Course content – PF23-Deeskalation

When behaviour challenges

In care, you will regularly meet challenging behaviour: behaviour that is difficult, distressing or dangerous for the people around the person, such as staff, fellow residents or relatives. It includes verbal or physical aggression (insulting, threatening, hitting, scratching, biting, throwing things), restlessness and agitation (walking about, fidgeting, trying to leave), resistance to care, loud calling or screaming, self-injury and withdrawal or apathy. The term ‘challenging behaviour’ replaces older, disparaging labels such as ‘problem behaviour’. It says that the behaviour challenges those around the person without condemning the person, because it is usually not malice but an expression of a need or distress (Module 2).

Professional handling has four parts: understanding the behaviour as communication and recognising its causes (Modules 2–3), de-escalation (Modules 5–7), prevention (Module 8) and safety (Module 9). De-escalation means deliberately preventing or reducing an escalation: calming a tense situation through calm, understanding and non-provocative behaviour. It is a core skill for safe, dignified care. It protects everyone involved, avoids violence and coercion, and addresses the actual causes.

From condemnation to understanding

The most important basic idea is the shift from condemnation to understanding. The traditional view judges the behaviour and the person: ‘He is aggressive’, ‘He only wants to provoke’, ‘He does it on purpose’. This view has three consequences. It labels the person and disregards their dignity. It hides the cause, because anyone who only sees ‘bad behaviour’ does not look for the need behind it. And it provokes the wrong reaction: annoyance and resistance lead to escalation, coercion or punishment. The professional view understands the behaviour as communication and the expression of a need or distress (Module 2): a message the person cannot express in any other way, such as pain, fear, being overwhelmed or an unmet need. This view respects the person’s dignity, opens the view to the cause and makes the right reaction possible. The key question changes from ‘How do I stop this behaviour?’ to ‘What is this person trying to tell me, and how can I help?’ This stance – behind the behaviour there is a person with a need – should guide every encounter. It is the basis for everything else in this course: recognising causes (Module 3), de-escalating (Modules 5–7) and prevention (Module 8).

Table: Challenging behaviour and de-escalation at a glance. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Behaviour is communication

The key to dealing with challenging behaviour is understanding that behaviour is communication. Aggression, restlessness, resistance or calling out rarely happen ‘for no reason’ or out of malice. They express something: a need, a state of distress or a feeling that the person cannot put into words, or does not want to. Behaviour is, in a sense, the person’s language – especially for people who cannot express themselves well verbally, for example because of dementia, aphasia or another communication impairment. The task of care is to decode this message: which need, distress or feeling lies behind the behaviour?

Common messages behind challenging behaviour are: pain (very common and often overlooked, especially when the person cannot say they are in pain); fear, for example of being touched without warning or of an unfamiliar place; unmet basic needs such as hunger, thirst, needing the toilet, feeling cold, tiredness or the need to move; being overwhelmed by too many stimuli or demands; loss of control and feeling patronised; being treated without respect; frustration at not being understood or not managing something; boredom; and illness-related causes such as dementia, delirium or mental illness. If you understand the message, you can address the cause – and the behaviour often settles.

The detective work: what lies behind it?

Finding the message behind the behaviour takes detective work: observing, asking and thinking with attention and empathy, because the cause is rarely obvious. Six questions help:

1. Observe the behaviour and its circumstances. When, where and how does it occur, and what happened just before? Patterns give clues: ‘always during personal care’ may point to pain, fear or shame; ‘in the evening’ to tiredness or overstimulation; ‘only with certain people or actions’ to a specific trigger.
2. Basic needs. Is the person in pain? Always check this first. Do they need the toilet? Are they hungry, thirsty, cold, hot or tired, or do they need to move? Meeting a simple need often resolves the behaviour.
3. Feelings. Is the person afraid? Do they feel overwhelmed, crowded, controlled, offended, helpless or bored?
4. Illness. Does dementia play a part, for example through disorientation or misperception? A sudden change may signal delirium – an acute confusion that often has a treatable cause and needs prompt medical assessment. A mental illness may also be involved.
5. Environment. Is there noise, bustle, crowding or time pressure (Module 8)?
6. Knowledge of the person. What do you know about their life story, preferences and earlier triggers? Ask relatives.

