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Managing violence without coercion
Managing Violence Without Coercion Dan Harris and Eileen F. Morrison
Managing violence has become a priority for nurses working in health care settings (bAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Although psychiatric nurses have a long history of dealing with and managing violent situations, very little attention has been given to a critical analysis of our traditional methods of managing violence. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional style in patients, as well as to critically examine interventions for managing violence. It is hoped that an honest examination will assist nurses to re-evaluate current practices for managing potentially difficult situations. Copyright © 1995 by W.B. Saunders Company
HERE IS NO doubt that the management of violence is becoming a priority for nurses working in health care settings (AAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Psychiatric nurses in particular have a long history of dealing with and managing violent situations. Although an accurate estimate is not available because of inaccuracies in reporting (Lion, Snyder, & Merrill, 1981), it seems that aggression and low level violence are relatively common occurrences in psychiatric hospital settings. Severe physical violence also occurs, but less frequently (Lewis-Lanza, 1992; Lion & Reid, 1983; Lipscomb & Love, 1992). As the amount of aggression and violence increases in health care settings, nurses must become more sophisticated in their assessment and management of potentially violent situations. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional
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style in patients, as well as to critically examine interventions for managing violence. LITERATURE REVIEW
The literature on violence focuses almost predominantly on individual factors related to violence, such as age, sex and psychiatric diagnosis (Brizer & Crowner, 1989; Lion & Reid, 1983; Monahan, 1981, 1984; Mulvey & Lidz, 1984). The violent patient has been described as a young male with a history of violence and criminal activities (Brizer & Crowner, 1989; Mulvey, 1993). Although the relationship of violence and diagnosis is controversial, substance abuse, seizure disorders, organic brain syndromes and schizophrenia have been associated with violence (Brizer & Crowner, 1989; Mulvey, 1993; Swanson, Holzer, Ganju, & Tsutumo, 1990). Because of considerable inconsistency of the research findings on individual patient factors, most scientists now argue
From the School of Nursing, The University of Alabama, Birmingham, AA, and the Medical College of Virginia Hospital & School of Nursing, Richmond, VA, Address reprint requests to Dan Harris RN, MSN, 876 Glenvalley Dr, Birmingham, AL 35206-3524. Copyright © 1995 by W.B. Saunders Company 0883-9417/95/0904-000653.00/0
Archives of Psychiatric Nursing, Vol. IX, No. 4 (August), 1995: pp. 203-210
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for an examination of the interaction of the person with his/her environment as an important area for future research (Brizer & Crowner, 1990; Monahan, 1984, 1992; Mulvey & Lidz, 1984). With a few exceptions, very little research has been conducted in psychiatry and/or nursing to provide a greater understanding of the interactional nature of violence. But many lessons can be learned from the research of other disciplines examining the interactional aspects of anger, aggression and violence (Newell & Dryden, 1991; Patterson, 1982; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991). The importance of reinforcement toward maintaining antisocial behavior in children has been studied by many, but most notably by Patterson (1982) looking at interaction patterns in families. Patterson carefully documented that children initially learn to be antisocial from parents who unknowingly reinforce such behavior. Nagging, scolding, or yelling are used in response to misbehavior. When the child continues to misbehave, the parents eventfully reach their boiling point and explode. Unfortunately, this acts as a reinforcer for the misbehavior because the parent still does not adequately discipline and/or expect compliance. In this way, the child readily learns the coercive effects of aggression and violence. Then the child uses coercion to shape the behaviors of those in his environment for his own benefit. Thus, social control is learned and becomes a primary way of relating with others. The most common finding related to the interactional nature of violence in the psychiatric literature is that violence is a common response to limit setting (Anderson & Roper, 1991; Brizer & Crowner, 1989; Davis & Booster, 1988; Depp, 1984; Morrison, 1990ab, 1992a, 1993ab; Roper & Anderson, 1991). In addition, some scientists have found a coercive, dominant, or manipulative nature in the persons with mental illness who are also violent (Anderson & Roper, 1991; Depp, 1984; Esser, 1979; Feltous, 1984; Geller, 1980; Davis & Boster, 1988; Feltous, 1984; Morrison, 1990b, 1992a, 1994; Paul & Lentz, 1977; Roper & Anderson, 1991). The literature suggests that persons use violence as a coercive or manipulative behavior to manage certain situations, especially limit setting situations. Building on Patterson's (1982) research, Morrison (1990b, 1992a) found that the psychiatrically
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ill do learn aggressive and violent behavior and use it to control those in their environment. Patterson's cycle of coercion (1982) and escalation was observed on a relatively routine basis in hospital settings, except that interactions occurred between nurses and patients, not families. As minor rules were ignored/broken, the staff ignored the patient or nagged, hoping for compliance. Despite these attempts, compliance did not occur. Eventually, the staff intervened. The situation escalated and a "take down" occurred. This scenario is very similar to what Patterson noted in the parent-child relationship when the child is noncompliant with a parent's corrections. Just as Patterson (1982) noted that children learn coercion in this way, so Morrison (1990b, 1992a) noted that a take down reinforced a patient's perception that violence was a valid method of gaining social control. The staff's physical response in the form of a take down reinforced the patient's image of himself as a tough guy and increased the likelihood of future violent confrontations. In fact, patients were more aggressive when nursing staff were in the dayroom than when they were not. Children have also been found to be more aggressive when supervised (Besevegis & Lore, 1983). To be consistent with Patterson (1982), Morrison labelled this interactive style coercive and identified it as a primary factor predictive of aggression and violence (1992a). Using a causal modeling design, this coercive style did indeed predict 35% of the aggression and violence in hospitalized psychiatric patients. When combined with a history of violence and length of hospitalization, 60% of the aggression and violence was predicted (Morrison, 1992a). These resuits strongly support the possibility of an interactional process tied to reinforcement patterns as an important cause of aggression and violence. Although findings are inconsistent, some environmental factors have been related to aggression and violence, including staffing ratios, space, and staff provocation. Of these, staff provocation is the most important issue. Although limit setting, detaining patients, and forcing medication are all cited as examples of staff provocation in the literature (Brizer & Crowner, 1989; Esser, 1970; Morrison, 1989), these can be understood within the context of a coercive interactional style (Morrison, 1992a). When patients who have made a practice of controlling their environment through aggression and violence are placed on a psychiatric unit
