Difficult behaviours

Managing aggression and violence

Introduction

Effective risk management is particularly important in prison, as some prisoners have major issues in dealing with anger and aggression. Risk management is a part of the health and safety rights and responsibilities of all staff. The health care manager has additional responsibilities under Health and Safety law to make an environmental risk assessment and take action, as appropriate, to reduce risk.

Aggression and violence are not a mental disorder, though people who are aggressive and violent may have one of a number of disorders. This section aims to give advice to help clinicians reduce the risk of violence and aggression and to deal with it if it occurs. The aim is not to ‘cure’ the individual of being aggressive, but to reduce aggression so that the clinician can address the individual’s other health problems safely.

Preparations to be made in advance

Layout of the healthcare centre

  • Avoid excess stimulation. Noisy waiting rooms, loud music or bright lights can overload an already tense or disturbed individual. Ensure waiting areas are well ventilated.
  • Consider, if possible, a destimulation area, eg a lounge area with toilet facilities for use by individuals who pose a particular risk.
  • Consider, in the longer term, developing a de-escalation suite or snoozelen room for use by patients who have become very agitated.

Layout of the interview room

  • Ensure a safe escape route for the patient (such as an unobstructed exit). A distressed individual would rather escape than fight; aggression levels rise if the individual feels cornered or has trouble finding an exit.
  • Ensure a safe escape route for yourself (eg be nearest the door). This is important if violence is premeditated or goal-directed, eg an individual is threatening a doctor to try to obtain particular drugs.
  • Ideally then both individual and clinician will have equal access to a safe exit, preferably separate exits. If this is not possible, then the clinician should be nearest the exit or the room should have an observation panel that allows a clear view from, say, secretary’s desk outside.
  • The door should open outwards or swing both ways to prevent possible barricades.
  • Discreet buzzer to call for help.
  • Décor and furniture should be as pleasant and relaxing as possible, eg easy chairs, pastel colours.
  • Other staff members to be clearly visible or seen to pass the room at frequent intervals.
  • Interview room to have externally locking doors, so that help cannot be locked out.
  • Scissors, knives or any other unnecessary objects that can be picked up and thrown should not be kept in the interview room.

Clothing and jewellery

Remove items of clothing that might cause injury if a potentially violent individual catches hold of them, eg earrings, necklaces, neckties, pens or pencils (from pockets), cigarette lighters. Do not wear clothes or shoes that may make a quick exit difficult.

Standard procedures

  • Fear can lead to violence. Provide information about the symptoms of the illness, any medical procedures, the names and roles of any clinicians who are also present and the role of the health centre.
  • Behave calmly. Non-verbal stress and anxiety can be difficult to distinguish from anger. To a patient who is confused, hearing voices or lost in distressing thoughts, a highly anxious clinician may be perceived as threatening.
  • Inform patients about anticipated delays. Offer appropriate resources (eg magazines, drink, bathroom, etc). Simple consideration can help reduce hostility.
  • If delays are anticipated, have a member of staff search the toilet area for objects that might be used as weapons. Maintain staffing levels to allow patients to be escorted to and from the toilet area.
  • Have a clear policy, written or reviewed within the last 3 years and known by all in advance, about the prescription and administration of opiates and benzodiazepines.

Visits to wings/units

If visiting a patient in their cell do the following.

  • Make staff aware of your presence before entering the cell.
  • Acknowledge the patient’s territorial rights and respect his/her personal space and possessions. Always ask whether you may enter the cell, sit down, etc. By doing so, you will allow the individual to retain a sense of control and thus will reduce a perceived threat.
  • Do not allow yourself to be directed to a seat you are uncomfortable with, eg sitting on the bed.

Recognising potential aggression at an early stage

Signs include the following.

  • Any change in behaviour that varies from what is normal for that individual.
  • Pale or flushed face.
  • Rising voice.
  • Focusing/narrowing of gaze.
  • Tensing of muscles.
  • Increased agitation and disturbance in behaviour, eg pacing.
  • Unusual calmness.
  • Disturbed communication.

