Dealing with violence and aggression is an area where health professionalsoften feel uncertain. Standing at the interface between medicine, psychiatryand law, the best actions may not be clear, and guidelines neither consistentlyapplicable nor explicit. An aggressive, violent or abusive patient may bebehaving anti-socially or criminally. But in acute medical settings it ismore likely that a medical, mental health or emotional problem, or somecombination thereof, is the explanation and usually we will not know the relative contributionof each element. We must assume that dif cult behaviour represents the communicationof distress or unmet need. We can prevent and de-escalate situations by understanding whythey have arisen, identifying the need, and trying to anticipate or meet it. In these situations‘challenging behaviour’ is much like any other presenting problem: the medical approach isto diagnose and treat, while trying to maintain safety and function. In addition, the personcentredapproach of trying to understand and address psychological and emotional distressis required. Skilled communication, non-confrontation, relationship-building and negotiationrepresent the best way to manage situations and avoid harm. If an incident is becomingdangerous, doctors need to know how to act to defuse the situation, or make it safe. Doctorsmust know about de-escalation and non-drug approaches, but also be con dent about whenphysical restraint and drug treatment are necessary, and how to go about using appropriatedrugs, doses, monitoring and aftercare. There are necessary safeguards around using theseapproaches, from the perspectives of physical health, mental wellbeing, and human rights.
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