From The Carlat Psychiatry Report, September 2018, Emergency Psychiatry

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Free Articles | Practice Tools and Tips

This text has been adapted with permission from the 10 Commandments for Safety by Avrim Fishkind, MD.

1. Respect personal space: 2 arm-lengths.
2. Do not be provocative. Body language is important. Do not cross your arms, stare, or conceal your hands.
3. Establish verbal contact. Introduce yourself by name and title. Only 1 person should verbally interact with the patient.
4. Be concise. Complexity leads to confusion and escalation. Keep it simple and repeat your message.
5. Identify wants and feelings. For example: “I really need to know what you expected when you came here.”
6. Listen closely to what the patient is saying. This doesn’t mean that you agree, but rather that you understand.
7. Agree or agree to disagree. You can agree in truth, in principle, or in theory. If you can’t agree, than agree to disagree.
8. Lay down the law and set clear limits. Inform the patient about acceptable behaviors in a matter-of-fact way and not as a threat.
9. Offer choices. Never deceive a patient by promising something that cannot be provided.
10. Debrief the patient and staff. What went well, what did not, and how can we improve?

If verbal de-escalation fails and the patient requires medications for de-escalation, try to approach it in the following way:

• Stating a fact: “I think you would benefit from medication.”
• Persuading: “I really think you need a little medication.”
• Inducing: “You’re in a crisis and nothing is working. I’m going to get you some emergency medication. It works well and it’s safe.”
• Coercing (the last resort): “I’m going to have to insist.”