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De-escalation and Violence in FBT

by Abby Sarrett-Cooper

Violence does not belong in a family. Violence does not belong in the family home. As family rules go, this is about as basic as the “golden rule” is in life. Sounds simple. Eating disorders, however, have their own rules. They are wrecking balls, they wreak havoc. The greater the havoc they create, the more successful they are at staying put right where they are within your beloved child. Hence, the reinforcers are set up perfectly for violence to be an effective tool of the eating disorder to win any meal, snack or other challenge to the eating disorder that is part of family treatment. Parents know that violence is taboo. The eating disorder knows that even the threat of violence is a sure-fire way to push parents back into a corner.  

As a DBT (Dialectical Behavior Therapy) therapist and a certified FBT (Family Based Treatment) therapist, I have helped parents navigate the intense emotional and behavioral dysregulation that places the family in the violent cross hairs of an eating disorder and other co-occurring mental health crises. There are tools to prevent getting into those cross hairs and others for stepping back out.  

Mindfulness and de-escalation are the swiss army knives of the parenting tool kit. Many times, we slip into the cross hairs of the eating disorder monster as a result of being pushed by the twin goblins, exhaustion and frustration. I have yet to work with a family who has not faced the physical and emotional reality of round-the-clock care giving. The increased demands on time, the intense emotions, and the rigidity and perseveration of the eating disorder are likely to escalate into dangerous places without specific strategies. 

It makes sense, therefore, to ask yourself what tasks can be dropped, shared, or modified to reduce the burden you are experiencing. This includes using take out foods, not making beds, and asking others to drive carpool as just a few examples. This is about taking a big picture inventory of what has to be done, prioritizing the eating disorder (as you already have) and letting go in order to preserve your energy for that priority. Some people find this very disorienting as the eating disorder has already invaded their lives and turned things on their head. Maintaining other parts of daily life can feel comforting or anchoring. At the same time, holding on to these routines and tasks can create rigidity that exacerbates frustration and exhaustion. To use an old expression – what doesn’t bend, will break. Therefore, focusing on what is not getting done or what is not working will only serve to exacerbate your own emotions and frustrations. Mindfully acknowledging and accepting what cannot be done or accomplished during this period of intense focus on the eating disorder will have the effect of reducing the intensity of your exhaustion and frustration.  

Similarly, acknowledging and accepting any and all of your own emotions and reactions will have the same effect of reducing their intensity. A large roadblock to acceptance is the judgments we hold about our actions, our feelings, and our lives. We tell ourselves how things should or should not be. If you notice that your inner dialogue begins with should or shouldn’t, you have found the starting point for mindful change. Once you catch that thought that “I should have had the meal ready earlier,” or “I shouldn’t need to ask my friend/brother/etc. to stop at the store for me,” you can STOP, BREATHE, RELEASE, REPLACE the thought. STOP – do not continue on that judgment train. Breathe – instead of continuing and RELEASE it. You might then even REPLACE those thoughts with “It makes total sense to ask for help,” or a similarly validating thought. Validation has the effect of reducing emotional intensity. This is true whether you are validating yourself, your partner, or your child. Try it right now! Tell yourself something that you know runs through your head that is actually invalidating and then take a breath and tell yourself something validating instead. It has an immediate impact on your body and your emotional reality. This practice is therefore, instantly de-escalating. The key to using this mindful process effectively in the moment when things are challenging is practicing in the moments when things are calm, perhaps right before bed.

The more effective you become at mindfully releasing judgments and finding ways to validate yourself, the more this tool will be effective in moments of interaction with your child, and the raging eating disorder. Let’s now go back to the should and should nots raging in our heads when the eating disorder begins its aggressive ascent at mealtime. I regularly hear parents share thoughts that “He shouldn’t be talking to me like that,” or “I can’t deal with this,” or “This is ridiculous, he/she is crazy,” or “She should be trying harder.” These are totally understandable thoughts and statements under the circumstances. Unfortunately, they also have the effect of escalating emotions in the parent and child. As judgments, they serve to invalidate, undermine, increase physical tension, and lead to a spiral of aggression. Alternately, using the same mindful STOP, BREATHE, RELEASE, REPLACE process will allow things to sit where they are as you regroup and find validation for yourself and your child. You have the moment to remind yourself that everyone is in pain and doing the best that they can in this moment – an important DBT assumption. There is no need to respond instantly to an irrational eating disorder. The greater need is to be present, be mindful, and not escalate the situation.

