safe situations. Difficulty trusting others, leading to strained relationships and social withdrawals. And then there's emotional deregulation, difficulty managing emotions, mood strings, impulsivity, or emotional numbness. They may struggle with self-soothing or using healthy coping mechanisms. They also might isolate difficulty forming or maintaining relationships. And then there's cognitive distortions and negative self-perceptions. They're believing they are unworthy, unsafe, or powerless. Persistent fear, guilt, shame, or mistrust. And then with self-destructive or risky behaviors, sometimes we're looking at substance use, self-harm, or reckless actions as coping mechanisms. And then there's also difficulty with impulse control and decision-making. And then there's also physical and health effects. Trauma can manifest as chronic pain, headaches, sleep disturbances, weakness with immune functions, higher risk of developing mental disorders like PTSD, depression, and anxiety. So SAMHSA has six principles of trauma-informed care here, and we have a nice infographic. And I'm going to dig into all of these topics just a little bit more. So the first one is safety. When your safety has been compromised, it's difficult to feel safe. Safety can both be physical and emotional. And then there's trustworthy and transparency. When someone's boundaries have been violated in the past, they may have a difficult time setting them. You want to be very clear about your role in the process. And then there's peer support. Those that we have worked with are experts in their own lives. They should have every opportunity to use their expertise and share it with others. And collaboration and mutuality. All services should be partnerships, and every opportunity for autonomy should be honored. Empowerment, voice, and choice. Traumatic experiences often involve losing one's voice and feeling like control is taking away. We must restore control whenever possible. Ask fewer questions and listen to more stories. Cultural, historical, and gender issues. The experience of negative and oppressive world is also traumatic, and people experience this differently based on their identities. In summary, adopting a trauma-informed approach is not accomplished through any single particular technique or checklist. It requires constant attention, caring awareness, sensitivity, and possibly a cultural change at an organizational level. Ongoing internal organizational assessment and quality improvement, as well as engagement with community stakeholders, will help to embed this approach, which can be augmented with organizational development and practice improvement. All right. So let's look into traumatic brain injuries, or we'll probably be referring to them as TBIs going forward in working with vulnerable populations. A traumatic brain injury, or TBI, is caused by a bump, blow, jolt, or penetrating injury to the head. It can be mild, like a concussion, moderate or severe, with effects lasting for days, months, or a lifetime. Common causes include falls, car accidents, sports, injuries, and assault. Cognitive impacts, or, you know, thinking and processing. Let's look at the impact of a TBI on these categories. So memory problems, forgetting appointments, misplacing items, trouble recalling new information, difficulty concentrating, easily distracted, or struggling to follow conversations, or complete tasks. Slower thinking and response time, taking longer to process information and making decisions. Impaired problem solving and planning, trouble organizing daily activities, or handling complex tasks. Language challenges, difficult finding words, understanding speech, or following instructions. And then there's emotional impacts, or mood and regulation. People could suffer from mood swings, shiftly quickening from happiness to frustration or sadness. Increased anxiety and depression, feeling overwhelmed, hopeless, or excessively worried. Irritability and frustration, you have a short temper, impatience, or difficulty handling stress. Emotional numbness, difficulty expressing or feeling emotions, and social withdrawal, avoiding friends, family, or public setting due to frustration or embarrassment. Behavioral impacts, these are actions and reactions. Impulsivity, acting without thinking, saying inappropriate things, or taking risks. Aggressive or agitation, short fuse, outbursts of anger, physical aggression in some cases can be seen. Lack of self-control, struggle with regulating emotions, or reactions in social situations. Sleep disturbances, like insomnia, excessive fatigue, or irregular sleep patterns. Apathy and low motivation, loss of interest in hobbies, work, or daily activities. A TBI can significantly impact cognitive, emotion, and behavior, even in mild cases. The effects may be based on the location of the severity of the injury. Recovery is possible with rehabilitation and therapy support systems. Trauma-informed care and accommodations can improve quality of life with those living with a TBI. When we're responding to crisis, understanding the implications of trauma, a traumatic and traumatic brain injury is critical. Incorporating sighted materials, such as visual cues, written instructions, or pictorial aids can help significantly help individuals process and respond in interventions. So, again, digging into cognitive and behavioral considerations when working with those with a TBI, individuals may struggle with rapid or verbal instructions or processing complex information. We would have to use clear, concise, written materials to try to communicate with them, or maybe using flashcards to help them find the words that they need to communicate with us what's going on with them. There's also memory impairments. Individuals may forget instructions quickly. We should provide written or visual instructions for reinforcement. Use step-by-step guides, checklists, large font documents for easier comprehension. Difficulty focusing and attention. Crisis situations can be overwhelming. Limit distractions and use clear visual cues to maintain focus. Avoid excessive flashing lights, loud noises, or clutter signage that may increase distress. Emotional regulation and visual cues. Again, this is like taking a look at the space that we're working in or that we're serving our clients in. Is it a relaxing space? Is it calming? Are there things around that might get people distracted? Again, using color-coded cards or flashcards to help individuals communicate with us a little better if they're having some problems at the moment, getting their point across, or speaking clearly. People in crisis feel safer with structure. Use visual roadmaps like step one, breathe, step two, identify sports, step three, next steps. Use visual cues to help them communicate. Use visual cues to help them communicate. Use visual cues to help them communicate. Use visual cues like step one, breathe, step two, identify sports, step three, next steps. You know, to help them get through the process. Break it down for them to make it a little bit easier. Let's look at communication strategies. Non-verbal communication tools have pre-written response cards for individuals struggling to speak during a crisis. Use gesture-based or pictorial aids to help individuals express their needs without words. Sometimes I've seen this on a wall, you