The answers show where to start: meet the need, ease the distress, avoid the trigger. Remedying the cause is more effective, more dignified and more lasting than fighting the symptom.

Table: Common ‘messages’ behind challenging behaviour. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Why escalation occurs

Prevention and de-escalation need a clear view of causes and triggers. Causes are the underlying reasons and conditions. Triggers are the specific stimuli or situations that set the behaviour off at a particular moment. Causes (Module 2) can be physical (pain, illness, unmet basic needs, side effects of medication), psychological (fear, being overwhelmed, loss of control, offence, frustration, boredom), illness-related (dementia with disorientation and misperception, delirium, mental illness) or environmental (noise, bustle, crowding, time pressure, unsuitable surroundings). Often several act together. The framework recommendations of the German Federal Ministry of Health describe a similar idea: background factors that are hard to change, and nearby factors – such as pain, hunger, noise or changing staff – that can trigger behaviour and are easier to influence (BMG, 2007).

Triggers differ from person to person. Common ones are: certain care situations, especially personal care with closeness, exposure and movement; being touched or addressed without warning; feeling patronised, controlled or forced; disrespectful treatment; too many stimuli or demands; frustration at not being understood or at a need not being met; time pressure in care; misunderstandings; and individual triggers such as certain people, words or situations, often rooted in the person’s life story. Knowing these triggers through observation, documentation and relatives makes it possible to avoid them (Module 8). Addressing causes and avoiding triggers together prevents a great deal of challenging behaviour.

How care itself can be a trigger

An important and self-critical insight is that care itself is often the trigger. This is easily overlooked, because people tend to look for the ‘blame’ in the person’s behaviour rather than in their own actions. Typical triggers in care are:

• The type of care. Intimate personal care in particular involves closeness, exposure, touch and shame. A person with dementia may not understand what is happening and feel attacked.
• The way it is done. Acting without warning or in a hurry, handling the person roughly, or deciding over their head and forcing them.
• Disrespectful communication. Talking down, ‘baby talk’, talking about the person instead of to them, not taking them seriously.
• Lack of relationship. An unfamiliar carer whom the person does not yet trust.

The good news: if your own actions are the trigger, you can change them. Announce and explain each step. Work calmly and without rushing, as gently and painlessly as possible. Speak respectfully and at eye level. Respect the person’s wishes instead of overriding them. Involve familiar people and build trust. If the person resists, pause, calm the situation and try again later or in a different way – without coercion. This is often one of the most effective ways to prevent challenging behaviour. It requires self-reflection (Module 12) and the willingness to see your own role as a possible trigger.

Table: Causes and triggers at a glance. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

How escalation arises

To de-escalate, it helps to understand the dynamics of escalation: how a situation builds up from calm to aggression. Escalation usually develops in stages that build on each other if nobody responds. In a simplified model, it starts with tension and restlessness (first signs), grows into increasing agitation (more irritable, louder, more resistant), may turn into open aggression (verbal or physical) and finally subsides in a recovery phase. Sometimes, however, the stages pass very quickly or the early signs are hard to see, for example in delirium or advanced dementia. The practical consequence: the earlier you intervene, the easier and more effective de-escalation is. That is why recognising early warning signs and acting early are central.

Early warning signs can include growing tension and restlessness (tense posture, nervousness), irritability (sharp tone, impatience), changes in facial expression and body language (angry look, clenched fists, threatening gestures), louder or faster speech, sudden withdrawal or getting worked up, and signs that are typical of the individual. If you notice them, you can de-escalate in good time: address the cause or need, respond calmly and with understanding, remove the trigger and create calm. This is far easier than calming open aggression – and it protects everyone.

