URAWarrior Clinical Crisis De-Escalation Protocol
Version 1.0
Updated July 2024
What is a Mental Health Crisis?
A crisis is any situation in which a person’s behaviors puts them at risk of hurting themselves or others and/or when they are not able to resolve the situation with the skills and resources available.
For the purpose of this crisis protocol, a mental health crisis defined as: “behavioral, emotional, or psychiatric situation which, but for the provision of crisis response services, would likely result in significantly reduced levels of functioning in primary activities of daily living, or in an emergency situation, or in the placement of the recipient in a more restrictive setting, including but not limited to, inpatient hospitalization.”
Here are some examples of situations or stressors that can trigger a mental health crisis:
Home or Environmental Triggers
- Changes to family structure
- Changes in relationship with boyfriend, girlfriend, partner, spouse
- Loss of any kind: family member or friend due to death or relocation, pet’s death
- Strained relationships with roommates, loved ones
- Changes in friendships
- Conflict or arguments with loved ones or friends
- Trauma or exposure to violence
- Poverty
School/Work Triggers
- Worrying about upcoming projects or tasks
- Feeling singled out by co-workers/peers; feelings of loneliness
- Mounting pressures, anxiety about deadlines
- Lack of understanding from peers, co-workers, teachers or supervisors who may not understand that behaviors are symptoms
- Real or perceived discrimination
- Failing grades, losing a job
Other Triggers
- Stops taking medication or misses doses
- Starts new medication or new dosage of current medication
- Medication stops working
- Use or abuse of drugs or alcohol
- Pending court dates
- Being in crowds or large groups of people
- Community violence or trauma
- Major crisis in the world such as natural disaster, terrorism
Here are some warning signs of a mental health crisis:
Inability to cope with daily tasks
- Doesn’t bathe, brush teeth, comb or brush hair
- Refuses to eat or eats too much
- Sleeps all day, refuses to get out of bed
- Doesn’t sleep or sleeps for very short periods of time
Rapid mood swings
- Increased energy level
- Inability to stay still, pacing
- Suddenly depressed, withdrawn
- Suddenly happy or calm after period of depression
Increased agitation
- Makes verbal threats
- Violent, out-of-control behavior
- Destroys property
- Culturally inappropriate language or behavior
Displays abusive behavior
- Hurts others
- Cutting, burning or other self-injurious behaviors
- Uses or abuses alcohol or drugs
Loses touch with reality (psychosis)
- Unable to recognize family or friends
- Is confused, has strange ideas
- Thinks they are someone they are not
- Does not understand what people are saying
- Hears voices
- Sees things that are not there
Isolation from school, work, family, friends
- Decreased interest in usual recreational activities
- Changes in friendships
- Stops going to school or work
Unexplained physical symptoms
- Facial expressions look different
- Increase in headaches, stomach aches
- Complains they don’t feel well
What are the Warning Signs of Suicide?
People who are thinking about taking their own lives may exhibit one or more warning signs, either through what they say, what they do, or moods and feelings that you detect.
A suicidal individual may talk directly about wanting to die or about taking their life. They may be more indirect and talk about having no reason to live, not wanting to be a burden to others, feeling trapped or experiencing unbearable pain.
A person’s suicide risk increases if a behavior is new or worsens, especially if it’s related to a painful event, loss, or change. You may see an increase in alcohol or drug use, reckless and/or aggressive behavior, isolation, sleeping or eating too much or too little, or giving away prized possessions. They may also be searching online for ways to take their life and acquiring the means to do so. You may observe that they have withdrawn from activities that they once enjoyed or that they have visited or called people to say goodbye. They may become preoccupied with death and begin to put their affairs in order.
You may detect anything from a change in mood to extreme mood swings. These changes may be expressed through irritability, unexplained rage, feelings of humiliation, and/or increased anxiety and depression. You may also observe an unexplained peacefulness or calmness that can indicate that they have created a plan for their suicide.
The more warning signs you see, the greater the risk. They need immediate care by a mental health professional or doctor. The National Suicide Prevention Lifeline is available 24/7 for crisis counseling, information, and referral services in your area.
If the individual is presenting suicidal warning signs, immediately recommend they call:
Suicide Hotline: Dial 988 or 1-800-273-TALK(8255)
De-escalation Techniques
A person in the midst of a mental health crisis cannot always clearly communicate their thoughts, feelings, or emotions. They may find it difficult to understand what others are saying. It is important to empathize and connect with the person’s feelings, stay calm and try to de-escalate the crisis.
De-escalation techniques that may help resolve a crisis:
- Keep your voice calm
- Avoid overreacting
- Listen to the person
- Don’t make judgmental comments
- Don’t argue or try to reason with the person
- Express support and concern
- Ask how you can help
- Keep stimulation level low
- Offer options instead of trying to take control
- Be patient
- Gently announce actions before initiating them
- Give them space, don’t make them feel trapped
If you haven’t been able to de-escalate the crisis yourself, you will want to suggest additional help from mental health professionals who can assess the person to determine the level of crisis intervention required. If these strategies do not work, advise the individual to seek outside resources for help:
National Suicide Prevention Lifeline
Call 1-800-273-TALK (8255) En español 1-888-628-9454 Use Lifeline Chat on the web The Lifeline is a free, confidential crisis service that is available to everyone 24 hours a day, seven days a week. The Lifeline connects people to the nearest crisis center in the Lifeline national network. These centers provide crisis counseling and mental health referrals.