know, feelings or things like that, so they can just easily pick something and get their their emotions or their feelings across to whomever they're working with at that time. Let's look at some more communication strategies. So we want to ensure that the exit signs and tools are very clear, well-lit, and accessible. Lots of times people who, when they get in a crisis situation, they want to make sure that they can, they have, you know, the freedom to leave, or they know how to get out of the room that they're in or the building that they're in. Provide visual safe plans in an easy to understand format, such as icons, instead of using long text. Make it easy for them to understand. Trauma-informed visual aid posters or handouts with grounding techniques, positive affirmations, and safety reminders can help for reassurance. All right, so now let's take a look at some preventative safety measures. Recognizing that trauma can influence behaviors and responses to stress, we want to utilize a calm, non-threatening tone in body language to avoid triggers triggering that fight or flight response that we covered just a few moments ago. Using our reflective listening and affirmation emotions to help the individual feel heard and understood or our motivational interviewing skills, avoiding dismissive language or minimizing their experience. So again, we want to make sure that we're hearing them and validating their concerns. Again, looking at maintaining a safe environment, positioning oneself near an exit and maintaining open posture to signal non-aggressive behavior when they're working with you, removing potential hazards from the room or on your desk that could be used as a weapon, potentially scissors, things like that. De-escalating techniques, again, speaking a slow, calm and even tone voice to reduce heightened emotions, offering choices to provide a sense of control such as would you like to sit down or take a walk? Avoiding a power struggle, using I statements instead of directives to prevent resistance. And you want to focus on collaboration rather than authority, right? You're working together, you're in a mutual relationship, you want to create that top trust in a safe environment for the individuals coming in that you're serving. Recognizing escalation cues. We're gonna be looking at identifying warning signs such as clenched fists, rapid speech or pacing, redirecting the conversation before agitation increases. That's a great skill to have. We're gonna touch on that as well as we move through our presentation today. Utilizing grounding techniques, encouraging the deep breathing exercises, sensory grounding. Again, you can do the breathing exercises with them, practice with them so that they can have the opportunity to do that with you and get comfortable with it. Engaging in mindfulness or distraction techniques to shift the focus from distressing emotions. And knowing when to seek help. Recognize when intervention from crisis professionals or law enforcement is necessary. Follow your agency protocols for emergency responses and documentation. Usually, again, these are things that you learn potentially during your onboarding and orientation with your organization is probably something that you should go over regularly, right? So that if a situation comes up, kind of everybody knows what the protocol is within your agency to support that person best. That's not a good- Hi there. This brief video is going to describe simple, calming and de-escalation strategies. When people are escalated, it often comes from a sense of threat or fear. Even if the threat is not real at the time, their past experiences with people in the world may have wired their brains to expect harm or danger. When we as humans perceive threat or are otherwise incredibly stressed or angry or scared, we activate our survival brain. This more primitive part of our brain has only one job, to keep us safe. It doesn't care about reason or logic. In fact, the thinking parts of our brain turn off and we act mostly on instincts. These instincts include reading nonverbal cues from our environment. Those nonverbal cues are actually more important than verbal cues or what people say to us. So when people are escalated, at their core, they want control. We give them control over their own safety and decisions. Do not block people, corner them, or block entrances or possible escape routes. As soon as you do, they want to fight or flee even more. Give two arms length distance. Keep our body posture open, so it does not appear that you are hiding anything. Keep your body posture as relaxed as you can, even if it's hard. A looming, towering figure only sends the message that you want to dominate. So if it feels okay to do so, ask them what would make them feel safe or feel better. Put the control back on their turf. Ask what would help. Ask what could happen next. One of the most famous practices and sayings for de-escalation is low and slow from Teresa Bullock. Low and slow refers to both your body movements and your voice or speech. Just like it sounds, we want to keep the tone of our voice low and the speed of our voice slow. When you lower your tone and speed, it makes it more possible for the other person to process what you are saying and not feel threatened, as opposed to a higher pitch tone and quick speech, which frankly increases stress. Then we also try to lower and slow down our body movements and posture. Try to sit in a chair or on the floor, especially if you're with children, and especially if the person who's escalated is lower down than you. Maybe they're on the floor or in a chair. If you get on an even playing field, this gives the nonverbal cue that you mean no threat. Try to slow down your body movements so as to not further alarm their cues for danger. Move slowly, walk slowly, keep your hands out and open where they can see them. Next, use the tip, name it to tame it, made popular by Dan Siegel. By naming emotions, we gain control over them. Therapists have known this forever. Acknowledge that they may be feeling anxious, angry, especially if it's a child. Stay with that feeling, validate it. Let them know the feeling is okay, as long as they stay safe. We also like to say, regulate over educate. When people are in distress, it's not the time to teach or educate or think back about what they could have done differently. The only goal is to regulate their emotions. Usually this is done by giving space and time, staying calm and helping provide a calming atmosphere. It takes the body 20 to 30 minutes to come back down the baseline after a perceived or an actual threat. Just think of your own situations when something really scared you or startled you. Even if you look like you're getting back to normal and your body is still pumping all those stress hormones for a while. So wait it out, just help people regulate. If a person was aggressive or destructive, especially if it's a child, there does of course need to be a consequence, but wait on talking about the consequence. Finally, two of the most important things you can do all along the way, and that's before people get too distressed or even while they're distressed, is to validate their feelings and be empathic. I see you're struggling, I see this is hard. If it's okay, I'll stay here with you until you feel better. Can you see my slides? Yes. Perfect, all