Defuse aggression before it becomes violence (verbal de-escalation)

Adoption of a non-threatening body posture

  • Use a calm, open posture (sitting or standing). Place yourself to the patient’s side or take up a side-on stance. Reduce eye contact by use of peripheral vision – as direct eye contact can be confronting.
  • Allow the individual adequate personal space. The amount varies between individuals, so be aware of signs that the patient feels you are too close or too far away.
  • Keep both hands visible with open palms as a calming gesture.
  • Do not stand if the individual is sitting or you will appear threatening.
  • Do not whisper or talk over the patient. Keep him/her involved in all relevant discussions wherever possible.
  • Avoid sudden movements that may startle or be perceived as an attack. Movement towards the individual may be perceived as a threat. Move backwards or sideways if you move at all. Do not turn your back on the individual.
  • Avoid audiences – an audience may escalate the situation.

Display an understanding

  • Remain calm and patient.
  • Speak firmly, slowly and clearly, but with normal tone and intensity – do not raise your voice. Avoid sounding accusatory or punitive.
  • Offer support: do not make retaliatory remarks. Reassure the individual that you accept that he/she is angry. If the individual makes a conciliatory gesture, respond accordingly.
  • Ask questions: ask how the patient is feeling. Do not say: ‘I know how you feel.’ Ask what is causing his/her anger. Ask how he/she thinks the situation can be resolved.
  • Give time for the individual to think about the situation, to hear the full story. Do not rush the individual.
  • Avoid interrupting the individual. If an interruption is necessary, do it quietly and calmly.
  • Show that you are willing to help where possible.
  • Make an apology if appropriate.
  • Do not take the individual’s comments personally. Abusive statements may be the only way the individual can express his/her feelings at the time.
  • Try to be honest with the individual and do not make promises that you cannot keep.
  • If physical contact is made (eg holding your hand or patting you on the back), try and remain calm. Do not pull away or overreact, as this may trigger suspicion.

Provide supportive feedback

Note the individual’s non-verbal cues and feed your impression back to him/her. For example:

You seem a bit agitated. Perhaps you can tell me why you’re feeling agitated, then I may be able to help you in some way.

I can see that you’re very upset about something. Tell me what’s upsetting you? Tell me what you would like me to do to help you.

This technique is often useful, but occasionally it infuriates the individual further. If this occurs, move on to another technique.

Provide the individual with choice

A choice of alternatives, even if none are what the individual would ideally like, may help him/her feel in control of their situation, and so may alleviate some of their distress. For example, you could say:

I can see that you’re extremely distressed and agitated by the voices you’re hearing. I can help you to feel better by giving you your usual tablets. You always tell me that the pills make the voices quieter. You can then go back to the unit. If you don’t want me to help you in that way then you can go into a room on the ward. The choice is yours. Tell me what you’d like me to do.

Time out

Time out may involve leaving the individual alone in an unlocked room for a few minutes or asking the person to take a break. It should be clear to the individual that the strategy is not a form of punishment. For example, you could say:

Look – this is getting intense (or emotional). Let’s take a break for a few minutes. It will help us (or me) to think.

If the situation escalates despite these efforts

Do not try to handle a violent individual on your own. If he/she claims to have a weapon, GET OUT of the room or building. If you cannot escape, then do the following.

  • Summon assistance. If possible, give the helpers information about the situation to prevent overreactions. (Staff running into a room where a patient is armed may trigger off an assault).
  • Stay calm.
  • Do not wrestle or argue with the aggressor.
  • Adopt a non-threatening stance. Keep your palms open as a gesture of calm. Minimise eye contact with the use of peripheral vision.
  • A side-on stance creates a smaller target with the vital organs protected and with better stability.
  • Obey the individual’s instructions and try not to upset him/her.
  • Speak only as much as is needed to keep the individual speaking – rather than acting.
  • If the individual calms down a bit, it may be possible to suggest that he/she puts the weapon on the table or in another safe place. Do not attempt to grab the weapon, but play for time until help arrives. Talk empathetically with the individual to continue to defuse the situation. However, do not agree with ludicrous delusions. It may help to say something like: ‘I can see you’re upset by this belief. Maybe it’s true; maybe it’s not’.
  • Use surrounding objects and furniture as shields if violence occurs.

Other forms of management of violent patients

Occasionally it may be necessary to use other means to prevent a patient from being violent. Where the patient has a mental illness and either gives permission for treatment to be administered or is not competent to give or withhold consent, then medication is an option. For advice on the use of rapid tranquillisation under common law, see Emergency treatment under common law.

