NURS 121 Manipulation, Anger & Aggression

De-escalation Tips for Mental Health Emergencies

1. Use a nonthreatening stance--open, but not vulnerable. Have them "take a seat" 2. Eye contact--not constant, brief to show concern 3. Commands--brief, slow, with simple vocabulary, only as loud as needed, repeat as needed. 4. Movement--Not sudden, announce actions when possible, keep hands where they can be seen. 5. Attitude--calm, interested, firm, patient, reassuring, respectful, truthful 6. Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client "I understand you are seeing or feeling this, but I am not." 7. Remove distractions, upsetting influences. 8. Keep the client talking/focused on the here and now. 9. Ignore rather than argue with provocative statements. 10. Allow verbal venting within reason. 11. Be sensitive to personal space/comfort zone. 12. Remove client to a quiet space; remove others from immediate area (avoid the "group spectators"). 13. Give some choices or options, if possible. 14. Set limits if necessary. 15. Limit interaction to just one professional and let that person do the talking. 16. Avoid rushing--slow things down. 17. Give yourself an out; don't put the client between yourself and the door.

disaster

A calamitous event of slow or rapid onset that results in a large-scale physical destruction of property, social infrastructure, and human life

Avoidance

A common response to conflict by nurses is to distance themselves from their client or to provide them less support.

Manipulation

A coping strategy that a patient employs to get his needs met without regard to other. An indirect, dishonest way to control or influence others.

Crisis

A crisis occurs when a stressful life event overwhelms an individual's ability to cope effectively in the face of a perceived challenge or threat.

Accommodation

A desire to smooth over a conflict through cooperative, but non-assertive responses.

Anger

A feeling of displeasure resulting from injury, mistreatment, opposition, and the like that typically shows itself in a desire to fight back or "get even."

Competition

A response style characterized by domination. In this contradictory style, one party exercises power to gain his own goals at the expense of the other person. It is characterized by aggression and lack of compromise.

Critical incident stress debriefing (CISD)

A type of crisis intervention, used to help a group of people who have witnessed or experienced a mass trauma event process its meaning and talk about feelings that otherwise might not surface.

Behavioral Indicators of Potential Violence: Motor Behavior

Agitated, pacing Exaggerated gestures Rapid breathing

Crisis state

An acute normal human response to severely abnormal circumstances; it is not a mental illness.

Crisis incident

An event, which is outside the usual range of experience and challenges one's ability to cope.

Recoil

An extended period of adjustment. This period can last from 2-3 weeks. Client behaviors can appear normal to outsiders, but the person often describes nightmares, phobic reactions, and flashbacks of the crisis event.

Situational Crisis

An unusually stressful life event that exceeds a person's resources and coping skills. Examples include unexpected illness or injury, car accident, loss of home, spouse, job, and so forth. In health-care settings most crisis are situational.

Aggression

Any physical or verbal behavior intended to hurt or destroy.

Actions/Approach for Catastrophic traumatic stress crises

Application of multiple levels of crisis/trauma intervention inclusive of all previously listed intervention strategies.

Environmental crises

Are associated with major changes in the ecosystem, such as global warming, volcanic eruptions, disease epidemics, wars, and severe economic depression.

Behavioral Indicators of Potential Violence: Affect

Belligerent Labile Angry

Actions/Approach for Somatic distress crisis and transitional stress crisis

Brief crisis intervention and primary outpatient mental health care/treatment

Nursing Dx Associated with Manipulation

o Impaired social interaction o Ineffective individual coping o Anxiety o Defensive coping o Noncompliance o Powerlessness

Developmental Crisis

predictable patterns of behavior and change occurring throughout the life span

Identify behaviors that people use to manipulate others and the environment

• Demands • Violating rules • Threats • Seductive behavior, flattery • Entitlement • Splitting

Discuss techniques for working effectively with manipulative people

• Identify problematic behaviors early • Use limit setting • Treatment plan • Allow the patient to have some control • Teach more adaptive coping techniques o Assertion skills o Anxiety relief skills

