You shall identify wants and feelings You’ve gotten the patient’s attention. Now it’s time to empathize and solidify the therapeutic alliance. Recognizing the patient’s wants and feelings becomes crucial at this point (Table 4).
Thus, if I find a patient banging his or her fists on the table and the walls, I approach the patient saying, “You seem angry…is there something you want that you’re not getting …and do you still really want it? Perhaps I can get it for you.” If a patient is crouched in the corner, looking as if he is going to strike out and run, I say, “You seem afraid …do you feel something terrible is going to happen to you? Can I help keep you safe?”
Once again, repeat these simple statements until the patient appears to relax, an indication that he or she thinks you understand what is wrong.
You shall listen Try to understand what the patient is saying—not what you think he or she is saying. I find it helpful to make sure that I have correctly understood by commenting, “Let me see if I understand you correctly.” This tells the patient you are listening accurately, and conveys further empathy.
Whatever you do, don’t argue with the patient. And if the patient insults you, don’t up the ante with a verbal retaliation.
You shall agree or agree to disagree Some believe that the most important part of de-escalation is the act of agreeing with the patient.
Agreeing with the patient without furthering a delusion or lying, however, is very difficult. For example, if an agitated patient asks if you believe aliens are torturing him or her, many of us would simply say, “no.” I would agree by telling the patient, “While I have not seen the aliens or seen you tortured, I believe that you are being tortured.” By so doing, I can diffuse the patient’s anger.
Agree for as long as you can with the patient’s experience. If you cannot go any further, you can always say, “We can agree to disagree.”
Table 4
Identifying thoughts and feelings for making empathic statements
| Thought | Feeling |
|---|---|
| I want something I didn’t get it I still want it | Angry |
| I want something I didn’t get it I’ll never get it | Sad |
| I want to avoid something bad happening | Fearful |
| Adapted from: Bedell JR, Lennox SS. Handbook for Communication and Problem-Solving Skills Training: A Cognitive-Behavioral Approach. 2nd ed. New York: John Wiley &Sons, 1996. | |
Be honest. It is OK to tell the patient that he is scaring you, other patients, or the staff. Tell the patient that injury to himself or herself, or to others, is unacceptable. Be prepared to be challenged repeatedly as you set firm limits. You may find it necessary to tell the patient that arrest and prosecution are possible if he or she assaults anyone.
Early in the de-escalation process, emphasize that there are consequences to the patient’s behavior. State both the positive and negative consequence of a behavior, then ensure that this statement is not perceived as a threat by asking the patient to make a choice.
You shall offer choices Choice is a powerful tool. For the patient who believes there is nothing left but fight or flight, being offered a choice, such as taking a time-out or a medication to decrease the anger, can be a welcome relief.
When an assault is imminent, do not expect the patient to engage in problem solving. Do not ask if they can name a behavior other than assaulting the staff that promises a better outcome. Be assertive. Quickly propose the possible alternatives to violence.
You shall debrief the patient Despite your best efforts, some patients will still end up in seclusion or restraints after their emotions escalate. Some may require emergency intramuscular medications. I recommend that the psychiatrist who wrote the order for seclusion, restraint, or emergency medications take the time to debrief the patient after the episode is over and the patient is calm. The benefits of debriefing include restoring a therapeutic relationship, diminishing the traumatic nature of such events as emergency intramuscular injections, and decreasing the risk of additional violent events.
Find a quiet location and begin by explaining why the intervention was necessary. Let the patient explain the events from his or her perspective. Then it is time for some problem solving in which you and the patient explore alternatives should he or she get angry again. Teach the patient how to request quiet time and how to recognize the early warning signs of impending violence. Let the patient know it is safe to approach the staff early and express anger while making a request for what he or she wants. You can also explain the role of medications in preventing violent acts.