TRC Toolkit: VERBAL DE-ESCALATION
A. FOUNDATIONAL INFORMATION
De-escalation is a process or strategies used to prevent, reduce, or manage behaviors associated with conflict. This includes verbal agitation, aggression, and violence during an interaction between two or more individuals. Verbal de-escalation can be a powerful tool to reduce a patient’s level of agitation, mitigate violence, and ensure that patients feel seen, heard, and believed. De-escalation skills are necessary to support the safety of patients and staff.
B. RECOMMENDATIONS FROM PROJECT BETA
Project BETA (Best Practices in Evaluation and Treatment of Agitation), has compiled de-escalation recommendations developed by experts in emergency medicine and psychiatric care. The recommendations from Project BETA focus on verbal de-escalation as an important initial treatment for agitation.
Project BETA Domains:
Respect personal space.
Don’t be provocative (monitor body language).
Establish verbal contact.
Avoid overwhelming the patient with too many staff in the room.
Identify wants & feelings.
Listen closely to what is being said.
Agree or agree to disagree.
Set clear limits.
Offer choice.
Debrief with patient and staff.
C. TECHNIQUES FOR VERBAL DE-ESCALATION
By adopting a curious stance we can collaborate toward healthier possible solutions. Problem behaviors frequently represent unmet needs or unmanageable emotions, and a lack of skills for meeting those needs or managing those emotions. They may also represent adaptive responses to past threatening environments. We want to understand the underlying needs and collaborate with the patient to meet those needs. We can validate how very real and difficult their feelings and needs are, and if we are genuinely trying to meet those needs and that is seen, the behaviors will often resolve.
Approach with curiosity.
Remember to treat every patient with respect and empathy.
Remember they may be experiencing a flashback.
Have appropriate number or staff available/within earshot.
Monitor body language.
Respect personal space.
Know when to tap out.
Escalated Patient + Personal Trauma Activation = Tap Out
Co-regulation Attempt + Negative Patient Response = Tap Out
Provide options for a patient’s healthy control over circumstances and interventions.
“Which arm would you like me to use?”
“How can I make you more comfortable with this procedure?”
“Please ask me any questions that arise for you as I explain the next steps.”
“We can go for a walk around the department after 30 minutes of calm behavior.”
Set boundaries.
Validate experiences and feelings.
“That sounds really hard. Tell me more.”
Try your hardest to do so from a place of truth and authenticity.
“I noticed you haven’t eaten today. Would you like help ordering food?”
Clearly communicate procedures, processes and expectations.
Provide coping skill coaching.
Identify the need being expressed – read between the lines.
Coping strategies
“Would you like a stress ball?”
“Do you think going for a walk would help?”
“Let’s do deep breathing together for two minutes. I’ll lead.”
“Can I bring you a warm blanket?”
D. COMMON BARRIERS TO EFFECTIVE DE-ESCALATION
Do your best to AVOID these common barriers to de-escalation:
Engaging in unnecessary power struggles. Avoid power struggles unless it is a MUST to maintain safety.
Minimizing or trivializing a patient’s experience or feelings. Well-meaning people often attempt to immediately fix the problem, and this can be counterproductive.
Ordering, threatening, arguing. Example: Instead of “Don’t do that,” try “Help me understand why you made that choice.”
E. CONSIDERATIONS FOR REGULATION WITH CHILDREN
Make changes to the physical environment. (Going for walks, windows and daylight, reduce noise, diversionary activities, wearing own clothing.)
Consider soothing sensory experiences. (Music, noise canceling headphones, rain sounds, pleasant aromas, tea or hot cocoa.)
Consider soothing rhythmic motor activities. (Stretching, yoga, weighted blankets, body socks, coloring books.)
Consider co-regulating physical contact with family members. (Holding hands, hugs, back rubs, reading a book together.)
Always prioritize verbal de-escalation over chemical or physical restraints, even if it is time consuming.
Consider posting schedules, ideally with simple visuals, and help youth to track time and anticipate transitions.
Use grounding techniques, breathing, observing with senses. (Breath work, body scans and progressive relaxation, tracking of the senses, drinking water, stretching and yoga).
Use the PACE strategy to set a positive and accepting tone from the start.
Positive – Your energy, body language, facial expressions, tone of voice, and optimism. Signal to the child and family that you are safe and pleased to connect with them.
Accepting – Choose to believe that “they are doing the best that they can.” Hold faith that children and youth are not intending to fail or to make our lives difficult. It is much more complex than that.
Curious – Adopt a “curious, not knowing stance.” Ask what might have happened to this child and family, and what might they be experiencing now as a result?
Empathetic – Seek to understand the child and family. Broaden your understanding beyond the “single story” of trauma.
F. CAREGIVER CONSIDERATIONS
If a child’s parent is overwhelmed, it is likely the child will be as well.
Partner with the parents, or whoever is present with the child and who has some degree of established relationship.
Co-regulate the parents and ask them to help co-regulate their child.
Keep the parents informed of next steps, time frames, decision points, and ask them to help keep the child informed.
Invite community partners who may have an established relationship with the child to be present.
Identify the ED staff who will be the primary contact for the child and family. Establish a deliberate connection with the child and family, and periodically check in.
Educate and ask families about stress:
The ED can be stressful, and it can remind us of stress from our past.
We can keep you most comfortable if we know what stress is like for you, so we can plan ahead.
What happens for you/your child when they’re really stressed? Any particular behaviors you would want us to know about?
Are there any particularly stressful things from your/your child’s past you would want us to know about?
What helps you/your child feel more comfortable when they are stressed? Can we plan some activities that might help?
G. RESOURCES & REFERENCES:
Appendix A: Emotional Regulation: Body Based Experiences
Appendix B: Emotional Regulation: Breath Work and Mindfulness
Appendix E: My Personal Support Plan
Appendix F: “You are in the Emergency Department with Your Child in Crisis, Now What?”
Appendix G: Zones of Regulation
Hughes, Daniel. (2017). Dyadic Developmental Psychotherapy: An Attachment-Focused Family Treatment for Developmental Trauma. https://doi.org/10.1002/anzf.1273
Hughes, Daniel, Ph.D., Dyadic Developmental Psychotherapy, Attachment Focused Treatment for Childhood Trauma & Abuse. http://www.danielhughes.org/p.a.c.e..html
Hughes, Daniel, Ph.D. (2017) Building the Bonds of Attachment: Awakening Love in Deeply Traumatized Children, 3rd Edition. Rowman & Littlefield Publishers.
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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298202/
Goldstein, Elisha. (2016). Mindful: Healthy Mind, Healthy Life. Thoughts are Not Facts https://www.mindful.org/thoughts-are-not-facts/
Wholehearted Counseling School Counseling, (2024). Resilience and Coping Strategies. https://wholeheartedschoolcounseling.com/resilience-coping-strategies/
The Tapping Solution Foundation. (2017). EFT Tapping Diagram, Taping Points for Kids. https://www.thetappingsolution.com/blog/eft-tapping-point-diagrams-for-kids/