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Evaluating and managing the violent patient
CONCEPTS, COMPONENTS, AND CONFIGURATIONS
Evaluating and Managing the Violent Patient William R. Dubin, MD Philadelphia, Pennsylvania
Emergency department personnel frequently encounter violent patients. Effective management depends on early recognition of clues of potential violence and a response that will defuse the threat. The author presents an evaluation schema which emphasizes diagnostic categories and behavior as predictors of violence. A specific hierarchy of treatment intervention is proposed, with special emphasis on the interpersonal dynamics between staff and patient. The author also discusses general steps that can be taken to reduce the risk of violence in an emergency department setting. Dubin WR: Evaluation and management of the violent patient. Ann Emerg Med 10:481-484, September 1981.
emergency management, violent patient; psychiatric emergency, management; violence, emergency department management INTRODUCTION The violent patient poses one of the most difficult treatment problems in emergency medicine. Generally these patients are brought in by family or police for treatment against their will. They can be verbally abusive and physically threatening. Furthermore, mismanagement of the violent patient can result in physical harm to staff and destruction of property. Although it is difficult to predict an individual's long-range potential for violence, a proper initial assessment can lead to an accurate prediction of the patient's potential for violence over a brief time period (not longer than one hour). The most effective management of the violent patient is preventive management. The crux of successful prevention depends on recognizing early the clues which indicate a high probability of violence and responding in a manner that will defuse the potential violence. This article outlines the procedures followed in the Jefferson Crisis Service for evaluating and managing potentially violent patients. Violence is defined as verbally threatening and/or assaultive behavior.
PREDICTION OF VIOLENCE Diagnostic Clues Diagnosis can be a helpful clue in assessing a patient's potential for violence. Frequently the diagnosis is immediately self evident, such as in cases of delirium, psychosis, or alcohol/drug intoxications and withdrawals. Fortunately sudden, unexpected attacks are rare, and violence occurs only after a period of mounting frustration and tension in the patient. Thus the physician has time during the interview to make a tentative diagnosis which alerts him to a patient's potential for violence. In the absence of a firm diagnosis, other clues must be relied upon. The diagnostic groups of patients with a propensity for violence include the following: 1. Drug or alcohol intoxication-- i-7 Patients who are intoxicated from alco-
From the Department of Psychiatry, Thomas Jefferson Hospital, Philadelphia, Pennsylvania. Address for reprints: William R. Dubin, MD, Department of Psychiatry,Thomas Jefferson Hospital, 11th and Walnut Streets, 4 Main, Philadelphia, Pennsylvania 19107.
10:9 (September) 1981
Ann Emerg Med
481/51
hol or drugs, especially amphetamines, LSD or phencyclidine, have a much greater potential for violence than do ordinary patients. 2. D r u g or a l c o h o l w i t h d r a w a l
1,7,s Patients in withdrawal often attempt to manipulate staff to obtain drugs to alleviate their withdrawal symptoms. When they are refused drugs by medical personnel, they often become threatening and abusive. Patients experiencing delirium tremens can be the most assaultive patients seen in an emergency department. _
_
3. A c u t e o r g a n i c b r a i n s y n d r o m e (delirium)2,7-1o The potential for
violence in these patients may be overlooked by the medical staff, who often become preoccupied with the medical problem of the patient. 4. A c u t e p s y c h o s i s - - 2,7,1o,13This includes patients with acute schizophrenic episodes and patients who are acutely manic. It has been our experience that manic patients are more dangerous because staff members tend to gain a false sense of security from the manic's expansive mood and good humor. However, manics can become quite violent when demands are placed on them. 5. P a r a n o i d c h a r a c t e r -
2,7,S,ll
Paranoid characters pose a potential for violence, especially when the examiner begins to probe for dynamic information despite the patient's resistance and warning to leave him alone. After repeated questioning and a period of increasing tension and turmoil, the patient may explode and attack. 6. B o r d e r l i n e p e r s o n a l i t y
- - 3,13
Generally these patients can become violent when they perceive the staff is rejecting them after their demands have not been met, or if they are intoxicated with alcohol or drugs. 7. A n t i s o c i a l
personality
--
Violence in these patients is generally associated with drug intoxication or withdrawal. Other diagnostic categories are potentially violent, including temporal lobe epilepsy, 5's'9'14 passive aggressive personality, 1°'12 and pathological i n t o x i c a t i o n1.3' ' 14 We, however, have not found these diagnostic categories to be as much of a problem because patients with temporal lobe epilepsy or pathological intoxication are brought to the emergency department after the assaultive behavior has occurred, and thus are automatically managed as violent patients.
2,10,12
Behavioral Clues The critical element in assessing 52/482
a patient's potential for violence is the behavioral clues. The best guide to behavioral clues has been formulated by Hackett 7 and includes the following: 1. P o s t u r e - - Observe how the patient is sitting during the interview. If the patient is sitting tensely on the edge of the chair or is gripping the arm rests, the interviewer should be cautious and alert to the fact that increased tension often precedes violent behavior. 2. S p e e c h - - The speech of the patient can be a clue to his degree of agitation. Is he talking in a calm voice, or is his voice loud and strident? Is the patient verbally threatening? The louder, more strident the patient's voice, the greater the potential for violence. 3. M o t o r a c t i v i t y - - Perhaps the most important and most ignored sign of impending violence is the patient's motor activity. The patient who is unable to sit still and who paces around the examining room or in the halls poses the most serious threat of violence. This behavior, in c o m b i n a t i o n with the abovementioned diagnostic categories, is a p s y c h i a t r i c e m e r g e n c y which demands immediate intervention.
