This article was published on April 6, 2022. It was last edited/ updated on April 26, 2022.
Agitation/ aggressiveness is a common issue that mental health clinicians have to deal with, most commonly in acute care situations (emergency room, inpatient psychiatric unit). Unfortunately, many or most of us have been in situations in which we were subjected to verbal aggression, threats, and, not rarely, even physical aggression. So, strategies for managing agitation and aggressiveness are extremely important for us to continue to master.
Unfortunately, research evidence on what works to prevent or de-escalate aggressive behavior among psychiatric patients is very limited (Gaynes et al., 2017). The clinical tips about the evaluation and management of agitation, aggressiveness, and violence in mental health settings that we provide in different articles on this website are based mainly on clinical experience and expert opinion.
First, please see the following articles on this website:
An overview of agitation and aggressiveness in mental health settings
Safety first! Preventing injury due to violence by patients
Next, on this page, we’ll discuss verbal de-escalation, an important skill that all mental health clinicians should actively learn and continue to improve.
Verbal de-escalation can be effective in many patients and may be used either alone or in combination with other interventions. It is usually preferable to “more restrictive” measures like administering medications for agitation or restraining the patient.
noncoercive approach. It has been found that such non-coercive interventions can lead to successful outcomes much more often than was previously believed to be possible (Richmond et al., 2012).
There is pressure from regulatory authorities to decrease the use of seclusion and restraints. The American College of Emergency Physicians (2020) says it clearly and simply: “When appropriate and safe, verbal de-escalation and standard treatment of underlying medical or psychiatric conditions should be attempted before restraints”.
So, on this page let’s look at how to implement verbal de-escalation of an agitated/ aggressive patient. Note: One of the important sources of guidance on this topic, which will often be referred to, is Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup (Richmond et al., 2012).
What NOT to do
Here are some things that are likely to increase the patient’s anger and aggressive behavior, or the risks from such behavior.
Don’t *always* try verbal de-escalation first
Yes, we should try our best to try verbal de-escalation before proceeding to chemically or physically restrain the patient. But, like most principles in the clinical practice of medicine, the application of this rule of thumb requires some judgment. To prioritize the safety of the patient and staff members, in some patients, based on their previous history, recent behavior, and current state, it may be appropriate and necessary to go directly to higher levels of interventions including, if needed, chemical or physical restraints.
Don’t keep an agitated, angry patient waiting
Patients who are known to be agitated and/or potentially violent should not be kept waiting. We should try to see them on a priority basis—out of turn and ahead of other patients if needed.
Don’t position yourself unthinkingly
– We should try our very best to position patients so that they can leave the space or room if they want to and don’t feel “cornered”. When patients feel cornered, they may be more likely to become aggressive.
– We should stay some distance away from the patient. This is not only to increase our safety but also because patients may become more agitated if we are in their personal space.
Don’t be provocative with your body language
Some body language tips are vague and hard to implement, for example, “Maintain a calm demeanor”. But, here are some concrete, do-able suggestions:
– We should not keep our hands in our pockets; they should be kept clearly visible. This is so that the patient can clearly see that we don’t have any weapon or object in our hands (Richmond et al., 2012).
– We should avoid standing directly facing the patient or staring persistently at them. Both of these may make us seem confrontational. Instead, we should develop the habits of standing facing slightly away from the patient and of varying our eye contact.
Don’t simply tell them to stop shouting or cursing
– The patient may be shouting/ cursing to try to bully the staff or because they are being hostile/ aggressive. But some patients may be shouting or cursing because they think that they have to do so in order to be heard. In such situations (shouting/cursing), telling them to stop shouting or cursing is likely to feel stifling and make them even angrier (Fauteux, 2010). Instead, what they need us to do is focus on why they are angry (Fauteux, 2010). That may help them to gradually calm down.
Don’t “set limits” that are not essential
– Clinicians with limited experience have heard that we should “set limits” with patients, and, of course, we should. But, what exactly does that mean? Please, please–-it does not mean that we should take a tough approach with patients and tell them that they will have to “follow all the rules”.
– With agitated/ aggressive patients, I think we should aim to set only the minimum limits that are essential. By “essential”, I mean that patients should clearly understand that they cannot be allowed to be physically violent. And, that various measures may need to be taken to make sure that both they and the staff members stay safe.
Don’t “make excuses”
Ahmad Shobassy, MD, suggests that when agitated patients express their frustration, we should try to see things from their viewpoint and empathize with how they feel. Giving reasons why the situation is what it is could be seen as “making excuses”. Giving reasons, even completely valid reasons, is less likely to reduce agitation than simply expressing empathy, regretting that the patient’s experience is distressing, and offering a straightforward apology (if an apology is appropriate).
He gives the following examples: If the patient is yelling at us about having had to wait for an hour to talk to us, we may simply apologize for the delay and then move on to something like “I am here to talk to you now, how can I help?”. Giving excuses to patients, such as “I am sorry. I was busy” or “You are not the only patient I have”, tends to trigger agitated patients because it seems to imply that they don’t have the right to be angry. And, it allows them to keep arguing by challenging the excuse; for example, “Then you need to hire more people!”
