Managing Challenging Behaviors in Mental Health

Introduction

This study aims to conduct an exploration of how mental health practitioners’ use communication skills and de-escalation techniques to manage challenging behaviors in an acute mental health setting. The first section will highlight the background and rationale of the study. Next, there will be an identification of the research aim, research objectives, and research questions. The second chapter will entail a statement of the search strategy. The search strategy section will be followed by the discussion of the main findings through literature appraisal, then a detailed outline of the conclusions containing a recap of the main points highlighted in the literature review.

Works by Jenner et al (2004) indicate that service users in mental healthcare are people with mental health issues who have been brought to health facilities for mental healthcare. Particularly, according to Phillips et al (2014), patients who have developed mental issues as a result of drug abuse, bipolar or posttraumatic stress can violently or aggressively express their thoughts. Hence, when a patient brought to receive mental healthcare become aggressive, they are termed as aggressive service users. In mental healthcare, practitioners use various techniques to address aggressiveness among service users – one of them being de-escalation techniques. According to Ritcher, (2006), de-escalation techniques are skills of managing aggressive or challenging behavior of mental health patients through effective communication skills; that help calm down the service user whenever they try to develop aggressiveness.

In the context of mental health, aggression is a term used to denote any behavior that is directed at a particular person by another, with the intention of causing harm. Lee et al (2003) observe that aggressive behaviors can be manifested verbally, physically or psychologically towards the other person, or can be manifested in the form of damage to the environment.

Nonetheless, it is monumental to identify and appreciate the difference between aggression and violence within the context of mental health. This is because as observed by Orygen Research Center (2007), the terms are often mistaken to have the same meaning, yet they do not. First, Ritcher, (2006) defines violence as a situation where one intentionally uses physical force to cause harm or damage to property or an individual; while on the other hand, aggression is defined by Tishler et al (2000) as a situation when one generally depicts an angry or violent behavior. Hence, clearly, there is a difference between aggression and violence. Ideally, as stated by Ilkiw-Lavalle et al (2002) a violent person may be aggressive but an aggressive person may not necessarily be violent. Besides, according to Ritcher, (2006), whereas aggression may lead to a verbal or physical attack, such attacks may not be based on harmful intentions. On the other hand, Farrell et al (2010) argue that violence is always a physical expression of aggression; it may be reactive, predatory, defensive and impulsive in nature. Besides, as opposed to aggression, violence can emanate from environmental or situational factors as a result of cultural or personal beliefs (Ritcher, 2006).

Existing literature also reveal that whereas aggression and violence have a negative effect on people both at an individual and societal level, violence is a bit differentiated because violent individuals may attack others physically or sexually, especially when they are under the influence of drugs (Ritcher, 2006).

Also, whereas it may be difficult to establish the exact factors that may contribute to violent or aggressive behavior, Orygen Research Center (2007) observe that both violent and aggressive people tend to have issues related to social status, institutional forces or personality issues. Moreover, observations by Tishler et al (2000) indicate that violent people often lose relationships, jobs and family members.

But existing literature also shows that there are various types of aggression, and that aggression can be understood in different ways, namely expressive aggression, hostile aggression, accidental aggression, and instrumental aggression. According to Phillips et al (2014), accidental aggression may be as a result of carelessness rather than intent. It is often experienced among kids during play, and also among adults especially when they are in a hurry. For instance, an individual in rush to catch a bus may hit a person. On the other hand, expressive aggression is manifested in harm, although the perpetrator may not have meant to cause harm (Ritcher, 2006). Hence, even though an expressively aggressive person may cause harm to another individual, this may not be his/her original intention. On a penultimate note, Ilkiw-Lavalle et al (2002) define hostile aggression as one that is targeted at causing psychological or physical harm to the other individual. Such acts may include bullying, rumor spreading or just engaging in malicious acts against another individual. This form of aggression may also result from provocation. Lastly, instrumental aggression, as described by Phillips et al (2014), often arises in situations where one feels their right has been denied. For example, a student may become aggressive when he feels his desk has been taken by another student by knocking his belongings off the desk.