Potential Approaches for Dealing with Difficult clients

CARE 1. Clarify the behavior that is a problem: -Use active listening skills to identify issues of concern to the client. -Use a calm tone and avoid conveying irritation. -Use medical and non-medical interventions to decrease anxiety (e.g., medicine, touch, relaxation, and guided imagery). -Factually state the problem. 2. Articulate why the behavior is a problem: -Explain the institution policies. -Explain the limits of your role. -Set limits. -Give family permission (e.g., to rest or to leave). 3. Request a change in the problem behavior: -Work with staff so all use the same information approach to the client's demands. -Develop a nursing care plan: involve patient in care and set goals; review and reevaluate whether nurse and client have same goals. 4. Encourage change: -Evaluate progress. -Provide education; explain all options, with outcomes. -Use incentives and withdrawal of privileges to modify unacceptable behavior. -Promote trust by providing immediate feedback.

Shock

Caplan described this as the initial response to a crisis situation with variations in emotions ranging from anger, laughing, hysterics, crying, and acute anxiety to social withdrawal.

Public crisis event

Commonly referred to as a disaster, affects a whole community or large groups of people simultaneously. People are acutely aware of the precipitating events, for example, with Hurricane Katrina and terrorist attacks.

Dysfunctional conflict

Conflict in which information is withheld, feelings are expressed too strongly, the problem is obscured by a double message, or feelings are denied or projected onto others.

Behavioral Indicators of Potential Violence: Mental Status

Confused Paranoid ideation Disorganized Organic impairment Poor impulse control

Actions/Approach for Mentally ill persons in crisis

Crisis intervention, psychopharmachology, case and medication monitoring, day treatment, and community support.

Actions/Approach for Psychiatric emergencies

Crisis stabilization, outpatient treatment, inpatient hospitalization, and/or legal intervention.

Field Expedient Tool to Assess dangerousness to Self or Others (DANGEROUS PERSON)

D-Depression/suicidal A-Anger/agitation, aggressive N-Noncompliance with requests/taking medication G-General appearance/inappropriate dress/poor hygiene E-Evidence of self-inflicted injury R-Responding/reacting to delusions or hallucinations O-Owns/displays weapon(s) U-Unorganized thoughts/appearance/behavior S-Speech pattern/substance/rate (too fast, too slow, jumps all over) P-Paranoid E-Erratic or fearful behavior R-Recent loss of job/loved one/home S-Substance abuse O-Orientation to date/time/location/situation/insight into illness N-Number and type of previous contacts with police, social or crisis workers.

Assertive behavior

Defined as setting goals, acting on those goals in a clear, consistent manner, and taking responsibility for the consequences of those actions.

Behavioral Indicators of Potential Violence: Body Language

Eyes darting Prolonged (staring) eye contact tor lack of eye contact Spitting Pale, or red (flushed) face Menacing posture, throwing things.

Aggressive behavior

Goal of dominating while suppressing the other person's rights. Often consist of "you" statements that fix blame on the other person.

Actions/Approach for Family crises

Individual, couple, or family therapy, case management, and crisis intervention focus with forensic intervention.

Collaboration

Is a solution-oriented response in which we work together cooperatively to problem solve. We commit to finding a mutually satisfying solution. This involves directly confronting the issue, acknowledging feelings, and using open communication to solve the problem.

Adventitious Crisis

Is not a part of everyday experience. It is unplanned, unusual, horrific, and beyond anyone's control. Examples of adventitious crisis include: -Natural disasters such as floods, earthquakes, fires, mudslides. -National disasters such as terrorism, riots, wars. -Crimes of violence such as rape, child abuse, assault, or murder. Disasters are catastrophic for large groups of people or whole communities simultaneously.

Burgess and Roberts' Stress-Crisis-Trauma Continuum

Level 1 & 2: Somatic distress crisis and transitional stress crisis Level 3: Traumatic stress crisis Level 4: Family crises Level 5: Mentally ill persons in crisis Level 6: Psychiatric emergencies Level 7: Catastrophic traumatic stress crises

Existential crisis

Occurs when a person questions the meaning of his or her life, and whether it has any value. Midlife crisis falls into this category.

Behavioral Indicators of Potential Violence: Speech Patterns

Rapid, pressured Incoherent, mumbling, repeatedly making the same statements Menacing tones, raised voice, use of profanity Verbal threats

Conflict

Tension arising from incompatible goals or needs in which the actions of one frustrate the ability of the other to achieve their goal, resulting in stress or tension.

