I.

Anger vs. Aggression

Anger is an affective state experienced as the motivation to act in ways that warn, intimidate, or attack those who are perceived as challenging or threatening. It occurs when there is a threat, delay, thwarting of a goal, or conflict between goals. Anger has been identified as a stage in the grieving process. Anger is a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with ones 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. Although anger is portrayed as a bad emotion that always leads to aggression, this is often not the case. Thomas asserts that the expression of anger may prevent aggression and help to resolve a situation. Anger can be associated with a number of typical behaviors, including (but not limited to) the following: Frowning facial expression Clenched fists Low-pitched verbalizations forced through clenched teeth Yelling and shouting Intense eye contact or avoidance of eye contact Easily offended Defensive response to criticism Passive-aggressive behaviors Emotional over control with flushing of the face Intense discomfort; continuous state of tension Aggression is defined as verbal statements against someone that are intended to intimidate or threaten the recipient. 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 perpetrators point of view is correct and not the victims. Aggression and violent behavior reflect a continuum from suspicious behavior to extreme actions that threaten the safety of others or result in injury or death. Aggression may be associated with (but not limited to) the following defining characteristics: II. Pacing, restlessness Tense facial expression and body language Verbal or physical threats Loud voice, shouting, use of obscenities, argumentative Threats of homicide or suicide Increase in agitation, with overreaction to environmental stimuli Panic anxiety, leading to misinterpretation of the environment Disturbed thought processes; suspiciousness Angry mood, often disproportionate to the situation Five-Phase Aggression Cycle Phase Definition Triggering An event or circumstances in the environment initiates the clients response, which is often anger or hostility. Escalation Clients responses represent escalating behaviors that indicate movement toward a loss of control.

Crisis

During a period of emotional and physical crisis, client loses control.

Signs, Symptoms, and Behaviors Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger Pale or flushed face, yelling, swearing, agitated, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem pr think clearly Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching,

Recovery

Client regains physical and emotional control.

Postcrisis

Client attempts reconciliation with other and returns to the level of functioning before the aggressive incident and its antecedents.

shrieking, inability to communicate clearly Lowering of voice, decreased muscle tension, clearer, more rational communication, physical relaxation Remorse, apologies, crying, quiet withdrawn behavior

III. Theories on Aggression A. Biological Current neurobiological research has focused on three areas of the brain, believed to be involved in aggression: the limbic system, the hypothalamus, and the frontal lobes. The limbic system is associated with the mediation of brain drives and the expression of human emotions and behaviors such as eating, aggression, and sexual responses. Alterations in function of the limbic system may result in an increase or decrease in the potential for aggressive behavior. Damage to the frontal lobes can result in impaired judgment, personality changes, problems in decision making, inappropriate conduct and aggressive outbursts. The hypothalamus, at the base of the brain, is the brains alarm system. Stress raises levels of steroids. After repeated stimulations, the system may respond more vigorously to all provocations. That may be one reason why traumatic stress in childhood may permanently enhance ones potential for violence. B. Psychological 1. Cognitive Beck (1976) proposed that cognitive schema such as judgments, self-esteem, and expectations influence angry responses. In a situation perceived as intentional, d angerous, and unprovoked, the recipients reaction will be intensified. The persons reaction will be further intensified if he or she views the offender as undesirable. 2. Behavioral One behavioral theory, drive theory, suggests that violent behavior originates externally. A person experiences anger and acts violently in response to interference with or blocking of a goal. Laboratory experiments and the reality of everyday experience have proved the limitations of this theory (Thomas, 1990). Another behavioral theory is social learning theory. In his research, Bandura (1973) drew attention to the role of learning and rewards in the expression of anger and violence. He studied interactions between mothers and children. The children learned that anger and aggressive behavior helped them get what they wanted from their mothers. C. Interactional Morrison (1998) challenges research and theories suggesting that aggression and violence are biologically or psychologically based. She asserts that these views lead to excusing the persons behavior. She proposes that violence among people in psychiatric settings is the same as violence in other settings. Therefore, the patients behavior should be considered a social problem and responded to on that basis. IV. Nursing Process Early assessment, judicious use of medications, and verbal interaction with an angry client can often prevent anger from escalating into physical aggression. A. Assessment Be aware of the factors that influence aggression in the psychiatric environment. Assess individuals carefully. A history of violent or personality disorders behavior is one of the best predictions of aggression. Determine how client handles behavior, and what is most helpful to him when assisting. Clients who are angry and frustrated believe that no one is listening to them are more prone to behave in a aggressive manner. Determine what phase of aggression cycle he/she is in, to know the appropriate interventions that may be implemented. Assessment must take place at a safe distance. To ensure staff safety and exhibit teamwork, it may be prudent for two staff members to approach the client. Three factors that have been identified as important considerations in assessing for potential violence include: 1. Past history of violence 2. Client diagnosis 3. Current behavior

