Psychiatric Emergencies: Empowering Connections to De-escalate Aggression

The National Alliance on Mental Illness defines a mental health crisis as a “situation in which a person’s behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community” (2). Also, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Like a physical health crisis, a mental health crisis can be devastating for individuals, families and communities” (3). The emergency department (ED) provides acute treatment for both types of crises.

During the initial months of the COVID-19 pandemic in March of 2020, EDs became flooded with medical emergencies related to the virus. The surge in mental health–related emergencies subsequently emerged. Research suggests that the social isolation, fear of contagion, economic stress (such as job loss), and grief surrounding the death of loved ones have had a damaging impact on mental health. A cross-sectional study by Holland and colleagues (4), using data from the Centers for Disease Control and Prevention’s (CDC’s) National Syndromic Surveillance Program, found that ED visit rates for mental health conditions, suicide attempts, drug overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019. These increases in psychiatric emergencies after COVID-19 surges have affected young adults and racially and ethnically minoritized populations most significantly (5).

The general population in the United States and globally has experienced negative psychiatric consequences related to the pandemic. Health care and mental health care professionals are not immune to this trauma, and many surveys have suggested that health care “burnout” is at an all-time high (6). Workplace violence has also been on the rise. The CDC’s National Institute for Occupational Safety and Health reported that over 75% of the 25,000 workplace assaults that result in days away from work annually in the United States took place in hospitals and other health care and social services settings. For health care professionals, the ED is a high-risk setting for aggression. Staff collaborating with patients in acute psychiatric crisis are at risk for physical and emotional traumatic injury (7).

Psychiatrists are not typically the first professionals on the scene interacting with agitated patients experiencing a psychiatric emergency. Police and security personnel may have brought the patient to the ED and remain present to maintain staff safety. Nurses and other health care staff are also present. In this crisis setting, the potential for violence of the patient toward personnel or for the personnel to invoke coercive methods to quell the agitation, such as restraints and involuntary medication, is high. This level of intervention may be necessary to maintain patient and staff safety in some situations. However, increased emphasis and training is required to ensure that all ED staff have expertise in noncoercive methods to assist the patient in gaining control using trauma-informed skills (3). “Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible” (8). Although staff in hospital mental health care settings are routinely trained in de-escalation techniques, psychiatrists have often been “the prescribers” in the emergency care rather than actively, empathically, and collaboratively helping patients calm themselves (9). The psychiatrist may be in the best position to evaluate the probable causes of the agitation, such as trauma, panic, substance use, psychosis, or other medical or behavioral issues.

Trauma-informed care is an essential element of crisis treatment. SAMHSA (3) set guiding principles for trauma-informed care. They include safety for patient and staff; trustworthiness and transparency; peer support and mutual self-help; collaboration and mutuality; empowerment, voice, and choice; and ensuring that cultural, historical, and gender considerations inform the care provided. The issues of implicit bias must be considered with each encounter. A systematic review found that health care professionals tend to associate Black patients with being less cooperative, compliant, and responsible in comparison with White patients (10). Another study reported that clinicians tend to associate Hispanic patients with medical noncompliance and partaking in risky behaviors (11). Research also indicates that racial disparities are present in the decision to restrain a patient. Black patients are more likely to be restrained while in the ED, even when controlling for confounding variables, such as diagnosis, sex, age, homelessness, and violence (12, 13). Trauma-informed best practices include attention to this potential bias each time an agitated patient presents to the ED.

Richmond and colleagues (8) proposed a three-step approach to de-escalation. First, the patient is verbally engaged; then, a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. The professional who is leading the de-escalating intervention requires ample time, self-composure, and team leadership skills to calm all involved.

Clinical Vignette

Ms. Cathy Smith is a 33-year-old mother of two who was diagnosed as having bipolar disorder at the age of 23 while she was in her first year of law school. Ms. Smith cared deeply about her children (ages 6 and 8) and worked to ensure that they attended the best school in the area. When her mood was stable, she was kind and nurturing. However, when she did not take her medication or her symptoms broke through, she lost motivation and neglected the children. More concerning was when Ms. Smith suffered a manic episode: She became agitated and threatening, declared that her children were not hers and were imposters, and claimed that she was married to movie stars. Mr. Smith, her husband, drove trucks on long-distance routes and often was not there to take over when Ms. Smith was becoming ill. Her disabling mood symptoms had become increasingly more common and more severe. She was a “frequent flier” to the ED. Staff were concerned and fearful when she came, as she was quite agitated and had attacked a nurse during one of her psychiatric emergency visits. Today, Ms. Smith was brought in by ambulance in restraints, and she struggled to pull free while screaming profanities and threats.