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where staff detain them involuntarily, force medication, and/or set limits, it is reasonable to assume that staff/patient conflicts resulting in violence will occur. These situations are highly coercive, since staff are trying to force something onto a patient who uses coercion and violence as a way to get control over others. Though not extensively documented, it has been shown that a generalized authoritarian or controlling attitude by staff increases violence (Morrison, 1992a, 1993b). Although recent interest in the effect of organizations on patient behavior has been minimal, with an increasing emphasis on quality of care and patient satisfaction, the effect of staff behaviors on patient outcomes is once again a priority (Fisher, 1993; Johnson & Morrison, 1993; Morrison, 1993b). The authoritarian aspects of institutions have been documented, but what is unclear is how much aggression and violence is caused by the controlling atmosphere. Medication, seclusion, and restraints are advocated as interventions for violence (Brown & Tooke, 1992; Corrigan, Yudofsky, & Silver, 1993; Eichelman, 1988; Tardiff, 1992; Tupin, 1983). Despite the attention given to these interventions, most clinicians would argue that these interventions are inadequate in decreasing the tide of violence on psychiatric units and we must explore other options for managing violence (Brown & Tooke, 1992; Soloff, Gutheil & Wexler, 1985). A fair amount of literature exists documenting the techniques for managing violent situations. In addition to the previously mentioned medications, restraints and seclusion, the following interventions are all emphasized: (a) being aware of own feelings; (b) allowing personal space; (c) using reflective statements; and (d) using nonthreatening body language (Felthous, 1984; Lion, 1987; Tardiff, 1992; Tupin, 1983). This literature base is fairly traditional and is loosely based on a variation of Freudian theory, which suggests that catharsis is therapeutic and that internal staff feelings will adversely influence patient behavior. However, very little empirical evidence exists to support these findings. In fact, research suggests that "venting" leads to increased anger (Tavris, 1989). Other options for managing violent situations are available. One such option is behavioral approaches, which have been used successfully with managing anger and violence in the mentally ill and with others (Corrigan, Yudofsky, & Silver,
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1993; Davis & Booster, 1988; Goren, 1991; Newell & Dryden, 1991; Patterson, 1982; Paul & Lentz, 1977; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991; Wong, Woolsey, Innocent, & Liberman, 1988; Wong, Slama & Liberman, 1987). Since this coercive style is learned through reinforcements, behavioral techniques are consistent with the understanding of violence posed here. For readers interested in behavioral techniques, the thoughtful review of behavioral techniques for managing violent psychiatric patients by Wong et al. (1988) or Tavris's (1989) book on managing anger are both recommended. CASE STUDY
Clinical vignettes are used to examine both the nature of violence currently occurring in psychiatric hospitals and practices for managing violent situations. Some of the interventions used in the vignettes were effective, whereas others were not. It is hoped that an honest examination will encourage other nurses to re-evaluate their current practices for managing potentially difficult situations. Mr. M is a clinical nurse specialist, with a total of 9 years of clinical experience in psychiatry including 3 years as a nurse manager. He has a masters degree in psychiatric nursing and he started his nursing career in intensive care, where he worked for 1 year. The first vignette will clearly document the nature of violence in psychiatric settings, where violence is a learned response and used in a coercive way.
lnteractional Style A male patient (Mr. S), in his early 30s, was transferred from the jail when his head banging couldn't be controlled. Criminal charges were pending for firing a shotgun into his girlfriend's house. He was frighteningly large and had a United States Marine Corps tatoo on his left foreann. He was not psychotic and had no previous psychiatric history, but he did have a history of abuse towards his girlfriend. A femaleRN had been assigned to do his (Mr. S) admission interview. He was very angry. When he became loud and verballyabusivetoward her, she left his room, but he continued to followher down the hall, threateningto throw her againstthe wall if she didn't let him out. My coworker continued to walk calmly away. As I approached, he began to be distracted from her and focus more on me. He began by telling me to back off, let him out. mind my own
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business; all interlaced with profanity, sexually based curses, and threats of bodily harm. I stopped.., waited a moment for him to quit cursing me, and said, "My name is Mike. I'm a nurse here. What can I do to help things?" "Just open the door and get out of the fucking way." He said this angrily and was taking a step back. That worried me. I took a step backward, too. "I'm sorry Mr. S, I can't open the door. I could lose my job." "Just open the fucking door. You think you can keep me here, big man? You think you're tough? You better get some help. I'll kill you." Now he was approaching me with fists raised. I was backing away but running out of room. "Come on, chicken shit, tough guy," he s a i d . . . By this time he was little more than an ann's length away and I was backed up to a locked door. This incident is very typical of violent incidents in psychiatric settings. A patient profile of history o f violence and no psychotic behavior is quite common, as is experience with the criminal justice system. At a superficial level, the patient wanted to get out o f the hospital and was ready to fight with anyone who got in the way. One interpretation is that the violence was a response to limit setting. However, if you examine the underlying dynamics o f the interactional processes, something else is also apparent, a coercive interactional style. When someone has a coercive interactional style, others are bullied and intimidated into giving up and giving in. The patient wants something and the situation escalates until he gets it. He repeatedly accused the nurse of being a " t o u g h g u y " , but the tough guy image was his and is a common mechanism that aids in bullying others. Aggressive and violent behavior escalates until the goat is achieved (Morrison, 1992b). In this case, anger gave way to yelling, raised fists, a threat to kill the nurse, and finally movement towards the nurse. The movement was another intimidating behavior designed to suggest that Mr. S would take action on his threat and try to kill the nurse if he d i d n ' t open the door. Although Mr. S's stated goal was to get out of the hospital, it is also very possible that he was using his hospitalization to serve some goal related to his legal problems. It is not uncommon for patients to manipulate the system so that a jail sentence could be served in the hospital or to build a case for being psychotic to minimize a jail sentence. However, we do not know enough about this situation to answer this question. The patient did return to the criminal justice system and about 1 month later successfully committed suicide outside of the system.
