“Violence is a universal scourge that tears at the fabric of communities and threatens the life, health and happiness of us all.”
(World Health Organization, 2002)
Every year, millions of people are violently victimized, injured and killed in the United States. The impact of violence is not only suffered by individuals and families but ripples through communities and society causing devastating damage at all levels.
Violence contributes to early death, chronic disease, mental health problems and a lower quality of life. It also places a heavy burden on the health and justice systems and erodes the economic fabric of communities by reducing productivity, decreasing property values and disrupting social services. The financial cost of violence is estimated in the trillions. For instance, the lifetime economic cost of intimate partner violence alone, is estimated to be $3.6 trillion and includes medical costs, lost productivity, criminal justice costs and victim property loss or damage. On the other hand, the human cost of grief, trauma and pain is incalculable.
No one is immune to violence and, any person regardless of age, race, gender, sexual orientation, or economic status may experience or perpetrate violence.
Is Violence Getting Worse in the U.S.?
The good news is that violence has declined significantly since the 1990’s. The bad news is that violence continues to be a serious problem that affects too many people every day. In 2017 alone, there were 5.6 million criminal victimizations including assault, rape and sexual assault, robbery, and murder. The Federal Bureau of Investigation (FBI) reports that in that same year, one violent crime occurred every 24.6 seconds, and every 30.5 minutes a person was murdered.
The Magnitude of Violence in the U.S.
- Homicide is the #1 leading cause of death for African-American males aged 15-34, the #2 leading cause for Hispanic males aged 15-34, and the #3 leading cause of death for all people aged 15-34 years.
- Suicide is #2 leading cause of death for young people aged 10-34, and the 10th leading for all ages.
- In 2018 there were 340 mass shootings in the United States, injuring 1,347 people, and claiming the lives of 373 individuals
- About 2 out of 5 women and 1 in 4 men experience some form of sexual violence in their lifetime (NCIPC & CDC, 2018).
- Violence can happen at anytime and anywhere, including the workplace. Each year about two million workers report having been victims of workplace violence.
Violence is Preventable
The real good news is that violence is preventable, and we can all learn how to stop it. Violence prevention starts with gaining a deeper understanding of what violence is, the forms it can take and the risk factors that can make someone more likely to become a perpetrator and/or a victim of violence. The next steps involve becoming proficient in identifying the warning signs of violence, developing skills to defuse threatening situations peacefully and effectively, and having access to a reliable emergency alert response system.
In most violent incidents an attacker doesn’t just snap but tends to show important signals that are often disregarded as they are often subtle, confusing or unclear. Learning the skills to defuse a dangerous situation, knowing how to respond during a crisis, and being able to request immediate help can save lives and keep yourself and others safe.
Part 1. Violence topics
- Definition of Violence
- Types of Violence
- Workplace Violence
- The 6 Most Dangerous Professions
- 20 Risk Factors that Could Make You a Victim of Workplace Violence
- Mental Illness and Violence
- 8 Warning Signs of Mental Illness that Everyone Should Know
How is Violence Defined?
The World Health Organization (WHO) defines violence as:
“The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”
This definition is commonly used in public health because it captures the range of acts by perpetrators and the subjective experiences of the victims. It includes:
- Different types of violence: Interpersonal violence, self-harming behavior and collective violence.
- Violent acts that are not only limited to physical acts but also threats and intimidation.
- A wide range of consequences of violence both obvious (physical harm) and less obvious (psychological harm, deprivation and maldevelopment).
Types of Violence
Violence into three main categories:
- Self-directed violence: Includes suicidal and self-harming behaviors (e.g. self-cutting). Suicidal behavior can range from thoughts about killing oneself to committing suicide.
- Collective violence: Members of a group committing violent acts against another group or set of individuals with the goal of achieving political, economic or social objectives. Some examples are: Terrorism, organized violent crime and armed conflicts.
- Interpersonal violence is divided in two categories:
- Family and intimate partner violence: mainly between family members and intimate partners and usually taking place in the home.
- Community violence: occurs between people who are unrelated and may or may not know each other. Usually takes place outside the home
- Interpersonal violence can take many forms, including youth violence, random acts of violence, sexual violence, child abuse, intimate partner violence, elder abuse, and workplace violence.
Workplace violence refers to any incident involving threats or acts of physical violence, harassment, intimidation or any other threatening disruptive behavior occurring at the workplace. It can affect and involve employees, clients, customers and visitors.