right. Techniques. Effective communication and deescalation are essential skills for peer support workers, particularly when engaging with individuals experiencing distress, crisis, or heightened emotions. The following techniques are supported by research and best practices in trauma-informed care. So let's dig into those. Active listening. Active listening is more than hearing. It's about fully engaging with the speaker. Reflective listening. Reflective listening helps clarify meaning and shows understanding. It sounds like you're feeling, right? Acknowledging and summarizing what they've said to you. Affirmations, acknowledging their strengths and builds confidence. You've been working really hard on this. Summarization organizes thoughts and ensures clarity in the conversation. Open-ended questions encourages deeper reflection and discussion. Avoid the writing reflex, resist the urge to correct or fix the person's problem. Empathy. Empathy in motivational interviewing is about understanding, not agreeing, or sympathizing. So when we're looking at expressing empathy, we want to use reflective statements to show genuine understanding of the person that you're working with, their feelings. You want to avoid judging, labeling, or confronting resistance directly. Empathy helps build trust and strengthen motivation for change. Encouraging change talk gently moves the conversations towards personal motivation and solution. So I'm sure in the work that you are all doing, this is something that you're doing with everybody in your conversations. But again, we're really focusing in on those that we're working with for potential de-escalation techniques. Hey there, everybody, and welcome to this video on 10 tips for verbal crisis de-escalation. I'm your host, Dr. Donnelly Snipes. Crisis represents danger and opportunity. And one of my mentors once said, change causes crisis and crisis causes change. When something changes, whether it's something we try to change or something that changes despite our best efforts, it puts us in a state of feeling vulnerable and feeling out of control and possibly in crisis. So it's important to remember that a person who is in crisis is often feeling out of control, which means there's an opportunity. There's an opportunity for them to figure out, okay, where do I go from here? But when they're in crisis, when they're feeling out of control, they're feeling threatened, which is not a place where they're going to be able to think clearly. That's where you're in danger. So first is calming and helping the person get into their wise mind. And second is opportunity. And that's where you work with the person when they're in their wise mind to figure out, okay, this is where we're at. What is the best way to improve the next moment? Where do you wanna go from here? Has Kyra texted you back? I don't wanna talk about it. How was the math test? Don't wanna talk about it. You need to talk to somebody. I talked to my Talkspace therapist. And afforded, and still don't wanna talk about it. Talkspace is super affordable, with or without insurance. And when you don't wanna talk, you can just text them. Oh, look, my therapist just texted me. People in crisis feel unsafe and powerless and are trying to regain those things. And it's important that we recognize that. Regardless of how they are displaying it, some people will withdraw, some people will get drunk, some people will have a very emotional display. But ultimately, all of those people all of those people are feeling unsafe and powerless. And they're trying to figure out, how do I make this feeling stop? How do I either feel more empowered or just make the feeling stop? These feelings may come from what is going on in the moment. So something could have happened that triggered them and threw them into crisis. Or something that happened in the moment triggered them, but not because there's a problem right now, but because it reminded them of something from the past and that threw them into crisis. So it's important to recognize that sometimes people will be triggered by what we might think is a relatively benign situation, but it is bringing up memories, traumas, problems from the past. And all of a sudden, they're feeling like they're back there again. People who are in crisis may also trigger crisis memories in those responding to them. So when the person who is responding, when the responder is in crisis, then the respondee or the person that originally was in crisis is gonna have more difficulty trusting them and feeling safe, because they're looking at you going, well, you're supposed to be the one that's in control. And yeah, I'm not seeing it. So it's important to recognize that people in crisis can trigger your stuff as well. And even if you keep it under wraps or keep it contained while you're handling that situation, you may need to process it after the crisis situation, because it may have opened some old wounds for you. So what are these 10 tips? Get grounded so you know you are safe in the moment. This is before you even approach them. Get grounded. Look around, go, okay, I'm safe right now. I can see that there are no apparent threats. We're good. Breathe and maintain that slow breathing. When you breathe slowly and deeply, it triggers the relaxation response, which manually overrides the stress response. So if you focus on your breathing, it's going to help you avoid starting to have an extreme stress reaction. So take a couple of slow, deep breaths. Breathe in for four, hold for four, exhale for four, hold for four, and maybe do it again before you approach the person, okay? Whether you're sitting in your car and you've got to approach them because they're on a park bench, or if you are having to respond to their home because you're an apartment manager and you've got a call about, you know, ruckus going on in the household, whatever it is. Take a few breaths, get yourself centered. Taking this extra 30 seconds or a minute to get grounded and get focused is going to be a lot more beneficial than rushing in there. Get the person's attention, generally without touching them. A lot of people, when they are in crisis, are feeling out of control and unsafe. So touching them can make them respond with aggression. They may not even think about it. They may just flail because, don't touch me, okay? We don't want to invade somebody's physical boundaries when they're already feeling unsafe. If they are sitting or standing, walk around until you can get in front of them so you can make eye contact. If they are sitting or staring at the ground, especially if they're sitting, sit next to them and try to get in their line of sight. That will help you make contact with them. But don't touch. There are a few exceptions to this especially with very very small children but as a general rule if you're going to touch it's important to ask ahead of time definitely not before you've made contact with the person you don't want to put your hand on their shoulder and try to spin them around and go hey let's talk that's gonna be bad so get their attention listen to what's going on or look at what's going on if they're crying if they are just devastated okay it doesn't take a genius to see that if they are enraged about something okay it doesn't take a genius to see that either so identify what they're