Adapting the Verbal Escalation Continuum to the Needs of the Hearing Impaired

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Being deaf in a hearing world can present many challenges to the individuals and to the persons providing them with services. Many of the techniques professionals have learned to use when dealing with crisis situations may not be as effective when working with individuals with hearing impairments. This article describes adaptations to the Crisis Prevention Institute's Verbal Escalation ContinuumSM as it applies to individuals who are deaf.

Have you ever needed to answer the phone while doing dishes?

Scratch your nose while making pizza dough?

Tried to talk to someone who covers his or her ears, or makes loud noises so he or she can't hear you?

Tried to read when there is little light to see?

When hands are the primary means of communication, and eyes are the primary means of reception, many problems arise if access to either or both is limited.

The feelings of frustration and helplessness that may arise in situations such as these, may occur in even greater magnitude while attempting to assist or communicate with an individual who is hearing impaired.

When this individual is in crisis and needs assistance to regain self-control, the challenges are more complex.

Modifying the CPI Verbal Escalation ContinuumSM may assist in correctly identifying the stages an  individual with hearing impairments may exhibit. A person with hearing impairments may demonstrate the stages of escalation differently than a hearing or verbal person. Staff need to intervene with a style that addresses the culture and communication pattern of the individual being assisted.

How should staff intervene when individuals with hearing impairments express refusal by closing off access to communication either by turning their back or shutting their eyes?

How should staff communicate while assisting a person to regain control?

Failure to recognize the need to adapt standard techniques to the specialized needs of the hearing impaired may cause needless escalation of crisis situations.

The steps of continuum for an individual with hearing impairments are likely to be as follows:

  • Unresponsive
  • Refusal
  • Ventilation
  • Intimidation
  • Tension reduction

As in the CPI Verbal Escalation ContinuumSM, the use of directives plays a central role in implementation. Some unique staff responses to each stage that ensure the individual feels supported, understood, and has the opportunity to regain rational control are detailed below.

The Unresponsive stage may begin with the person ignoring staff by closing down access to receptive language. Lack of eye contact or refusing to look may occur. This may be the most frustrating part of the continuum for persons providing them with assistance.

It is important for staff to remain rationally detached and in control and to allow ample time for the individual to initiate communication. Staff should attempt, if possible, alternate means of communication by using pictures or writing. This may assist the unresponsive person through less intrusive or intimidating techniques.

Continue to be supportive at this point. Do not force communication; rather, wait for the individual to open his or her own line of communication.




















  • Loud vocalizations
  • Extreme movements
  • Object manipulation












  • Physical threats
  • Scare tactics




  • Walking away from situation
  • Sitting down
  • Looking away; closing eyes
  • Making a noise
  • Closed body language




Tension Reduction








  • Affect change
  • Compliance to the directive
  • Relaxation
  • Eye contact
  • Receptive/expressive Language return



  • Ignoring
  • Close down access to receptive language
  • No eye contact



Once communication is restored, questioning may occur in the form of information seeking or challenging questions. Staff should respond in the manner outlined in the CPI Verbal Escalation ContinuumSM.

  • If the individual with a hearing impairment asks an information-seeking question, answer it!
  • If the individual has the opportunity to make choices, allow him or her to do so.
  • If the question is challenging or if the directive must be complied with, ensure cooperation through the techniques listed below.

At this stage in the adapted continuum, individuals continue to be unresponsive and begin to escalate by refusing to comply with the directive or with attempts to communicate. They may walk away from the situation, go to another area and sit down, look away, or close their eyes. Body language may become closed. Loud vocalizations may be heard at this time, another sign of escalation.

Staff should position themselves near the individual to gain attention. It is preferable to permit the individual to retain his or her personal space. Staff should use hand movement in the individual's line of sight to gain attention. This is not always possible. For some individuals, it may be necessary to get close enough so that you risk invading personal space. For example, staff may have to move in, touch the arm of the individual gently, then move back. The passage of time is very important in this step. Do not force communication; wait for the person to be willing to respond. The directive may need to be repeated.

A prompt hierarchy is a tool for ensuring the cooperation with a directive. The prompt hierarchy focuses on redirection, and uses time to allow the individual to cooperate with a directive.

