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De-escalation: Two techniques to try

Author Laura Hale Brockway

Verbal de-escalation can be an effective way to assuage an angry or overwrought patient. But how does it work? This article will discuss two techniques that can be used to help de-escalate patients in tense situations.

(These techniques may not apply in every context. When responding to escalating behavior, consider the individual patient, the circumstances, and the overall situation. If at any time the patient threatens harm or you feel unsafe, contact the police or call 911 immediately.)


 

Miller’s Law

Miller’s Law (from psychologist George Miller) refers to the technique of imagining that what the patient is telling you is true. “If you are truly trying to imagine how it could be true, you will be less judgmental, and the patient will sense that you are interested in what he is saying and this will significantly improve your relationship with the patient.” (1)

“That is: The proper response when someone says, ‘My toaster is talking to me!’ is ‘What is your toaster saying?’, followed by very careful and attentive listening.” (2) 

A far more common scenario would be to respond with attention and empathy when a patient tells you “It took me 45 minutes to find a place to park,” or “I was on hold for an hour trying to get an appointment for a mammogram.” A response such as “How frustrating. How are you feeling now?” or “I would be upset about that too. I’m sorry this has happened” would be appropriate.

Please note that applying Miller’s Law does not mean you should agree with a patient’s delusional belief. Instead, you might respond by saying that you believe the patient is having this experience. “It must be pretty scary to feel that no one can help you with your headache pain.” (3)

Instead of following Miller’s Law, many people do the opposite, says Dr. Suzette Haden Elgin, linguist and author of Language in Emergency Medicine: A Verbal Self-Defense Handbook. “They hear someone say something that they find unacceptable or outrageous; they immediately assume that what was said is false; and then they try to figure out what's wrong with the person who said it.” (2)

Not listening and jumping to conclusions makes “misunderstanding and communication breakdown inevitable . . . Always begin by applying Miller's Law. Don't make the additional mistake of thinking that this will slow you down,” says Dr. Eligin. “The danger of wasted time and effort is in failing to listen, misunderstanding, and then having to untangle the resulting mess and set it right. Miler's Law will save time.” (2)


Ignore the bait

Dr. Elgin describes another technique that can be used to help de-escalate patients. As explained in The Gentle Art of Verbal Self-Defense, the technique involves defusing verbal attacks by not taking the bait (the part of the interaction that is designed to get your attention and provoke a reaction) and responding directly to the presupposition stated in the attack. (4) Here’s an example.


 

A less effective interaction

Patient: If you really wanted to help me, you wouldn’t just leave me in this cold room to bleed to death.

Physician: I didn’t just leave you. I had other patients to take care of. Patients are treated according to their appointment time. And it doesn’t look like you’re bleeding to death.

“Responses like these are natural and understandable, but they’re poor strategy and guaranteed to waste time.” This type of response means you’re “taking the bait and running with it.” (5) 


 

A better interaction

Patient: If you really wanted to help me, you wouldn’t just leave me in this cold room to bleed to death.

Physician: Of course I want to help you. Now let’s take a look at that wound.

This response works because it ignores the bait and addresses the presupposition that the physician does not want to help the patient. It also allows the physician to move immediately to treating the patient. Here is another example.


Patient: You’re not the only doctor in town, you know.

Physician: You’re absolutely right. [Begin taking care of the patient]

This response is appropriate because you are simply agreeing with an obvious statement. “Nothing you could do will surprise the attacker more, or make it more difficult for him or her to go on with the attack.”  (5)


Resources

For more information on these de-escalation techniques, please see the following resources.

  • “Advanced tips for verbal de-escalation of agitated/aggressive patients” from Simple and Practical Mental Health
  • Language in Emergency Medicine: A Verbal Self-Defense Handbook by Suzette Haden Elgin 
  • The Gentle Art of Verbal Self Defense by Suzette Haden Elgin


 

Resources from TMLT



Sources

  1. Richmond JS, Berlin JS, Fishkind AB, 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 Medicine. September 2011. DOI: 10.5811/westjem.2011.9.686. Accessed August 28, 2023.
  2. Elgin, SH. Language in Emergency Medicine: A Verbal Self-Defense Handbook. Chapter 1, The Aunt Grace Syndrome. 1999. Available at https://adrr.com/aa/new.htm. Accessed August 29, 2023.
  3. Simple and Practical Medical Education. Advanced tips for verbal de-escalation of agitated/aggressive patients. April 26, 2022. Available at https://simpleandpractical.com/agitation-aggressiveness-verbal-de-escalation/. Accessed August 30, 2023.   
  4. Elgin, SH. The Gentle Art of Verbal Self Defense. 1999.
  5. Elgin, SH. Language in Emergency Medicine: A Verbal Self-Defense Handbook. Chapter 5, Verbal Attack Patterns, Part 1. 1999. Accessed August 30, 2023.