Mental health & crisis management 7 APRIL qui z

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Anger, Aggression & Violence Abuse & interpersonal violence

Defining Key Terms

Anger

strong uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs or rights; “ it is a feeling”

Aggression

verbal statement against someone intended for intimidation; “ is a behaviour, an action”

Violence

a physical act of force intended to cause harm to a person or an object and conveys a perpetrator’s point of view

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Anger

Introduction

Anger is “a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs, or rights”

Anger is usually described as a temporary state of emotional arousal, in contrast to hostility, which is associated with a more enduring negative attitude

Anger is part of the fight/flight response; although anger is portrayed as a bad emotion that always leads to aggression, this is often not the case

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Introduction

Some of the words used interchangeably with anger include annoyance, frustration, temper, resentment, hostility, hatred, and rage

In addition, the word angry is used to describe both a transient emotional state and a personality trait

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

The experience of anger

An internal event that involves thoughts, images, and bodily sensations

Can serve as a warning that demands are greater than available resources

The meaning of angry episodes develops from the beliefs held about anger and the interpretation given to the episode and these are shaped by influences such as culture, language, and gender

Anger is a normal human emotion; it is the dysfunctional expression of anger that may be threatening to the self or others

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Expressions of anger

Verbal (e.g., yelling) and motor behaviours (e.g., stomping one’s foot) are involved in the expression of anger

Difficulties in expressing anger have been associated with psychiatric disorders

“Anger turned inwards” has been implicated as a contributor to mood disorders, especially depression

Several medical disorders have linked with the suppression of anger, including essential hypertension, migraine headaches, psoriasis, rheumatoid arthritis, and Raynaud’s disease

Behavioural expressions of anger vary

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Chris Mackey Psychology. (2018, December 12). Managing anger and aggression. Retrieved from https://www.youtube.com/watch?v=a29nKy8wsdE

Violence

Introduction

While anger is an emotion, aggression and violence are actions

Aggression is defined as “verbal statements against someone that are intended to intimidate or threaten the recipient”

A study of verbal aggression on psychiatric units indicated that the types of verbal aggression by prevalence were abusive language, shouting, threats, expressions of anger, and racist comments

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Introduction

Violence is defined as “a physical act of force intended to cause harm to a person or an object and to convey the message that the perpetrator’s point of view is correct and not the victim’s”

Aggression and violent behaviour reflect a continuum from suspicious behaviour to extreme actions that threaten the safety of others or result in injury or death

Research focused on inpatient psychiatric units has found that higher levels of aggression were associated with clients detained under mental health legislation (Bowers et al., 2011), high client turnover, unit doors being locked, and higher staffing ratios

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Increasingly, the complexity of aggression and violence occurring in health care settings is being recognized

A systemic perspective of aggression and violence in mental health care has been proposed that identifies four related phenomena:

environmental (e.g., layout of the unit, noise level)

intrapersonal/client (e.g., age, gender, trauma, diagnosis)

clinician (e.g., skills, stress level, attitude towards aggression)

mental health care system (e.g., policies, cultural factors, control orientation)

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Theories

This section discusses some of the dominant theoretical explanations for anger, aggression, and violence. A single model or theory cannot yet fully explain anger, aggression, and violence; instead, the nurse must choose the most useful models for explaining a particular client’s experience and for planning interventions

Theories of aggression

Biological

Caused by developmental difficulties, malnutrition, toxins, tumors, trauma

Damage to cerebral cortex

History of abuse/ family violence

“ Emotional circuit”

limbic system, cerebral

cortex, frontal and

temporal lobe.

Neurochemical and low serotonin

Psychological

Aggression or violent behaviour are instinctual impulses and events in the environment that stimulate instinctual urges

Protect against a threat

Behavioural

Violence originates internally

People experience anger as a result of feeling that goal is being blocked or interference with achieving it

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer

Halter, M.J., Pollard, C.L., & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd Ed.). Milton, ON: Elsevier.

Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis

Neurochemical Model & Low Serotonin Syndrome

In recent decades, knowledge has increased about the complex role of neurotransmitters in human behaviour

Serotonin is a major neurotransmitter involved in mood, sleep, and appetite

Low serotonin levels are associated not only with depression but also with irritability, increased pain sensitivity, impulsiveness, aggression, vulnerability to alcoholism, and obsessive– compulsive behaviour

People with a history of aggressive behaviour have been found to have a lower-than-average level of serotonin

Studies of humans with known aggressive tendencies, such as violent offenders, have repeatedly shown lower-than- average concentrations of 5-hydroxyindoleacetic acid (5-HIAA), the major metabolite for serotonin

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Theories of aggression

Social Learning

Children learn anger and aggression

Learn that it gets them what they want

Sociocultural

Violent behaviour has multi determinants i.e. social expression in family and peer settings

Influenced by gender

The Social Learning Theory, developed by Albert Bandura in 1977 suggests that individuals model behavior they witness. This theory has been the most relevant theory to criminology. Bandura asserted that aggression must explain three aspects:

1) “how aggressive patterns of behavior are developed;”

2) “what provokes people to behave aggressively.”

