Many communities in the US do not have an established mental health crisis response, which means this work often falls on law enforcement officers or EMS providers. Because many regions have pressured law enforcement to step back from mental health crisis response, EMS responders have found themselves responding to an increased volume of mental health emergencies, which has not historically been a significant component of EMS training.

One of the most challenging aspects of a behavioral health emergency is navigating the myriad of emotions on scene. In addition to the mental state of the patient, family, friends, and other bystanders may be upset or fearful. To complicate matters further, the patient is not usually the one who called for help and, in many cases, does not want outside resources involved at all!

Due to an increased volume of mental health and behavioral emergencies and inadequate training for EMS (and other healthcare) providers, the rates of violence against healthcare workers are on the rise, and EMS workers are at especially high risk: 60% higher than nurses, and six times the average risk of all workers in the US.¹ It is estimated that 61% of US paramedics have been assaulted in their careers at least once, and 25% have been injured in an assault.¹

EMS workers are threatened by patients, family, or other bystanders on average once every three months, and while some level of risk is considered “part of the job,” our families and friends expect us to get home safely.¹ With our already-high risk of violence and increasing role in mental health crisis response in mind, here are four tips each for de-escalating a dangerous scene. (See our follow-up article on Suicide Attempts and Suicidal Ideation for talking with patients who are experiencing those specific emergencies)

De-Escalation Tips

1. Use time, distance, and shielding. You’ve probably learned a bit about HAZMAT response, and maybe even about responding to terror attacks if you’ve been practicing EMS any time after 9/11/2001. Just as you might reduce your risk of harm from IEDs, “dirty bombs,” or a chemical spill, use time, distance, and shielding to protect yourself from on-scene violence. This technique is borrowed from unarmed police in other countries, who must still respond to violent scenes and assure their safety and the safety of the public. Officers can often avoid meeting force with force by slowing down (taking time) and building rapport from a safe distance. This technique resulted in a 25% reduction in use-of-force and a 36% reduction in workplace injuries when employed in one large US police agency^.2
   
   Another way EMS providers can shield themselves is by placing obstacles between themselves and the patient. For example, placing a medical kit, cardiac monitor, or the gurney between you and an agitated patient is non-threatening and creates separation. In an ambulance, consider sitting behind the patient in the “airway chair” or “captain’s chair,” and consider sandwiching seatbelts between a sheet and a blanket, which will buy you more time if the patient decides they no longer want to be on your gurney. Ensure that you have a route of escape, and make sure the patient feels he/she has the same: if they feel cornered, they may operate as though their only option to escape is by attacking you.³
2. Let one person do the talking. One team member should speak with the patient when establishing verbal contact and building rapport. This will avoid conflicting instructions from different responders and limit confusion.3 Other responders can remain nearby if assistance is needed, perhaps even out of sight, to avoid a “show of force” appearance or making the patient feel surrounded. A good place to start regarding rapport building is by letting the person know you are here to help and asking what help they may think they need.
3. Listen actively. Active listening starts by giving the patient time to talk and paying attention to what they say, then responding by paraphrasing their statement or asking a clarifying question.³ For example, you might use a phrase like “I want to make sure I’m fully understanding; it sounds like you are upset because __________” or “I’m hearing that you’ve been experiencing a lot of pain, I’m sorry, that must be exhausting. Where does the pain bother you most right now?” By using this technique, you demonstrate to the patient that you heard and understood what they said, building rapport. Occasionally, simply feeling heard might be the patient’s main goal for the interaction.
4. Give options and set limits. If you have children, you may know the trick of offering them a choice between two chores: “I need you to either vacuum or empty the dishwasher; which would you like to do?” This technique allows your child to feel empowered, even when you are ultimately controlling the situation. The same technique can be used with your patients.³ For example, ask, “Do you want to sit in the chair or lay on the gurney?” Both options lead to the hospital by ambulance, which might be your ultimate goal, but the patient gets to choose the conditions, leaving them feeling in control. Other conditions the patient can control might be the number of blankets or pillows on the gurney, lights on vs. lights off, heat or air conditioning, and whether they want to talk during transport. Offering to bring important items, like getting a cell phone or jacket from the closet, can be seen as an act of kindness—it’s harder to be upset with people who are kind to you.