What distance should you try to maintain from an individual who is displaying aggressive behaviors?

Violent and aggressive behaviours have a huge impact, affecting the health and safety of the young person as well as carers, staff and others using the service.

As far as possible, focus on preventing, anticipating and reducing the risk of violent and aggressive behaviour occurring.

Involve the young person in decisions about their care wherever possible, and collaborate with whoever has parental responsibility. When supporting the young person to manage and minimise any violent or aggressive behaviours, consider their physical, intellectual, emotional and psychological maturity, including any variation in their development.

Understanding the likely causes of violent and aggressive behaviours helps to prevent them happening. Together with the young person, when they are in a calm and safe space.

Think about times when they have shown violent or aggressive behaviour, and what might have triggered it.

Triggers can be:

  • something that happened or a feeling such as disappointment or anger
  • shaped by delusions, hallucinations, confusion, disorientation, or misinterpretation
  • affected by their perception of the environment or the behaviour of others.

Consider their history, including any experience of abuse or trauma and how they responded during any previous incidents of violent and aggressive behaviour.

Talk about what happens when they are becoming distressed and angry, and what helps them to feel calmer.

Identify any cognitive, language, communication or cultural factors that might increase the risk of violent and aggressive behaviour.

Record this information in the care plan and support the young person, if they wish, to make an advance statement recording their wishes in case they become agitated in future.

This could include what they would find acceptable, when and how staff should intervene and how to minimise harm or discomfort should restrictive interventions be needed.

Give copies of this information to the young person and make sure they understand it.

Difficult behaviour is usually the symptom of a problem and not the problem itself.

East Riding of Yorkshire Council

De-escalation means using techniques, both verbal and non-verbal, to reduce agitation and avoid violent and aggressive behaviour. It may include the use of ‘when needed’ medication in combination with other techniques.

De-escalation requires advance planning and it is more likely to be successful when staff:

  • Have a close working relationship with the young person and are able to sensitively monitor changes in their mood or composure.
  • Show respect and empathy at all times.
  • Use verbal and non-verbal skills to help the young person avoid or manage situations that are known to be difficult.
  • Encourage the young person to recognise their own triggers and early warning signs.
  • Consider whether the young person might benefit from help to develop greater self-control and techniques for self-soothing.

If the young person becomes agitated:

  • start any actions agreed in their care plan and advance plan straightaway
  • use one member of staff as the main communicator
  • control your own verbal and non-verbal expressions of anxiety or frustration
  • use calming techniques and distraction
  • offer them the opportunity to move away to a quiet room or area
  • keep in mind the aim to build emotional bridges and maintain a relationship.

Only use restrictive interventions if all attempts to defuse the situation have failed and there is a risk of harm to the young person or other people. Continue to attempt de-escalation during the restrictive intervention.

What distance should you try to maintain from an individual who is displaying aggressive behaviors?

To help reduce the risk of violent and aggressive behaviours, and avoid the use of restrictive interventions wherever possible, staff should have training specific to working with young people. Training should include a focus on de-escalation and cover:

  • the early signs of agitation, irritation, anger and aggression
  • the likely causes of aggressive or violent behaviour
  • de-escalation techniques and ways to encourage relaxation
  • the importance of personal space
  • how to respond to agitation in a reasonable and professional way that avoids provocation.

Anyone who might use restrictive interventions should be trained in how to do so safely with young people.

Staff should be aware of relevant legislation, organisational policies and procedures, and how to respond effectively and appropriately.

Share information within the organisation about the triggers and early warning signs identified by the young people using the service to help inform learning and practice.

This content has been co-produced by NICE and the social care institute for excellence (SCIE). It is based on NICE’s guideline and quality standard on violence and aggression.

As health care professionals, we are sometimes faced with patients in crisis. An estimated 4 percent of visits to primary care physicians involve psychiatric or social crises. Proper assessment and intervention are essential to ensure the safety of the patient and others.

For purposes of this article, crisis moments refer to those points in time when individuals lose physical and rational control of their behavior. Almost always, there are warning signs a person’s behavior is moving toward a crisis.

