Chapter 24: Crisis and Anger Management

Chapter 24: Crisis and Anger Management

Crisis = acute, time-limited event (~4–6 weeks) where normal coping mechanisms fail.

During intervention: client assumed to have been previously mentally healthy.

Not pathological, but a struggle for equilibrium/adaptation.

Outcome = psychological deterioration or growth.

Personal in nature → what is a crisis for one may not be for another.

Common Crisis Characteristics

• Sudden event, little/no preparation

• Event perceived as overwhelming or life-threatening

• Loss/decrease in communication with significant others

• Feeling displaced from familiar environment

• Actual or perceived loss

Types of Crises

Situational/External

• Unanticipated events that disrupt daily life

• Examples: divorce, job loss/change, unexpected life event

Maturational/Internal

• Linked to developmental transitions requiring new coping skills

• Examples: marriage, retirement, having a child

Adventitious

• Result of natural or man-made disasters

• Examples: hurricanes, earthquakes, terrorist attacks

• Can also include large-scale psychological trauma affecting whole communities

Situational/External Crisis

Unanticipated events that disrupt daily life

Examples: divorce, job loss/change, unexpected life event

Maturational/Internal Crisis

Linked to developmental transitions requiring new coping skills

Examples: marriage, retirement, having a child

Adventitious Crisis

Result of natural or man-made disasters

Examples: hurricanes, earthquakes, terrorist attacks

Can also include large-scale psychological trauma affecting whole communities

adventitious

(adj) occurring by chance rather than design/nature, coming from outside (not native), formed accidentally or unusually

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis?

a

Rape

b

Marriage

c

Severe physical illness

d

Job loss

b Marriage

---

Rape is an example of an adventitious crisis. It is not a part of everyday life.

Loss of a job is an example of a situational crisis.

Severe physical illness is an example of a situational crisis.

Crisis Assessment

Suicidal or homicidal ideation (may require admission)

Client’s perception of precipitating event

Cultural/religious needs

Support system availability

Present coping skills

Physical assessment

Signs of disorganization

Overwhelm, anxiety

Inadequate problem solving

Anger or aggression

Crisis Risk Factors

Unresolved losses

Current life stressors

Concurrent mental & physical health issues

Excessive fatigue or pain

Age/developmental stage

Crisis Protective Factors

Strong support system

Prior experience handling stress/crisis

Expected Findings – Phases of a Crisis

Phase 1: Escalating anxiety → defense responses activated.

Phase 2: Defense mechanisms fail → functioning disorganized, trial-and-error attempts to cope.

Phase 3: Trial-and-error fails → severe or panic-level anxiety → fight, flight, or withdrawal behaviors.

Phase 4: Overwhelming anxiety → anguish, helplessness, powerlessness, dissociation (depersonalization, detachment), depression, confusion, or violence toward self/others.

Nursing Care in Crisis

Goal: Provide rapid assistance to resolve the immediate problem.

Initial task: Promote safety → assess potential for suicide or homicide.

Admit to inpatient facility if needed.

Address physical needs first.

Initial Interventions

• Identify current problem & direct interventions.

• Take an active, directive role (encourage client participation in planning).

• Help client set realistic, attainable goals.

Strategies to Decrease Anxiety

• Build therapeutic nurse-client relationship.

• Remain with the client.

• Listen, observe, maintain eye contact.

• Ask questions about client’s feelings & event.

• Show genuineness and caring.

• Communicate clearly with direct instructions.

• Avoid false reassurance & nontherapeutic responses.

Additional Nursing Interventions

• Teach relaxation techniques.

• Identify/teach coping skills (e.g., assertiveness training, parenting skills).

• Develop an action plan with client:

  • Short-term

  • Focused on crisis

  • Realistic & manageable

  • Self-assessment by nurse included

  • Debriefing for staff

Critical Incident Stress Debriefing

Group approach for people exposed to a crisis situation.

A nurse in the emergency department is assisting with the care of a client who sustained minor injuries in a motor vehicle crash. The client’s spouse was killed in the accident. Which of the following actions should the nurse take first?

a

Determine if the client has thoughts of self-harm.

b

Ask the client how the accident occurred.

c

Assist the client in setting short-term treatment goals.

d

Instruct the client on use of coping strategies.

a Determine if the client has thoughts of self-harm.

Crisis Medications

Antianxiety meds: alprazolam, diazepam, oxazepam

Antidepressants: paroxetine, bupropion, fluoxetine

Psychotherapeutic Interventions

Primary care:

• Identify potential problems with client

• Teach coping mechanisms

• Encourage lifestyle changes

Secondary care:

• Intervene during acute crisis to promote safety

Tertiary care:

• Support during recovery from severe crisis

• Services may include: outpatient clinics, rehab centers, crisis stabilization centers, short-term residential programs, workshops

Client Education

• Community resources:

  • Crisis stabilization, hotlines, warm lines

  • Mobile and peer crisis services

• Adhere to follow-up appointments

Anger Management

Anger = emotional response to frustration.

• Positive → motivates change when expressed healthily.

• Negative → when denied, suppressed, or expressed inappropriately (e.g., aggression).

Suppressed anger may manifest as: physical symptoms, depression, anxiety, PTSD, unresolved grief.

Aggression = verbal/physical attack; often goal-directed to harm person/object.