Currently, in prisons in England and Wales, Prison Service guidance allows that where a patient has a medical condition leading to the violent behaviour, a doctor may order the use of ‘medical restraint’, ie the use of a ‘special cell’ or of a loose canvas restraint jacket. In addition, for all forms of violent behaviour, as a very last resort, a prison governor may order the use of ‘mechanical restraint’, ie the use of a body belt with metal cuffs or the use of special accommodation. Where a governor has ordered the use of either mechanical restraint or special accommodation, the role of the doctor is to assess whether there is any medical reason for not using these and, if there is, to order their use to be ended immediately.

In the use of any such form of physical restraint, the following are essential points of principle.

  • It should be used as a last resort and for the shortest time possible.
  • Steps should be taken to ensure the minimum possible invasion of the individual’s dignity, eg audiences should be moved away.
  • The individual should be treated in a way likely to calm rather than aggravate their aggression, eg speaking to them calmly and with respect.
  • The individual’s mental state should be regularly assessed and an opinion urgently sought from a psychiatrist if there is any history or current indication of mental illness, self-destructive behaviour or substance misuse.
  • Where the patient has a mental disorder, care and treatment should be planned if necessary and appropriate under common law (see Emergency treatment under common law). Where indicated, steps should be taken to remove them urgently to a hospital where treatment can be given (see Interface with the NHS and other agencies).
  • Where the patient has a history of very difficult behaviour, a full, multidisciplinary assessment and care plan should be arranged (see Management of prisoners with complex presentations and very difficult behaviours).

Action to take after a violent outburst

Staff

  • Staff members involved will require support and appropriate attention, if required, to meet psychological or physical needs following an incident.
  • It is usually helpful for participants to discuss their experiences of the incident. Staff should together talk about what happened, how they felt, what went wrong, what went right and how to handle such situations more effectively in the future. The new information should be shared with staff who were not directly involved in the incident. This kind of review is equally helpful in situations where a violent outburst seemed very likely but which was prevented.
  • Some staff may suffer injury (eg orthopaedic strain) during restraint. Encourage staff members to check any potential injuries with the occupational health service.

Patient

A record should be made in the individual’s file. In a prominent position inside the file (NOT on the front cover) record: ‘See (date)’ and give the date of documentation of violent episode. Then, in the notes on that date, give a detailed record of the violence. Include the grade or severity of the violence, the circumstances in which the violence occurred (eg whether the individual was psychotic or drunk) and whether the violence was provoked.

Offer to discuss the incident with the individual when he/she has recovered. He/she is likely to feel shaken after such an event, especially if restraint or medication were used. If the violent incident was out of character for the individual, he/she may have trouble understanding why it occurred. If the violence was part of a pattern of aggressive behaviour, the individual may be more willing at this point to accept help for his/her violence.

Assess the individual to exclude possible physical and neurological causes for the violence. Arrange a multidisciplinary psychiatric assessment to determine a management plan. Violence is associated with the following.

  • Any cause of confusion, either acute (delirium) or chronic (dementia). A thorough medical check-up is advised (see Delirium and Dementia).
  • Acute psychosis.
  • Paranoid states.
  • Acute organic brain syndromes.
  • Head injuries.
  • Substance abuse or withdrawal.
  • Personality disorders, eg antisocial characteristics or borderline disorder.

Where the violent outburst is part of a pattern of aggressive behaviour that is relatively mild, assertiveness training and anger management training may be helpful. (ref 1) Where problems in controlling anger or aggression have led to the crime the individual has committed, the individual may be eligible for one of the relevant offending behaviour courses.

References

1 Stermac. Anger control treatment for forensic patients. Journal of Interpersonal Violence 1986; 1: 446-722.

Medication

The Royal College of Psychiatrists guidelines (ref 1) allow psychotropic medication to be used in patients with chronic aggressive behaviours where there is:

  • a high level of arousal/anxiety that cannot be reduced by environmental, behavioural or other therapeutic methods or
  • a low threshold of stress tolerance that cannot be reduced by environmental, behavioural or other therapeutic methods.

