Non-Coercive De-Escalation

At some point in your job as a clinician you will encounter an aggressive individual. The situation is often tense and can quickly escalate beyond the necessary proportions. Think back to the last time you had to deal with an aggressive patient or relative. How did you manage it? This article discusses different de-escalation strategies you can use in order to reduce the chance of aggression escalating into conflict.

An Introduction to Non-coercive De-Escalation

Aggressive individuals are encountered in many different settings; it might be in the GP practice, in the emergency department, on the wards or in clinic. These individuals might be patients, they could be relatives of a patient, friends of a patient or even a colleague! The reasons for their aggression will vary greatly and may even be organic in nature.

Non-coercive management of aggression involves engaging the aggressive individual verbally, forming a collaborative relationship and working to verbally de-escalate them from their agitated state. This occurs without the use of force or threats to achieve compliance.

Goals of De-Escalation

To ensure the safety of the angry individual, patients, staff and others in the area.
Help the angry individual manage their emotions and distress.
Help the angry individual maintain or regain control of their behaviour.
Avoid the use of restraint where possible.
Avoid coercive interventions that could result in escalation of agitation.

Getting Started

In the first instance, it is important to engage the individual and help them become an active partner in de-escalation. This involves the use of verbal and non-verbal communication with the aim of helping the individual calm themselves down as they re-establish their own internal locus of control. Verbal de-escalation is usually successful within five minutes, although a little additional time may be needed for more complex cases.

Begin by introducing yourself; state your name and role and find out the name of the individual. Explain that you want to help but also set firm boundaries. Then give some time for the patient to state their concerns. Do not give your opinions on the issues, especially those beyond your control. You should attempt to identify the trigger for the escalation in their behaviour and manage them where possible. If there are any unmet needs, try to correct those that can be easily remedied (i.e. pain control). If a decision needs to be made, give them time to consider what has been said. Remember that silence is a useful tool for helping individuals reflect on their actions. Finally, recruit trusted friends or relatives to help improve the situation.

In some instances, there will be patients you cannot de-escalate. This commonly occurs in delirious patients and may also be seen with psychiatric patients. In these cases, you should be persistent with your attempts at verbal de-escalation and only use medication as a last resort. Be sure to recognise your limits; de-escalation can be mentally taxing and may place you in harms way. If you feel as though your safety or that of others is at risk, you should seek assistance from security straightaway. The presence of security may help persuade individuals to co-operate.

Early Recognition of Agitation

Early recognition of agitation can lead to early de-escalation and resolution of any conflict before things spiral outwards. Use of an objective scale to monitor agitation can help in these regards. One example is the Behavioural Activity Rating Scale (BARS). Any patient or individual who displays signs meeting level 4+ should be reviewed and attempts made at de-escalation. Signs of early restlessness might include foot tapping, hand wringing, hair pulling, repetitive thoughts, irritability or heightened responsiveness to stimuli.

Types of Aggression

Psychologist Kenneth Moyer identified eight types of aggression during his work in 1968. They are predatory, inter-male, fear-induced, irritable, maternal, territorial, instrumental and sex-related aggression. Several of these forms might be seen in aggressive individuals in the workplace. They are as follows:

Instrumental Aggression

This is aggression directed towards obtaining a goal and is not driven by emotion. It may be a learned response and can be handled by using unspecified counter offers. For example, you might suggest enacting their threat is not a good idea. If they ask, “What do you mean?”, you will respond with “let’s not find out”.

Fear driven aggression

This is aggression associated with attempts to flee from a threat. They do not want to be hurt and may attack to prevent someone hurting them. Give them plenty of space and do not intimidate the patient or make them feel threatened. Match the patient’s pace until they start to focus on what is said, rather than the fear they feel.

Irritable Aggression

This is aggression induced by some frustration and directed towards an available target. There can be many different causes, but two common types are described below.

Violated boundaries. This occurs when someone feels cheated, humiliated or emotionally wounded. They are angry and trying to regain their self-worth and integrity. They want to be heard and have their feelings validated. In these instances, you might try to agree with them in principle.
Chronically angry at the world. They give no reason for their anger and need to release the constant pressure they feel as a result of their world view. They make unrealistic demands, use them as an excuse to attack out and enjoy creating fear and confusion. Do not offer them a response to their demands. Make attempts to remove all unnecessary people from the area. When interacting, use emotionless responses and offer them choices rather than the violence they want.

General Guidelines for De-Escalation

The following guidelines are based on the Best Practices in Evaluation and Treatment of Agitation (BETA) guidelines as described in a consensus statement on the verbal de-escalation of the agitated patient.