Several pieces of literature have highlighted the cause of aggressive behavior as well as the theoretical perspectives of aggressive behavior. For instance, the general aggression model holds that people act aggressively as a result of various person-centered factors that are mediated by several other variables such as arousal and cognition National Health Service (NHS, 2003). Nonetheless, the scope of the present study does not include the general etiology of aggression, but rather, the study will focus on the use of communication skills as well as other techniques to manage these behaviors in mental health setting.

Orygen Research Center (2007) points out that aggression may occur in various health settings such as the emergency setting as well as the inpatient setting. But, according to Tishler et al (2000), practitioners involved in active mental health setting are more likely to experience patient aggressive behaviors. That said; it is important to take note of Webber’s (2006) assertions that when aggression is left untreated or poorly managed, it can escalate to violence, which creates risk for both the aggressor as well as those in their surrounding such as the health practitioners, fellow patients or even family members. The importance of the issue of aggression in the mental health setting is further understood within the context of existing statistics on workplace violence, which indicate that at least 4% of the global workforce experience physical aggression and that among this population, nurses are three times more susceptible to the risk of workplace aggression than any other profession (Spenser & Johnson, 2016). Spenser and Johnson also quote a study that reviewed 424 studies and reported that 32% of workplace violence occurs in psychiatric hospitals and that the acute healthcare settings are also at higher risk. Besides, statistics by the NHS Project (2015) reveal that whereas approximately 67,864 NHS staff experience workplace violence annually, a majority of them (67%) occur in mental health settings. Statistics quoted by Spenser and Johnson (2016) also indicate that a significant percentage of NHS staff (14%) have experienced an incidence of workplace violence either from a colleague, service users, the public or relatives.

Violence caused by challenging behaviors are estimated to have a significant impact on the health practitioners offering de-escalating services, and these impacts may be rated as mild or severe (Farrell & Salmon, 2009). For instance, according to Farrell et al (2010), practitioners who experience verbal aggression within the mental health setting may be demoralized and may find it challenging to be productive or perform well in their duties. Besides, remarks by Ilkiw-Lavalle et al (2002) indicate that when practitioners in the mental health setting are increasingly exposed to violence by service users, they are likely to develop increased stress, reduced job satisfaction, hence being unable to effectively deliver the required quality standards of care.

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Various techniques of addressing aggressiveness among service users have been documented in existing research. For instance, Ilkiw-Lavalle et al (2002) recommend interventions such as rapid tranquillization, physical restraint, or seclusion as some of the most common methods of addressing aggression within mental health settings. But, some of these remedies are only applicable in specific situations, especially considering the service user’s right to receive quality and safe mental health care. For instance, according to Phillips et al (2014), seclusion is only recommendable for use in situation when it is impossible to manage the service user’s risk as well as the risk of other people’s lives in private or communal environments – because seclusion is usually unpleasant for both the service user and the practitioners. Moreover, because seclusion and restraint do not involve any communication skills, they do not fall as part of de-escalation skills.

Whereas these techniques have been effective in special situations, they are more invasive and may cause an increase in the risk of injury to both staff and the service users – and are in fact always useful when de-escalation techniques have failed (Ritcher, 2006). Hence, to ensure that the service users are not exposed to risk or harm, any episode of escalating aggression needs a prompt response with de-escalating techniques before the practitioner can resort to any other techniques such as restraint and seclusion. But according to Rippon (2000), de-escalating during challenging behaviors involves a complex process of both verbal and non-verbal communication used by practitioners so as to prevent service users from escalating their aggressiveness during challenging situation. Against this background, the main aim of the study is to explore how mental health practitioners use communication skills and de-escalation techniques to manage challenging behaviors in an acute mental health setting.

Research Question

What are the communication skills used by mental health practitioners to de-escalate mentally ill patients with challenging behaviors?

