Course content – PF23-Deeskalation
The modules of this course – work through them in order.
4. Module 4 · The Dynamics of Escalation
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.
Learning objectives of this module
- You understand the dynamics of escalation (stages/phases).
- You recognise the early warning signs of an incipient escalation.
- You know that early de-escalation is the most effective.
- You intervene early.
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.
Dynamics of escalation
| Phase | Feature / action |
|---|---|
| Tension/restlessness | Early warning signs – de-escalate early! |
| Growing agitation | Irritable, louder – still open to influence |
| Open aggression | Hardly approachable – safety takes priority |
| Relaxation | Subsiding – aftercare (Module 10) |
Table: Phases of escalation and what to do. Source: own illustration, AI-assisted.
Your own behaviour as part of the dynamics
Escalation is often an interaction between the people involved, not just ‘the person’s behaviour’. With your own behaviour, you can fuel or defuse it. Escalating behaviour is confrontational or threatening: contradicting, lecturing, reproaching, belittling, threatening, showing power, rushing, a loud or sharp voice, threatening body language, crowding the person, coercion. The person feels attacked, threatened or patronised and becomes more agitated – a vicious circle develops. De-escalating behaviour is calm and non-threatening: composure, listening, a calm voice, open body language, acknowledging feelings, no contradiction or provocation. The person feels heard and safe, and the tension can fall.
Your reaction is never neutral. A common mistake is to answer tension with tension. In practice: shape your own behaviour deliberately to be calm and non-confrontational (Modules 5–7), especially when a situation is getting tense; reflect on your own triggers – what makes you irritable? (Module 12); and see your own part in the dynamics instead of holding only the person responsible. Staying calm under provocation takes self-control and practice. It is not always easy, but it can be learned – and it is often decisive.
Recognised early, de-escalated early
A care worker notices early signs of growing tension in Mr K.: an irritable tone, restless movements, a tense face. Instead of carrying on or reacting irritably herself, she intervenes early and calmly. She interrupts the stressful activity, stays calm and friendly and asks what he needs. It turns out that Mr K. is overwhelmed and needs a break. She creates calm and gives him time. The tension subsides, and the escalation is prevented.
Carrying on. The same morning, but the care worker is behind schedule. She notices Mr K.’s irritable tone but wants to finish: ‘We’re nearly done – stop that now.’ When he pushes her hand away, she raises her voice and carries on. Mr K. shouts, knocks a cup off the table and raises his fist. She steps back out of reach and calls a colleague. It takes a long time before he calms down, and both are shaken.
How to classify it: The early warning signs were seen but not acted on. Time pressure, a raised voice and continuing the care fuelled the escalation until open aggression was reached – the phase in which de-escalation is hardest and safety comes first (Module 9). Stepping back and getting help was right at that point. Anyone who is attacked may defend themselves, but only with what is necessary to stop the attack (self-defence, § 32 StGB). Afterwards, both need aftercare (Module 10); the incident should be documented and discussed in the team so that the next time, the early signs lead to a pause.
| Aspect | Case study: early de-escalation | Version B: carrying on |
|---|---|---|
| Early warning signs | noticed and acted on | noticed, but ignored |
| Own behaviour | calm, interrupts, asks | time pressure, raised voice |
| Need behind it | overwhelmed, needs a break – recognised | not explored |
| Phase reached | tension | open aggression |
| Outcome | escalation prevented | threat, both shaken, aftercare needed |
Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.
Exercise: Do you recognise the early warning signs of an incipient escalation (tension, irritability, changed body language)? Do you intervene early (instead of waiting)? Reflect on your own behaviour: do you de-escalate or escalate (through calm vs. confrontation)?
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1. Early signs: For one person you care for, write down their individual early warning signs – what changes in voice, face, posture or movement before a situation becomes tense? Ask colleagues and relatives what they notice. 2. What helps: Note what has calmed the person in the early phase (a break, a drink, a familiar person, a quieter room, a different time).
3. Your own part: In which situations do you react with tension yourself – time pressure, insults, tiredness? Choose a personal ‘stop signal’, for example a deep breath, half a step back or lowering your voice. 4. Team: Document the early signs and helpful approaches in the care plan so that everyone can act early.
- Escalation usually builds up in stages: tension, agitation, open aggression, recovery – sometimes very quickly.
- The earlier you act, the easier de-escalation is; in open aggression, safety comes first.
- Know the person’s early warning signs and respond to them – pause instead of carrying on.
- Your own behaviour is part of the dynamics: calm defuses, confrontation fuels.
Self-reflection (voluntary)
Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.
1. Which early signs do you notice in the people you care for before a situation becomes tense?
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2. How do you react when you are under time pressure and someone resists?
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3. What helps you personally to stay calm when you are provoked?
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4. Think of a situation you managed to defuse early. What exactly did you do?
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References for this module
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
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