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Aggressive & Violent Behavior

(In terms of adults with mental illness)

Vicki Notes

By 2010 an estimated 25% increase in admissions of violent clients to specialty mental health facilities will occur.

Aggressive behavior generally includes abusive language, violent threats of harm, physical assault to self or others, & damage to property. Behavior may be understood in terms of negative appraisals & attitudes toward self, others, the world & the future.

Aggression, hostility-related variables & violence




Aggressive behaviors & violence occur in all clinical diagnostic categories à however certain subgroups of psychiatric diagnosis have been linked with violent behavior such as:

Profiles related to aggressive behavior

Client arrest profiles – show that those hospitalized in public psychiatric facilities tend to have higher arrest rates than the general public. Arrests for violent behavior were higher in antisocial personality, paranoid schizophrenia & substance abuse disorder à and highest in schizoaffectrive disorder.

Inpatient profiles – show that most incidents occur the 1st week of hospitalization & steadily decline, are highest in males 26-35 y/o and females 36-45 y/o. Physical incidents occurred more with men & suicide occurred more often with women. The most common diagnosis was schizophrenia (highest for assault), substance abuse or major depression.

Outpatient profiles

Families with a mentally ill member

General Population vs. Seriously Mental Ill



Neurotransmitter Dysregulation

Substance Abuse

The Social learning view (or theory)

Environmental & situational determinants

The Nursing Process


Some studies say the single best predictor of violence is a history of violence à Ask that question, "Do you feel like hurting yourself or anyone else?" (This does not suggest violence to the person but gives them a route of expression by talking about it rather than acting out)

There should be concern about the following types of patients as well:

Some of the tools (scales or tests) used to measure aggressive behavior include the:

Nursing Diagnosis

Patient Outcomes and Goals

Discharge Planning


Three Intervention Strategies

Safety Guidelines when Interacting with Angry or Potentially Aggressive Patients:

Verbal Intervention

There are 3 phases to verbal intervention to prevent the escalation of violence:

  1. Make contact- appear calm and in control when approaching the patient. Speak in a normal tone and nonjudgemental. Watch their verbal and nonverbal behavior. Tell them what you see them doing behaviorally and how you think they feel. Then check your understanding. Example: Sue, I see you pacing and hitting your leg with a magazine. You seem angry. Are you angry?
  2. Discovering the source of distress- use open-ended questions to elicit more meaningful descriptions. Encourage the patient to describe and clarify the problematic feelings and what triggers them (increases the patient self-awareness). Don’t ask why questions (puts them on the defensive). Do not "parrot" this patient rather paraphrase.
  3. Focus on the patients competency and alternative problem solving: If possible talk with the person how their ideas regarding a plan that would help them deal with the situation.

Limit Setting

The following are useful for setting limits:

  1. Assess the need for limit setting.
  2. Describe the patient’s unacceptable behavior and communicate expected behavior and give alternatives. Acceptable substitute behaviors for example are walking with the nurse, talking about feelings and thoughts, or participating in recreational therapy.
  3. State the limit. Inform the patient exactly what the consequence or limit is.
  4. Help the patient understand the reason for the limit. Explaining consequences gives the patient a sense of responsibility for the outcomes or results of behavior.
  5. Enforce the limit. When a patient tests a limit, they experience some anxiety and having the stuff respond in a predictable manner ensures the safety and protection of the patient and provides security and comfort.

Remember DISC:

D - describe patient behavior

I - indicate desired behavior

S - specify nurses’ actions

C – confronts with positive or negative consequences

Intervention with medication in managing aggression:

Seclusion & Restraint

According to Task Force of the American Psychiatric Association indications for use of seclusion and restraint are:

  1. To prevent harm to patient and others- if no others means are effective.
  2. Prevent serious disruption of treatment program or damage to environment.
  3. As part of an ongoing behavior treatment program.
  4. As the patients request (for seclusion, used for violence, patient on the verge of exploding).
  5. Seclusion and restraint should be viewed as important as CPR in mental health.

***Be sure to read Box 31-2 on page 622, Guidelines for Seclusion and Restraint of Violent Clients.

When the decision for use of seclusion and restraint is made, the staff:

*Each team member holds a limb and transports patient to seclusion or to apply restraints, (include wrist and ankle

cuffs, sheet restraints and camisoles {straight jackets}).

Behavior Therapy

Cognitive Therapy

- Often responses of anger are deeply ingrained.

Group and Family Therapy


Cultural Issues

Legal Issues


Barabara Schoen Johnson (1997) Adaptation & Growth Psychiatric-Mental Health Nursing 4th ed.