While the word “workplace” may make us think of an office in a building, a workplace can be any location permanent or temporary where an employee performs work-related duties. A workplace can include buildings, surrounding perimeters, parking lots, field locations, clients’ homes or offices, and the commute to and from work.
Workplace violence can be physical and/or psychological. Physical violence is often more evident and easier to recognize and can range from slapping and pushing to sexual assault, suicide and homicide.
The most common form of workplace physical violence is simple assault, an attack without a weapon that results in no injuries or minor injuries requiring fewer than two days in the hospital (e.g. a black eye, scratches or cuts).
On the other hand, psychological violence is not always easily identified and includes verbal abuse, bullying, stalking, intimidation, harassment and threats. Both types of violence can cause harm physically, mentally, spiritually, morally or socially.
Is Workplace Violence a Serious Problem?
Yes, workplace violence is a serious problem in the U.S. The Occupational Safety and Health Administration (OSHA) reports that each year, about 2 million individuals are victims of workplace violence, and the number of these types of incidents is vastly underreported.
Workplace violence not only affects the health, wellbeing and dignity of employees but also poses a threat to the efficiency and success of organizations. It costs organizations billions in lost productivity, legal expenses, property damage, negative public image and security costs.
Workplace violence statistics:
- Workplace violence is the #3 leading cause of fatal occupational injuries.
- Shootings account for 80% of workplace homicides.
- The rate of workplace violence for government employees is more than three times greater than the rate for private-sector workers.
Who are the perpetrators and victims of workplace violence?
The #1 most common characteristic of perpetrators of workplace violence
When it comes to workplace violence, the most common characteristic attackers present is an altered state of mind that can be attributed to a) a medical condition such as dementia or delirium, b) decompensated mental illness, or c) substance use or withdrawal.
- Most perpetrators of workplace violence are strangers.
- Robbers and other assailants commit most workplace homicides (70%) followed by work associates (21%).
- In about a quarter of workplace violence incidents, the offender was believed to be using drugs or alcohol.
- In healthcare settings, it is patients who commit most violent acts against healthcare professionals (80%).
Victims of Workplace Violence
Women suffer most of the non-fatal workplace violence, but men die as a result of workplace violence much more often than women. In 2016, 82% of fatal workplace violence victims were men and 18% were women.
When women are killed in the workplace, it is often at the hands of a relative or domestic partner (43%). Men, on the other hand, are mostly killed by a person committing a robbery or by an unspecified assailant.
Most victims of workplace violence tend to be young. In 2017, workers aged 20-34 had the highest rates violence at the workplace.
The 6 most Dangerous Occupations
Although workplace violence can happen to anyone, individuals in these occupations have higher rates of violence:
- Law enforcement
- Mental health
- Retail sales
- Law enforcement: About 56% of workplace violence against government employees is committed against those working in law enforcement and security.
Workplace violence is the #1 cause of both fatal and non-fatal injuries among correctional officers.
- Mental health: The rate of workplace violence for mental health professionals is four times higher than the overall rate for all professions.
- Transportation: this includes bus and taxi drivers and other transportation occupations. The workplace violence rate for these professions is 2.3 times higher than the overall rate for all professions.
- Retail sales: Bartenders have the highest workplace violence rate of all retail sales occupations; their rate is comparable to mental health professions.
More than half of all workplace homicides happen in retail or service settings such as conveniences stores, taxi services, and gas stations.
- Medical: this includes physicians, nurses, technicians and other medical occupations. Those who work in healthcare are four times more likely to be victimize than workers in private industry
Nurse aides working in nursing homes with dementia patients are at the greatest risk for assault. The majority of such workers (59%) reports being assaulted once a week, and 16% report suffering assaults on a daily basis.
- Education: Those working in technical or industrial schools present the highest rates of workplace violence in the teaching professions. School shootings are another great concern for educators. In In 2018 there were 24 school shootings with injuries or deaths in the U.S. and 114 people were killed or injured. Among those who were killed, a quarter were school employees.
20 Risk Factors that Could Make You a Victim of Workplace Violence
Knowing which risk factors are associated with workplace violence can help employers assess possible vulnerabilities and take appropriate precautions to minimize the risk and increase safety for all employees.
Here are some of the most common risk factors that are known to increase the chance for experiencing violence at the workplace:
- Working with volatile and mentally unstable people
- Exchanging money with the public
- Lack of emergency communication
- Working alone or in small groups
- Poor lighting in corridors, parking lots, offices, stairs, etc.