Clients who frequently show anger/aggression may have underlying insecurity, guilt, fear, or rejection.

Important: Clients with mental illness are more likely to self-harm than harm others.

Anger Comorbidities

Depressive disorders

Substance use disorders

Bipolar disorder

PTSD

Alzheimer’s disease

Personality & psychotic disorders

Clients overwhelmed → poor coping skills

Anger Categories/Taxonomies of Disorder

Preassaultive:

• Client shows increasing anger, anxiety, hyperactivity, verbal abuse.

Assaultive:

• Client commits act of violence.

• Seclusion/restraints may be required.

Postassaultive:

• Staff reviews incident with client after the event.

Seclusion and Restraints

Use only as last resort, following all legal guidelines.

Requirements:

• Provider prescription (reason, type, time limit, criteria for release).

• Client must be evaluated face-to-face within 1 hour by RN, provider, or PA.

Monitoring:

• Never leave restrained client alone.

• Continuous monitoring/documentation q15 min.

• Monitor for breathing, physical issues, and injuries.

• Assess hydration, nutrition, toileting, comfort, and skin integrity.

• ROM exercises at least q2h.

Care standards:

• Avoid unnecessary harm; follow individualized care.

• Document all meds administered.

• Encourage behavior that promotes release.

• IM meds may be needed if aggression is life-threatening and no meds given before.

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? 

Select all that apply.

a

Lethargy

b

Defensive responses to questions

c

Disorientation

d

Facial grimacing

e

Agitation

b

Defensive responses to questions

d Facial grimacing

e Agitation

---

Lethargy is more likely to be observed in a client who has depression

Disorientation is more likely to be assessed in a client who has a cognitive disorder.

Anger Risk Factors

History of aggression, poor impulse control, violence

Poor coping skills, limited support systems

Comorbid conditions that increase violence risk:

• Psychotic delusions

• Command hallucinations

• Violent angry reactions (cognitive disorders)

Living in violent environment

Limit-setting by nurse (can escalate anger in some clients)

Anger Clinical Screening Tools

Dimensions of Anger Reactions

PROMIS (Patient-Reported Outcome Measurement Information System)

STAS (State-Trait Anger Scale)

CAS (Clinical Anger Scale)

Anger Expected Findings

Behavioral signs: pacing, restlessness, hypersensitivity, being easily offended

Eye contact: intense or absent

Facial expressions: frowning, grimacing

Body language: clenched fists, waving arms

Physiological signs: rapid breathing

Postures: leaning forward, tense stance

Verbal clues: loud, rapid talking, yelling, shouting

Substance-related: drug/alcohol intoxication

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?

a

“I wish you would not make me angry.”

b

“I feel angry when you leave me.”

c

“It makes me angry when you interrupt me.”

d

“You’d better listen to me.”

d “You’d better listen to me.”

Anger Nursing Care

Ensure safe environment for client, staff, and others.

Follow facility policies on handling aggression.

Assess for triggers or preconditions of anger.

Practice self-awareness (nurse self-assessment).

Use contingency management (rewarding calm behavior with privileges or activities).

Steps to Handle Aggressive/ Escalating Behavior

Respond quickly.

Remain calm and in control.

Encourage verbal expression of feelings using therapeutic communication (reflective listening, silence, active listening).

Allow client personal space.

Maintain eye contact, sit/stand at client’s level.

Communicate with honesty, sincerity, nonaggressive stance.

Avoid accusatory/threatening language.

Offer choices and describe options clearly.

Reassure presence of staff for safety.

Set limits:

• State expectations calmly (“I need you to stop yelling and walk with me to the day room”).

• Offer physical outlets (e.g., walking).

• Explain consequences (loss of privileges).

• Use medications if limit-setting fails.

• Have 4–6 staff nearby for show of force if necessary.

After an Aggressive/Violent Episode

Discuss ways for client to maintain control.

Reassess milieu for contributing factors.

Encourage client to share what triggered the aggression.

Debrief staff to evaluate actions.

Document fully:

• Pre-incident behaviors

• Nursing interventions used

• Client’s response

Client Debriefing

Conduct after seclusion/restraint is removed.

Discuss misperceptions.

Show support for client’s reintegration.

Identify prevention strategies for future episodes.

Listen to client’s perspective.

Allow client to voice concerns if they feel rights violated.

Recognize any trauma experienced.

Adapt plan of care as needed.

Medications for Aggression & Impulsivity

Atypical Antipsychotics

• Olanzapine, Ziprasidone

  • Therapeutic intent: Control aggressive/impulsive behaviors

  • Preferred over haloperidol (fewer severe adverse effects)

Typical Antipsychotic

• Haloperidol

  • Therapeutic intent: Controls aggressive/impulsive behaviors

  • Nursing actions:

    • Monitor for parkinsonian and anticholinergic effects

    • Check vitals, hydration, and assess for muscle rigidity (risk of neuroleptic malignant syndrome)

Other Medications

• Used to treat underlying disorder contributing to aggression:

  • Antidepressants (SSRIs)

  • Mood stabilizers (Lithium)

  • Sedative-hypnotics (Benzodiazepines)

---

Client Education

• Keep follow-up appointments

• Attend support groups

Care After Discharge

• Continue to manage medications

• Develop problem-solving skills