Frequently, nurses in forensic mental health units set limits on the behavior of their service users (Mason, Dulson, & King, 2009). The behaviors of service users that often result in limit-setting range from playing music too loudly and swearing to more serious infractions (e.g., acting out in a seductive manner) (Peternelj-Taylor, 1998). “Explaining to service users the consequences of doing something improper” was reported by nurses and service users in a Swedish forensic mental health unit to be the specific interaction that occurred most frequently (Rask & Brunt, 2006, p. 105). Limits can be set by nurses in ways that are acceptable or rejected by service users. One consequence of rejection may be that a service user behaves aggressively toward the nurse.
Aggressive behavior by users of forensic mental health units jeopardizes the health and well-being of both staff and service users; it also negatively impacts the atmosphere of the unit (Daffern & Howells, 2002; Daffern, Howells, & Ogloff, 2006). Despite this, little empirical research has explored the interpersonal interventions, including verbal de-escalation and limit-setting, that allow for the therapeutic management of service user-perpetrated aggression in forensic mental health units. Most research in the field has focused on characterizing the risk factors of service users that are associated with aggression. As a result, few research-driven guidelines are available to help forensic mental health nurses engage service users in a way that limits aggression (Richter, 2006). Instead, a variety of physical and psychosocial interventions are currently used to prevent and manage aggression, with no general consensus on the most beneficial method (Gournay, 2000).
The way in which nurses in forensic mental health units set limits, as well as the manner with which they use de-escalation skills, are thought to have a significant influence on aggression. However, neither of these interventions has been particularly well researched and the techniques that are commonly advocated have little theoretical or empirical support. Furthermore, despite the importance of setting limits and verbally de-escalating aggression, the forensic mental health nursing literature has not addressed how nurses effectively undertake these interventions.
This paper seeks to contribute to both research and practice by reviewing the existing literature on two important concepts in the prevention and management of aggression: limit-setting and de-escalation. With so many diverse interventions being used, a review was considered necessary to establish the use of these interventions in mental health settings (both in theory and in practice), the empirical research supporting their use, and the theoretical underpinnings on which they are based. It will also ascertain which of these methods are most effectively able to contain and reduce aggressive behaviors while at the same time maintaining a therapeutic alliance. Journal articles, books, consultation documents, position statements, guidelines, and program manuals were identified using web-based journal databases including PSYCHLit, PubMed, and Google Scholar, and other resources were taken from resources at Monash University, Centre for Forensic Behavioral Science and the Thomas Embling Hospital, the state of Victoria, Australia's forensic psychiatric inpatient service. This strategy resulted in 41 documents being considered for this review.
Limit-setting involves establishing the parameters of desirable and acceptable behavior. In some published papers, limit-setting refers to all attempts to regulate service user behavior, whether preplanned (such as the creation of hospital policies) responses to nondisruptive situations (such as the enforcement of rules) or in response to disruptive or aggressive behavior (such as the use of restraint, seclusion, or verbal de-escalation techniques) (Vatne & Fagermoen, 2007; Vatne & Holmes, 2006). In other papers, limit-setting is defined more narrowly as staff responses to nonaggressive situations (Lancee, Gallop, McCay, & Toner, 1995). For the purpose of this review, limit-setting refers to setting limits on service user behavior before a service user has become aggressive.
Limit-setting is a daily occurrence in mental health settings; unfortunately, it is also one of the most common precipitants of aggression toward nursing staff (Nijman, 2002; Nijman, a Campo, Ravelli, & Merckelbach, 1999; Vatne, 1995). Further, there is evidence that limit-setting is negatively associated with staff and client perceptions of the therapeutic alliance (Neale & Rosenheck, 2000). Setting limits on service user behavior in such a way as to minimize aggression and maintain safety while facilitating growth can therefore be considered core business for forensic mental health nurses (Crichton, 1997; Lowe, Wellman, & Taylor, 2003; Vatne & Fagermoen, 2007). Unfortunately, specific limit-setting techniques tend not to be described in guidelines or training programs dealing with the management of service user aggression (see, for example, American Psychiatric Nurses Association, 2008; National Institute of Clinical Excellence, 2005b). Rather, limit-setting is referred to in general terms.
