Any of the illnesses described in the preceding sections can present challenges to management due to mood or psychotic symptoms. In addition, some patients without Axis I mental disorders can be challenging to work with, due to personality disorders, interpersonal hostility, or general unpleasantness.

The following strategies can be effectively used to de-escalate a situation:

• Respect the patient's physical space (>2 arm lengths when possible) and avoid provocative body language (avoid excessive, direct eye contact; avoid arm folding; keep hands visible and unclenched).

• Minimize the number of staff members in contact with the patient.

• Address the patient by her preferred name (first vs last name).

• Be concise and keep your vocabulary simple, giving her time to process.

• Use active listening and clarifying statements (“What I'm hearing is . . . ” or “Tell me if I have this right . . . ”).

• Identify the patient's expectations and wants so that you can respond empathically and express a desire to work together with the patient toward her goals. Never deceive a patient by promising something that cannot be provided for her.

• Find something about the patient's position with which you can agree.

• Set clear limits and boundaries about acceptable behavior. Gently but firmly indicate that limits are being set due to your desire to help.