Dealing with Aggressive Behavior

One study estimates that an adult with schizophrenia is fourteen times more likely to be attacked by a violent criminal than he is to be arrested as a violent offender. A much greater threat is the risk that people with schizophrenia pose to themselves; more people with schizophrenia harm themselves than harm others.

The threat of violence increases during psychotic episodes and in people with paranoid symptoms, which is another reason to encourage a person with the brain disease to adhere to his treatment plan. Alcohol and illegal drug use can increase the incidence of violence.

Rare Cases of Violence

For a small minority of patients, the troubling voices they experience and the perceived threats posed by some delusions have the potential to make patients a threat to others. These relatively rare cases often attract a great deal of publicity. As a result, they seem to the general public to occur much more frequently than they really do. Such occurrences might be compared to the rare event of a person who has a heart attack while driving and accidentally drives across a schoolyard, killing several people. When assaults do occur, the majority of them are directed against people close to the person with the disease, and they take place in the home.

Question

How do you interact with a jittery patient?

If something seems to make the person uneasy, avoid doing it and try to insulate the patient from others who might upset her. Don't look at the person's eyes if it makes her nervous. Respect her personal space so she feels secure. Don't touch the person unless she indicates it is okay. Avoid subjects that are obviously upsetting.

Leave the patient and call for help from others better prepared to handle actual or imminent physical threats if the patient becomes aggressive. Paramedics are taught not to put themselves at risk to help others; if the emergency responder is injured, he cannot assist others. The same rule should apply to you if someone becomes hostile and poses a physical threat.

A person with schizophrenia may respond to a hallucination or delusion as if it were real. Try to anticipate this possibility. Understand that she may be responding to a very scary threat. You can help by not increasing her agitation. Instead, calm her, if possible, by being a calming influence. It is a good idea to:

  • Have a ready means of exiting the situation. Always have an easy escape route planned to quickly get away from the situation if needed.

  • Have the phone number of emergency services handy.

  • Have the phone number of a reliable mental health care professional handy.

  • Keep trying to get help if someone you call refuses to get involved.

  • Brief the police, rescue squad, emergency medical technicians, mental health workers, or other emergency responders about the patient's medical history, diagnosis and needs.

  • Explain to the patient who the emergency responders are, why they have come, and what they are going to do.

  • Adapted from the Schizophrenia Bulletin.

    If a patient having a psychotic episode tells you something bad is going to happen or makes threats, assume the warnings are serious, particularly if the patient has delusions of persecution. Get assistance, but try to do it in a way that does not aggravate the patient's feeling of persecution. Calling the police or other assistance in the presence of a suspicious, aggressive patient may make her react more aggressively.

    Involve the police as a last resort, but do not hesitate to do so if you are not able to defuse the crisis. Remember: keep your safety and the safety of others, including the patient, in mind at all times.

    Don't Argue

    It is more important to listen when dealing with someone in crisis than it is to impose your idea of “sense” or your opinions on him. It might be difficult not to correct a person who is convinced of an obviously false belief, or who is seeing or hearing something that is not real, but you will not help by challenging him. For him, it does not seem real, it is real.

    At the same time, try not to be patronizing. It will not help, for example, if you agree with or encourage a paranoid person's conviction that others are threatening his in some way. The task requires empathy and a calming presence. Just like you, the patient may need to talk about her feelings and experiences. Listening to a patient discuss bizarre and troubling delusions can be difficult. It will not help if you pretend nothing is wrong. Explain that you understand why he feels the way he does and that it must be very stressful for him. Offer to help the patient find a way to relieve the source of the stress.

    Alert

    If someone's psychotic symptoms become severe, remain as calm as you can. Follow the steps in the patient's customized emergency plan if there is one. Determine whether the person is a threat to herself or others. Don't leave the patient alone if she might hurt herself. Contact someone the patient trusts and ask him to talk to the patient. And, of course, leave and call for help if you feel threatened in any way.

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