Past History A past h i s t o r y of violent behavior is another important clue to predicting violence. If the patient states that he has attacked people before and he now feels like he wants to attack someone, the interviewer should assume the patient will act on his feelings, and psychiatric intervention should be initiated. At times there is a tendency to overlook verbal threats of violence, but in view of a history of violence, a verbal threat is a serious prognostic sign. MANAGEMENT OF THE VIOLENT PATIENT General Treatment When a violent or potentially violent patient is first interviewed, it is helpful to interview the patient alone because he m a y feel overwhelmed and threatened by staff; this sense of v u l n e r a b i l i t y m a y f u r t h e r a g i t a t e him. 14 However, when the interviewer feels uneasy and anxious or is unsure of how the patient is going to respond, the interviewer should ask police, security, or family to remain nearby in the hall so that if the patient becomes violent, the additional personnel will be close enough to help control him. All Ann Emerg Med
patients should be interviewed with the interviewer between the patient and the door. If the i n t e r v i e w e r thinks the patient poses an extremely high potential for violence, he should consider interviewing him with the door open or in the hall with security personnel present: 7 Treatment personnel should not approach patients suddenly or rapidly. 15 The interviewer should allow some physical distance to remain between himself and the patient. Especially with psychotic patients, the closer the interviewer moves to the patient, the more likely it is that he will increase the patient's anxiety level. 11 A useful guideline is to stay at least an arm's length away. s P l a c e m e n t of p a t i e n t s in the emergency department setting can also have an effect on their potential for violence. A patient should not be placed near other disturbed patients who are provocative. 11 Neither should he be left alone, 14'16 for this could be interpreted as rejection or could allow h i m to h u r t h i m s e l f while unobserved. If possible, he should be placed in a quiet area of the emergency d e p a r t m e n t where the e n v i r o n m e n t a l s t i m u l a t i o n is minimal, but where he can be readily observed and evaluated by the staff. Placing a patient in an area where there is frequent patient and staff traffic, or where he must contend with the constant noise of police sirens, may provoke a potentially violent patient who is feeling frightened and overwhelmed.
Specific Management The most effective t r e a t m e n t approach is to talk to the patient. A direct, calm inquiry as to what is going on or '~how can we help you?" will greatly alleviate anxiety. Most often the patient is relieved to have someone to talk with whom he feels is going to help him. s The interviewer should try to encourage the patient to express his feelings verbally. 14 Only after the patient shows some degree of relaxation and rapport with the examiner should the current illness be discussed. The interviewer should conduct himself in a manner that conveys to the patient an expectation of appropriate behavior. 17 It is important to convey to a patient t h a t violence is not acceptable, and that his lack of control will be dealt with by the staff's firm control. 9'1~ A helpful comment might be, "I'm going to stop you from losing control." The staff should also acknowledge that the patient can do 10:9 (September) 1981
harm, ie, "Look, you can really hurt someone with that chair. ''16 When a patient is loud and belligerent, the technique of talking softly will frequently result in him lowering his voice. Staff members, however, frequently let their fantasies about the threatening patient interfere in a way that further provokes anxiety and tension in the patient. A patient can detect a staff member's anxiety, and this often leads to an exacerbation of the patient's agitation and c u l m i n a t e s in v i o l e n t behavior) '16'1s'19 It is important not to force the issue of talking with a patient if a staff member feels particularly anxious or out of control. If talking does not defuse the situation, t h e n offer the p a t i e n t something to eat or drink. Frequently, offering food before the interview attenuates the patient's anxiety and serves to demonstrate the interviewer's genuine interest. Based on our experience, a combination of talk and food will generally defuse the vast majority of potentially violent situations. If talk and food do not attenuate the patient's tension, then medication is recommended. The interviewer should remark that he can see the patient is upset and nervous and that he would like to offer him some medication. Medication should be used to decrease a patient's tension and anxiety. The relief it brings is usually welcomed by the patient. 9'16 However, "Effective m a n a g e m e n t does not involve rendering the patient helpless and physically inert, but rather helps him to modulate his • ,,12 own aggressiveness. In the patient who is paranoid and reluctant to talk to the interviewer, the psychiatrist could comment that he knows the patient is having thoughts and feelings that are upsetting, and if he takes medication this will help him feel a little more relaxed. Although studies 2° indicate that rapid tranquilization can be achieved with intramuscular medication, we prefer instead to offer the patients a concentrate in orange juice. The patients are generally much more receptive to this and we have found tranquilization to be as rapid as with intramuscular injection• Generally tablets and capsules have too long an absorption time to exert an immediate effect. The literature 2°'23 on rapid tranquilization suggests a dosage range which is empirically determined by the size, age, and weight of the patient, eg, smaller, frailer, older patients would 10:9 (September) 1981