The prompt hierarchy:

  1. Give the general instruction.
  2. If no help, wait for the individual to respond. The length of time allowed should be based on what is reasonable for the individual. The idea is to give the individual a chance to respond without creating a pressurized or power-struggle situation. If no response, then proceed:
  3. Introduce a nonspecific cue using sign language. Sign "what's next?" and wait for a response. If no response, then proceed:
  4. Give specific instruction, breaking down the task into steps. For example, if the directive was "please come with me" and the individual fails to comply, give the next directive as "stand up." This is the first step to the directive, "please come with me." Wait for a response. If he or she still does not respond, then proceed:
  5. Introduce a gestural cue. Use a gesture and specific signed instruction. For example, use an arm movement to gesture "stand up" along with the sign, or actually sit down and stand as sign "stand up" to demonstrate and emphasize the instruction. Wait for response. If there still is no response:
  6. Repeat the hierarchy until cooperation is achieved, but only if the person is not in danger of injuring him/herself or others. Focus only on the directive given, avoid eye contact or extraneous signing and movement. If the person is in danger of escalating further, physical guidance and specific instruction may be needed. Gently use physical guidance only if this person is not defensive when being touched. Do not use physical guidance in a forceful way or in a manner that will cause a power struggle or aggression. If there is still no response:
  7. Staff may need to repeat the hierarchy several times until the individual cooperates with the directive.

The next step in the modified continuum is ventilation. For an individual who is hearing impaired, this may occur in the form of loud vocalizations, object manipulations, banging, throwing objects, or extreme body movements.

As with anyone, allow the individual to vent. Focus your attention on the directive after the individual begins to regain control. Again, time and space is very important.

Intimidation may be demonstrated through threatening signs or gestures. The individual may make physical threats by shaking a fist or swinging an arm as if to hit. Movements may be exaggerated. In the same way voice control and volume may be used to make a point by a hearing person, a person without hearing may be more likely to use body language.

Staff may need to seek assistance if you anticipate needing to intervene physically. Another person will be critical at this stage to help with signing. Continue to maintain space and use time to your advantage to prevent further escalation. If physical interventions are necessary before help arrives, use touch to communicate. This can be done through the use of gentle pressure while holding the person or by positioning your hand to sign the word "fine" on his/her chest while using a restraint. This procedure reassures the individual that he/she can retain control. People can tell a great deal by the manner in which they are touched.

Tension Reduction
As in the CPI Verbal Escalation ContinuumSM, the last step is Tension Reduction. Staff will begin to see a change in the individual as he/she regains control and becomes more relaxed. Receptive and expressive language will return. He or she may begin to use eye contact and cooperate with directives.

Staff response is one of Therapeutic Rapport. Do not be judgmental, especially in your body language. Redirect the individual to the task and/or activity at hand.

At all times, be especially aware of your nonverbal cues. Individuals who are hearing impaired rely heavily on body language and facial expression as methods of communication. The degree of force in your movements or sign language, the tension in your body, the expression on your face, or how quickly or slowly you are moving are likely to be used by the individual as cues to your comfort level or level of vulnerability. It's important to display a calm, controlled response.

The techniques and examples described above are the results of a collaborative effort between staff of The Kennedy Institute Behavioral Support Services Project and the staff of a program for hearing impaired individuals in Baltimore, Maryland.

With all individuals, the best approach is one which is based on a combination of theoretical knowledge and personal insight into the personality, hopes, desires, and patterns of the behaviors of each individual we encounter.

No single method can be relied on to be equally effective with all individuals. Adaptations to particular circumstances and that stress individual responses may be necessary. It is hoped that continued reflection upon our collective experiences and mutual sharing of information will enhance our capacity to ensure the safety and welfare of the individuals served by agencies we provide with Nonviolent Crisis Intervention® training.

Smith, Marcia Datlow. 1990. Autism and Life in the Community, Successful Interventions for Behavioral Challenges. Baltimore, Maryland: Paul H. Brooks Publishing Company.

Michael Marshall and Denise Stile
National Report Summer 1991 Volume 11, Number 1

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About the Author

“Every individual on this earth deserves to be treated with compassion, understanding, and the right to keep their dignity intact. This can be difficult to honor at times when someone loses control of their behavior, but that’s where Rational Detachment and not taking it personally really kicks in. What has helped me be able to do this well goes back to the first day I was introduced to Nonviolent Crisis Intervention® training. I was a participant before becoming a Certified Instructor (and before working for CPI), and over the years I have had so many opportunities to use what I learned way back then. Today, I live the skills automatically. It’s an honor to have been given those skills to live the philosophy of treating others the way I want to be treated.”

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