One more point needs to be emphasized before discussing how this situation resolved. Considering Mr. S ' s violent history towards his girlfriend, Mr. S should never have been assigned to a female nurse. The choice of victim is usually very stable; either vulnerable others (women/or children) or men (Morrison, 1990b). In this case, Mr. S had a much greater likelihood of assaulting the female nurse, than he did of assaulting a male nurse. The story continues as Mr. M discusses how this situation resolved. By this time he was little more than an arm's length away and I was backed up to a locked door. Stop! I didn't shout, but I did speak loudly and firmly. "I don't work here to fight people. I'm a nurse. I take care of sick people. That's why I'm here. You want to win a fight? O.K.-You've won. I give up. Now what happens? . . . . "I just want out. I'm not crazy!" The situation deescalated. This situation resolved after this exchange since Mr. M did not buy into the fight for control. He gave up control when he said " y o u want to win a fight . . . OK . . . y o u ' v e w o n " . This is a very creative solution to the problem, since he gave up control without giving in, that is, without opening the door. Once the patient rea.lized that Mr. M would not let him out, there was no reason to continue the violence. Another way of looking at the situation is to say that the violence did not work, that is, violence was not rewarded. A second issue is that early on, Mr. M successfully removed the intended victim (female) from the situation. A third possible factor might have influenced the resuit. Mr. M also told the patient that he was frightening staff and patients. Although Mr. M does not usually intervene in this manner, he thought it was helpful in this case. In general, this intervention is risky because some patients want staff to be frightened and intimidated and if so, would increase their violence when given this information. To the author's knowledge there is no research that documents the effectiveness of this intervention. In this next scenario, Mr. M provides us with another creative solution to a violent situation. A 20-year-old young man, an offensive lineman of a major university football team, who was admitted for an acute schizophrenic break, was shouting at the top of his lungs. He had turned over one chair. He held another chair in his hands at chest height. As he paused for a moment, I asked "Jim, what's happening?" I was standing several feet
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away. "Jim, what's going on here?" My voice was somewhat softer this time. Jim lowered the chair a bit, half crying and half shouting, he continued to talk about people pushing him around. "Jim, let's talk in your room," I said quietly. "What?" he said. I repeated myself and he began to look around as if he didn't know what to do next. "It's O.K. to put the chair down now," I said quietly. "Let's talk in your room." He put the chair down and we started toward his room. In this case, Mr. M deliberately softened his voice, almost to a whisper. The patient had to interrupt his outburst to hear what the staff was saying. Speaking in a quiet, soft tone seems to end verbal confrontations because the patient has to attend and listen carefully to what is being said. This intervention had a calming effect and fostered de-escalation. In addition, Mr. M ' s invitation to talk and permission to put the chair down contributed to a quick resolution. Although filing charges against psychiatric patients continues to be controversial, the following vignette provides an example in which a threat of taking legal action had a positive effect on the patient. Ms. P, a 25-year-old, attractive, electrical engineer, with a good job, was admitted to the unit on an involuntary basis. Within 10 minutes she attacked staff. I and several other staff members responded to the scene to help subdue her. As we held her, she relaxed. She spoke more calmly. She agreed to rest on her bed for a while. As staff began to turn loose of her, she remained calm. Then, when she was no longer being held, she kicked a staff person in the face and laughed. She was again subdued, this time with leather restraints. Clearly, this patient was aware of and delighted in her fight with the staff. The injured nurse and the hospital decided to pursue criminal assault charges against the patient. On hearing this, Ms. P calmed considerably. She apologized and asked the nurse not to press charges. The nurse agreed. In this case, the threat of assault charges accomplished three goals. First, the message was communicated that violence would not be tolerated and that consequences existed for breaking this rule. Although this expectation is stated in most psychiatric units, it is rarely enforced. Second, a threat of legal action clearly communicated that she was responsible for her behavior. When this message was given, she responded by acting in a more responsible manner. Third, a threat o f legal action changes the reward system for the violence and effectively acts as a negative consequence. How-
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ever, improvement in her behavior was only temporary. Shortly after discharge, she was fired from her job as an electrical engineer after more disruptive behavior at work. It is possible, that the temporary improvement in her behavior was manipulative, so that the hospital would drop the assault charges. Perhaps it would have been more effective if the hospital had successfully filed charges. The following situation describes how behavioral techniques can be used to change socially inappropriate behavior. A young woman (Ms. M), in her early 30s, in the manic phase o f a bipolar illness, was admitted to the hospital. She exhibited considerable hypersexual behavior, cozying up to male patients and staff, grabbing crotch's and rubbing their chests. Ms. M approached me while I was seated on the couch. She stopped a couple of feet directly in front of me. I said hello. She raised her dress above her head. She wore no underclothes. When she lowered her dress there was a defiant look on her face. Instead of commenting on her behavior, I introduced myself and asked if she would like to join a card game we were forming. She declined the game. Later that evening I asked her to help as I walked an elderly woman in the hall. She helped and I thanked her. Before she was discharged she sought me out and said thank you so much. "You've helped me a lot" She seemed sincere. This intervention was effective since Ms. M never again approached the CNS in a sexual manner, although she continued this behavior with many others. Ignoring the behavior accomplished two things with respect to reinforcement principles (Morrison, 1990b). First, in cases such as these, patients use inappropriate social behavior to gain attention. Staff comply by giving negative attention; telling her that her behavior is inappropriate or telling her to put her dress down. Both of these responses reinforce the inappropriate behavior by providing attention, albeit negative. The second accomplished goal was that Mr. M did not allow the patient to control the interaction and create distance through intimidation. While ignoring the behavior, he asked her to join in a card game. This intervention implicitly communicated a set o f appropriate expectations; not the response she hoped for, but an appropriate intervention that worked at eliminating the behavior while she interacted with Mr. M. However, if others in the environment continue to reinforce the inappropriate behavior it will continue. In addition, without the support of those outside the hospital who will be in the im-
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portant role o f caretaking, the b e h a v i o r will continue.
Staff Provocation A second contributor to violence in institutional settings that must be addressed is the effect of staff provocation through excess control and authority. Several investigators (Depp, 1984; Fisher, 1993; Morrison, 1990a, 1993b) described a process in psychiatric settings where administration and staff defined psychiatric nursing in terms of managing patients and their psychotic behavior. When a unit's philosophy is based on control or the management of patients, then physical techniques take on a predominant role (Lion, 1987), especially with respect to managing violent situations. Mr. M has a unique perspective since he is 6 ft. and 6 in. and weighs in the 300-1b range. In the following two scenarios, he describes how he was received on two different psychiatric units. Unit 1: My HN let me know that I may have a built-in disadvantage in working with seriously mentally ill clients. My new supervisors were concerned that my size would be frightening to some clients or simply offsetting to others. I became very self-conscious about being as respectful and nonthreatening to clients as I could. O n this unit, Mr. M was a v e r y successful nurse because he focused on learning h o w to relate with patients, h o w to c o m m u n i c a t e a caring attitude, and h o w to s h o w respect for patients. In contrast, Mr. M w o r k e d on a second unit, which has a philosophy e m p h a s i z i n g control. O n this unit, he was valued because o f his p e r c e i v e d ability to physically m a n a g e patients. Unit 2: A few nurses made the comment to me that they were glad to see a large male RN working on the unit. I often heard remarks like "It's about time," or "We're glad to see you," or "This is more like it." All such remarks were made in reference to my size. On my first day at my new job a loud banging and commotion was heard down the hall. I rushed to the scene with the rest of the staff. As the newest team member I waited to be given directions on what to do. I looked at the rest of the team to see who was going to be talking to the disturbed client who was in the process of trashing his room. No team member made a move. Finally I said, "Who's going to talk to him?" They all looked at me and one said, "You are. You're the biggest." W h e n the tradition o f toughness exists, staff are e m p l o y e d s i m p l y for their ability to physically m a n a g e patients (Morrison, 1990b). Those with an additional advantage such as size or k n o w l e d g e o f martial arts are particularly w e l c o m e d . These emp l o y m e n t strategies do not necessarily i m p r o v e the therapeutic e n v i r o n m e n t ( J o h n s o n & M o r r i s o n , 1993). Mr. M tells a story about a particularly bad