Preparation and the Environment

Training with de-escalation techniques is an important step for preparing to deal with an aggressive individual. Reading this article is a good first step, but you can go further and ask your department for role play or simulation to practice the skills in real time. Other useful interventions include designing spaces for safety or ensuring your department is adequately staffed, although these cannot be made during the heat of the moment.

Anyone can learn the skills and techniques needed to be successful at verbal de-escalation. The most important thing to bear in mind is that you must start with a good attitude towards the individual. Hold them in a positive regard and try to empathise with them. Recognise that they are probably doing the best they can under the current circumstances, whether there is an organic cause driving the aggression or not.

There are some small adjustments that can be made to the environment during the acute management of an aggressive individual. Try to make a safe space by removing furniture or any objects that can be thrown or used as weapons. Make efforts to ensure exits remain free and accessible for both staff and the aggressive individual. If possible, move away from public spaces to a private area to talk.

General De-escalation Guidelines

If you become overrun with emotions or are frightened of the aggressive individual, this will impact your ability to work. Monitor your own emotional and physiologic response and try to remain calm. Remember, the majority of information is conveyed by body language or tone of voice. BETA have identified 10 domains of de-escalation that help clinicians care for agitated patients.

Respect the patient’s personal space

Try to maintain at least 2 arm’s length distance. This gives you space to move away if needed and gives the individual the space they need.
Ensure exits are accessible without anyone blocking them.

Do not be provocative: avoid iatrogenic escalation

Demonstrate body language that you will not harm the patient, that you want to listen and that you want everyone to be safe.
Show your hands are empty, bend your knees slightly and stand at an angle from the patient so as not to appear confrontational.
Have a calm demeanour and avoid excessive eye contact. Keep your body language congruent with what you are saying.
Do not challenge, insult or humiliate the patient.

Establish verbal contact

Only one person should verbally interact with the individual. This should be the first person to make contact with them, unless they are unable to verbally de-escalate the patient.
Introduce yourself to the patient and provide orientation and reassurance. Be polite and explain that you are there to keep them safe.

Be concise: keep it simple and use repetition

Agitated individuals may have an impaired ability to process verbal information. Use short sentences and simple vocabulary.
Give the individual time to process what has been said and let them respond.
Persistently repeat your message until it is heard. Combine this with listening to the patient and agreeing with their position wherever possible.

Identify wants and feelings

Use free information to work out what the individual wants. This is the trivial things they say or display with their body language. It allows rapid connection with the individual by using empathy and offering to get them what they want (if reasonable).
Examples might include the need for space, someone to talk to, medication or a specific document.

Listen closely to what patient is saying

Use active listening to convey through conversation and body language that you are paying attention to what is being said and how they feel.
Be less judgemental. Assume what the other person is saying is true and try to imagine what it could be true of. Whether or not you think those feelings are justified, they are real to the other person.

Agree or agree to disagree

Find something about the patient’s position with which you can agree. This is effective for developing a relationship. There are three ways to do this:

Agree with the truth i.e. ‘what you have said isn’t wrong’
Agree with a principle i.e. ‘everyone deserves to be treated respectfully’
Agree with the odds i.e. ‘there are probably other people upset with this too’

If you are being asked to agree with something that is obviously not true, you might acknowledge that you have never experienced this, but you believe that they are having the experience they are describing.

Lay down the law and set clear limits

Establish what is an acceptable behaviour. Tell them that injury to them or others is unacceptable.
Set limits in a reasonable and respectful manner. Demonstrate your intent and desire to help but not to be abused.
Violation of a limit must result in a consequence which is related to the behaviour and is both reasonable and presented in a respectful manner.
Coach the patient how to stay in control. Once a relationship has been established, use gentle confrontation with instructions. For example, ‘I can see that you are pacing, let’s take a seat for just a moment’.

Offer choices and optimism

Be assertive and quickly propose alternatives to violence if events are spiralling out of control. Offer choices to individuals who having nothing left but fight or flight. This is a source of empowerment.
Offer things that can be seen as acts of kindness such as food, drink or blankets. The choices must be realistic and do not promise them something that cannot be delivered.
If medication is indicated, try to get the patient to request medication to calm them down. If they don’t ask for medication, offer it as a means to help them calm down.
Be genuinely optimistic and let them know that things will improve and that they will be safe and regain control. Give realistic time frames.

Debrief the patient and staff

Debrief the patient. Explain why any intervention was necessary, let the patient explain events from their perspective and explore alternatives for managing aggression should it occur again. Ask what works when they are upset or what can we do in the future to help them regain control.
Debrief the staff. Ask them what went well and what didn’t go so well. What improvements would they recommend for the next time?