Patients often have both mental health and substance use disorders. Moreover, patients landing in the emergency department (ED) are often in the midst of a crisis, which sometimes leads to aggressive or violent behaviors. It is important to be familiar with your hospital’s protocol and to know how to call for help. Never put yourself in danger. Always ask permission from the health care team before consulting with a patient in crisis.

Stages of Crisis

Essential concepts in the stages of a crisis include:

  • Stage 1: Crisis Prevention – Support the patient and engage in motivational interviewing
  • Stage 2: Crisis – Implement de-escalation techniques and contact the health care team
  • Stage 3: Response – Alert staff and the crisis prevention team and provide physical intervention if necessary
  • Stage 4: Post Crisis – Debrief and focus on self-care

Practical Strategies for Verbal De-escalation

De-escalation is a combination of strategies and techniques to reduce any patient’s agitation and aggression. De-escalating helps to prevent violent behavior and reduce the risk of harm to patients and caregivers. De-escalation techniques can help to avoid the use of restraints or seclusion, reduce patient anger and frustration, improve staff-patient connections, enable patients to regain personal control, and help patients to develop feelings of hope, security, and self-acceptance. During stage 2 of crisis care, a patient may resist care and begin escalating a situation. Consider these strategies as you work with a patient to verbally de-escalate:

  • Respect the individual’s personal space; do not get uncomfortably close or block exits. 
  • Do not be provocative or respond in anger; be in control and measured. 
  • Ignore challenging questions.
  • Establish verbal contact calmly with the individual. 
  • Be concise and speak in short, easy-to-understand sentences or phrases. Repeat yourself often.
  • Be empathetic and nonjudgmental. Listen closely to what the person is saying. 
  • Identify the individual’s wants and feelings, and try to accommodate reasonable requests.
  • Choose what you mandate wisely. 
  • Focus on feelings.
  • Agree or agree to disagree with the person’s concerns while avoiding negative statements. 
  • Set clear limits with expected outcomes, but do not make demands or order specific behavior.
  • Offer choices and optimism. 
  • Allow silence for reflection and decision-making. 
  • Afterwards, review the event and look for areas of improvement.

Responding to Aggression

Patients in crisis are unstable and may be argumentative, act out, or refuse treatment.

STAMP is a validated tool for use in the ED to identify potentially aggressive patients:

  • Staring and eye contact
  • Tone and volume of voice
  • Anxiety
  • Mumbling
  • Pacing

Be aware of your own actions and remain in control:

  • Focus thoughts on safety
  • Be aware of your own triggers
  • Regulate and control your breathing
  • Try using self-talk—remain safe” or “remain calm”
  • Try to relax—practice some quick physical relaxation skills, such as relaxing your hands
  • Try not to personalize the person’s anger or share their emotion

Crisis Intervention and De-escalation Training

Be prepared when crises inevitably occur. California Assembly Bill 508 requires that all hospital employees regularly assigned to EDs receive training and education on security topics, including safety measures, aggression and violence-predicting behaviors, and verbal and physical maneuvers to diffuse or avoid violent behavior. If you have yet to receive this training, you should request it from your supervisor. Additional resources include:

Learn more about the intersection of behavioral health and substance use in Section 6 of our CA Bridge Navigation Toolkit.