Most often, aggression becomes violence when our internal escalation becomes external, when our frustration boils over, when the problem of our emotional intensity overrides our problem-solving ability. Violence is a solution of last resort. Mindfulness helps shift thoughts, allows you to let go of what does not serve, and sit with the things we cannot change. Yoga, meditation, and prayer are all versions of mindfulness practices. In addition, DBT therapy can be adjunctive to FBT as a way to teach these skills to the whole family. There are many resources out there to develop a mindfulness practice that will serve to increase your ability to validate self and others, increase emotional regulation, and in turn reduce the likelihood of frustration and exhaustion turning a situation dangerous.

The “experts” agree that de-escalation is the first, best strategy for crisis intervention. In fact, a 2016 review by the University of Nebraska of US crisis intervention programs for consumers showed that EVERY program recommends de-escalation as the first line of action in a crisis by a wide margin. One of these programs, developed by the Ohio Department of Education, describes 9 steps for de-escalation that include the types of mindful interventions detailed above (points 4, 6, 7, and 9 below) and it’s worth noting that even the concrete, behavioral strategies require mindfulness to implement.

  1. Send others away from the area.
  2. Call for help (call a family member who can help or call 911).
  3. Remove dangerous objects or attempt to get the child into a safer room.
  4. Don’t try to discipline; don’t use words, don’t try to reason.
  5. Stand at least one leg length away from the child. Instead of standing face-to-face, stand to the side (L-shape) of your child. This stance is nonconfrontational and non-threatening.
  6. Remain in control; stay calm and quiet. Allow yourself to disengage emotionally, and don’t take the behavior personally.
  7. Be flexible; your child cannot.
  8. Use a pillow or cushion to protect yourself if the child strikes or hits.
  9. Take deep breaths to help you stay calm. 

Do not try to restrain your child UNLESS the behavior is a clear danger to you or to the child. Physical intervention increases aggressive behavior and can inadvertently cause injury to you or to the child.* 

You will notice that the last recommendation made by the Ohio Department of Education’s program involves physical restraint and a strong warning regarding its use. This is, in fact, shared by all programs in the University of Nebraska review. Physical restraint, sometimes referred to more benignly as safety holds, trail de-escalation by a wide margin in each of the programs reviewed. Crisis intervention programs all describe the need for extensive training to use these holds safely and effectively. Training that most parents do not have.  Without this training the guidelines warn of the risk of increased aggression and causing inadvertent injury through these holds. There is a related risk of reacting reflexively in physical encounters that is very common yet may bring the intervention of child protective services.

There are times, despite all these practices and your most skillful actions, the eating disorder rides the wrecking ball of violence into your home. Your child throws the dinner plate, crashing it into a splattered mess of shards and food on the floor. He or she comes running at you in the kitchen, pushing, hitting or kicking so you do not prepare the snack. Now what? Through mindful practice you have the presence of mind to remove everyone, including yourself to a safe distance and begin saying your “safety script.” It’s called a safety script because the goal is to establish safe limits for your child and everyone else in the home including yourself. “This is a safe place, and I won’t let anyone (hurt you, throw things at you, etc. …) I can’t let you (hurt me, your sister, throw things …) because this is a safe place. I will call for help to make sure this is a safe place.” It needs to be spoken with strength and calm conviction that this is your firm expectation. Even when your child is the one initiating the violent behavior it is important to begin the script with the first part establishing your home as a safe place for your child. You may even want to practice this like anyone memorizing a script.  This script will serve many purposes; it will create 10 seconds to breathe, to de-escalate for yourself and your child, and a calm warning to your child as to what will happen next and preparation for yourself to make the next move. You must call for help.

Most parents are incredulous at the suggestion to call for help through emergency services or 911 here in the US. Some parents have become accustomed to escalating behaviors over time, making it hard to see the danger in front of them. Many parents don’t want to acknowledge that their child is dangerous because they know the behavior is not intentional and/or part of the eating disorder. Some parents are embarrassed or ashamed that things have become dangerous. The safety script is a way of reminding yourself of that golden rule that everyone deserves a safe home and that you will do what is necessary to create that. Understandably there is also the fear of being blamed or of the consequences of calling authorities. These fears can be mitigated too.

Whenever you call 911, be sure to inform the dispatcher that your child has a mental illness and that you are calling due to a mental health crisis involving a minor so that the officers who respond have this information before they arrive. Some police departments have special Crisis Intervention Trained (CIT) officers who deal with young people and with mental illness or family crises. You can also ask that they do not use lights or sirens when they respond. Some families call their local police departments when there is not a crisis to explain the circumstances and ask about intervention services that are likely to respond during a family mental health crisis. Many families learn about other emergency intervention services in their communities when they make this type of “cope ahead” call. Another similar call can be made to your local emergency room to explain the circumstances and ask what to expect if you bring your child to the ER or is brought there by emergency services. Another important conversation to have in advance of any emergency is with you pediatrician to discuss what they can do to prepare a local ER in the event the need arises.  

