Dr Tanuja Gandhi (Host 1): Welcome to Mindcast, a podcast from the children's mental health experts at Bradley Hospital. I'm Tanuja Gandhi with my co-host Greg Fritz. And here today, we have Kristen Kichefski, who is the Chief Nursing Officer at Bradley Hospital. Kristen, thank you for joining us.

Kristen Kichefski: So happy to be here. Thank you so much for having me. And yes, I'm the Chief Nursing Officer at Bradley, and I have the honor of leading and supporting staff who provide the care to the children and the adolescents.

Dr Greg Fritz (Host 2): Well, welcome, Kristen. It's great to see you again and have you here joining us. As a psychiatric nurse, it's clear that one of your areas of expertise is in de-escalation training, which really is what we're going to focus on today. So, we want to know what de-escalation is, first of all. I mean, I think we know, but our listeners need to know, yes.

Kristen Kichefski: Exactly. Well, it's the opposite of escalation, right?

Host 2: Yeah. Exactly.

Kristen Kichefski: But, essentially, yes, de-escalation training is a passion of mine, and it's really assisting an individual to sort out difficult feelings, manage emotions, and really prevent those escalations, helping somebody really realize how to calm before something turns into a crisis.

Host 1: Kristen, I know much of your work has been around training other healthcare providers in de-escalation techniques. I imagine it comes from your years of experience in using these techniques while working with children and adults in your clinical work. What can you share with us today about the techniques you've learned and used and what really works?

Kristen Kichefski: De-escalation is really helping others maintain control over their emotions before they reach a level where their emotions become either emotionally harmful or physically harmful. So, it's really not about telling somewhat what to do, how to think or how to behave. But it's about meeting somebody where they're at and helping them process their feelings in a way that's meaningful and positive to them. So, I always like to start with that, right? What is the purpose really of that de-escalation, and helping somebody calm down.

A big part of de-escalation is really recognizing an escalation before it happens. Sometimes when people get very upset or very emotional, they could put themselves in a crisis situation that could put them or somebody else in harm's way. And so, we really want to prevent that and recognize what that looks like to each individual before they reach a point. And so, sometimes we would do this in the hospital setting where will just get to know somebody by saying like, "Tell me what it looks like when you get upset. Does your face get red? Are you tapping your knee? Do you start pacing?" We really upon admission ask those questions of the child or the caregiver so we can really help people as soon as possible. And then, I also, like what I'm teaching, ask people to think about a time where they were really upset or really angry and how well they were able to absorb information. Because I think putting yourself in that place helps you understand what somebody is going through when they're escalated, and it really changes your approach to the situation.

Host 1: I'm hearing that to de-escalate a situation, you have to identify the reason that's leading to the escalation. I'm assuming you know my next question, what do you think are the most common reasons for escalation? But before we even get to that, I'm wondering, in your experience, do you think it looks different in children and adults? Whatever we are describing as escalation, what does that look like?

Kristen Kichefski: It can look different, and it can look the same. You know, I mean, people get frustrated. People shut down. It can start with somebody losing eye contact, somebody visibly maybe having their heart beat, somebody getting restless, somebody disengaging from a conversation, suddenly getting quiet; somebody getting into somebody else's space, almost trying to provoke a response. These are all things that we would see in children and adults.

The really difficult thing is that children sometimes really can't put their thoughts into words. So when you ask them, "Well, what's the matter?" Sometimes they have no idea what's the matter until later on they may calm down. And that really leads to some of these causes of why people get upset.

Host 2: So, just to be clear that this is meat and potatoes for a psychiatric hospital and inpatient, but it's also relevant to what goes on at home with parents and kids. So when we're talking about the hospital, we can also use those tactics for dealing with our children or, in some of our cases, our grandchildren.

Kristen Kichefski: Absolutely. And our goal in the hospital settings is not to use techniques that would not work at home. We want to help families really build the skill and help children build the skill. So, one of the things we really go to as an identified reason, we call it HALT. Are you hungry? Are you angry? Are you lonely? Are you tired? A lot of times after someone gets upset and they calm down and we ask them like, "What was going on right then?" And they were like, "I was really hungry. And I didn't know how to ask or I didn't think I could have something," or "Everybody was over there talking without me." So, kind of getting to know your child or your grandchild or your patient and trying to see what do those cues look like for them and then really trying to identify, and sometimes it's later. Sometimes we're identifying that later, because it's really hard to talk about why you're upset while you're upset.

But a lot of times the reasons are going to be something's unfair or unjust. Something is perceived to be not the same for me as it is for somebody else. And I don't know how to deal with that. I don't understand it. Or it could be a sensory input that's really agitating. And this is really huge for people who are non-verbal or for our kids who may not be able to put into words what's going on. They maybe don't have the skill yet or they just don't have that internal feeling to say what's going on. And so, this could be as simple as "The room's too loud," "It's too cold," "I'm too hot." Hunger is another sensory input. And so, really trying to Identify what those causes are is really important.