EMOTIONAL SIGNS: Crying, Yelling, No Talking at All, Arguing, Inappropriate Laughter, Fear, Confusion

BEHAVIORAL SIGNS: Rocking/Swaying, Rapid Breaths, Shaking Extremities, Pressured Speech, Tenseness in Body, Loud or Quiet, Clenched Fists, Poor Eye Contact, Pacing, Skittish Behaviors

The following tips can aid in early interventions and increase the likelihood of staff de-escalating an incident before it becomes dangerous.

  1. Respect All Individuals’ Personal Space
    Personal space is the area around us that we consider an extension of ourselves. Anxiety rises when personal space is invaded. Heightened anxiety makes it more likely a person will act out in a more serious way. To avoid such a response, maintain at least an arm’s-length distance from a person whose behavior is escalating. In this way, you will also reduce danger to yourself by maintaining a margin of safety that allows you time to react.

    If you must touch an anxious person to provide medical care, explain what you are about to do before you begin. If the person objects, decide if: 1) the procedure can wait; 2) someone else might be better suited to provide the care; or 3) the procedure must be done at this very moment. This third alternative should be a last resort, chosen only due to acute medical necessity.

  2. Be Aware of Your Own Body Position and Feelings
    In addition to maintaining adequate space between you and an anxious person, avoid direct, eye-to-eye, toe-to-toe positions, as they might be interpreted as challenging. Positions perceived as challenging can evoke a “fight or flight” response from the other person, and neither of those reactions is likely to be helpful. Standing at an angle to the person and off to the side is much less likely to escalate an agitated person’s behavior. Be aware of your own feelings (e.g., fear, anger, etc.) and consider asking for assistance from other staff if you feel the need.
  3. 3. Be Empathic to Others’ Feelings
    Try not to judge or discount the feelings of others. Pay attention to them, and don’t be afraid of silence. Your calm, supportive presence is often more important than what could be conveyed with any words you might say.
  4. Keep Nonverbal Cues Nonthreatening
    As a person begins to lose control of rational thought, the person becomes more tuned into your body language. Nonverbal communication — including gestures, facial expressions, movements and tone of voice — becomes paramount in conveying a calm, respectful attitude.
  5. Ignore Challenging Questions
    When a person challenges your authority or an organizational policy; try to redirect the individual’s attention to the issue at hand. In general, it’s better to ignore the challenge and restate your request.
  6. Set and Enforce Reasonable Limits
    If patients or family members become belligerent, defensive or disruptive, and calmly establish limits and directives clearly and concisely. When setting limits, offer simple, clear choices and consequences to the acting-out individual. Be sure the consequences are reasonable and enforceable. Be clear and firm, but avoid displaying anger, fear or hostility.
  7. 7. Permit Verbal Venting When Possible
    It is often the safest and best alternative to let the person shout, removing others from the area when feasible. As a person is venting, there will be peaks and valleys in the outburst. If you cannot allow the person to continue venting, state the directives and reasonable limits during the “valleys” in the venting process.
  8. 8. Identify Real Reason for the Behavior
    Even in the midst of an angry tirade, there is useful information to be gained about what a person is thinking and feeling. Anxious patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they are experiencing than to the ways staff members are performing their duties. Try to listen for the feelings behind the facts. Restate the message you think you have received in order to determine if you correctly understood the person’s intent.
  9. Stay Composed, Avoid Overreacting
    It’s hard not to take things personally. It is essential to do your best to remain calm and professional — at least on the outside. Your composed, rational response can go a long way toward influencing the person’s behavior in a positive way.
  10. Use Physical Techniques Only as a Last Resort
    Physical restraint should be used only when people’s behaviors are dangerous to themselves or others. Physical intervention itself always carries some risk of injury to staff or to the person being restrained. Such interventions should be used, therefore, only when it is more dangerous NOT to intervene and by competent staff members who are trained.

These are some basic steps we hope all staff members can use to improve their interventions in potential crisis situations. The points above are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that can be effective.

Resources: https://www.crisisprevention.com/Blog/June2011/Responding-to-Abusive-Patient-Behavior-Part-2