3) “what determines whether they are going to continue to resort to an aggressive behavior pattern on future occasions.”

The theory is a combination of the Social Control Theory and the Social Learning Theory in that it emphasizes a weak societal bond and learning that encourages deviant behavior. This theory is meant to examine all of the influential factors an individual may experience throughout his/her life.

This theory is more of a developmental theory which suggests that societal, learning, and delinquency factors all contribute to an individuals involvement in organized crime. The theory further states that individuals with weak social bonds will form other bonds with other delinquents who share the same poor values.

Violence

Creates a critical challenge to the safety, well-being, and health of the clients and others in their environment

Nurses should always assume an organic component (drugs, alcohol, psychosis, or delirium) underlying the aggression in clients presenting with disorganized impulsive or violent behaviors, until proven otherwise

Client body language offer clues to escalating anxiety, particularly agitation, threatening gestures, or darting eye movements

Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders -- Chapter 16

Violence

Treatment of violent clients consists of immediately providing a safe, non-stimulating environment for the client

Often clients calm down if taken to an area with less sensory input

The client should be checked thoroughly for potential weapons and physically disarmed, if necessary*** Note this should only be done by authorized personnel/police – SAFETY for all is priority

Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders -- Chapter 16

Predictors of Violence

History

Previous episodes of aggression/rage or violence

Escalating irritability

Intruding angry thoughts

Fear of losing control

Additional factors: brain injury, substance abuse

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis

Nursing Management

Mental health and aggression

Many clients who have mental health problems do not behave aggressively or violently

To develop a means of predicting aggressive and violent behaviours, some researchers have attempted to determine the relationship between medical diagnosis and violence

Others have focused on the role of a person’s history in predicting violence or examined demographics, client characteristics, and unit climate

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Mental health and aggression

Although media attention highlights violence related to mental illness, research shows that “the mentally ill as a group pose little risk of violence”

Persons with severe mental illness, such as schizophrenia or bipolar depression may be at a slightly higher risk for violent behaviour but they are overwhelmingly more likely to be victims of violent crime (prevalence 6 to 23 times greater than others)

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

While the following is a great learning example for the management of anger and aggression, please note the video does have some aggression

I am here if you would like to debrief after or watch together. Please do not hesitate to talk to me if this is triggering or if there is anything you would like to discuss

Remember you are NEVER alone!

BJC HealthCare. (2014, July 8). Do this, not that! Providing care for medical patients with psychiatric issues. Retrieved from https://www.youtube.com/watch?v=UgLb7sPslUo

TABLE 20-1 Behavioral Indicators of Potential Violence

Behavioral Categories	Potential Indicators
Mental status	Confused
	Paranoid ideation
	Disorganized
	Organic impairment
	Poor impulse control
Motor behavior	Agitated, pacing
	Exaggerated gestures
	Rapid breathing
Body language	Eyes darting
	Prolonged (staring) eye contact or lack of eye contact
	Spitting
	Pale, or red (flushed) face
	Menacing posture, throwing things
Speech patterns	Rapid, pressured
	Incoherent, mumbling, repeatedly making the same statements
	Menacing tones, raised voice, use of profanity
	Verbal threats
Affect	Belligerent
	Labile
	Angry

Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders -- Chapter 16

BOX 20-3 - De-escalation Tips for Mental Health Emergencies

• Use a nonthreatening stance—open, but not vulnerable. Have the client “take a seat”

• Eye contact—not constant, brief to show concern

• Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed

• Movement—not sudden, announce actions when possible, keep hands where they can be seen

• Attitude—calm, interested, firm, patient, reassuring, respectful, truthful

• Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client “I understand you are seeing or feeling this, but I am not”

• Remove distractions, upsetting influences

• Keep the client talking/focused on the here and now

Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders -- Chapter 16

BOX 20-3 - De-escalation Tips for Mental Health Emergencies

• Allow verbal venting within reason

• Be sensitive to personal space/comfort zone

• Remove client to a quiet space; remove others from immediate area (avoid the “group spectators”)