- The belief that violence is tolerated in the workplace and reporting incidents will have no effect.
- Working in isolated areas.
- Presence of firearms.
- Working with people under the influence of drugs or alcohol.
- Working in deliveries.
- High worker turnover.
- Working where alcohol is served.
- In healthcare: transporting or moving patients.
- Working late at night.
- Inadequate security.
- Working in high-crime areas.
- Long waits for service.
- Lack of staff training on violence prevention skills and inadequate safety policies.
- Poor environmental design that may block vision or escape routes.
Mental Illness and Violence
Mental Illness is more common than you think
Although we sometimes think that mental illness is rare and wouldn’t happen to us or to a loved one, the reality is that nearly one in five adults in the U.S. experiences mental illness in a given year.
Mental illness refers to mental, behavioral, or emotional disorders that can cause mild to severe functional impairment and interfere with major life activities. Said simply, mental illness affects the way a person thinks, their feelings, mood, their ability to enjoy life and their capacity to function at school, work and home. Some examples of mental illness are: Major depressive disorder, posttraumatic stress disorder, bipolar disorder, schizophrenia and personality disorders.
Unfortunately, people suffering from mental illness often go without treatment for months, years, and sometimes, even their entire lives. Lack of adequate mental health treatment places individuals with mental health issues at higher risk for serious negative outcomes such as incarceration, victimization, suicidality and violence.
Stigma around mental illness can lead people to think their symptoms are not valid or that what they are experiencing is a sign of weakness or somehow their fault. These types of beliefs could not be further from the truth and only prevent people from seeking needed mental health care. There’s clear evidence that mental illness is not the fault of the person who has a mental health condition but is caused by environmental and biological factors. Psychiatric conditions are real medical conditions that can be treated effectively.
Are mentally ill people dangerous?
Although the media has helped portray the mentally ill as inherently dangerous, the reality is that most violent crimes are committed by people who are not mentally ill. Individuals with severe mental illness are actually more likely to become victims of violence than perpetrators.
With that said, mental illness can increase the likelihood of violent behavior in a small portion of individuals, particularly when other risk factors are present. For instance, the risk of violence is 3 to 5 times greater for men with schizophrenia, and 4 to 13 times greater for women with schizophrenia. Some diagnoses associated with violence include psychotic disorders, bipolar disorder, PTSD and some personality disorders.
Serious mental illness has been found to be associated with mass homicides in half of the cases. Common symptoms in perpetrators of mass shootings include acute paranoia, delusions, and depression.
Mentally ill individuals are also at risk for harming themselves. Up to 50% of individuals diagnosed with schizophrenia or bipolar disorder attempt suicide at some point in their lives.
Overall, when mentally ill individuals act violently, it is not only due to their mental illness. The presence of certain risk factors increases the likelihood of perpetrating violence in individuals with psychiatric disorders.
Risk factors that increase the likelihood of violence in the mentally ill
- Lack of adequate mental health treatment.
- A history of physical abuse, juvenile detention and parental arrest.
- Substance abuse.
- Perceived threats.
- Recent stressors such as divorce, unemployment or victimization.
- Lower socioeconomic status.
- Being young and male.
Warning: The First Psychotic Episode
Studies of individuals with serious mental illness show that the risk for committing violent acts including homicide, is greater during the person’s first psychotic episode.
When someone experiences a psychotic episode their brain’s ability to make out reality is affected causing disruptions in their thoughts and perceptions. Psychotic symptoms can include hearing, seeing or feeling things that are not there, becoming fearful or suspicious or having trouble thinking clearly.
Sometimes psychosis can signal the start of a more serious mental illness such as schizophrenia or bipolar disorder. Often psychosis starts to appear in the late teens to early thirties. Psychotic symptoms in these types of conditions tend to appear gradually but the person may not understand what’s happening.
Mental Health Treatment Can Saves Lives
The earlier the diagnosis and start of evidence-based treatment, the better the chances for recovery. This is why it is important to recognize the warning signs of mental illness and seek help and support as soon as possible, whether it is for you or someone you care about. Receiving effective treatment is key in reducing the risk for perpetrating and experiencing violence.
- Mentally ill individuals receiving effective treatment are not more dangerous than the average person.
- When individuals with serious mentally illness act violently, they are generally not receiving or not complying with recommended treatment.
