Abstract
BACKGROUND:
In response to a request for training by a state vocational rehabilitation unit on verbal de-escalation for staff, the authors searched the literature on de-escalation best practices specifically in the context of vocational rehabilitation. There was a paucity of literature on the topic. To meet the training request for the state vocational rehabilitation staff, the authors paired the psychometrically validated English Modified De-Escalating Aggressive Behaviour Scale (EMDABS) best practices with motivational interviewing (MI) techniques to support verbal de-escalation.
OBJECTIVE:
The objective of this article is to describe the best practices of the EMDABS and how certain MI techniques and attitudes can support verbal de-escalation efforts by staff in the vocational rehabilitation process.
METHODS:
The authors searched literature on de-escalation best practices specifically in the context of vocational rehabilitation.
RESULTS:
The authors found the psychometrically validated EMDABS best practices paired with MI techniques are potential useful tools to support verbal de-escalation in the process of vocational rehabilitation.
CONCLUSION:
MI techniques and the EMDABS best practices are useful tools for vocational rehabilitation and employment services staff. Research is needed regarding the applicability of these techniques and practices across the full range of vocational rehabilitation clients.
Introduction
At times in the vocational rehabilitation process, some individuals may become agitated for a variety of reasons. As a Vocational Rehabilitation Counselor (VRC) or Employment Professional (EP) you need to know how to calm this agitation to avoid verbal and physical aggression and potential loss of employment. According to Mavandadi et al. (2013), verbal de-escalation is the process of “calmly communicating with an agitated client in order to understand, manage, and resolve their concerns. Ultimately, these actions should help reduce the client’s agitation and potential for future aggression or violence” (2016, p. 358).
For example, a VR client may come into the office or work already agitated, exhibiting behaviors such as a raised voice or even throwing things. While every office needs to have and follow safety protocols for staff, knowing how to calmly talk to the individual and potentially come to a resolution could save the situation from escalating into aggressive or violent behavior, the client leaving the office without a resolution, a closed case, and/or being fired from a job.
This article will examine the findings from Mavandadi et al. regarding verbal de-escalation best practices and demonstrate how both the “spirit” of motivational interviewing (MI) and some of its techniques support the process of verbal de-escalation.
The English Modified De-escalation Aggressive Behaviour Scale (EMDABS)
There are seven best practices that are important to the technique of de-escalation, which have been psychometrically validated through the EMDABS or English Modified De-escalation Aggressive Behaviour Scale (Mavandadi et al., 2016). The EMDABS was developed for the purpose of establishing best practices in mental health institutions for verbal de-escalation to reduce the use of restraint, seclusion, and medication for patients who were escalated, and was based on the original German-language DABS (De-escalating Aggressive Behaviour Scale) developed by Nau and colleagues (2009). The EMDABS is the English version of the original scale enhanced to include specific descriptors of least desirable, acceptable, and best practices for verbal de-escalation. It was psychometrically validated for use in research and practice.
This research identifies seven best practices when attempting to de-escalate an individual which include:
Valuing the client –Provide genuine acknowledgement that the client’s concerns are valid, important, and will be addressed in a meaningful way. Reducing fear –Listen actively to the client and offers genuine empathy while suggesting that the client’s situation has the potential for positive future change. Inquiring about the client’s queries and anxiety –Communicates a thorough understanding of the client’s concerns and works to uncover the root of the issue. Providing guidance to the client –Suggests multiple ways to help the client with their current concerns and recommends preventative measures. Working out possible agreements –Takes responsibility for the client’s care and concludes the encounter with an agreed-upon short-term solution and a long-term action plan. Remaining calm –Maintains a calm tone of voice and steady pace that is appropriate to the client’s feelings and behavior. Refraining from risky behavior–Maintain a moderate distance from the client to ensure safety without appearing guarded or fearful.