Host 1: I was thinking about one of the things you mentioned being loneliness. What we've seen in the families we take care of in the hospital during the pandemic and post-pandemic is there's just a new dimension of loneliness, like a lack of socialization or limited opportunities to socialize during the pandemic. And these children, they fell behind not just in like social interaction with peers, but also in education, school being another source of that opportunity for socialization. But coming out of it, there is a certain amount of loneliness that you carry with you from that experience of the pandemic. And families have struggled with both their own experience of loneliness from the pandemic and what their children are experiencing. Escalation as in the episodes of escalation that have happened, or the episodes when you see a child vulnerable and crying or in need of more reassurance have looked so much different, because the needs have been very different.

Kristen Kichefski: It really has. And when you think about that time and you think about the children who maybe they were virtually learning. And maybe they didn't have all the outlets that they normally have, or maybe their school was closed altogether. And they lost all of those skills of expressing themselves, not just connecting with others, but then expressing their wants and needs also. And so when that loneliness sets in or that lingering feeling of uncertainty from that time comes in, it looks different the way people are processing it and how they're expressing it. And it is coming out, I believe, a little grander and more frequent.

Host 1: And going back to your de-escalation techniques, when you're trying to calm someone down, you're helping them in that one episode, but understanding the reason then highlights the need to keep doing it or keep supporting them. So, the escalation continues to be managed and gets better.

Kristen Kichefski: It's all about building skills. It's all about building skills, and every time we work with somebody and we help them through any sort of difficult period that they're having. We hope that something about that experience resonates. And we may have to do the same thing over and over again, and this is so difficult as a parent. You're trying that same technique over and over and over again. And then, you know, just, "It's okay. let's. Talk about it. Tell me what's going on." And then, finally, it catches. And then, all of a sudden, somebody is able to come to you and say, "Let me tell you what's going on." So, it's a little bit of a quicker de-escalation where people are learning how to self-manage their own emotions. But our ability as caregivers, as parents, as clinicians, to really approach somebody who's upset, sad, agitated, escalated, in a really steady, calm, non-judgmental manner and really provide that validating support is what the children need to really be able to build their skills and grow.

Host 2: You know, I was thinking this past weekend, I was helping my stepson take care of his three-year-old. We were together, these two guys were putting this three-year-old little girl to bed and she wanted to read a book that she's read. Apparently, she's wanted to read it every night for the last month or something. And so, he was sick of it. He said, "We're not going to read that tonight. We're going to read something else." Well, she wanted to read the book and it's escalating and he found himself getting irritated, and who hasn't been there, right?

And I'm sitting there thinking, "Let's see, I'm the grandfather so I better keep my mouth shut." Well, fortunately, my son-in-law's a light bulb went off, and he said, "Forget it. We're going to read the book. Come on." And that de-escalated the whole thing. When you mentioned keeping yourself from escalating yourself is a good de-escalation technique. That reminded me of that episode.

Kristen Kichefski: Absolutely. I mean, people take their cues from the safe person who's near them. So, she was taking her cues and the situation is going to keep building. "He's upset. I'm upset. He's upset. I'm upset. Oh, he's not upset anymore." We also call sometimes avoiding the power struggle. There's a big difference between giving in and meeting somebody where they're at with their needs. And I always say, "We're not going to give in. There's no winners or losers here." These are children that are trying to grow. So, there's a difference between avoiding a power struggle, identifying a need, and meeting somebody where they're at, and that old though of, "I'm not going to give in."

Host 2: What happens if you do everything right, but it still doesn't work?

Kristen Kichefski: Well, you listen to a podcast. You know, we really want to identify what the individual needs in that moment. Sometimes it's validation. Sometimes we're going to bring somebody who's lost control back down with some real just good old fashioned validation. And sometimes we say we validate the valid. But sometimes we really just restate and clarify. There's all these like terms that we use in the hospital. But basically, we all know what this looks like, right? "You're really upset. That really angered you," and then give a nice pause." And let them say, "Yes, it did." "Why did that anger you? What happened? Tell me about it." "I bet you thought that was unfair." Little techniques, right? Where we're restating and validating and hearing. If somebody is in a place to do that, that is just an amazingly powerful tool.

But equally powerful is using silence. Sometimes somebody just needs to get it out. Sometimes people need a good cry and a scream, you know, and sometimes we sit and listen. I've done that plenty of times as a nurse, I've done it plenty of times as a mom and an aunt, actually, you know, and what have you. You know, just sit and listen and wait for them to get it all out. "Do you feel better?" "Okay. Do you want to talk about it? Do you want to go for a walk? Do you want to go outside? What should we do now?" And then, wait until they're in a good spot to talk about it further. And we already talked about avoiding the power struggle, and that is just really, really huge. A power struggle when somebody feels like they've lost control and when somebody's emotions are not in their control is only going to increase their desire to regain control.

