LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 301.03 Management of Aggressive Client Behavior in Settings Without Lanterman-Petris-Short Designation
 
  PROCEDURES
  1. Staff shall identify the potential for client aggressive behavior on the basis of observation, assessment, and known history:
    1. If established staff shall:
      1. Immediately notify entities in accord with DMH Policy 303.01 Tarasoff;
      2. Apprise their immediate supervisor; and
      3. Request additional staff support as indicated.
    2. Staff shall use codes and alarm procedures identified in the DMH Injury and Illness Prevention Plan (IIPP), Section VIII, Clinic and Field Safety to request assistance of:
      1. Additional staff,
      2. Sheriff’s Security Officers (SSOs),
      3. Contracted Security Guards (CSGs), and
      4. Local law enforcement if necessary.
  2. Staff shall minimize risks to people and damage to property including:
    1. R​​​​emoving nearby articles that could serve as potential weapons, and
    2. Advising other clients or staff to leave the immediate area.
  3. Staff shall attempt to respectfully engage clients in identifying mutual actions that could resolve the situational cause of the aggressive behavior.
  4. Appropriately trained staff shall employ Non-Violent Crisis Intervention techniques and other clinically appropriate treatment modalities in order to decrease aggressive behavior and restore a safe milieu.
    1. Administration of medications by any route without client consent is not permissible.
  5. Staff shall incorporate De-escalation skills including:
    1. Building Rapport:
      1. Introduce yourself
      2. Use the client’s name
      3. Be genuine and authentic in your communication
      4. Create hope using the future tense
      5. Offer several options
    2. Active Listening:
      1. Listen closely
      2. Pay attention
      3. Don’t interrupt
      4. Validate feelings
      5. Empathize
      6. Summarize/Paraphrase
      7. Clarify
      8. Avoid ‘why’
      9. Use non-verbal prompts
    3. Non-Verbal Communication:
      1. Environmental Awareness
      2. Eye Contact
      3. Remain Calm
      4. Facial Expression
      5. Body Language
      6. Movement
      7. Give Space
    4. Para-Verbal Communication
      1. How you say something
      2. Volume of voice
      3. Tone of voice
      4. Pitch of voice
      5. Pace of speech
      6. Emphasis on certain words
  6. An involuntary hold may be initiated:
    1. Contact appropriate LPS authorized staff within approved programs for assessment
    2. If the client is placed on an involuntary hold wishes to leave the clinic/area, staff shall:
      1. Not attempt to physically detain that person.
      2. Attempt to safely and respectfully convince the client to stay. 
      3. Discuss the risk/benefits for staying, alternatives, and benefits to their recovery.
      4. Notify the Program Manager or designee and/or,
      5. Request assistance from law enforcement.
    3. Should there be immediate risk to life, staff may, but shall not be required to, intervene as necessary in order to mitigate that risk, including calling 911 for emergency assistance.
      1. Clients leaving against professional advice shall be asked whether family members or significant others may be contacted. If contact information is available by written authorization or verbal consent, staff shall initiate such contacts immediately.
  7. When clinical staff determine the aggressive behavior is unlikely to respond to mental health intervention, the Program Manager or designee may initiate steps for termination in accord with DMH Policy 312.01 Clinical Termination of Mental Health Services. (I think this item can be moved to section H. - it seems odd to have it as an option during the crisis or emergency but makes sense to discuss after the incident)
  8. Following incidents of aggressive behavior Program Managers or their designees shall:
    1. Facilitate a debriefing of the incident with the staff involved;
    2. Review the event, including actions of staff, SSOs, and CSGs;
    3. Review emergency codes, alarms, and other systems utilized for possible corrective actions; and
    4. Facilitate an assessment of foreseeable risks for danger from individuals toward staff, clients, or others in conjunction with the DMH Human Resources Health and Safety Office and Clinical Risk Management.
    5. Facilitate a debriefing with team, supervisors, and available collateral assuring:
      1. Others are available for support
      2. Risk-re-assessment
      3. Identification of triggers and warning signs
      4. Recognition of what helped the crisis pass
      5. Connection to treatment, services, significant others
    6. Document as appropriate in the clinical record.
    7. Document all necessary Safety Intelligence and Security Incident Reports.