feeling I see that you are really terrified right now or I see that you are really enraged or other words that may be more appropriate that YouTube wouldn't like okay tell them you want to help and you would like to know what's going on I see that you are devastated I really want to help you I see that you're feeling just completely overwhelmed can we talk about this can you tell me what's going on because I really want to help genuine compassion goes a long way however genuine compassion with acknowledgment of where they are a lot of times well meaning people will come up to them and the first thing they say is calm down uh uh if I could calm down I'd be doing that already don't start with calm down please validate or acknowledge whatever word you want to use how they're feeling right now I can see that you're feeling this way and that has got to be terrifying I really want to help you and would like to know what's going on that phrase or paragraph right there goes so far the next step you want to hear what's going on but when people have an audience if it was an anger situation they may feel like they've got a safe face so it's gonna be harder to de-escalate them if it is anxiety they you know again may feel unsafe but the more people are around and watching them the more it's gonna increase their anxiety they feel like they're under a microscope if they're in crisis regardless of the emotion anger anxiety devastation let's move we can either sit down here and get the bystanders to go away sometimes that's what you need to do because the person doesn't want to move or can't move ideally you help them move to another safe place you can walk when I worked in residential and we would have residents that would get into a an altercation one counselor would take one resident and another counselor would take another resident and we would walk separate places in the on the property because walking actually helps people calm down and there's a lot of explanation behind that that you probably don't care about right now but when people walk it can help it's also less threatening to walk and talk because you're side-by-side when you're looking at somebody face-to-face it can feel intimidating or threatening or feel like they're judging so walking and talking puts you in a neutral situation likewise if you sit and talk make sure that if they're sitting you're sitting if you're standing you're taking a power position that may feel threatening to them offer them a piece of gum I know you're like what they found and Harvard research has actually found that chewing gum stimulates the vagus nerve stimulates the nerves that are connected through the face and trigger the relaxation response so offer them a piece of gum they don't even have to blow bubbles with it they can just chewing it often helps trigger that relaxation response so you've got another little tool in your toolbox this is how to get in shape fast the best way to boost your metabolic rate and get in shape is not keto, it's not paleo. Attempt to help them get to a place where they have privacy and no audience so either walk somewhere if you're an apartment manager ideally help them walk to maybe the manager your office in the clubhouse where you can talk make sure that you're not putting yourself in any sort of dangerous situation but also you're trying to remove the audience that way they don't feel like they're on display they don't feel like they're being judged they don't feel like they've got to continue to make a statement then let them tell their story and avoid invalidating their beliefs ok so you've acknowledged what you're observing as far as what you think they're feeling right now you've said you want to help you've taken steps to get them to a place where they have some privacy now you're going to let them tell their story and you're going to hear it from their perspective their perspective is their perspective you don't have to agree you just need to hear it from their perspective and try to imagine what it must be like from their perspective and then ask them what they see as a solution this is a step towards keeping them back control and empowering them to make the next move what is it that needs to happen to resolve this situation and how can I help once you get them thinking once you ask that question you've moved them from their emotional mind to their wise mind and then you can work together to make a plan so it sounds really simple it can be very exhausting and it can feel very overwhelming at times but some of the key points are to make sure not to invalidate the person's thoughts or feelings they're theirs and to not invalidate their space their boundaries you don't want to touch them unless you've been given permission and talking about in future slides here so moving on to recognizing signs of escalating agitation yeah a nice overview of what we just listened to increase restlessness pacing clenching fish fidgety tapping your you know just general signs of irritation agitation changes in the tone and volume in their voice speaking faster louder being hostile or defensive rapid or shallow breathing and verbal threats or proactive statements more signs of escalating agitation there's nonverbal cues such as sweating trembling dilated pupils refusing to comply intense eye contact or avoidance sudden uncharacter uncharacteristic silence can be a signal of internalized frustration before an outburst or physical aggression throwing stuff slamming doors making threats things of that nature you so now we have another video on understand understanding de-escalation you oh it's this place hi I'm dr. Zeller I'm one of the psychiatrists I don't know I need to leave I don't know what this place is my horse locks you can't get out what can I do to help you you can get me out of this damn place let's talk about getting you out of here until you can turn around and talk with me I can't help you who are you I'm a psychiatrist here my name is dr. Zeller and I'm here to help not to hurt what's going on tell me what's happening how I can help you we've estimated that somewhere between 20 and 25 percent of the folks that we see in our psychiatric ER will experience an episode of agitation during their visit with us so it's something that we take very seriously and we want to intervene as promptly as possible to prevent bad outcomes and when we think about agitation we think of it as a spectrum where it can be a little less severe at one end where maybe somebody's irritable and restless to up to the very far end where where somebody would be combative and violent and we definitely don't want to get to that end so we'd like to intervene at that at the near end what's going on tell me what's happening how I can help you I don't know who you are the police took my wallet all my ID I need to get the hell out of here I'm really scared I don't need to be here okay sounds like you're going through a really tough time yeah yeah I am when you go through a tough time like this what helps you to relax being at home I'm not at home right now that can't really happen quite yet that's right but maybe if we talk a little bit about what's happening we can make things better no I want to talk to my brother where's the phone because I need to call the police I'm gonna call 9-1-1 you get the hell out of here when somebody's going through an