Thoughts on Dealing with Aggressive Behavior

One of the most common problems we have faced on the services is the control of aggressive behavior by the individuals. For the most part, external controls, such as restraint and administration of medication have been utilized. Our goal is to: a) minimize the provocations by the staff, by explaining to them the various triggers or pressure points that evoke this behavior. Next, they need to be trained in utilizing methods to calm the individual down: a) talking to them to elicit what’s bothering them, or if it’s too hot a topic, discussing a pleasurable activity, such as having a visit from a brother; b) becoming active by talking a walk, listening to music, or playing catch with a ball; c) more passive coping, such as using mindfulness. All of the above may help to reduce the number of outbursts, but do not really effect the internal dynamics, which power the aggressive response, when it is activated.

In addressing this problem, we look for the meaning of the provocative stimulus: the most general meaning is that the individual feels diminished in some respect. For example, being told they have to take their medication means being controlled, in other words, losing control over their environment. The exaggerated meaning is that they have no control; however, the more poignant meaning is that they are being degraded by this form of social control, and therefore, are worthless. The next consideration is that, in working with the individual, to modify the internal dynamics, the approach needs to be collaborative. The first step, as with all individuals, is to establish an engaged relationship with the individual. Sometimes, you are called upon to help with an individual with whom you have not already formed a relationship. In some cases, facilitating the individual’s expressions of feelings about being subdued, or prior to that being devalued and hurt, helps to defuse the anger, in other words, deactivate the aggressive mode.

After there has been a sense of collaboration or at least connection established, it is possible to take the next step, which is to explore with the individuals the advantages and disadvantages of their aggressive behaviors (try to use the kind of expressions that the individual uses, such as “hitting other people”). First, it is valuable to explore with the individuals’ their ultimate goals (get back into the community, join the family, get a job, etc.), or more proximal goals, such as doing more things on the unit leading up to getting discharged, such as getting along better with the staff, and avoiding having to be restrained. Then, review examples of advantages of not striking out: “I stand a better chance of reaching my goals and people will stop being critical of me.” Some examples the advantages of striking out, elicited from the individual, include: “I can get back at people for insulting me, I will feel better if I let things out, I will feel worse if I don’t let things out, people will respect me more, I will feel more in control of the situation.” Then, review the disadvantages of striking out: “I actually lose control of the situation and I feel bad afterwards. Hopefully, the individual will see the aggressive behavior as an obstacle in the way of the goals, and see advantages in at least trying out methods of controlling the outbursts. More broadly, the idea of getting back at people is of such small significant when compared to the broader picture of having one’s life back.

It is often a value to model specific behavior to be engaged in when the patient feels upset, and is driven to hit somebody: the therapist can reenact a particular scene or have the individual fill in the details of how he/she felt and thought. The next step is for the therapist to simulate how the patient felt and to demonstrate various methods, for cooling the anger or diverting the attention. There are things, for example, that the individual could say to himself/herself, such as count to ten, take a walk, etc. After the individual has rehearsed this, a number of times, it would be well to use imagery. The individual imagines himself/herself in the situation, tries to feel the emotion, and fights the impulse to strike out at the environment. Positive imagery can also be used. The individual could imagine anticipated pleasurable events in the future, or pleasurable events in the past. Another use of imagery has been termed compassionate imagery, for example, imagining somebody weak or in distress that one would feel sorry for, sometimes imagining a pet that’s been hurt, seems to work. A number of research studies have shown this to be a powerful intervention in psychosis. Another aspect would be forgiveness imagery, which could be effective with people who misread or overreact to apparent slights. Finally, total acceptance may be used in imagery.

The ultimate factor has to do with reenacting, with the therapist, a traumatic event from the past, actually reliving it with all of the emotion and impulses associated with it. Then, utilizing corrective restructuring, such as what they say or do doesn’t mean anything, or if I think they are putting me down, that’s their problem. The point of this is to identify the catastrophizing that the individual does, before striking out, and decatastrophizing. The final strategy is the identification of the individual’s belief system and helping the individual to modify it: “If you don’t strike back at them, then they will run all over you (the opposite of course is, by striking out the staff does run all over the individual).” Other beliefs are “If you don’t strike back, they will consider you a pushover (and that is intolerable).” “This is a dog-eat-dog world, and you have to keep fighting just to stay alive (the elegant solution is to enable the individual to modify this belief system).”