Anger, Hostility, Aggression, and Crisis Intervention Clinical Guide

Foundations of Crisis, Anger, Hostility, and Defense Mechanisms

  • Crisis Definition: A crisis is defined as a "sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem."
  • Anger Definition: Anger is a normal human emotion characterized as a strong, uncomfortable, emotional response to a provocation, whether real or perceived (such as a crisis).
    • Anger results when an individual experiences feelings of frustration, hurt, or fear.
    • It energizes the body for defense by triggering the fight-or-flight response.
  • "Acting Out" Defense Mechanism:
    • "Acting out" is an immature defense mechanism.
    • The patient deals with emotional conflict or stress through physical or verbal actions rather than through reflection or expressing feelings.
    • Through acting out, the patient attempts to overcome feelings of powerlessness or helplessness.

Clinical Assessment and Physical Characteristics of Anger

  • Importance of Assessment: Nurses must be aware of all symptoms associated with anger and aggression to form an accurate clinical assessment.
  • Prevention: The single best intervention for managing anger and aggression is prevention, which is intimately connected to accurate assessment.
  • Characteristics and Symptoms Cluster of Anger:
    • Intense distress
    • Clenched fists
    • Frowning
    • Increased energy
    • Gritting the teeth
    • Fatigue
    • Pacing
    • Withdrawal
    • Eyebrow displacement
    • Flushed face
    • Emotional overcontrol
    • Voice changes
    • Yelling or shouting
    • Diaphoresis

Hostility, Psychological Models, and Inward Anger

  • Hostility Definition and Characteristics:
    • Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, and threatening behavior (verbal aggression).
    • It is specifically intended to intimidate or harm others.
    • A hostile person frequently feels threatened or powerless.
    • Hostility can progress directly to physical aggression.
  • Kübler-Ross Grieving Model:
    • Stage I: Denial
    • Stage II: Anger
    • Stage III: Bargaining
    • Stage IV: Depression
    • Stage V: Acceptance
  • "Anger Turned Inward":
    • Individuals who become fixed or stuck in Stage II (Anger) of the grieving model may become depressed.
    • "Anger turned inward" serves as a mechanism to maintain control over pent-up rage.
    • This psychological state carries a strong negative connotation.

Aggression Classifications and Defining Characteristics

  • Emotional Origins: Aggression can arise from internal feeling states including anger, anxiety, tension, guilt, frustration, and hostility.
  • Classification Spectrum of Aggressive Behaviors:
    • Mild: Sarcasm
    • Moderate: Slamming doors
    • Severe: Threats of physical violence against others
    • Extreme: Physical acts of violence toward others
  • Defining Characteristics of Aggression:
    • Sarcasm
    • Verbal or physical threats
    • Change in voice tone
    • Degrading comments
    • Pacing
    • Throwing or striking objects or people
    • Suspiciousness
    • Suicidal ideation
    • Homicidal ideation
    • Self-mutilation
    • Invasion of personal space
    • Increase in agitation or irritability
    • Disturbed thought processes and perception
    • Misinterpretation of stimuli
    • Anger disproportionate to an event

Violence Risk Factor Assessment and High-Risk Diagnoses

  • Key Prevention Principle: Prevention is the key to managing violent behavior.
  • Underlying Feeling: The individual who becomes violent usually experiences underlying feelings of helplessness.
  • Three Core Assessment Factors for Potential Violence:
    1. Past history of violence
    2. Client diagnosis
    3. Current behavior
  • Past History of Violence: The most widely recognized risk factor for violence in a treatment setting is a past history of violent behavior.
  • Clinical Diagnoses High in Correlation with Assaultive Behavior:
    • Substance abuse / intoxication
    • Schizophrenia
    • Post-Traumatic Stress Disorder (PTSD)
    • Organic brain disorder
    • Personality disorders
    • Bipolar mania
  • High-Risk Current Behaviors:
    • Hyperactivity
    • Immediate need for attention

Outcome Identification for Patient Care

  • Target Patient Outcomes: When assisting a patient with the management of anger and aggression, measurable outcomes dictate that the patient will:
    1. Recognize the feeling of anger.
    2. Seek out staff to talk about angry feelings.
    3. Take responsibility for own feelings and anger.
    4. Demonstrate internal control over anger.
    5. Diffuse anger before losing control.
    6. Use tension generated by anger in a constructive manner.
    7. Be free of harm to self or others.
    8. Use step-by-step problem-solving solutions versus becoming violent.

