Immediate safety

If violence is occurring that is not safely and quickly containable by staff, then you must call the Emergency Services, or alert colleagues so that they can do this.

Many teams like to have a simple codeword that signals to all that a significant incident is unfolding which needs support, such as:

"I am going to need the pink file that is somewhere on my desk, fairly soon, please."

KeyWorkers should have access to skills training in basic Breakaway' techniques, but this is not presented here in the manual - LOCAL TEAMS might wish to add details about local trainings here - keeping this up to date would fall under Managing Risk (one of the Core Features of AMBIT, and supported by good Governance in the team).

Prevention

The key skill is to avoid violence occurring, rather than to manage it once it has erupted. There are notes on Crisis Contingency Planning - which describe how to make plans for foreseeable problems.

De-escalation techniques

When a young person is becoming violent they are clearly not Mentalizing - and are likely to be in rather 'primitive' states of mind; either Psychic equivalence or Teleological thinking. It is important not to talk to them in ways that do not take this into account - if they are convinced that the thoughts in their head are accurate:

"This person wants to hurt me and I must protect myself by hurting them first"

...then trying to reason with them at that point is likely to be pointless - and could further aggravate them. Instead, try to come alongside their mental state by ACKNOWLEDGING how awful it must be to be in this predicament (thinking someone else is trying to hurt me, etc,) and reassure them that you are there to help if you can.

How to speak

Speak softly, and calmly, with lots of reassurance and reminders of where we are, what we are about here, etc. (However, bear in mind that sometimes if the worker becomes CALMER it just enrages the young person more - particularly if they are in Psychic equivalence - in these cases Marked mirroring is an effective technique to use.

Use of Self

This is described more at Therapist's use of Self. Explain the effect of their behaviour on you - as much as possible in a way that models a Mentalizing stance - ie. allowing transparency to your thoughts, not assuming any knowledge about the young person's state of mind, and not denying or 'correcting' any statements that they do make about their experience in that moment. What is in their mind at this time is what is there - you should never deny or criticise the contents of a young person's mental state although you will wish to demonstrate interest in better understanding their mental state.

"I thinking to myself here that I am nervous, a bit scared that I could get hurt, and I know I don't think so well when I am scared; can we find a way to calm things down so everyone feels safe enough to think, and so I can try to be more helpful - or less unhelpful - for you?"

"I want to be helpful, and to keep things safe here, can we go and sit down and work out a plan to deal with this situation?"

Take responsibility

Take responsibility for any misunderstandings of your own that may have contributed to the young person's anger:

"I think I may well have got something very wrong just now, and I am very sorry if I did - I am wanting to be helpful but I may have been unhelpful by mistake; I want you to know that I do make mistakes sometimes but I do try to learn from these. Can you help me understand where I went wrong - was it when...?"

Consider Shame

Do remember the links between SHAME and violence and scrupulously avoid saying or doing anything that might increase the young person's sense of shame.

Body language

• Avoid direct eye-to-eye contact which may be provocative - look downwards instead, holding the person in your 'peripheral' vision.
• Stand sideways on to reduce the 'target' area, and avoid any sense of "squaring up" to the young person.
• Hold your hands out, in an open posture, at the level of your stomach, with palms down, fingers slightly spread, to show that you are not threatening them in any way.
• As far as is possible, try consciously to relax the muscles in your upper arms, and face, and to keep your facial expression benign and relaxed.

Video example

There are no hard and fast rules for dealing with eruptions of aggression or violence, but this role-played video is an attempt to show some techniques. Here the worker is rather trapped in the chair, but aspects of his management worth highlighting include:

• Manages to give enough eye contact to signal respect, without so much as to offer a threat.

• The head is bowed at times to signal respect (with the head bowed it is possible to watch for movements in the aggressor's lower body that might signal further escalation and attack.)

• The hands are held out in front of the body (offering the hope of defence if things were to escalate, but also showing the aggressor clearly that there is no hidden weapon/punch).

• The worker takes responsibility for "getting us into this"

• The worker uses facial expressions and tone of voice to offer a Marked mirroring of the aggressor's intense feelings - attempting to give a strong message that the intensity and reality of the aggressor's mental state is accepted, not denied, but emphasising the wish to understand better as well.

• There is regular effort at Broadcasting Intentions - stating (the obvious but crucial facts) about the wish to be helpful, not to upset...