Assessing and managing psychosis, drug misuse and violence and aggression

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Chapter 16 Assessing and managing psychosis, drug misuse and violence and aggression

Rosie Doy, Elizabeth Jane Blowers, Emma Sutton

Primary survey 269
Psychotic illness 270
Features of psychosis and differentiation from organic confusion 270
Specific types of illness 273
Responding to a person in crisis 275
Services available 276
Substance misuse 278
The nature of substance misuse 279
Assessing substance misuse 280
Brief interventions 280
Violence and aggression 282
Personal and scene safety 282
Post-incident support 286

Primary survey

The objectives of this chapter are listed in Box 16.1. Assess the risk of self harm or the potential of harm to others, including you. Call for urgent back up if this is the case. You may need to call the police if you think there are real and immediate risks of violence. If you judge management of the patient will require the use of the Mental Health Act, you will need to mobilise an Approved Social Worker (ASW), the patient’s GP or a doctor approved under Section 12 of the Mental Health Act (1983).

Box 16.1 Chapter objectives

Psychotic illness

image To discuss the recognition of psychosis in primary survey positive patients and those with non-life-threatening psychotic presentations
image To describe mental health assessment, differential diagnoses and therapeutic approaches to the person with psychotic symptoms
image To clarify referral and care pathways

Substance misuse

image To identify the tiers and responsibilities related to substance misuse service delivery
image To discuss first-line assessment and recognition of problems related to substance misuse and appropriate care pathways
image To explore psychosocial issues, co-morbidity and care strategies for primary survey negative patients who have misused drugs

Violence and aggression

image To clarify the challenge of violence and aggression in health care
image To explore reasons why violence and aggression occur
image To discuss personal and scene safety, the use of the assault cycle, de-escalation skills and post-incident staff support

Psychotic illness

This section will discuss:

image the differentiation between psychotic illness and an organic acute confusional state
image schizophrenia
image bipolar disorders (manic depression)
image post-natal psychosis.

Around 1% of the population experience at least one acute episode of schizophrenia1 and a similar number will be affected by bipolar disorder (manic depression) at some time during their lives. Post-natal depression and psychosis is now the leading cause of all maternal deaths by suicide.

Features of psychosis and differentiation from organic confusion

In psychosis, the person typically loses the ability to distinguish between reality and thoughts due to hallucinations or delusions. These symptoms usually first appear in the late teens or early twenties (slightly later for women).

The symptoms of psychosis can be difficult to categorise. Disturbance of thought is key to the diagnosis. This thought disturbance can take -many forms. Delusions (false beliefs) and hallucinations are common. Auditory hallucinations are common – these may take the form of voices commenting on the patient’s actions or voices discussing the patient. The patient may believe that thoughts are being either inserted into or removed from their mind. Overwhelming negative feelings such as apathy, neglect and severe blunting of mood are common in severe depressive syndromes (Box 16.2).

Box 16.2 Signs and symptoms of psychosis

image Delusions – false, fixed beliefs that are not amenable to change despite objective and contradictory evidence to the contrary
image Hallucinations – disordered perception of senses including hearing voices (auditory), visual, taste (gustatory), smell (olfactory), feeling strange sensations (tactile) – these may cause the person to act on their perceptions
image Mood (affect) disturbances
image Social isolation, withdrawal and apathy – poor social and living skills, self-neglect
image Thought (cognitive) disturbances – the person may believe that thoughts are being inserted into or taken out of their mind; or that their thoughts are being broadcast; they may have disordered thinking and communicate bizarrely or incoherently
image Unpredictable or bizarre behaviour

Patients who have had a previous episode of psychotic illness are likely to be known to the specialist mental health services, though many are managed completely within primary care. It is likely that most pre-hospital and emergency care practitioners will encounter patients in crisis who have an undetected illness (the incidence of new cases of schizophrenia is 1–2 per 10 000 population per year) or those experiencing a relapse.

Exclusion of an acute organic confusion

It is not always easy to distinguish between medical/physiological disorders and mental illness presentations. Medical problems are potentially treatable and may indicate a life-threatening emergency that may be amenable to treatment (Box 16.3). History of fits, diabetes, head injury, –recent febrile illness or acute confusion should be excluded (a full list is given in Chapter 15). Check the temperature, level of consciousness, orientation and speed of onset as these can help distinguish between and physical or psychiatric cause (Table 16.1).

