1. Take the Difficulty out of Difficult People: Assess/De-Escalate People with Signs of Mental Health Crisis
Detective Matthew Tinney
Detective Lawrence Saavedra
Albuquerque Police Department
Crisis Intervention Unit

2. Objectives
Basic understanding of people with personality disorders and psychosis.
Communication and de-escalation skills with focus on these populations.
Safety and anticipating behaviors.
Introduce the PURE model of negotiations, de-escalation, and safety.
Review 7 active listening skills

3. Clues to Mental Illness
General Inappropriateness of Behaviors
Comments
Clothing
Gestures
Disoriented for Time
Speech
Pressured Speaking
Abnormally Slow
Delusions or Hallucinations

4. Red Flags for Danger
• Pacing in place or back and forth • Hands are balled into fists • 100 yard stare • Eye contact avoidance • Bladed stance

5. Safety Issues Know your escape routes
Keep sharp and blunt objects away
Have a safe word
Trust your fear

6. Safety Tips Safe Distance Clear path to the door Bladed stance
Nothing between you and the door
Bladed stance
Emergency procedures in place
Easy access for emergency personnel

7. Tips for Assessing Mental State
Open Ended questions
Designed to get people talking, without further
guidance
Emotion Labeling
Identify the emotion being spoken or presented in their actions
Current Terms
Consumer
Peer

8. Anticipating Behaviors
“Never make predictions, especially about the future.” -- Yogi Berra.
Prepare for the worst, hope for the best, and use your skills to maximize chances of a good outcome.

9. The Perils of Predictions
It is impossible to predict behaviors in almost anyone.
People living with mental illness who are also in crisis are, by their nature, unpredictable … this doesn‘t mean violent.

10. The Perils of Predictions
Even highly trained people are not accurate enough to make reliable predictions.
Past behavior is by far the best predictor of future behaviors.

11. Difficult Clients Personality Disorders Borderline Antisocial Paranoid
Narcissistic

12. Difficult Clients
People displaying Mania
People displaying Psychosis

13. Effective Communication with Difficult Clients
Rapport with difficult clients can be challenging
Specific Techniques can be used to make difficult clients much easier to work with, and even fun

14. Effective Communication with Difficult Clients
PURE Communication and Negotiation
Pause
Unite
Refocus
Educate

15. PURE - Pause
Take a pause to prepare, and when in the room, pause for safety. When dealing the with difficult clients (other than safety), the most important thing is preparation.
Know what types of clients get to you and what kind of reactions they bring up.
Have a “Fail Safe” or BAMDO ready when engaging with difficult people.
Know about any history of violence.

16. PURE - Pause First get your emotions under control!
It’s your own emotions that de-rail the process, not theirs.
Pause, take a breath, gather yourself.

17. Prepare a BAMDO Best Alternate to Most Desired Outcome
Prepare for the worst, and strive for the best
What are you willing to accept?
If the client is demanding things you won’t give them, is it so bad just to document well and let them leave?

18. Pause – Don’t rush the client into the interview
Pause, before “Getting into it.” Even 30 seconds goes a long way.
Simple Rapport and First impressions are essential. We sometimes forget that the interview starts long before the formal interview.
Simple pleasantries and small talk can be invaluable.
Rapport should continue throughout the interview.

19. Pause – prepare the client
Let them know what to expect. No surprises, prepare them, “This should take about and hour, I may have to ask some personal question, and there will be lots of paperwork”

20. PURE - Unite
Unite with their concerns. Understanding is the key to empathy and unity.
Empathy is the ability not just to understand the client, but to convey that understanding to the client.
Empathy is not sympathy.
What is the best way to achieve Empathy and Understanding?

21. Understand
Listening
To Unite, you must listen! You can find their concerns, unless you hear what they’re trying to tell you.
Listening is the key to empathy, understanding, and unity. If the person truly feels you are listening to them, they will feel you care and that will come across as empathetic.

22. PURE – Unite in face of tough emotions
Understand and accept your own emotions.
Get emotions under control before moving on. People hear nothing unless they can process the information.
Understand the clients emotions. Label their emotions; even if you’re wrong, it’s okay and is essential for rapport.

23. Understand
If the client is making requests that you feel might be inappropriate, don’t negotiate about what they want directly. Find out first what it is that they truly want.
Negotiate and communicate about the substance at the root of the matter not the branches.
If a person wants more money in a job, maybe what they really want is more time with the family.

24. Unite when emotions are high
If the person is too revved up to let you through, use de-escalation and the seven active listening skills.

25. Unite – The Seven Active Listening Skills
Reflective/Mirroring
Open-Ended Questions
Minimal Encouragers
Emotion Labeling
Paraphrases
“I” messages
Effective Pauses

26. Role Playing Emotion Labeling Turn to the person next to you
One person turn back to presentation
Guess the emotion you see on their face

27. Surprised

28. Angry

29. Fear

30. Shame

31. Emotional Labeling Switch

32. Disgust

33. Happy

34. Sad

35. Flirty

37. Unite! By listening, you can begin to unite with their concerns.
Begin transition to Refocusing
Change focus from them attacking you to the both of you attacking the problem together.
Sit on the same side of the table.

38. PURE - Refocus
If someone is demanding, difficult, making accusations, refocus their anger and dissatisfaction into a less damaging or more productive directions, towards the problem or a neutral 3rd party.
Make sure problems are faced together.
What can you say to this? “You people are all the same, no one gives a damn, no one helps!”

39. Refocus
“It’s obvious that this problem means a great deal to you. It seems like you have had a lot of trouble in the past. I can’t speak for other lawyers or the experiences you have had with them. What I want to do, is make the most of our time together.”

40. Refocus
“The system is not so good, but if we work together, I think we can help you.”
“You’ve been through more trouble than I can imagine. But through all of this, can you think of anything good that has come out of your terrible experience?”

41. PURE - Educate
Unless invited to do so, don’t tell people what to do. Educate them about the situation and ask them for solutions.
Solutions that are client based are lasting solutions

42. Educate If the client can’t come up with solutions, ask questions …
What do you think can be done?
What if we tried …?
How about we … ?

43. Educate
If they can’t come up with any solutions, offer a menu of acceptable choices. If they refuse any of the choices, offer further education.
“You refuse to follow my advice, you can do that, but I will have to …”

44. Applying PURE to specific Difficult Clients
Borderline
Emotional regulation is the hardest part.
Keep yourself calm! And don’t forget to keep yourself calm!
People with Boarderline thrive on chaos.
Set firm boundaries around yourself.
Keep everyone involved on the same page.
Try to have a single point of contact.

45. Applying PURE to specific Difficult Clients
Narcissistic
Play into their narcissism without making promises.
“You seem like a very smart guy, you know how this systems works, probably better than anyone.”

46. Applying PURE to specific Difficult Clients
Antisocial
Know the signs and beware!
Don’t give into their charm.
They are usually narcissistic, and this can be appeased.

47. Applying PURE to specific Difficult Clients
Paranoid
They trust no one. Don’t expect that to change.
Be as transparent as possible.
Don’t play into nor fight their paranoia.

48. Applying PURE to specific Difficult Clients
Manic Behaviors
Use paraphrasing to interrupt.
It’s okay to laugh, just don’t laugh at them.
Expect narcissism and borderline type behaviors.
Psychotic Disorders
Don’t argue about their delusions
Don’t indulge their delusions

49. Thanks
Questions? Matthew Tinney Lawrence Saavedra