De-escalation and limit-setting in forensic mental health units

Abstract

Limit-setting and de-escalation are commonly used nursing interventions that are critical to the effective maintenance of the therapeutic milieu and the prevention and management of aggression in forensic mental health units. However, despite their purported importance, the techniques used in these interventions are rarely described. Further, these techniques are seldom based on empirical research or derived from a theory or model of aggression or interpersonal behavior. The purpose of this review is to examine the extant literature on limit-setting and de-escalation and consider how these activities could be enhanced. In concluding, this review emphasizes the potential benefits of drawing upon (1) a model of aggressive behavior and (2) a theory and literature examining interpersonal behavior, to enhance limit-setting and de-escalation skills.

Care planning for aggression management in a specialist secure mental health service: An audit of user involvement

“…Being aware of one's own tone of voice and body language are both indicated as part of verbal de‐escalation, as is remaining calm and being non‐confrontational (Price & Baker ). Similarly, good communication skills and providing a safe place for de‐escalation to take place are both regularly cited as cornerstones of de‐escalation (; Roberton et al ).…”

Police management of mental health crisis situations in the community: status quo, current gaps and future directions

“…The management of aggression in inpatient settings is based on two core concepts, namely de-escalation and limit-setting. What was very interesting, therefore, was that a recent review of the use of de-escalation and limitsetting in inpatient psychiatric settings found that there was very little by way of an empirical evidence base to demonstrate that any techniques commonly used and/or advocated actually worked (Roberton et al 2012). However, in place of this, there are a series of clinical practice guidelines, which have been drawn from the collective clinical wisdom of experienced mental health clinicians (NICE Clinical Guideline 25 2005).…”

“…Finfgeld-Connett (2009) and other authors (Johnson and Delaney 2007) have also reported that de-escalation strategies are more successful when communicating with the person in a respectful, empathic, calm and controlled manner. By embracing reciprocity, authenticity, simple and direct instructions, and fostering patient choice through providing options, this type of therapeutic stance has contributed to better outcomes (Lancee et al 1995, Roberton et al 2012). This stance links in neatly with more recent research into the application of interpersonal theory, considered along indices of affiliation and control, to the management of aggression (Kiesler 1983).…”

“…De-escalation serves to diffuse an individuals' aggression by the use of verbal and non-verbal skills; it is included in numerous clinical practice guidelines, training programmes and handbooks (Cowin et al 2003, Roberton et al 2012. The major goal of this technique is to provide sufficient time for the individual to regain control and to get them past the 'crisis point' without further escalating the situation.…”

“…Furthermore, a more considered appreciation of the role of interpersonal style may be helpful in to the context of providing further means of de-escalation, limitsetting skills and opportunities across a number of different psychiatric crisis situations (Roberton et al 2012).…”