Mental Health Treatment Resources
- Treatment locator: https://findtreatment.samhsa.gov/ or call 24/7: 1-800-662-HELP (4357)
- Peer support groups through the National Alliance of Mental Illness (NAMI) https://www.nami.org/Find-Support/NAMI-Programs/NAMI-Connection
- Support groups for family members https://www.nami.org/Find-Support/NAMI-Programs/NAMI-Family-Support-Group
- NAMI: 800-950-NAMI
- Suicide prevention, free and confidential support for people in distress, 24/7: 1-800-273-TALK (8255)
8 Signs of Mental Illness that Everyone Should Know
The signs and symptoms of mental illness can vary, depending on the type of disorder the person is experiencing and other factors. Learning about the warning signs of mental illness can help identify a developing problem and seek treatment early. Doing so may not only minimize the risk of violence but also reduce the severity of mental illness, delay it or even prevent it altogether.
- Social withdrawal
- You may notice the person drops out of activities enjoyed before, keeps losing friends and starts concentrating too much on him or herself.
- Other signs include sitting and doing nothing for long periods of time and declining school, work, or athletic performance.
- Mood disturbances
- Feelings of hopelessness.
- A deep sadness unrelated to recent events.
- Depression that lasts more than 2 weeks and lose interest in activities previously enjoyed.
- Thinking or talking about suicide is another important warning sign of a mood disorder or another type of mental illness.
- Sleep or appetite changes
- Noticeable changes in appetite (eating too much or too little).
- You may notice the person starts sleeping too much, or in contrast is unable to sleep (insomnia).
- Irregular expression of feelings
- This can include hostility that is out of character.
- The person may also start to show apathy or indifference to situations, even important ones such as a promotion, graduation or another life event.
- Inability to express joy.
- You may also notice that the person laughs at odd or inappropriate times or for no reason.
- Changes in behavior
- Hyperactivity, inactivity or switching between the two.
- Poor hygiene, for example, the person stops showering and brushing his teeth and doesn’t want to change or wash his clothes.
- Car accidents (may point to inability to concentrate or disturbances in the thought process).
- Some people experiencing symptoms of mental illness also start using drugs and alcohol in an attempt to regulate their emotions and state of mind.
- Bizarre behavior such as staring inappropriately, adopting strange postures and grimacing.
- You may also notice an unusual sensitivity to noises, light or clothing.
- Distorted reality: Difficulty perceiving reality, experiencing delusions (false beliefs that others don’t share) or hallucinations (seeing, hearing, feeling or tasting things that others can’t).
- Lack of insight: the person is unable to notice important changes in his or her own feelings, behavior or personality.
- Thought disturbances:
- Excessive or strange fears, suspiciousness or paranoia.
- Inability to concentrate.
- Feeling daily problems are too much and being unable to cope with daily or minor problems.
- Irrational statements.
If you notice several of these symptoms in yourself or a loved one, it’s important to seek an evaluation and discuss treatment options with a licensed mental health professional.
Part 2. Violence Prevention Skills
- The 5 signs of Imminent Violence that Everyone Should Know
- 12 Things You’ll Need to do Before De-escalating a Situation
- Traits of Successful De-escalators
- 6 Techniques to De-escalate a Threatening Situation
- Active Listening Skills in Violence Prevention
- What is a Mental Health Crisis?
- 6 Warning Signs of an Impending Mental Health Crisis
- 6 Things You Should Never Do in a Mental Health Crisis
- How Mental Illness Affects Behavior and Perception
- Do’s and Don’ts in Mental Health Crisis Intervention
- When Should you Call 911?
The 5 signs of Imminent Violence that Everyone Should Know
Before a person explodes in anger and attacks others, he or she will typically exhibit verbal and nonverbal indicators that signal escalating anger and potentially imminent violent behavior.
- We can help remember such signs using the GAINS mnemonic:
- Gestures of anger, such as shaking a fist, prolonged staring, slamming a door, throwing objects and yelling.
- Acting suspicious, anxious, fearful, or hostile.
- Incongruent behavior that doesn’t match the words; for example, a person stating that he or she is “fine” while pacing and becoming increasingly agitated.
- Noticeable signs and symptoms of stress, such as sweating, flared nostrils, clenching the jaw, jugular vein distension, elevated heart rate, shaking or trembling, and muscle tension.
- Systematically pacing, tapping feet, shaking knees, sighing, running fingers through the hair repeatedly, rubbing the forehead.