Unsurprisingly, given the lack of detail describing limit-setting, there is a lack of empirical research delineating the methods of limit-setting that most effectively prevents aggression while facilitating the therapeutic alliance. One important exception is the empirical study of limit-setting undertaken by Lancee et al. (1995), who examined limit-setting in a roleplaying between mental health service users and nurses. In this study, six limit-setting styles were tested: belittlement (responses that cause a service user to defend his position); platitudes (generic responses with a lack of attention to the specific circumstances); offering a solution without options (telling a service user what to do without offering possible courses of action); offering a solution and options; affective involvement (expressing care and concern while attending to the subjective experience of the service user); and affective involvement plus options. Results showed that only three of these styles were effective in setting limits without generating anger: offering a solution and options; affective involvement; and affective involvement plus options. Of particular note, only affective involvement plus providing options was an effective limit-setting style when dealing with impulsive service users. In a later qualitative study, Vatne and Fagermoen (2007) examined data from observations, interviews, and written narratives. They identified two perspectives with regards to limit-setting: correcting and acknowledging. Correcting saw the service user as “deviant” and sought to correct their behavior by control or coercion. Acknowledging, on the other hand, was associated with compassion and respect. This perspective sought to help suffering service users through cooperating interventions. The authors concluded that the acknowledging perspective was more effective in preventing escalation of service users’ feelings of powerlessness, as well as their disruptive behavior. Together, these studies suggest that staff interpersonal skills and a cooperative problem solving style are keys to limit-setting strategies that also reduce the likelihood of aggression.
Recent research on limit-setting is also limited by a lack of theoretical foundation. For example, in Vatne and Fagermoen's (2007) study, “practical rationality” was identified as the theoretical framework on which their approach to understanding limit-setting was based. In this understanding, the focus is on staff members’ reasons for their actions when setting limits and an assumption is made that people have good reasons for their actions and can reflect upon those reasons. A comprehensive review of the historical factors relevant to limit-setting (Vatne & Holmes, 2006) emphasized that humane limit-setting involves the integration of two values: respect for the service user as a human being and the need for order and discipline in society. While this identifies some important underlying principles of limit-setting, there is a need for a theoretical framework that seeks to explain how limit-setting can lead to aggression and, therefore, how it can be performed in such a way as to minimize aggressive responses. The current lack of a theoretical base means that, while limit-setting is widely recognized as an important point at which potential service user aggression can be minimized, it is poorly understood in a research context and, as a result, somewhat ad hoc in its current implementation in mental health settings.
De-escalation involves the use of verbal and nonverbal skills to gradually resolve potentially aggressive situations by redirecting the service user to a calmer personal space (Cowin et al., 2003). It is often recognized as an important part of aggression management in mental health settings, particularly with regards to decreasing the use of seclusion and restraints (Johnson, 2010; National Alliance on Mental Illness, 2003).
De-escalation appears in the policy documents of the few professional organizations that have guidelines for dealing with aggressive behavior in mental health settings. The National Institute of Clinical Excellence (NICE) (2005b) included de-escalation in their clinical practice guidelines on the short-term management of disturbed/violent behavior in in-patient psychiatric settings and emergency departments. The American Psychiatric Nurses Association (2008) released a position paper on managing workplace violence that identified “preventing de-escalation (sic) and managing aggression and violence” as an effective nursing role. De-escalation also features in the aggression management policies of some individual hospitals. A “de-escalation kit” was put together by a task force in one Australian hospital in an effort to increase its nurses’ ability to deal with aggressive situations (Cowin et al., 2003). Further to this, books on the management of violence in healthcare settings frequently include sections on de-escalation (Dix, 2008; Leadbetter & Paterson, 1995; Richter, 2006), as do aggression management training programs (Delaney, Cleary, Jordan, & Horsfall, 2001; Jonikas, Cook, Rosen, Laris, & Kim, 2004). According to a recent study by Farrell and Cubit (2005), modules on “communication, therapeutic relationships, and diffusion techniques” are present in the vast majority of aggression management training programs. In sum, the inclusion of de-escalation in guidelines, training programs and handbooks is a testament to its perceived importance.
