A Calmer Approach: How to Manage and De-Escalate Patient Agitation

I have a vivid memory of standing in the doorway of a patient’s room, being met instantly with a pair of narrowed eyes glaring back at me. It was my first inpatient medicine service as an intern, and I had admitted this patient, a 55-year-old man, for a GI bleed. He lay in bed, shaking and shouting, “Do you have any idea how long I’ve been waiting?!” I opened my mouth to reply—but nothing came out.

A patient’s anger and agitation often mask deeper emotions, such as fear, anxiety, grief, and shame. Expressing these primary feelings can feel too vulnerable, so anger steps forward as an outward expression instead. Health care workers are five times more likely than the average American worker to experience workplace violence (whether physical or verbal), but what we see on the surface is rarely the full story. There is always a primary driver underlying these expressions of emotion.

Looking back, I know the patient’s anger didn’t come out of nowhere. I was the unfortunate recipient of a response that had been brewing for hours.

Discontent often starts mildly: perhaps the patient felt grumpy or anxious, had a tense jaw or other frustrated facial features, or displayed nervous movements. As emotions escalate and agitation builds, patients may grow uncooperative or have verbal outbursts. By the time I entered the room, my patient’s frustration had reached a boiling point, which is when we see verbal or physical aggression. These visible outbursts are usually flagged, and clinicians are often alerted when patients reach this stage. They may call for security assistance, physical restraint, or chemical sedation. But what if we could better recognize the early warning signs and intervene before emotions spiral out of control?

There is no standard definition of agitation, because it can present very differently depending on the circumstances. To address this, the 1st International Experts’ Meeting on Agitation gathered twenty specialists in psychiatry in 2016 to come to a consensus. They identified four specific signs of early agitation: the inability to stay calm, motor or verbal hyperactivity, emotional tension, and difficulties in communication.

Once agitation is recognized, the widely accepted first-line approach is verbal de-escalation.

This encompasses a set of calming communication techniques to defuse escalating emotion, for which there are dozens of individual skills and approaches. Since it’s common to forget the right words in the moment, I partnered with a team of communication experts in the fields of internal medicine, psychiatry, and palliative care at the University of Pittsburgh to identify six evidence-based skills that aligned with existing validated scales to create the “CALMER” framework for more effective verbal de-escalation.

We subsequently developed and piloted an in-person training session for 4th year medical students using standardized patients, evaluated it with an objective structured clinical exam (OSCE), and after receiving positive feedback, rolled it out further. Two years later, more than five hundred students, residents, and faculty across the country have trained with the CALMER framework. The training has also been integrated into the medical school curriculum of several large academic institutions.

Below you'll find a summary of CALMER, which you can apply the next time you recognize escalating emotion in patients.

When we enter the room with an angry patient, there’s a gap. We don’t know what they’ve been through or what they are feeling, so we need to build common ground. Staying calm means having an even tone of voice and a steady pace. We can do this by taking a few mindful breaths before entering a patient’s room, prioritizing open body language with unclenched hands, and taking a seat to set the stage. It’s hard not to focus on our own emotions, especially if we feel confused or attacked, but verbal jabs being thrown at you often aren’t about you.

Clinicians often have a “righting reflex” with the desire to jump right to a solution. But this gives the patient something to argue against.

Before trying to de-escalate the emotion, it’s vital to acknowledge that the patient’s concerns are valid, important and will be addressed. One of the best ways to do this is to agree. Not with their behavior, but with their concern. You could agree with the facts: “I agree, you have waited for a long time,” or with the principle: “I agree, every patient should be seen in a timely manner.” When someone is aggressive towards us, they are expecting a reaction. But when your first contribution is agreement, it’s hard to fight against someone who’s not fighting back.

We have all practiced active listening, and it is pivotal here. The nonverbal nodding, eye contact, and sitting forward with statements like, “I cannot imagine” or “tell me more” are powerful. One underutilized skill is called altercasting, described in Dale Carnegie’s book, How to Win Friends and Influence People. With altercasting, you voice one positive quality you inferred from listening, such as, “you seem like a very caring parent.” These qualities are tough to disagree with and motivate your patients to live up to that image.

It’s one thing to say, “I understand”, but mirroring allows us to prove it. We can use phrases like, “It sounds like you’re really anxious about the procedure.” Or, “What I’m hearing is you’re scared about next steps.” The patient may say “no” and tell you their true feelings. Or they’ll say “yes” and are now agreeing with you on an emotion deeper than anger.

It’s worth noting that the first four steps (Calm, Acknowledge, Listen, Mirror) often need to be repeated within a patient encounter. Agitated patients may not be able to process your words the first time and repetition through the first four skills is often necessary.

After you’ve better assessed the patient’s status, it’s time to empower the patient with specific choices and solutions. In addition to their stated concern, certain options apply to all patients. For instance, you can always offer options for how information will be shared by asking, “Can I provide an update?” or “can I call anyone in the family?”. You can ask the patient for preferences on medications (e.g., pill vs. liquid vs. IV vs. topical), or offer acts of kindness by providing food, a blanket, or even just offering to leave the door open or closed.

It’s important to end the encounter by taking responsibility over something. Your patient may feel like they have been dismissed several times before you walked in. So before ending the conversation, protect the relationship you just helped to build with a comment like, “I will go follow up on our plan, and I will be back by the end of the day with an update”.

It’s crucial to note that if a patient’s agitation makes you worry about your safety or the safety of others, you should leave, and security may need to be called. This framework also does not apply to patients who use discriminatory language or microaggressions.

When using the CALMER framework at the right time, our patients may not end the encounter happy or even content, and that’s okay. De-escalation allows us to uncover underlying emotions, build some common ground, and find acceptable solutions to prevent further aggression—all while protecting our patients and staff from escalated anger.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.