The lowest dose possible should be used. Medication should be part of a comprehensive plan including environmental factors and other therapies. Consult a specialist about prescribing for this indication. For advice on rapid tranquillisation, see Emergency treatment under common law.

References

1 Royal College of Psychiatrists. Strategies for the Management of Disturbed and Violent Patients in Psychiatric Units. Council Report CR41. London, 1995.

If it is suspected that a patient may be violent to others

Potentially violent individuals raise legal, ethical and clinical problems for clinicians. It is generally accepted internationally that a health professional has a duty to protect a person whom a patient threatens to harm by warning that person or contacting the police. UK case law supports this providing the decision about the serious risk is taken on adequate information and the information is disclosed to the appropriate authorities. This includes all potential victims of violence, including domestic violence and including groups of individuals (eg female staff). Where a clinician believes there is a reasonable chance that a patient will seriously harm someone else (eg a family member or prison officer), you should do the following.

Assess the risk of violence

Factors associated with potential violence:

  • History of violence (the single strongest predictor).
  • Intention to commit violence (most important clinical variable).
  • Male gender.
  • Being unemployed.
  • Living or growing up in a violent subculture.
  • Coming from a violent family.
  • Abuse of drugs or alcohol.
  • Having weapons available.
  • Having victims available.
  • History of poor impulse control.
  • Factors that weaken self-control (eg psychotic illness, paranoid thinking).

Assess the strength of motive and intention. This is the most important predictive clinical variable. If you suspect violence, ask the following questions:

  • ‘Are you angry with anyone?’
  • ‘Are you thinking of hurting anyone?’

If ‘yes’, then ask the following.

  • ‘Who are you angry with, or thinking of hurting?’
  • ‘When do you think you might hurt [the person mentioned]?’
  • ‘Where will you do this?’
  • ‘How long have you been thinking this way?’
  • ‘Are you able to control these thoughts about hurting [the person mentioned]?’
  • ‘Do you think you would be able to stop yourself from hurting [the person mentioned] if you wanted to?’
  • For how long do you think you can control your thoughts about hurting [the person mentioned]?’
  • ‘Have you ever purposely hurt someone in the past?’
  • (If ‘no’) ‘How close have you come to hurting someone in the past?’

Be aware of a hierarchy of expressions of intent.

  • ‘I wish he were dead’: thought – lower risk.
  • ‘I’m going to kill that bastard’: intention – higher risk.
  • ‘I’m going to stick a knife in Joe Bloggs when he comes to my cell’: definite plan – highest risk.

If you believe that the individual is likely to commit serious violence against another person, then you have a legal and ethical obligation to both the patient and the potential victims of violence to try to prevent the violence (see Ethical issues).

Discuss your concerns and intended action with the potentially violent individual

Where possible, it is usually best to tell the patient that you are concerned about his/her threats, and that it is your duty to tell the third party about the threats that have been made against him/her. This line of action demonstrates concern for the patient and is less likely to damage the therapeutic clinician-patient relationship than taking no action.

If in doubt, seek urgent consultation with a superior or secondary mental-health services. Telephone consultation is better than none at all.

Keep careful, detailed, written notes (including notes of the results of any consultation).

Protect the third party against violence.

  • Inform discipline staff (SIR – Security Incident Report).
  • If the patient satisfies the criteria for mental disorder, admit and obtain an urgent transfer to the NHS (see Liaison and referral to the NHS).
  • Take appropriate steps to make sure that the person who is the target of the threat is alerted. If he/she is another prisoner or member of the prison staff, inform the duty governor. If the potential target is outside the prison, inform the police. Once the police are informed of such a threat of violence, they too have a duty to warn that person of the risk of violence and, if necessary for the protection of the public and the individual, to discuss the threat with the local multi-agency public protection panel.
  • Evidence of child abuse, where you have reason to believe that a child is at current or future risk, should be reported to the appropriate authorities (see Child protection).
  • Inform the patient of the action you are taking. Where possible, carry out the warnings in the presence of the patient (eg telephone the duty governor in the presence of the patient). This will ensure that you talk about the patient in a considered way and will reduce the chance of the patient developing paranoid ideas about what has been said in his/her absence. However, if you believe that discussing your intentions with the patient will put you at risk, then you should warn the third party without informing the patient.