day w h e n unstable elderly patients w e r e walking around, patients were arguing, and staffing was short. His interactions were particularly directive. A 30-year-old woman, working as a paralegal, with a diagnosis of bipolar, approached me from behind and struck me in the head very harshly with her shoe. I was so startled, I whirled around drawing back my fist. When I saw her standing there, she made no attempt to duck or withdraw. Stunned, "I s a i d . . , what on earth are you doing?" She said "you can't treat us like this! We're not your slaves!" Later, Mr. M c a m e to realize that the patient was responding to his directive interactions with the other patients which she p e r c e i v e d as " b o s s y . " As Mr. M reflected on his e x p e r i e n c e , he told o f another incident that he d i d n ' t handle v e r y well. H o w e v e r , other staff intervened and m a n a g e d the situation in a thoughtful and caring manner. Several years ago at mealtime on a locked unit, I noticed that a male schizophrenic patient had removed the stainless steel dinner knife off his tray and placed it in his back pocket. I attempted to sneak up on him and grab it from his pocket. He saw me, quickly jumped up and brandished the knife pushing me into a comer. A psychiatric technician, spoke in a calm voice to the patient saying, "It's O.K. to put the knife down. You've proved yourself. There's no need to carry this any further." The C N S acted inappropriately, but the situation resolved w h e n the psychiatric technician told the patient what he needed to hear, that is, " y o u ' v e proved y o u r s e l f " eliminating the need to continue the fight. Mr. M learned f r o m this e x p e r i e n c e to give up w h e n possible. He was fortunate to h a v e such g o o d role models w h o interacted with patients in a thoughtful and caring m a n n e r and e l i m i n a t e d the need for a p o w e r struggle. T h e s e situations are not u n c o m m o n and most nurses w o r k i n g on psychiatric units can d e s c r i b e similar incidents in which staff acted in controlling w a y s in response to patients w h o were challenging. DISCUSSION
Several e x a m p l e s of clinically violent situations have been r e v i e w e d and analyzed. S o m e o f the interventions were effective, while a f e w w e r e not. T h r o u g h o u t the analysis, an interactional theory o f aggression and v i o l e n c e was p r o p o s e d that argues for the c o e r c i v e nature o f v i o l e n c e in persons with a mental illness (Morrison, 1990b, 1992b, 1993b). Clearly, prevention o f escalating events is the key to the m a n a g e m e n t o f v i o l e n c e in psychiatric settings. Seclusion is used far too often and tech-
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niques that have insufficient empirical support should be re-examined (Morrison, 1993a). Literature does exist to provide direction for understanding the interactional nature of violence and we must begin the process of examining our own behaviors and responses to patient behaviors and changing those responses when necessary. It is hoped that an honest examination of these vignettes will encourage nurses to re-evaluate their practice. Many hospital nurses are concerned about violence and are demanding that administration institute additional controls regarding safety. The underlying problem with this approach, however, is that as hospitals become more controlling, violence will increase. This is not an effective solution for the problem! The health care system must become less controlling and more responsive and user-friendly for both nurses and patients (Johnson & Morrison, 1993). Nurses are encouraged to focus on the prevention of violence before it starts and to manage potentially violent situations using some of the principles outlined earlier in this article. Avoid power struggles; allow patients to win struggles for control without giving in to unrealistic demands. Ask patients what is important while they are in the hospital and give it to them if possible. Make them true partners in their care. Teach them verbal skills of negotiation and collaboration. Encourage involvement in decision-making and show respect when they are able to act independently. Institute consequences for violent or threatening behavior. Lore and Schultz (1993) argued that Americans believe that aggression either cannot or should not be controlled. It is true that those of us in psychiatry are a good example of this since we want to believe that violence is an impulsive behavior. This interpretation comes from our adherence to outdated theories that have limited explanatory power, A norm against violence must be established in every aspect of society, including psychiatric units and enforced when necessary (Feltous, 1984; Johnson & Morrison, 1993; Lore & Schultz, 1993). If violence occurs, clinical staff must take action; consequences must occur!
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Anderson, N.L.R., & Roper, J.M. (1991). The interactional dynamics of violence, Part II: Juvenile detention. Archives of Psychiatric Nursing, 5, 216-222. Besevegis, E., & Lore, R. (1983). Effects of an adult's presence on the social behavior of preschool children. Aggressive Behavior, 9, 243-252. Brizer, D.A., & Crowner, M. (1989). Current approaches to the prediction of violence. Washington: American Psychiatric Press. Brown, J., & Tooke, S. (1992). On the seclusion of psychiatric patients. Social Science in Medicine, 35, 711-721. Corrigan, P.W., Yudofsky, S.C., & Silver, J.M. (1993). Pharmacological and behavioral treatments for aggressive psychiatric inpatients. Hospital & Community Psychiatry, 44(2), 125-133. Davis, D.L., & Boster, L. (1988). Multifaceted therapeutic interventions with the violent psychiatric inpatient. Hospital and Community Psychiatry, 39, 867-869. Depp, F.C. (1984). Assaults in a public hospital. In J.R. Lion & W.H. Reid (Eds.). Assaults in psychiatric facilities (pp. 21-45), New York: Grune & Stratton. Editorial (1992). Violence in the workplace. Journal of the
American Association of Occupational Health Nursing, 40(5), 212-213. Eichelman, B. (1988). Toward a rational pharmacotherapy for aggressive and violent behavior. Hospital & Community Psychiatry, 39, 31-39. Esser, A.H. (1970). Interactional hierarchy and power structure on a psychiatric ward. In S.J. Hutt & C. Hutt (Eds.). Behavioral Studies in Psychiatry. Oxford: Pergamon Press. Feltous, A.R. (1984). Preventing assaults on a psychiatric inpatient ward. Hospital & Community Psychiatry, 35, 1223-1226. Fisher, A.A. (1993, November). Ethical considerations in the care of the dangerous mentally ill. Presented as part of a symposium titled Caregiving and Violence in Psychiatric Settings. ANA Council of Nurse Researchers Scientific Session, Washington DC. Geller, M.P. (1980). Sociopathic adaptations in psychotic patients. Hospital & Community Psychiatry, 31(2), 108112. Goren, S. (1991). Answers Professionally Speaking: What are the considerations of the use of seclusion and restraint with children and adolescents. Journal of Psychosocial Nursing and Mental Health Services, 29(3), 32-36. Johnson, K., & Morrison, E.F. (1993). Control or negotiation: A health care challenge. Nursing Administration Quarterly, 17(3), 27-33. Lewis-Lanza, M. (1992). Nurses as patient assault victims: An update, synthesis, and recommendations. Archives of Psychiatric Nursing, 6, 163-171. Lion, J.R. (1987). Training for battle: Thoughts on managing aggressive patients. Hospital & Community Psychiatry, 38(8), 882-884. Lion, J.R., & Reid, W.H. (1983). Assaults within psychiatric facilities. Orlando: Grune & Stratton. Lion, J.R., Snyder, W., & Merrill, G.L. (1981). Underreporting of assaults on staff in a state hospital. Hospital & Community Psychiatry, 32, 497-498.