“Whose turn is it to work with Ms. Smith today?” the charge nurse inquired, a note of sarcasm in his voice.

“Well,” Dr. Hayes replied in an apprehensive tone. “Give me a mindfulness minute and I will see what I can do to be helpful.” Dr. Hayes had perfected brief mindfulness practice as an effective method of calming and remaining in the moment.

When Dr. Hayes went into the room with Ms. Smith, she remained in restraints and was still struggling. When Dr. Hayes approached, Ms. Smith spit at her.

“Shall I get an IM prn [intramuscular injection as needed], Dr. Hayes?” the assigned nurse asked.

“No, not yet, please,” Dr. Hayes replied.

Dr. Hayes left the room, retrieved a chair, and brought it into the room. She sat down to be more at Ms. Smith’s eye level but not so close as to be threatening. The security officers stood a few feet away, at the ready.

“Hello, Ms. Smith,” she began. “I am Dr. Hayes, the psychiatrist. I am sorry that you are in restraints, but it’s not OK to shake the gurney, yell, and spit. Please stop so that I can ask the security guards to stand outside the room and we can talk about what you need. OK?”

“Yes, get the [expletive] out of my sight,” Ms. Smith spewed toward the security officers.

Dr. Hayes nodded, and the security guards left the room and stood outside the open door, just out of Ms. Smith’s sight. Dr. Hayes thanked them. The room was quieter, and no one was standing over Ms. Smith as she remained in restraints.

“Get these [expletive] things off of me,” Ms. Smith insisted, tugging at the restraints.

Dr. Hayes gazed empathically into Ms. Smith’s eyes. “I don’t blame you for being upset. The restraints look uncomfortable. I would like to work together to be sure you can be safe so they can be removed.”

“You all are just on a power trip to see if you can subdue a celebrity,” Ms. Smith said scornfully.

Dr. Hayes remained silent. After a long pause, Dr. Hayes said quietly, “Would you like to listen to music to calm down? I was told you are a Beyoncé fan.”

Ms. Smith’s muscles were tense, but she had stopped struggling and cursing. “Last time I tried that, the police came and took my earbuds away,” Ms. Smith complained.

“I’ll tell you what—as long as you can remain safe, I will ask if you can keep them. You need to be safe, though.”

“Sure, sure,” Ms. Smith replied. “My husband, George Clooney, doesn’t even know I’m here. I need to call him right now! He will come get me.”

“I’m sorry. No calls,” Dr. Hayes replied. “The nurse is going to get the earbuds and the Beyoncé mix.”

Both waited quietly until the earbuds appeared.

“Thank you for calming down, Ms. Smith,” Dr. Hayes said sincerely. “Would you rather start the music now, or wait until you are out of restraints?” Dr. Hayes asked.

“Now,” Ms. Smith replied quickly.

“OK, but we can’t have them too loud, as we still need to be able to talk. I am trusting you that you will not hurt me after the restraints are removed,” Dr. Hayes said matter-of-factly.

“I won’t hurt you,” Ms. Smith replied.

“And no hurting others, as well,” Dr. Hayes added.

“Not as long as they keep their filthy hands off me,” Ms. Smith replied.

“If you are calm and safe, there will be no need for hands on,” Dr. Hayes reassured her, “but that is up to you. You need to be safe.”

The earbuds were placed carefully in Ms. Smith’s ear canals, and the music started. Over the next 5 minutes, Ms. Smith’s body relaxed, and she began to sway with the music.

“May we bring you your medication now?” Dr. Hayes queried. “I think you missed some doses of olanzapine, so we want to restart it.”

“Yuck,” Ms. Smith said loudly, but she took the medication as offered. The security guards removed the restraints over the next 15 minutes, as Ms. Smith remained calm.

On debriefing after having been in behavioral control for some time, Ms. Smith reported that she thought listening to music and “being left alone and not touched” works best to help her calm when she is upset. Staff debriefing suggested that having police and others close by but out of sight and using music was helpful. They found Dr. Hayes’s approach effective and instructive.