Guidance may also be available from your local multi-agency public protection panel.

Policies and training

Policies are needed on the following.

  • Management of critical incidents, including debriefing, recording, staff training.
  • Risk assessment.
  • Staff training.
  • Use of restraint.
  • Prescription and administration of opiates and benzodiazepines.
  • Use of restraint.

References

Adapted from Andrew G, Jenkins R (eds). Management of Mental Disorders, UK edn. Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse, 1999; and The Bethlem and Maudsley NHS Trust, 1994, Preventing and Managing Violence: Policy and Guidelines for Practice. Report of Trust Working Party. London: Maudsley.

Adapted from the dangerousness checklist in Breakwell G. Facing Physical Violence. London: British Psychological Society, 1989.

Stermac. Anger control treatment for forensic patients. Journal of Interpersonal Violence 1986; 1: 446-722.

Royal College of Psychiatrists. Strategies for the Management of Disturbed and Violent Patients in Psychiatric Units. Council Report CR41. London, 1995.

Dirty protests

Why do people make dirty protests?

People may make dirty protests for a variety of reasons.

  • They may be making a political or personal protest.
  • They become involved in power struggles, seeking a goal such as a transfer to another prison, and they are unprepared to recognise boundaries or authority. This pattern is much more commonly seen in prisoners with a personality disorder. Lack of cognitive and negotiating skills can lead rapidly to a prisoner progressing from normal accommodation to segregation and a dirty protest.
  • Mental illness is less common but does occur. Other disorders, such as a brain tumour, are also possibilities. Prisoners may have both mental illness and a personality disorder.

Assessment

Because of the possibility of mental illness and other disorders, a full assessment is essential. Dirty protests should be assumed to be manifestations of health problems until proven otherwise. Dirty protests may also result in infections.

Healthcare staff engaged in assessing and then attempting to meet the healthcare needs of a prisoner on a dirty protest face a very unpleasant task. Facilities should be made available to allow staff to conduct a full assessment. Examinations of a prisoner’s health should be held in adequate conditions, in circumstances that allow the prisoner to express him/herself freely and by a healthcare professional who is competent in assessing their mental state. An interview room is required. The prisoner’s inmate medical record (IMR) should be to hand (and read) before the examination and the results of the examination entered into it. Observation of the patient alone, without talking to him/her, is never sufficient. Guidance on conducting a mental state assessment can be found on the disk .

While it is very important that the prisoner’s mental state is regularly assessed, the frequency of such assessments and the need for a physical examination should be assessed on clinical grounds. If the healthcare worker has any concerns around the prisoner’s mental health and/or if there is any record on the IMR of previous mental-health problems, he/she should arrange for a specialist assessment to be undertaken as soon as possible.

Management

All prisoners

  • It may be possible for the protester to protest in another way. The Board of Visitors, chaplain and probation officers are likely to be able to represent the protester to others.
  • Health staff should try not to be drawn into conflicts between the protester and prison staff. A neutral stance can be helpful if the protester starts to self-harm and requires medical treatment. A calm, caring, professional attitude may reduce tension on all sides.
  • The physical health of the individual should be monitored. This may require specialist input from local NHS Trust staff. Early discussions with outside staff may be more efficient than more urgent discussions later. In offering these health interventions, the individual’s capacity to consent or refuse consent should be considered (see Consent and capacity).
  • Subject to considerations of confidentiality, the security implications of medical management should be discussed with prison staff.
  • Caring for prisoners engaged in dirty protests is unpleasant and challenging for staff. Even where psychiatric staff have confirmed an absence of mental illness, they may be able to provide support to staff who remain in direct contact with the prisoner.

Prisoners with mental illness and/or personality disorder

The key principles of management are set out in Management of prisoners with complex presentations and very difficult behaviours. Multidisciplinary assessments, enhanced care plans and follow-up are likely to be indicated.

Resources for patients and primary support groups

Agencies that may support individuals in alternative ways of protesting include the following:

  • Board of Visitors
  • The Prisoners’ Advice Service: 020 7405 8090 (Monday-Friday, 9:30 am-5.30 pm) (Provides free legal advice and information to prisoners in England and Wales about their rights, the application of prison rules and the conditions of imprisonment)