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Lipscomb, J., & Love, C.C. (1992). Violence towards health care workers: An emerging occupational hazard. Journal of the American Association of Occupational Health Nursing, 40(5), 219-228. Lore, R.K., & Schultz, L.A. (1993). Control of human aggression: A comparative perspective. American Psychologist, 48(1), 16-25. Monahan, J. (1981). Predicting violent behavior: An assessment of clinical techniques. Beverly Hills: Sage. Monahan, J. (1984). The prediction of violent behavior: Toward a second generation of theory and policy. American Journal of Psychiatry, 141(1), 10-15. Monahan, J. (1992). Mental disorder and violent behavior: Perceptions and evidence. American Psychologist, 47, 511521. Momson, E.F. (1990a). The tradition of toughness: Psychiatric nursing care by nonprofessional in institutional settings. Image, 20(4), 222-234. Morrison, E.F. (1990b). Violent psychiatric patients in a public hospital. Scholarly Inquiry for Nursing Practice: An International Journal, 4(1), 65-82. Morrison, E.F. (1992a). A coercive interactive style as an antecedent to aggression and violence in psychiatric inpatients. Research in Nursing and Health, 15, 421-431. Morrison, E.F. (1992b). A hierarchy of aggressive and violent behavior in psychiatric inpatients. Hospital & Community Psychiatry, 43, 505-506. Morrison, E.F. (1993a). Toward a better understanding of violence in psychiatric settings: Debunking the myths. Archives of Psychiatric Nursing, 7, 328-335. Morrison, E.F. (1993b, November). The culture of caregiving and aggression in psychiatric settings. Presented as part of a symposium titled Caregiving and Violence in Psychiatric Settings. ANA Council of Nurse Researchers Scientific Session, Washington DC. Morrison, E.F. (1994). The evolution of a concept: Aggression and violence in psychiatric settings. Archives of Psychiatric Nursing, 8, 245-253. Mulvey, E.P. (1993, January). Theoretical link: Violence and mental disorder. Paper presented at the Workshop on Treatment of Violent Mentally I11 Persons in the Community: Issues of Research, Policy and Services. Sponsored by Violence and Traumatic Stress Research Branch, National Institute of Mental Health, Washington DC. Mulvey, E.P., & Lidz, C.W. (1984). Clinical considerations in
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the prediction of dangerousness in mental patients. Clinical Psychology Review, 4, 379-401. Newell, R., & Dryden, W. (1991). Clinical problems: An introduction to the cognitive-behavioral approach. In W. Dryden & R. Rentoul (Eds.). Adult clinicalproblems: A cognitive-behavioral approach, (p. 1-26). New York: Routledge. Patterson, G.R. (1982). A social learning approach: Coercive family processes. Eugene: Castalia Press. Paul, G.L., & Lentz, R.J. (1977). Psychosocial treatment of the chronic mental patient. Cambridge, Mass: Harvard University Press. Reiss, A.J., & Roth, A. (1993). Understanding and preventing violence. Washington D.C.: National Academy Press. Roper, J.M., & Anderson, N.L.R. (1991). The international dynamics of violence, Part I: An acute psychiatric ward. Archives of Psychiatric Nursing, 5, 209-215. Soloff, P.H., Gutheil, T.G., & Wexler, D.B. (1985). Seclusion and restraint. Hospital & Community Psychiatry, 36, 652-657. Swanson, J.W., Holzer, C.E., Ganju, V.K., & Tsutomu, R. (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiologic catchment area surveys. Hospital & Community Psychiatry, 41, 761-770. Tardiff, K. (1992). The current state of psychiatry in the treatment of violent patients. Archives of Psychiatry, 49, 493-499. Tavris, C. (1989). Anger, the misunderstood emotion. New York: A Touchstone Book. Tulloch, R. (1991). Anger and violence. In W. Dryden & R. Rentoul (Eds.). Adult clinical problems: A cognitivebehavioral approach, (p. 88-113). New York: Routledge. Tupin, J. (1983). The violent patient: A strategy for management and diagnosis. Hospital & Community Psychiatry, 34, 37-43. Wong, S.E., Woolsey, J.E., Innocent, A.J., & Liberman, R.P. (1988). Behavior treatment of violent psychiatric patients. Psychiatric Clinics of North America, 11, 569580. Wong, S.E., Slama, K.M., & Liberman, R.P. (1987). Behavioral analysis and therapy for aggression psychiatric and developmentally disabled patients. In L.H. Roth (Ed). Clinical treatment of the violent person (pp. 20-53). New York: Guilford Press.
Managing violence has become a priority for nurses working in health care settings (bAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Although psychiatric nurses have a long history of dealing with and managing violent situations, very little attention has been given to a critical analysis of our traditional methods of managing violence. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional style in patients, as well as to critically examine interventions for managing violence. It is hoped that an honest examination will assist nurses to re-evaluate current practices for managing potentially difficult situations. Copyright © 1995 by W.B. Saunders Company
HERE IS NO doubt that the management of violence is becoming a priority for nurses working in health care settings (AAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Psychiatric nurses in particular have a long history of dealing with and managing violent situations. Although an accurate estimate is not available because of inaccuracies in reporting (Lion, Snyder, & Merrill, 1981), it seems that aggression and low level violence are relatively common occurrences in psychiatric hospital settings. Severe physical violence also occurs, but less frequently (Lewis-Lanza, 1992; Lion & Reid, 1983; Lipscomb & Love, 1992). As the amount of aggression and violence increases in health care settings, nurses must become more sophisticated in their assessment and management of potentially violent situations. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional
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style in patients, as well as to critically examine interventions for managing violence. LITERATURE REVIEW
The literature on violence focuses almost predominantly on individual factors related to violence, such as age, sex and psychiatric diagnosis (Brizer & Crowner, 1989; Lion & Reid, 1983; Monahan, 1981, 1984; Mulvey & Lidz, 1984). The violent patient has been described as a young male with a history of violence and criminal activities (Brizer & Crowner, 1989; Mulvey, 1993). Although the relationship of violence and diagnosis is controversial, substance abuse, seizure disorders, organic brain syndromes and schizophrenia have been associated with violence (Brizer & Crowner, 1989; Mulvey, 1993; Swanson, Holzer, Ganju, & Tsutumo, 1990). Because of considerable inconsistency of the research findings on individual patient factors, most scientists now argue
From the School of Nursing, The University of Alabama, Birmingham, AA, and the Medical College of Virginia Hospital & School of Nursing, Richmond, VA, Address reprint requests to Dan Harris RN, MSN, 876 Glenvalley Dr, Birmingham, AL 35206-3524. Copyright © 1995 by W.B. Saunders Company 0883-9417/95/0904-000653.00/0
Archives of Psychiatric Nursing, Vol. IX, No. 4 (August), 1995: pp. 203-210