Many violent crises are disarmed when a parent displays the willingness to engage 911 or authorities. The eating disorder may take heed at the warning that a call is the next step, recognizing that it is approaching a line that threatens its existence. Similarly, the call itself or the arrival of authorities may have the same impact. In other families it may take the uncomfortable, annoying, and inconvenient experience of being brought to a hospital, a long wait in an emergency room (with parents providing food and snack as timing dictates) and a psychiatric evaluation for the eating disorder to understand just how hard the family will fight for their child. Many parents are disappointed when a call to emergency services does not result in a trip to the hospital or if it does, the child is quickly discharged after a brief evaluation thinking this a waste of time. Parents often say, “that did nothing” or “he/she now knows that nothing will happen.” I explain that the opposite is true. Something did happen; something important. You were willing to go to the mat for your child. Far from being a waste, this experience sent a strong message to the eating disorder that you mean what you say about a safe home and safe family and that you will always take whatever action is necessary to ensure this. 

Hopefully, your practice of mindfulness and de-escalation will keep violence at bay. Your primary goal is always to keep your child safe in the moment as you fight to vanquish the eating disorder entirely. Remember that it makes sense to ask for help – whether in your day-to-day chores, to free up your time and energy to battle the eating disorder, or to have company in the house that may prevent the eating disorder from showing itself and  escalating into violence. Asking for help is a position of strength, and the eating disorder will see it as such. Your child will see it as an expression of your love.

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9 Comments

  1. Mary O’B

    Thank you so much for this information! Fortunately, in my experience, it’s better late than never. We have been dealing with my daughter’s ED and now other multiple mental illnesses for 9 years. I never knew how to handle the violent eruptions that continue to take place and me, my husband and older daughter (w/o ED) have been chronically traumatized. This information needs to be sent to ALL ED programs, counselors, psychiatrists, parents – new to EDs and those who have suffered along with their sick children for a while. It’s the most extraordinary update I have received in a long, long time. I’m sending this to our care team right now.

  2. Rachael

    Thank you for this post. It is really helpful to think through how to desescalate violence. I’ll be sharing this with my loved ones 🙂 one suggestion: please include what abbreviations mean. There is no explanation for FBT or DBT. Thanks!

  3. Nicole Vorkapic

    The timing of your article is no coincidence. It’s godsend!
    I’m so happy to see that as a true FBT supporter, that you also encourage the use of other therapeutic modalities. During our daughters 4 months of inpatient at ERC Dallas where we were exposed to FBT, EFFT, DBT and other modalities. We came home and engaged the only FBT licensed therapist in our state. She was adamant that seeking out other modalities to fight Anorexia was not true FBT. I begged for help to carry on the training my husband and I received at ERC relating to the behavior and emotion regulation. I could see with each week passing at home, how my husbands ability to deeacalate and manage my daughters outbreaks were getting worse. And our therapist was making it worse. I fired her.
    In the last 4 weeks, The new therapist I found engaged all these tremendous modalities. She came highly recommended. My D liked her and shared more with her than any other therapist. I was encouraged and optimistic. My D confided in the therapist about 2 specific situations involving her dad which lead to a child protective services reporting. Ther therapist wasn’t wrong and only validated my cry for help earlier and continued strain on my marriage. The therapist fired us shortly after saying she couldn’t support my D’s need virtually. Nothing is more scary.
    I’m engaged with my insurance company to seek out other FBT/EFFT/DBT therapists anywhere. Telehealth works and it’s my only Option.
    Thank you so very much for sharing this content!

  4. Jennifer Aviles

    This discussion of violence de-escalation is extremely important. Co-existing diagnoses like borderline personality disorder make the possibility of necessary police intervention far more likely. We have needed to call 911 and we are fortunate that there are crisis teams here although they are at times overwhelmed and not available which is why it is so important to emphasize your family member is mentally impaired. There are times when de-escalation is just not possible, too, and police intervention is necessary to break an ever increasing cycle before you or your family member is seriously hurt.

  5. Jean M

    Thank you- this is so needed as I deal with a daughter who is inpatient for ED and then caring for her children. My thought at the start of this struggle was to not make the ED mad. Hard, hard times. Thank you for validating.

  6. laney

    This is such an important and often neglected topic in the discussion of eating disorders. Thank you for writing about it Abby. I agree that is important to explain carefully the situation if you need to make an emergency call. I would also recommend, if possible, having someone intercept the emergency responders when they arrive to make sure they understand what they are walking into. A poor reaction on the part of emergency responders can make things worse and have a very negative influence on their future effectiveness.

  7. KAZ

    Thanks for writing on this topic my AN d was never violent to us she took her anger out on herself with SH but this information is very helpful to use with other mental health issues too and with individuals under either alcohol or drug influenced violence
    Staying calm and the validating I have found to be most useful indeed

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