Trauma-Informed De-escalation Strategies for Behavioral Health Professionals

What do you do when a client becomes aggressive and escalates into anger? 

Many behavioral health professionals work with clients who have experienced trauma and may be challenged to stay calm in treatment sessions. Learning how to recognize when someone is experiencing emotional dysregulation and to intervene in a compassionate way is part of a trauma-informed approach to treatment.

In this Workforce Development Module video, Trauma-Informed De-escalation & Engagement Strategies, Michele Paliotta, LICSW, explores a trauma-informed approach to treatment, providing practical de-escalation and intervention techniques that can be used in day-to-day practice. She also emphasizes the importance of self-care for clinicians. 

How does trauma inform clients’ emotional responses? And what are some trauma-informed de-escalation techniques that clinicians can use?

The Trauma Response

Trauma is what happens when the extreme stress of an event or circumstances overwhelm someone's ability to cope. It has damaging and lasting effects on health and relationships.

Trauma exists in threats to physical or emotional health such as violence, hate crimes, sexual abuse, or anything that causes extreme stress. Living in under‑resourced neighborhoods, moving a lot, and experiencing racism are all stressors that have lasting effects on bodies and minds. Trauma has a disproportionate impact on marginalized populations.

Trauma has an impact on all of us, but everyone’s response to trauma is different. 

According to the Centers for Disease Control and Prevention (CDC), 61% of people report experiencing at least one type of adverse childhood experience (ACE) before age 18, with 1 in 6 experiencing 4 or more types of ACEs.

Trauma is when an experience or situation causes a person to go into “fight or flight” response. The following are some examples of experiences that may be traumatic:

• Physical, sexual, and emotional abuse
• Childhood neglect
• Living with a caregiver with mental health or substance use disorders
• Sudden, unexplained separation from a loved one
• Poverty
• Racism, discrimination, and oppression
• Violence in the community, war, terrorism 

Trauma-Informed Care

Trauma-informed care has become an essential part of clinical and organizational practice. Its principles can also guide de-escalation strategies. In short, trauma-informed care shifts the focus from What’s wrong with you? to 

• What happened to you?
• What’s going on?
• What helped to create what you’re feeling now?

Trauma-informed care improves the outcome for clients and reduces the risks of clinician burnout.

When seeking trauma-informed de-escalation strategies, clinicians often think about the context that is motivating clients to behave or act the way they do. The question to consider is: What do our clients need to be healthy and thriving? This means looking at environmental factors. These can be

• Income
• Nutrition
• Housing
• Pregnancy/parenting
• Involvement with the criminal justice system
• Institutional barriers/racism

Much of this comes down to consistency and safety. How has the person interacted with the world, and how has the world interacted with them? 

Even though many trauma factors are beyond our control, acknowledging the three Es of trauma — events, experience, and effects — helps build trust and promote healing. 

A final tenet of trauma-informed care is that the individual’s experience of the event determines whether it is traumatic for them. Clinicians need to pay attention to their own biases and validate what clients say is traumatic for them.

When clinicians conduct ACEs screenings, they are gathering valuable information about the traumatic experiences that shape clients’ responses to perceived threats. This information can help provide context if clients have trouble regulating their emotions.

10 Domains of De-escalation

De-escalation is a method used to prevent potential violence. It involves purposeful actions, verbal communication, and body language to calm a potentially volatile situation. 

In Trauma-Informed De-escalation & Engagement Strategies, Paliotta shares the following general principles for de-escalating potentially violent situations.

1. Respect personal space.

2. Don’t be provocative.

3. Establish verbal contact.

4. Be concise.

5. Identify feelings.

6. Listen closely to what the client is saying.

7. Agree or agree to disagree.

8. Set limits.

9. Offer choices and optimism.

10. Debrief client and staff.

De-escalation Strategies

Clinicians can help diffuse volatile situations by:

• Understanding anger. Anger is considered a secondary emotion that arises from hurt, sadness, fear, and insecurity.
• Thinking about safety for the client and for yourself. If you do not feel safe being alone with an individual, remove yourself from the situation.
• Practicing reflective listening.
• Asking open-ended questions.
• Offering choice.
• Continuing to offer support/help. 

Check In with Your Own Emotions

What can you do when a client has trouble regulating their emotions?

Clinicians can do a self-check-in to get grounded. 

• What are you feeling?
• What do you want to do right now?
• What are you displaying to this person?
• Know your limits, and know when to seek additional help. 

Take a Walk?

If comfortable and safe, it can be a good idea to ask a client to walk with you to a safe area—around the block or the building. Walking reduces stress and creates safety. 

Check Tone

How are you communicating to the client? Are you being assertive/supportive or aggressive/adversarial?

Posture Check

Posture is especially important when engaging with de-escalation. Adjust posture to reduce intimidation. For example, don’t stand over people. Have an open, inviting posture, such as sitting side-by-side or kneeling.

A Trauma-Informed Approach to De-escalation

In the Connecticut Women’s Consortium training On-Demand De-escalation and Engagement Strategies: A Trauma-Informed Approach, Chris Dorval, MSW, LCSW, shares additional insights on helping clients with aggressive and drug-seeking behaviors. In addition to the trauma-informed principles discussed above, Dorval suggests exploring techniques such as bilateral fist clenching, tapping, and boxed breathing to encourage rational thinking. 

He also suggests Motivational Interviewing as a strategy for strengthening a person’s own motivation and commitment to change. 

When organizations and behavioral health professionals embrace trauma-informed approaches, de-escalation is part of a continuum of care that embraces the full range of human expression and emotion.