De-escalating Folks When Psychotic and Potentially Violent

Monica Cassani
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I have a few stories I’ve written about, within the context of other posts on Beyond Meds, of times I’ve de-escalated people who might have otherwise become violent. I’m sharing them here just so that people can see what is possible and why I know that we can do much better than we do in many circumstances where people end up being re-traumatized unnecessarily when suffering in crisis. People, in general, are afraid when other people act with hostility. This is a natural human instinct, of course. However, meeting people in crisis by returning fear and violence will often backfire. Finding a way to connect can instead be healing for everyone involved.

I talked about these experiences the other day when I participated in the Crisis Intervention Team training with some of my local law enforcement. One of the officers had his own experiences of de-escalating armed and hostile distressed people and nodded in agreement as I talked about this. It was a powerful experience to share stories with those officers of the law. You can read about it here and I highly recommend you do. It was wonderfully encouraging to have the rapt attention of 6 sheriff’s deputies. They really wanted to know how to get better at helping people avoid losing their freedom in what is often a really difficult situation for everyone involved.

I made the suggestion to the officers that it’s worth always assuming that the situation can be de-escalated. And that relationship with another human being can happen in 30 seconds if one learns to connect. Once a relationship — a connection — is made with another person it’s possible to calm and create trust. And, finally, if the assumption is always made that it’s possible to connect with our fellow human beings even when they’re in distress and fearful and hostile, then each time one is called to be in a crisis situation is a learning experience, an opportunity to learn more about relating to our fellow human beings. We may not always accomplish what we know is possible, but we will have done all we can to create a positive healing experience instead of exacerbating the situation. It’s about learning and being kind to both ourselves and others. Not about being perfect. Life is messy sometimes and that’s often really clear when facing people in emotional crisis of all kinds.

Below are the excerpts from prior posts where I’ve written about the times I’ve been able to help distressed human beings who were wielding weapons.

From having had a knife held to me by two psychotic individuals I speak from experience when I say psychotic people can be communicated with. They can be calmed. They can be disarmed (literally and figuratively.) I don’t hesitate to say that I imagine that 99.9% of agitated psychosis can be quelled with love.

I loved the people who held knives to me. It’s that sweet and simple. I had compassion for them. I saw their fear and I did not respond with fear. In one instance the man holding the knife was a client in my office. I was alone in the office with him. He got agitated while talking to me and stood up and drew out a long butcher knife and swung it ominously around in the air in front of me, threatening. I became very calm and I began to speak soothingly to him. “You don’t want to hurt me, S____. Give me the knife.” I repeated this a few times. He looked confused, hurt, pained–then he gave me the knife and apologized. I escorted him out of the building and he left.

The second guy who held me at knife point was someone out of his mind on LSD. We were on the street at 3 am. I was walking home from work. He jumped wildly about me, yelling, “I’m a crazy mother-fucking Indian on acid!! You better watch out.” I calmly started asking him questions. “When did you take the acid? Do you know that you’re scaring me? I don’t think you want to hurt me.” He too came down quickly. He backed off and also apologized. He went on his way. (read more – My Forced Psychiatric Treatment)

What might surprise you, is where I learned to do that. It was when I was in what many would call a “manic” and psychotic state. Mania (and psychosis in general) is simply (and perhaps sometimes not so simply) an unintegrated part of the psyche. Once it’s integrated it’s no longer a problem and in fact can deeply inform many aspects of life.

I wrote about it in the first post on this blog:

…I was having my first manic episode. The wonders of the world opened up to me–all things were possible – I was one with the universe. I was charismatic and people were drawn to me. I was not, at first, out of control. Instead I had a confidence I had never experienced before. I associated with people from all walks of life and felt a deep love for all of humanity. In this altered state I had many exceptional experiences. I will share one with you.

I came out of my suite one day to the sounds of people yelling. I looked down the hall and saw a young man wielding a gun pointed at someone who had done him wrong in a drug deal. A veil of peace came upon me. I calmly walked up to the man who was still yelling at his customer with gun in hand. I gently put my hand on his shoulder. He turned to look at me seemingly disarmed. I said “you don’t want to hurt anyone…come on let’s go.” I took his arm and led him away to the stairwell. We walked down to the first landing and stopped. I spoke to him about love and peace, we hugged and he left. I don’t remember exactly what I said and I know if sounds terribly cheesy, but it worked. I felt a huge sense of power and oneness with humankind. — (read more – The Beginning)

I’m not suggesting that all was peachy in my life when I first experienced that sort of connection with someone most people would have been (reasonably) frightened by. If you continue to read that post you’ll see I was having a difficult time in many ways. The out of control psyche ain’t  pretty, but it sure as heck can be tamed and integrated and healed if one gets the proper care and guidance.

We can become whole again and we can learn from what we know at the times when things are chaotic and scary. It’s not all wrong, it’s simply distorted. And what I learned, what I had access to when I helped that man leave the building before he hurt someone, has stayed with me always. My understanding of the nature of humanity has only deepened throughout the years. I am no longer manic, nor do I get manic anymore, but I learned a whole lot from when I was. This is something we should be helping all our troubled young people learn how to do. That is, we need to teach them to integrate their difficult mind states so that they become sources of strength and wisdom rather than pain and danger. This is very possible. I know 100s of people who’ve managed to do this. We need to make it part of systemic care for the most vulnerable in our society that they might have the opportunity to heal and thrive.