The everyday use of de-escalation is made somewhat more complicated by the fact that there is no standard approach or accepted “best practice” method of de-escalation in mental health settings. The NICE guidelines recommend specific de-escalation techniques including: manage others in the environment; explain to the client what the staff member intends to do; give clear, brief, and assertive instructions; ask for facts about the problem; encourage reasoning; and ensure that nonverbal communication is nonthreatening and nonprovocative (NICE, 2005a, 2005b). While helpful, these recommendations are based on the “experience of the Guideline Development Group” rather than a theoretical model or empirical evidence. Unfortunately, little theoretically based empirical research has been carried out into the effectiveness of any given approach to de-escalation (Harris & Rice, 1997; Johnson & Hauser, 2001) and when de-escalation has been evaluated the results have not always revealed a reduction of aggression subsequent to staff training in de-escalation skills (see, for example, Laker, Gray, and Flach (2010) who examined the effectiveness of de-escalation and restraint training on a Psychiatric Intensive Care Unit (PICU) by comparing the number and severity of incidents on the PICU before and after training and found that there was no significant difference in either number or severity of incidents, concluding that either the training did not improve de-escalation skills or staff found the skills difficult to put into practice.
Exploratory research into de-escalation in mental health settings has involved focus groups (Cowin et al., 2003; Delaney et al., 2001); observational/phenomenological studies (Johnson & Delaney, 2007; Johnson & Hauser, 2001); and metasynthesis of qualitative studies (Finfgeld-Connett, 2009). These studies have utilized the experience of mental health nurses and other mental health staff in order to identify a number of important de-escalation techniques. A review of these studies reveals a number of techniques that are commonly considered to be important components of de-escalation.
First, general interpersonal skills feature highly in the research. A metasynthesis by Finfgeld-Connett (2009) revealed that the ability to stay sincerely connected with the service user was a helpful response style with regards to aggression escalation. Termed authentic engagement, this style allows the staff member to elicit the service user's story and understand the situation. It allows the service user to maintain a sense of dignity by recognizing aggression as a way to express emotion and communicate need. The outcomes of authentic engagement were seen as more therapeutic than other response styles such as inflexibility and disengagement. Similarly, interpersonal skills such as empathy, reciprocity, respect, and mutuality were also seen as important components of de-escalation that produced more helpful outcomes in aggressive situations (Finfgeld-Connett, 2009; Johnson & Delaney, 2007; Johnson & Hauser, 2001). One other interpersonal feature was the ability of staff to manage their emotions in an aggressive situation. Staff members who were able to respond to the situation and not their own frustration were considered to be more successful at de-escalating aggressive service users (Johnson & Delaney, 2007).
Second, specific communication skills are often noted as an important part of de-escalation. The value of speaking in a calm and controlled manner is often noted, as is the importance of giving simple and direct instructions (Johnson & Delaney, 2007; Johnson & Hauser, 2001).
Third, a number of studies identify de-escalation as a process that begins with an ability to assess the initial situation. Johnson and Hauser (2001) interviewed a number of mental health nurses who had been identified as skilled at de-escalating the escalating service user. They found that these nurses were particularly proficient at reading the dangerousness of the situation and assessing the potential impact of the situation. Johnson and Delaney (2007) also explored the process of escalation in two adult mental health units in the United States. They found that a critical condition for successfully intervening in escalating situations was an ability to notice what constituted the beginning of an incident.
