For AIDS service organizations and community health centers, delivering care to people living with HIV and AIDS (PLWHA) requires clear communication and use of effective conflict-management strategies. That was the key takeaway from SYNChronicity 2020’s Sept. 10 presentation on de-escalation.
SYNC 2020’s virtual meeting for health care and service providers covered numerous HIV and related LGBTQ health issues, but this harm reduction–driven institute was particularly important because of its focus on establishing respectful relationships between clients and providers.
The anecdote- and data-filled session offered a comprehensive breakdown on de-escalation that included defining trauma and conflict, recognizing the different ways that they can manifest, resolving tension, and acknowledging that there are inherent power imbalances riddled throughout the health care system.
According to the session’s three presenters, every level of interaction with PLWHA must be delivered through a trauma-informed lens, with open eyes and ears for ongoing struggles and consideration for their specific needs.
As it relates to providing access, this means accepting that PLWHA are frequently impacted by stigma related to the virus, economic hardship, unstable housing, chemical dependencies, and depression. But, the presenters were quick to note that whether or not these conditions are a factor, clients are all deserving of care and should never be pathologized.
While addressing the clinical definition of trauma—a stressful event or chronic stressful events that continue to repeat—and the consequences of prolonged exposure to it, Haley Coles of Sonoran Prevention Works emphasized that it is often minimized by “cookie-cutter ideas” that fail to account for the devastating impact of “living in a world that does not accept you or that wants to hurt you.”
Nathalia Gibbs of Harm Reduction Coalition shared that she sees trauma as a change in “how people see what’s normal,” which makes it “very difficult to shift back to a normal that isn’t there anymore.” This disruption can make establishing trust between clients and new care providers difficult, even when the new provider is not responsible for inflicting the original crisis.
Coles connected the implications of this dramatic shift of one’s sense of normalcy to the dysregulation that trauma induces between the brain and body and the changes that this can induce in a person’s DNA through epigenetics. Epigenetics is the study of cellular change in phenotype without a change in genotype, which can be triggered by stress, resulting in intergenerational trauma. In addition to affecting one’s behavior, trauma can also change a person at their foundational level.
For Coles, this means that “people are anticipating violence from us. They are anticipating that we will fail them and let them down.” She illustrated this with a story about an interaction that she had with a man who appeared to be experiencing a drug overdose. While she was attempting to offer the man assistance, he reacted to her with hostility. “I think I startled him, and he was mean to me, and that has nothing to do with me.”
Instead of returning the hostility, Coles said that she “didn’t take it personally” and accepted that he had no reason to trust her and was probably reacting to past trauma. More than that, Coles said that his response was “par for the course” and “something that we need to expect and support people around.”
This is especially true when helping clients sign up for care or insurance, because of the byzantine regulations that they are required to navigate without any understanding of why those measures exist or how to overcome them.
In another anecdote, Coles shared that due to COVID-19 and the fear of potential exposure, a client of hers was no longer able to use his medication-assisted treatment (MAT) at his clinic. Instead, he was given treatment to take home, but his sober living facility refused to allow him to keep the MAT on its premises.
“So this person has jumped through so many hoops and is at the mercy of multiple systems, and [these] systems don't interact with each other; they often oppose each other.” She regarded the incident as compounded trauma, and not the first time that her client had experienced something like this.
What is equally damaging in Gibbs’ opinion is that the medical system forces clients “to capitalize off of their pain.” In her estimation, if clients do not project sufficient stress, they are treated as if they are unworthy of care, respect, or dignity.
This forces “people to bear all of their trauma in order to receive care, or to receive better care,” while contorting the client-to-provider relationship by making access to services conditional on suffering. In these instances, services are put on hold because they were deemed inessential until a client proves why they are crucial.
The legacy of these experiences can lead some people to exhibit disproportionate reactions to seemingly insignificant issues.
For some clients, escalation is how they communicate that they feel unsafe or feel that their needs are not being taken seriously. According to Gibbs, this may not follow a logical “moment to moment” progression, which makes it important to understand what escalation is and how it can manifest.
Escalation is a rapid rise in emotions, usually in a negative context. The consequences of not intervening when people begin to escalate is that if violence occurs, a client may be barred from receiving future services by a care organization or risk an altercation with the police.
For Gibbs, this makes the pre-escalation phase essential to recognize. That means looking for cues and responding to them before an explosion ensues.