receive doses at the lower end of the dose range. Recommended doses include: Navane ~ 10-15 mg Stelazine ~ 10-15 mg Haldol ~ 5-10 mg Serentil v 25-50 m g sedating drug Thorazine ® 50-75 mg - sedating drug All drugs are given every 30 minutes in concentrate or i n t r a m u s c u l a r l y until tranquilization is achieved. The goal of rapid tranquilization is to reduce the tension, anxiety, and hyperactivity of the patient. Rapid tranquilization, however, will not diminish hallucinations and delusions, which require a longer period of appropriate neuroleptic treatment• Using the medication in the lower dosage range, we have found one to three doses is generally sufficient to induce tranquilization without sedation• We are aware that the recommended doses do not correlate well if compared in terms of relative potency• However, these doses have been found e m p i r i c a l l y the most effective when used in concentrate for rapid tranquilization, and the discrepency in potency is now under further study. Most patients seem to be concerned that they will become too sedated and should be reassured that all attempts will be made to avoid '~knocking them out." In the paranoid patient a larger initial dose (the equivalent of two doses) might be given if there is concern about future compliance during the interview. If the physician is having difficulty establishing rapport with the patient, it is often helpful to seek help from someone who seems to have had some positive interaction with the patient. This might be a security guard, a family member, or a secretary• This person should talk with the patient under the supervision of the physician, and once the patient is calm he should be encouraged to take medication. If this fails and the threat of violence still exists, the next strategy is to call in security guards. When calling the security guards, the interviewer should use a code name. If the patient hears one staff member telling another to call security or the police, this will often incite him to violence. We refer to security as "Dr. Armstrong" and this allows them to be called without agitating the patient• When security personnel arrive they should not immediately rush into the patient's Ann Emerg Med
room; instead, a staff member should meet the security guards and place them so they can be seen by the patient. Their presence will reassure the patient that if he gets out of control there are enough personnel to restrain him. It is crucial for the patient to feel there are enough staff to prevent him from losing control and harming himself o r o t h e r s . 9'14'17'24 The reassurance of seeing the security guards will frequently defuse the tension the patient is experiencing• The security guards are a critical part of the management team. In our experience, successful management of violent patients depends on the staffs confidence in the security personnel and, conversely, the security personnel's confidence in staff. When security guards are needed, the treating staff should spend a few minutes briefing the guards on the patient's problem and how they will be able to help in treatment. The physician should clearly spell out their role. Frequently security personnel are frightened and unsure of what they should do, and the comm u n i c a t i o n between the t r e a t i n g staff and security will not only serve an educational function, but will also serve to improve their cooperation. TM When possible it is beneficial to have permanent security guards in the emergency department because they will develop an expertise in managing patients that is difficult to develop on a part-time basis. It is also useful to have frequent in-service training for security personnel in which they are taught rudimentary patient management. If none of the above interventions is successful and the patient's agitation reaches a point at which restraints are necessary, security is asked to restrain the patient. Once the decision is made to restrain, it should be acted upon immediately without staff debate of the issue• Physical restraints can be humane and effective) 2 Negotiating with the p a t i e n t is g e n e r a l l y futile. Staff members should not interfere with the security force while they are restraining a patient. For maximum safety five people should be used when restraining a patient: one for each limb and one to help hold the p a t i e n t ' s head to keep him from biting. 7 If the patient is swinging a chair or some other weapon, distracting the patient by throwing a blanket over him or by approaching him with a light mattress will help protect the staff while subduing the patient) 7 The presence of one or two 483/53
n u r s e s t a l k i n g to the p a t i e n t while the security guards restrain him o f t e n c a l m s him and r e n d e r s h i m more compliant. Once the p a t i e n t is i n r e s t r a i n t s , h o w e v e r , t h i s is a psychiatric emergency, and all a t t e m p t s by the staff a r e a i m e d a t g e t t i n g the patient out of restraints. This usually involves rapid tranquilization and supportive therapy. Physical r e s t r a i n t s a r e u s u a l l y necessary when the p a t i e n t r e m a i n s a g i t a t e d and n o n - c o m p l i a n t , eg, when he will not t a k e medication, sit down, go into t h e i n t e r v i e w room, etc. The patient, "Cannot be t a l k e d to, reasoned w i t h , p e r s u a d e d , contained, delayed or denied ...,,12 Restraints may be needed to protect the patient and the staff. The l e g a l i t i e s i n v o l v e d in restraining p a t i e n t s a r e complex because each state h a s its own m e n t a l health laws which d e t e r m i n e u n d e r what conditions p a t i e n t s m a y be restrained a n d t r e a t e d a g a i n s t t h e i r will. F u r t h e r complicating the issue is the fact t h a t laws g o v e r n i n g restraints and t r e a t m e n t by psychiatric personnel differ from laws governing r e s t r a i n t s a n d t r e a t m e n t by non-psychiatric personnel. Each physician, however, is s t r o n g l y advised to become a w a r e of the s t a t e laws governing t h e r a p e u t i c r e s t r a i n t and t r e a t m e n t in p a t i e n t s who refuse it. F u r t h e r discussion of these legal i s s u e s is b e y o n d t h e scope of t h i s article. If a p a t i e n t has a weapon, the interviewer has the r i g h t to refuse to examine h i m until he e i t h e r surrenders t h e weapon or allows s e c u r i t y guards to search him and remove it. If the p a t i e n t surrenders the weapon, the i n t e r v i e w e r should have the pat i e n t place it on the table or floor. In normal circumstances, the interviewer should n e v e r t a k e a weapon directly from the patient, v The p a t i e n t m a y instinctively pull the t r i g g e r or lunge at the interviewer. A final problem which frequently occurs in the e m e r g e n c y d e p a r t m e n t is disruptive, violent behavior b y a n o n - p a t i e n t , eg, a f r i e n d or family m e m b e r who accompanies the p a t i e n t to t h e e m e r g e n c y d e p a r t ment. To our knowledge, t h e r e are no articles which address this problem.