Proceed with Caution
- If you have identified GAINS signs, proceed with caution to decide your best course of action.
- De-escalation techniques can help defuse a threatening situation and reduce the risk of violent behavior.
- The immediate goal when using such techniques is to build rapport with the angry person to reduce their level of anger and risk of physical assault and increase the level of safety for everyone involved.
- Before you use such techniques, we will review several things you’ll need to take into account.
12 Things You’ll Need to do Before De-escalating a Situation
The first step is ensuring that the conditions are safe for de-escalation. If that isn’t the case, leave, call for help and activate the emergency alert response system or panic button. Here are some important things you will need to consider before implementing de-escalation techniques:
- Identify potential escape routes.
- Remain in an area where others can see you and position yourself close to an exit.
- If the area is unsafe (e.g., you’re alone and there are no visible exits), consider moving to a safer area.
- Consider your surroundings and individuals who may potentially assist you.
- Be aware of weapons or objects that could be used as weapons (e.g. chairs, box cutters, heavy or sharp objects).
- Take into account the safety of others who are present.
- Consider any knowledge you have of the person (e.g. a client who you know is going through a divorce and has been drinking too much).
- Think about the meaning of the behavior (e.g. co-worker who has just been fired and is angry).
- Ask yourself if the behavior seems alarming or strange. (e.g. sounds incoherent, confused, sees or hears things that aren’t there).
- Know how to use your organization’s emergency alert system. It’s important to have an emergency system or panic button that employees can use instantly to quietly alert key staff and/or law enforcement of dangerous situations.
- Activate work safety protocols if the situation warrants it.
- Do a quick check-in with yourself. Are you calm or able to calm yourself down? If you’re visibly agitated or angry, de-escalation techniques will be less likely to work.
Traits of Successful De-escalators
When implementing de-escalation techniques, it’s important to remain as calm as possible. Take a moment to take a few deep breaths before starting. Successful de-escalators are great listeners who are also:
- Self-aware [link active listening skills]
6 Techniques to De-escalate a Threatening Situation
If you’ve determined that the conditions are safe for de-escalation you can use the techniques described in the LOWLINE theoretical model. This approach is based on established principles of communication and empathetic listening to help de-escalate difficult and potentially threatening situations.
This model has been used in many contexts and professions from nursing to customer service and involves applying 6 techniques: Listen, Offer, Wait, Look, Incline, Nod, Express= LOWLINE
When you’re dealing with an angry person it may be tempting to respond quickly but it is important to first listen using active listening skills. Note that you will need to use active listening skills throughout the entire de-escalation process, not just in the beginning.
Active listening isn’t merely hearing the words a person is saying but being able to read:
- Non-verbal signals such as facial expression and body language.
- Paraverbal communication including tone of voice, inflection and volume.
Additionally, active listening involves using non-directive and non-intrusive feedback to let an angry person know you’re paying attention to the person and have interest in what they are experiencing. This means that instead of quickly offering suggestions or explanations, you will allow the person to talk freely. Anything that makes the person to explain instead of arguing can help lower the confrontation level.
Non-directive feedback can include open ended questions or comments such as:
- “Can you tell me more about that?”
- “Please let me understand exactly what happened”.
Image: McMains, M. J., & Mullins, W. C. (2014). Crisis negotiations: Managing critical incidents and hostage situations in law enforcement and corrections. New York: Routledge.
Offer the angry person the opportunity to vent and explore their feelings. Acknowledge their anger and offer to listen to their concerns. This is not the moment to contradict them or argue but to validate their feelings.
You can say:
“I can see that you’re angry, will you let me help you with your concerns?”.
“I want to work with you, please tell me what’s upsetting you”.
An angry person will not always be able to explain the cause of their anger and you may need to ask them additional questions. For example: “When did you start to feel upset?”
Don’t be tempted to fill all silences with words. Give the person time to respond.
Count to ten before responding if the situation starts to feel awkward.
Look at the person but make sure not to stare. Continue paying attention to non-verbal cues and facial expressions. Maintain a neutral expression and smile when appropriate.
Inclining your head or tilting it to the side is a non-verbal sign of interest in what the other person is saying.
Nodding when appropriate can show maintained interest and willingness to listen without interrupting.
Continue using active listening skills and express empathy and a desire to understand.