Nursing Planning, Implementation, and Communication Protocols

  • Staff Demeanor and Boundary Setting:
    • Always remain calm when dealing with an angry patient.
    • The overarching goal is to strengthen the patient's control of feelings and impulses.
    • Set clear verbal limits on inappropriate behavior.
    • Delineate explicit consequences for the inappropriate expression of anger.
    • Avoid touching the patient when they become angry.
    • Ignore initial derogatory remarks made by the patient.
  • Self-Reflection and Tension Release Interventions:
    • Require the patient to keep a diary of angry feelings, documenting what triggered them and how the feelings were resolved.
    • Help the patient identify constructive ways of releasing tension, including physical outlets and appropriate channels for expressing anger.
    • Encourage the patient to seek out staff as soon as angry feelings emerge.
  • Assertive Communication Role-Modeling:
    • Role-model appropriate ways of expressing anger assertively.
    • Model statement: "I dislike being called names. I get angry when I hear you saying those things about me."

De-escalation Techniques and Emergency Intervention Protocols

  • Escalation Management:
    • Continuously observe the patient for escalation of anger.
    • Assess staffing resources and attempt to diffuse anger beginning with the least restrictive means.
  • Aggression Management Techniques:
    • "Talking Down": Model statement: "Jerod, you seem very angry. Let’s go to your room and talk about it."
    • Physical Outlets: Provide constructive physical outlets such as punching a pillow or a punching bag.
    • Offer Self: Model statement: "I will stay here with you, if you want."
    • Sequence: Always utilize verbal strategies prior to initiating physical interventions.
  • Emergency and Restraint Protocols:
    • Administer oral (PO) medications as indicated.
    • Call for immediate assistance using institutional emergency calls (Code Gray).
    • Prepare for restraint protocol:
    • Administer intramuscular (IM) medication.
    • Assign 1:1 dedicated staff for constant monitoring.
    • Complete required documentation.
    • Conduct ongoing clinical assessment.
    • Hold a mandatory staff debriefing.

Clinical Evaluation Criteria

  • Evaluation Questions for Patient Care:
    • Has the patient escaped serious injury?
    • Is the patient able to maintain anxiety at a manageable level?
    • Does the patient demonstrate appropriate problem-solving skills?
    • Is the patient able to deal with emotional reactions in an appropriate manner?
    • Does the patient have a plan to deal with anger as it resurfaces?

Smith's Stress Model and the Five Stages of the Assault Cycle

  • Smith's Stress Model Overview: Smith's stress model incorporates the assault cycle, which outlines five stages forming a predictable pattern or chain of aggressive responses to emotional or physical stress.

  • 1. Triggering Phase:

    • Definition & Dynamics: A stress-producing event occurs for the patient, triggering the initiation of a stress response to a stimulus.
    • Nursing Interventions:
    • Convey empathy and support.
    • Use clear, calm, and simple statements.
    • Encourage the patient to maintain self-control.
    • Facilitate problem-solving and explore alternative options.
    • Redirect the patient to a quiet area.
    • Offer tension reduction measures.
    • Consider offering oral PRN medication (PO medication / PRN).

  • 2. Escalation Phase:

    • Definition & Dynamics: Behaviors escalate, indicating movement toward loss of control. The patient regresses to familiar old habits of expressing anger inappropriately. Staff must recognize the patient's individual response patterns and characteristics of aggression.
    • Nursing Interventions:
    • Assemble staff for a "show-of-force" to take control.
    • Take charge using firm directions.
    • Redirect the patient to a quiet, safe area.
    • Administer oral PRN medication to ease agitation.

  • 3. Crisis Phase:

    • Definition & Dynamics: A period of severe emotional and physical crisis during which the patient completely loses control.
    • Nursing Interventions:
    • Staff intervene therapeutically to preserve safety for the patient, milieu, and team members.
    • Apply seclusion and/or physical restraints.
    • Consider emergency intramuscular (IM) medications.
    • Initiate intensive nursing care.

  • 4. Recovery Phase:

    • Definition & Dynamics: A period of "cooling down" during which the patient's agitation slows down and they return toward normal responses.
    • Nursing Interventions:
    • Continue intensive nursing care.
    • Process the incident with staff and other patients on the unit; reassess the unit milieu.
    • Assess both patient and staff for physical injuries.
    • Evaluate the patient's progress toward regaining self-control.
    • Clearly state the criteria required for discontinuance of seclusion and restraints.

  • 5. Post-Crisis Depression Phase:

    • Definition & Dynamics: A period during which the patient attempts reconciliation with others.
    • Nursing Interventions:
    • Process the incident thoroughly with the patient.
    • Discuss underlying feelings.
    • Explore alternatives for more appropriate expressions of anger in the future.
    • Progressively reduce the degree of restraint and seclusion.
    • Reintegrate the patient back into the milieu.