54/484
Our policy is to have security personnel h a n d l e t h e d i s r u p t i v e , v i o l e n t non-patients. When this occurs, emergency department staff memb e r s v i e w t h e s i t u a t i o n as a civil r a t h e r t h a n a m e d i c a l problem. In som~ i n s t a n c e s , a f t e r c o n f r o n t i n g hospital security, the non-patient will request to see a p s y c h i a t r i s t or e m e r g e n c y p h y s i c i a n . I n t h i s case the n o n - p a t i e n t t h e n becomes a patient.
CONCLUSION A c a r e f u l a s s e s s m e n t of t h e patient's behavior, coupled w i t h app r o p r i a t e diagnostic clues, can give an i n t e r v i e w e r a r e l i a b l e m e a n s of predicting the i m m i n e n c e of violence in a given patient. The k e y e l e m e n t s in defusing a patient's potential for violence center on the willingness of the i n t e r v i e w e r to t a l k w i t h the patient in a firm, e m p a t h e t i c m a n n e r . W h e n used judiciously, m e d i c a t i o n a n d r e s t r a i n t s a r e i m p o r t a n t adjuncts in helping to control violent or potentially violent patients. The goal of the t r e a t m e n t should be to provide patients with a setting that will facilitate a release of tension while conveying to the p a t i e n t a sense of security and safety.
REFERENCES 1. Cohen S: Aggression: The role of drugs. Drug Abuse and Alcoholism Newsletter 8:1-4, 1979. 2. Tuason VB: The psychiatrist and the violent patient. Dis Nerv Syst 32:764-768, 1971. 3. Lion JR, Bach-y-Rita G, Ervin FR: Violent patients in the emergency room. Am J Psychiatry 125:1706-1711, 1969. 4. Eaton ME, Stetten IW, Kitchen AD, et ah The Missouri automated psychiatric history: Symptom frequencies, sex differences, use of weapons and other findings. Compr Psychiatry 12:264-276, 1971. 5. Bach-y-Rita G, Lion JR, Clement CE, et ah Episodic dyscontroh A study of 130 violent patients. A m J Psychiatry 127: 1473-1478, 1971. 6. Leroy P, Hartocollis P: Nursing aides and patient violence. A m J Psychiatry 133:429-431, 1976. 7. Hackett T: Management of the Violent Patient. Syllabus, Massachusetts General Hospital and Harvard Medical School, Department of Continuing Education,
Ann Emerg Med
course in Emergency Psychiatry and Crisis Intervention, July 1977. 8. Rockwell DA: Can you spot potential violence in a patient? Hospital Physician 8:52-56, 1972. 9. Lion JR, Bach-y-Rita G, Ervin FR: The self-referred violent patient. JAMA 205: 91, 1968. 10. MacDonald JM: The threat to kill. Am J Psychiatry 127:1473-1478, 1971. 11. K a l o g e r a k i s MG: The assaultive psychiatric patient. Psychiat Q 45:372381, 1971. 12. Lion JR: Conceptual issues in the use of drugs for the treatment of aggression in man. J Nerv Ment Dis 160:76-81, 1975. 13. Madden DJ, Lion JR, Penna MW: Assaults on psychiatrists by patients. Am J Psychiatry 133-422-425, 1976. 14. Lion JR: Evaluation and Management of the Violent Patient. Springfield, Illinois, Charles C. Thomas, 1972. 15. DiBella GA: Educating staff to manage threatening paranoid patients. Am J Psychiatry 136:333-335, 1979. 16. Lion JR, Levenberg LB, Strange RE: Restraining the violent patient. J Psychiatr Nurs Mental Health Services 10:911, 1972. 17. Stewart AT: Handling the aggressive patient. Perspectives in Psychiatric Care 16:228-232, 1978. 18. Adler G, Shapiro LN: Some difficulties in the treatment of the aggressive acting out patient. Am J Psychother 27: 548-556, 1973. 19. Whitman RM, Armao BB, Dent OB: Assault on the therapist. Am J Psychiatry 133:426-429, 1976. 20. Dolon PT, Hopkin J, Tupin JP: Overview: Efficacy and safety of the rapid neuroleptization method with injectable haldeperidol. Am J Psychiatry 136:273278, 1979. 21. Appleton WS, Daris JM: Practical Clinical Psychopharmacology, ed 2. Baltimore, Maryland, Williams and Wilkins, 1980, p 29. 22. Anderson WH, Kuehnle JC: Strategies for treatment of acute psychosis JAMA 229:1884-1889, 1974. 23. Mason AS, Granacher RP: Basic principles of rapid neuroleptization. Dis Nerv Sys 12:547-551, 1976. 24. Lion JR, Pasternak SA: Countertransference reactions to violent patients. Am J Psychiatry 130:207-210, 1971. 25. Lenefsky B, de Palma T, Lorirers D: Management of violent behaviors. Perspectives in Psychiatric Care 16:212-217, 1978.