Finally, a collaborative approach to problem solving was recognized as a helpful part of de-escalation. Nurses who were skilled at de-escalation were able to offer the service user suggestions and choices in a respectful manner that embraced reciprocity (Finfgeld-Connett, 2009). This included asking the service user what they might find helpful and allowing sufficient time for a response (Johnson & Hauser, 2001).
Exploratory research has therefore revealed a number of de-escalation techniques that may be useful to nurses in mental health units and which are also worthy of future study. Much of this research has, however, been somewhat disconnected from the limited theoretical work on de-escalation; few techniques have been evaluated, and those techniques that have been studied show inconsistent impact on the prevention of aggressive behavior. Several authors have outlined models of de-escalation, and a brief review of these models is likely to clarify potential directions for future study.
Models of de-escalation
In some cases, models of de-escalation simply pull together the important components of de-escalation, with no attempt to outline the relevant underpinnings of escalation and de-escalation processes. Stevenson (1991) identifies three major factors as important when de-escalating an aggressive situation: knowing yourself; knowing the service user and the situation; and knowing how to communicate therapeutically. Intervention is thought to begin with understanding how the service user is feeling and what he or she needs in the situation. This is established through the use of therapeutic communication—communication which is founded on respect for the rights and dignity of the service user. It involves: providing adequate personal space; using open body language; speaking in a low and calm tone of voice; using open-ended sentences; and avoiding punitive or threatening language. Throughout this process, the more self-aware and centered the staff members are, the more effective they are thought to be when dealing with service users. While Stevenson provides a comprehensive account of a variety of de-escalation skills, there is no rationale behind the inclusion of these techniques. Further to this, only one piece of empirical evidence is given in support of these techniques: a study by Lanza (1988) that suggests that “violence-prone” people tend to need up to four times more space than would ordinarily be required.
Similarly, Richter (2006) also presents a model of nonphysical conflict management/de-escalation that is not clearly based on a model of escalation. Richter does however identify some important features of conflict escalation. He identifies the key factor for escalation as the incompatibility of two parties’ expectations, and describes the process as mutually reinforcing, suggesting that the reactions of each person become increasingly harmful as the situation progresses. He also notes that the escalation to violence can take anywhere from several seconds to several hours. Despite these observations, the recommendations for conflict de-escalation are simply a collection of “basic rules” such as: maintaining an attitude of empathy, concern, respect, sincerity, and fairness; assessing the risks associated with each available option; controlling the situation, not the service user; sharing risk assessment and decision making with colleagues; intervening early; gaining time; applying techniques with self-confidence and certainty; avoiding power plays; and making staff aware of general safety issues. A variety of verbal and nonverbal communication techniques are also presented. While evidence is provided in support of most of these “basic rules,” the rules themselves are clearly or directly linked to the observations made by Richter about conflict escalation. As such, this model also appears to be simply a collection of the important components of de-escalation.
There are other models of de-escalation, however, that are more closely based on theoretical conceptualizations of the processes by which aggressive situations escalate and de-escalate. An early model was proposed by Boettcher (1983) who saw aggression as an immediate and direct way of communicating an intense human need that is learned and reinforced in the socialization process. Several stages of aggressive behavior were outlined by Boettcher. First, one or more biopsychosocial needs are blocked, consistent (with the early frustration–aggression hypothesis (Dollard, Doob, Miller, Maurer, & Sears, 1939). This poses a threat to the mechanisms by which anxiety is avoided or minimized, and a state of anxious arousal occurs. Once the person is in a state of severe anxiety, his or her perceptual field is narrowed, learning is markedly diminished, and psychological discomfort increases. This results in increased feelings of helplessness and entrapment. The person then engages in behaviors which are believed to decrease these uncomfortable feelings. Aggression is one such behavior that is thought to temporarily diminish anxiety by providing a sense of immediate power. In this model, then, aggression is seen as a learned response that is used in order to reduce the severe anxiety created by a blocked or unmet biopsychosocial need. With this model in mind, de-escalation involves collecting information relevant to the biopsychosocial needs of the service user and collaboratively establishing goals pertinent to these needs.
