Working in psychiatric emergency rooms and inpatient units, you may encounter aggressive or violent behavior, as it’s not uncommon in these high-acuity settings. That said, there’s a growing recognition that violence is not something staff should accept as “just part of the job.” With this in mind, many hospitals now offer training programs like AVADE, CPI, MOAB, or PMAB to improve workplace safety and support staff in managing high-risk situations (see “Violence Prevention Training Acronyms” box on page 4). These programs vary in focus. AVADE, MOAB, and PMAB incorporate physical self-defense or intervention techniques for situations where de-escalation fails, while CPI emphasizes verbal de-escalation and nonviolent approaches. Any of these or similar training programs, regardless of their specific emphasis, will equip you with tools to defuse aggression and protect yourself and others. If you have access to such programs, be sure to take advantage of them. Their role-playing scenarios are especially useful for gaining valuable hands-on experience. But even without formal training, you can take significant steps to keep yourself and others safe by adopting the strategies I’ll outline here.

This article focuses specifically on nonpsychopharmacologic approaches to managing aggression. Of course, psychopharmacology plays a critical role in inpatient settings, especially for patients in acute agitation or psychosis, and there are well-established protocols for rapid tranquilization, PRN use, and longer-term medication strategies. We’ve covered those approaches in a previous issue (see “Medications to Rapidly Treat Psychotic Agitation,” CHPR Oct/Nov/Dec 2021), so they’re not the focus here.

From the Clinical Update
“Violence Prevention in Acute Psychiatric Settings: Staying Safe in Challenging Environments”
By Victoria Hendrick, MD
The Carlat Hospital Psychiatry Report
Volume 6, numbers 3 and 4
April/May/June 2026

Screen for risk: Who’s at risk and why
Reducing the risk of violent incidents begins with identifying potential threats and risk factors. Gather information about a patient’s prior violent behavior, substance use history, or psychiatric conditions linked to impulsivity or aggression, like borderline personality disorder, bipolar disorder during manic episodes, intermittent explosive disorder, or psychotic disorders with paranoia or command auditory hallucinations.

It’s also helpful to assess the type of violence that a patient may be at risk for:

• Impulsive violence is reactive and emotionally driven, often triggered by frustration, provocation, or perceived threats. It’s common in patients who have limited emotional regulation or low frustration tolerance.
• Psychotic violence is driven by delusions or hallucinations, especially paranoid delusions or command auditory hallucinations.
• Predatory violence is rare but serious—premeditated, goal directed, and not emotionally driven. It may involve planning and targeting and often requires closer supervision and firm boundaries.
• Cognitive impairment–related violence can occur in patients with dementia, delirium, or brain injury. It’s often due to confusion, misinterpretation of staff intentions, or fear during personal care.
• Substance-induced violence may stem from intoxication, withdrawal, or chronic effects of substance use. It can present as impulsive, psychotic, or disinhibited aggression.

Use this knowledge to take precautions, like assigning additional staff, initiating early calming interventions, placing patients in high-visibility rooms, and making sure staff have access to emergency response tools like panic buttons. Consider using validated tools like the Brøset Violence Checklist (Almvik R and Woods P, Int J Psychiatr Nurs Res 1999;4(3):498–505;).

Create a safer, calmer environment
Make sure your environment promotes safety. As much as possible, arrange the interview space to allow for clear sight lines, accessible exits, minimal blind spots, and adequate lighting. When working with patients who are agitated or have a history of aggression, choose an open space, ensure security is nearby, and stop the interview if the patient begins to escalate.

Some units have adopted features from EmPATH models in an effort to reduce environmental stimuli that can contribute to agitation. Popular features include quieter spaces with ample room, soothing colors, and staff trained to engage patients early, before escalation occurs (see our interview with Kimberly Nordstrom on EmPATH units in CHPR Jul/Aug/Sept 2022).

Enhance security measures
A visible and responsive security presence acts as both deterrence and support. If these measures aren’t already in place at your hospital, consider requesting:

• Wearable alert buttons
• Panic buttons for high-risk areas
• Security cameras
• Metal detectors in the ED

Recognize early warning signs
An essential aspect of violence prevention is spotting risks before they have a chance to escalate.

• Watch for behavioral clues, like pacing, clenched fists, or tense posture.
• Listen for verbal signals like raised tones or angry muttering.
• Identify patient-specific triggers. Some patients are particularly sensitive to triggers like personal space violations, feeling ignored, or sensory overload. Proactively address these to prevent escalation.

Use de-escalation techniques
If you find yourself in an increasingly heated situation, creating a stable, low-stimulation environment can help you reduce tension (see “Principles of Verbal De-Escalation” box below).

• Use non-threatening, reassuring language—something simple like, “I hear you. Let me help,” can go a long way in defusing frustration.
• Minimize overstimulation by reducing loud noises, bright lights, or other disruptive environmental factors.
• Be mindful of your body language: Maintain an open posture, stand at a slight angle to avoid appearing confrontational, speak with a calm, steady voice, and keep an arm’s-length distance.
• Practice active listening by acknowledging the patient’s emotions and concerns.

When violence escalates: Defensive strategies
While the goal is always to prevent escalation, there may be rare situations where violence occurs despite your best efforts. If neither escape nor calling for help is an option, you may need to rely on self-defense techniques to stay safe. Role-playing scenarios, offered during training programs such as the ones discussed at the start of this article, can help you develop these skills. If you’re unfamiliar with self-defense techniques, learning even basic tips can help you stay safe. Explore resources available from vetted sources (www.tinyurl.com/bdes8rba). Remember: 

• Deflect attacks with blocking techniques
• Escape holds through disengagement maneuvers; practice these maneuvers to break free safely
• Physical restraint should be a last resort and should only be performed by trained staff

From the Clinical Update
“Violence Prevention in Acute Psychiatric Settings: Staying Safe in Challenging Environments”
By Victoria Hendrick, MD
The Carlat Hospital Psychiatry Report
Volume 6, numbers 3 and 4
April/May/June 2026

Strengthen team protocols and prevention plans
Clear guidelines and strong teamwork are essential for reducing workplace violence. All staff should be familiar with documentation and reporting protocols, which support effective follow-up and quality improvement. Hold regular multidisciplinary meetings, including representatives from security, psychiatry, and nursing, to review incidents and strengthen prevention strategies. After an incident, debrief as a team to reflect on what went well, identify what could be improved, and provide peer support for anyone affected emotionally or physically by the event.

Carlat Verdict: When you work with patients in acute states of agitation or paranoia, aggression is sometimes unavoidable. That said, you can lower the risk by screening patients, recognizing early warning signs, using de-escalation techniques, and improving security measures. If your hospital offers violence prevention training or role-playing exercises, be sure to take advantage of them to build your confidence and readiness. Even if you’ve already had training, consider a refresher, as these skills can fade over time.