Most of these involuntary evaluations are managed without incident; but, sometimes the patient refuses to participate in the process. When a patient fails to cooperate with either assessment component they may be considered to be holding the process hostage.
Over the past few weeks several examples of hostage taking behavior have presented themselves in “my” ED. One fellow came in after a police standoff and refused to talk to anyone or give a urine sample to complete the medical screen, another was intoxicated and LOUD and kept several police officers busy until he went to sleep, a restless lady presenting a flight risk, and one older retired professor with behavior problems secondary to dementia. Each case presented different dimensions of the same idea: hostage-taking behaviors.
In the basic hostage situation one person takes control of another person and refuses to release them. The goal is to trade the captive for some good. When the behavioral health patient holds an ED hostage they are controlling the assessment process. It is not always clear what the patient’s goal is, but can usually be framed around the desire to dictate terms of release. There is often a narcissistic reach for power in action.
The patient that takes the assessment process hostage is holding a desperate position in a lose-lose game. Such a position is played from a place of powerlessness, where the patient is seeking control of their situation and/or emotions. Although they may not realize it, this patient is the most powerful person in the room.
One of the behavioral health worker’s tasks is to promote the patient’s feelings of power and channel that power into the development of the safety plan and, ultimately, into their taking control of their recovery.
What tools are available to respond to the hostage-taker?
Well, I fully believe in paying attention to the basics of patient care and behavior management. The stronger the foundation, the better plans can be built. Responding to hostage-taking behaviors is no exception. That means promote respect and dignity, practice effective communication, and observe positive behavior management strategies.
As a refresher, here is a reminder of what behavior is/isn’t (from [1])
BEHAVIOR IS:
- Any action that can be seen or heard
- Is observable
- Is measurable
BEHAVIOR IS NOT:
- Your reaction to the situation
- Your interpretation of the situation
- Your expansion of the situation
And the ABCs of behavior management:
A=Antecedent: The event occurring before a behavior.This event prompts that behavior.
B=Behavior: Response to the events that can be seen or heard.
C=Consequence: The event(s) that follow(s) the behavior.This effects whether the behavior will occur again.
- When the behavior is followed by a pleasant consequence, it is more likely to reoccur.
- When the behavior is followed by an unpleasant consequence, it is less likely to reoccur.
Regarding the importance of communication (from [2])
“Effective communication is an essential part of caring for patients. Yet there is evidence that in practice communication continues to be problematic.
The research base shows that: Poor communication can have serious consequences leading to complaints by patients and their relatives
Poor communication can leave patients feeling dissatisfied, frustrated, anxious and so uncertain that it affects their ability to comply with recommended treatments
Good communication can influence patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure as well as decrease reported pain and drug usage
Insufficient training in communication is a major factor contributing to stress, lack of job satisfaction and emotional burnout in healthcare professionals”
To set up an effective box to provide for safety of the patient and community in the ED setting a few things are necessary.
Remove the patient to the least stimulating area available, where they can be observed without being the focus for other visitors. This reduces attention and stimulation, promotes dignity, and creates a situation where the patient can deescalate safely.
Make the patient as comfortable as possible within the confines of the treatment environment. Emergency departments are not designed for comfort, they are designed for efficiency. But the offer of a pillow, warm blanket, decaf drink, and food can go a long way in developing rapport—and, ultimately, the safety plan.
The tincture of time will do the rest. There is no need to do much more. Nursing care is generally not required once the patient has been installed in a calm setting. If the patient is in custody they are confined to a small area and not a threat for wandering. Nature will do more to dictate when samples are obtained for the medical screen than anything that you can do.
The biggest mistake made in the ED setting, in my opinion, is to respond to challenging patient behaviors with a power struggle. Power struggles are demeaning to staff and patient. More importantly, they escalate the very behaviors that provide the challenge.
The flow of the emergency behavioral health assessment and safety planning process flow begins with recognition of the position of the patient. Powerlessness is the presenting cognitive position more often than not. In the search for power patients may resort to hostage taking behaviors. Effective management of these behaviors is built with empathy and respect by the ED staff for the patient and allowing time to work its magic in deescalating the patient’s emotional state.
RELAX, it’ll be all right….
Cites:
[1] Retrieved by rmcox on 2 june 2012 from http://www.bbbautism.com/behavior_management_strategies.htm
[2] Retrieved 01 june 2012 by rmcox from http://www.connected.nhs.uk/index.php?option=com_content&view=article&id=2&Itemid=2
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