For mental health professionals in psychiatric emergency settings, preventing aggressive and assaultive behaviors is a priority. All too often, psychiatric training simply pays lip service to training in the necessary skills for the de-escalationof the violent patient. Instead, the pharmacology of behavioral emergencies is overemphasized. This issue is all the more significant in an era in which mental health advocacy groups, ethicists, and attorneys apply pressure on us to find new ways to avoid seclusion, restraint, and the involuntary use of intramuscular medications for psychiatric emergencies.

How frequent is the threat of assault? Consider this: Psychiatrists face a 40% to 50% chance of being assaulted during their careers, with resulting injury or loss of work. This likelihood peaks during residency training (1). Eighty percent of psychiatric nurses, 20% of psychologists, and 10% of social workers are seriously assaulted. In state hospitals, rates of 11.7 to 16.9 injuries per 100 employees have been reported (2). In the psychiatric emergency service (PES), nurses are six times more likely to be assaulted compared with psychiatrists, whereas psychiatric technicians, who maintain real-time security and safety, are three times more likely to be assaulted (3). What’s more, security at our nation’s inpatient psychiatric facilities and psychiatric emergency services is often minimal, resulting in a variety of potentially destructive weapons finding their way into such facilities.

In one PES in a large city, a metal-detecting arch revealed the following items brought to the emergency room in a period of 1 year: 2,066 cigarette lighters; 1,155 knives; 65 razors; 26 canisters of Mace or pepper gas; 2 rounds of ammunition; 1 stun gun; 1 firearm; and a large assortment of potential weapons such as can openers, tweezers, and so forth (4). Another PES study using a metal-detecting arch and a hand wand revealed 1,324 knives; 97 cans of Mace; and 33 handguns over a 6-month period (5).

Most emergency mental health workers do not adequately arm themselves with the bare essentials of self-protection. The American Psychiatric Association Task Force on Psychiatric Emergency Services recommends that each staff member receive yearly training in managing behavioral emergencies in the least restrictive, most effective way (6). Expert consensus guidelines regarding management of aggressive behaviors in both adults and children have been developed (7,8); however, evidence-based practices are lacking.

Clinical programs should adopt one of many training programs available in the prevention and management of aggressive behaviors (PMAB). Training must address the threefold issues of observation for and recognition of impending aggression, verbal de-escalation and use of the least restrictive techniques, and the management of actual physical aggression. Standards for measuring and reporting acts of aggression in health care institutions do not exist, with the probable result being a dramatic underreporting of assaults (9).

Literature concerning prevention and management of aggressive behavior first appeared in the mid-1970s (10); however, there are no controlled studies comparing training models in terms of safety, efficacy, or risks and benefits. Published articles have reviewed the need for training, limit setting, verbal de-escalation, use of psychopharmacologic medications, and implementation of seclusion and restraint. Given the lack of outcome data, Morrison and Love (11) have proposed that PMAB programs should be assessed in five domains: the content (inclusion of verbal and physical interventions), the feasibility or ease of implementation, the psychological comfort of the staff (staff confidence in handling aggression), the program’s effectiveness in decreasing seclusion and restraint and staff and patient injuries, and the cost.

The Mandt System was one of the first PMAB training programs. The program, first developed in 1975 and revised in 2002, was designed to help with aggression of persons in residential facilities (12). The Mandt System stresses building healthy relationships and communication skills, conflict resolution through problem solving, behavior support, assisting (physical holds that are for support and assistance), separating (removal of weapons, biting, hair pulling), safe physical restraint and “takedowns,” and liability and legal issues.

The St. Thomas program (13) documented the use of films, discussion, communication skills, situational awareness, and timing of interventions. This training program demonstrated that institutions could reduce the incidence of aggressive behaviors and decrease the number of work hours lost to staff injuries.

PMAB was developed by the Texas Depart-ment of Mental Health and Mental Retarda-tion (14). PMAB emphasized a change in staff mind-set that made verbal de-escalation a priority; provided for empowerment of the patient by offering choices; taught quick, decisive action steps; and integrated non-pain-inducing maneuvers to neutralize a patient if physically attacked.

In 1991, Stevenson (15) emphasized a model focusing on assessing verbal and body language cues and responding in a calm, nonthreatening, and caring manner. He also emphasized the use of quiet places for 8- to 10-minute intervals. The Crisis Prevention Institute (CPI) program has been shown to be effective in resolving crises and has been instituted widely in the United States. CPI techniques have been shown to help avoid seclusion and restraints, as well as staff and patient injuries, in 82.4% of the episodes observed and across a wide variety of diagnoses and levels of functioning (16). Some unique features of the CPI technique include its “seven principles for effective verbal communication” and a description of four levels of crisis with corresponding staff interventions by level (17).

Programs specific to children and adolescents include the Therapeutic Crisis Intervention (TCI) model developed in 1980 (18), which stresses the linking of feelings and behaviors and alternatives to aggression for children and adolescents. Also, Management of Out of Control Behavior in Children and Adolescents: A Comprehensive Training Guide was developed by the New York State Office of Mental Health Work Group on Preventive and Restrictive Interventions in 1997 (19).

Psychiatric emergency services administration must adopt one of many training programs available, or develop their own if research and testing of the model is available. The programs described should not be construed as an exhaustive list of available training programs in PMAB. Despite the input of agencies such as the Joint Commission on Accreditation of Healthcare Organizations and the Occupational Safety and Health Administration, there are no studies comparing training models in terms of safety, efficacy, or risks versus benefits, and new models are frequently being developed (20).

The assessment and observation of aggressive behaviors is covered elsewhere in this text. A review and description of the physical maneuvers used in management of actual aggressive behaviors, usually based on martial arts techniques, are beyond the scope of this text. Verbal de-escalation techniques can be understood based on ten domains, which represent a synthesis of the available literature (21).

Each encounter with a violent patient is idiosyncratic. This makes it difficult to develop a
one-size-fits-all flowchart or critical pathway to describe the sequence of verbal interventions for de-escalation. The ten domains that follow can be used whenever needed, and mixed and matched as necessary to de-escalate agitated patients, but follow a natural sequence that closely matches how events unfold in the clinical situation.

Remember that as you approach, assess who is involved and what is happening, recall what you know about the patient, and consider that you may be perceived as an additional enemy or attacker. Decide whether to call for additional staff as you approach the scene. For protection, turn rings with stones inward and remove necklaces, ties, and dangling earrings. Be aware of exits. Approaching the agitated patient should not be an opportunity for a show and should be a space to maintain dignity and privacy. Remove all unnecessary staff and patients to minimize injury and prevent possibly trauma-inducing views of the events. Patients who witness the incident may incite the agitated patient, egging him or her on to fight. Quickly remove the noncombative combatant if there is a fight between two people.