The earlier, the better

The most important practical principle is: the earlier you de-escalate, the easier and more effective it is. In the early phase, the person is still approachable: they can listen, think and be calmed to some extent. Addressing the cause, a calm response and a quieter setting often settle the situation. In the late phase of open aggression, the person is in an emotional state of emergency and hardly accessible to reason. De-escalation is then much harder, and safety comes first (Module 9). In practice this means:

• Watch for the early warning signs – do not wait, ignore them or simply carry on.
• Look for the reason behind the rising tension and address it early.
• De-escalate early: respond calmly, create calm, reduce stress and meet the need (Modules 5–7).
• If necessary, interrupt a stressful activity – for example a care task that causes resistance – and try again later or differently instead of pushing through.

Your own behaviour is part of the dynamics from the very beginning: calm behaviour counteracts the escalation, while confrontational or hurried behaviour fuels it (see below). Recognising early signs and acting in good time can prevent or reduce many escalations.

Table: Phases of escalation and what to do. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Calm as the key

Every de-escalation starts with the right inner stance – even before the techniques in Modules 6 and 7. Its most important element is calm: staying composed yourself, especially when a situation is tense or aggressive. Your calm transfers to the other person and lets you act with a clear head. Agitation, panic or irritability transfer too: they provoke and lead to rash action. Staying calm under threat is not easy, because your own stress alarm goes off. But it can be learned – through deliberate self-control and breathing, inner distance (not taking the aggression personally, Module 2) and practice.

Further elements of the basic stance are: understanding the behaviour as an expression of distress instead of condemning the person (Modules 1 and 2); not taking aggression personally, because it is usually an expression of distress or illness and not really aimed at you (Module 2); respect for the person’s dignity, even in conflict; empathy, which means taking the person’s feelings seriously; calm self-confidence that is never threatening or superior; and a visible willingness to help. The verbal and nonverbal techniques build on this stance. Without it, they work much less well.

Staying calm when things get difficult

Your own calm is the centre of de-escalation – and often the hardest part. In a threatening situation the body raises the alarm: tension, a racing heart, fear or anger, the urge to fight or flee. This alarm pushes you towards a reflex: fighting back (shouting back, defending yourself, confronting), panicking or freezing. These reflexes usually make things worse. Confrontation escalates (Module 4), panic is contagious, and freezing prevents clear action. Deliberate calm means noticing the reflex and controlling it.

Six things help you to do this. Self-control and breathing: notice your stress reaction, breathe slowly and deeply, and tell yourself to stay calm. Inner distance: see the aggression as an expression of distress or illness, not as a personal attack (Module 2) – “this is not about me, this is their distress”. An understanding stance (Modules 1 and 2): if you see the behaviour as a need, you respond with empathy rather than irritation. Knowledge and preparation: knowing how de-escalation works gives you confidence. Experience and practice, including de-escalation training, make calm action easier over time (NICE, 2015). Your own safety (Module 9): knowing about distance, your escape route and how to get help reduces fear – and fear makes calm impossible. Calm is the foundation for every technique and has a calming effect in itself. It is not always easy, but it can be learned and is worth working on deliberately.

Table: Elements of the de-escalating basic stance. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Calming with words

Verbal de-escalation means calming a person deliberately through language. It builds on the basic stance from Module 5. The key principles are: a calm, friendly voice – speak calmly, warmly and slowly, because the tone often has a stronger effect than the words; active listening – let the person finish and ‘let off steam’ without interrupting; acknowledging and naming feelings (‘I can see that you are very angry’), so that the person feels heard; showing understanding (‘I understand that this makes you uneasy’); simple, clear language with short sentences, because an agitated or confused person cannot process anything complex; offering help (‘I would like to help you – let us find a solution together’); and I-messages instead of reproaches.

Just as important is what you avoid: arguing, contradicting and lecturing – above all, do not correct a person with dementia who perceives reality differently; reproaches, belittling and criticism; threats, ultimatums and shows of power; orders such as ‘You must now …’; irony and condescension; and a hurried, impatient or loud tone. The aim is that the person feels heard, understood, taken seriously and not threatened (NICE, 2015). This is what calms a situation.

