The assault cycle, de escalation and staying safe

Amara I want to start somewhere uncomfortable. A lot of care staff are told that aggression is just part of the job.

Nadia And it is not. Let me separate two things, because they get confused and the confusion causes harm. Understanding why aggression happens is useful. Being expected to absorb assault is not the same thing at all.

Amara So why does it happen?

Nadia Very rarely malice. Fear. Pain. Delirium. Dementia. Intoxication or withdrawal. Frustration at waiting or at not being heard. And the humiliation of having lost control over ordinary things, like when you eat and who sees you undressed.

Amara And you say that is practical, not just compassionate.

Nadia Deeply practical. If the cause is unmet pain, then paracetamol changes the behaviour and no amount of de escalation technique will. If the cause is being told what to do by a stranger, a genuine choice changes it in about five seconds. So before you manage behaviour, exclude pain, infection, constipation, needing the toilet, hunger, thirst and overstimulation.

Amara Tell me about the assault cycle, because I have heard the term and never had it explained.

Nadia Five phases. Baseline. Trigger. Escalation. Crisis. Recovery. And then a post crisis phase where the person is often exhausted and full of remorse.

Amara Which one matters most?

Nadia Escalation. That is where de escalation works. In crisis it barely works at all, and this is the single most useful thing in this module.

Amara So if somebody is already in crisis and I am talking them down?

Nadia You are probably prolonging it. Once a person is in crisis your objective changes. It is no longer talking them down, it is keeping everyone safe until the arousal falls. Reasoning with somebody in crisis is like reasoning with somebody who is drowning.

Amara What about recovery? That sounds like the safe bit.

Nadia It is the bit that catches people out. Arousal comes down slowly, so a second trigger during recovery sends the person straight back to crisis from a much lower starting point. Give time and space before any conversation. Do not go straight in with we need to talk about what just happened.

Amara Right. De escalation. What actually works?

Nadia Reduce the audience. Reduce the noise. And reduce the number of people talking to exactly one. Three staff all speaking at once is escalation, not help.

Amara And physically?

Nadia Give more space than feels natural. Lower your voice instead of raising it, which is counterintuitive and it works, because people match your volume. Slow your speech. Keep your hands visible and open.

Amara What do I say?

Nadia Short sentences. Their preferred name. Acknowledge the feeling out loud: I can see you are angry, and I want to sort this out. Do not argue about facts, because you will win the argument and lose the person.

Amara And what should I never say?

Nadia Calm down. It has never calmed anybody in the history of the world. Also you need to relax, and there is no need for that. All three tell the person their feeling is illegitimate, which is a fresh trigger.

Amara You mentioned offering a choice.

Nadia Two real options. Not an instruction dressed up as a question. Would you rather sit here or come through to the quiet room. Choice restores control, and lost control is usually what caused this in the first place.

Amara Let us talk about my safety. Where do I stand?

Nadia At an angle rather than square on. Square on is confrontational and it also means you cannot move. Stay beyond arm's reach and out of kicking range. Never let the person get between you and the door, and know where the second exit is before you need it.

Amara Anything to move?

Nadia Ligature and weapon risks within reach, where you can do it safely. And that includes things people forget. Your own lanyard. Scissors. A hot drink.

Amara When do I leave?

Nadia When the risk exceeds what you can manage. And I want to say clearly that leaving is a professional decision, not a failure. Summon help, follow the escalation route, and if you are a lone worker, use the check in system and the agreed distress phrase.

Amara What about restraint?

Nadia Not from this course, and not from any online course. Restraint carries a real risk of death, particularly prone restraint or anything restricting the chest or airway. It requires in person training under a recognised framework, it is a last resort, for the shortest possible time, and it is always recorded and reviewed.

Amara Afterwards. What should happen and what usually happens?

Nadia What usually happens is nothing. People do not report, especially verbal abuse, because they have decided it is normal.

Amara And the cost of that?

Nadia The staffing level never changes. The waiting time never changes. The layout never changes. The individual's unmet need never gets found. Under reporting is precisely why nothing improves. So report everything, debrief the team, and where it is appropriate debrief the person too, because many are ashamed afterwards and will tell you exactly what set them off if you ask at the right moment.

Amara And the colleague who was on the receiving end?

Nadia Check on them properly, not in the corridor. And take the cumulative effect seriously. One incident is an incident. Being shouted at every shift for two years is an injury, and it is the one nobody writes down.