Methodology

Search Strategy

This study relied on a systematic search and analysis of literary materials to achieve its objectives. The process entailed a detailed identification and gathering of research evidence from existing literary materials to answer the research question and achieve the research objectives. Therefore, to come up with a comprehensive summary of how healthcare practitioners use communication skills and de-escalation techniques in health care settings to address challenging behaviors in a mental healthcare setting, the study systematically evaluated existing evidence and analyzed these pieces of evidence in regards to their ability to answer the research question. The first step in the search strategy was the identification of literary materials from specific online databases i.e. EBSCO and Proquest.

During this process, as illustrated in the PRISMA chart below, 700 relevant literary materials were identified. There were no other materials identified from other sources apart from the two online databases. The 700 literary materials were then subjected to screening and removal of duplicates, a process which led to an elimination of 427 literary materials. 423 literary materials were then subjected to further screening to ensure that they aligned to the predetermined inclusion/exclusion criteria. The first screening for eligibility led to the elimination of 400 articles because they were not written in the English language. On the other hand, the second screening for eligibility led to an elimination of 14 literary materials because they were not written in full text. Ultimately, the search strategy yielded 9 literary materials to be included in the literature review.

Inclusion Criteria

Only literary materials that written in the English language were included for literature review; researcher to easily understand and interpret the evidence they present. Besides, only the studies that could be accessed in full-text were included in the study so that the researcher could comprehensively access the evidence and apply them to the research objective

Exclusion Criteria

All the studies that did not meet the inclusion criteria were excluded

PRISMA tool illustrating article search process

Discussion

The Use of De-Escalation Techniques

Existing guidance on violence management as provided by National Institute of Health and Care Excellence (NICE, 2015) defines de-escalation engaging in talks with an agitated or angry service user in a manner that averts violence by instilling self-control and calm in them. Sometimes referred to as talk-down or defusing, de-escalation is a complex technique which involves both verbal and non-verbal communication techniques and skills that must be employed by the practitioner within a range of settings to ensure that the service user’s aggressive behavior does not escalate.

To date, literature has documented various de-escalating techniques that practitioners can use on service users e.g. avoiding shouting, use of calm tone, avoiding threatening words on service user. In regards to non-verbal communication, Rippon (2000) points out that some of the techniques include maintaining eye contact, taking a firm body stance, ensuring personal safety and maintaining high level of self-awareness.

Literature by Spenser & Johnson (2016) suggests that both non-verbal and verbal communication techniques are effective in de-escalation because when used appropriately, they are capable of bringing the service user to a calmer personal environment. However, despite the wide consensus that de-escalation techniques are widely recommended and used for aggression management, Spenser & Johnson (2016) acknowledge there is a paucity of research evidence highlighting its effectiveness. Besides, Spenser & Johnson (2016) cites a study by American Association for Emergency Psychiatry Project BETA De-escalation Working Group which estimates that an effective de-escalation technique should not take more than 5-10 minutes before returning the agitated service user to calm. Hence, it is possible to conclude that the main intention for de-escalation techniques is to produce an immediate effect in reducing the service user’s aggressiveness rather than for long-term purposes.

NICE (2015) stipulate that de-escalation should be used as an early intervention to manage the aggression and prevent it from entering a crisis stage. According to Orygen Research Center (2007), It has several potential benefits to service users as well as practitioners; such as better health and well-being as well as safe practice respectively, especially in situations where there is a need to avoid physical interventions.

The important nature of de-escalation has made it a target of staff training and career development. According to Rippon (2000), more health institutions are beginning to notice the important nature of having a hospital staff with adequate knowledge in de-escalation techniques and therefore more practitioners are enrolling in aggression management training programs. However, Orygen Research Center (2007) opine that there currently, there is a paucity of knowledge on the benefits of de-escalation, even though reports by Ilkiw-Lavalle et al (2002) indicates that it contributes to staff confidence and morale.

