Anger management and stress reduction techniques are important components of prevention in psychiatric and alcohol and other drug treatment facilities and should be a component of a psycho-education program. How staff treats clients who are angry and/or frustrated has a direct impact on the probability of aggressive or violent behaviors. Helping to keep the unit or group positive and peaceful begins at intake with the assessment and collection of the history regarding aggressive behavior. This assessment will continue through the admission process, and be part of the psychiatric, nursing and social work assessments throughout treatment.
Intake staff, admission staff, and program staff should systematically communicate with patients and their families, when appropriate, about treatment goals, progress and that patients will be encouraged and expected to make every effort to manage their own behavior. When patients are a part of the treatment goals and have control over parts of their progress they are less threatened and frustrated by the loss of control of a program with rules and parameters.
The management of aggressive behavior continues after the intake and assessment with diagnosing and treating the underlying psychiatric illness and being aware of the propensity for aggressive behavior in certain situations. The evaluation of a patient should include a review of aggressive behavior, including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events that are associated with aggressive acts. Cultural factors may influence the triggers and expression of aggression by patients and the response to aggression by staff and these factors should be considered in treatment facilities. Cognitive limitations, neurological deficits and learning disabilities should be noted during the intake evaluations.
The treatment plan should include strategies to prevent aggressive behavior, de-escalate behavior before it escalates, and initiate or refer out to, when necessary, psychological treatments for treating the underlying psychopathology when present.
Patients with a history of aggressive behavior may benefit from anger management, problem-solving and psycho-educational programs.
Staff can help to prevent aggression by:
- Attend and support current training programs; maintain skill level consistent with job requirements
- Learning and applying applicable policies and procedures
- Being aware of each clients history
- Following the rules and boundaries established by the program and facility
- Treating all clients fairly and with respect
Staff should always treat the patients with respect. Judgmental attitudes, authoritative directives will likely result in anger and shame, feelings that in turn can result in negative behaviors.
As mentioned previously, communication is crucial for effective treatment and for the patients compliance, as well. Staff members should explain who they are, what they are going to do and why it is necessary. Speak to the patients about their treatment and offer them choices wherever practical. Staff should frequently check with the patient or client about their level of comfort with the physical surroundings and so forth. If it is impossible to comply with a patients request, explain why.
Staff must always provide for the safety of all other patients, as well. As tensions rise, it is important to enlist the help of staff that are familiar with the patient, and have successfully redirected behavior(s) in the past.
Before aggression is apparent staff can verbally redirect and assist the patient to a quiet area of the facility that is free from all stimuli, and is away from other patients or residents. Time outs can be utilized for behaviors, which place others in potential danger. This can be offered as an opportunity for the patient to manage their emotions on their own rather than a directive as if from a parent to a child.
Positive reinforcement for a patient who successfully calms their potential aggression should be offered through comfort measures and words. Always document the effectiveness of interventions on the part of the staff and the individual.
Be Alert to Situations that could lead to aggressive behavior. The earlier staff intervenes, the easier it is to de-escalate a potentially dangerous situation.
Pain and discomfort increase aggression. Assess for signs of acute pain. If the cause of the behavior is believed to be pain related, perform a pain assessment and notify a physician as warranted for tests, treatments, or alterations to the current plan.
Alcohol impairs judgment, making people much less cautious than they usually are. It also disrupts the way information is processed. An intoxicated person is much more likely to view an accidental event as a purposeful one, and therefore act more aggressively. It is likely that similar impairment occurs during drug treatment, especially during the detox phase. This means that people in the early stages of recovery are more likely to misinterpret events and become angry or aggressive.
Tips to Avoid Aggression:
- Follow established policies and procedures
- Be alert for signals that a potentially violent persons problems are getting worse
- Don’t ignore troubling client behavior, statements, or attitudes
- Be aware of clients personal situations that could trigger an aggressive reaction
- Have another staff member present when you have to give bad news to a client if you’re concerned about possible violence
- Model calm and appropriate behavior for clients
- Be knowledgeable about warning signs for aggressive/violent behavior
- Treat all clients fairly
- Be aware of client histories, personalities and coping styles
- Pay attention during change of shift reports
- Watch clients behavior and affect
- Intervene as early as possible to prevent incidents from escalating
- Use common sense
- Make sure that movies/TV shows etc are appropriate for the therapeutic environment
- Speak in soft and calm tones when confronting a client
Explain your purpose or intention:
- Give clear, brief, assertive instructions, negotiate options and avoid threats.