Leadbetter and Paterson (1995) conceptualize aggressive behavior as an interactive process led by a pattern where negative emotions increase and rationality decreases. They propose a model of escalation and de-escalation involving stages of changing cognitions, emotions, and behaviors. In the first stage, known as the triggering phase, the dominant emotion is anxiety. This stage is characterized by agitated or avoidant behavior. The second stage involves a transition toward a negative perception of the current situation and is marked by anger. In the third stage, known as the crisis phase, the aggressor's anger becomes focused on specific people and others’ behaviors are more likely to be interpreted as threatening. The fourth stage is the summit of the escalation curve and is known as the destructive phase. Physical aggression is most likely to take place in this stage, as impulse control is reduced. After this stage, arousal levels begin to reduce and the descent phase begins, although perception remains heightened. In stage six, the immediate risk to others decreases although anger is still the dominant emotion. The final stage—resolution—may involve depression, physical exhaustion, disorientation, and contrition.
This conceptualization of aggressive behavior allows for a model of de-escalation that is both responsive and stage specific. The authors propose a number of de-escalation strategies that, at the different stages, aim to maintain communication and minimize factors which promote arousal. In the early stages of arousal, the focus is on attending to and communicating with the service user using active listening skills such as open questions, paraphrasing, and reflection, as well as the interpersonal skills of warmth, empathy, and genuineness. Once the situation escalates to the crisis phase, the focus becomes risk management, including removing bystanders and containing threatening behavior. This is done by outlining the possible consequences and outcomes of the service user's behavior, using conditional limit-setting, and distraction/diversion. When the service user's aggression descends, the focus is on imposing appropriate sanctions as well as continuing to explore the underlying triggering issues.
Having established this model, Leadbetter and Paterson (1995) also outline a number of important practice principles underlying the use of de-escalation: try to understand the feelings and issues which promote the use of aggressive behavior; maintain the self-esteem of all people involved; maximize the choices available to the aggressor; respond early and proportionately; address both short- and long-term goals; develop self-awareness; share responsibility with other staff members; and be proactive in managing the factors that may contribute to aggressive behavior. Finally, they highlight the importance of staff attitudes by identifying five interpersonal skills as important in maintaining therapeutic relationships and avoiding aggression: empathy, respect, genuineness, concreteness, and integrity, defined as “a confident awareness of one's competences and responsibilities” (p. 57).
Dix (2008) proposes a cyclical model of de-escalation involving three separate but interdependent components: assessment of the situation; communication skills; and problem solving tactics. When considering these components, Dix uses a model of aggressive behavior based on situational analysis. This model identifies four factors which lead to the behavioral result of aggression: the situation; an appraisal of the situation; an emotional response of anger; and decreased inhibitions (influenced by the person's values and attitudes toward aggression). De-escalation involves the assessment of each of these components, allowing intervention to be targeted at a number of specific points. The importance of nonverbal communication principles is highlighted, such as keeping an open body posture at the same height as the service user, maintaining a comfortable proximity of at least one meter, and keeping a congruent facial expression. These are to be used alongside verbal communication principles such as using a calm, warm, clear tone of voice, making short, clear, and specific statements, and avoiding the use of jargon. The third component of de-escalation identified by Dix is negotiation and problem solving tactics. This involves trying to create a win–win situation, creating in the service user a sense of empowerment (real or perceived). It also involves attempting to align the goals of the service user and the staff, shifting the focus from confrontation to discussion.
Each of these models has attempted to capture the processes underlying escalation and, therefore, the most effective method de-escalating aggressive situations. While many important aspects of the escalation–de-escalation process have been captured, there is not one comprehensive model that has garnered universal agreement.