Restoration (or reconstruction)

The final phase of crisis intervention. This phase involves taking constructive actions to face and resolve the reality issues present in a crisis situation.

Crisis intervention

The systematic application of problem solving techniques, based on crisis theory, designed to help the client move through the crisis process as swiftly and painlessly as possible and thereby achieve at least the same level of pre-crisis functioning.

Actions/Approach for Traumatic stress crisis

Traumatic and group crisis-orientated therapy

Explain nursing data to be gathered for the person who shows evidence of anger or aggression

...

Crisis Intervention Strategies-Roberts

1. (Assessment): Assessing lethality and mental status 2. Establishing Rapport and Engaging the Client 3. (Assessment): Identifying Major Problems (i.e. information from client regarding crisis) -Dealing with Feelings -Recognizing Personal Strengths -Providing Truth in Information 4. (Planning): Exploring Alternative Options and Partial Solutions -Involving Social Support Systems 5. (Planning): Developing a Realistic Action Plan -Focusing on the Present -Incorporate Previously Successful Coping Strategies 6. (Implementation): Developing an Action Plan, Developing Reasonable Goals -Designing Achievable Tasks -Providing Structure and Encouragement -Providing Support for Families. 7. (Evaluation): Developing a Termination and Follow-up Protocol

Intervention for Grief and Depression

1. Acknowledge family's grief and depression. 2. Encourage them to be precise about what it is they are grieving and depressed about; give grief and expression a context. 3. Allow the family appropriate time for grief. 4. Recognize that this is an essential step for future adaptation; do not try to rush the grief process. 5. Remain sensitive to your own unfinished business, and hence comfort or discomfort with family's grieving and depression.

Intervention for Anger, Hostility, Distrust

1. Allow for venting of angry feelings clarifying what thoughts, fears and beliefs are behind the anger; let the family know it is okay to be angry. 2. Do not personalize family's expressions of these strong emotions. 3. Institute family control within the hospital environment when possible (e.g., arrange for set times and set person to give them information in reference to the patient and answer their questions.) 4. Remain available to families during their venting of these emotions. 5. Ask families how they can take the energy in their anger and put it to positive use for themselves, for the patient and for the situation.

Interventions for Initial Family Responses to Crisis

1. Anxiety, Shock, Fear 2. Denial 3. Anger, Hostility, Distrust 4. Remorse and Guilt 5. Grief and Depression 6. Hope

Identify appropriate nursing actions needed to maintain safety when a person exhibits anger, aggression or violence.

1. Apologize 2. Validate their feelings 3. Give them options, give them back control 4. Avoid being defensive 5. Avoid going straight to setting limits. Empathic listening • Give undivided attention • Ask questions • Listen carefully to facts and emotions • Allow silence for reflection • Use restatement, paraphrasing and validation to clarify the message • If valid, accept responsibility and correct it if possible • Offer alternatives. Paraverbal communication • Space issues, do not touch • Nonjudgmental attitude • Components: tone, volume and cadence o Tone: avoid impatience o Volume: lower the volume o Cadence: deliver message with even rate and rhythm. Control the environment • Never let yourself be cornered • Remove harmful objects • Decrease stimuli • Limit nonessential people Empathy with or without options has been shown to be the most effective style conflict resolution.

Strategies for Dealing with an Angry Client

1. Call the client by name while making occasional eye contact. 2. Use active listening while allowing client to ventilate some of his or her anger and discuss his problem. 3. Use body language that is confident but non threatening: neutral position, hands down by your side, one foot in front of the other in a relaxed posture; do not "crowd" the client, maintain space (a safe distance). 4. Take a deep breath and respond in a low, calm, gentle tone eof voice (avoid being defensive). 5. Restate the issue briefly, be friendly. 6. For some clients with brain damage or mental illness, it is appropriate to remove them from the source of their irritation to a calm environment, sort of a time-out. 7. Help client identify his or her own anger, for example: "I notice you are clenching your fists and talking more loudly than usual. These are things people do when angry. Are you feeling angry right now?" 8. Give permission to feel angry, but set limits on acting out/violent behavior: "it's okay to feel angry about...but not okay to act on it," or "It's natural to feel angry about...but throwing isn't okay..." 9. Avoid arguing, saying no, hurrying, or touching. 10. Offer to work with client to help him deal with the issue. 11. Get help immediately or leave if you feel in danger of physical harm; always maintain a space for safety and plan an exit.