- Move towards a ‘safer place’, i.e. avoid being trapped in a corner.
Encourage a reasoning (for their behavior):
- Encourage reasoning by the use of open questions and enquire about the reason for the aggression.
- Questions about the ‘facts’ rather than the feelings can assist in de-escalating (e.g. what has caused you to feel angry?)
- Show concern through non-verbal and verbal responses.
- Listen carefully and show empathy, acknowledge any grievances, concerns or frustrations. Don’t patronize their concerns.
Ensure that your non-verbal communication is non-threatening:
- Consider which de-escalation techniques are appropriate for the situation.
- Pay attention to non-verbal clues (i.e. eye contact). Allow greater body space than normal.
- Be aware of your own non-verbal behavior, such as body posture and eye contact.
- Appear calm, self controlled and confident without being dismissive or over-bearing.
Defusing or Talking Down an Explosive Situation
When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation techniques are appropriate.
There are two important concepts to keep in mind:
- Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of arousal so that discussion becomes possible.
- De-escalation techniques are abnormal. We are adrenally driven to fight or flight when scared. However, in de-escalation, we can do neither. We must appear centered and calm even when we are terrified. Therefore these techniques must be practiced before they are needed so that they can become “second nature.”
It is essential that the Worker Stay in Control of Him/Her Self
- Appear calm, centered and self-assured even though you don’t feel it. Anxiety can make the client feel anxious and unsafe which can escalate aggression.
2. Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when scared).
3. If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you see the client (not in front of him/her)
4. Do not be defensive-even if the comments or insults are directed at you, they are not about you. Do not defend yourself or anyone else from insults, curses or misconceptions about their roles.
5. Be aware of any resources available for back up. Know that you can always leave, tell the client to leave or call the police should de-escalation not be effective
6. Be very respectful even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. We want him/her to know that it is not necessary to show us that they should be respected. We automatically treat them with dignity and respect.
The Work should practice the Physical Stance of:
- Never turn your back for any reason
2. Always be at the same eye level. Encourage the client to be seated, but if he/she needs to stand, you stand up also.
3. Allow extra physical space between you – about four times your usual distance. Anger and agitation fill the extra space between you and your client.
4. Do not maintain constant eye contact. Allow the client to break his/her gaze and look away.
5. Do not point or shake your finger.
6. Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Cognitive disorders in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
7. Keep hands out of your pockets, up and available to protect yourself. It also demonstrates non-verbal ally, that you do not have a concealed weapon
The De-escalation Discussion with the Client:
1. Remember that there is no content except trying to calmly bring the level of arousal down to a safer place.
2. Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Speak calmly at an average volume.
3. Respond selectively; answer only informational questions no matter how rudely asked, e.g. “Why do I have to fill out these (g-d forms?” This is a real information-seeking question). DO NOT answer abusive questions (e.g. “Why are all social workers ass holes?) This question should get no response what so ever.
4. Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both alternatives are safe ones (e.g. Would you like to continue our meeting calmly or would you prefer to stop now and come back tomorrow when things can be more relaxed?)
5. Empathize with feelings but not with the behavior (e.g. “I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff.)
6. Do not solicit how a person is feeling or interpret feelings in an analytic way.
7. Do not argue or try to convince.
8. Wherever possible, tap into the client’s cognitive mode: DO NOT ask “Tell me how you feel. But: Help me to understand what your are saying to me” People are not attacking you while they are teaching you what they want you to know.
9. Suggest alternative behaviors where appropriate e.g. “Would you like to take a break and have a cup of coffee (tepid and in a paper cup) or some water?
10. Give the consequences of inappropriate behavior without threats or anger.
11. Represent external controls as institutional rather than personal.
12. Trust your instincts. If you assess or feel that de-escalation is not working, STOP! Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the police.
There is nothing magic about talking someone down. You are transferring your sense of calm, respectful, clear limit setting to the agitated person in the hope that he/she actually wishes to respond positively to your respectful attention. Do not be a hero and do not try de-escalation when a person has a gun. In that case, simply cooperate.