Box 16.3 Screening for physical causation

Medical assessment/emergency indicated if:

image fever
image history of recent fit
image impaired or depressed level of consciousness
image known diabetic
image loss of awareness of surroundings
image recent onset of confusion, disorientation and memory impairment
image signs of head injury or recent history of head injury (2 weeks)
image suspected chest or urinary tract infection (esp. in the elderly)

Table 16.1 Features distinguishing organic from functional causes of psychosis

  Organic Functional
Age >40 years <40 years
Onset Sudden Gradual
Physical abnormalities on examination Yes No
Activity Hypo-/hyper-active, tremor, ataxia Rocking, repetitive action, posturing
Consciousness Impaired Awake and alert
Orientation No Yes
Lucid thoughts Some Infrequent
Hallucinations Visual Auditory
Memory impairment Recent memory Remote memory

Psychiatric assessment

The objectives are to obtain an accurate history of the presenting problem, assess the patient’s mental state and personality, and to identify possible causes/triggers to the current situation. In addition to the usual approach to history taking and past medical/psychiatric history of the patient, it is useful to assess the patient’s expectations/wishes and their appropriateness. The patient’s mental state should then be assessed; this may involve the use of the Mental State or Mini Mental State Examinations (see, for example, the Oxford Handbook of Psychiatry2). Another approach to mental state examination is given in Box 16.4.

Box 16.4 The ABCDE model – initial psychiatric assessment

image A Appearance – neglected, dishevelled, inappropriate dress for weather/environment?
image B Behaviour – disinhibited, impulsive, bizarre, aggressive, unpredictable, withdrawn?
image C Communication – incoherent, rapid and disconnected, confused, limited/uncommunicative?
image D Ideation – beliefs, delusions, preoccupied, perception, hallucinations, thought processes?
image E Emotion – excitable, euphoric, suspicious, sad, flat, depressed, inappropriate to situation, rapidly changing (labile)?

The patient’s presentation may be complicated by emotional arousal (e.g. anger), the misuse of alcohol and co-morbidity. An example of the latter is ‘self-medication’ with cannabis by patients experiencing the symptoms of schizophrenia. In the UK 9–35% of people with schizophrenia misuse alcohol or drugs.

Analysis

The categorisation of severe mental illness is not easy. You do not have to make a definite diagnosis – indeed it may be inadvisable to ‘label’ a patient in the first contact emergency situation. However it is important to have some appreciation of the main categories. These are summarised in Box 16.5.

Box 16.5 Differential diagnoses of psychotic disorder – specific mental disorders

image Acute or transient psychotic disorder – usually associated with acute stress and resolves in 2–3 weeks
image Bipolar disorder (also called manic depression) – cyclic disorder characterised by repeated episodes of elevated mood (mania) and depression
image Persistent delusional disorder – characterised by a single delusion or set of related delusions; there are no hallucinations nor disturbances in mood, speech or behaviour
image Post-natal depression and psychosis
image Psychoactive substance abuse
image Schizophrenia
image Severe clinical depression with psychotic features

Specific types of illness

Schizophrenia

The main symptoms are of thought disorder. Belief that thoughts are being inserted or removed or transferred to the patient are common. Auditory hallucinations such as a commentary of patient’s actions or a voice anticipating or repeating the patient’s thoughts are often described. Delusions are common. The patient is often isolated and may exhibit apathy and blunting of mood.

Develop rapport and therapeutic relationship taking account of language and culture of the patient. Involve patients and carers/advocates in care decisions. Look for a previously documented crisis care plan and check concordance with and previous response to any treatment/medication package. Assess alcohol and substance use or misuse.

In an acute episode of psychosis, especially the first experience, the person may be absolutely terrified and confused. There may be suicidal ideas (about 10% of patients with schizophrenia will commit suicide within 5 years of the onset of their illness; about 30% of people with schizophrenia attempt suicide at least once). They may ‘hear’ voices demanding that they harm themselves.3 Those most at risk are male patients, the unemployed, socially isolated or recently discharged from hospital.

TIPPhysical examination may also be necessary; schizophrenia is associated with a high mortality, with death on average 10 years earlier than the general population. Cardiovascular disease and/or diabetes are responsible for many of these excess deaths1,4

Bipolar disorder

Bipolar disorder is defined by NICE5 as: ‘an episodic, potentially life-long, disabling disorder (with) diagnostic features including periods of mania and depression characterised by periods of abnormally elevated mood or irritability, which may alternate with periods of depressed mood. These episodes are distressing and often interfere with occupational or educational functioning, social activities and relationships.’

The evidence shows that there is often a considerable delay between the onset of the disorder and first contact with services.

Most people experience some changes in mood, but a patient with mania (Box 16.6) has a persistently high and euphoric mood, which is out of keeping with their circumstances and the environment. A key feature of management is to provide a calm, structured environment with avoidance of over-stimulation balanced with space for walking to use up excess –energy. Hospital admission is therefore often necessary. In contrast, hypomania (i.e. when the symptoms are not extreme enough to significantly impair work/relationships) can be managed within primary care.