The Nature and Objectives of De-Escalation

Challenging behaviors among mentally ill patients can manifest themselves in different ways. For instance, Azeem et al (2015) observe that agitation is one of the most predominant causes of challenging behaviors among the mentally ill, and this can cause behavioral emergencies such as violence. However, whereas traditional methods of treating agitated mentally ill patients (involuntary medication and routine restraint) have been popular for a while now, a greater emphasis has been put on communication as a non- coercive approach. For instance, Bernstein & Saladino (2007) points out that if communication skills are implemented with genuine commitment, practitioners can achieve better results than traditionally expected. Consequently, Chigbundu (2015) acknowledged that a three-step communication model has been invented within the practice domain whereby first, the patient is verbally engaged before establishing a collaborative relationship with them (second step). Afterward, the third step is to verbally de-escalate the patient out of the agitated state. This communication technique holds some similarities with the methods published by Lazeares (1975) several years ago.

Ideally, the management of agitation and other challenging behaviors among this group of patients has improved over time. For instance, according to Bowers (2014), the modern way of managing agitation is ‘helping the patient to calm themselves’ as opposed to the traditional way of ‘calming the patient’. These assertions are in agreement with the writings by Bowers et al (2015) that the use of verbal and non-verbal communication to manage agitation and other challenging behaviors among the mentally challenged is a patient-enabled approach that encourages the patient to develop their own internal locus of control.

Bowers et al (2013) argue that the main aim of de-escalation is to enhance the patient’s safety, help the patient manage their distress and emotions while maintaining or regaining control of their behavior, to minimize the use of restraint, and to reduce the use of coercive de-escalation techniques. However, literature by Chigbundu (2015) shows that these objectives may be difficult to achieve especially because in an active mental healthcare setting, different situations present different challenges. For instance, in an active mental health care setting, emergency situations may arise, and in these situations, both the patient and the practitioners may slip not an irrational state of expediency while engaging with each other. Similar assertions where made by Daffern et al (2012) who noted that a practitioner who has several patients to attend to may decide to use medication to avoid verbal engagement, yet such an early use of medication may appear to be humiliating, rejecting, or dismissive to the patient – this can lead to more challenging behavior (e.g. agitation or violence) from the patient.

According to Drach-Zahawy et al (2012), the use of communication techniques to deescalate challenging behaviors among this group of population is theoretically based on the proposition most of these challenging behaviors (e.g. agitation) are emotional syndromes that are associated with different forms of emotions. Yet, Dubin & Ning (2008) indicate that escalation of agitation occurs on a continuum namely, development of anxiety to higher anxiety, higher anxiety to agitation, and from agitation to aggression. Consequently, according to Duperouzel (2008), patients with some of these behaviors may find it difficult to engage in conversations and thus may require a more tactful way of management.

Communication Skills for De-Escalating Patients with Challenging Behaviors

Accord Respect to the Patient

Finfgeld-Connett (2009) says that one non-verbal communication technique that practitioners can use to de-escalate challenging behavior is to accord respect to the patient’s personal space. To expound, Chigbundu (2015) write that when approaching the patient, practitioners should maintain an arm’s length distance between them and the patient so as to not only give them the space they require but also to provide the space for safety flight if the patient decides to physically attack. Similar remarks are made by Hankin et al (2011) that when practitioners create a space between them and the patient during an engagement, they feel safe and it becomes easier to get out of the patient’s way if possible. Chigbundu (2015) justifies this technique by explaining that some of the mentally challenged patients must have had a history of trauma, and therefore they might be having previous traumatic experiences that can easily be triggered when certain aspects of personal space are not adhered to. For instance, mentally challenged patients who have undergone experiences of rape may be too sensitive to personal space. Moreover, a patient who has been living in the streets may be too sensitive to their personal belongings. These historical circumstances may create a sense of vulnerability among mentally challenged and this may be a predisposing factor to challenging behaviors.