- “I can see how that made you feel offended”
- “I understand how that made things worse for you”
- “I can see why you feel that way”
Paraphrasing is another active listening skill, and an effective way of showing empathy and validates the person’s feelings, this involves rewording what the other person has said and summarizing the encounter, pointing the mentioned reasons for the anger:
“You thought that we were meeting at 10:00 instead of 11:00 and you’re angry because you wasted time waiting for me when you’re so busy and on top of that you had to wait in traffic to get here”.
After you notice the person has visibly calmed down, explore options on how to resolve the situation. Offer support and advice. You can ask: “What can we do to resolve this?”
Likely there will not be one single solution, so several feasible options should be explored.
Often times, reassurance that the person’s concerns are being taken seriously and not merely being paid lip service to will suffice.
Do’s and Don’ts When Using De-escalation Techniques
- Do intervene early.
- Show genuine concern for the person and adopt a non-authoritarian manner.
- Speak in a calm and gentle voice.
- Be aware of your own body, how you’re looking at the other person and how you’re moving.
- Avoid being passive or indifferent.
- Avoid touching and coming too close to the person.
- Do not show anger or take offense.
- Do not make judgmental comments.
Active Listening Skills in Violence Prevention
Active listening skills are useful in all aspects of social interaction, they help convey to the other person we are actively engaged, we care, and we are listening. They are particularly helpful in de-escalating an angry person who may become violent. When you use active listening skills, you are not only hearing the words a person says but reading the complete message communicated verbally and non-verbally.
Verbal communication is simply what we say, and how we say it. In verbal communication, we may consider the content of what we are saying, and also our speech patterns. The rate, tone, inflection and volume of your voice are important factors to consider (i.e. paraverbal communication).
When using active listening skills, you will need to pay attention to the person’s nonverbal signals such as facial expressions and body language. Non-verbal communication includes your body language and how you physically approach a situation. It is important your body language (or non-verbal communication) be congruent with what you are saying verbally. You are more likely to be considered authentic in your presentation if your verbal and non-verbal communication matches.
Facial expressions are considered the most significant way we provide non-verbal communication to one another. Studies have shown that when communication is broken down, 7% is verbal (words that are spoken), 38% is vocal (the tone and pitch in your voice), and 55% is nonverbal messages. For these reasons, it is important to focus on maintaining a calm demeanor and facial expressions whenever we’re listening to a person in crisis.
Anger Worry Frustration
While words, or verbal communication can be misleading at times, body language is usually dependable. Body language is another nonverbal way of communicating and refers to the gestures, movements, and mannerisms by which a person communicates with others.
Body language includes:
Harmony between verbal and nonverbal communication can indicate trustworthiness
Body language can quickly assist us in de-escalating a potential crisis situation by assessing the angry person’s body language and controlling our own (remember the GAINS signs).
How your body language can defuse or worsen a crisis
When we’re using active listening skills, we must also be aware of our body language, otherwise we can inadvertently send the wrong message and worsen a delicate situation. For example, if you’re dealing with an angry client and stand in front of him with legs hips width apart and arms crossed, you could signal an authoritative gesture. If you are looking to approach someone in an open way to build rapport, this may not be the stance to utilize and could instead, make a person escalate.
- Leaning your body forward, speaking fast, and using animated hand movements during conversation can convey to someone that you are discussing something important and it’s time for others to join in on the matter.
- Conversely, leaning backward in conversation, with slow rate of speech, and slower body movements can send a message of caution when considering the message
These simple nonverbal intricacies can completely change the message received.
Other non-verbal signs to note
- Usually, someone who is smiling and maintaining eye contact may appear happy or approachable.
- Someone who may avoid eye contact, blush, or avoid people, may be embarrassed.
- Individuals who are fearful tend to be wide-eyed or nervously looking around.
- An individual who is worried may look down, start to pace, fidget, and cannot focus on the issue at hand. An individual who is surprised may jump back and have an opened mouth.
- Someone who is skeptical may squint their eyes or even tilt their head down in a pronounced way.
Eye contact is also a very important part of non-verbal communication that is part of one’s facial expression. Skilled professionals are aware of the power of eye contact. Enough eye contact can make one feel that you are being attentive and interested in what they have to say.
On the other hand, too much eye contact can make an individual feel nervous, uncomfortable, or even threatened. If we have an individual who may be experiencing a mental health issue and they are exhibiting signs of paranoia, it may not be useful to stare at them and maintain intense eye contact, as they may perceive this as a threat.