Box 16.6 Signs and symptoms of mania

image Bizarre or inappropriate behaviour
image Decreased sleep which may lead to exhaustion
image Delusions and hallucinations
image Elevated mood
image Enhanced libido, flirtatiousness, sexual disinhibition and promiscuity
image Flight of ideas – racing thoughts
image Grandiose ideas and inflated self-esteem
image Impaired concentration, distractibility
image Impaired judgement and decision making
image Impulsive behaviour and recklessness, disregard for danger; spending sprees
image Increased energy and activity levels
image Increased pain threshold
image Irritability, truculence and aggression
image Labile moods – quickly changing, e.g. from elation to anger
image Poor insight
image Pressure of speech which may be difficult to understand

Be aware that many medications may induce the symptoms of mania including antidepressants, other psychotropic medication, anti-parkinsonian medication, cardiovascular and respiratory drugs, anti-TB medications, steroids and drugs of misuse.

Post-natal depression and psychosis

Following childbirth, around 70% of women experience ‘baby blues’; this usually occurs 3–5 days after the birth and resolves quickly. However, about 10% experience post-natal depression which exhibits the same symptoms as a severe (major) depression.6 Secondary survey would be supported by use of the Edinburgh Post-natal Depression Scale.7

A small percentage of new mothers (0.1%) develop puerperal psychosis (Box 16.7) – this normally develops within 3 weeks of the birth.

Box 16.7 Signs and symptoms of post-natal psychosis

image Delusions and hallucinations (as indicated above)
image Feelings of guilt
image Low mood which may alternate with elation and euphoria
image Sleep disturbances
image Appetite problems
image Confusion
image Ambivalence towards the baby

This is a serious illness and may require prompt specialist intervention and the admission of the mother and baby. ‘Why Mothers Die’ – The Confidential Enquiry into Maternal Deaths8 indicates clearly that 50% of the women who commit suicide (Box 16.8) have a previous history of serious mental illness, 25% related to their last childbirth. This is in fact the leading cause of maternal death. Four times as many suicides occurred following delivery than in pregnancy itself and many women with puerperal psychosis who kill themselves do so later than 6 weeks following delivery.

Box 16.8 Summary of findings related to women who commit suicide

image 87% were white
image 83% were over the age of 25 years
image 46% were over the age of 30 years
image 55% had previous children
image 54% were seriously ill, either suffering from a postpartum psychosis or a very severe depressive illness
image 50% had a previous history of serious illness, of whom half had been admitted to a psychiatric unit
image 50% were in contact with psychiatric services during their index maternity, 75% of whom were receiving some form of treatment
image Only one woman with significant post-partum mental illness had been admitted to a specialist mother and baby unit
image 65% of the suicides died violently, half from hanging or jumping from a height, clearly reflecting the profound disturbance of their mental state and intention to die
image Only 35% died from an overdose of prescribed medication

These illnesses were therefore neither hidden nor undetected.

(From: Why Mothers Die8)

Appropriate in-patient services may be difficult to access depending on locality since there is a national shortfall in the number of ‘mother and baby’ beds available.

Responding to a person in crisis

Whatever the category of psychotic diagnosis, the development of a therapeutic relationship and effective active listening skills are key components in helping the distressed patient in the crisis situation (Box 16.9). The client needs to feel accepted and understood by a practitioner who is trustworthy, interested, helpful and understanding. Such an approach will help -to prevent violence and aggression and facilitate assessment and appropriate referral of the patient.

Box 16.9 Responding to a person in crisis

image Accept the experienced reality but do not confirm or argue with the patient’s beliefs
image Acknowledge the person’s feelings, e.g. anger, fear – give the patient time and space to calm down, and do not take it personally
image Avoid labels, e.g. schizophrenic, alcoholic
image Do not ask too many questions
image Do not escalate the situation
image Do not patronise
image Encourage concordance with medication
image Encourage personal control where possible
image Explain everything
image Gain consent before talking to the family/carers
image Help in the ‘here and now’ – aim is not to cure the patient but to manage the current crisis
image Listen to the person’s concerns
image Look and listen for clues and incongruence in communication (mismatch between body language and what is said)
image Maintain detailed documentation
image Maintain personal and scene safety
image Make appropriate eye contact
image Plan and agree clear goals
image Reassure the patient and their family/carers
image Risk assessment and management
image Set and state clear boundaries if the person is demanding, disinhibited, etc.
image Use local referral pathways and liaise with appropriate specialist services
image Use the patient’s name
image Very careful reality testing may be helpful, i.e. offering alternative explanations

Services available

In the past, the first occurrence of an acute crisis or a relapse episode of psychosis led to admission to an acute inpatient bed. More recently such crises are tending to be managed in the community (Box 16.10). Crisis resolution and home treatment teams (CRHTTs) are designed to provide out-of-hours care for acutely ill patients with psychosis via intensive community home-based support and treatment, thereby avoiding the additional trauma and stigma of a hospital admission. Under the guidance of specialist mental health services rapid tranquillisation may be offered to enhance effective and early intervention and management of the patient.