Acknowledging the feeling – a powerful de-escalator

Among the verbal techniques, acknowledging and naming feelings is often one of the most effective. An upset person is in an emotional state of emergency, driven by anger, fear, despair, helplessness or hurt (Modules 2 and 3). At that moment their greatest need is often to be heard and taken seriously. Sentences such as ‘I can see that you are very angry’ or ‘I notice that you are worried’ meet exactly this need. The emotional pressure eases, and the person becomes more willing to calm down and talk. Many escalations grow because a person feels ignored; acknowledging the feeling breaks this cycle.

Two points matter. Acknowledging the feeling does not mean agreeing with the person on the matter or meeting a demand. You acknowledge the feeling, which is real. The matter can be clarified, and boundaries set, later when the agitation has subsided. And it is not a trick but genuine empathy (Modules 2 and 5). In practice: perceive the feeling, name and acknowledge it calmly, then listen and offer help.

Table: What to do and what to avoid in verbal de-escalation. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

De-escalating with the body

Alongside language (Module 6), nonverbal de-escalation – through body language, presence and space – is of great importance; the nonverbal level often has a stronger effect than the words. In a tense situation the person perceives your body language very precisely, often unconsciously. A calm, open, non-threatening presence de-escalates; a threatening, superior or hurried one escalates. The key principles are: a calm, open posture – relaxed, no crossed arms, no threatening gestures or fists; calm, slow movements – nothing jerky that could startle; visible, open hands – open palms signal ‘no threat’, so not in your pockets, behind your back or clenched; eye contact without staring – attentive and calm, never a fixed, challenging stare; a calm, friendly facial expression; and attention to space and distance.

Space and distance are particularly important. Keep an appropriate distance: too much closeness feels threatening, escalates and endangers your own safety – an upset person needs room. Do not push the person into a corner or a confined space, as this creates panic and resistance; leave both of you a way out. Do not tower over the person or block their way – where possible, be at eye level. And keep your own escape route free (Module 9). Together with verbal de-escalation, this signals ‘no threat, calm, safety’ (NICE, 2015).

Giving space, avoiding threat

Two related principles deserve a closer look: giving space and avoiding threat. Both de-escalate, and both protect your safety. An upset person has an increased need for space and reacts sensitively to closeness. Stepping into their personal space or crowding them feels threatening and can lead to panic, resistance or aggression. So keep an appropriate, rather larger distance, do not move in on the person while agitation is high, and leave them freedom of movement and a way out. Distance also gives you time to react if an attack occurs (Module 9).

Avoiding threat means avoiding anything that looks superior or dominant: towering over the person, a wide dominant stance, crossed arms, a pointing finger, fists, sweeping or jerky movements, blocking the way, staring. Several staff members approaching at once can also feel like a show of force. Help may be needed for safety, but the presence should not be needlessly threatening; ideally one person leads the conversation (NICE, 2015). Instead, choose a calm, open posture, as far as possible at eye level, with open hands, calm movements and a calm face. If you lower yourself to eye level, for example next to a seated person, make sure you can still stand up and step back quickly. Never put yourself in a corner or without an escape route (Module 9).

Table: Elements of nonverbal de-escalation. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Prevention is better than de-escalation

The best way of dealing with challenging behaviour is prevention: heading it off so that escalation happens less often or not at all. This is usually easier, more dignified and safer than de-escalating afterwards. Prevention starts with the causes and triggers (Modules 2 and 3). First, recognise and meet needs – basic needs such as freedom from pain, going to the toilet, food, drink, warmth, movement, rest and attention, as well as individual needs – before unmet needs turn into challenging behaviour. Second, avoid triggers: know the general and individual triggers (Module 3) and avoid them or handle them differently, for example by announcing care, working calmly and gently and reducing sensory overload. Third, adapt the environment (see below).

Fourth, relationship and communication: a familiar, trusting relationship and respectful communication that announces what will happen help the person to feel safe, so fear, hurt and resistance arise less often. Fifth, structure and meaningful activity, especially in dementia: a clear daily routine and occupation against boredom and restlessness. Sixth, attentive observation: notice early warning signs and respond early (Module 4). Seventh, documentation and handover: record triggers and approaches that worked and pass them on in the team, so that everyone acts preventively (NICE, 2015). Prevention addresses the causes instead of dealing with the consequences.

