Course content – PF23-Deeskalation
The modules of this course – work through them in order.
1. Module 1 · Fundamentals: Challenging Behaviour & De-escalation
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.
Learning objectives of this module
- You know the term ‘challenging behaviour’.
- You understand it as an expression of needs/distress (not malice).
- You know the meaning of understanding, de-escalation, prevention and safety.
- You understand the concept and the aim of de-escalation.
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).
Challenging behaviour & de-escalation
| Aspect | Meaning |
|---|---|
| Behaviour | Aggression, restlessness, resistance, calling out, etc. |
| Understanding | Expression of need/distress (not malice) |
| De-escalation | Defusing escalation calmly/with understanding |
| Scope | Understanding, de-escalating, preventing, securing |
Table: Challenging behaviour and de-escalation at a glance. Source: own illustration, AI-assisted.
De-escalation instead of coercion and violence
De-escalation matters so much because it offers an alternative to coercion and violence. When challenging behaviour is not understood, some people resort to freedom-restricting measures (FEM, such as restraints or locked doors), sedating medication used as ‘chemical restraint’, physical force or punishment. These reactions are harmful. They do not address the cause: the need remains unmet and the behaviour is only suppressed. They cause harm: they increase fear, helplessness and aggression, violate dignity and carry risks of their own. They are strictly regulated by law: freedom-restricting measures need a legal basis and are permitted only as a last resort, and violence is prohibited. And they can start a spiral of escalation, because force provokes more resistance. De-escalation is the better alternative, professionally and ethically. It looks for the cause and calms the situation without confrontation and without coercion. It is more effective, more dignified and safer, and it respects the law. For this reason, current German guidelines recommend prevention and de-escalation as the first response and coercive measures only as a last resort (BMG, 2007; DGPPN, 2026). De-escalation is therefore not just a technique but the expression of an understanding, non-violent stance.
Understanding instead of restraining
Mr M. (dementia) suddenly becomes aggressive during personal care: he lashes out and screams. An inexperienced staff member wants to hold him ‘for safety’. An experienced colleague chooses de-escalation instead. She interrupts the care, steps back, stays calm and speaks soothingly. Then she looks for the cause: Mr M. is evidently in pain when his arm is moved, and he is frightened by being touched without warning. She arranges for the pain to be treated, announces each step and tries again later, calmly and with a familiar person. The aggression subsides, and the care succeeds later without coercion.
Holding instead of understanding. The same morning, but this time no experienced colleague is nearby. The staff member holds Mr M.'s arms firmly so that she can finish washing him. Mr M. screams louder, pulls away and scratches her hand; afterwards he has a red mark on his forearm. The care is broken off. For the rest of the day Mr M. is tense and refuses every approach. Nobody has found out yet that moving his arm causes him pain.
How to classify it: Holding a person against their will is coercion. It is only lawful in narrowly defined situations, for example to avert an acute danger, and never as a routine way of getting care done. Here it did not remove the cause (pain and fear), it increased the distress on both sides and put everyone at risk. The incident has to be documented and discussed in the team so that the next attempt starts with understanding instead of force.
| Aspect | Case study: de-escalation | Version B: holding |
|---|---|---|
| First reaction | interrupt, step back, stay calm | hold the arms to continue |
| View of the behaviour | expression of pain and fear | resistance that has to be overcome |
| Cause | pain identified and treated | remains unknown |
| Outcome | care succeeds later without coercion | care broken off, injuries on both sides |
| Dignity and law | respected | coercion without a lawful reason |
Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.
Exercise: Reflect on your stance: do you condemn challenging behaviour (‘aggressive/difficult’) or do you understand it (expression of distress/need)? Do you (or colleagues) resort to coercion – or to de-escalation/understanding? How could you understand and de-escalate more?
Show suggested approach
Think of a concrete situation from the last few weeks and answer three questions in writing: 1. Which words did I (or the team) use for the person – describing ("pulls his arm away when washed") or labelling ("is aggressive")? 2. What was the first reaction – stepping back and calming down, or continuing and holding? 3. Which need or distress could have been behind the behaviour (pain, fear, overload, an unmet need)?
If you find labels, rewrite them as observations. If the first reaction was to continue or hold, plan an alternative: interrupt, step back, speak calmly, look for the cause, try again later or with a familiar person.
- Challenging behaviour is usually the expression of a need or distress, not malice.
- Professional handling has four parts: understanding, de-escalation, prevention and safety.
- Coercion does not remove the cause; it is lawful only in narrowly defined situations and as a last resort.
- The key question changes from "How do I stop this?" to "What is this person trying to tell me?"
Self-reflection (voluntary)
Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.
1. Which words do you or your team use when talking about people with challenging behaviour?
Show prompt
2. When did you last feel the urge to "just get it done" despite resistance?
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3. Which needs or kinds of distress could lie behind the behaviour you meet most often?
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References for this module
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
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
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
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