10:9 (September) 1981
Evaluating and Managing the Violent Patient William R. Dubin, MD Philadelphia, Pennsylvania
Emergency department personnel frequently encounter violent patients. Effective management depends on early recognition of clues of potential violence and a response that will defuse the threat. The author presents an evaluation schema which emphasizes diagnostic categories and behavior as predictors of violence. A specific hierarchy of treatment intervention is proposed, with special emphasis on the interpersonal dynamics between staff and patient. The author also discusses general steps that can be taken to reduce the risk of violence in an emergency department setting. Dubin WR: Evaluation and management of the violent patient. Ann Emerg Med 10:481-484, September 1981.
emergency management, violent patient; psychiatric emergency, management; violence, emergency department management INTRODUCTION The violent patient poses one of the most difficult treatment problems in emergency medicine. Generally these patients are brought in by family or police for treatment against their will. They can be verbally abusive and physically threatening. Furthermore, mismanagement of the violent patient can result in physical harm to staff and destruction of property. Although it is difficult to predict an individual's long-range potential for violence, a proper initial assessment can lead to an accurate prediction of the patient's potential for violence over a brief time period (not longer than one hour). The most effective management of the violent patient is preventive management. The crux of successful prevention depends on recognizing early the clues which indicate a high probability of violence and responding in a manner that will defuse the potential violence. This article outlines the procedures followed in the Jefferson Crisis Service for evaluating and managing potentially violent patients. Violence is defined as verbally threatening and/or assaultive behavior.
PREDICTION OF VIOLENCE Diagnostic Clues Diagnosis can be a helpful clue in assessing a patient's potential for violence. Frequently the diagnosis is immediately self evident, such as in cases of delirium, psychosis, or alcohol/drug intoxications and withdrawals. Fortunately sudden, unexpected attacks are rare, and violence occurs only after a period of mounting frustration and tension in the patient. Thus the physician has time during the interview to make a tentative diagnosis which alerts him to a patient's potential for violence. In the absence of a firm diagnosis, other clues must be relied upon. The diagnostic groups of patients with a propensity for violence include the following: 1. Drug or alcohol intoxication-- i-7 Patients who are intoxicated from alco-
From the Department of Psychiatry, Thomas Jefferson Hospital, Philadelphia, Pennsylvania. Address for reprints: William R. Dubin, MD, Department of Psychiatry,Thomas Jefferson Hospital, 11th and Walnut Streets, 4 Main, Philadelphia, Pennsylvania 19107.
10:9 (September) 1981
Ann Emerg Med
481/51
hol or drugs, especially amphetamines, LSD or phencyclidine, have a much greater potential for violence than do ordinary patients. 2. D r u g or a l c o h o l w i t h d r a w a l
1,7,s Patients in withdrawal often attempt to manipulate staff to obtain drugs to alleviate their withdrawal symptoms. When they are refused drugs by medical personnel, they often become threatening and abusive. Patients experiencing delirium tremens can be the most assaultive patients seen in an emergency department. _
_
3. A c u t e o r g a n i c b r a i n s y n d r o m e (delirium)2,7-1o The potential for
violence in these patients may be overlooked by the medical staff, who often become preoccupied with the medical problem of the patient. 4. A c u t e p s y c h o s i s - - 2,7,1o,13This includes patients with acute schizophrenic episodes and patients who are acutely manic. It has been our experience that manic patients are more dangerous because staff members tend to gain a false sense of security from the manic's expansive mood and good humor. However, manics can become quite violent when demands are placed on them. 5. P a r a n o i d c h a r a c t e r -
2,7,S,ll
Paranoid characters pose a potential for violence, especially when the examiner begins to probe for dynamic information despite the patient's resistance and warning to leave him alone. After repeated questioning and a period of increasing tension and turmoil, the patient may explode and attack. 6. B o r d e r l i n e p e r s o n a l i t y
- - 3,13
Generally these patients can become violent when they perceive the staff is rejecting them after their demands have not been met, or if they are intoxicated with alcohol or drugs. 7. A n t i s o c i a l
personality
--
Violence in these patients is generally associated with drug intoxication or withdrawal. Other diagnostic categories are potentially violent, including temporal lobe epilepsy, 5's'9'14 passive aggressive personality, 1°'12 and pathological i n t o x i c a t i o n1.3' ' 14 We, however, have not found these diagnostic categories to be as much of a problem because patients with temporal lobe epilepsy or pathological intoxication are brought to the emergency department after the assaultive behavior has occurred, and thus are automatically managed as violent patients.