Avoid Provocative Language

Chigbundu (2015) strictly recommends that practitioners should avoid being provocative with their language when addressing such patients. In fact, Hopper et al (2012) indicate that while engaging with the patient, the practitioner must demonstrate a body language that indicates that they are interested in listening to the patient, that they will not harm the patient – while showing their intention not to harm anyone. This can be practiced by avoiding concealed hands that suggest carrying of a weapon, or avoiding clenched hands. Similar recommendations are made by Chigbundu (2015) who said that while addressing such patients, practitioners should slightly bend their knees while avoiding a direct face with the patient in order to avoid appearing confrontational. According to Hueske (2008), excessively staring at the patient with direct eye contact can be interpreted as confrontational and aggressive. Ultimately, as advised by Bowers et al (2015), the practitioner has to strike a balance between being too open and maintaining a closed body language (e.g. turning away or arm-folding) because the latter can also communicate lack of interest. These assertions are in agreement with the observations made by Bowers (2014) that the practitioner’s body language must be congruent with what they are trying to say because otherwise, the patient might perceive them as being dishonest, or even appear to be ‘faking it’, thereby making them more agitated or angry. On the same note, Goetz (2014) observe that practitioners should avoid humiliating the patient through insults or anything that can be construed as humiliating because humiliation is a form of threat to a person’s integrity and mentally challenged patients can feel agitated when they become humiliated.

Verbal Interaction

Existing research also significantly dwell on the verbal contact between the patient and the practitioner. Lo (2015) recommends that when attempting to de-escalate the patient, only one person should interact verbally with the patient and that the first person to verbally make contact with the patient should be the one to implement the de-escalation procedure. However, in the event that that person is not professionally trained to perform that role, immediate changes should be made by designating a trained person. This recommendation is made based on the premise that the patient may get confused when multiple people are interacting with them, and this may lead to further escalation. Similar observations by Reyome (2009) suggest that while interacting with the patient, another bystander should be ready to alert other members of the team on any eventuality.

Results of the review also show that while establishing a verbal contact with the patient, practitioners should politely introduce themselves to the patient while providing reassurance and orientation (Chigbundu, 2015). In doing so, they should explain their role by asserting that they are there to avail safety and to ensure that nothing bad happens to them. However, Chigbundu (2015) insists that when the patient is experiencing higher levels of agitation, additional reassurance should be given to them by informing them that the practitioner is there to help them regain control. Nevertheless, Lo (2015) suggests that the practitioner should always know the patient’s name and that it is important to make a judgment on whether it is better to call the patient with their first or last name. This is because according to Lo (2015), the formality of calling patients with their last names may raise suspicion in them or appear patronizing. Against this backdrop, Bowers (2014) recommends that if the practitioner is not sure about the most suitable name to call the patient with, they should ask the patient which name they prefer from the beginning of the interaction. This has some effects on how the practitioner will be able to control the situation.

Clear Messaging

The existing body of literature also highlights the need to be concise and straight to the point while interacting with the patient. For instance, Reyome (2009) observes that an agitated patient’s inability to process certain verbal information necessitates the use of simple vocabulary and short sentences. Lo (2015) also agrees that the use of complex verbal language may cause confusion or lead to escalation. Hence, practitioners can be able to de-escalate or avoid escalation of challenging behaviors by giving the patient time to process what has been said before providing additional information or responding. On the same note, Chigbundu (2015) say that when verbally communicating to this group of patients, practitioners can facilitate de-escalation by persistently repeating the message they are trying to put across. This is because the patient’s agitated status inhibits them from effective processing of information. Hence, repetition can assist in easily making requests, proposing alternatives or offering choices to the patient without escalating their agitation. However, Hueske (2008) suggests that repetition should be considered alongside other assertiveness skills such as active listening and agreeing with the patient’s position whenever necessary.

