Summary: One common belief is the assumption that through our recognition of patient’s needs and also by a lot of empathic attention we will be stamping out the risk of the worst violent behaviors

Threatening and violent behaviors should have a safe management

By Silvio Saidemberg*

Summary: One common belief is the assumption that through our recognition of patient’s needs and also by a lot of empathic attention we will be stamping out the risk of the worst violent behaviors. Skillful handling of patients should not preclude us from recognizing that more should be done to prevent violence from patients against other patients and staff members. One single occurrence may be too tragic to be ignored as a possibility. Predicting, understanding and developing reasonable interventions are a continuous exercise towards safety.

Definition: Threatening or violent behavior means any physical or verbal act, threat, or assault that causes physical or emotional suffering, or damage to property.

Relevance to an inpatient setting: "Unfortunately, a belief that personal attacks only happen to other people can leave us very vulnerable. Few of us believe that we will be subjected to violence and aggression". By understanding how an attacker behaves, we can learn to respond in a way that lessens the aggression and violence that may be inflicted on others or ourselves.

To provide a comprehensive understanding of the factors and triggers that may precipitate and escalate aggressive behavior.
To assess potentially dangerous situations.
Through the understanding of aggressor and victim behavior, there is the hope that there will be development of confidence with the use of more effective ways to manage and prevent violent/aggressive behavior

Illustrative Example:

A woman in her fifties with a history of violent temperament since her childhood presents an escalation of her verbal outbursts to the point of hitting her husband. Since that was a recent episode, the husband consults a popular advising columnist. He tells that while he was driving during their vacation he did laugh at something his wife considered serious; the children of the couple were in the back seat. Her response to his laughter was to hit him across the face. The wife did not show any remorse for her assault against the husband even much after the occurrence.

The columnist makes five important comments:

The acknowledgement that violence whether verbal or physical cannot be tolerated.
The wife’s out of control anger must be effectively controlled for the protection of others.
Every person feels angry at some point. Anger can be triggered by many things, including feeling fearful and helpless.
Suppressing anger until it erupts is one cause of violent outbursts.
The wife is in need to be helped to express her anger in ways that will be more effective and constructive, like to learn to say a few chosen words that make the point.

Discussion: A question about the above illustrative example is inevitable: couldn’t the husband avoid laughing at his wife, knowing about her sensitivities? Anger may be still hard to be predicted, understood or conquered through reasonable interventions, like the ones suggested above. Professionals in the mental health area will need to manage threatening and violent behaviors in spite of having much less previous contact with a patient than the husband victimized by his wife in our example. Also, even if a better management of emotions is a possibility, does the patient realize to be in such an urgent need to learn better ways to express oneself? Besides, how long will one take to change one’s way?

A- Behavior Risk Assessment:

Previous acquaintance with patient, patient threatens violence, verbal aggression, rater feels threatened, and patient damaged property are the most important criteria, and ethnic background and gender are the least important (ref.: 2)
Does the person have a history of impulsive, aggressive/violent behavior?
Do we have an understanding of the past triggers for those behaviors?
Are we as staff members aware of those triggers in each new patient?
Are we taking time to review those triggers and making sure that our peers and other patients in the same environment are forewarned about the potential for inadvertently setting that person off?
Does the person have any prejudice against the caretakers or other patients? Is this prejudice being properly identified?
Does the person feel discriminated against?
Is there a history of trauma that the patient may or may not disclose?
Is there any reason for the patient to believe that by being verbally or even physically abusive to others this will not bring any consequence?
Is the patient so self destructive to the point of not caring anymore for consequences?
Is the patient restless, pacing the floor, with signs of irritability?
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B- Victim Risk Assessment:

Does the person have the habit to confront or to make a strong point that exposes the frailty of the other person?
Does the person use humor in a too personalized fashion?
Does the denial of a request is done in a non-careful and non-caring way?
Are the possible hurtful feelings considered and recognized?
After a denial of a request, are possible substitutive actions considered?
Are we aware that behavioral reinforcements might not be reinforcements at all for the desired objective? One’s own concept of reinforcement has nothing to do with what is really reinforcing to others. We may be perceived as manipulative and morally wrong in our intent to reinforce.
The acceptance of the substitutive action is carefully measured in terms of satisfaction? Do we reflect those feelings of frustration that were inflicted when one is deprived from the original intent? Do we mean what we say? Are we being really empathetic?
In case of refusal for the suggested substitution, is the patient consulted about how he sees options and choices?
Does the patient have an alliance with the caretakers to accept changes?
Sometimes the bad judgment of a patient will have an impact on the angry response: no matter what is done or proposed, no positive understanding will follow.