The milieu as a de-escalation factor

The environment, often called the milieu, is an important and frequently underestimated factor. It affects wellbeing and behaviour, especially in dementia: an unfavourable environment can trigger challenging behaviour, a favourable one can reduce it (BMG, 2007).

Unfavourable factors include sensory overload – noise, bustle, a television running, many people, glaring light – which overwhelms people with dementia in particular and can lead to restlessness, aggression or withdrawal; cramped, crowded spaces; time pressure in care routines, which transfers to residents; disorientation in a confusing environment, which creates fear; conflicts among residents; and a cold, uncomfortable atmosphere. Favourable factors include a calm, homely atmosphere; the right level of stimulation – neither overwhelming nor boring, with quiet areas and places to withdraw to; orientation and security; enough space; structure and meaningful activity; and a calm, unhurried mood among the staff themselves. In practice, care teams can limit noise and television, create quiet corners, support orientation, offer activities and avoid passing on their own stress (NICE, 2018).

Table: Approaches to prevention and how they look in practice. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Protecting yourself

When there is physical threat or violence, your own safety and that of others comes first. Self-protection is a legitimate part of dealing with challenging behaviour: nobody has to put themselves in danger or accept violence. Its principles are: keep your distance – it gives you time to react and also calms the situation (Module 7); keep your escape route free – do not let yourself be cornered, and position yourself so that the door is behind you, not behind the person; watch for dangerous objects that could be used as a weapon or thrown, and keep them out of reach; get help in good time – colleagues and, if necessary, the emergency services; and avoid unnecessary risks – caution, not heroism.

In an acute physical attack, get distance, protect yourself, get to safety and call for help – in Germany the emergency number is 112, the police can be reached on 110. Protect others at risk, such as fellow residents, too. Nobody has to endure an attack. Self-protection does not contradict de-escalation, it complements it (Module 5): you de-escalate calmly and keep your safety in view at the same time; in serious danger, safety comes first. Prevention (Modules 3 and 8), the team (Module 12) and aftercare (Module 10) are also part of it.

Legal position: anyone who wards off a present, unlawful attack on themselves or others acts in self-defence or in defence of others (section 32 StGB, German Criminal Code). The defence must be necessary, i.e. the mildest effective means: moving away, keeping distance, getting help, briefly fending off or releasing a grip. If the person is not acting culpably because of their illness (e.g. in dementia or delirium), moving away takes priority over fighting back. Holding, restraining or locking someone in over a longer period or regularly is a freedom-restricting measure. It needs the consent of the person if they are able to consent. Otherwise their legal guardian (Betreuer) or an authorised representative with a written power of attorney that expressly covers such measures must consent, and the custodianship court must approve it (section 1831(4) and (5) BGB, German Civil Code). In an acute emergency, a brief measure can be justified as necessity (section 34 StGB) if the danger cannot be averted otherwise. It must be proportionate and documented; a measure lasting more than about 30 minutes or repeated is no longer brief (DGUV, 2018).

No duty to endure violence

A sometimes misunderstood principle: nobody has a duty to endure violence or threats or to put themselves in danger. In the helping professions there is sometimes the idea that you must ‘put up with everything’ – out of a sense of duty, out of empathy for an ill person, or because ‘it comes with the job’. This idea is wrong and harmful. Violence against care workers is not part of the job, and nobody has to risk serious harm for the sake of care. Understanding that aggression is usually an expression of distress or illness (Module 5) does not mean having to endure it: you can understand the behaviour and protect yourself at the same time. In practice: in serious danger, put your own safety first; do not regard violence as normal; take your own strain seriously and get support (Module 10). Violence at work is also an occupational safety issue: the employer must assess the risks, including psychological strain, and take protective measures such as prevention concepts, training, support and aftercare (sections 3 and 5 ArbSchG; DGUV, 2018). This needs an open culture in which violence is not hushed up but reported, followed up and prevented.