Because the scale was designed specifically for mental health patients, VR and EP staff can have confidence that these practices will likely work for clients who have mental health conditions and may also apply to individuals with other disabilities as well, as the techniques listed are based in foundational counseling skills and principles such as active listening, respect, value, and collaboration. This set of skills and values are similar to the principles of Trauma Informed Care identified by SAMHSA (2014) which include safety, trustworthiness, peer support, collaboration, empowerment, and cultural considerations. “Individuals with disabilities are more likely to have experienced trauma over the course of the lifespan, however, these experiences and their impact on individual functioning have yet to be fully recognized within rehabilitation counseling practice, research, and education” (O’Sullivan, p. 299). For example, a person who has a history of trauma themselves or in their family background may be emotionally volatile (DeAngelis, 2019) and therefore may benefit from the application of de-escalation techniques.
Motivational interviewing (MI) spirit and selected techniques
MI is an evidence-based practice that can be effective in engaging VR clients in their rehabilitation process (Chan et al., 2018). The “spirit” of MI and MI techniques are also very compatible with and similar to the values, principles and skills contained in the EMDABS. For that reason, we chose MI –including the spirit of MI and certain MI skills –as a concrete way to apply the seven de-escalation best practices identified with the EMDABS.
The spirit of MI
Motivational interviewing emphasizes respect for the client and a way of interacting that is totally non-threatening. Miller and Rollnick (2013) describe the “spirit” of MI as partnership, acceptance, compassion, and evocation; they highlight this mindset as necessary, in addition to the application of its techniques.
Partnership
Your attitude toward the person you are trying to assist to de-escalate is very important and in MI is described as coming together as two experts (Miller & Rollnick, 2013). As a VRC or EP, you are the expert in the employment field, and the person you’re working with is the expert on themselves. In MI, the VRC/EP establishes a trusting relationship by listening to, respecting, and building on the expertise of the client regarding their own life. This is consistent with the EMDABS best practice (1) valuing the client.
Acceptance
Acceptance does not mean approval (Miller & Rollnick, 2013). It means you’re recognizing that the person has inherent worth as a human being; that you try to understand what their experience is and what is going on with them; that you respect their autonomy; and that you acknowledge their strengths and efforts. Showing this type of respect will aid in offering an opportunity to establish a trusting relationship from the beginning. This is also compatible with the EMDABS best practice (1) valuing the client.
Compassion
Miller and Rollnick (2013) state: “To be compassionate is to actively promote the other’s welfare, to give priority to the other’s needs” (p. 20). Judgments have no place here; judgments are the antithesis of compassion and will be antithetical to the process of verbal de-escalation which is built on the principle of valuing the client. Compassion is exemplified in the EMDABS best practices (2) reducing fear and (3) inquiring about the client’s queries and anxiety.
Evocation
This principle means that you do not have all the answers (Miller & Rollnick, 2013). You are working in partnership with the person to help them come to their own conclusions about how to solve a problem –you assist them in evoking their own problem-solving. The spirit of MI is based on strengths. Miller and Rollnick state, “people already have within them much of what is needed, and your task is to evoke it, to call it forth” (p. 21). Evocation is compatible with the EMDABS best practices (3) inquiring about the client’s queries and anxiety and (5) working out possible agreements.
MI technique: Asking permission
One of the best ways to establish an equal partnership and show respect from the beginning is to use the motivational interviewing technique of “asking permission” (Saunders, 2011). Asking permission lets the person have a say in what’s going to happen next. Asking permission shows that you are “valuing the client,” best practice (1) from the EMDABS. For example, you could say something like, “I’m wondering if you’re open to me sharing ideas about what you’ve talked about so far?” That’s an example of asking permission to provide feedback and guidance –best practice (4).
MI set of techniques: OARS
OARS stands for open-ended questions, affirmations, reflective listening, and summaries, and is a group of active listening skills used in counseling. MI has grouped them together, and it is important to remember that they need to be applied within the spirit of MI as described above. It’s not just the skill that is important, it is the attitude behind the skill that conveys the values of respect, acceptance, compassion, and partnership which are also prevalent in the EMDABS best practices.
Open-ended questions
Open-ended questions are either questions or statements that invite an answer beyond a one-word response. They serve to draw out the person to help them describe their experience, and they keep the conversation going between the VRC or EP and the client. They are not yes/no or one-word answer questions. Begin by asking “what...” or “tell me about...,” such as “What was that experience like for you?” or “What changed?”