Generally speaking, eye contact can convey the following: if they are maintaining eye contact, they are relaying an interest in what you are saying.
- Looking down and away may be a sign of modesty.
- Often times, when we look up in conversation, it is because we are trying to recall information.
- Not maintaining eye contact can be considered a sign that one may not be telling the truth.
- Staring should be avoided, as this can be considered an aggressive act by some.
What is a Mental Health Crisis?
A mental health crisis is a short-term incident involving acute mental distress that occurs when a person’s behavior places them at risk of hurting themselves or others and/or keeps them from taking care of themselves and functioning effectively in the community.
Mental health crises are considered emergencies and should be treated as such, meaning that they should be addressed immediately and effectively.
Often mental health crises happen when someone is not in treatment, but they can also occur when the person is actively receiving mental health care. Mental illness is unpredictable by nature. This is why it is particularly important to know the warning signs of a mental health crisis and be aware common stressors than may act as triggers.
Stressors that could trigger a mental health crisis
Some stressors that can contribute to a mental health crisis include:
- Home or environmental stressors: break-ups, divorce, losses (death, divorce, losing a job, etc.), relocation, conflicts with others, trauma and exposure to violence.
- School or work stressors: feeling singled out by co-workers or peers, real or perceived discrimination, failing grades or losing a job.
- Other stressors: being in a crowd, experiencing natural disasters, pending court dates, using drugs or alcohol, starting a new psychiatric medication or a different dose, treatment stops working, stopping medication or not taking it as prescribed.
6 Warning Signs of an Impending Mental Health Crisis
The first step in managing a mental health crisis is recognizing it. Familiarize yourself with the following warning signs:
- Inability to perform daily tasks such as showering, brushing teeth, eating, changing clothes, etc.
- Rapid mood swings, that go from mania (e.g. increased energy, inability to stay still, pacing) to depression or vice versa.
- Increased agitation, recklessness, making verbal threats, destroying property, out of control or violent behavior.
- Abusive behavior to self (e.g. self-cutting) or others.
- Psychosis: the person loses touch with reality, doesn’t recognize family or friends; seems confused, has strange ideas or thinks they’re someone they’re not. The person may also be unable to understand what others say, hear voices that no one else does, see or sense things that are not there.
- Paranoia: having unwarranted and irrational suspiciousness and mistrust of people, groups or organizations, believing them to be conspiring to cause them harm. A person suffering from paranoia experiences intense anxiety and fear revolving around unrealistic threats.
If you notice the aforementioned symptoms in yourself or another person, don’t hesitate to seek guidance from a mental health professional who can recommend a proper course of action.
6 Things You Should Never Do in a Mental Health Crisis
- Wait for things to get better on their own. Without treatment, symptoms may worsen, and permanent harm may result (e.g. suicide).
- Deny, ignore or minimize the symptoms.
- Try natural remedies instead of consulting a psychiatrist or qualified mental health professional. Remember, mental disorders are real medical conditions that can be treated successfully.
- Try to handle the situation on your own. You will need support.
- Promise secrecy. This is different than being discrete, when you promise not to tell anyone about concerning mental health symptoms you could be doing more harm than good and contribute to the person’s isolation. Instead, you can tell the person you care too much for them to keep a secret that can only hurt them. “You need help and I’m here to help you get it” can be a good response.
- Make comments such as:” it’s all in your head”, “just snap out of it”, or “you’ll be fine, don’t worry”.
How Mental Illness Affects Behavior and Perception
When someone is experiencing acute psychiatric symptoms, they may not be able to clearly communicate their thoughts, feelings, needs or emotions. It may also be hard to understand or hear others (particularly if they’re experiencing hallucinations).
The goal in an emergency is to stabilize the situation and get the person needed treatment as soon as possible, this may include an involuntary hospitalization if the patient is refuses needed inpatient treatment. The latter is recommended when the symptoms are too severe and the risk of harm to others or self is too great.
Connecting and empathizing with the person is key to de-escalate the crisis and maintain safety. Before intervening, it is important to know that mental illness (and some medications or substances) may affect how a person communicates and perceives different situations, particularly if they are not in treatment. For example:
- A person who is acutely psychotic may be paranoid and overly suspicious of others’ intentions. Approaching this person in an overly firm way could actually escalate the situation and potentially validate the person’s delusions.
- Individuals living with schizophrenia or other psychotic disorders, may also be experiencing hallucinations, such as hearing voices that only they can hear, which in itself may affect their ability to stay focused and follow instructions.
