Quick Tips: De-escalation of Situations for Occupational Therapy Mental Health Psychosocial

  1. Remain calm and speak in a calm and soothing tone.
  2. Establish verbal contact.
    • Listen actively and acknowledge the person’s feelings and concerns.
    • Use open-ended questions to gain more information and understanding of the situation.
    • Use “I” statements, active listening, and reflective language.
    • Avoid using confrontational or argumentative language.
    • Identify patient’s wants and feelings.
    • Agree or agree to disagree.
    • Set clear limits.
    • Find a way to respond that agrees with or validates the patient’s position. Don’t give up immediately. Do not be afraid to repeat this message to be heard.
    • Offer choices and optimism.
    • Provide a sense of control and autonomy; decrease helplessness.
  3. Be mindful of non-verbal language and expressions.
    • Use a non-threatening stance and approach.
    • How you approach and the direction also is a consideration.
  4. Address basic human physical needs, e.g., water, food, warmth, rest, breaks.
  5. Remain at a safe distance and use nonverbal cues such as open body posture to show that you are approachable. Respect personal space.
  6. Communicate by calling for help to escalate the situation with the appropriate staff or personnel as you de-escalate and/or step out.
    • If needed, use a team approach with other healthcare providers to help de-escalate the situation and do not attempt to do it on your own.
  7. Ensure the environment is safe for the management of the agitated patient.
    • Furniture can allow for access to exits for both the patient and staff.
    • There should be adequate exits; know where they are located.
  8. Be mindful of the patient potentially throwing objects or using them as weapons.
    • Non-movable furniture ensures that they cannot be used as weapons, but may still create a false sense of security.
    • Any object has the potential to be a weapon and should be removed or secured.
    • Monitor for objects that may be taken and hidden by the patient.
  9. Have the right staff for the right job. Some personnel such as security may potentially be triggers for the patient and should be used only when needed.
  10. Consider the impact of the patient’s behavior on others such as others patients and visitors.
  11. Recognize your limits in dealing with an agitated patient. Seek additional help when needed.
  12. Document the situation. This includes the actions taken and the outcome. This documentation can be used to improve care and safety for future patients and to identify any areas that need improvement in your organization.
  13. Debrief the patient and staff[1]Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman Jr, G. H., Zeller, S. L., Wilson, M. P., … & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of … Reference List

Try to understand the underlying cause of the person’s agitation or aggression. This can be related to pain, confusion, fear, or a lack of understanding. By identifying and addressing the underlying cause, you can help to alleviate the person’s distress and reduce the likelihood of a future escalation. Understand and respect the person’s cultural and personal background. This can include understanding their beliefs, values, and communication styles, which can help you to connect with them and build trust. Some possible factors include:

  • Cognitive (e.g., attention)
  • Neurological (e.g., stroke, seizures, dementia, sundowning)
  • Psychosocial, e.g., depression, bipolar
  • Physical, e.g., shock
  • PTSD
  • Fear
  • Cultural and/or language barriers
  • Trauma (Consider Trauma Informed Care, TIC)
  • Staff manipulation, e.g., staff splitting, faking of symptoms
  • Malnutrition
  • Hypoglycemia (diabetes)
  • Intoxication or drug’s effects
  • Drug withdrawal from drug abuse (also use CIWA)
  • Unintended withdrawal effects from opioid reversal medication such as Naloxone (Narcan)
  • Medications side effects
  • Pain (acute, chronic)
  • Infection, e.g., UTI
  • Poor rest and sleep; insomnia
  • Psychosis (hallucinations; positive AND negative psychosis)
  • Suicide ideation
  • Social factors, e.g., perceived racism from staff, mistreatment by staff, shift changes
  • Crowds, numerous new admissions
  • Institutional factors, e.g., being handcuffed
  • Personality disorders
  • Environmental, e.g., loud annoying sounds, noxious smells
  • Sensory integration dysregulation
  • Lack of locus of control or freedom
  • Deviation from routine, unpredictability
  • Time: anniversaries
  • Historical or recent events
  • Family or domestic dispute and abuse

Lastly, be aware of your own stress levels and emotional state, and take care of yourself. This can include taking breaks when necessary, debriefing with colleagues, and seeking support when needed. Consider taking time off work, even if brief such as coming an hour late to give yourself some time and space. Seek additional help for yourself and use “OT on yourself”.

References

References
1 Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman Jr, G. H., Zeller, S. L., Wilson, M. P., … & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17.
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.