De-escalation as the Primary Strategy for Managing Agitated Individuals
Sept. 23, 2026
Agitated individuals experiencing behavioral emergencies are among the most challenging situations faced by EMS and police. While physical restraint and sedation are occasionally necessary for managing agitated individuals, they carry significant risks. De-escalation, which seeks to help the person calm themselves, should be thought of as the primary strategy.
In cases where the patient’s combativeness may cause harm to themselves or to others, paramedics and police must decide whether to restrain and/or sedate the individual. Restraint and sedation are important interventions, but they carry significant risks. Patients who are physically or mechanically restrained can become injured. Restraint and sedation can also result in hypoxia, acidosis and, in rare cases, death. Patients often report significant negative psychological impacts following restraint or sedation. EMS providers and police can also be injured. Responders and the agencies and governments who employ them may face significant consequences as a result of negative outcomes associated with restraint and sedation, including financial liability.1,2 In rare cases, responders have faced criminal liability. Paramedics have also reported feelings of guilt and post-traumatic stress disordered following negative outcomes.
Ambulance clinical guidelines for managing agitated patients typically recommend that verbal de-escalation be attempted as the initial approach.3,4 In 2011, as part of Project BETA (Best Practices in Evaluation and Treatment of Agitation), Richmond et al. published “Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry” which recommended verbal de-escalation in the out-of-hospital and hospital environments. More recently, the Police Executive Research Forum recommended de-escalation as a key strategy for reducing the risk of restraint-related death.5 The stated goal of de-escalation is helping the patient calm themselves, thereby reducing the need for restraint and sedation.6De-escalation training has been widely adopted by police as a means to reduce the use of force by police and reduce the risk of harm to agitated individuals.7,8
There are real barriers to the potential of de-escalation to reduce the impact of bias. The “communication skills required to de-escalate aggressive behavior are not conferred easily and require appropriate training and practice.”6,9,10 Unfortunately, EMS providers receive little formal training in de-escalation and report learning de-escalation skills on-the-job.9,11 Police and other law enforcement have increased education in de-escalation, primarily through a course entitled Crisis Intervention Training.6 Ambulance providers need similar, evidence-based, simulation-based training in de-escalation.
Communication, environmental modification, positioning, tone of voice, and understanding individual psychology are interventions every bit as important as airway management or hemorrhage control. In addition, many of these chaotic scenes are caught on video and as such, demonstration of competence, confidence, and compassionate de-escalation attempts are protective for first responders.
Done well, de-escalation can:
Reduce the need for force
Reduce injuries to individuals and responders
Avoid unnecessary restraint
Improve individual trust
Lower medicolegal risk
Reduce implicit bias
It can often be successful even in situations where it seems unlikely to succeed, including where the individual initially seems uncooperative.6 De-escalation often requires extended efforts to be successful. The psychiatric literature indicates that inexperienced providers often give up too soon.6
Like any other clinical procedure, these skills require effective education and deliberate, simulation-based practice.
1. Why Did More Than 1,000 People Die After Police Subdued Them With Force That Isn’t Meant To Kill? FRONTLINE | PBS | Official Site | Documentary Series. Accessed August 19, 2026. https://apnews.com/article/associated-press-investigation-deaths-police-encounters-02881a2bd3fbeb1fc31af9208bb0e310
2. PRONE: Investigation finds 132 people who died facedown, handcuffed and under the weight of officers. KUSA.com. June 7, 2022. Accessed August 19, 2026. https://www.9news.com/article/news/investigations/prone/73-6d1a4dfe-5f89-4530-9645-eb8bc4e0a2db
3. Thiessen MEW, Godwin SA, Hatten BW, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med. 2024;83(1):e1-e30. doi:10.1016/j.annemergmed.2023.09.010
4. Roberts L, Masters S, Henderson J. Reviewing Australian paramedic clinical practice guidelines for persons experiencing a mental health crisis. Australas Emerg Care. 2026;29(2):125-137. doi:10.1016/j.auec.2025.09.007
5. P.E.R.F. 15 Principles for Reducing the Risk of Restraint-Related Death. Policeforum.org. https://www.policeforum.org/trending20sep24
6. 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. West J Emerg Med Integrating Emerg Care Popul Health. 2012;13(1). doi:10.5811/westjem.2011.9.6864
7. Engel RS, McManus HD, Herold TD. Does de‐escalation training work?: A systematic review and call for evidence in police use‐of‐force reform. Criminol Public Policy. 2020;19(3):721-759. doi:10.1111/1745-9133.12467
8. P.E.R.F. 15 Principles for Reducing the Risk of Restraint-Related Death. Policeforum.org. https://www.policeforum.org/trending20sep24
9. Keefe B, Carolan K, Wint AJ, Goudreau M, Scott Cluett W, Iezzoni LI. Behavioral Health Emergencies Encountered by Community Paramedics: Lessons from the Field and Opportunities for Skills Advancement. J Behav Health Serv Res. 2020;(47(3):365-376). doi:10.1007/s11414-020-09687-4
10. Mitchell M, Newall F, Bernie C, Brignell A, Williams K. Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings: A systematic review. Int J Nurs Stud. 2024;158:104842. doi:10.1016/j.ijnurstu.2024.104842
11. Roberts L. De-escalation CPGs. Published online August 12, 2026.
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