Table: Principles of self-protection at a glance. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

After the escalation

After an escalated situation, aftercare and follow-up matter – for the person concerned and especially for the care worker and the team. Follow-up has five parts: 1. Caring for the person, who may also be exhausted or upset: give safety, calm and attention, restore the relationship, and do not hold a grudge or punish. 2. Supporting the care workers involved, because aggression – verbal or physical – causes fear, hurt, stress and sometimes injury. 3. Documentation of the course, triggers, measures and any injuries – for traceability, learning and, where relevant, legal and occupational safety purposes. 4. Analysing the incident without blame: how did it come about, and what can we learn to prevent or de-escalate better next time? 5. A team debriefing for exchange, relief and learning.

The care worker's own follow-up is particularly important. Aggression and violence are stressful and must not be played down (‘it comes with the job’, ‘don't make a fuss’) or suppressed. What helps is exchange in the team, support from colleagues and management, acknowledgement of the strain and, especially after serious incidents, a debriefing or supervision. This protects against consequences such as anxiety, stress, trauma and burnout, and is part of the employer's duty of care (sections 3 and 5 ArbSchG). A violent incident at work that causes physical or psychological harm counts as an occupational accident. The employer must report it to the accident insurance if the employee is unable to work for more than three days; the statutory accident insurance recommends reporting violent incidents even without sick leave (section 193 SGB VII; DGUV, 2018).

Taking the care worker’s strain seriously

Aggression and violence put more strain on care workers than is often admitted. Possible effects are fear – in the situation and afterwards, for example of it happening again; hurt from insults or attacks – verbal violence hurts too; stress and exhaustion; self-doubt and guilt (‘Did I react wrongly?’); physical injuries; and, after serious incidents, traumatic stress with fear, sleep problems or re-experiencing. These reactions are real, yet often played down – because ‘it is part of the job’, because violence against staff is normalised, or because people feel they have to be strong. Unprocessed strain can build up and lead to lasting anxiety, exhaustion, burnout, fear of going to work, withdrawal or even leaving the profession. What helps: talking in the team – the most important and most accessible support; acknowledgement by colleagues and management that the strain is real and that violence is not normal; support from management, such as relief, protective measures and follow-up; a structured debriefing after serious incidents; and, where needed, professional help such as supervision or psychological support. After an occupational accident, the statutory accident insurance institutions offer fast psychotherapeutic support (DGUV, 2018). The organisation must provide this framework as part of its duty of care (sections 3 and 5 ArbSchG). You yourself can take your strain seriously, seek exchange and accept help when you need it.

Table: Elements of aftercare and follow-up. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Special situations and groups

Some situations and groups need particular attention. In dementia, challenging behaviour usually expresses a need or distress that the person cannot communicate otherwise – pain, fear, being overwhelmed, too many stimuli, disorientation. Look for the cause, validate feelings instead of correcting or arguing (Module 6), give safety and familiarity, reduce stimuli, stay calm and avoid coercion. In delirium (acute confusion), think of a treatable physical cause – infection, dehydration, medication, pain – and have any sudden confusion or deterioration assessed by a doctor; accompany the person calmly and without confrontation. In a mental illness or crisis (e.g. psychosis, severe depression, suicidal thoughts, panic), stay calm, give safety, take the person seriously and do not confront; involve specialist help where appropriate (doctor, psychiatric service, crisis service). If there is an acute risk of suicide or another acute crisis, get help immediately.

With addiction or intoxication (alcohol, drugs, withdrawal), aggression is more likely and behaviour less predictable: pay particular attention to your own safety (Module 9), stay calm, do not provoke and get help where appropriate. With children and young people or people with an intellectual disability, adapt your approach to age and individual abilities. The basics stay the same: understand the cause (Module 2), act calmly and de-escalate (Modules 5–7), prevent (Module 8), protect your own safety (Module 9) and, in delirium, mental crisis, suicidality or addiction, involve medical or specialist help. Above all: if behaviour or confusion changes suddenly, always think of an acute, treatable cause.