2,10,12
Behavioral Clues The critical element in assessing 52/482
a patient's potential for violence is the behavioral clues. The best guide to behavioral clues has been formulated by Hackett 7 and includes the following: 1. P o s t u r e - - Observe how the patient is sitting during the interview. If the patient is sitting tensely on the edge of the chair or is gripping the arm rests, the interviewer should be cautious and alert to the fact that increased tension often precedes violent behavior. 2. S p e e c h - - The speech of the patient can be a clue to his degree of agitation. Is he talking in a calm voice, or is his voice loud and strident? Is the patient verbally threatening? The louder, more strident the patient's voice, the greater the potential for violence. 3. M o t o r a c t i v i t y - - Perhaps the most important and most ignored sign of impending violence is the patient's motor activity. The patient who is unable to sit still and who paces around the examining room or in the halls poses the most serious threat of violence. This behavior, in c o m b i n a t i o n with the abovementioned diagnostic categories, is a p s y c h i a t r i c e m e r g e n c y which demands immediate intervention.
Past History A past h i s t o r y of violent behavior is another important clue to predicting violence. If the patient states that he has attacked people before and he now feels like he wants to attack someone, the interviewer should assume the patient will act on his feelings, and psychiatric intervention should be initiated. At times there is a tendency to overlook verbal threats of violence, but in view of a history of violence, a verbal threat is a serious prognostic sign. MANAGEMENT OF THE VIOLENT PATIENT General Treatment When a violent or potentially violent patient is first interviewed, it is helpful to interview the patient alone because he m a y feel overwhelmed and threatened by staff; this sense of v u l n e r a b i l i t y m a y f u r t h e r a g i t a t e him. 14 However, when the interviewer feels uneasy and anxious or is unsure of how the patient is going to respond, the interviewer should ask police, security, or family to remain nearby in the hall so that if the patient becomes violent, the additional personnel will be close enough to help control him. All Ann Emerg Med
patients should be interviewed with the interviewer between the patient and the door. If the i n t e r v i e w e r thinks the patient poses an extremely high potential for violence, he should consider interviewing him with the door open or in the hall with security personnel present: 7 Treatment personnel should not approach patients suddenly or rapidly. 15 The interviewer should allow some physical distance to remain between himself and the patient. Especially with psychotic patients, the closer the interviewer moves to the patient, the more likely it is that he will increase the patient's anxiety level. 11 A useful guideline is to stay at least an arm's length away. s P l a c e m e n t of p a t i e n t s in the emergency department setting can also have an effect on their potential for violence. A patient should not be placed near other disturbed patients who are provocative. 11 Neither should he be left alone, 14'16 for this could be interpreted as rejection or could allow h i m to h u r t h i m s e l f while unobserved. If possible, he should be placed in a quiet area of the emergency d e p a r t m e n t where the e n v i r o n m e n t a l s t i m u l a t i o n is minimal, but where he can be readily observed and evaluated by the staff. Placing a patient in an area where there is frequent patient and staff traffic, or where he must contend with the constant noise of police sirens, may provoke a potentially violent patient who is feeling frightened and overwhelmed.
Specific Management The most effective t r e a t m e n t approach is to talk to the patient. A direct, calm inquiry as to what is going on or '~how can we help you?" will greatly alleviate anxiety. Most often the patient is relieved to have someone to talk with whom he feels is going to help him. s The interviewer should try to encourage the patient to express his feelings verbally. 14 Only after the patient shows some degree of relaxation and rapport with the examiner should the current illness be discussed. The interviewer should conduct himself in a manner that conveys to the patient an expectation of appropriate behavior. 17 It is important to convey to a patient t h a t violence is not acceptable, and that his lack of control will be dealt with by the staff's firm control. 9'1~ A helpful comment might be, "I'm going to stop you from losing control." The staff should also acknowledge that the patient can do 10:9 (September) 1981
harm, ie, "Look, you can really hurt someone with that chair. ''16 When a patient is loud and belligerent, the technique of talking softly will frequently result in him lowering his voice. Staff members, however, frequently let their fantasies about the threatening patient interfere in a way that further provokes anxiety and tension in the patient. A patient can detect a staff member's anxiety, and this often leads to an exacerbation of the patient's agitation and c u l m i n a t e s in v i o l e n t behavior) '16'1s'19 It is important not to force the issue of talking with a patient if a staff member feels particularly anxious or out of control. If talking does not defuse the situation, t h e n offer the p a t i e n t something to eat or drink. Frequently, offering food before the interview attenuates the patient's anxiety and serves to demonstrate the interviewer's genuine interest. Based on our experience, a combination of talk and food will generally defuse the vast majority of potentially violent situations. If talk and food do not attenuate the patient's tension, then medication is recommended. The interviewer should remark that he can see the patient is upset and nervous and that he would like to offer him some medication. Medication should be used to decrease a patient's tension and anxiety. The relief it brings is usually welcomed by the patient. 9'16 However, "Effective m a n a g e m e n t does not involve rendering the patient helpless and physically inert, but rather helps him to modulate his • ,,12 own aggressiveness. In the patient who is paranoid and reluctant to talk to the interviewer, the psychiatrist could comment that he knows the patient is having thoughts and feelings that are upsetting, and if he takes medication this will help him feel a little more relaxed. Although studies 2° indicate that rapid tranquilization can be achieved with intramuscular medication, we prefer instead to offer the patients a concentrate in orange juice. The patients are generally much more receptive to this and we have found tranquilization to be as rapid as with intramuscular injection• Generally tablets and capsules have too long an absorption time to exert an immediate effect. The literature 2°'23 on rapid tranquilization suggests a dosage range which is empirically determined by the size, age, and weight of the patient, eg, smaller, frailer, older patients would 10:9 (September) 1981