C- Circumstances that facilitate contrary behaviors and aggressive outbursts:

Pain.
Tiredness.
Hunger/ thirst/ other physiologic needs.
Fear/ suspiciousness.
Irritability.
Feeling emotionally hurt.
Feeling humiliated.
Having to wait for needs to be met.
Being psychiatrically treated against one’s will.
Perception that there is a harsh interaction with caretakers.
Perception that the team is fractured and if he cannot get what he wants from one staff member he will get from another one.
Perception of being ridiculed. Staff has to be careful with jokes and laughter; even though a light environment should be created with humor being used to approximate persons.

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D- Useful measures to counteract unruly and aggressive behaviors:

To maintain a respectful and caring attitude towards patients and staff members.
To maintain flexibility and communication with the professional team to foster the necessary changes of the course of action whenever possible and deemed necessary.
To have a clear hierarchic structure with the leadership being consulted and followed. Professional work implies in responsibility taking as a consequence of decision-making. Identify behaviors that imply: "I take all the decisions and you assume all the responsibility."
In the professional milieu, passive aggressive maneuvers have to be detected and corrected, after all professionals want to correct these inadequate behaviors in their patients.
To avoid promising anything to the patient that might not be clearly lawful and adequate and in accord with hospital/mental health regulations. Sometimes what we propose seems to be adequate; however, has the patient the ability to understand our intention? If not, we cannot propose.
Make the patient as comfortable as possible, basic needs must be met; in a hospital, restrictions are many times necessary, the team should support the restrictions that are essential and avoid being indulgent to the patient to "prevent patient’s disapproval/anger".
Ask an uncomfortable patient to sit down on a comfortable chair or to lie in bed, whatever makes one more comfortable, as you assess needs.
Whenever making an assessment of beds, seats and environment, we have to make sure that the maximum comfort and ergonomic considerations are being made in the choice of furniture. Many patients have chronic pain; the idea that more comfort will invite patients to stay in bed belongs to the moral treatment era, when mental illness was seen as the direct result of the seven mortal sins, laziness being one of those. We want our patients to assume a moral and healthy life in a comfortable and respectful environment.
To act speedily when any patient is abusing verbally or physically staff members or other patients: be sure that each episode is immediately taken care of. It may be necessary a crisis intervention with the participation of more than one staff member. However, the patient may continue to be more ready to escalate in aggressive behaviors than being amenable to express feelings appropriately. Some PRN/stat oral medication should be offered as soon as the distress of the patient is assessed and there is agreement that the aggressive action stems from that heightened level of distress.
A room where the patient can stay quietly should be offered as an alternative if it is too painful or upsetting for the patient to communicate feelings/needs or to deal with the rules of acceptable social expression.
Seclusion room should be offered when a higher level of safety considerations need to be taken in consideration.
Physical restraint is warranted when the risk of violence and self-harm is too high. Physical restraint and stat medications IM should be considered after the least invasive approaches fail.
Coping mechanisms should be reviewed with the patient after the crisis subsides.
Medication review will take place to ameliorate response in all those cases where temper outbursts are not feasible to be controlled otherwise. However, the staff members should not expect miracles from medications, particularly when a patient has ingrained attitudes that glorify violence and abuse against others. In such cases a patient may need to be transferred to a maximum-security facility or to a long-term treatment program that will address the violent behavior. Legal action against the aggressor should be considered at the discretion of the victims and in accord with the severity of the attack.

Conclusion: behavior risk assessment, victim risk assessment, identification of circumstances that may facilitate aggressive behaviors and a set of useful measures to counteract unruly/aggressive behaviors are practices that need to be developed and researched further in all mental health programs, probably this is not done more due to the presumption that the expertise in those programs will suffice. Probably it won’t.