In the case of sudden change, think of delirium

A potentially life-saving rule: if behaviour or confusion changes suddenly, think of delirium. Delirium is an acute disturbance of attention and awareness, usually with a physical cause that can be treated – unlike dementia, which develops slowly. It often shows as challenging behaviour: sudden restlessness, aggression, disorientation or hallucinations. But it can also be quiet (hypoactive delirium): the person becomes withdrawn, slow and drowsy and eats less – this form is often missed (NICE, 2023). In people with dementia, delirium is easily mistaken for ‘the dementia getting worse’. Yet it needs prompt medical assessment, because the cause – e.g. a urinary or chest infection, dehydration, side effects of medication, pain or low blood sugar – has to be found and treated; untreated, delirium can become dangerous. The key warning sign is suddenness: changes within hours or days, especially in someone who was previously more stable. Further signs are fluctuating attention and alertness, new hallucinations or delusions, a disturbed sleep-wake rhythm and sudden disorientation. In practice: observe and document the change, ask about possible causes (infection? fluids? new medication? pain? blood sugar?) and inform the doctor – do not just calm or sedate the behaviour. Until the cause is treated, accompany the person with de-escalation: calm, reassurance, orientation, familiar people, no confrontation (NICE, 2023). Recognised and treated in time, delirium often resolves.

Table: Special situations and their particular features. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Reflecting and working together

Two aspects round off de-escalation competence. The first is self-reflection. How you handle challenging behaviour depends strongly on your own reactions, ‘sore spots’ and patterns – your behaviour shapes the dynamics of escalation, and your calm is decisive (Modules 4 and 5). Helpful questions are: How do I react in tense situations – calmly or irritably? What are my sore spots, i.e. what makes me react sensitively? How well do I stay calm? Do I take aggression personally? Reflecting alone, through feedback or in training and supervision helps you to develop your own competence deliberately.

The second is the team: dealing with challenging behaviour is a team task, and nobody has to cope alone. The team supports through mutual help in critical situations (Module 9), shared standards – an agreed approach, documented triggers and helpful responses (Module 3) – debriefing and learning from one another and sharing the strain (Module 10), and an open, supportive and learning team culture.

Bringing it all together

In summary, dealing with challenging behaviour rests on these building blocks: the stance – understanding behaviour as an expression of distress instead of condemning it, de-escalation instead of coercion (Module 1); understanding – behaviour as communication, causes (above all pain) and triggers, including your own behaviour (Modules 2–3); the dynamics of escalation and early warning signs (Module 4); the de-escalating basic stance – calm, not taking it personally, empathy and safety (Module 5); verbal and nonverbal de-escalation – listening, acknowledging feelings, not arguing, calm body language, giving space (Modules 6–7); prevention through meeting needs, avoiding triggers and adapting the environment (Module 8); self-protection – no duty to endure violence (Module 9); aftercare and learning without blame (Module 10); special situations such as dementia, delirium, mental crisis and addiction (Module 11); and self-reflection and teamwork (Module 12).

The overarching message: understand challenging behaviour and de-escalate it – calmly, safely and with dignity. The key is the shift from condemnation to understanding, combined with a calm, empathetic stance, de-escalation techniques, prevention, self-protection, aftercare, reflection and teamwork. This approach addresses the cause, respects the person, avoids escalation and protects everyone involved – the person concerned, the care staff and others. Coercive measures remain a last resort that the law limits tightly (BMG, 2007; DGPPN, 2026), and sedating medication needs a medical indication – neither replaces the search for the cause. De-escalation is a learnable competence for safe, dignified care. We hope this course helps you to meet challenging behaviour with understanding, calm and dignity – for the people entrusted to you, for yourself and for everyone involved.

Table: De-escalation at a glance – summary of the course. Source: own illustration, AI-assisted.

Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.

Self-reflection (voluntary)

Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.

Checklists for everyday practice

References & legal framework

Legal sources

Arbeitsschutzgesetz (ArbSchG) [Occupational Safety and Health Act], section 3 Grundpflichten des Arbeitgebers [basic duties of the employer], as in force in October 2026. https://www.gesetze-im-internet.de/arbschg/__3.html

Arbeitsschutzgesetz (ArbSchG) [Occupational Safety and Health Act], section 5 Beurteilung der Arbeitsbedingungen [assessment of working conditions], as in force in October 2026. https://www.gesetze-im-internet.de/arbschg/__5.html