People heal from having had psychotic experiences all the time, in many different ways. The paths to wholeness are endlessly diverse.

For some such stories see:  Psychosis Recovery: stories, information and resources

Important reminder: most people labeled with mental illness and psychosis and mania do not ever get violent. In fact statistics indicate that they are more often, in their vulnerability, subject to being targets of violence. 

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This article first appeared on Monica Cassani’s website, Beyond Meds.

18 COMMENTS

  1. Monica thanks for sharing your experiences of being with people in crisis.

    I want to respond and say something of what it’s like from another side, that of being the mother of 3 sons who have experienced psychoses and the daughter of a mother who experienced the same. Three generations of my family experiencing altered mind states and subsequent psychiatric treatment, myself included.

    First I have to say that it’s very tough seeing your son (or daughter), your mother (or father) in mental distress or an altered mind state, the person you love and want to keep safe, free from harm. You have to go through it to know what it feels like and then each of us will still have a different experience. The child that you have carried inside you, given birth to, is struggling, in pain, and it seems that you are powerless to help. I’ve been there, it’s the toughest experience I’ve had in my life of 61 years.

    The usual connections with your family member may have disappeared and there is a separation, a chasm which may seem impossible to bridge. Sitting with the discomfort is not enough and other support is needed. It may be that the only support available is admission to a psychiatric unit for respite and treatment. I never wanted to go there but had no other options. Same with my family members. There was no peer respite centres, no crisis support at home, no early intervention teams, no open dialogue project. Only psychiatry and psychotropic drugs. That’s the reality for many of us in families who are having to cope with distressed or “psychotic” family members living in the same house, block of flats, in cities and rural areas.

    I have seen it from both sides, of being a psychiatric survivor and a carer, and the former has helped with being the latter. I was a carer before becoming a mental patient. I think anyway that it’s all part of the same for none of us are free from madness and the effects of psychiatry. Even those who have never been in the institution.

  2. “In fact statistics indicate that they are more often, in their vulnerability, subject to being targets of violence.” Isn’t this true of everybody? You’re more likely to be a victim than a perpetrator. I’ve seen variations of the quoted statement elsewhere and I’ve always thought that, while it’s true as far as it goes, it doesn’t really add to the debate. I think it’s more helpful to point out that the mentally ill are exponentially more likely to be a victim of violence than the average person is.

    For myself, I’m not afraid of crazy people. The only people who have ever assaulted me have been wearing uniforms and collecting paycheques.

    • I met a guy while locked in hospital who was scribbling from the mouth as a result of the drugs he had been given. He could only speak his first language, Finnish. I understand a little and we got talking.

      He told me that he had got drunk and stoned on cannabis, and had fought with his wife. The police were called and he was chained up hands and feet. The duke here is if a police officer arrests you, and you vomit in the cells, your prisoner your mess. They didn’t want to take him to the cells to sleep it of so told him that when they got him to the police station they were going to pack rape him. Of course he struggled, and then they called mental health who took him to the hospital and drugged him out of his brain. This of course meant he lost much of his ability to speak English.

      I explained to the hospital manager what he was telling me, and that basically they police had set up the hospital to take a drunk/stoned man, coz they didn’t want him. Should have seen the managers face. Of course because of liability they weren’t going to back away from the mistake. So a man that needed a night in the cells to calm down and sober up gets 8 weeks locked in a hospital, and drugged out of his brain.

      Funny thing was that they had him convinced by the time he left the hospital that he was mentally ill and needed the drugs.

      So yeah Monica, the police do sometimes escalate the situation, not always unwillingly.

      Good luck with educating them.

  3. Great post Monica. As someone who works part time in a hospital setting, I have worked with many hundreds of people who have become angry, aggressive and potentially violent. It is always better if I have had the chance to make a connection with that person beforehand so he knows me and doesn’t see me as threatening. But if not I try to be real and not become fearful.

    Just a few days ago, a woman was very manic and started to throw chairs around. I knew her well and went in to talk to her. She started screaming at me loudly just a few inches from my face. I listened calmly and tried to ask questions. After a while she saw I wasn’t going to be aggressive to her and she calmed down a bit and talked to me. I could start to hear why she was so angry. I won’t go into details but what she said made sense. Her frustration and anger were very very justified, born out of trauma.

    Out of those hundreds of people I’ve worked with, almost all of them were able to deescalate. However, I will acknowledge that there are a few that are not simply psychotic and scared. There are some that are predatory towards vulnerable people, are intently looking for ways to inflict harm. Because of the setting (psych hospital) it is very unlikely that they will receive criminal prosecution. It is these few that are the most challenging.