Open-ended questions or statements are delivered in a friendly and curious tone. You are interested. You want to know more. It goes back to the MI collaborative spirit discussed above. Also, remember that when you ask a question, you need to give space for the person to answer –time to process their answer to your question. If you come across as hurried and rushed to check things off a list, they are likely to shut down. Open-ended questions are compatible with several of the EMDABS best practices such as (1) valuing the client, (3) inquiring about the individuals fears, and (5) working out possible agreements.
Consider the following scenario: someone comes into the VR or EP office, or into their workplace red in the face and yelling. If they are greeted with the words: “Are you angry about something?” (closed-ended) they are likely to either shout “yes, obviously!” or perhaps even deny it and say “no, I’m not angry!” The closed-ended response does not allow for any elaboration. An open-ended response stated in a caring way such as “You seem angry, tell me what’s going on for you” allows the person to elaborate on their situation and opens the possibility of dialog and problem-solving. Facial expression, tone and body language should all be open as well, indicating care for the person and a desire to hear what they have to say. At the same time, keeping oneself physically safe is imperative, and we will discuss this further in the article.
Affirmations
These are statements that show appreciation for what someone is going through –acknowledging and highlighting the person’s values, strengths, and achievements. An affirmation is not a judgment and it’s important to understand the difference between praise and affirmation. Miller and Rollnick (2013) state:
In general, avoid affirmations that begin with the word “I,” because these focus more on you than on the client. “I’m proud of you,” for example, may be well-intentioned and even well received, but clearly has parental overtones. Like good reflecting, good affirming usually centers on the word “you.” (p. 65)
Here are some examples showing appreciation:
“Wow, that must have been challenging.” “You showed a lot of courage by doing that.” “You’re really serious about wanting to work.” “Thank you for coming in a little early to complete your paperwork.”
Affirmations can support a number of the EMDABS best practices such as (1) valuing the client, (2) reducing fear, and (3) inquiring about the client’s queries and anxiety. Communicating affirmations shows that you’re really paying attention to what is going on for them and helping them to appreciate and affirm their accomplishments. You can find something to affirm even if things are not going well or the individual appears unhappy. Make it a habit to do this regardless of the circumstances.
Reflective listening is a demonstration of your deep and careful listening. You can demonstrate that you are carefully listening through a variety of ways. For example, you may repeat and rephrase some of what has been said. This does not mean parroting back their exact words but rephrasing it in your own words to check on whether you understood their meaning. If you have missed the mark, they will let you know. You don’t need to worry about getting it wrong, and the process of clarifying can be helpful to both of you.
A powerful aspect of reflective listening is that it can reflect the other’s unstated emotion. It is like holding up a mirror to them of their experience and emotions, and that comes across as empathy.
Some examples of reflective listening statements include the following:
“Sounds like you’re pretty agitated.” “You’re really frustrated about that.” “And you’re feeling maybe scared about that and wondering if anything is ever going to change.” “You feel defeated.” “And now you just want some help so you can take the next step and be employed again.”
When you give a reflective statement, remember that it is a statement and not a question. Your voice inflection turns down at the end, not up. You are taking an informed risk by making a statement that you think reflects the person’s experience: “they are statements of understanding” (Miller & Rollnick, p. 53). If you are correct, they will agree and probably add more. If you are wrong, they will probably just tell you that you are wrong and state it in a different way so that you understand. As we discussed above, your voice tone is especially important. If you are communicating in an empathetic tone, you are likely to find the person opening to you. Conversely, communicating in a judgmental, sarcastic, or impatient manner is likely to shut all communication down and possibly escalate negative emotions.
Reflective listening supports the EMDABS best practice (2) reducing fear –people feel understood when you listen closely to them and let them know they’re heard. It also supports the EMDABS best practice (6) remaining calm –(and that’s referring to you-you need to remain calm in a de-escalation). If the job seeker is agitated, do not match their emotion –state their emotion back to them in a calm and caring way. Here are some reflective listening starters:
It’s almost as if ... From your point of view ... In other words, you’re saying ... It seems to you that ... So, you feel ... You’re feeling ... You’re wondering if ... Your fear is ... (Saunders, 2011)
Consider the following scenario. Tad is new on the job, and he states to you: “You know, they just keep bugging me while I’m trying to work, and I can’t get anything done. I feel like punching them when they do that.” A first impulse may be to problem-solve with Tad. However, jumping into problem-solving without reflecting empathy first may serve to escalate the situation rather than de-escalate it. To use a reflective statement, think about what Tad is feeling and offer that back to him in a statement. A feeling is an emotion such as “sad, mad, glad, afraid” or variations of those such as “frustrated, irritated, vexed, angry,” for “mad.” Remember it’s a statement and not a question. Instead of saying “Do you feel angry?” You would say, “It sounds like you’re angry” or “You’re feeling angry.” When you make a guess, it shows you are really listening and trying to empathize. It’s ok if you get it wrong! The person will correct you.