agitation episode they're not a bad person even though may come across that way to some people like they're they're hostile or sarcastic or or saying mean things to somebody but what's really happening is that somebody is having a very very difficult psychiatric crisis and they really do want help they're just really not expressing it in such a way that that the average person would go oh this is somebody who needs their help the best way to work with somebody who is agitated is not to be agitated back to them and it's often easy to forget that in the heat of the moment if somebody's saying I don't understand why I'm here you don't say back to them just sit down don't worry about it we'll let you know because that's just gonna make them more frightened and it can lead to more agitation one of the most important things not to say is sit down and shut up and it's so frequently something that people are gonna say some version of that I'm gonna call 9-1-1 and get the hell out of here you know I can talk about getting your doctor we can get you out of here yeah it's a great place though but it's gonna take a few minutes we need to talk about why you're here I don't know what this place this is a safe place it's a psychiatric facility why I'm in all kinds of different distress or not feeling that well and I understand you don't think that's going on with you I'm seeing all these people here and they're scaring me and there's people there's a guy over there look at all the staff I'm talking to that guy what are they gonna do to him a good de-escalation involves empathetic listening intervening in a calm way make sure people feel that this is a safe environment that we're here to help and not to hurt you aren't crowding them not glaring at them but you're looking like you're receptive and helpful there's a certain way that we'd like to approach arms are gonna be at your side your hands are typically outwards you're relaxed your knees are maybe bent just a little bit so you look at ease you're there safe and open and welcoming I had a little bit over two arm lengths of space between me and our patient he had what we call a line of egress a way that he could escape which we didn't want him to follow but he could see it that would help him to relax nonetheless now I'm seeing all these people here sometimes when people are agitated their thoughts are kind of racing in their head they're not hearing things the first time so clearly we use these short phrases and repeat them until they really start to sink in everybody here is in a different situation but this is a safe place we're here to help we don't hurt people we help people I think out of all the things what I really like to ask people is what what can we do to help you what do you need right now what what what tell us what would make things better many many times have talked to individuals who've just undergone a psychiatric agitation crisis and they'll say nobody would listen to me everything would have been so much better if somebody just would have listened let's talk about you what can we do right now to help you feel better I'm a psychiatric hospital my brother put me in a psychiatric hospital it's a safe place it's a safe it is a safe place and we're here to help so would Dave you like something to eat maybe something to drink would that help maybe going somewhere where we're a little bit away from all this the rest of the crowd we can sit down and talk and you can have something to eat probably the most important thing is helping people to calm down and regain control on their own with a little bit of help from us one of the ways you could regain control is if you feel you have your own ability to make decisions and so offering people choices gives them the chance to choose and gives them a little bit more of a say in what's going on around them and that in and of itself can help people to relax maybe they want to go to a room and lie down maybe with a with the lights dimmed a bit sometimes people want to listen to music maybe just getting away from a stressful situation somewhere in the emergency room getting them to a different part of the emergency room can be enough maybe going somewhere where we're a little bit away from all this the rest of the crowd we can sit down and talk and you can have something to eat I am hungry I haven't eaten for 12 hours stupid cops they kept me against my will and that's illegal in a place like this if you've never been somewhere like this before it can look a little strange and unusual like I said it's safe and this is a place where we help people and we want to help you how about we get you something to eat you and I can go and sit and talk while you have something to eat with that I'd really rather just have just do that what you need to do to get me out of here okay I can talk all about how we can get you out of here but first we need to sit down and have a chat it is a little something to eat sit down and we can talk this place okay okay come with me we'll go get something to eat we'll go sit down all right I don't just stay close don't be close to me they say it would be faster just to put somebody in restraints and give them a shot but if you think about it when we talk about verbal de-escalation we're usually saying just a few minutes maybe three four or five minutes that should be all you really need and when you're only talking about five minutes and helping somebody compassionately to get better and to relax and calm down that much easier to do restraining and giving medications actually doesn't isn't faster at all that's gonna take a few minutes we need to talk about why you're here if you're going to put somebody in restraints first you have to get a big group of people together make a move on an individual take them down a nurse is going and getting medications and then coming back and need staff again so that they can hold somebody down to give them the injection it's 20 or 30 minutes that you're doing because that was quicker than the five minutes of de-escalation it really doesn't make a whole lot of sense when you look at it that way the other thing about it is is that we found out that the vast majority of assaults from patients to staff occur during that tackling an agitated person to take them down and put them into restraints it's really a win-win to try to do de-escalation and intervene in this compassionate collaborative way as opposed to the old-fashioned restraint and sedate what's been really really amazing is that when one hospital is getting really good and they start having these great outcomes and the word gets around and then other hospitals want to pick up on it and pretty soon all the hospitals in a district or a region are doing it and everywhere we keep hearing about it we keep hearing the same great things where staff are getting really proud of what they're doing and they really feel like they're being health care providers rather than jailers if you will having a different way to do things has been I think so exciting and when you do see that sea change in staff they get excited they want to tell everybody else about it and the word continues to spread back to our presentation, summarizing some of the de-escalation tips we've already learned today during our time together, as well as watching the videos, staying calm and regulated, using a non-threatening