Arbeitsschutzgesetz (ArbSchG) [Occupational Safety and Health Act], section 12 Unterweisung [instruction of employees], as in force in October 2026. https://www.gesetze-im-internet.de/arbschg/__12.html

Bürgerliches Gesetzbuch (BGB) [German Civil Code], section 1831 Freiheitsentziehende Unterbringung und freiheitsentziehende Maßnahmen [deprivation of liberty through placement and freedom-restricting measures], as in force in October 2026. https://www.gesetze-im-internet.de/bgb/__1831.html

Sozialgesetzbuch Siebtes Buch (SGB VII) [Social Code, Book VII – statutory accident insurance], section 8 Arbeitsunfall [occupational accident], as in force in October 2026. https://www.gesetze-im-internet.de/sgb_7/__8.html

Sozialgesetzbuch Siebtes Buch (SGB VII) [Social Code, Book VII – statutory accident insurance], section 193 Pflicht zur Anzeige eines Versicherungsfalls durch die Unternehmer [employers' duty to report an insured event], as in force in October 2026. https://www.gesetze-im-internet.de/sgb_7/__193.html

Strafgesetzbuch (StGB) [German Criminal Code], section 32 Notwehr [self-defence], as in force in October 2026. https://www.gesetze-im-internet.de/stgb/__32.html

Strafgesetzbuch (StGB) [German Criminal Code], section 34 Rechtfertigender Notstand [necessity as justification], as in force in October 2026. https://www.gesetze-im-internet.de/stgb/__34.html

Guidelines and professional sources

Arbeitskreis Schmerz und Alter der Deutschen Schmerzgesellschaft [Working group on pain and old age of the German Pain Society]. (2013). Hinweise zur Verwendung von BESD (Beurteilung von Schmerzen bei Demenz) [Notes on using BESD (assessment of pain in dementia)]. https://www.schmerzgesellschaft.de/fileadmin/pdf/BESD_Kurzanleitung_130626.pdf

Bundesministerium für Gesundheit [Federal Ministry of Health] (Ed.). (2007). Rahmenempfehlungen zum Umgang mit herausforderndem Verhalten bei Menschen mit Demenz in der stationären Altenhilfe [Framework recommendations on dealing with challenging behaviour in people with dementia in residential care]. https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Berichte/Bericht_Rahmenempfehlungen_zum_Umgang_mit_herausforderndem_Verhalten_bei_Menschen_mit_Demenz_in_der_stationaeren_Altenhilfe.pdf

Deutsche Alzheimer Gesellschaft [German Alzheimer Society]. (2022). Informationsblatt 18: Schmerz erkennen und behandeln [Information sheet 18: Recognising and treating pain]. https://www.deutsche-alzheimer.de/fileadmin/alz/pdf/factsheets/infoblatt18_schmerz_erkennen_dalzg.pdf

Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN). (2026). S3-Leitlinie Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen [S3 guideline: Avoiding coercion – prevention and treatment of aggressive behaviour in adults] (Version 3.0, AWMF register no. 038-022). https://register.awmf.org/de/leitlinien/detail/038-022

Deutsche Gesetzliche Unfallversicherung (DGUV) [German Social Accident Insurance]. (2018). Prävention von Gewalt und Aggression gegen Beschäftigte im Gesundheitsdienst und in der Wohlfahrtspflege: Eine Handlungshilfe für Arbeitgeber und Arbeitgeberinnen [Preventing violence and aggression against employees in health and social care: A guide for employers] (DGUV Information 207-025). https://publikationen.dguv.de/widgets/pdf/download/article/3429

National Institute for Health and Care Excellence (NICE). (2023). Delirium: Prevention, diagnosis and management in hospital and long-term care (Clinical guideline CG103; first published 2010, last updated 2023). https://www.nice.org.uk/guidance/cg103

National Institute for Health and Care Excellence. (2015). Violence and aggression: Short-term management in mental health, health and community settings (NICE guideline NG10). https://www.nice.org.uk/guidance/ng10

National Institute for Health and Care Excellence. (2018). Dementia: Assessment, management and support for people living with dementia and their carers (NICE guideline NG97). https://www.nice.org.uk/guidance/ng97