When people feel heard and understood, they feel safe, and they can begin to relax. Their defense mechanisms lower, and they calm down. It’s important to take time to communicate empathy and not rush to a resolution, rather than jumping to a solution that you think will fix it.
A summary statement is a reflection that pulls together and summarizes several things. It is a way to check whether you understand what the person has told you. This is important because people may talk rapidly when agitated and may find it difficult to put their thoughts together in a logical way when upset or talking about something traumatic. The summary statement also helps to slow things down, which has a calming effect on everybody. Introduce your summary by saying something like, “I’m just going to see if I understand what you’ve said so far.” Then pause and breathe (which helps you to remain calm) and calmly share what you have heard. Again, if you get something wrong, that is okay –they will correct you. If you are showing them empathy, interest, and respect for their experience, they are likely to respond positively and want to help you understand.
An example of a summary statement might be:
So, let me see if I have this right. You had to wait six months to get services from Vocational Rehabilitation, and then you worked six months with an employment consultant. You still don’t have a job, and you’re really worried about the bills because you’re not able to get them paid. Is that right?
As mentioned above, the individual will either agree or correct the VRC or EP and continue the conversation. Summary statements are compatible with many of the EMDABS best practices such as (3) inquiring about the client’s queries and anxiety, (4) providing guidance to the client, and (5) working out possible agreements. They can also assist in remaining calm (6) as they are a mechanism to pause and slow things down.
Best practice (7): Refraining from risky behavior
So far, we have discussed motivational interviewing techniques and how they relate to the de-escalation best practices 1–6 identified in the EMDABS. Now we’re turning our attention to best practice (7) which has to do with risky behavior on the part of the practitioner. Consider this scenario. A client comes into a VR office and begins yelling at the VRC about the EP not getting them a job. The VRC who has been overworked becomes agitated, stands up, and starts pointing their finger at the client telling them to sit down. Because that behavior will serve to further escalate the situation, it is potentially risky. Putting yourself in too close proximity to someone who is agitated may put you at risk for physical harm, and it will not assist you in verbal de-escalation. The EMDABS best practice (7) specifically states: “Maintains a moderate distance from the client to ensure safety, but does not appear guarded and fearful” (Mavandadi et al., 2016, p. 364). These recommendations are in addition to whatever plan your office has for ensuring safety among staff in emergency situations. Consider using these best practices, skills, and techniques in addition to whatever safety plan your office has in place.
Conclusion
As we have demonstrated in this article, the spirit and techniques of MI support staying safe in terms of verbal interactions because they enable the VRC/EP to remain calm and apply the best practices of the EMDABS. We recommend these techniques for both in-person and virtual situations. People want to be listened to and heard. Even if the person is not behaving rationally, or may be demonstrating some mental health symptoms, such as psychosis, they still want to be heard. Do not argue with them if they seem irrational, simply use the MI techniques of Asking Permission and OARS within the best practices of the EMDABS to invite them and guide them in a way to resolve the immediate problem. Because these practices were developed specifically for mental health patients, they are applicable to individuals with mental health conditions. Further research is warranted to determine applicability to other disability populations who participate in VR services.
Footnotes
Acknowledgments
The authors would like to extend their appreciation to Dr. Judith Gross for her assistance and mentorship.
Conflict of interest
The authors have no conflict of interest to report.
Ethical considerations
This study, as a literature review, is exempt from Institutional Review Board approval.
Funding
Research for this article was supported in part by a grant from the Indiana Family and Social Services Administration, Division of Disability and Rehabilitative Services, Vocational Rehabilitation Services, contract # 0000000000000000000020734.
Informed consent
Informed consent was not obtained due to the nature of the study (literature review).