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for an examination of the interaction of the person with his/her environment as an important area for future research (Brizer & Crowner, 1990; Monahan, 1984, 1992; Mulvey & Lidz, 1984). With a few exceptions, very little research has been conducted in psychiatry and/or nursing to provide a greater understanding of the interactional nature of violence. But many lessons can be learned from the research of other disciplines examining the interactional aspects of anger, aggression and violence (Newell & Dryden, 1991; Patterson, 1982; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991). The importance of reinforcement toward maintaining antisocial behavior in children has been studied by many, but most notably by Patterson (1982) looking at interaction patterns in families. Patterson carefully documented that children initially learn to be antisocial from parents who unknowingly reinforce such behavior. Nagging, scolding, or yelling are used in response to misbehavior. When the child continues to misbehave, the parents eventfully reach their boiling point and explode. Unfortunately, this acts as a reinforcer for the misbehavior because the parent still does not adequately discipline and/or expect compliance. In this way, the child readily learns the coercive effects of aggression and violence. Then the child uses coercion to shape the behaviors of those in his environment for his own benefit. Thus, social control is learned and becomes a primary way of relating with others. The most common finding related to the interactional nature of violence in the psychiatric literature is that violence is a common response to limit setting (Anderson & Roper, 1991; Brizer & Crowner, 1989; Davis & Booster, 1988; Depp, 1984; Morrison, 1990ab, 1992a, 1993ab; Roper & Anderson, 1991). In addition, some scientists have found a coercive, dominant, or manipulative nature in the persons with mental illness who are also violent (Anderson & Roper, 1991; Depp, 1984; Esser, 1979; Feltous, 1984; Geller, 1980; Davis & Boster, 1988; Feltous, 1984; Morrison, 1990b, 1992a, 1994; Paul & Lentz, 1977; Roper & Anderson, 1991). The literature suggests that persons use violence as a coercive or manipulative behavior to manage certain situations, especially limit setting situations. Building on Patterson's (1982) research, Morrison (1990b, 1992a) found that the psychiatrically
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ill do learn aggressive and violent behavior and use it to control those in their environment. Patterson's cycle of coercion (1982) and escalation was observed on a relatively routine basis in hospital settings, except that interactions occurred between nurses and patients, not families. As minor rules were ignored/broken, the staff ignored the patient or nagged, hoping for compliance. Despite these attempts, compliance did not occur. Eventually, the staff intervened. The situation escalated and a "take down" occurred. This scenario is very similar to what Patterson noted in the parent-child relationship when the child is noncompliant with a parent's corrections. Just as Patterson (1982) noted that children learn coercion in this way, so Morrison (1990b, 1992a) noted that a take down reinforced a patient's perception that violence was a valid method of gaining social control. The staff's physical response in the form of a take down reinforced the patient's image of himself as a tough guy and increased the likelihood of future violent confrontations. In fact, patients were more aggressive when nursing staff were in the dayroom than when they were not. Children have also been found to be more aggressive when supervised (Besevegis & Lore, 1983). To be consistent with Patterson (1982), Morrison labelled this interactive style coercive and identified it as a primary factor predictive of aggression and violence (1992a). Using a causal modeling design, this coercive style did indeed predict 35% of the aggression and violence in hospitalized psychiatric patients. When combined with a history of violence and length of hospitalization, 60% of the aggression and violence was predicted (Morrison, 1992a). These resuits strongly support the possibility of an interactional process tied to reinforcement patterns as an important cause of aggression and violence. Although findings are inconsistent, some environmental factors have been related to aggression and violence, including staffing ratios, space, and staff provocation. Of these, staff provocation is the most important issue. Although limit setting, detaining patients, and forcing medication are all cited as examples of staff provocation in the literature (Brizer & Crowner, 1989; Esser, 1970; Morrison, 1989), these can be understood within the context of a coercive interactional style (Morrison, 1992a). When patients who have made a practice of controlling their environment through aggression and violence are placed on a psychiatric unit
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where staff detain them involuntarily, force medication, and/or set limits, it is reasonable to assume that staff/patient conflicts resulting in violence will occur. These situations are highly coercive, since staff are trying to force something onto a patient who uses coercion and violence as a way to get control over others. Though not extensively documented, it has been shown that a generalized authoritarian or controlling attitude by staff increases violence (Morrison, 1992a, 1993b). Although recent interest in the effect of organizations on patient behavior has been minimal, with an increasing emphasis on quality of care and patient satisfaction, the effect of staff behaviors on patient outcomes is once again a priority (Fisher, 1993; Johnson & Morrison, 1993; Morrison, 1993b). The authoritarian aspects of institutions have been documented, but what is unclear is how much aggression and violence is caused by the controlling atmosphere. Medication, seclusion, and restraints are advocated as interventions for violence (Brown & Tooke, 1992; Corrigan, Yudofsky, & Silver, 1993; Eichelman, 1988; Tardiff, 1992; Tupin, 1983). Despite the attention given to these interventions, most clinicians would argue that these interventions are inadequate in decreasing the tide of violence on psychiatric units and we must explore other options for managing violence (Brown & Tooke, 1992; Soloff, Gutheil & Wexler, 1985). A fair amount of literature exists documenting the techniques for managing violent situations. In addition to the previously mentioned medications, restraints and seclusion, the following interventions are all emphasized: (a) being aware of own feelings; (b) allowing personal space; (c) using reflective statements; and (d) using nonthreatening body language (Felthous, 1984; Lion, 1987; Tardiff, 1992; Tupin, 1983). This literature base is fairly traditional and is loosely based on a variation of Freudian theory, which suggests that catharsis is therapeutic and that internal staff feelings will adversely influence patient behavior. However, very little empirical evidence exists to support these findings. In fact, research suggests that "venting" leads to increased anger (Tavris, 1989). Other options for managing violent situations are available. One such option is behavioral approaches, which have been used successfully with managing anger and violence in the mentally ill and with others (Corrigan, Yudofsky, & Silver,
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1993; Davis & Booster, 1988; Goren, 1991; Newell & Dryden, 1991; Patterson, 1982; Paul & Lentz, 1977; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991; Wong, Woolsey, Innocent, & Liberman, 1988; Wong, Slama & Liberman, 1987). Since this coercive style is learned through reinforcements, behavioral techniques are consistent with the understanding of violence posed here. For readers interested in behavioral techniques, the thoughtful review of behavioral techniques for managing violent psychiatric patients by Wong et al. (1988) or Tavris's (1989) book on managing anger are both recommended. CASE STUDY
Clinical vignettes are used to examine both the nature of violence currently occurring in psychiatric hospitals and practices for managing violent situations. Some of the interventions used in the vignettes were effective, whereas others were not. It is hoped that an honest examination will encourage other nurses to re-evaluate their current practices for managing potentially difficult situations. Mr. M is a clinical nurse specialist, with a total of 9 years of clinical experience in psychiatry including 3 years as a nurse manager. He has a masters degree in psychiatric nursing and he started his nursing career in intensive care, where he worked for 1 year. The first vignette will clearly document the nature of violence in psychiatric settings, where violence is a learned response and used in a coercive way.