    • Back in the mid-80’s, one of the things Paul Sherman did was to create Citywide Case Management in Denver. An integral part of the team was the Consumer Case Manager Aides, the first peer providers in the country. There were three different teams: the Acute Treatment Unit; the Homeless/Crisis Unit; and the Residential/Case Management Unit. After the six-month internship, I had the academic credential and went on to become a Case Manager. I later worked as a therapist on the Acute Treatment Unit, a locked inpatient unit. However, at first, I started with the Homeless Unit.

      The Homeless/Crisis Unit did two things. First, we’d go find the person. The people served were the H.U.G.’s (High User Group). Perhaps they’d be living under a bridge. We’d approach them and ask if we could be of assistance. We’d offer a sandwich, a blanket or even a new box in which to live. Often we’d be told to just go away and leave them alone. We would but we’d tell them that we’d be back tomorrow because it was our job to try and help them. Perhaps after several visits, we’d be tested and the person would ask for a new box to live in. We’d then drive all over trying to secure the best large refrigerator box we could. Eventually, as the person accepted more help, we could get them into housing and assistance including jobs and eventual independent freedom. This was completely free choice by the person. That’s the reason why I went into this story.

      The other thing we did was meet with the Denver police at every shift change. We made sure they all had our number and they’d call us first if they encountered a situation where they even thought the person might be one of “ours.” We made sure our Crisis team (part of the Homeless team) responded immediately. The officers never even had to get out of their cruiser. We’d often talk to the person, de-escalate the situation and send the person on their way. No hospitalization or meds necessary. No force and no coercion.

      The thing that made this all work was that we were empowered by the Mayor to release the officers back to patrol. They didn’t have to complete paperwork, they didn’t have to haul the person off to someplace else, they didn’t have to take the person into custody and then wait around to pass that custody off to others and they could get back on patrol to catch real criminals. The whole deal saved big bucks and everyone was happier and healthier. The only time I can recall out of hundreds of incidents that we needed the police was when the person was demonstrating super human strength and we figured that he was on PCP (angel dust).

      I tell you this because I think it’s a better approach than CIT. Cops are taught intimidation at the academy. Their uniforms, the badges, the guns, the body posture, the tone of voice all are very commanding of respect and intimidation. They can’t help it. CIT trains the officers in medical model diagnosis with the help of NAMI. CIT creates junior therapists of the officers as they judge and diagnose and otherwise discriminate against people. Then, the people are hauled off to “treatment” where they’ll no doubt get forced or coerced into being locked up and drugged. Also, as long as CIT is touted as being the best or only viable model, people won’t look at other possibilities such as that which I described above. CIT’s greatest claim is that they practice de-escalation techniques. That’s nothing new. They use the de-escalation techniques that have been in use for close to 100 years in the hospitality industry (hotels and restaurants). So, CIT uses intimidation to de-escalate and get people into “treatment” where we are dying over 25 years too soon.

      Please consider not supporting CIT but rather creating your own model that uses peers and supports choice without using force and coercion. I have given just one possibility for doing something different that doesn’t use force and coercion, that doesn’t require scary uniformed intimidation and that saves dollars and resources. De-escalation techniques were common when I volunteered at the Free Clinic in the 60’s and we also learned to just “be” with the person and to listen. Now those same techniques have new fancy names like “mindfulness” and “Intentional Peer Support” and “active listening” and DBT, etc. Please think about doing something other than CIT.

    • Yeah, one of the nurses on the ward I was on had a tendency to fly at people, arms waving. She seemed awfully unaware of her own affect. She reminded me of an article I read long ago about a group of mental health care workers who would observe in a hospital they didn’t work in, and they concluded that almost every time a patient got upset that one or more of the staff and/or family had treated them in a way that would upset anybody. Then, of course, they got to tut-tut at the patient’s reaction.

  4. Monica and Pat, Time for a small accomplishment from inside the belly of the beast. How many times in and out . Hauled in paddy wagons or ambulances, held down , forced injected, (I always thought it was thorazine) leather strapped down, ankles and wrists ,on my back, to the bed alone in a room, for endless hours , even days , electro shocked ,escaped 5 times ,caught within 24 hrs. only once and then up a level tortured and experimented on.Wait a minute ,isn’t just surviving a great accomplishment? Anyways from inside when someone new to the routine backed up angry and ready to fight into one of the rooms, refusing meds and I happened to hear and see it there was sometimes a small window while the staff was gathering its forces . I’d slowly walk in and say I’m just someone locked in here just like you are . Look I’ve been through this before .They’ed tell me no way were they going to take the “pills ” Quietly I’d explain the situation how no matter what, they would bring as many staff as needed to force the issue, and if at least we could tell them you would take the pills you could avoid the hold down, strap down injection. I was able to do it about 3 times. I ‘m not 100% sure if it was helpful or a betrayal but I tried and I think it was a small accomplishment.
    Monica and Pat I know you are both examples to learn from and deserve the deepest Respect and Thanks from anybody that realizes even parts of what you both have accomplished and continue to accomplish. G-D bless us all going forward.

  5. Unfortunately, most first responders across the country receive all or at least some of their training in dealing with the “mentally ill” from the corrupt Big Pharma front group, the National Alliance for Mental Illness (NAMI). In the resort city in which I live, this entails a day of training and workshops with lunch at a fine hotel.