Text “HELLO” to 741741 The Crisis Text hotline is available 24 hours a day, seven days a week throughout the U.S. The Crisis Text Line serves anyone, in any type of crisis, connecting them with a crisis counselor who can provide support and information.
Call 1-800-273-TALK (8255) and press 1 or text to 838255 Use Veterans Crisis Chat on the web The Veterans Crisis Line is a free, confidential resource that connects veterans 24 hours a day, seven days a week with a trained responder. The service is available to all veterans, even if they are not registered with the VA or enrolled in VA healthcare.
Call or text 1-800-985-5990 The disaster distress helpline provides immediate crisis counseling for people who are experiencing emotional distress related to any natural or human-caused disaster. The helpline is free, multilingual, confidential, and available 24 hours a day, seven days a week.
Substance Abuse and Mental Health Services Administration (SAMHSA)
Call or text 1-800-985-5990 For general information on mental health and to locate treatment services in your area, call the SAMHSA Treatment Referral Helpline at 1-800-662-HELP (4357). SAMHSA also has a Behavioral Health Treatment Locator on its website that can be searched by location.
Call 1-866-488-7386 or text START to 678678. A national 24-hour, toll free confidential suicide hotline for LGBTQ youth.
National Domestic Violence Hotline
For any victims and survivors who need support, call 1-800-799-7233 or 1-800-799-7233 for TTY, or if you’re unable to speak safely, you can log onto thehotline.org or text LOVEIS to 22522.
Call 1-844-762-8483. The StrongHearts Native Helpline is a confidential and anonymous culturally-appropriate domestic violence and dating violence helpline for Native Americans, available every day from 7 a.m. to 10 p.m. CT.
The National Sexual Assault Telephone Hotline
Call 800.656.HOPE (4673) to be connected with a trained staff member from a sexual assault service provider in your area.
NAMI, the National Alliance on Mental Illness
Call 1800 950 6264. NAMI is the nation’s largest grassroots mental health organization dedicated to building better lives.
Contact Caregiver Action Network’s Care Support Team by dialing 855-227-3640. Staffed by caregiving experts, the Help Desk helps you find the right information you need to help you navigate your complex caregiving challenges. Caregiving experts are available 8:00 AM – 7:00 PM ET.
The Partnership for Drug-free Kids Helpline
Call 1-855-378-4373 if you are having difficulty accessing support for your family, or a loved one struggling with addiction faces care or treatment challenges resulting from COVID-19 circumstances, the Partnership for Drug-free Kids’ specialists can guide you. Support is available in English and Spanish, from 9:00 am -midnight ET weekdays and noon-5:00pm ET on weekends.
Not in immediate danger
If you do not believe the individual is in immediate danger, suggest they call a psychiatrist, clinic nurse, therapist, case manager or family physician that is familiar with the person’s history. This professional can help assess the situation and offer advice. The professional may be able to obtain an appointment or admit the person to the hospital. If they cannot reach someone and the situation is worsening, take action by suggesting they call 911 or their county mental health crisis team.
LEAP Method
Dr. Xavier Amador, in his book, I am Not Sick, I Don’t Need Help, outlines a communication skill (L.E.A.P.) that can be used to engage the individual and help them stay calm. LEAP stands for Listen, Empathize, Agree and form a Partnership. It is a family-friendly version of a form of therapy called motivational enhancement therapy.
Steps to using the LEAP method:
LISTEN. The goal is to listen to the individual’s needs without making judgment, to understand their point of view and to use reflective listening to state back that you understand (not necessarily agree with) what they said or need.
- Listen and learn; drop your agenda
- Use questions, not statements
- State what you heard - all of it (reflecting)
- Let the person correct you
- Don’t avoid scary topics or thoughts (even delusions)
- Know their “hot button” fears
- Don’t rush it
- Don’t have an emotional reaction to what you hear
- Don’t try to problem-solve
- Avoid going right to empathy
- Give your opinion:
- ONLY if asked
- Delay 3 times before answering
- Follow the 3 A’s: Apologize, Acknowledge that you could be wrong, Agree (to disagree)
EMPATHIZE. If you want the individual to consider your point of view, it is necessary for you to understand theirs. This is not the same as agreeing with them; it’s about empathizing with them about how they feel.
- Express empathy for feelings
- This doesn’t mean you have to agree with beliefs
- Normalize: “I think I would feel that way too (if I had those beliefs).”
- Listen + Empathy = “What do you think?”
- Common feeling and experiences to empathize with:
- Frustration
- Gear
- Discomfort
- Hopes and dreams (desired)
AGREE. Find common areas on which both you and the individual can agree. Acknowledge that the individual has personal choices and responsibility for the decisions they make about their behaviors and the consequences of those choices.
- Stick to perceived problems and symptoms only
- Review advantages and disadvantages of treatment or adherence from the person’s perspective
- Agree to disagree when needed. It’s okay to set boundaries
- You can try to correct misinformation gently
- Reflect back and highlight the advantages. Use this as the basis for a plan.
PARTNER. Form a partnership to achieve shared goals. This involves you and the individual developing an action plan to meet agreed-upon goals.
- Move forward with agreed-upon goals
- Use phrases that support feelings of control and safety
- “Would that be all right?”
- “Do I have that right?”
- “So, let me see if I got this straight. Are you saying that . . . ?”
- “Would you mind if I . . .”
- “I can see why you’d feel that way . . .”
- “I am sure it is upsetting to hear and I know you don’t agree. It’s just how I feel. Can we agree to disagree on this one?”