B. Data Analysis Ineffective coping related to negative role modeling and dysfunctional family system evidenced by yelling, name calling, hitting others, and temper tantrums as expressions of anger. Risk for self-directed or other-directed violence related to having been nurtured in an atmosphere of violence; history of violence. C. Outcome Identification Expected outcomes for aggressive clients may include the following: Is able to recognize when he or she is angry and seeks out staff to talk about his or her feelings. Is able to take responsibility for own feelings of anger. Demonstrates the ability to exert internal control over feelings of anger. Is able to diffuse anger before losing control. Uses the tension generated by the anger in a constructive manner. Does not cause harm to self or others. Is able to use steps of the problem-solving process D. Implementation Interventions are most effective and least restrictive when implemented early in the cycle of aggression. A. Managing the Environment Planned activities or groups such as card games, watching and discussing a movie, or informal discussions give patients opportunity to talk about events when they are calm. Scheduling one-on-one interactions with clients indicates nurses genuine interest. Consider safety and security of other clients who may need protection from intrusive or threatening demeanor of the clients. B. Pharmacological treatment Focuses on the underlying or co-morbid psychiatric diagnosis such as schizophrenia or bipolar disorder. Examples of medications are the following: Lithium: bipolar disorder, conduct disorders (in children) Carbamazepine (Tegetrol) and valproate (Depakote): aggression associated with dementia, psychosis, personality disorders. Clozarpine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa): dementia, brain injury, mental retardation, personality disorders Benzodiazepines: reduce irritability and agitation in older adults with dementia, but can result in loss of social inhibition for other personality disorders clients. C. Managing Aggressive Behavior 1. Triggering phase Approach client in a nonthreatening, calm manner,. Convey empathy for the clients anger or frustration. Encourage to express angry feelings verbally, suggesting that he/she must stay in control. Use clear, simple, short statements. Suggest that client goes to a quiet area, or move other clients to decrease stimulation. Medications PRN may be given. Relaxation techniques. Physical activity, such as walking, may help the client relax and become calmer. 2. Escalation phase The nurse must take control of the situation. Provide directions using a calm, firm voice; client must take a time out for cooling off in a quiet area or his/her room. Tell client that aggressive behavior is not acceptable and we are here to help client regain control. 3. Crisis phase When client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Decision to use seclusion or restraint should be based on the facilitys protocols and standards for restraint and seclusion. Obtain a doctors order. 4. Recovery phase As client regains control, he/she is encouraged to talk about the situation or triggers that led to the aggressive behavior. Help client relax, perhaps sleep, returning to a calmer state. Help to explore alternatives. Assess

