De-escalation is a trained skill and a team effort
Actions of those in distress often driven by fear rather than a desire to do harm
When you come across somebody who is agitated, aggressive and yelling, your first instinct is probably to run the other way. But there are ways to effectively engage an agitated person to help them calm down so you can have a conversation and hopefully help them. This skill is called deescalation.
In my work as an emergency department psychiatrist at the Centre for Addiction and Mental Health (CAMH), I’m part of a team working to de-escalate people experiencing a variety of psychiatric symptoms.
It might sound simple, but de-escalation is a skill that requires training and experience to get comfortable using specific strategies. It also takes a team to help ensure everyone’s safety — I don’t recommend anyone try it alone.
Usually, it takes the form of communication, but there are lots of things we do to help someone in a heightened emotional state. We might offer the person a glass of water, something to eat, a blanket or nicotine replacement such as gum. Or, we might offer them choices — where to sit within the room, or whether they want the lights on or off.
The first thing to keep in mind is that when someone’s experiencing a mental-health or emotional crisis, if they’re behaving in an aggressive or threatening manner, they’re probably scared. Their actions are driven by fear, rather than a desire to harm anyone.
Many of the people we see in the emergency department are experiencing psychosis — a set of symptoms that makes it difficult to distinguish what’s real from what’s not — and have paranoia fuelling their aggression.
It’s important to recognize these “escalated” expressions are often acts of defence. They may believe their life or the lives of family members are in danger.
Or, they may believe their loved ones are conspiring against them and wish them harm. Those kinds of beliefs would be scary for anyone to live with.
It’s also important to find common ground with someone who may be in need of de-escalation in order to gain their trust. Find something to agree with them about — like the kernel of truth in what the person is saying or a principle. If possible, avoid saying “no” or disagreeing with them.
For example, imagine a person comes to the emergency department and believes they’re being pursued by someone who wants to hurt them. The person is carrying a knife because they believe they need it for their own protection. Instead of saying “No weapons allowed here, give it to us or we’ll call the police,” I might say: “I’m so glad you’re at the hospital. You’re in a safe place now. We’re going to hold on to the knife for you, so that we can all be safe. Let’s sit down and talk.”
In the field of mental health, we use trauma-informed care. This framework assumes that all of the people we care for have been traumatized at some point in their lives. We know the experience of just coming to the emergency department — whether on one’s own or with police — is traumatizing.
Because of this, we’re mindful about the language we use and how we interact with our patients so that we don’t run the risk of re-traumatizing them or making their symptoms worse.
If you have a friend or family member with a mental illness or an addiction, CAMH offers a range of supports and educational resources.
We hear of too many incidents of family members who end up injured — or worse — while trying to manage an escalating situation with a loved one experiencing psychosis. Call 911 sooner than later if you have safety concerns — for yourself or anyone else.
Here in Toronto, we’re fortunate to have Mobile Crisis Intervention Teams (MCIT), which partner registered mental-health nurses and specially trained police officers to respond to emergency calls when someone’s experiencing a mentalhealth crisis. An MCIT will go to a call with a Primary Response Unit, which helps ensure everyone is safe. Dr. Brittany Poynter is an assistant professor in the Department of Psychiatry at the University of Toronto’s Faculty of Medicine. She is also the clinical head of the Gerald Sheff and Shanitha Kachan Emergency Department at CAMH. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email doctorsnotes@thestar.ca.