General knowledge of psychiatric emergency care is crucial for all healthcare professionals involved in emergency services, not just those specializing in psychiatry. This is because they frequently encounter patients with behavioral conditions that can directly or indirectly affect the clinical context. Adhering to best practices and guidelines for psychiatric emergency care not only leads to better diagnosis and treatment planning, but also enhances comprehensive patient care ^1,2.

One of the difficulties in this context is the handling of non-cooperative patients-those who, owing to a variety of factors (not all of which are psychiatric; some may be social, legal, or other), exhibit behaviors that complicate the doctor-patient relationship. These behaviors can range from challenging communication (such as sarcasm, withholding information, or belittling remarks) to open verbal aggression and even physical aggression towards people and objects, including medical staff and others. In such scenarios, many healthcare providers find themselves unprepared ³ and often rely on intuition or past habits, which can negatively impact their performance (in terms of resident education, for example) and emotional wellbeing ⁴.

The most effective approach in these situations is verbal de-escalation, which comprises a set of knowledge, attitudes, and practices aimed at preventing escalation of verbal or behavioral issues by the patient. This non-coercive and collaborative method helps the patient “calm themselves” before attempting to “calm the patient” ⁵. This approach has the added benefit of challenging conventional beliefs such as the notion that violence is always necessary to control such situations. This reduces the likelihood of hospitalization ⁶ and increases the safety of everyone involved.

Although the capacity to de-escalate verbally varies among individuals, anyone can acquire and apply the fundamental techniques of verbal de-escalation effectively. The essential characteristic of this scenario is a positive attitude, including respect for the patient and the capacity to empathize. Staff should acknowledge that patients are doing their best given their circumstances. Moreover, there are ten domains ⁵ that enhance the likelihood of a non-violent resolution when dealing with a non-cooperative patient.

Respect personal space.

Do not be provocative.

Establishing verbal contact.

Be concise.

Identify needs and feelings.

Listen closely to what the patient is saying.

Agree or agree to disagree.

Set clear rules and limits.

Offer choices and optimism.

Debrief with the patient and staff after the event.

Each of these domains is briefly explained as follows.

Respect personal space: Maintain a distance of at least one arm's length from the patient. This not only provides the patient with the necessary space but also allows the doctor to retreat if the patient becomes physically aggressive. It is not recommended to obstruct a patient's path unless it is necessary for a medical procedure because doing so can increase the likelihood of physical confrontation ⁵.

Do not be provocative: Ensure that you convey your intention to not cause harm through both verbal and nonverbal communication while demonstrating genuine body language. Your hands should be visible and relaxed, as hiding them could be interpreted as a sign that you are concealing weapons. Steer clear of closed-body language, such as folding your arms or turning away, as it might convey disinterest ⁷. By maintaining an open posture and displaying a calm demeanor, one can reassure the patient that they are there to listen to and create a safe environment for everyone.

Establishing verbal contact: When communicating with a patient, it is recommended that only one person speak to them, typically the initial point of contact. If initial contact is not available, another person should be designated immediately. During the interaction, a team member should inform the rest of the staff about the situation and keep other individuals away from the patient. Moreover, it is essential to introduce oneself to the patient and provide respectful guidance and assurance regarding their current circumstances and expectations ⁵.

Be concise: Use straightforward sentences and uncomplicated language to communicate with agitated patients who may struggle to comprehend intricate information ⁸. Allow the patient sufficient time to process information before providing additional details. Repeat important points to ensure successful de-escalation given the limited capacity for processing the information mentioned earlier.

Identify needs and feelings: Speculate reasonably the cause of the behavioral disturbance observed during the initial consultation. It is important to ask all patients about their preferences and whether they can accommodate them. Phrases such as, "I'd like to understand what you were expecting when you came here," along with assurance, "Even if I can't fulfill your request, I still want to know so that we can explore alternative ways to support you," can be helpful. Moreover, readily available information, including unrelated speech, body language ⁹, and past encounters with the patient, can be utilized. This prompt connection enables healthcare personnel to respond empathically and communicate eagerness to assist patients.

Listen closely to what the patient is saying: Utilize active listening and convey through verbal acknowledgment, conversation, and body language that you genuinely pay attention to what the patient is saying and feeling. Clarifying statements such as "Let me ensure that I comprehend you accurately..." or "to reiterate, you mentioned..." are helpful techniques, as they emphasize that understanding does not necessarily imply agreement. In the context of patient-centered care, encouraging verbal participation and active listening can improve patient outcomes and satisfaction with healthcare services. Studies on caring behavior development highlight the importance of empathy and effective communication in patient interactions, emphasizing the role of verbal and nonverbal cues in demonstrating caring behavior ¹⁰.

Agree or agree to disagree: Studies have shown that patient-provider alliances significantly enhance patient activation, particularly in mental health settings ¹¹. Therapeutic alliance, characterized by agreement on treatment goals and a strong bond between the provider and patient, is a critical factor in promoting patient engagement and self-care. When interacting with patients, it is important to find some common ground with what the patient is saying: Patients will find it difficult to see someone who agrees with them as a potential threat. To accomplish this, there are three approaches to consider: accepting factual information, agreeing in principle, and acknowledging the likelihood of a situation. If honest agreement is not feasible, expressing understanding of the patient's perspective through phrases such as "I understand that it appears that way from your viewpoint" can be beneficial.

Setting clear rules and limits: It is crucial that the patient is fully apprised of acceptable and unacceptable conduct (harm to oneself and others). This information should be conveyed not as a threat but rather as a procedural matter in a fair and courteous manner. It is important to establish boundaries that convey one’s intention and desire to assist without providing opportunities for the patient to exploit these limits. Mutual respect and dignity in dealing with one another must be upheld ⁵.

Offer choices and optimism: Providing options is the sole means of empowering a patient, who believes that verbal or physical violence is the only or necessary response. To prevent the situation from escalating into assault, alternatives to violence should be suggested. Therefore, these alternatives are considered practical. Avoiding misleading patients by promising something that cannot be provided because of ethical restrictions or service policies ⁵.

Debrief with the patient and staff after the event: When working with an agitated patient, it falls under the responsibility of the health staff to restore the therapeutic relationship to mitigate the traumatic nature of any coercive intervention and decrease the likelihood of further violence. Effective communication among all parties involved is necessary to explore potential alternatives for future aggression management. Patients should be taught how to request a "time-out" and how to appropriately express their anger. Explaining the role of medication in preventing acts of violence and seeking feedback from the patient on whether their concerns have been adequately addressed are also important. Furthermore, the health staff should communicate with the patient's family who has witnessed the event. They should also feel free to discuss what went well during the episode and what could be improved for future encounters, while recommending potential changes. In line with the debriefing process, it is crucial to consider strategies for enhancing communication with patients with low health literacy levels. Healthcare providers should be equipped with the necessary support to recognize and address low health literacy, adapt their communication styles, and ensure that patients comprehend the information conveyed. By tailoring communication to meet the needs of patients with varying levels of health literacy, healthcare professionals can enhance patient understanding, engagement, and overall health outcomes ¹².

By incorporating these recommendations, healthcare professionals can enhance their approach to managing uncooperative patients in emergency care settings. Training programs that focus on crisis management can shift the perspective from one of hopelessness to one that offers viable solutions. These programs should include strategies for dealing with crisis situations, such as providing healthcare workers with the necessary skills to navigate challenging scenarios effectively. Additionally, training should encompass non-technical skills such as crisis management, decision-making, leadership, and communication, which are essential for handling emergencies.