Box 16.10 Services available (these will vary according to locality)

image Acute Admission Units (however there is a national shortage of ‘mother and baby’ beds)
image Acute Day Hospitals
image Approved Social Worker
image Assertive Outreach/Assertive Community Teams (AOT/ACT)
image Community Mental Health Teams (CMHT)
image Crisis Resolution and Home Treatment Teams (CRHTT)
image Duty Psychiatrist
image Early Interventions Teams (EIT)
image Mental Health Link (Primary Care Gateway) Workers
image Police
image Primary Care Teams
image Self-help Groups

In summary, effective recognition of psychotic presentations, detailed assessment including risk identification and enhanced awareness of available services will support the urgent/unscheduled care practitioner in managing the person experiencing a psychotic crisis. The assessment and crisis management approaches suggested here are supported by current clinical guidelines and NSFs and form the general principles for effective intervention for a mental health client in distress.

In the emergency care context it is acknowledged that there will frequently be time pressures, as well as lack of confidence impacting on the practitioner and team’s ability to fully implement the suggested guidelines and strategies. It is therefore useful for the urgent care worker to establish and develop working relationships with liaison mental health practitioners (in A&E or emergency assessment centres), mental health crisis resolution teams, and mental health link workers (in primary care), so that urgent referrals and joint assessment protocols can be developed.

Substance misuse

Following publication of the national drug strategy, ‘Tackling drugs to build a better Britain’9 there has been increased focus on the provision of drug treatment services that will work effectively with other health, social care and criminal justice service providers in order to provide seamless treatment and care to substance misusers. As part of that strategy ‘Models of Care’10 provides the framework that is intended to achieve equity, parity and consistency in the provision of substance misuse treatment and care in the UK. Treatment tiers and services are identified that are inclusive of all healthcare settings, providing guidance on the levels of intervention, assessment and expectations of those working within a given tier. This systematic approach to service structure is also designed to enable clearer recognition and access to the appropriate tier of service following identified need (Table 16.2).

Table 16.2 Structure of service provision for substance misusers

Tier Service provision
Tier 1 Non-substance misuse specific services (to include primary care providers; emergency care settings; general medical inpatient settings; general psychiatric care providers)
Tier 2 Open access substance misuse services (may include NHS and independent sector; health/social care or self-referrals accepted; offering advice, brief interventions, support and counselling, low-threshold prescribing)
Tier 3 Structured community-based substance misuse service (offering structured treatment programmes including substitute prescribing programmes, detoxification, day programmes and therapies)
Tier 4 (a) Residential substance misuse specific services (offering prescribing and rehabilitation) (b) Highly specialist non-substance misuse specific services

Emergency care settings are acknowledged as being a significant Tier 1 service due to the prevalence of overt or covert substance-related –presentations within urgent/unscheduled care. In addition it is the emergency and primary non-specialist services that commonly offer a starting point for people wishing to engage in a treatment programme. As such the necessity and value of appropriate assessment and early identification by practitioners within this field is apparent.

Emergency medical intervention may be integral to the care and recovery of a presenting substance misuser, however this chapter concentrates on the process of assessment and identification of need that form the basis of engaging with the substance misusing client.

The nature of substance misuse

Individual perceptions and experience of substance misuse will be diverse and are influenced by personal experience and beliefs, social norms, and cultural context. Diagnosis of misuse therefore has to accommodate and recognise the relevance of both objective and subjective characteristics identified within an assessment process (Box 16.11).