Chigbundu (2015) observe that sometimes the patient might have some feelings or wants that should be identified by the practitioner. For instance, the patient may want to interact with an empathetic listener, intervening with a problematic employer or spouse, or they may be in need of medication. Hence, whether it is possible to grant the patient’s needs or not, it is important to ask them their needs. For example, the practitioner may ask for the patients’ expectation when they come for mental healthcare and let them know that even if it is not possible to meet all these expectations, it is still important to know them (Chigbundu, 2015). In this regard, Hueske (2008) recommend that practitioners can use free information to identify the patients’ feelings and wants. In doing so, they can observe some ‘free things’ that from the patient’s communication cues such as their body language or past experiences with the patient. By establishing a rapid connection facilitated by free information, practitioners are able to integrate empathy into their responses while expressing passion and desire to help the patients get what they need concurrently with de-escalating the patient’s agitation. This is especially important because just as a sad person would want something they have given up on having, mentally ill patients with agitating behaviors would be fearful of getting hurt (Bowers, 2014).

A major communication skill recommended by existing pieces of literature is that of paying close attention to what the patient is saying. According to Bowers (2014), practitioners must be listening closely to the patient’s verbal communication while expressing it through verbal acknowledgment, body language and through the conversation. This assures the patient that what they are saying is being listened to, thereby slowing down their emotions. Furthermore, Reyome (2009) recommends that the practitioner should repeat back what the patient has said to enhance assurance and satisfaction. This does not imply that they agree with the patient, rather, it indicates that they understand what the patient is trying to communicate.

From a theoretical perspective, Hueske (2008) suggests that practitioners can use Miller’s Law to closely pay attention to what the patient says. Fundamentally, Miller’s Law states that to clearly understand what a person is trying to say, one must assume that the statements are true while trying to imagine what it could be true of. According to Lo (2015), the use of this law will help the practitioner to understand the patient’s message while trying to imagine whether the message is true. This helps in being less judgmental thereby helping the patient sense that they are being listened to. For example, if the patient’s agitation emanates from the belief that someone is following him with an intention to harm, the practitioner can imagine the patient’s situation and try to engage in a conversation about why this is happening to them and why someone is trying to hurt them. This will depict the practitioner’s interest and enable the patient to engage in a conversation about what is causing their agitation. By engaging in such a conversation, the patient will begin to see the practitioner’s caring nature and this enhances de-escalation (Hueske, 2008).

Agree or Disagree With the Patient

Another important aspect of communication with the mentally ill patient for purposes of de-escalation is how to effectively agree or disagree with them. Bowers (2014) emerged with a technique called ‘fogging’ which entails finding something within the patient’s position which one can agree with. According to Bowers (2014), this technique is quite effective in enhancing the practitioner’s relationship with the patient, to allow for an easier de-escalation. Within this technique, there are three ways in which a practitioner can agree with the patient namely: agreeing with the truth, agreeing in principle, and agreeing with the odds. for example, in regards to agreeing with the truth, the practitioner can agree with the patient who is agitated after three attempts of drawing blood from him by saying that “ yes, I have hurt you thrice, do you mind if I try again?”. In regards to agreeing principally, a practitioner can agree with a patient who is agitated for being harassed with police by not generally agreeing that he is correct but by saying “I think the police should treat everyone with respect”. Lastly, to agree with the odds, the practitioner can agree with a patient who is agitated for having waited for so long to see the doctor by saying that “there are probably other patients who would be angry also”. Using these techniques can enable practitioners easily agree with the patients because to avoid agitation, they should be agreeing with the patient as frequent as possible. However, Bowers (2014) advice that while agreeing with the patient, the practitioner should never admit that they have had similar experiences before, but rather express that they believe the patient is experiencing such a situation. Nonetheless, Lo (2015) indicates that if there is no other way of agreeing with the patient, practitioners should just accept to disagree.

Communicate the Rules

Existing pieces of literature also indicate that one way of de-escalating challenging behaviors in a mental healthcare setting is by communicating to the patient the rules and setting the limits. According to Chigbundu, (2015), it is critically important for the practitioner to clearly inform the patient of the existing rules regarding unacceptable behaviors, by for example telling them that causing injury to them or to others, or telling that they stand a risk of being arrested or prosecuted if the assault anyone. However, Lo (2015) insists that such information should be communicated in a non-threatening way.