receive doses at the lower end of the dose range. Recommended doses include: Navane ~ 10-15 mg Stelazine ~ 10-15 mg Haldol ~ 5-10 mg Serentil v 25-50 m g sedating drug Thorazine ® 50-75 mg - sedating drug All drugs are given every 30 minutes in concentrate or i n t r a m u s c u l a r l y until tranquilization is achieved. The goal of rapid tranquilization is to reduce the tension, anxiety, and hyperactivity of the patient. Rapid tranquilization, however, will not diminish hallucinations and delusions, which require a longer period of appropriate neuroleptic treatment• Using the medication in the lower dosage range, we have found one to three doses is generally sufficient to induce tranquilization without sedation• We are aware that the recommended doses do not correlate well if compared in terms of relative potency• However, these doses have been found e m p i r i c a l l y the most effective when used in concentrate for rapid tranquilization, and the discrepency in potency is now under further study. Most patients seem to be concerned that they will become too sedated and should be reassured that all attempts will be made to avoid '~knocking them out." In the paranoid patient a larger initial dose (the equivalent of two doses) might be given if there is concern about future compliance during the interview. If the physician is having difficulty establishing rapport with the patient, it is often helpful to seek help from someone who seems to have had some positive interaction with the patient. This might be a security guard, a family member, or a secretary• This person should talk with the patient under the supervision of the physician, and once the patient is calm he should be encouraged to take medication. If this fails and the threat of violence still exists, the next strategy is to call in security guards. When calling the security guards, the interviewer should use a code name. If the patient hears one staff member telling another to call security or the police, this will often incite him to violence. We refer to security as "Dr. Armstrong" and this allows them to be called without agitating the patient• When security personnel arrive they should not immediately rush into the patient's Ann Emerg Med
room; instead, a staff member should meet the security guards and place them so they can be seen by the patient. Their presence will reassure the patient that if he gets out of control there are enough personnel to restrain him. It is crucial for the patient to feel there are enough staff to prevent him from losing control and harming himself o r o t h e r s . 9'14'17'24 The reassurance of seeing the security guards will frequently defuse the tension the patient is experiencing• The security guards are a critical part of the management team. In our experience, successful management of violent patients depends on the staffs confidence in the security personnel and, conversely, the security personnel's confidence in staff. When security guards are needed, the treating staff should spend a few minutes briefing the guards on the patient's problem and how they will be able to help in treatment. The physician should clearly spell out their role. Frequently security personnel are frightened and unsure of what they should do, and the comm u n i c a t i o n between the t r e a t i n g staff and security will not only serve an educational function, but will also serve to improve their cooperation. TM When possible it is beneficial to have permanent security guards in the emergency department because they will develop an expertise in managing patients that is difficult to develop on a part-time basis. It is also useful to have frequent in-service training for security personnel in which they are taught rudimentary patient management. If none of the above interventions is successful and the patient's agitation reaches a point at which restraints are necessary, security is asked to restrain the patient. Once the decision is made to restrain, it should be acted upon immediately without staff debate of the issue• Physical restraints can be humane and effective) 2 Negotiating with the p a t i e n t is g e n e r a l l y futile. Staff members should not interfere with the security force while they are restraining a patient. For maximum safety five people should be used when restraining a patient: one for each limb and one to help hold the p a t i e n t ' s head to keep him from biting. 7 If the patient is swinging a chair or some other weapon, distracting the patient by throwing a blanket over him or by approaching him with a light mattress will help protect the staff while subduing the patient) 7 The presence of one or two 483/53
n u r s e s t a l k i n g to the p a t i e n t while the security guards restrain him o f t e n c a l m s him and r e n d e r s h i m more compliant. Once the p a t i e n t is i n r e s t r a i n t s , h o w e v e r , t h i s is a psychiatric emergency, and all a t t e m p t s by the staff a r e a i m e d a t g e t t i n g the patient out of restraints. This usually involves rapid tranquilization and supportive therapy. Physical r e s t r a i n t s a r e u s u a l l y necessary when the p a t i e n t r e m a i n s a g i t a t e d and n o n - c o m p l i a n t , eg, when he will not t a k e medication, sit down, go into t h e i n t e r v i e w room, etc. The patient, "Cannot be t a l k e d to, reasoned w i t h , p e r s u a d e d , contained, delayed or denied ...,,12 Restraints may be needed to protect the patient and the staff. The l e g a l i t i e s i n v o l v e d in restraining p a t i e n t s a r e complex because each state h a s its own m e n t a l health laws which d e t e r m i n e u n d e r what conditions p a t i e n t s m a y be restrained a n d t r e a t e d a g a i n s t t h e i r will. F u r t h e r complicating the issue is the fact t h a t laws g o v e r n i n g restraints and t r e a t m e n t by psychiatric personnel differ from laws governing r e s t r a i n t s a n d t r e a t m e n t by non-psychiatric personnel. Each physician, however, is s t r o n g l y advised to become a w a r e of the s t a t e laws governing t h e r a p e u t i c r e s t r a i n t and t r e a t m e n t in p a t i e n t s who refuse it. F u r t h e r discussion of these legal i s s u e s is b e y o n d t h e scope of t h i s article. If a p a t i e n t has a weapon, the interviewer has the r i g h t to refuse to examine h i m until he e i t h e r surrenders t h e weapon or allows s e c u r i t y guards to search him and remove it. If the p a t i e n t surrenders the weapon, the i n t e r v i e w e r should have the pat i e n t place it on the table or floor. In normal circumstances, the interviewer should n e v e r t a k e a weapon directly from the patient, v The p a t i e n t m a y instinctively pull the t r i g g e r or lunge at the interviewer. A final problem which frequently occurs in the e m e r g e n c y d e p a r t m e n t is disruptive, violent behavior b y a n o n - p a t i e n t , eg, a f r i e n d or family m e m b e r who accompanies the p a t i e n t to t h e e m e r g e n c y d e p a r t ment. To our knowledge, t h e r e are no articles which address this problem.