Box 16.11 Key diagnostic criteria (not all of which may be present)

image Compulsion and cravings. The person describes a subjective awareness of the need or desire to take the substance. This is often strongest during attempts to reduce or stop
image Salience. The substance becomes an increasingly significant part of the person’s life, often involving increasing frequency and quantity of substance used. Priority may be given to drug- seeking or drug-related behaviours relative to other previously valued activities
image Neuroadaptation. Physical symptoms of dependency may develop including tolerance and withdrawal
image Use to avoid withdrawal. A pattern of perpetuated or continual use may present due to either physical or psychological ‘withdrawal’. This may include the absence of physical dependency whereby the person has a belief system that without the substance they will be unable to function or cope
image Continued use despite negative effects. This may occur even where the potential damage is quite clear to the individual
image Reinstatement. A rapid or repetitive return to use can be noted after a period of abstinence

Discussion of substance misuse tends to emphasise cases where individuals are misusing illicit substances, however the principles and approaches described within Government strategy and this chapter would also apply to those misusing alcohol or any non-prescribed psychoactive substance.

Clinical criteria are available to aid recognition of substance misuse as a health problem, but additionally a number of more holistic and person-centred perspectives are appropriate. Substance misuse may refer to addiction, where physical dependence is implied, but may also include terms such as abuse, dependency or problematic usage. This varying language can cause confusion in both practitioners and individuals misusing substances, leading to potential difficulties in deciding when and indeed if the person is engaging in potentially harmful usage.

If an individual identifies their current use of a substance as causing difficulties in any aspect of wellbeing then it is helpful to accept these concerns as valid and their use should therefore be considered to be problematic. In assessing the presence of substance misuse, a number of themes or criteria are commonly considered and are reflected within both ICD11 and DSM12 criteria.

Assessing substance misuse

Within ‘Models of Care’,10 guidelines are offered to inform how practitioners working in all tiers of service provision assess. Three levels of assessment are identified including screening and referral; triage substance misuse assessment; and comprehensive assessment.

Tier 1 services including emergency departments and unscheduled care settings are expected to demonstrate consideration of a number of themes as part of a level 1 ‘screening and referral’ assessment (Box 16.12). It is expected that all practitioners working within this tier of service are competent in this area.

Box 16.12 Tier 1 level 1: screening and referral assessment

Content of assessment

image Identification of substance misuse problem

– Is the person currently using a psychoactive substance?
– If so, what substance(s), how much, by which method, how often, for how long?
– Is usage stable, increasing?
– Is it a problem?
– How does the person perceive their use, are they motivated to change?

image Identification of related or co-existing problems

– Consider the physical, social and psychological impact of substance misuse including medical and psychiatric complications
– Does the person present with co-morbidity? Do they have other health problems unrelated to their substance misuse?

image Identification of risks

– What kind of risk may the person face from the substance and mode of usage, from their own behaviours or physical/mental state, from the social/physical environment they are in?
– What types of risk may the person present to themselves (suicide/self-harm), to others including the practitioner, to the physical environment?

image Assessment of urgency of referral

– The culmination of previous content gathered. Commonly informed by aspects of risk. Where a risk is identified it may be helpful to consider:

– imminence; how soon might the risk event occur?
– severity; how bad will it be if it happens?
– likelihood; how likely do I think it is to happen?
– This can be helpful in deciding the urgency of action needed

Outcome of assessment

image Identification of an appropriate service for referral

– Will be informed by content of assessment, and should consider the person’s needs, wishes and motivation
– A non-dependent client may benefit from immediate ‘brief intervention’ (see below)
– A low risk client with relatively uncomplicated presentation and motivation may be advised of or referred to Tier 2 services
– Complex, vulnerable or high-risk presentations where significant need and/or prescribing/detoxification are indicated might be referred directly to Tier 3 services

It is essential that in undertaking an assessment of substance misuse, respect and regard for the client is demonstrated. Substance misusers often have experienced a number of traumatic life events leading to their use of substances. The reasons why a person may use are complex and multifaceted13 and as such moral judgements and assumptions are unhelpful to both the client and practitioner. Whilst practitioners in urgent and unscheduled care environments may not have the time or opportunity to explore why someone has developed a problem, they can usefully accept that whatever the reason, it is valid. A non-judgemental, open and conversational approach to assessment is advocated.

Brief interventions

Individuals presenting with ‘early’ problems can be usefully targeted and brief interventions offered to minimise future significant misuse and maximise long-term positive outcomes.14 This approach has proved especially beneficial where a person does not present with overt dependence and is particularly relevant to emergency and primary care practitioners. Brief intervention (Box 16.13) is extremely effective and may take as little as 15 minutes to complete.