lnteractional Style A male patient (Mr. S), in his early 30s, was transferred from the jail when his head banging couldn't be controlled. Criminal charges were pending for firing a shotgun into his girlfriend's house. He was frighteningly large and had a United States Marine Corps tatoo on his left foreann. He was not psychotic and had no previous psychiatric history, but he did have a history of abuse towards his girlfriend. A femaleRN had been assigned to do his (Mr. S) admission interview. He was very angry. When he became loud and verballyabusivetoward her, she left his room, but he continued to followher down the hall, threateningto throw her againstthe wall if she didn't let him out. My coworker continued to walk calmly away. As I approached, he began to be distracted from her and focus more on me. He began by telling me to back off, let him out. mind my own
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business; all interlaced with profanity, sexually based curses, and threats of bodily harm. I stopped.., waited a moment for him to quit cursing me, and said, "My name is Mike. I'm a nurse here. What can I do to help things?" "Just open the door and get out of the fucking way." He said this angrily and was taking a step back. That worried me. I took a step backward, too. "I'm sorry Mr. S, I can't open the door. I could lose my job." "Just open the fucking door. You think you can keep me here, big man? You think you're tough? You better get some help. I'll kill you." Now he was approaching me with fists raised. I was backing away but running out of room. "Come on, chicken shit, tough guy," he s a i d . . . By this time he was little more than an ann's length away and I was backed up to a locked door. This incident is very typical of violent incidents in psychiatric settings. A patient profile of history o f violence and no psychotic behavior is quite common, as is experience with the criminal justice system. At a superficial level, the patient wanted to get out o f the hospital and was ready to fight with anyone who got in the way. One interpretation is that the violence was a response to limit setting. However, if you examine the underlying dynamics o f the interactional processes, something else is also apparent, a coercive interactional style. When someone has a coercive interactional style, others are bullied and intimidated into giving up and giving in. The patient wants something and the situation escalates until he gets it. He repeatedly accused the nurse of being a " t o u g h g u y " , but the tough guy image was his and is a common mechanism that aids in bullying others. Aggressive and violent behavior escalates until the goat is achieved (Morrison, 1992b). In this case, anger gave way to yelling, raised fists, a threat to kill the nurse, and finally movement towards the nurse. The movement was another intimidating behavior designed to suggest that Mr. S would take action on his threat and try to kill the nurse if he d i d n ' t open the door. Although Mr. S's stated goal was to get out of the hospital, it is also very possible that he was using his hospitalization to serve some goal related to his legal problems. It is not uncommon for patients to manipulate the system so that a jail sentence could be served in the hospital or to build a case for being psychotic to minimize a jail sentence. However, we do not know enough about this situation to answer this question. The patient did return to the criminal justice system and about 1 month later successfully committed suicide outside of the system.
One more point needs to be emphasized before discussing how this situation resolved. Considering Mr. S ' s violent history towards his girlfriend, Mr. S should never have been assigned to a female nurse. The choice of victim is usually very stable; either vulnerable others (women/or children) or men (Morrison, 1990b). In this case, Mr. S had a much greater likelihood of assaulting the female nurse, than he did of assaulting a male nurse. The story continues as Mr. M discusses how this situation resolved. By this time he was little more than an arm's length away and I was backed up to a locked door. Stop! I didn't shout, but I did speak loudly and firmly. "I don't work here to fight people. I'm a nurse. I take care of sick people. That's why I'm here. You want to win a fight? O.K.-You've won. I give up. Now what happens? . . . . "I just want out. I'm not crazy!" The situation deescalated. This situation resolved after this exchange since Mr. M did not buy into the fight for control. He gave up control when he said " y o u want to win a fight . . . OK . . . y o u ' v e w o n " . This is a very creative solution to the problem, since he gave up control without giving in, that is, without opening the door. Once the patient rea.lized that Mr. M would not let him out, there was no reason to continue the violence. Another way of looking at the situation is to say that the violence did not work, that is, violence was not rewarded. A second issue is that early on, Mr. M successfully removed the intended victim (female) from the situation. A third possible factor might have influenced the resuit. Mr. M also told the patient that he was frightening staff and patients. Although Mr. M does not usually intervene in this manner, he thought it was helpful in this case. In general, this intervention is risky because some patients want staff to be frightened and intimidated and if so, would increase their violence when given this information. To the author's knowledge there is no research that documents the effectiveness of this intervention. In this next scenario, Mr. M provides us with another creative solution to a violent situation. A 20-year-old young man, an offensive lineman of a major university football team, who was admitted for an acute schizophrenic break, was shouting at the top of his lungs. He had turned over one chair. He held another chair in his hands at chest height. As he paused for a moment, I asked "Jim, what's happening?" I was standing several feet
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away. "Jim, what's going on here?" My voice was somewhat softer this time. Jim lowered the chair a bit, half crying and half shouting, he continued to talk about people pushing him around. "Jim, let's talk in your room," I said quietly. "What?" he said. I repeated myself and he began to look around as if he didn't know what to do next. "It's O.K. to put the chair down now," I said quietly. "Let's talk in your room." He put the chair down and we started toward his room. In this case, Mr. M deliberately softened his voice, almost to a whisper. The patient had to interrupt his outburst to hear what the staff was saying. Speaking in a quiet, soft tone seems to end verbal confrontations because the patient has to attend and listen carefully to what is being said. This intervention had a calming effect and fostered de-escalation. In addition, Mr. M ' s invitation to talk and permission to put the chair down contributed to a quick resolution. Although filing charges against psychiatric patients continues to be controversial, the following vignette provides an example in which a threat of taking legal action had a positive effect on the patient. Ms. P, a 25-year-old, attractive, electrical engineer, with a good job, was admitted to the unit on an involuntary basis. Within 10 minutes she attacked staff. I and several other staff members responded to the scene to help subdue her. As we held her, she relaxed. She spoke more calmly. She agreed to rest on her bed for a while. As staff began to turn loose of her, she remained calm. Then, when she was no longer being held, she kicked a staff person in the face and laughed. She was again subdued, this time with leather restraints. Clearly, this patient was aware of and delighted in her fight with the staff. The injured nurse and the hospital decided to pursue criminal assault charges against the patient. On hearing this, Ms. P calmed considerably. She apologized and asked the nurse not to press charges. The nurse agreed. In this case, the threat of assault charges accomplished three goals. First, the message was communicated that violence would not be tolerated and that consequences existed for breaking this rule. Although this expectation is stated in most psychiatric units, it is rarely enforced. Second, a threat of legal action clearly communicated that she was responsible for her behavior. When this message was given, she responded by acting in a more responsible manner. Third, a threat o f legal action changes the reward system for the violence and effectively acts as a negative consequence. How-
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ever, improvement in her behavior was only temporary. Shortly after discharge, she was fired from her job as an electrical engineer after more disruptive behavior at work. It is possible, that the temporary improvement in her behavior was manipulative, so that the hospital would drop the assault charges. Perhaps it would have been more effective if the hospital had successfully filed charges. The following situation describes how behavioral techniques can be used to change socially inappropriate behavior. A young woman (Ms. M), in her early 30s, in the manic phase o f a bipolar illness, was admitted to the hospital. She exhibited considerable hypersexual behavior, cozying up to male patients and staff, grabbing crotch's and rubbing their chests. Ms. M approached me while I was seated on the couch. She stopped a couple of feet directly in front of me. I said hello. She raised her dress above her head. She wore no underclothes. When she lowered her dress there was a defiant look on her face. Instead of commenting on her behavior, I introduced myself and asked if she would like to join a card game we were forming. She declined the game. Later that evening I asked her to help as I walked an elderly woman in the hall. She helped and I thanked her. Before she was discharged she sought me out and said thank you so much. "You've helped me a lot" She seemed sincere. This intervention was effective since Ms. M never again approached the CNS in a sexual manner, although she continued this behavior with many others. Ignoring the behavior accomplished two things with respect to reinforcement principles (Morrison, 1990b). First, in cases such as these, patients use inappropriate social behavior to gain attention. Staff comply by giving negative attention; telling her that her behavior is inappropriate or telling her to put her dress down. Both of these responses reinforce the inappropriate behavior by providing attention, albeit negative. The second accomplished goal was that Mr. M did not allow the patient to control the interaction and create distance through intimidation. While ignoring the behavior, he asked her to join in a card game. This intervention implicitly communicated a set o f appropriate expectations; not the response she hoped for, but an appropriate intervention that worked at eliminating the behavior while she interacted with Mr. M. However, if others in the environment continue to reinforce the inappropriate behavior it will continue. In addition, without the support of those outside the hospital who will be in the im-
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portant role o f caretaking, the b e h a v i o r will continue.