• Give some choices or options, if possible

• Set limits if necessary

• Limit interaction to just one professional and let that person do the talking

• Avoid rushing—slow things down

• Give yourself an out; do not put the client between yourself and the door

Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders -- Chapter 16

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Planning & implementing interventions

The following assumptions are important to consider in planning interventions:

The nurse and client collaborate to find solutions and alternatives to aggressive and violent outbursts

Anger is a normal emotion

All people have the right to express their anger

All people have a responsibility to express their anger in a way that does not, emotionally or physically, threaten or harm others

In most instances, the person who behaves aggressively or violently can assume responsibility for the behaviour

The nurse views the client from the perspective of acknowledging that the client has solved problems before and is only temporarily in need of help

The nurse understands that norms for behaviour are created within the context of a particular environment and are influenced by the client’s history and culture

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Planning & implementing interventions

Nurses who work collaboratively with potentially violent clients must also keep in mind that they can take certain actions to minimize personal risk:

Using nonthreatening body language

Respecting the client’s personal space and boundaries

Positioning themselves so that they have immediate access to the door of the room in case they need to leave the room

Choosing to leave the door open to an office while talking to a client

Knowing where colleagues are and making sure those colleagues know where they are

Removing or not wearing clothing or accessories that could be used to harm them, such as scarves, necklaces, or dangling earrings

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Abuse & Interpersonal Violence

Types of Abuse

Abuse of Women

2 to 4 million cases per year

Highest risk 18 -24, over 65 pregnant and have a history of childhood victimization

Types battery, rape sexual assault, stalking

Abuse of Men

Sexual assaults of men are higher in resent years.

Males also inflected with emotional and physical abuse

Abuse of Children

Child Neglect (43%)

Physical Abuse (31%)

Sexual Abuse (10%)

Incest

Non-family members

Pedophilia

Emotional abuse

Rejecting; Isolating; Terrorizing; Ignoring; Corrupting

Munchausen syndrome by Proxy

Secondary abuse: Children of battered women

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis

9 Types of Interpersonal Violence

Physical

Sexual

Psychological

Emotional

Spiritual

Cultural

Verbal

Financial

Abuse

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Cycle of Violence

Deliberate and systematic

Used to gain control

Intentional

Type of violence chosen

Rage

Cool/calculating

Pattern of escalation

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis

Epidemiology and comorbidity

One of the most important public health issues in Canada

Comorbidity

Secondary effects of violence

Depression

Suicidal ideation

Chronic post-traumatic stress symptoms

Dissociation

Interpersonal disturbances

Substance abuse

Revictimization

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Ecological model

Identifies risk factors:

Poverty

Social isolation

Alcohol/substance abuse

Access to firearms

And conditions:

A perpetrator

A person vulnerable to abuse (e.g., child, woman, older adult, mentally ill, or physically challenged person)

A crisis situation

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Characteristics of perpetrators

Consider their own needs more important than the needs of others

Poor social skills

Extreme pathological jealousy

May control family finances

Dominance, power, and control are the primary drives

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Characteristics of vulnerable persons: Women

Pregnancy may trigger or increase violence

Violence may escalate when makes move toward independence

Greatest risk for violence when the woman attempts to leave the relationship

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Characteristics of vulnerable persons: Children

Younger than 3 years

Perceived as different

Remind parents of someone they do not like

Product of an unwanted pregnancy

Interference with emotional bonding between parent and child

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Characteristics of vulnerable persons: Older adults

Poor mental or physical health

Dependent on perpetrator

Female, older than 75 years, living with a relative

Older adult father cared for by a daughter he abused as a child

Older adult woman cared for by a husband who has abused her in the past

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Application of the nursing process

Assessment

General assessment

Interview process and setting

Self-assessment

Should include:

Violence indicators

Level of anxiety and coping responses

Family coping patterns

Support systems

Suicide or homicide potential (or both)

Drug and alcohol use

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Application of the nursing process

Diagnosis

Risk for injury

Risk for violence

Outcomes identification

Abuse protection

Abuse recovery

Implementation

Reporting abuse

Counselling—safety plan

Case management

Therapeutic environment

Promotion of self-care activities

Health teaching and health promotion

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Prevention of abuse

Primary prevention

Measures taken to prevent the occurrence of abuse

Secondary prevention

Early intervention in abusive situations to minimize their disabling or long-term effects

Tertiary prevention

Facilitating the healing and rehabilitative process

Providing support

Assisting survivors of violence to achieve their optimal level of safety, health, and well-being

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.