Managing Agitation – Psychological methods

Introduction

The key to managing an agitated patient is to allay their fears and anxieties in an unfamiliar and potentially threatening and confining environment.   The following approach should not be attempted if the patient is imminently going to harm themselves or others.  Prompt involvement of a security team or police will be required.  Ideally, the patient is quickly physically restrained and sedated for close monitoring and more detailed evaluation.  However,  it is important to not place anyone in harm’s way if this can’t be achieved safely. This may mean letting the patient abscond.

Useful phrases to employ

Building empathy

  • “You clearly look upset.  Can you tell me what is wrong”
  • “I suspect a few distressing things have happened to you today that has led to this.  You might feel a bit better telling us about it”
  • “You might not think we care about you but it would be terrible if something bad happened after if we let you go without knowing why you were brought here”

Getting trust

  • “While you are here with us, can I get you something”
  • “We aren’t here to harm you but just to make sure you or anybody else won’t get hurt”
  • “The reason why you are being kept here is so we can find out what has been upsetting you”
  • “The only reason security are here is for everyone’s protection.  I can tell them to go if you can show that you will have a reasonable conversation with us and cooperate with our assessment”
  • “The reason why we have had to put on the restraints is because we feel the situation has gotten out of hand.  They will only be on temporarily but for the moment we will need to leave them on” 

Creating insight

  • “I am finding your behaviour a bit frightening.  I’m sure the other patients and staff here feel the same way”
  • “Have you noticed that you are now shouting.  Can you see that might be upsetting for everyone concerned”
  • “Some people noticed you were doing x, do you think that could be seen as a bit concerning or unusual to others”
  • “Your friends here were worried enough to bring you here, so I think we should first find out if there was a good reason”
  • “You have come all this way now, so we might as well sort everything out before you make other plans”
  • “You seem quite upset, would you like some medication that will help settle your nerves”

Empowering the patient whilst setting limits

  • “Before we can let you go, we need to know what is going on so that we know you and everyone else will be safe”
  • “The sooner you let us know what happened, the sooner we can be confident everything will be ok , and the sooner you can go home”
  • “For the moment because I am uncomfortable with the situation can I get you a cold drink rather than a hot drink”
  • “If you are going to place a phone call to someone, it is important that the conversation is calm and civil”
  • “I have the security team outside the door at the moment for my safety.  I rather not have to involve them and rather let you take control of your own behaviour”
  • “We could give you a tablet or if you prefer an injection.  Which one would you like”
  • “I don’t think in your current state of mind that it would be a good idea for you to leave the hospital”
  • “You have been calm for the last couple hours.  We can release one restraint every 15 minutes if you remain so.  If not, we will have no choice but to put them on again.”

Prevention

It is far better not to let a patient escalate to the point where great effort is required to calm them down again.  There can be early warning signs that a patient is becoming agitated e.g. fidgeting, stamping, pacing, looking furtively around, muttering, sighing and swearing.  Simply engaging the patient and asking what is wrong or offering food or drink helps build empathy and a line of communication and trust.

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