Don’t appear to be ordering the patient around
– If possible, we should try to avoid telling the patient what to do in a way such that the patient feels that they are being “ordered around” by us. Instead, we should make “requests” of the patient.
Tips on the PROCESS of talking to an agitated/ aggressive patient
Build a bond
Our first goal is to establish verbal contact (Richmond et al., 2012), and then build on it.
– We should usually start by introducing ourselves and what our role in the treatment team is.
– It may be helpful to ask agitated patients whether they need anything, like food, water, an extra blanket, and so on (Richmond et al., 2012).
– In particular, offer food or a beverage even if the patient has not asked for these (but not something that can be used as a weapon, of course). If something to eat is offered and the patient accepts, this seems to be particularly helpful for creating a relationship.
One at a time, please
– While a “show of force”—having many staff members present—is usually helpful in reducing the risk of patients acting in a physically aggressive way, only one person should be speaking to the patient at one time (Richmond et al., 2012).
Simple, slow, and repetitive
Patients who are agitated may be overwhelmed by their inner experiences.
– Use short sentences and simple, non-technical words. providing additional information. Using complex explanations can make an agitated person more confused.
– Give the patient time to process what has been said and to respond before continuing on to other things we want to say (Richmond et al., 2012).
– We should repeat our message, in different words, until it is heard by the patient (Richmond et al., 2012).
It’s OK to interrupt us
Tip from Ahmad Shobassy, MD: An agitated patient may interrupt us repeatedly. This may be because the patient is upset and want to “vent”. Instead of admonishing agitated patients for interrupting us, it might be best to allow them to interrupt us but not do so ourselves.
What might help to verbally calm an angry patient down
Here are two broad principles about how to do this:
The patient doesn’t need to shout in order to be heard
We should ask ourselves—What is going on here?
Is it:
1. Frustration about the situation
2. An attempt to “bully” the staff, or
3. Hostility that could be a warning sign of impending violence (Fateux, 2010)?
We should understand that their frustration and anger may be due to perceived injustice or to the feeling that they are being ignored. Patients may feel that they have to yell in order to be heard. In such situations, telling them to stop shouting or cursing is likely to feel stifling and make them even angrier (Fauteux, 2010).
For patients who seem to be angry and agitated due to frustration about their situation, we should generally:
1. Let them express their frustration. Allow the patient to talk. Let them exhaust the list of their concerns.
2. Focus on why they are angry (Fauteux, 2010). That may help them to gradually calm down.
If the person is shouting or cursing in order to be heard, it is likely that they will stop if they are heard. But, if they are shouting to intimidate the staff or to be threatening, they probably won’t stop simply by being heard; more will need to be done (Fauteux, 2010).
Got empathy?
Firstly, let’s be clear that “validating the patient’s feelings” does not mean that we should say to angry patients that their feelings are appropriate or justified. But, before we can reassure patients or correct any misperceptions that may be contributing to their anger, we must express to them that we can see and understand why they are angry. Do you see the difference between these two?
The American Association for Emergency Psychiatry recommends two specific approaches to increasing empathy and rapport (Richmond et al., 2012):
1. “Miller’s law“, which states, ‘‘To understand what another person is saying, you must assume that it is true and try to imagine what it could be true of.’’ They noted that by following this law, we will be trying to imagine how what the patient thinks could be true, which would make us less judgmental. When patients sense that we are interested in what they are saying, this is likely to improve our rapport with the patient (Richmond et al., 2012).
2. Fogging, which is an empathic intervention in which we try to find some aspect of what the patient is saying that we can agree with. For ways to do this, please see the next section.
Three ways to agree with a patient
In the previous section, we noted that fogging is an empathic intervention in which we try to find some aspect of what the patient is saying that we can agree with. It is recommended that we should agree with the patient as much as possible (Richmond et al., 2012).
The American Association for Emergency Psychiatry guideline notes that there are 3 ways to agree with a patient (Richmond et al., 2012):
1. Agreeing with something that is true. For example, “You have been waiting for over an hour to see the doctor”.
2. Agreeing in principle. For example, if the patient feels that he is being disrespected by the staff, we may say something like, “I definitely agree that everyone should be treated with respect”.
3. Agreeing with the odds of what the patient is saying. For example, if a patient who is angry says that the hospital food is terrible, we could say something like, “I’m sure that some other patients also don’t like the food”.
But, what if the patient is reporting a delusional belief? Should we agree with that? Obviously not. In such a situation, we can say something that indicates that we believe that it is true that the patient is having that experience. For example, we may say something like, “It must be pretty scary to feel that people are following you and are trying to kill you”.
Two tips for speaking to a patient who is making threats
At times, patients who are angry or agitated may start making specific threats of some kind. Of course, there are many extremely important things that we can and must do to ensure our safety and that of the patient. Those take priority.
But, in this section, we will discuss two important principles underlying verbal strategies for trying to de-escalate the situation when a patient is making threats.
