Managing Aggression

Definition

Violence and aggression is behaviour that is obviously likely to cause harm to another person, and/or behaviour that would be fear-inducing to the average person. It is not defined by the resulting damage to the victim, but by the act. Therefore, aggression includes harassment, bullying, threats, and intimidation, as well as physical violence.

Who is violent and how

See the personality disorder ‘top tips’ for further information on violent offending associated with different types of personality. In summary, violence might occur

• As an emotionally volatile response – often a reaction to difficulties in all types of relationships – within borderline personality disorder. That is, violence linked to a loss of temper.
• As an instrumental (that is, deliberate, conscious and purposeful) act in antisocial personality disorder. That is, violence used in order to intimidate or commit an acquisitive crime.
• As a rather prickly and hostile response to either shaming or intrusive experiences in individuals with paranoid, schizoid or narcissistic personality disorder.

It is important to remember that aggression is closely linked to substance misuse. Probably more than 50% of violent crime is committed when a service user is under the influence of alcohol. With illicit drug users, violence is more likely to be linked to irritability and frustration when committing an acquisitive crime (in order to get money for more drugs) particularly when in a state of ‘craving’.

Why be violent?

Aggression can be thought of as a behaviour which has a meaning and a function which is hidden – sometimes hidden from the service user as well as the practitioner. Service users who have limited skills in managing conflict, or experience difficulties in expressing themselves, are more likely to resort to violence in order to try and express their feelings or resolve situations.

However, it is important to remember that some service users have been brought up in social environments where aggression is thought of as a positive, or only, means of survival. Such individuals may not feel that their behaviour is a problem for them.

You can try and work out the meaning and function of aggression from the list below:

• Communicating distress to others
• It’s the only way to solve problems in their social environment
• Trying to make other people feel vulnerable instead of themselves
• Avoiding exposure of feelings of shame
• Self defence
• Trying to regain control by dominating interpersonal situations
• Seeking a ‘buzz’ (including releasing a biological ‘natural high’ from a surge of endorphins in the brain)
• Striving to feel ‘real’, and in touch with the world
• To get what they need (material goods)

Impact on the practitioner

Service users who self harm – particularly those who do it fairly regularly – have an impact on the practitioner. You might feel:

Fear – you really wonder if the service user is going to hit you, he seems so angry and so near to losing control.

Anxiety – you can’t tell whether the service user is going to seriously hurt or kill someone, and you just can’t shake off that worried feeling, even when out with friends or when going to sleep.

Anger – you don’t like the service user’s attitude towards women, ethnic minorities, you or your colleagues. He seems to be dismissive of the impact his behaviour has on others, and of all your attempts to help him. He seems to imply it is your responsibility to sort things out, not his.

Hopelessness – you wonder what the point is, when all your efforts lead to nothing. One after another, all your violent service users are recalled or re-offend.

The two C’s – control and capitulate

The above feelings draw you into behaviours which fall on a spectrum from being controlling towards the service user, to capitulating (that is, letting things go which should really be challenged). Controlling behaviours including adding licence conditions and hostel rules in order to try and stop unhelpful or rule breaking behaviour. It might include warnings and threats to discharge or recall a service user, or trying to insist that their account of the offence is ‘wrong’, and the victim is ‘right’. Capitulation is something we all do when very busy, demoralised or exhausted; sometimes insisting on sticking to the rules or keeping the boundaries just seems a step too far. We let things go for an easier life, or to avoid conflict which might actually feel rather frightening.

The practitioner’s stance  – do’s and don’ts

Managing aggression and violence

There are three steps to managing aggression, set out in the Figure below

Identify the service user’s history of aggression, including the types and the reasons.

Analyse, in collaboration with the service user, the patterns of aggression in order to work out what are the triggering events. Triggers to aggression can be

• thoughts (are you ‘taking the piss?’, do you think I’m a push over?, never lose control)
• feelings (anger, fear)
• behaviour (drunk or socialising in a notoriously ‘rough’ pub)
• relationships (a row or rejection)

In order to help the service user think about triggers, you might want to develop a time line of relevant triggers. Some might occur just before the act of aggression, but others might have happened earlier in the day or a few days beforehand. The time line below provides an opportunity to add in the consequences as well as the triggers to aggression. Sometimes, service users find it very difficult to identify something negative about the consequences of an aggressive incident, particularly if their social environment is a violent one.

Timeline

 Intervene

Now you have a clearer idea of the problem, and the likely triggers, you need to work with the service user to develop a plan. This is usually called a Relapse Prevention Plan. It needs to include the following elements:

• 1. Realistic risky situations for the service user (external factors)
• 2. Common triggers (internal factors, like thoughts and feelings)
• 3. Strategies for managing risky situations and triggers which include:
• Avoidance of particular triggering situations (external)
• Self-monitoring of problematic thoughts and feelings (internal)
• A few self control techniques and alternative strategies for managing feelings

Tips for planning

Managing Aggression in the Room

When a service user becomes aggressive in the room (or in the hostel or other residential area), it is likely to feel rather frightening – perhaps unexpected and slightly shocking – and everyone finds it difficult to think clearly in such situations. Of course, you may need to ring an alarm or shout for help – don’t hesitate to do this.
When trying to manage a service user’s obvious distress or rage, it’s best to keep things simple: there are three steps to managing most incidents.  They are described below.

The most common mistakes made by staff are:

• Asking what the problem is when the service user is too angry to explain, and they just shout at you
• Becoming distracted after an incident and failing to do whatever you said you would do, within the time you promised to do it

Both these mistakes lead to an escalation in aggression. However, if you manage to follow the three steps, more often than not, the service user will calm down.