Host 1: So, I was thinking while you were talking about the power struggle, sometimes we've seen how adults try to match the tone of the child who can be very persistent and loud in wanting to get their needs met or is basically upset or escalated as we're talking about. I'm not sure that really works if we're trying to ask the child to calm down while we're ourselves raising our voice and basically matching.

Kristen Kichefski: That is so true. And it kind of goes back to that technique when I'm teaching. And I say, "Think about when you're upset." If I'm really stressed out and anxious and somebody goes, "Relax? Am I going to relax? I'm not, I'll tell you that." And if somebody's yelling at us, do you instantly decide, "Wait a minute, I'm upset, and now you're yelling at me? And I'm upset?" Children are us. We all have patterns of emotion. We don't want to expect more from our children than we could do ourselves, you know? So, it's fascinating when we stop and think about it like that. "Well, wait a minute. If that was that important to me, and I was that upset, what would somebody yelling at me to calm down do for me?"

Host 1: Oh, that's such wonderful advice. You know, when working with children, sometimes, I found myself stuck in a corner saying, "Okay. What other tricks do I have in my bag to make a breakthrough here and tell this child I'm listening?" But sometimes it's just hard. And we've all been in that position where you feel like, "Yeah, this situation didn't go very well," where parents feel terrible about the interaction with the child, or the child feels terrible about having a meltdown, or basically yelling and screaming and being escalated. In our work here, we teach children how to do repair around an episode that they feel bad about later on. And that's everyone, right? Parents, children, everyone, you can have this episode where you lost control and you feel really bad about it after. Do you have any examples or ideas of how this repair work can be done when families are working with kids at home?

Kristen Kichefski: Oh, absolutely. And, you know, repair is so important, like you said. How do I reconcile it with myself and do that apology? And sometimes the apology doesn't look like I'm sorry. We're not all able to bring ourselves to that point sometimes. And sometimes the child's not sorry. Just the way I'm sure everybody listening can remember a time, maybe they weren't that sorry, but repair is still important to move on. So, sometimes a repair is an apology. "I am really sorry I stole that french fry off your plate" or "I'm really sorry that I hid your doll and got mad at you and yelled," or whatever they're sorry about. Sometimes that works really well.

Sometimes it works equally as well to write a letter or draw a picture. Sometimes it works equally as well to say, "Well, you know, I really feel bad about that. How do I move on?" It's like, "Well, you know what? Maybe I would like it if you would bake some cookies with me. That would make me feel good. Would that make you feel good too? Would that close this out?" And so, there's all sorts of different things. But I think that what's really important is allowing the child the space to recover from the episode, because what we don't want to happen is that resonating feeling where they start thinking that these instances where they are having difficulty managing their emotions define them and define how people see them.

Host 1: So, it sounds like repair is more of a reflection on the situation. Identifying how you felt in it, identifying those emotions, which were very difficult. And if there's another party involved, one way to do the repair would be to apologize. But otherwise, having a discussion about how we can get past what happened would be repair work.

Kristen Kichefski: That's all repair work, absolutely.

Host 2: And it always depends on the age of the kid as to what you can do. So, what the 13-year-old can do is so different than what a six-year-old can do.

Kristen Kichefski: It's so true, and it has to be meaningful to them as well.

Host 1: Right. I've had kids, Dr. Fritz, who've said, "I don't find any need to go apologize to this other kid who was so mean to me. I think I'm totally justified." What do you do in those situations? How do we do repair then?

Kristen Kichefski: Well, on the units, what we would do is get them some sort of activity that may bridge it, because, "Yes, okay, I get it. We're going to still work on that. But maybe in the meantime, we will work on this skill that may help the situation when it happens next time," or, "No, you were really upset. And so, you tore their papers and threw them all over the hallway. And then, somebody had to come by and clean it up. So, maybe you can write a letter saying you're sorry to the person who had to come clean it up." You know, I mean, something that really closes it out.

Host 1: And in these moments, we've had situations where the kid is like, "Yeah, if someone did that to me, I would have been upset. So, I get it. If Johnny tore Jimmy's paper, I don't like Jimmy, but I get why that would upset him, and I will not do it again," even that's a form of repair. And then saying, "Hey, we can do something else together."

Kristen Kichefski: Absolutely.

Host 2: So, thank you, Kristen, for being here today. This has been really interesting. So as we're winding up, do you have one overarching takeaway that our listeners would do well to think about as the first step or the critical step for de-escalating?

Kristen Kichefski: For me, the most important thing is remove your ego, take yourself out of it. Focus on the individual, focus on the child, focus on your grandson, focus on whomever it is, and take yourself out of it because they're the ones in distress.

Dr Tanuja Gandhi (Host 1): Thank you, Kristen and Greg. This was a very insightful discussion. Initially, when we thought about talking about de-escalation techniques, it was hard to envision how this would go because I could think of all the examples of children I worked with, both success stories and challenges saying, "Oh boy, that was tough." But this was actually very helpful. And for our listeners, if you found today's episode interesting, please check out our other podcasts at www.bradleyhospital.org/podcast. Please share it with your friends and do send us some feedback.