tone and body language, using your reflective listening, reflecting back what you're hearing them say to you, acknowledging, making sure that you're understanding how they're feeling, you're hearing them properly, acknowledging their feelings, giving space and avoid crowding, speak softly and slowly, use a calm, low voice, clear language, avoid power struggles, offer choices. As we've heard a couple of times today, offer to go, if they'd like to go for a walk, that might help calm people down, and having a conversation, walking side by side, might be less threatening than facing each other, watching for signs of de-escalation, watching as their agitation increases, and the person is more going towards problem solving in the situation. When and how to intervene. Now again, your agencies might have protocols around this, and we're just giving some guidelines here to think about when you're working with people who might be needing some de-escalation. Again, watching for those early signs or mild agitation, using your reflective listening, acknowledging their emotions, reducing environment stressors, offer choices, moderate agitation, increased verbal and physical tension, so they continue to de-escalate, but be prepared for possible intervention. Again, this is where you might have agency protocols and certain people that handle these types of situations, but you want to set clear and simple boundaries, such as I want to help, but I need you to lower your voice so we can talk using a calm and firm voice. Avoid arguing with them or, you know, escalating them more. Encourage safe expression, you know, asking them, tell me what's bothering you. Again, if they're having a hard time communicating, maybe using some flash cards or verbal cues that they could help them explain what's going on with them and what might be helpful to them. Encouraging physical space or break, right? Again, get them away from where they are, outside fresh air or just change of scenery. Observe for further escalation, watch for clenched fists, rapid breathing, or increase aggression. So, when to seek assistance. You do not want to intervene alone. You want to seek assistance if any of the following occur, right? The threats of violence, loss of rational thinking, you know, they start getting incoherent speech, delusions, or paranoia. They start destroying property, physical aggression, start hitting, kicking stuff, weapons, or dangerous items. Again, we talked about earlier in the presentation, making sure that the space is as safe as it could be. Removing any threatening items, scissors, things like that, off the desk, where folks might be able to grab them. Medical emergency, you know, if the individual appears to be under extreme distress, you know, dealing with that, the physical effects that might be manifesting in them. Who to call for help. Again, these are probably numbers that you have handy so that you don't have to go fumbling through records to try to find these numbers. But again, if you have security in your agency, or do you need to call law enforcement for assistance? Crisis intervention teams, if you have that in your building, readily available to you. Same thing with mental health professionals. Maybe there's crisis folks in your community that you can call in that can help to avoid calling in law enforcement. And then emergency medical services if that's needed for those that you're working with. So now let's look at a little bit of self-awareness and action versus reaction. Understanding action versus reaction. So action is an intentional response. You know, it's thoughtful, deliberate, intentional, a very conscious response to the situation and the person that you're dealing with at the moment. It's based on self-awareness, emotions, regulations, critical thinking. I know when I find myself working with somebody who's getting escalated, my self-awareness, you know, my breathing and making sure I'm clearly speaking, things like that. So I really have to go into vigilance for my own regulation and keeping myself regulated during the interactions. Which leads to better problem solving, healthier communications, personal growth. Some examples, again, taking a deep breath before responding, considering the consequences before acting. So again, I really have to be mindful about when I'm communicating to the individual that I'm working with and not talk out of my own stress or anxiety because maybe I'm getting a little amped up as the situation gets a little amped up. Understanding action and reaction a little bit more. Reaction is impulse-based response, immediate emotional, often unconscious response to a situation. It's driven by instinct or external triggers. Emotion can generally lead to regret, misunderstanding, or unintended consequences. An example being yelling when you're frustrating, making a snap decision without thinking. So again, just considerations that we think of as workers in this field and how we're reacting in these situations. And sometimes doing like role-playing with team members or if you're having, you know, staff meetings, things like that to kind of go through some scenarios that maybe may have happened in the past or scenarios that could happen in the future just so people kind of get to experience it and understand how to handle it, practice those skills, tools that they've learned, and put them into practice. How to cultivate self-awareness, right? It's recognizing our own emotional triggers, identifying situations that provoke strong emotional reactions for us. Common triggers usually are criticism, rejection, feeling unhurt, or stressful situations. Why am I feeling this way? What is this reaction telling me? Again, usually when you've had some, you know, heated work with an individual that might have triggered something in yourself and kind of gotten you thrown out of, you know, whack for a little bit, you know, just make sure that you're using your support systems to talk through these types of scenarios as well and, you know, taking care of your own health and wellness. Practicing emotional regulations, right? Pause before responding, take a deep breath. It's okay to think for a minute or two while you're processing what you're hearing and what your response is. Name the emotion. Instead of reacting, you can acknowledge I'm feeling frustrated. Use mindfulness techniques, you know, ground yourself with deep breathing or visualization or things that you have picked up through, you know, through your life that help kind of get you back into a grounded state. How to cultivate self-awareness. Shifting from reaction to action. Assessing the situation. Sometimes, right, is it worth reacting to? Do, what are the potential consequences? You know, do I need to react to this right now? And then choosing your response. Is it constructive? Is it constructive? Are you acting on an impulse? Again, just kind of maybe taking a few minutes before you respond to give yourself that grace. Reframe negative thoughts. Instead of this is unfair, what can I learn from this? Practicing thoughtful communication. Listening actively before responding. Using those I statements. I feel overwhelmed. Instead of you always. Asking clarifying questions instead of assuming intent. We talked about that earlier in the presentation as well. You know, am I hearing you correctly? It