- Individuals who are in a manic episode often have poor impulse control and may misinterpret social cues. It is not uncommon for them to be out of place and to speak and laugh loudly, often for no apparent reason.
Don’t Underestimate the Risk
People who are experiencing acute psychotic symptoms and are also abusing substances may be unpredictable and are capable of extreme violence.
It is important to clarify that psychotic symptoms are not exclusive to schizophrenia; they can appear in other mental disorders such as mood disorders or may be the result of substance abuse.
Contact information to have in case of a mental health crisis
- The number of the person’s treating mental health professionals, they will also have a number for crisis if you call afterhours, make sure to have it in your emergency contact numbers.
- Phone numbers of support people.
- 800-950-NAMI (Monday to Friday), 10 AM – 6 PM ET
- If you can’t call you can also text “NAMI” TO 741741
Do’s and Don’ts in Mental Health Crisis Intervention
- Keep a calm voice.
- Listen to the person and express support and concern.
- Ask how you can help.
- Move slowly.
- Give the person space.
- Ask permission if you need to come closer.
- Announce your actions before initiating them.
- Be patient.
- Keep a calm voice.
- Listen to the person and express support and concern.
- Ask how you can help.
- Move slowly.
- Give the person space.
- Ask permission if you need to come closer.
- Announce your actions before initiating them.
- Touch the other person.
- Give orders, offer options instead.
- Try to reason or argue with the person.
- Be judgmental (e.g. “you should’ve taken your medications”).
- Make sudden movements.
- Try to manage the situation alone, having someone else present or on the phone can help defuse a situation.
- Stand over the person (sit if the person is seated).
- Joke or laugh, it may be interpreted as ridicule and increase agitation.
- Don’t hesitate to call 911 if you feel unsafe, threatened or fearful.
When Should You Call 911?
You will need to assess the urgency of the situation to determine your actions and who to involve.
- Is the person in danger of hurting themselves, others or property? This can include both actions and threats. Remember the definition of violence and all that it entails.
- If the answer is yes, you need to call 911 and ask for immediate assistance or activate the emergency alert system.
What do I say when calling 911?
When you call 911 say that someone is experiencing a mental health crisis, explain the diagnosis if you know it, and describe the nature of the emergency (why you believe they’re in danger of hurting themselves, others or property), your relationship to the person and whether there are weapons involved.
The 911 operator will ask for your name, the person’s name, age and description, the person’s current location and whether the person has access to a weapon.
- Ask the 911 operator to send CIT officers if available, these are specially trained officers who work with people with mental illness and de-escalate situations. They’ll also be familiar with the community’s mental health resources.
- CIT stands for Crisis Intervention Training.
Share this Information with the 911 Operator
- Mental diagnosis and history (include hospitalizations).
- Current and discontinued medications.
- Previous suicide attempts, any current threats of suicide or self-harming behavior (e.g. self-cutting).
- Prior violence, any current violent threats.
- Drug use and the type of drug if you know it.
- Current stressors.
- Hallucinations, delusions, loss of touch with reality.
Be specific about the concerning behaviors, focus on recent events and right now as opposed to the past.
For example: instead of saying “my boyfriend is acting weird”, you can say:
“my boyfriend’s behavior is worrying me because he stopped taking his medication for bipolar disorder, has not been to work for the past three days, has not been sleeping, is constantly pacing and believes his co-workers ridicule him and want to harm him. He has been talking about “making them pay”, I’m afraid to talk to him, and I’m not sure if he’s planning to hurt someone”.
After You Call 911….
Medical and or first responders and law enforcement may become involved. When they arrive, they will make a determination on the best course of action.
If you don’t feel safe staying with the person, leave the location immediately.
If you feel safe with the person: remain calm, allow the person to move freely, reduce noise and bright lights, don’t disagree or argue, announce your actions in advance (”I’m going to the kitchen to get some water”), use short and simple sentences. If the person isn’t talking, it’s ok to stay quiet.
What to do when Officers Arrive
- Remain calm and explain that this is a mental health crisis.
- Provide relevant and concise information about the person (diagnosis, medications, symptoms, threats, weapons, etc.).
- Don’t yell, argue or be in the officers’ way. It’s important that the officers stay calm.
- The officers may take the person to the ER, send him or her in an ambulance or allow you to transport your loved one to the ER. The important thing is to get the person an evaluation and needed treatment.