Tips for Collaborating With the Agitated Patient

De-escalation involves transferring a sense of calm and genuine interest in the patient’s needs and wishes by using respectful, clear, limit setting. The goal is to build rapid rapport and a sense of connection with the agitated patient. Honest communication builds trust, even if what is being said is not what the patient wants to hear. An agitated patient likely is processing very little of what is said, so calm, simple sentences and nonthreatening voice tone and gestures are more successful (14).

Although psychiatrists may be crucial to de-escalating the agitated patient, trusting one’s instincts and ensuring one’s safety and the safety of ED staff is critical. Patients almost never want to hurt staff and may later be remorseful or humiliated by the behavior they displayed when they were agitated and out of control (14).

The American Association for Emergency Psychiatry reviewed Best Practices in Evaluation and Treatment of Agitation (Project BETA) (9). They reiterated that keeping the clinician safe is the first step toward patient safety. “When the clinician approaches the agitated patient, they must monitor their own emotional and physiologic response so as to remain calm and capable of verbal de-escalation” (15). Clear your mind. Mindfulness exercises are one way of focusing and clearing one’s mind and remaining calm and composed.

The following strategies for de-escalation of the agitated patient include recommendations from SAMHSA (3), Fishkind (14), Project BETA Consensus Statement of the American Association for Emergency Psychiatry (8, 9), and Hogan and Goldman (16).

1. Respect personal space. The physical space should be designed for safety, with a minimum of objects that may be thrown by a patient who is agitated. The space should minimize overstimulation. The patient should be given enough personal space so as not to feel threatened. Egress should not be blocked.

2. Do not be provocative. Demonstrate by tone and body language a joint goal of helping everyone remain safe. Security and police officers must understand that a patient’s abnormal behavior is a manifestation of mental illness, and that de-escalation is the preferred treatment. There should be agreement ahead of time that there will be one ED staff member who is well trained and has a calm demeanor that will be the lead in the de-escalation process. Security personnel play a crucial role in containing active violence but can sometimes cause more fear in patients. Having security personnel close by but not active in the de-escalation process is typically more effective. This may be especially true for patients of color or other minoritized groups.

3. One person from the team should establish verbal contact. Multiple individuals interacting is confusing for the patient and often for the treating team as well. Introducing yourself and your role to the patient and providing orientation and reassurance helps build trust.

4. Be concise and keep it simple. All individuals who are agitated or dysregulated tend to process very little of what is said. Keep verbalizations short, provide time for processing the information, and repeat the information as needed. Low affect, with clear and concise repetition, is essential to successful de-escalation.

5. Identify wants and feelings. This may be done by asking or attending carefully to what the patient communicates from their body language, knowledge from past encounters, or even trivial things a patient says. The aggressive patient has specific wants, such as feeling safe. Identifying these wants is important in working empathically with each patient.

6. Listen closely to what the patient is saying. Do not interrupt. Listen intently to the entirety of the other’s communication before reflecting and responding. Use Miller’s Law: “To understand what another person is saying, you must assume that it is true and try to imagine what it could be true of” (1). In genuine attempts to imagine how it could be true, you will be less judgmental, and the patient will sense your authentic interest and caring.

7. Agree, or agree to disagree. Attempting to find something about the patient’s position with which you can agree helps develop a relationship of honesty. One may agree with the truth, agree in principle, or agree with the odds. For example, if a patient says that “anyone would be upset if they had to wait this long,” agreeing that “there probably are other patients who would also be upset,” agrees with the odds. If there is no way to honestly agree with the patient, agree to disagree.

8. Lay down the law and set clear limits. Good basic working conditions require that both the patient and clinician treat each other with respect, with clear communication about acceptable behaviors. Limit setting must be reasonable and presented in a respectful manner. Coach the patient in how to stay in control once a basic working relationship has been established.

9. Offer choices and optimism. A patient who feels helpless and in “fight-or-flight” mode may believe that they must resort to physical violence to maintain safety. Offering choices may be the only source of empowerment for this patient experiencing agitation. In the vignette, offering music and giving a choice about when the patient wanted the earbuds was a simple, realistic, but meaningful choice for the patient. Medication may be offered in a similar manner, with agreement on the goal of helping the patient feel calm and in better control.

10. Debrief the patient and staff on what worked well and what might be improved in the future. Explain why the intervention was necessary. Listen carefully and acknowledge with appreciation the patient’s feedback. Staff debriefing is also important. We are all trying to get to the same end—helping the patient stay safe and in control and collaborating to their ability in their care.