When a person in crisis is highly agitated, the first option is to attempt non-physical “verbal de-escalation.” Verbal de-escalation is aimed at meeting the agitated person’s immediate needs, and calming the situation so that it does not escalate, resulting in danger or damage to the client or others. When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation techniques are appropriate.
In a potentially violent situation, peer support specialists can help to maintain safety by appearing calm, centered and self-assured. Anxiety can make the person receiving services feel anxious and unsafe which can escalate aggression. Using a modulated, low monotonous tone of voice also helps to calm the situation. Removing neckties, scarves, hanging jewelry, religious or political symbols will help to avoid injury. Avoiding defensive verbal responses and defensive body language will also help to maintain calm in a crisis situation. It is important for peer support specialists to be aware of the resources that are available for back-up if the situation should escalate. Be very respectful even when firmly setting limits or calling for help.
Suicidal and Homicidal Risks
Peer support specialists should be aware that part of their job is to be constantly alert for signs of homicidal or suicidal intent in persons receiving services. Best practice research indicates that asking other people about their intentions regarding harm to self or others does not “create thoughts in people’s minds.” Rather, these kinds of questions allow people to talk about the unspeakable. It is especially important that peer support specialists avoid being judgmental or adding their own beliefs to these conversations. They should be caring, interested, and objective when asking clients about their feelings and intent to harm others or themselves.
Suicide is a constant threat in all mental health settings. Many persons receiving services feel quite hopeless, powerless, and depressed by their diagnosis and life situation. They are often discriminated against by both professionals and the community. Side effects from medications can make people feel worse and often cause physical changes that result in looking or acting differently than others, such as skin disorders or odd movements and expressions.
Mental health disorders can cause people to feel that they have no future and would be better off dead. Peer support specialists need to be watchful for people who have given up and are planning to take their own lives. Sometimes, these plans are well thought out and at other times they are impulsive, occurring without planning. Understanding the importance of always being aware of self-destructive signs and symptoms in persons receiving services is critical in outpatient settings, since the peer support specialist may only have short amounts of time with a person who receives outpatient services.
Peer support specialists working in inpatient settings see people who are often in crisis. This fact increases the risk of suicidal behavior. All this leads to the need to know the person receiving services, and to talk to other staff whenever there might be a problem. Peer support specialists act as advocates when they are concerned about someone and ask questions of supervisors and peer staff to follow-up these concerns.
Homicidal risk is difficult to predict. A main guideline to follow is that when anyone indicates the desire to harm someone in the community, this fact needs to be verbally passed on to the treatment team and physician and also documented, including to whom the information was given. These kinds of threats may be clear and obvious or very unclear. Examples of statements that might indicate a homicidal threat are:
- “I cannot live without her.”
- “She’ll be sorry she did this to me”
- “I hate him.”
- “It is his entire fault that I am here.”
Such comments need to be followed up with specific questions regarding the person’s intent such as:
- “Do you imagine hurting her?”
- “What do you want to happen?”
- “How are you going to handle this?”
Recognizing Decompensation or Relapse
Generally, a person is considered to be in recovery from a behavioral health disorder when they are following their recovery plan and managing their lives relatively well despite the disorder. Being “in recovery” does not mean that all life experiences are smooth or stress free, just that the person is able to fulfill their developmental roles and that their illness is not progressing or causing active problems for them or their families. Part of an effective recovery plan includes teaching individuals about the dangers of decompensation (return or worsening of symptoms) and how to monitor signs and symptoms to avoid a serious crisis. Peer support specialists are ideally suited to provide such teaching, including the use of their lived experience in appropriate disclosure.
For people with mental health disorders, relapse issues are sometimes characterized by changing medication schedules, stopping taking medication altogether, or missing appointments. Other symptoms can include avoiding other people, changing sleep or eating habits, feeling paranoid or suspicious of others, or feeling suicidal. When relapse of a mental disorder results in serious disturbances of thought and action to the point that the individual is unable to function normally, it is referred to as “decompensation.”
The management of decompensation is primarily the responsibility of the client, but it is important for peer support specialists to understand this process since they may be among the first to notice that a client is decompensating or at risk of decompensating. This video talks about the issue of relapse in mental health disorders.