May 30, 2019

Mental Health Crisis on the Train: How to De-escalate a Disruptive Person in Distress


I sat across from a woman on the “L” last week during my commute into the office. It seemed clear to me that she was in a rough place. She quietly talked to herself as she lounged across three seats, staring blankly out the window. She hadn’t showered in several days, her shoes were tattered and oversized, and she had a congested, phlegmy cough.

She got off the train a few stops later, but I continued to think about her. I thought about the various people struggling with major mental illness who I’ve encountered on the train, in the grocery store, in parks, on street corners; all around Chicago. My compassion was stirred as I remembered some of the people I’ve met, but I also felt uncomfortable. Someone experiencing acute psychosis, for example, can have odd behaviors and disorganized thinking. They may hear or see things that are not real but seem very real to them. This can be scary for them and lead to agitated behavior. It can also be scary for those around them who witness their distress and are unsure how to help. For me, I have felt fear that I might make a situation worse or lacked confidence that I can actually help someone. Being in a public space can also be intimidating to get involved. An organization called Mental Health First Aid USA provides excellent training for the public on how to respond to mental health crisis. In this blog I will share a few tips from their training that I hope you can take with you and will help you know how to respond the next time you encounter a mentally distressed person.

Safety First

Do you feel safe? Take note of how you are feeling. Never put yourself at risk of harm. If you are not feeling safe, remove yourself from the situation and call 911. If you do need to call 911, describe the person’s behavior to the operator and ask for their help to dispatch a mental health provider to the scene. It is also beneficial to let the operator know if the person is intoxicated or has a weapon. Involving law enforcement can sometimes aggravate a person further. This should not discourage you from calling for help in an emergency situation. Maintain safety by trying to protect the person, yourself and others from harm.

Is the distressed person safe? A person in acute psychosis is more likely to cause harm to themselves than others, while aggressive behavior is most often associated with drug or alcohol intoxication. Threatening harm to self or others is a mental health emergency, and you should call 911 for help.

If you feel safe, and you do not believe the person is at risk of harming themselves or others, you can attempt to de-escalate the situation. However, if you are unable to de-escalate the agitated person you should always call for help. You can let the agitated person know who the unfamiliar people are and that they are there to help.

De-Escalation Strategies

Be Calm and Listen without Judgment. Use a calm and caring voice and let the person know that you are there to help.”Hello, my name is____. I am here to help you.” You can ask, “What will help you feel safe and in control?” Pay attention to your body language and avoid anxious movements. You want to de-escalate the situation, so refrain from confrontation, debate, sarcasm, or criticism of their thinking or experience. Do not laugh at, dismiss, or act alarmed by a person’s false beliefs or unreal perceptions. Empathize with their experience.

Give options. Giving choices and physical space is important. For example, give choices for how you can help. “Would you like me to call someone for you or just sit with you or do something else?” Comply with requests if they are not unsafe. If they want you to change where you are sitting or stop crossing your legs, comply if you can. If they want to pace, let them have room to pace. Do not block their movement. Again, keep an eye out for safety and how you are feeling. Maintain your access to an exit.

Give Hope and Encourage Help. Reassure them that you are there to help them and want to keep them safe. As well, reassure them that there are options for further help and that things can get better. There are people trained professionally to help. You might ask, “Have you felt this way before? What helped then?” or “Do you have a doctor or nurse that we can call?”

In conclusion, when attempting to de-escalate a disruptive and distressed person, assess and respond to safety issues first. If you choose to de-escalate the situation remember to remain calm and non-judgemental, communicate care and help, give options, provide encouragement to seek professional help, and offer hope that things can get better.

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