sounds like, right, making sure that you're really understanding where they're coming from. Learning from past reactions. Reflect on past situations where you reacted impulsively. What could you have done differently? Using journaling or self-reflection exercises to track emotional patterns. Again, these are also things that you can talk about during, you know, maybe your supervision meetings or with peers at work. You know, just how, how could you have handled things differently coming or how could you come out of that situation feeling a little bit better about the conversation? Taking care of yourself. When to take action versus when to step back. Again, we have some guidelines here. Again, I'm going to have you reflect on your agency guidelines and protocols around how these situations are handled. Or maybe if your agency doesn't have any guidelines or protocols around situations where de-escalation might be needed, coming up with protocols or guidelines of what that might look like. So there's clarity with everyone on staff should a situation come up. So let's take a look at when to take actions. When you have clarity on the situation and can respond thoughtfully. The response aligns with your values and long-term goals and the situation requires immediate problem solving or leadership. So again, your agency, there might be people with inside the agency that get called in during certain situations. So knowing if you have that support on staff, when to know when you should step back from a situation. If you're feeling emotionally overwhelmed or triggered, the response could escalate conflict or harm relationships or more information is needed before making a decision. Sometimes there are certain people within your organization or on staff that get along with clients that you serve better than others. So I know there's been times when I've been working with somebody and I can tell they're getting agitated about something that I have gone and got another staff member to work with them because they just have a great relationship with them. They've already built that trust and they will be able to move forward more efficiently with the conversation than I can. And then there's been other times where, yeah, I have been personally triggered by certain situations that I'm stuck in conversation with and it's probably just best that I step away and have somebody else handle it. It's totally fine. So let's take a look at post-incident support debriefing, processing, and self-care. I have been talking about team debriefs a little bit throughout our time today. A team debriefs and reflect practices on essential components of maintaining a resilient and effective workforce, particularly in high-stress environments such as health care, emergency response, and peer support work. According to the National Center for PTSD, regular debriefs help teams process challenging experiences, enhance communication, and foster a supportive work culture. So again, I always encourage teams, if there is a situation that's incurred, have a debrief about it afterwards. What went well? Could they have done something differently? Lessons learned? Then it might be a one-on-one debrief with the individual or the staff member that was in that heated situation. Again, just making sure that they're okay. But team debriefs, reflective practice, there are many great learning opportunities in that exercise. Key benefits of team debriefs and reflective practices. Emotional processing and support. Debriefs provide a structured space for individuals to share emotions, validate experiences and reduce stress, helping to prevent burnout and secondary trauma. Continuous learning improvements. Reflection on experiences allows team to identify what worked well, what could be improved, leading to better outcomes and more effective strategies. Enhance team cohesion and trust. Open discussions create a culture of transparency, psychological safety and mutual support, strengthening team dynamics. So some more benefits of team debriefing and reflective practices. Enhance team cohesion and trust. Open discussions create a culture of transparency, psychological safety and mutual trust, strengthening team dynamics. Increased self-awareness and professional growth. Reflective practices encouraging individuals to examine their reactions, biases and decision-making processes. Promoting self-improvement and skill development. Improved service delivery. Teams that engage in regular reflection are more adaptive, responsive and able to provide higher quality care and support to those that they serve. Structuring a debrief. Okay, so let's just look at how a debriefing session could go in your organization, right? Check-in, begin with a brief emotional and mental status check-in. You might already be doing this in your organization or if you're not, you might wanna just at every meeting have a regular check-in, kind of where's everybody at? How's everybody doing? What's working well? You know, where folks need support. The event review. So discuss the key aspects of the situation without assigning blame. Again, this conversation is a productive conversation these are where we have lessons learned and also noting things that went well and we know what to use in the future. Impact and reaction. Encouraging team members to express how the event affected them. Again, those lessons learned, identified what worked well and what could be improved. And then also giving yourself some grace because it's hard in those high stress situations sometimes to, you know, remember all those best practices and things that we need to do. So, you know, if you missed a step or something like that, again, give yourself some grace, you know, and we just keep learning as we go along. Action steps, develop strategies for moving forward and preventing similar challenges. So again, discussing how can we avoid this next time? Does any of this result in protocol or guideline changes? You know, do you need to go back to your policies and procedures to rewrite protocols? I always encourage folks to kind of look at those regularly anyway, just to make sure they're all up to date. Because lots of times protocols and procedures change as we move on and have lessons learned. And then check out, and on a positive note, reinforcing team resilience and strength. Self-care techniques for the team and wellbeing. Of course, in the work that we do, we often forget to take care of ourselves as we should. So just a reminder of our emotional and psychological self-care, debriefing and peer support. So again, engaging in those regular debriefs and peer check-ins to process the experiences and emotions. We're all in this together. So make it a regular routine as part of your weekly schedule. Journaling, some folks like to journal, reflect on the daily experiences, challenges, successes to gain insight and release those emotions. Mindfulness in meditation, practice deep breathing, grounding exercises or guided meditation to stay present, reduce stress. Or again, getting up, taking a break, going for a little walk around the building can also be very mind clearing for some folks. Therapeutic support, seek professional counseling or peer support groups when needed. Must not forget about our physical self-care as well. Exercise and movement, engaging in all of those recreational activities