Similarly, maintaining your usual social eye contact is more tolerable to the agitated patient than consistently staring or averting your eye. Adirect gaze may be interpreted as aggressive behavior, while averting your eyes signals fear; either state may prompt the patient to become aggressive.
Always maintain an “escape route” for you and the patient. Do not make the patient feel he or she is trapped with no egress. If the patient feels you are too close and tells you to “get out of the way,” do so immediately.
You shall not be provocative A calm demeanor and facial expression are important. Be soft-spoken and do not allow an angry tone to slip into your voice. Imagine yourself with a patient you enjoy working with, and use that level of empathy and concern with the agitated patient. Use a relaxed stance with your knees bent, arms uncrossed, and your palms upward. As you may be tense or anxious, try to prevent yourself from balling your hands into fists. A fist, made even as your hands hang down at your sides, will be noticed by the patient.
Never threaten the patient. The sure way to lose control of the situation—and destroy your therapeutic alliance—is to use any form of coercion. Your initial therapeutic alliance with the patient is a critical factor in an effective de-escalation. The agitated patient should be involved in a fair, collaborative, and meaningful process that allows the patient self-expression.
You shall establish verbal contact Members of your clinical staff should resist the temptation to intervene individually. The first person to make contact should be the designated clinician to de-escalate the patient. If for any reason you do not feel capable of performing this duty, quickly identify which staff member will verbally engage the patient.
Table 3
CHECKLIST FOR ASSESSING VIOLENT TENDENCIES
| Questions | Yes | No | |
|---|---|---|---|
| 1. | Is the patient abusing alcohol or other substances? | ○ | ○ |
| 2. | Is the patient demonstrating alcohol or other substance intoxication? | ○ | ○ |
| 3. | Is the patient making threats to harm others? | ○ | ○ |
| 4. | Has the patient ever committed violent acts with subsequent arrests or in conjunction with criminal activity? | ○ | ○ |
| 5. | Was the patient physically abused as a child? | ○ | ○ |
| 6. | Has the patient demonstrated recent acts of violence (including damage to property)? | ○ | ○ |
| 7. | Has the patient recently brandished weapons, including objects that may be used as weapons (e.g., forks, rocks)? | ○ | ○ |
| 8. | Does the patient have thoughts or fears of harming others? …with intent? …with current plan? …with means? | ○ ○ ○ ○ | ○ ○ ○ ○ |
| 9. | Does the patient have command auditory hallucinations? …with specific instructions? …with response…with familiar voice? | ○ ○ ○ ○ | ○ ○ ○ ○ |
| 10. | Is the patient clinically depressed with severe psychomotor agitation, suicidal ideation, panic attacks, or suicidal plan with urge to take family with him/her? | ○ | ○ |
| 11. | Is the patient experiencing a paranoid delusion? …with planned violence toward the person as persecuting the patient? …with a hallucination-related delusion? …with history of acting on such a delusion? …which is systematized? …with accompanying intense anger or fear? | ○ ○ ○ ○ ○ ○ | ○ ○ ○ ○ ○ ○ |
| 12. | Is the patient experiencing threat control override symptoms? …thought insertion? …delusion of being followed? …made feelings? …sensation of mind control by external force? | ○ ○ ○ ○ ○ | ○ ○ ○ ○ ○ |
| 13. | Does the patient have a personality disorder with rage, violence, or impulse dyscontrol? | ○ | ○ |
| 14. | Does the patient have one of the following risk factors: male, age 15-24, low socioeconomic status, few social supports, brain disease, frontal lobe syndrome? | ○ | ○ |
| 15. | Does the patient display catatonic or manic excitement? | ○ | ○ |
| 16. | Does the patient have more than one major Axis I diagnosis? | ○ | ○ |
If the patient is yelling and screaming, or perhaps has already broken a chair or hit the wall, offer additional reassurance that you want to help him or her regain control.
You shall be concise When making verbal contact, remember the adage that less is more. Use short phrases or sentences and a simple vocabulary. Wordiness will cause confusion.
Here is a common scenario: You can see outside the nursing station that a patient’s temper is rising. The patient is pacing and slamming his or her fists on a tabletop. You ask the psychiatry resident to go help the patient. Barely 30 seconds later, the resident informs you that the patient just “ignored” him or her.
Agitated patients, especially those with psychosis, should not be expected to hear you the first time. After all, how often do your own spouse, children, or close friends hear you the first time? I often find that I may have to repeat a simple phrase to a patient as many as a dozen times until I am understood. Repetition is essential whenever you set limits, offer choices, or propose alternatives.