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Our policy is to have security personnel h a n d l e t h e d i s r u p t i v e , v i o l e n t non-patients. When this occurs, emergency department staff memb e r s v i e w t h e s i t u a t i o n as a civil r a t h e r t h a n a m e d i c a l problem. In som~ i n s t a n c e s , a f t e r c o n f r o n t i n g hospital security, the non-patient will request to see a p s y c h i a t r i s t or e m e r g e n c y p h y s i c i a n . I n t h i s case the n o n - p a t i e n t t h e n becomes a patient.
CONCLUSION A c a r e f u l a s s e s s m e n t of t h e patient's behavior, coupled w i t h app r o p r i a t e diagnostic clues, can give an i n t e r v i e w e r a r e l i a b l e m e a n s of predicting the i m m i n e n c e of violence in a given patient. The k e y e l e m e n t s in defusing a patient's potential for violence center on the willingness of the i n t e r v i e w e r to t a l k w i t h the patient in a firm, e m p a t h e t i c m a n n e r . W h e n used judiciously, m e d i c a t i o n a n d r e s t r a i n t s a r e i m p o r t a n t adjuncts in helping to control violent or potentially violent patients. The goal of the t r e a t m e n t should be to provide patients with a setting that will facilitate a release of tension while conveying to the p a t i e n t a sense of security and safety.
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course in Emergency Psychiatry and Crisis Intervention, July 1977. 8. Rockwell DA: Can you spot potential violence in a patient? Hospital Physician 8:52-56, 1972. 9. Lion JR, Bach-y-Rita G, Ervin FR: The self-referred violent patient. JAMA 205: 91, 1968. 10. MacDonald JM: The threat to kill. Am J Psychiatry 127:1473-1478, 1971. 11. K a l o g e r a k i s MG: The assaultive psychiatric patient. Psychiat Q 45:372381, 1971. 12. Lion JR: Conceptual issues in the use of drugs for the treatment of aggression in man. J Nerv Ment Dis 160:76-81, 1975. 13. Madden DJ, Lion JR, Penna MW: Assaults on psychiatrists by patients. Am J Psychiatry 133-422-425, 1976. 14. Lion JR: Evaluation and Management of the Violent Patient. Springfield, Illinois, Charles C. Thomas, 1972. 15. DiBella GA: Educating staff to manage threatening paranoid patients. Am J Psychiatry 136:333-335, 1979. 16. Lion JR, Levenberg LB, Strange RE: Restraining the violent patient. J Psychiatr Nurs Mental Health Services 10:911, 1972. 17. Stewart AT: Handling the aggressive patient. Perspectives in Psychiatric Care 16:228-232, 1978. 18. Adler G, Shapiro LN: Some difficulties in the treatment of the aggressive acting out patient. Am J Psychother 27: 548-556, 1973. 19. Whitman RM, Armao BB, Dent OB: Assault on the therapist. Am J Psychiatry 133:426-429, 1976. 20. Dolon PT, Hopkin J, Tupin JP: Overview: Efficacy and safety of the rapid neuroleptization method with injectable haldeperidol. Am J Psychiatry 136:273278, 1979. 21. Appleton WS, Daris JM: Practical Clinical Psychopharmacology, ed 2. Baltimore, Maryland, Williams and Wilkins, 1980, p 29. 22. Anderson WH, Kuehnle JC: Strategies for treatment of acute psychosis JAMA 229:1884-1889, 1974. 23. Mason AS, Granacher RP: Basic principles of rapid neuroleptization. Dis Nerv Sys 12:547-551, 1976. 24. Lion JR, Pasternak SA: Countertransference reactions to violent patients. Am J Psychiatry 130:207-210, 1971. 25. Lenefsky B, de Palma T, Lorirers D: Management of violent behaviors. Perspectives in Psychiatric Care 16:212-217, 1978.
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