DE-ESCALATING VIOLENT PSYCHOSIS: TELL A STORY

A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.

 

The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.

 

INTRODUCTION

Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”

 

PAST

“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”

 

PRESENT

“My job is to make you better. I am going to be talking to you and doing a physical examination.”

 

FUTURE

“When we are done we will determine the best treatments and the best place for you to continue to get better.”

 

REASSURANCE OF SAFETY

You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.

 

DEFINE THE RULES

“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”

 

SHARE POWER WHEN POSSIBLE

To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”

 

ANTICIPATORY GUIDANCE

“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”

 

RESTORATION AFTER USING FORCE

Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”

 

AGENDA SETTING

“What are you most concerned about?”

“What would you most like to see accomplished today?”

 

How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.

 

TAKE HOME POINTS:

-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict

 

References:

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.