Staff Provocation A second contributor to violence in institutional settings that must be addressed is the effect of staff provocation through excess control and authority. Several investigators (Depp, 1984; Fisher, 1993; Morrison, 1990a, 1993b) described a process in psychiatric settings where administration and staff defined psychiatric nursing in terms of managing patients and their psychotic behavior. When a unit's philosophy is based on control or the management of patients, then physical techniques take on a predominant role (Lion, 1987), especially with respect to managing violent situations. Mr. M has a unique perspective since he is 6 ft. and 6 in. and weighs in the 300-1b range. In the following two scenarios, he describes how he was received on two different psychiatric units. Unit 1: My HN let me know that I may have a built-in disadvantage in working with seriously mentally ill clients. My new supervisors were concerned that my size would be frightening to some clients or simply offsetting to others. I became very self-conscious about being as respectful and nonthreatening to clients as I could. O n this unit, Mr. M was a v e r y successful nurse because he focused on learning h o w to relate with patients, h o w to c o m m u n i c a t e a caring attitude, and h o w to s h o w respect for patients. In contrast, Mr. M w o r k e d on a second unit, which has a philosophy e m p h a s i z i n g control. O n this unit, he was valued because o f his p e r c e i v e d ability to physically m a n a g e patients. Unit 2: A few nurses made the comment to me that they were glad to see a large male RN working on the unit. I often heard remarks like "It's about time," or "We're glad to see you," or "This is more like it." All such remarks were made in reference to my size. On my first day at my new job a loud banging and commotion was heard down the hall. I rushed to the scene with the rest of the staff. As the newest team member I waited to be given directions on what to do. I looked at the rest of the team to see who was going to be talking to the disturbed client who was in the process of trashing his room. No team member made a move. Finally I said, "Who's going to talk to him?" They all looked at me and one said, "You are. You're the biggest." W h e n the tradition o f toughness exists, staff are e m p l o y e d s i m p l y for their ability to physically m a n a g e patients (Morrison, 1990b). Those with an additional advantage such as size or k n o w l e d g e o f martial arts are particularly w e l c o m e d . These emp l o y m e n t strategies do not necessarily i m p r o v e the therapeutic e n v i r o n m e n t ( J o h n s o n & M o r r i s o n , 1993). Mr. M tells a story about a particularly bad
day w h e n unstable elderly patients w e r e walking around, patients were arguing, and staffing was short. His interactions were particularly directive. A 30-year-old woman, working as a paralegal, with a diagnosis of bipolar, approached me from behind and struck me in the head very harshly with her shoe. I was so startled, I whirled around drawing back my fist. When I saw her standing there, she made no attempt to duck or withdraw. Stunned, "I s a i d . . , what on earth are you doing?" She said "you can't treat us like this! We're not your slaves!" Later, Mr. M c a m e to realize that the patient was responding to his directive interactions with the other patients which she p e r c e i v e d as " b o s s y . " As Mr. M reflected on his e x p e r i e n c e , he told o f another incident that he d i d n ' t handle v e r y well. H o w e v e r , other staff intervened and m a n a g e d the situation in a thoughtful and caring manner. Several years ago at mealtime on a locked unit, I noticed that a male schizophrenic patient had removed the stainless steel dinner knife off his tray and placed it in his back pocket. I attempted to sneak up on him and grab it from his pocket. He saw me, quickly jumped up and brandished the knife pushing me into a comer. A psychiatric technician, spoke in a calm voice to the patient saying, "It's O.K. to put the knife down. You've proved yourself. There's no need to carry this any further." The C N S acted inappropriately, but the situation resolved w h e n the psychiatric technician told the patient what he needed to hear, that is, " y o u ' v e proved y o u r s e l f " eliminating the need to continue the fight. Mr. M learned f r o m this e x p e r i e n c e to give up w h e n possible. He was fortunate to h a v e such g o o d role models w h o interacted with patients in a thoughtful and caring m a n n e r and e l i m i n a t e d the need for a p o w e r struggle. T h e s e situations are not u n c o m m o n and most nurses w o r k i n g on psychiatric units can d e s c r i b e similar incidents in which staff acted in controlling w a y s in response to patients w h o were challenging. DISCUSSION
Several e x a m p l e s of clinically violent situations have been r e v i e w e d and analyzed. S o m e o f the interventions were effective, while a f e w w e r e not. T h r o u g h o u t the analysis, an interactional theory o f aggression and v i o l e n c e was p r o p o s e d that argues for the c o e r c i v e nature o f v i o l e n c e in persons with a mental illness (Morrison, 1990b, 1992b, 1993b). Clearly, prevention o f escalating events is the key to the m a n a g e m e n t o f v i o l e n c e in psychiatric settings. Seclusion is used far too often and tech-
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niques that have insufficient empirical support should be re-examined (Morrison, 1993a). Literature does exist to provide direction for understanding the interactional nature of violence and we must begin the process of examining our own behaviors and responses to patient behaviors and changing those responses when necessary. It is hoped that an honest examination of these vignettes will encourage nurses to re-evaluate their practice. Many hospital nurses are concerned about violence and are demanding that administration institute additional controls regarding safety. The underlying problem with this approach, however, is that as hospitals become more controlling, violence will increase. This is not an effective solution for the problem! The health care system must become less controlling and more responsive and user-friendly for both nurses and patients (Johnson & Morrison, 1993). Nurses are encouraged to focus on the prevention of violence before it starts and to manage potentially violent situations using some of the principles outlined earlier in this article. Avoid power struggles; allow patients to win struggles for control without giving in to unrealistic demands. Ask patients what is important while they are in the hospital and give it to them if possible. Make them true partners in their care. Teach them verbal skills of negotiation and collaboration. Encourage involvement in decision-making and show respect when they are able to act independently. Institute consequences for violent or threatening behavior. Lore and Schultz (1993) argued that Americans believe that aggression either cannot or should not be controlled. It is true that those of us in psychiatry are a good example of this since we want to believe that violence is an impulsive behavior. This interpretation comes from our adherence to outdated theories that have limited explanatory power, A norm against violence must be established in every aspect of society, including psychiatric units and enforced when necessary (Feltous, 1984; Johnson & Morrison, 1993; Lore & Schultz, 1993). If violence occurs, clinical staff must take action; consequences must occur!
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