The Ten Commandments


    The Ten Commandments

    Verbal de-escalation is a powerful and effective skill to help calm agitated and aggressive patients. This method is proven safe, effective and decreases the likelihood for restraints. Among properly trained physicians this process takes less than 5 minutes. Just follow these “10 Commandments.”

    1. Respect personal space. 2 arms length.
    2. Do not be provocative. Body language is important. Do not cross arms, stare, or conceal your hands.
    3. Establish verbal contact. Introduce yourself by name and title. Only one person should verbally interact with the patient.
    4. Be concise. Complexity leads to confusion and escalation. Keep it simple and repeat your message.
    5. Identify wants and feelings. “I really need to know what you expected when you came here.”
    6. Listen closely to what the patient is saying. This doesn’t mean you agree, but rather that you understand.
    7. Agree or agree to disagree. You can agree in truth, in principal or in theory. If you can’t agree, than agree to disagree.
    8. Lay down the law and set clear limits. Inform the patient about acceptable behaviors in a matter-of-fact way and not as a threat.
    9. Offer choices. Never deceive a patient by promising something that cannot be provided.
    10. Debrief the patient and staff. What went well, what did not, and how can we improve?

    If verbal de-esclation fails and the patient requires medications for sedation try to approach it in the following way: 

    • Stating a  fact: “I think you would benefit from medication.”
    • Persuading: “I really think you need a little medication.”
    • Inducing: “You’re in a crisis and nothing is working. I’m going to get you some emergency medication. It works well and it’s safe.”
    • Coercing (the last resort): “I’m going to have to insist.”

    Bonus points if you can you guess which commandment is my favorite… (It’s #8!)


    Richmond, Janet S., et al. “Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.” Western Journal of Emergency Medicine 13.1 (2012).



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