Box 16.13 The components of brief intervention – FLAGS

image F – Feedback on risk or health implications due to drug use
image L – Listen to the patient’s concerns
image A – Advise patient about the consequences of continued drug use
image G – Goals of treatment should be defined, e.g. to reduce or cease drug consumption
image S – Strategies for treatment should be discussed, e.g. limit setting on use, recognising triggers to use, and accessing support. A follow-up appointment may be made

Violence and aggression

Healthcare practitioners are at risk from patients, relatives and the public generally; additionally patients also present risks to each other.15 Ambulance trust staff are reporting an increase in violence and aggression cases and 43% of the incidents reported in acute trusts are within Accident and Emergency departments.16 The prevention and management of these episodes is a significant challenge for the providers of primary and emergency health care. Overall within NHS organisations there are 11 incidents per 1000 staff monthly but the rate is 2.5× higher in mental health and learning disabilities trusts.

By the very nature of emergency care, individuals who come into contact with services are likely to be experiencing some form of distress. Physical and mental illness (which may include substance misuse and patients suffering from psychosis) can lead to changes in perception, which may increase misinterpretations of the intentions and actions of healthcare staff. Anxiety heightens an individual’s senses. Potential cultural difficulties with non-verbal communication misunderstandings and misinterpretation as well as language may also trigger distress and frustration17,18 (Box 16.14).

Box 16.14 Reasons why violence and aggression occur

image Factors internal to a patient:

– physiological arousal
– misperception, e.g. of sounds, actions
– psychological aspects, e.g. feelings of loss of control, anxiety, fear, acute distress
– acute sensory deficits – hearing or sight loss leading to breakdown in communication
– unrealistic expectations

image Staff attitudes, lack of understanding of patient expectations
image Organisational factors
image Situational and environmental factors
image Actions of others, e.g. family

(Adapted from NICE, 200517)

Anger is not the only prerequisite of violence and aggression. Angry people are not always violent, but a link between this powerful emotion and associated potentially dangerous behaviour is accepted. Factors which may exacerbate a person’s anger are summarised in Box 16.15.

Box 16.15 Factors which make people angry

image Lack of respect
image Not being listened to
image Loss of control
image Sense of injustice
image Discrimination
image Lack of competence in others

Personal and scene safety

Good risk assessment skills (Boxes 16.16 and 16.17) are necessary in the urgent/unscheduled care arena. Personal and professional safety —-of practitioners may be largely attributed to good habits and systems. It is the good safety behaviour which is carried out all the time which can make the difference in potentially life-threatening situations, rather than additional precautions taken in particular circumstances.

Box 16.16 Summary of patient and environmental risks

image Confusion
image Alcohol or drugs
image History of violence
image Hallucinations and delusions (explored below)
image Longer than normal/expected response time
image Forced entry to gain access to patient
image Crowds – especially at clubs, pubs or concealed spaces with restricted access
image Lone workers without back-up
image Radio black spots
image Domestic violence
image Presence of others perceived as a threat (including, for example, police or security staff)

Box 16.17 Tips for enhancing personal safety

image Good communication systems with agreed codes
image Alarm systems
image Radio provision
image Information links with police re locations
image Flagging systems
image Good quality patient information including realistic response times
image Lone workers without back up should not attend pub fights or domestic violence situations or locations with known access substance misuse or crowd difficulties

(Adapted from DoH 200219)

The assault cycle

The assault cycle (Box 16.18) is a theoretical model which offers general advice rather than specific predictions. The trigger phase is a time -at which distraction may be important. It also offers an opportunity to assess and prepare for any potential risks. Escalation is the phase which may lead directly to assault. These phases offer opportunities for skilled de-escalation of a situation. Within the crisis phase a potential assailant experiences physical and psychological arousal. Control over aggressive impulses and the ability for rational thought decreases and this may lead to assault. The practitioner will also experience physical and psychological responses that may influence their control and effectiveness. At this stage self-management with a focus on safety issues related to the client, self and others is important.

Box 16.18 The assault cycle

Trigger phase

Behaviour moves away from baseline, e.g. agitation, poor concentration, raised voice

image Interventions: identify potential risks; early use of de-escalation techniques may include distraction

Escalation phase

Behaviour escalates

image Interventions: continued use of de-escalation techniques

Crisis phase

Patient and staff member are both aroused and assault is imminent or occurring

image Interventions: reasoning is no longer possible; manage own physiological and physical responses with an emphasis on safety of all involved – escape, use of barriers, alarms/shouting to summon help

Recovery phase

Patient is calming and returning to baseline

image Interventions: most intervention errors occur at this stage – be aware of the potential for ‘flare up’; do not attempt an exploration of the incident at this stage

Post crisis phase

The patient is low in mood, remorseful, guilty, ashamed, despairing

image Interventions: explore the reasons for the incident; reject the behaviour not the person; ensure all others involved receive support

TIPHelpful actions: escape (note your escape routes carefully); protect self by use of barriers; engage the support of others

After crisis comes the post-crisis phase – this is where most intervention errors occur. It is vital to acknowledge the potential for events to ‘flare up’ as significant time is required for individuals to calm both psychologically and physiologically (often cited as at least 90 minutes). In the final recovery phase an assailant may be mentally and physically exhausted and is commonly remorseful, ashamed, distraught and despairing. At this stage individuals may be responsive to interventions designed to relieve guilt which reject the assaultative behaviour but not the individual as a person, understand the incident and identify strategies to prevent a recurrence. It is vital that full attention is also given to the needs of the victim.