Sidestep the threat
When a patient makes a threat, we have a dilemma.
– On the one hand, it is NOT a good idea to directly challenge the patient with regard to the threats (Fauteux, 2010). That may lead to such patients trying to show us that they mean business by proceeding to act on their threats.
– On the other hand, we do have to indicate that it is NOT acceptable to make threats.
What should we say to the patient then? A good response might be one that:
– Does not directly challenge the patient regarding the threat
– States that threats are not appropriate or necessary
– Tries to move forward by indicating to the patient that we are going to try to solve the patient’s problem.
For example, we may say something like the following: “I can see why you’re angry. But, there is no need to make threats. Let’s stop that and instead focus on how we can solve your problem” (modified from Fauteux, 2010).
Show the patient that there IS a way out
– We do not want patients who are making threats to feel that they are stuck in a corner and the only way to save face is to act on the threats they have made (Fauteux, 2010). So, we should point out to patients who are making threats that their real goal is not to act on their threat but to get what they want (Fauteux, 2010).
– A related strategy is one that is needed if our attempts to de-escalate the situation are not working and we are concerned that the patient may act on the threat that was made. A verbal strategy in this situation is to remind the patient that they have not reached “the point of no return” (Fauteux, 2010). An example of such a response may be: ” I know that you made a threat, but you haven’t done anything wrong; so let’s figure out how to make this work” (modified from Fauteux, 2010).
This ends our discussion of strategies for verbal de-escalation of patients who are angry, agitated, or aggressive. On other pages on this website, we’ll discuss other interventions that may be needed to deal with such situations—ensuring the safety of the patient and others, risk evaluation, identification and management of the underlying condition, oral medications, injectable medications, open seclusion, locked seclusion, and physical restraints. See Related Pages below.
Simple and Practical Medical Education thanks Ahmad Shobassy, MD for his valuable comments and suggested edits for this article.
Dr. Shobassy is a Clinical Assistant Professor of Psychiatry at the University of Michigan School of Medicine in Ann Arbor, Michigan, USA.
Related Pages
An overview of agitation and aggressiveness in mental health settings
Safety first! Preventing injury due to violence by patients
Advanced tips for verbal de-escalation of agitated/ aggressive patients
Autism spectrum disorder: Evaluation of irritability, agitation, aggressive behavior
When calm needs to be injected: Intramuscular and intravenous injections for agitation or aggressiveness
How to manage agitation in a pregnant woman
Autism spectrum disorder: Medications to treat irritability, agitation, or aggressive behavior
How to manage neuropsychiatric symptoms in persons with dementia
Key Points from the APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia
Citalopram for agitation in Alzheimer’s disease
Valproate for neuropsychiatric symptoms in dementia?
Carbamazepine for neuropsychiatric symptoms in persons with dementia?
Gabapentin for neuropsychiatric symptoms in persons with dementia?
Case: Agitation in a patient with Alzheimer’s disease
Should we use droperidol, which is available again?
L-methylfolate can sometimes precipitate irritability, agitation, insomnia, or aggressiveness
References
American College of Emergency Physicians. Policy statement: Use of patient restraints (revised February 2020). Available at this link. Last accessed on April 7, 2022.
Fauteux K. De-escalating angry and violent clients. Am J Psychother. 2010;64(2):195-213. doi: 10.1176/appi.psychotherapy.2010.64.2.195. PMID: 20617790.
Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, Coker-Schwimmer E, Weber RP, Sheitman B, Zarzar T, Viswanathan M, Lohr KN. Preventing and De-escalating Aggressive Behavior Among Adult Psychiatric Patients: A Systematic Review of the Evidence. Psychiatr Serv. 2017 Aug 1;68(8):819-831. doi: 10.1176/appi.ps.201600314. Epub 2017 Apr 17. PMID: 28412887.
Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. 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 Feb;13(1):17-25. doi: 10.5811/westjem.2011.9.6864. PMID: 22461917; PMCID: PMC3298202.
References not used yet on this page
Hankin CS, Bronstone A, Koran LM. Agitation in the inpatient psychiatric setting: a review of clinical presentation, burden, and treatment. J Psychiatr Pract. 2011 May;17(3):170-85. doi: 10.1097/01.pra.0000398410.21374.7d. PMID: 21586995.
Petit JR. Management of the acutely violent patient. Psychiatr Clin North Am. 2005 Sep;28(3):701-11, 710. doi: 10.1016/j.psc.2005.05.011. PMID: 16122575.
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You may have mentioned this and I have just overlooked it, but I have always found that one of the best ways to lower the tension with an agitated person is to speak very quietly. There is no point in raising your voice to be heard by someone who is shouting. They aren’t going to listen anyway. By speaking softly you can often engage the attention of the agitated person and they will stop shouting so that they can hear what you are trying to say to them. Also, if you slow and deepen your breathing, it will help you stay calm and the agitated person will often match their breathing to yours. Just make sure you don’t sound as if you are sighing in exasperation.
This is such an excellent set of suggestions! Thanks a lot!