Anger is easy to recognize by signs of mounting tension. Loud voice, inappropriate staring, banging objects, clenched fists, agitated pacing, and verbal threats are common in the angry patient before a violent episode. Although this seems self-evident, it is surprising how many violent acts occur when these signs are obvious and noted by staff, yet no de-escalation measures are taken.
A patient’s verbal threats can actually help the clinician. This “red flag” alerts staff to focus on de-escalation techniques and prepare for a violent situation.
Confusion can be an underlying risk factor in patients with delirium or nonspecific organic brain syndrome. These patients may strike out unexpectedly when health care personnel are attempting to do routine procedures, and clinicians are sometimes caught off-guard when operating in a care-giving rather than defensive mode.
Table 1
Will this patient become violent? Questions to consider before a clinical encounter
Long-term behavior
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Immediate situation
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Clinicians can often avoid arousing confused patients by using orienting techniques and explaining their actions. For example, a nurse might say, “Hello Mr. X, I am a nurse and you are in this hospital for treatment of your illness. I will need to use this machine to check your blood pressure.”
Humiliation. Men in particular can react aggressively to loss of self-esteem and feelings of powerlessness. Take note if a man has been humiliated in front of family before being brought for evaluation; for example, was he removed by police in an emergency detention situation? This patient may need to act out violently to restore his sense of self.
Staff can lessen a patient’s potential to act on humiliation by using a therapeutic, esteem-building interview technique. For example, address the patient as “Mr.” instead of by first name, and highlight his strengths or accomplishments early in the interview.
Table 2
Risk factors for violence among psychiatric patients*
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| * As identified in the literature. |
Step 4: Structure the interview for safety
The time you take before an interview to learn about a patient’s violence history, context, and arousal state is time well-spent and more patient-specific than past diagnoses. This information allows you to prepare for a safe intervention.
Interview environment. The physical and social environment where you interview the patient may contribute to violence potential.
- Is the patient being interviewed in a cramped room or an open hallway?
- Is the evaluation unit overcrowded?
- Are security personnel visible?
- Is the examiner of the same race or ethnic background as the patient?
Cramped and overcrowded conditions on a psychiatric ward have been associated with higher rates of patient violence.2 In one case of context-specific violence, a veteran with known institutional transference issues toward the government attacked providers in a VA hospital on several occasions but did not exhibit this behavior in other, non-VA medical settings.
Take control of the interview and treatment situation. Use the physical space and personnel as you would any other intervention tool—to increase safety and decrease potential for violent behavior. For example, some patients do better when interviewed in a small, private setting. Other interviews must be conducted in a triage area while police escorts hold the patient and handcuffs remain on.
Ideally, you and the patient should have equal access to the door if you conduct the psychiatric interview in an enclosed room. With high-risk patients, arrange your seating at a 90-degree angle—rather than face-to-face—to limit sustained, confrontational eye contact. Sit at greater than an arm swing or leg kick away from the patient, and require him or her to remain seated during the interview (or you will promptly leave).
In the outpatient practice, terminate the interview or evaluation session if a patient in a negative affective arousal state does not allow verbal redirection. Before you make any movement to exit, however, announce, “I am leaving the room now.”
Trust your intuition. I do not enter a closed, private space with a patient unless I feel safe. If I feel afraid, I take that as a valuable warning that further safety measures are necessary.