The assault cycle makes a series of assumptions. These are that violence is often used when someone feels powerless in relation to the professional or the system. Intervention is possible at all times except the crisis phase, when physical safety is paramount. The client and the worker experience high levels of physical or psychological arousal during episodes of aggressive behaviour, and this will affect how they both behave; the practitioner should be able to access appropriate training to develop techniques to overcome this.

De-escalation

De-escalation involves the use of techniques to calm down a threatening situation and should be applied early prior to any other interventions being used (Box 16.19).

Box 16.19 Advice to de-escalate the situation

image One person should take control and steps must be taken to manage the environment
image Where weapons are involved a staff member should ask for the weapon to be placed in a neutral location rather than handed over
image Other people may be removed from the area by moving towards a safe place and avoiding being trapped in a corner
image The aggressor may be taken to a quieter but safe area where help is at hand
image Creating space
image Enlisting support from others
image Identify potential risks from others

(Adapted from NICE 200520)

De-escalation involves self-awareness of the messages that the worker is conveying through their verbal and non-verbal communication (Box 16.20). In effective de-escalation a person shows concern and attentiveness through non-verbal and verbal responses – listening carefully, acknowledging any concerns or frustrations, and not being patronising or minimising the patient’s experience. The worker’s non-verbal communication is non-threatening and not provocative.

Box 16.20 Key de-escalation principles

image Attend to non-verbal cues including eye contact
image Allow greater body space than normal
image Adopt a non-threatening but safe posture
image Appear calm, self-controlled and confident
image Do not appear dismissive or over-bearing
image Explain intentions giving clear, brief, assertive instructions

The worker who has taken control asks for facts about the problem and encourages reasoning by asking open questions and inquiring about the reason for the anger. Threats are avoided. This works to establish rapport and emphasises co-operation – offering and negotiating realistic options. Expressions of anger need to be treated with appropriate measured and reasonable responses. In a crisis situation staff are responsible for taking steps to avoid provocation (Box 16.21). It is unrealistic to expect a person exhibiting disturbed/violent behaviour to simply calm down.

Box 16.21 De-escalation techniques

Environmental

image One staff member to take control
image Move to a safe area
image Minimise other distractions such as noise
image Move others
image Create space
image Ensure support is close at hand
image Ask for weapons to be put down
image Consider any sensory impairments
image Attend to the cultural context

Verbal

image Minimise risks of misinterpretation
image Show concern
image Explain intentions
image Offer and negotiate realistic options
image Avoid threats
image Establish rapport and emphasise co-operation
image Give clear, brief assertive instructions
image Ask open questions
image Listen carefully to concerns – do not minimise these or be patronising

Non-verbal

image Minimise risk for misinterpretation
image Show concern
image Non-threatening posture
image Allow personal space
image Manage eye contact

(Adapted from NICE 200520)

Post-incident support

Individuals experience emotional, cognitive and physiological reactions during the first six weeks after an assault. A single episode of violence or aggression may have a profound impact or the effects may be the result of cumulative abuse. Feelings experienced after an assault include -disbelief, helplessness and frustration, accompanied by resentment and resignation. In most cases these symptoms are resolved after the first six months. It is in this initial most vulnerable period of time when support needs to be available. It is not only the person who is assaulted that suffers; witnesses need support.

Psychological debriefing (also referred to as Critical Incident Stress Debriefing – CISD) was originally developed for use by groups of emergency workers post-incident. This is a structured, supportive approach led by a trained facilitator (Box 16.22).

Box 16.22 Stages of CISD

image The introduction of team and establishing ground rules
image Establishing the facts of the incident
image Exploring the thoughts, decisions and impressions of those involved
image Exploring emotional reactions
image Normalisation of post-trauma reactions, offering anticipatory guidance and advice on helpful coping
image Exploring future planning and coping including mobilisation of support
image Disengagement

(Adapted from Dyregrov 198921)

There is disagreement as to the effectiveness of this approach, with some suggestion that it may actually be harmful. Individuals have varied coping strategies and it should be made very clear to those who have been involved in incidents that a range of different support is available and that attendance at debriefing is not the only option nor is it compulsory.