Bowers (2014) suggests that while laying down the rules, practitioners should ensure that they demonstrate their intention to be of help to the patient but not to be abused. Whenever the practitioner is feeling uncomfortable with the patient, they should acknowledge that feeling by telling the patient that their behavior is provocative or threatening. That said, Reyome (2009) suggests that the expression of fear should be done emphatically while communicating that any harm caused by the patient may interrupt of derailing the help that the practitioner is trying to deliver.

Against this background, Reyome (2009) state that while laying down the ‘rules of engagement’, the practitioner should ensure that the rules cover the need for mutual respect between them and the patient. On the other hand, the rules must also cover the fact that any violations will be met with consequences that are related to specific behaviors, are reasonable and are delivered in a presentable manner. Against this information, Reyome (2009) acknowledges that some behaviors such as breaking the furniture of punching the wall may signify the need for restraint, whereby the de-escalation procedures can still continue with some increased levels of consequences or limit setting. However, while doing all these, the patient should be reassured that the intention is to help them regain control over their behavior and to enable them to adopt reasonable behaviors. Practitioners can help the patient stay in control by coaching them on how to keep calm. According to Berring et al (2016), once a relationship has been created between the patient and the practitioner; the practitioners should try to teach the patient how to stay in control using gentle confrontational instructions.

Offer Choices

Another de-escalation technique is to offer the patient choices, especially when the patient is at a position where they can only either fight or flee. According to Bowers (2014), offering the choice can be an effective source of empowerment when the patient believes that the best option is to engage in violence. In doing so, practitioners should ensure that they are assertive and quick to propose alternatives to the violence. Besides, Reyome (2009) advices that while offering choices, practitioners should offer things that show kindness such as something to drink, access to a phone, or magazines. However, these choices must be realistic because any attempt to deceive the patient with unfulfilled promises may make them more agitated.

Conclusion

This literature review has found that communication skills can effectively be used to de-escalate mentally ill patients with challenging behaviors in a mental healthcare setting. The review has shown that both verbal and non-verbal de-escalation techniques have a potential of decreasing challenging behaviors such as aggressiveness, violence, and agitation. However, whereas much research has focused on the psychopharmacologic approaches to de-escalation of challenging behaviors, there is a dearth of discussion on the communication skills that can be used for the same purpose.

Nonetheless, modern clinical practice has indicated much support for non-coercive interventions for de-escalation, where the patient collaborates with the practitioners in the management of their challenging behaviors. This review has established that these techniques can be more effective that restraining or coercive techniques of managing non-challenging behavior. However, there are some situations that coercive interventions may be unavoidable, and thus the need for further research on how coercive interventions can be used effectively to avoid causing harm to the patient. It has been found that instead of using restraint or forced medication, practitioners in the mental health setting can use verbal and non-verbal communication skills to successfully de-escalate mentally ill patients with challenging behaviors such as aggressiveness, agitation or violence while building trust and better relationship with them. These techniques may help build confidence among the patients while enabling them to seek earlier help to avoid future episodes of challenging behaviors. Nonetheless, there was a dearth of information within the reviewed literature regarding the most effective ways of developing these skills among the practitioners. Further research is therefore needed on how to develop effective communication skills for enhancing the practitioners’ ability to de-escalate mentally ill patients with challenging behaviors. The researcher recommends that future research should focus on communication techniques for de-escalation especially in the domain of information technology.

Limitations of the Study

Whereas this study has had several useful findings, it was prone to several limitations that might have had an effect on the validity of its findings. The researcher used a variety of literary materials as sources of large amounts of data. However, the problem with this large amount of data is that the quantity may not necessarily mean appropriateness. This is because most of the data were collected to answer different research questions. The current study encountered similar challenges, but to ensure they do not affect the validity of the study, the researcher answered the current research question with a partial consideration of the data at hand. This was facilitated with the inclusion/exclusion criteria that delimited the studies included for review based on relevancy. Secondly, the research was not in much control of the quality of data collected due to reliance on secondary data. However, there was a critical evaluation of the study quality before including them in the study.

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