staff member for any injuries and complete required documentation (incident reports, flow sheets). Staff has a debriefing session. 5. Postcrisis phase Client is removed from restraint or seclusion as soon as he/she meets the behavioral criteria. Nurse should not lecture or chastise client for aggressive behavior but should discuss behavior in a calm, rational manner. Client can be given feedback for regaining control, with the expectation that he will be able to handle feelings or events in a non aggressive manner in the future, client should be reintegrated into the milieu and its activities as soon as he can participate. E. Evaluation Care is most effective when the clients anger can be defused in an earlier stage, but restraint or seclusion is sometimes necessary to handle physically aggressive behavior. The goal is to teach angry, hostile, and potentially aggressive clients to express their feelings verbally and safely without threats or harm to others or destruction of property. I. What is manipulation? Manipulation is defined as a deliberate thought process. A cognitive, shrewd, artful, planning, setting into motion a plan, an idea and make that idea a reality; a response, not a reaction. Manipulators attempt to indirectly control or influence the actions and behavior of others. Instead of being direct with their methods, the manipulator uses underhanded tactics to force their will. Because they are subtle, the manipulative personality easily goes undetected and overlooked, and the person or people being manipulated dont realize whats going on until its too late. Or not at all. They may believe that they are obligated to do what the manipulator wishes, and feel guilty if they dont. The manipulative personality may be a family member, friend, or colleague. three main types of manipulative personality: The Narcissist The Narcissist is the ultimate manipulator. They are egotistic, self-absorbed and feel entitled to nearly everything they desire. They lack empathy and consideration for others, so they will easily manipulate to their own gain. They think it is their right to have others do what they say. The Needy The Needy person is the most difficult type of manipulator to let go of. They are experts at making you feel sorry for them, and making you feel like you are the only person that can help them. Some Needy personalities dont realize that they are manipulative. They have learned to depend on others for their needs, and simply dont know how to get along without help. They may cry or become offended when accused of manipulation. Those that realize they are manipulative may become passive-aggressive in their attempts to regain control. The Martyr This type of personality will give you everything but at a price. They will do you favors, give you special attention, and be overly considerate, but they expect much in return. Their giving is tied to their desire to be considered a good person or be considered important to another person. They cash in on the favors theyve done for you to get you to comply with their wishes. Common phrases heard from the Martyr include, After all Ive done for you and I would do it for you. Manipulators tactics Diversion - he's expert at knowing how to change the subject, dodge the issue or in some way throw us a curve. Lying Manipulators often lie by withholding a significant amount of the truth from you or by distorting the truth. They are adept at being vague when you ask them direct questions. This is an especially slick way of lying' omission. Guilt Tripping - Manipulators are often skilled at using what they know to be the greater conscientiousness of their victims as a means of keeping them in a self-doubting, anxious, and submissive position.

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II. a.

b.

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Playing Victim Role - This tactic involves portraying oneself as an innocent victim of circumstances or someone else's behavior in order to gain sympathy, evoke compassion and thereby get something from another. Seduction - are adept at charming, praising, flattering or overtly supporting others in order to get them to lower their defenses and surrender their trust and loyalty.

e.

III. Assessment -Intellectualization or rationalization of problems -Seductive behavior or sexual acting out -Refusal to participate in activities -Dependency -Low self-esteem/ low self-confidence -Forgetfulness -Dishonesty -Covert aggressive behaviors are chosen over self-assertive behaviors -Stubbornness -Denial of problems or feelings -Inability or refusal to express emotions directly -Manipulation of staff, family, and other individuals -Playing one person against another -Attempting to gain special treatment or privileges IV. Nursing Diagnosis 1. Manipulative behavior related to: Anger, hostility or resentment Fear of vulnerability Dishonesty 2. Disturbance in interpersonal communication related to: Decreased ability to express feelings Anger or hostility Dishonesty 3. Lack of insight related to: Denial of problems Denial of feelings such as anger Resistance to change Low self-esteem Early rejection by significant other 4. Low self-esteem related to: Feelings of worthlessness Guilt V. Expected Outcome -Verbalize increased insight into their behavior -Express feelings verbally and non-verbally -Demonstrate decreased manipulative behavior -Participate in the treatment program and activities -Communicate directly and honestly with other Individuals and staff about self and personal feelings -Establish and maintain mature, non-manipulative relationships and patterns of dealing with other people and situations VI. 1. 2. 3. 4. 5. 6. Nursing responsibilities Deal effectively with the Individual who uses manipulative behavior in interactions, relationships, and life situations Decrease manipulation of staff members Decrease the Individual's denial of problems, promote their insight Decrease the Individual's attention-seeking behavior, acting out, and secondary gains Promote healthy and appropriate adult behavior and interactions; promote the individual's self-esteem Decrease the Individual's somatic complaints