Podcast: How a Supportive Stance Can De-Escalate Crisis Situations

Woman sitting on a step with her head in hands looking stressed

One morning at Telecare

Clients admitted to the Telecare facility in Lakewood, Washington—a locked, 16-bed acute care psychiatric unit—are often placed there on involuntary holds. That means either family or friends have initiated the hold, or else there has been a crisis situation that entails an arrest, and the jail system determines that the person is not thinking clearly enough to participate in the court process.
According to Toby Estler, a licensed marriage and family therapist and a social services specialist at Telecare, clients admitted on involuntary holds can be especially challenging because their confinement can cause resentment and rebellion.
Sometimes, people from adjacent counties require an involuntary hold and are admitted temporarily to Telecare because the psychiatric units in those adjacent counties are full to capacity. As soon as a bed opens up at a facility in the client’s home county, however, they are required to be transferred there, because that’s usually where the resources they need are most readily available.
And that was the circumstance one morning when a young and physically imposing man admitted to Telecare from another county was told he would be transferred, by ambulance later that day, to a facility in his home county. The client had been at Telecare for about 10 days.
According to Toby, “He knew the way the program worked. He knew what was expected of him. And he actually had decided that he wanted to stay in this county, but due to his residency, that wasn't going to be possible.”

Toby asked the young man if he wanted to talk about it for a few minutes. At that instant, “He jumped into this very ferocious-looking posture, where his legs were one laid out in front of him, and one behind. His arm was cocked back; his fist was clenched, almost if you can imagine somebody about to throw a javelin. He was very kind of stretched out. And he was a fit, lean individual. And he said, ‘Yeah, sure. I'm willing to talk. What do you want to talk about?’” recalls Toby.
Using a skill from CPI’s Nonviolent Crisis Intervention® training, Toby took a Supportive Stance and redirected. Toby explains: “So I was talking with him with the nurse that was running the unit that morning. And we kept our distance, and we said, ‘Well, that's great. You know, thanks for being willing to talk. But we're noticing that breakfast is just coming around. So how about you have some breakfast, and then we talk a little bit later?’"
Toby thought a chance to relax and refuel might help the client calm down.
So after allowing him time to eat breakfast, Toby and the nurse returned and asked if he felt up to talking. When the man leapt into the same aggressive posture, it became clear to Toby “that this was possibly going to become a really dangerous situation, where somebody was going to get hurt.”
Remaining positive, they thanked the man for being willing to talk, told him gently that they would be going ahead with the transfer, and left the room. Then they had the rest of the staff help move other clients in the room to a different part of the unit, so that if the client acted-out physically, the others would be separated from the danger a hands-on intervention might present.
Realizing that the ambulance was on its way, Toby had additional staff ready to intervene in case the client began to physically act out. But they also noticed that he was showing no signs of escalation, like throwing punches or overturning furniture. “He's very intimidating, but I think one of the pieces that the CPI training has given us is being able to recognize and tolerate that level of behavior and still be able to say, ‘Right now, nobody's being hurt, and if we try and grab a hold of this guy, then maybe somebody will get hurt.' So what we can do, at least at the moment, is just stay where we're at and see if we can stop it getting any more intense. And that, in and of itself, is a win.”

The ambulance arrives and a team comes in rolling a gurney, the client’s mode of transport back to the ambulance. At this moment Toby gives the man an option: “[We] came to him and said, ‘Hey, look. This is a long trip. Would you like to take some medicine just to kind of calm your apprehension for the journey?’ He said, ‘Yes,’ and about 15 minutes later he was sitting on the gurney, chatting with the ambulance folks, and they wheeled him off the unit and took him down to Thurston County.”
This story represents another instance of utilizing—and trusting, while taking precautions—CPI’s Crisis Development Model and de-escalation skills to create a positive, peaceful outcome in a situation that may have otherwise resulted in restraints and possible injury.

How staff perceptions about CPI training changed at Telecare

Sometimes, participants new to CPI’s Nonviolent Crisis Intervention® training think of it primarily as a “take-down” course before they attend the program. During the interview, I asked Toby if he encountered that attitude among new participants at Telecare.
“Yeah, definitely, definitely,” answered Toby. “When I asked people who were doing the training for the first time, ‘What are you anticipating today's going to be about?’ most of them are understandably oriented to the thought that this is going to be about, you know, how I physically restrain people. How do I defend myself when somebody is trying to attack me? So they see [Nonviolent Crisis Intervention® training as] some kind of blend of restraint and self-defense. And they're quite surprised when I ask them at the end of the training—they have a much different perspective where they understand that predominantly the CPI training has been about verbal interventions, about learning to identify and read behaviors, and being able to interact with folks in a way that the physical intervention is avoided.”

#CPItraining is about managing challenging behavior in a way that physical intervention is avoided.

Outcomes at Telecare since the inception of CPI training

Toby and his team at Telecare began recording statistics about outcomes since the facility first opened back in 2011, and CPI training has been in place from the very beginning. According to Toby, the ongoing, mandatory training (the One-Day Introductory Seminar is required once a year for all staff, and refresher courses are offered every month) has had a remarkably positive effect on outcomes at Telecare.
For one, Telecare’s dedication to consistent repetition of training has had a positive, cumulative effect. “I think as a culture we've developed greater and greater skill at using CPI. And so over that time, when we look at the figures, we've seen almost a 70% drop in the use of seclusion over the five plus years that we've been open. And we've also seen an 80% drop in the use of physical restraint,” explains Toby. (To see a case study of the Telecare facility in Lakewood, including these statistics, click over to TechValidate.)

How Telecare is focused on recovery-centered treatment

The Telecare organization embraces a recovery framework, the Recovery-Centered Clinical System, or RCCS, that is based on the importance of a collaborative approach. Toby explains how the RCCS works: “I would say that [there are] two important pieces: one, that the culture here is focused on the idea of recovery, and [two], making that the focus of our work. So with each individual, we're asking them to invite us into their world, and try and identify what works for them, what their strengths are, and co-create a plan with them that really speaks to their uniqueness. . . . It really begins to focus the recovery conversation on the individual rather than presenting them with a predestined treatment program that they either get into or don't. So you know, we're looking to help people get excited about their own wellness rather than telling them what wellness looks like.”

We help people get excited about their own wellness rather than telling them what it should look like.
Guest biography
Toby Estler, M.A., LMFT is a licensed marriage and family therapist in both Washington state and California. He has been working at Telecare’s adult in-patient evaluation and treatment center in Lakewood, WA for three years as a social service specialist and in 2014 joined the team of CPI facilitators, offering monthly trainings to new and current staff.
Since starting in the field in 2000, Toby has worked in a variety of mental health delivery systems, including Wraparound, acute in-patient adolescent, community mental health centers, and educational settings. Toby also maintains a private practice seeing clients in person and online. When not working, he’s most likely to be found running trails through the forests, hills, and mountains of Washington.