Conclusion and directions for future research and practice development
Both limit-setting and de-escalation are widely acknowledged as important concepts and skills that are relevant to nursing staff-service user interactions and the prevention and management of aggressive behavior in forensic mental health units. This review of the extant literature indicates that both theory and empirical research in these areas have been neglected, resulting in “best practice” methods being (with rare exception) established from anecdotes derived from clinical practice; though worthwhile, this is limited. In particular and somewhat surprisingly, none of the de-escalation or limit-setting frameworks described here have referred to, or been based upon, contemporary models of aggressive behavior or a theory of interpersonal behavior. This is somewhat remarkable given that both strategies are supposedly used by nurses to prevent and contain aggression. It is our argument that reference to a model of aggressive behavior and a theory of interpersonal behavior would be useful to nursing staff who are attempting to understand, prevent, and manage aggression in forensic mental health units.
Future research and practice development in limit-setting and de-escalation might consider the General Aggression Model (GAM; Anderson & Bushman, 2002), one of the most contemporary and integrated models of aggressive behavior. The GAM incorporates elements of a number of domain-specific theories of aggression. It characterizes the ongoing social interaction of a person in a situation into three important categories, each of which contributes to aggressive behavior: (1) inputs—those person- (e.g., a dominant interpersonal style or paranoia) and situation-related (e.g., crowding, staff behavior) factors that influence aggressive behavior; (2) the cognitive, affective, and arousal routes that are aroused by the person and situation inputs; and (3) the outcomes of the underlying appraisal and decision processes that lead to aggressive behavior. The GAM highlights the need to examine those personal attributes of service users that they bring to the mental health unit that increase their likelihood of aggression. It also draws attention to the important role of the environment and how service user and environment interact. Reference to the GAM has the potential to highlight a range of important environmental factors that might influence limit-setting and de-escalation and better assist staff understand aggressive behavior in forensic mental health units.
A second body of empirical and theoretical work that may be drawn upon to develop and enhance limit-setting and de-escalation practice relates to interpersonal theory (Kiesler, 1987; Leary, 1957) and associated studies of interpersonal style. Interpersonal style is important because it provides a framework for understanding how people prefer to interact with others; this is particularly important to the study of limit-setting and de-escalation and may help to understand why some service users respond poorly to mental health hospitalization and the behavior of nursing staff as they strive to provide treatment. The characteristic interpersonal style of service users, particularly a hostile-dominant interpersonal style, has been shown to predict aggression in forensic (Daffern, Duggan, Huband, & Thomas, 2008) and civil (Daffern, Day & Cookson, in press) mental health units. A hostile-dominant interpersonal style is also negatively related to the therapeutic alliance nursing staff share with service users (Daffern, Day, & Cookson, in press). Measures of interpersonal style are therefore critical to forensic mental health nurses who must engage service users in treatment of their mental disorder/s and offending behavior. Interpersonal style is also a significant determinant of aggressive behavior toward nursing staff. Future research into the development and testing of limit-setting and de-escalation strategies might draw upon interpersonal theory (Kiesler, 1987; Leary, 1957) and those studies that have identified the characteristics and behaviors of staff that relate to service user satisfaction and compliance (Kiesler & Auerbach, 2003). Service user satisfaction and compliance are likely to be inversely related to aggressiveness; interpersonal behaviors and staff characteristics that are related to compliance and satisfaction can therefore be considered in the development and testing of novel limit-setting and de-escalation methods.
Further empirically based research into the use of limit-setting and de-escalation is needed, as is integration of these concepts into existing theoretical frameworks of de-escalation. Without such research, these skills are likely to remain poorly understood in a research context and, consequently, continue to be implemented on an ad hoc basis. A richer understanding of these concepts may allow nurses working in forensic mental health settings to effectively contain and reduce aggressive behaviors while at the same time maintaining a therapeutic alliance with service users.
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