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Crisis Intervention
Week Six
The Potentially Violent Patient
The focus for Week 6 will be background about the potentially violent patient and successfully managing this type of situation to the benefit of the patient and the responders.
The textbook seems to imply that potentially violent patients are having a psychiatric emergency. This seems to me to be very limiting. The impact of violence to self and others covers many topic areas. The specific topics of domestic violence, mental illness, alcohol & drug usage and assaults will be part of future week's assignments.
Some basic assumptions to work from when thinking about the potentially violent patient are:
- Anger is a normal response to something a person perceives as a frustration of desires or a threat to one's needs.
- Anger is a normal human emotion that is crucial for individual growth and a factor present in all relationships.
- Triggers or 'buttons' are those areas that are sensitive for you. Are you aware of triggers that you might react to in a given situation? Can you put those aside and deal with a given situation rationally?
- Most of the studies referring to violence in the work place associate the feelings of powerlessness, being overwhelmed, loss of confidence in ability and lack of self esteem as part this complexity.
The Assault Cycle
- Triggering Phase -- (buttons get pushed) stress producing event occurs and person doesn't let go of the stress or deal with it
- Escalation Phase - behaviors occur that indicate movement toward loss of control
- Crisis Phase - period of emotional and physical crisis - in which full blown battery occurs
- Recovery Phase - period of cooling down - a return to normal responses
- Post Crisis Depression phase -- may include crying, apologies, and reconciliation interactions. Repression of passive / aggressive actions.
Assessing Potential for Violence
- What is the availability of weapons / is there any indication for using items as weapons
- Does this person have roots / connections to other people in a positive way? The absence of connectedness increases violence potential.
- Is there a history of violence or aggression towards self or others? This could also be indicated as issues with people in authority. If a person has been violent before, it increases the risk factors.
- Substance usage, either alcohol or recreational drugs, changes a situation dramatically. It may make the situation more volatile and unstable.
- Does the person you are responding to indicate thinking processes that include paranoia, impulsivity, hostility or agitation? These increase the risk factors.
Types of Power Struggles
- Defending your credibility - are you comfortable with your skills? There is no need to defend yourself. Know your limitations and accept them.
- Button pushing - (triggers) those issues that are sensitive / this can be your buttons or the person you are working with.
- Threat & ultimatums - consequences are appropriate and needed / setting successful limits can be vital in these situations / but setting limits and holding the other person to a consequence is different than threatening and ultimatums. These are more of a challenge many times to the other person.
- Past history / negative reminders make matters worse / resolving events of history need to be done when people are calm and able to think
Becoming involved in power struggles is extremely non-productive. Focus attention to the specific behavior at hand. This is a time to be that real, honest self.
Intervention
- Know yourself
- Verbal deescalation
- Simple / direct language / but not belittling
- Be careful not to crowd a person verbally as well as physically
- Validate the persons feelings and right to have those feelings
- Be careful to clarify perceptions
- Give consistent messages
- Help the person explore ways to gain control
- Avoid power struggles
- Non - Verbal deescalation
- Understand non-challenging body language
- Calm / relaxed / open
- How do you convey fear to another through behavior?
- Concept of personal space - sometimes as big as four times the usual space
- Always allow for escape routes
- Touch - may be helpful or harmful
- Be comfortable with silence
- Allow time - it takes time
- Be aware of environmental factors
- Setting limits successfully
- Avoid personal power struggles
- Establish clear objectives & limits
- Be able to enforce consequences
- No ultimatums or threats
- Be a skilled listener
- A care provider with self confidence will be able
- Principles of restraining
- Restraints should be viewed as last option
- Ensure a safe environment for all involved
- Legal implications / varies per state
- Perception from the patients view / attempt to gain patient's cooperation
- Responders need to be confident but not confrontational
- The dignity of the patient should be respected as much as possible during the situation and restraining
- Refer to your EMT text or to an agencies protocol
- This topic will also be addressed more in class time (wk 8)
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Restraints:
It occasionally may be necessary to employ 'reasonable' force or to use restraints when dealing with unruly or violent patients who are not able to make rational, informed decisions regarding their care. EMS agencies have specific protocols that should be followed when it is necessary to restrain patients, usually law enforcement are part of this action.
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Activities for Week Six
- Reading:
- Participation:
- One helpful internet site for the following assignment would be:
Center for the Study and Prevention of Violence: www.colorado.edu/cspv
- Identify at least one program from your local area, in the school or community, which is trying to affect the continuance of violence. Give a brief description of the program.
Post your discovery on Web Board - Week 6 Activity 1
Ex: Salem area - "Hands are Not for Hurting" - a program of education and declarations from parents to not use their hands to hurt their children.
- Respond in your Sport Discussion Group to the question asking about triggers and respond at least to 2 others in your group. Please try to get into the discussion groups several times during the week and respond to each other. It does make for more interesting topics.
- Worksheets:
- Steps for restraining a violent patient are given in Activity 2 for Wk 6. Respond to the questions posed for a discussion about the pros and cons of various methods and needs for using a restraining process.
Post this on Web Board - Week 6 Activity 2
- Post your responses to the following situations on Web Board - Week 6 Activity 3 will be found in your discussion group.
What I'm asking you to do is come up with some words that you would use to respond to this individual. Then give a couple of sentences of rationale.
 An angry family member: "When are they going to hire some decent help? All I see is incompetence!"
 A patient is drunk and grabs one of the crew, saying, "I'm going to smash your face in!"
 An 80-year-old female in your care center suddenly becomes confused and combative, speaking with words that do not relate to any questions or the situation.
 An 18-year-old female in your gym class suddenly becomes confused and combative.
- Quiz:
- You will find a brief quiz in your private conference on the Web Board by Wednesday. Please go into the conference, press the edit button and that will allow you to put your answers into the quiz conference. This will be worth 20 worksheet points. The Due date is Sunday, November 5th for full credit.
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