In summary, the effective recognition, prevention and management of violence and aggression is of central importance to emergency care staff. This is a complex area encompassing a wide range of reasons why aggression and violence occurs. Recognition and an understanding of the role that staff, patients and environmental factors play in ameliorating the outcomes in potentially explosive situations is central to the provision of high quality care. Individuals and groups of staff have a vital role to play in maintaining personal and scene safety. This will be promoted by the employment of good safety behaviour all the time, with additional precautions as indicated.

References

1 Prodigy. Schizophrenia guideline, 2004. Available online: http://www.prodigy.nhs.uk/guidance.asp?gt=Schizophrenia (5 Mar 2007)

2 Semple D, Smyth R, Burns J, Darjee R, McIntosh A. Oxford handbook of psychiatry. Oxford: Oxford University Press, 2005.

3 Andrews G, Jenkins R. Management of mental disorders. (UK edition). World Health Organization, London, 1999.

4 National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE, 2002. Available online: http://www.nice.org.uk/pdf/CG1NICEguideline.pdf (5 Mar 2007)

5 National Institute for Health and Clinical Excellence. Bipolar disorder clinical guidelines. London: NICE, 2004. Available online: http://www.nice.org.uk/guidance/cg38/niceguidance/pdf/English (5 Mar 2007)

6 Doy R, Burroughs D, Scott J. ABC of community emergency care. Issues in Mental Health – consent, the law and depression – management in emergency settings. Emerg Med J. 2005;22:279-285.

7 Cox J, Holden J, Sagovsky R. Detection of post-natal depression: development of the 10-item Edinburgh Post-natal Depression Scale. Br J Psychiatry. 1987;150:782-876.

8 RCOG. Why Mothers Die 2000–2002. Report on confidential enquiries into maternal deaths in the United Kingdom. Available online, 2002 http://www.cemach.org.uk/publications/WMD2000_2002/content.htm. (5 Mar 2007)

9 UKADU. Tackling drugs to build a better Britain: the Government’s 10-year strategy for tackling drug misuse. London: Department of Health, 1998.

10 DoH. Models of care for substance misuse treatment. London: Department of Health, 2002.

11 WHO. International classification of diseases (ICD 10) – Classification of mental and behavioural disorders. Geneva: World Health Organization, 1992.

12 American Psychiatric Association. Diagnostic and Statistical Manual of Diseases (DSM-IV). Washington, DC: APA, 1994.

13 Peterson T. Exploring substance misuse and dependence: explanations, theories and models. In: Peterson T, McBride A, editors. Working with substance misusers, a guide to theory and practice. London: Routledge, 2002.

14 Hulse G, White J, Conigrave K. Identifying treatment options. In: Hulse G, White J, Cape G, editors. Management of alcohol and drug problems. Oxford: Oxford University Press, 2002.

15 Chambers N. ‘We have to put up with it – don’t we?’ The experience of being the registered nurse on duty, managing a violent incident involving an elderly patient; a phenomethodological study. J Advanced Nursing. 1998;27:429-436.

16 NAO. A safer place to work: protecting NHS and ambulance trust staff. London: National Audit Office, 2003.

17 National Institute for Health and Clinical Excellence. Clinical Guideline 25. London: NICE, 2005.

18 Paterson B, Leadbetter D, McComish A. De-escalation in the management of aggression and violence. Nursing Times. 1997;93(36):58-61.

19 Department of Health. Zero tolerance zone fact sheets. London: DoH, 2002. Available online: www.nhs.uk/zerotolerance/intr.htm (15 May 2005)

20 National Institute for Health and Clinical Excellence. The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. Clinical Guideline 25. London: NICE, 2005.

21 Dyregrov A. Caring for helpers in disaster situations – psychological debriefing. Disaster Management. 1989;2:25-30.

Further reading

Joint Royal Colleges Ambulance Liaison Committee. Clinical Practice Guidelines version 3.0, University of Warwick/JRCALC. Available online:, 2004 http://www.library.nhs.uk/emergency/. (5 Mar 2007)

Mynors-Wallis L, Moore M, Maguire J, et al. Shared care in mental health. Oxford: Oxford University Press, 2002.

Simon C, Everitt H, Birtwhistle J, Stevenson B. Oxford handbook of general practice. Oxford: Oxford University Press, 2002.

Wright S, Gray RK, Parkes J, Gournay K. The recognition, prevention and therapeutic management of violence in acute in-patient psychiatry: a literature review and evidence-based recommendations for good practice. Available online:, 2002 http://www.ukcc.org.uk/aDisplayDocument.aspx?DocumentID=665. (5 Mar 2007)

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