Mental Health Monthly #11: De-escalation: Changing Confrontation to Collaboration

Contributor: Dr. Kimberly Nordstrom

• De-escalation usually takes less time than physical and chemical restraints, which leads to decreased injury to staff members, better patient trust and increased patient throughput as accepting facilities oftentimes delay transfer acceptance following physical restraints
• Prepare to engage prior to entering their room in two ways: cognitively and emotionally
  • Why do you want to de-escalate the patient? Remind yourself you don't want to introduce more trauma
  • Check your emotions, and ensure you don't bring your emotional state into
• If possible, engage the patient when they're in mild agitation before their anger is out of control
• Be authoritative not authoritarian or permissive, impart your expertise in medicine and explain your rationale to them without claiming to be an expert on them personally
• Small acts of kindness like the provision of a warm blanket, snacks or voluntary medications appropriate to the situation can aid in establishing trust and rapport
• Take a break to cool off if the interaction is too charged
• Verbal de-escalation pearls:
  • Respectful introduction, etiquette can be perceived as empathy to a patient in crisis
  • Confirm story and allow patient to offer corrections to what you've been told
  • Utilize active listening techniques, both verbally and nonverbally
  • Avoid assigning blame, but use distant third parties if necessary without being detrimental to your colleagues
  • Offer choices in medications within your clinical comfort zone for the patient

Verbal De-escalation videos:

Identification and Assessment of Agitation

Basic Elements of Verbal De-escalation

More Practice with Verbal De-escalation

Advanced Skills in De-escalation

Personal Safety and Escape Skills

References:

1. Berlin JS. Collaborative De-escalation. In: Zeller SL, Nordstrom KD, Wilson MP, eds. The Diagnosis and Management of Agitation. Cambridge: Cambridge University Press; 2017:144-155. doi:10.1017/9781316556702.012
2. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

Summarized by Mason Tuttle