Expecting the Unexpected: Responding to Unpredictable Behavior

Hospital, school and university staff dealing with individuals who are addicted to drugs or alcohol must maintain their professionalism, as well as keep their messages to the agitated person short and non-judgmental.

Professionals working with people pursuing recovery from addictions are familiar with unpredictable behaviors. Resolve dissipates overnight. Significant relationships are viewed as unimportant, or seemingly insignificant relationships take on heightened importance. Grandiose attitudes emerge, and reckless choices are made. Depression magnifies emotional responses. Irrational thinking impacts critical decisions, and bizarre behavior creates chaos. Staff must be prepared to expect the unexpected and respond rationally when the inconceivable happens.

Addiction to alcohol or drugs is a constant inner battle, and the fight often reaches unintended victims. Anger and hostility can be startling or frightening, and a staff response of anxiety or fear can fuel the fire. It is important for staff to understand not only the aspects of addiction that may impact behavior, but also how their own responses can help or hinder de-escalation and resolution.

Maintaining professionalism in these moments of chaos is key in building therapeutic rapport. Responding to someone who is irrational requires a different approach than when interacting with someone who is anxious, confused or depressed. Verbal outbursts can be defused in a manner that makes escalation to physical aggression less likely. Although stress-producing for those around, the expression of hostility or anger through verbal venting expends the energy and emotion the individual in crisis has built up. It is ultimately less dangerous for that energy and emotion to be exhausted verbally than through physical acting-out behaviors. Staff who explore the verbal escalation process, are skilled at recognizing behaviors, and understand when and how to intervene with directive responses, can prevent high-risk behaviors. Training and rehearsal reduce the potential that our own fear or anxiety produces unproductive “fight or flight” reactions by patients and other individuals with addictions  in these moments of stress.

Remain Calm and Don’t Bring Up the Past
When intervening verbally with someone who is under the influence, it is important to keep your messages short and simple so the individual is better able to understand that your immediate goal is to help maintain safety. This is not the time to judge, counsel or discuss treatment planning or poor decision making. An irrational person is not processing these types of messages. Maintain a calm and patient tone to avoid becoming a behavioral trigger yourself. Avoid sounding judgmental, and don’t bring up the past. Ensure that you are sending the message that you are concerned about the person’s safety and well-being. Give a directive that clearly states what you want the individual to do next. For example: if your goal is for the escalating individual to return to a group meeting while he or she is verbally venting and expressing hostility or even threats, your directive might be, “Take a deep breath and have a seat on the couch.” Any act of compliance can begin to re-introduce rational thinking.

As breathing returns to normal and tension is reduced, another simple directive such as, “Try to stay quiet and just breathe slowly for a minute” offers a prelude to choice making. Effective limit-setting is an art that prompts good choices in the wake of bad ones. An effective limit could be, “You can go back to the group now to avoid an absence and status reduction and we can talk about this later. Or, you can stay here and we will discuss the status reduction in our meeting with your therapist this afternoon. It’s your choice — I’ll get you a cup of water and give you a minute to decide.”

Debrief to Close the Loop and Prevent Future Incidents
When the incident is over, a purposeful debriefing is key to re-establishing therapeutic rapport and preventing future incidents. Perhaps most important, meaningful debriefing helps develop trust and identifies aspects of care the individual needs to foster resilience on his or her road to recovery. While it is best to debrief soon after the incident, it isn’t necessary for it to take place immediately. It is also important that both the individual and staff are back in control emotionally and physically before debriefing. Obviously, if the individual was under the influence of drugs or alcohol during the incident, or is detoxing, it is necessary to allow time before discussing the incident.

Debriefing is a powerful tool that allows staff to look for avenues to prevent future unpredictable behaviors. Confusion, embarrassment or remorse experienced by the person who acted out are natural in the aftermath of a crisis incident and debriefing offers the opportunity to resolve those feelings. Clarity about consequences for behavior is also an outcome of debriefing. Debriefing helps staff to empower the person in recovery by allowing the individual to better understand where the behavior may be coming from and to find better coping mechanisms in the future. It is also an important time to identify resources for necessary referrals.

Help Them Replace Inappropriate Behaviors With Good Ones
During a debriefing process, patterns of behavior are often identified. When considering patterns, it is important to look for triggers to the behavior and explore what function the behavior is serving for the individual. Identify and discuss more productive replacement behaviors that might help the individual fulfill the function of the less productive behavior.

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