Intervention for Hope

1. Clarify with families their hopes, individually and with one another. 2. Clarify with families their worst fears in reference to the situation. Are the hopes/fears congruent? Realistic? Unrealistic? 3. Support realistic hope. 4. Offer gentle factual information to reframe unrealistic hope (e.g., "With the information you have or the observation you have made, do you think that is still possible?"). 5. Assist families in reframing unrealistic hope in some other fashion (e.g., "What do you think others will have learned from _____ if he doesn't make it?" "How do you think ____ would like for you to remember him/her?"

Intervention for Remorse and Guilt

1. Do not try to "rationalize away" guilt for families. 2. Listen and support their expression of feeling and verbalization's (e.g., "I can understand how or why you might feel that way; however..." 3. Follow the "howevers" with careful, reality-oriented statements or questions (e.g., "None of us can truly control another's behavior"; "Kids make their own choices despite what parents think and want"; "How successful were you when you tried to control_____'s behavior with that before?"; "So many things happen for which there are no absolute answers").

Characteristics Associated with the Development of Assertive Behavior

1. Express your own position, using "I" statements. 2. Make clear statements. 3. Speak in a firm tone, using moderate pitch. 4. Assume responsibility for personal feelings and wants. 5. Make sure verbal and nonverbal messages are congruent. 6. Address only issues related to the present conflict. 7. Address only issues related to the present conflict. 8. Structure responses so as to be tactful and show awareness of the client's frame of reference. 9. Understand that undesired behaviors, not feelings, attitudes, and motivations, are the focus for change.

Intervention for Anxiety, Shock, Fear

1. Give information that is brief, concise, explicit and concrete. 2. Repeat information and frequently reinforce; encourage families to record important facts in writing. 3. Determine comprehension by asking family to repeat back to you what information they have been given. 4. Provide for and encourage or allow expression of feelings, even if they are extreme. 5. Maintain constant, non anxious presence in the face of a highly anxious family. 6. Inform family as to the potential range of behaviors and feelings that are within the "norm" for crisis. 7. Maximize control within hospital environment, as possible.

Principles of conflict resolution

1. Identify conflict issue. 2. Know own response 3. Stay focused on issue. 4. Identify options 5. Use standards/criteria 6. Separate issue from people involved.

Defuse Intrapersonal Conflict

1. Identify the presence of an emotionally tense situation. 2. Talk the situation through with someone. 3. Provide a neutral, accepting environment. 4. Take appropriate action to reduce tension. 5. Evaluate the effectiveness of the strategies. 6. Generalize behavioral approaches to other situations.

Intervention for Denial

1. Identify what purpose denial is serving for family (e.g., Is it buying them "psychological time" for future coping and mobilization of resources?). 2. Evaluate appropriateness of use of denial in terms of time; denial becomes inappropriate when it inhibits the family from taking necessary actions or when it is impinging on the course of treatment. 3. Do not actively support denial, but don't dash hopes for the future (You might say, "It must be very difficult for you to believe your son is nonresponsive, and in a trauma unit.") 4. If denial is prolonged and dysfunctional, more direct and specific factual representation may be essential.

Behaviors that create anger in others

1. Providing unsolicited advice. 2. Conveying ideas that try to create guilt. 3. Offering reassurances that are not realistic. 4. Communicating using "gloss it over" positive comments 5. Speaking in a way that shows you do not understand your client's point of view. 6. Exerting too much pressure to make a person change their unhealthy behavior. 7. Placing blame, speaking in an accusing tone. 8. Portraying self as an infallible expert. 9. Using excessively histrionic language or sarcastic retorts. 10. Using an authoritarian tone. 11. Using "hot button" words that have heavy emotional connotations.

Prepare for the conflict resolution encounter

1. Purpose-What is the purpose or objective of this information? What is the central idea, the one most important statement to be made? 2. Organization-What are the major points to be shared, and in what order? 3. Content-Is the information to be shared complete? Does it convey who, what, where, when, why, and how? 4. Word choice. Has careful consideration been given to the choice of words?