that you enjoy or maybe challenging yourself to some new ones. Rest and sleep, prioritizing sleep and maintaining a consistent bedtime routine, limiting screen time before bed. Again, that's probably something that we all need to do. And there's many families out there and getting a good rest all night can be a challenge for sure. Hydration and nutrition, stay hydrated, right? Feed your body, make sure to drink water throughout the day, taking care of yourself. Social and relational self-care, healthy boundaries, set limits on workload and avoid over-committing to horrific behaviors. Connect with supportive people, spend time with family, friends or colleagues who uplift and encourage you. Engage in fun activities, make time for hobby and leisure activities that bring you joy. And then looking at self-care techniques for professional and workplace self-care, take breaks, step away from work periodically to reset and recharge. Work with your family and friends and work periodically to reset and recharge. Work-life balance, that's probably something a lot of people were always tweaking as we go along here, maintaining a separation between work responsibilities and personal time. And lots of time for people that the work in the industry we do of helping people, those boundaries can be a little bit more hard to set when you're at work and when you're outside of work. Use available resources, access wellness programs, employee assistance services and professional development opportunities that may be available to you through your work. Crisis self-care, recognizing early warning signs, be aware of stress, fatigue, irritability or emotional exhaustion. You know, sometimes people don't feel it coming on and then all of a sudden you've crashed, but then reflecting back, you're like, oh yeah, I've been feeling this coming on for months. So be aware, pay attention to yourself. Develop a coping plan, have a list of calming strategies to use when feeling overwhelmed. Breathing exercises, going outside, listening to music, knowing when to seek help, right? Reach out to your supervisor or your friends, mental health professionals. There's many times free services out there for folks that don't have insurance, but make sure to take care of yourself while you're taking care of everybody else out there. Okay, there is some case studies and scenarios. We will just cover just a few of them before we end our time together here today. Let's take a look at Sarah. Sarah, a peer support worker at a recovery center notices that James, a participant, is becoming increasingly agitated after being denied access to a meeting due to lateness. He begins raising his voice and pacing. Here are some response strategies. Sarah uses a calm tone and reflects James's feelings. I can see you're frustrated. It sounds like this situation is really upsetting. She gives some space, takes a step back, maintaining an open posture to avoid appearing confrontational, offering choices. We can talk about this here, or we can step outside where it's quieter. James takes a deep breath and agrees to discuss alternative solutions. Here's another one that we can look at. Lisa, a staff member at a harm reduction center interacts with John, a man experiencing homelessness, with a history of trauma. When asked to fill out intake paperwork, John suddenly becomes defensive, yelling, why do you need my information? I'm not telling you anything. He clenches his fist and appears ready to leave. Lisa acknowledges John's feelings. I understand that giving your personal information can be uncomfortable. You're in control, and you only need to share what you're comfortable with. Non-threatening body language, so Lisa avoids sudden movements and keeps her hands visible. Providing predictability. She says, let me explain how we use this information to help. Would that be okay? And then the outcome is John relaxes slightly and agrees to listen, allowing Lisa to explain the process in a way that reduces his fear. Crisis intervention for a person with a TBI. David is a man with a TBI, from a past incident. Enters a drop-in center. He appears confused and overwhelmed, struggling to answer basic questions. When a staff member asks for his ID, he shouts, I don't know where it is. Just leave me alone. Crisis response. So the staff member, recognizing TBI symptoms. Staff member that TBI can, oh, I'm missing a word there, I think. Making sure that staff members know that TBI can cause memory loss, difficulty processing information and emotional dysregulation. And lots of times we don't know if somebody has a TBI, right, we're just seeing the behaviors. Simplifying the communication. So they reduce sensory stimuli, speaking in short, clear sentences. It's okay, take your time. Let's check your pockets together. An example of using the visual aid, staff provides a picture-based checklist to help David understand his options. And the outcome is David finds his ID and calms down after being given structured, clear steps. Here's an example of when to seek assistance. Anna, a peer support worker, is assisting Tom who is upset after losing his housing. Tom begins pacing, clenching his fists and muttering, I have nothing left, I should just end it. Here's the decision-making process. Assessing the risk. Anna recognizes signs of distress and asks, are you feeling like you wanna hurt yourself or someone else? When Tom nods but doesn't elaborate, Anna follows the protocol. Contacting a crisis intervention team while staying with him. Then she's using grounding techniques. She helps Tom focus on breathing and reminds him of past strengths and support systems. And the outcome is the crisis team arrives and Tom is connected to immediate mental health resources. So again, this agency had protocols in place. Anna knew exactly what needed to happen in this situation and she had support in backing her up in dealing with this individual. And then there are some additional role-playing scenarios that are here that you are welcome to use in a group if you wanna talk through some yourself. And as we get to the end of our presentation today, here is a summary of the cited material that was used. It was also mentioned throughout the presentation slides, which you will all get a copy of. Now, as we end our time together today, I'm gonna add this survey link to the chat box, or if you don't mind, if you wanna take out your phones, scan this QR code. Oops. Once I bring it back up. You know me, I click too much. Me and my clicking. Is it up? No. Of course not. Okay, is it up now. Yes. All right. Thank you, folks. Yeah, and just take a minute like Kristen said to either take a photo of the, the QR code or the link. The survey is very brief and it's very important submission of the surveys provides the data that allows us to continue to offer training such as this one at no charge. So we appreciate you taking the time to tell us what you thought of the presentation today. It provides us really valuable feedback on how we can continue to improve the services that we provide. Thank you.

Opioid Response Network

substance use disorders

harm reduction

trauma-informed care

communication strategies

crisis management

emotional well-being

traumatic brain injuries

Substance Abuse and Mental Health Services Administration

self-care

team cohesion

preventative safety measures