Signs of imminent escalation do not always show up in expected ways. They can include obvious shifts in body language, raised volume and profanity, slamming hands onto counters, or expressions of self-harm; but for some people, becoming quiet or reduced communication is their tell that they are upset.
Coles made the case that because providers can’t always know why a person has stopped communicating, constant conversational check-ins are essential. She also cautioned administrators to avoid taking things personally, because the conflict is not their problem; meeting the client’s need is.
Once escalation has begun, Gibbs believes that there are numerous opportunities to return the encounter to a more productive place. That is why she says it is essential for providers to have policies in place that encourage and support their administrators in being communicative by fostering relationships so that the pre-escalation phase never erupts into conflict.
In terms of communication and neutralizing escalation as soon as it appears, Gibbs suggested that providers investigate the problem by asking solution-oriented questions, determine what is needed, offer workable solutions that address the conflict, remain flexible, and establish resolutions to ensure that the issue does not occur again.
Conflict and De-Escalation
Kacey Byczek of Harm Reduction Coalition described conflict as a situation in which people have fundamentally different viewpoints around a singular event. Coles added that it can manifest when one’s ego is challenged. Gibbs shared that she looked at conflict from a de-escalation standpoint: conflicting needs that don’t align.
After listing the clinical definition for conflict—a disagreement in which those involved see a threat to their needs being met and their concerns being addressed—Gibbs stated, “A key element is that each person might have a different perception of any given situation.” This refers to the unknown history that clients bring into a space and how they prioritize their needs.
Though meeting one’s clients’ needs should always take precedence, doing so with the immediacy that they may desire is not always possible. TheBody recently addressed this in a report on disruptions to medical care during the COVID-19 shutdown. Some clients lost access to their medical care due to changes outside of their control and felt conflict escalation was their only means of recourse.
Byczek mentioned that before COVID isolation went into effect, some of her clients came into conflict because hygiene products were not immediately available or because they wanted to watch TV in her clinic’s waiting room but were unable to. While the reason that certain issues erupt into crisis may not be discernible, it is important to begin de-escalating procedures as soon as they do.
Coles shared that body language is important to consider when de-escalating. She advised against standing over someone, because of the power imbalance that it can induce. For instance, when addressing someone who is sitting on the floor, she will kneel to the participant’s eye level to help them feel at ease.
The goal of de-escalation is to eliminate the need to fight in order to protect oneself. That also means that care providers must look at their own body language and how they are using their hands. Coles said that “approaching or coming at somebody” with your hands can be scary, which makes “where we position our bodies to other people” important to consider.
Another important consideration is that de-escalation is not the time to correct a client’s behavior or to tell them how to act. Doing so is an abuse of power and can potentially destroy any sense of trust that has been gained.
Byczek stated that escalation related to power dynamics is important to understand, because “providers and participants never have a fair power dynamic.” The provider can dictate how services are administered and can reduce access or take them away at any given point.
This also means recognizing when it is not your place to handle a situation due to existing power dynamics. For instance, Byczek shared that when confronting a fight between two men of color at her clinic, it was important for her to step back, because her power dynamic as a white woman made them uncomfortable. She said that it was more appropriate for her Black supervisor to step in.
If that had not been an option, Byczek says that she would have made her body language as neutral and non-threatening as possible.
When it comes to de-escalation, Gibbs reminded conference attendees that being good at it means looking beyond what is happening in the moment as a stand-alone event and using the experience to develop a stronger relationship.
She also emphasized the need to drop assumptions about mental health. She explained that even if providers think they know why a client is reacting a certain way, all efforts should be made to avoid pathologizing the participant or reducing them to their circumstances.
Speaking to the pervasive history of racism and its link to medical mistrust, Gibbs noted that providers will not solve racism or any other problem while implementing de-escalation, but they might help a client receive the help that she or he deserves.
Ultimately, de-escalation is about setting healthy boundaries. It is also an ongoing process that will have to be repeated, because people living with trauma and HIV do not overcome their challenges immediately.
When attempting to de-escalate a situation, remember that 55% of the impact that you have will come through your body language, 35% will come through the tone of voice that you use, and 10% will come through your actual words. And even if it feels like appeasement, it is OK to show kindness. In fact, that might be the thing that helps a person realize that you are on their side and want to help.