De-escalation of Psychiatric Patients

patientsIt is becoming an all-too-familiar occurrence: a healthcare worker is violently attacked. According to the National Nurses Union, healthcare workers experience workplace violence at rates 5-12 times higher than the average employee.

Mental health challenges can contribute to the problem. According to Reuters, 70 percent of staff members in a mental health setting said they had been physically assaulted in the past year. Clearly, this is potentially harmful for both patients and caregiver.

Learning to de-escalate these situations—without restraining or medicating—can be beneficial for all involved. While there can’t be an exact model since every situation is different, here are two strategies that may help.

The 10 Commandments of De-Escalation

Published in Current Psychiatry in 2002 and in 2012 in the Western Journal of Emergency Medicine, Avrim Fishkind, MD, offered these rules for verbal de-escalation:

  1. Respect personal space.
  2. Do not provoke.
  3. Establish verbal contact.
  4. Be concise and repeat yourself.
  5. Identify wants and feelings.
  6. Listen.
  7. Agree or agree to disagree.
  8. Lay down the law.
  9. Offer choices.
  10. Debrief the patient and staff.

The LOWLINE Method

Another method, initially described by Mike Lowry, Graham Lingard and Martin Neal in Nursing Times in 2016, combines techniques for both words and body language that can help diffuse the situation. It is called the LOWLINE method.

L Listen. “Skilled listening can make it possible to pre-empt an angry outburst by looking for, or reading, non-verbal signals, or by listening to paraverbal communication, that is, tone, inflection and volume. Patients are unlikely to have chosen to be in their relatively vulnerable situation; it is likely they might be fearful, so anger may be the response.”

O Offer. “When a patient appears to be angry or is demonstrating early signs of anger, it is important for nurses to notice it and to state what they see or hear, so the patient can be sure their feelings are being taken seriously.”

W Wait. Don’t fill the void with words.

L Look. Make eye contact, but don’t stare. Smile if appropriate, or maintain a neutral expression.

I Incline the head to present a non-threatening posture.

N Nod to show continued attention.

E Express a desire to understand or empathize.

Whether one method or a combination of both is used, it is important that the goal be to diffuse the situation and create a safe outcome for both the patient and caregiver.


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Nursing Times
Western Journal of Emergency Medicine

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