Psychiatric Pearl: Address The Fear, You Address The Anger

[Thunderwolf, MSN, RN]

When faced with an angry patient, what goes through your own mind? What are your typical responses? What interventions have you tried and used effectively? How did these interventions work or fall apart? What were the outcomes? And how did you feel afterwards once the crisis had moved on?

In answering these questions and before addressing the issue of the angry patient, some time needs to be spent first looking at yourself before facing these situations. Looking at your past examples, when faced with anger directed at you, what happened? Did you become angry yourself? Did you feel your pulse race? Did you feel hurt or feel like running? Did you go into an automatic response of behavior or "into mode?" The thing I am trying to point out (when faced with anger in front of us) is that fear or anger may also be triggered from within. Is this a bad thing? No. Is this a good thing? Yes and no. Let me explain.

You have heard or may have witnessed that anxiety, fear, and even anger can often be contagious...and it is. Like when one person yawns, someone else close by often tends to yawn also. People do not live in a vacuum. On a deep level, we respond and trigger each other. When you become triggered by someone angry or fearful in front of you, what happens? Be honest. When you become angry or fearful in front of someone else, what happens? Again, be honest. Knowing this about ourselves and others is important.

When fear or anger are present, the energy behind it has typically built up already to toxic levels, allowing for spread or outward leakage to occur to you and others. As a psychiatric nurse, when your own anger or fear has been triggered, it may often be a good indicator as to what is going on inside the patient...like a mirror. The feelings inside of you may be very similar to the patient's. Let this be a cue for you. So, if you were the patient and having this emotion (fear or anger), what would you need to reach equilibrium once again?

The contagion of fear or anger can often become detrimental when it is allowed to go unchecked and is allowed to build up, then requiring an explosion in order to resolve itself. This is not good. Like a grenade, casualties can result. Additional energies are often required to clean up the mess. So, waiting it out and hoping for the best is not productive at all. Explosions powered by either fear or anger may have been long coming, could have been prevented, and may now become evident by the patient needing to release this energy via acting out or by violence. The same may also be evident when anyone else is caught in the cycle...a visitor, a colleague, or even the nurse him/herself. So, if you become aware of the emotion of fear or anger, now is a time to intervene...not later, but now. As a nurse, if being mindful of the nature of both fear and anger and how it works and spreads, you can become a proactive change agent in reversing it dead in its tracks...preventing the need for explosions.

Fear and anger are two very powerful emotions. But, in and of themselves, they do not occur for no reason. There are reasons...regardless if they are real or imagined. Often times, fear and anger become linked like kissing cousins. When one is present, the other is close behind. One example would be a paranoid patient. The higher the paranoia, the higher the risk for anger. If the intensity of the fear is permitted to increase, the risk becomes higher also for anger to be expressed in outbursts. If unresolved or permitted to build, eventual violent acting out may result (explosions). So, by addressing the fear, the anger also gets addressed via association. Knowing this is extremely helpful. Typically, however, anxiety tends to be the underlying or base emotion of both fear and anger. If you address the underling anxiety, you often end up addressing the fear and/or anger in front of you. Like with the grenade analogy, anxiety tends to provide the emotional fuel. When anxiety becomes more concentrated, it becomes more potent....which makes the difference between a little bomb versus a big one. As a nurse, you do your patient great service addressing the presence of anxiety and preventing its build up.

So what do you do when faced with an angry patient? First, perform your own reality check. Check your own emotions and how have they been triggered. If you are gearing up, you need to be mindful that the best thing to do is to gear down. If you respond back with your own fear, frustration or anger to the angry patient, you just may provide additional fuel to him/her, escalating the situation more. Second, get or call for assistance to help you. This helps in two ways. One way is that it helps diffuse the energy focused directed on you. The second is that the patient is now provided evidence that the intensity of the moment now calls for additional support.

When I am approached by an angry patient, I consider it an invite to explore and/or to come to understand this patient's fears. Remember, fear and anger are but kissing cousins in many ways. The outward anger is apparent. No mystery here. What has yet to be answered though is the fear connected to this outward display of anger. So, when I see an angry patient, I also tend to see a fearful patient. This puts things in better perspective for me and helps guide my approach. Many times, the patient's fears become obvious as well, as they are being verbalized by the patient as he/she spews forth his/her anger. If this is the case, I attempt to address them by listening for them and asking supportive questions. Sometimes, these fears are kept hidden by the patient. Hidden fears, however, can only be addressed later on after trust has been established first and after the current crisis has been resolved. So, if the patient's fears are being verbalized, good. If they are not, I listen closer for them. If unsure, I ask or seek clarification. If fears are kept hidden during this moment, I attempt to alleviate the base fuel for high emotion by addressing issues of anxiety that may be present for this patient or are common for people in this situation. So, in a nutshell, the schematic of my approach is: Anger-->Fear-->Anxiety-->Fear-->Anger

When it comes to anger and the angry patient, often times, the most effective step is to simply gear yourself down, close your mouth, and listen. When you do speak, the use of volume can also be an effective tool. The louder the patient's voice, the softer yours becomes. In a way, it is but an invite to the patient to speak at the volume level you are choosing. Eventually, the patient's volume will match your own. Inform the patient that you are listening and wish to understand him/her correctly from where he/she is coming from. If need be, pointing out your fellow colleague (standing close by to you) that he/she is but another means to validate what is being heard correctly.

Depending upon the patient and/or the situation, I may explore with the patient his/her expressed fears....but utilize the term "needs" instead of the term "fear". The term "fear" is a loaded term and engenders fuel all its own. Shy away from fuel engendering words and from words that may add to confusion (ie words that may have additional meanings). By using the term "needs" instead of the term "fear", it hastens further dialog.

Until the situation diffuses, the communication starts off as a one way street...the patient is provided the platform to talk, vent, and/or express his/her "needs"...and you are the listener. State to the patient clearly, "I am listening." Occasionally, you may also repeat back briefly what the patient said, word for word. "You said, I am upset over the food and nobody cares. I hear you." While listening, take cues from the patient when it is now time to ask some follow up questions. When you provide active listening, you are subtley working on building trust between the two of you. By listening, you are showing the patient that you extending a hand of collaboration with him/her...working together, not against each other.

Body language is important too. When faced with an angry patient, provide him/her distance. Make sure that you are not backed into a corner and cannot escape. Never place the patient between you and the door. Observe the patient's stance and degree of muscle tension. Observe the character and energy contained in his/her eyes and hands. The eyes and hands have their own language. Are the eyes wide, staring, or darting? Are the pupils dilated or pinpoint? Are the hands clenched, in and out of the pockets, dancing in the air, repeating gestures? Observe the energy being produced and expressed. The expressed energy in body language will cue you to the energy being produced or eliminated internally.

Monitor your own body language, and if possible, have it reflect or model a level of relaxed posture. I often will cup my hands in front of me just below or at my waist level...almost reflecting a meditative posture...a relaxed posture. My stance is held just off a little to the side, not square on with the patient. Square on stances may be interpretated as threatening or challenging. Holding your stance just a bit off to the side with your hands near your waist is also a protective posture for you. If a patient should kick or strike out at you, you have better opportunity to either step back, avoid, duck, or block the blow coming at you. Eye contact by you should be just a tad less than used in normal interaction. Eye contact by you is not to be interpreted as challenging or to be used as a challenge. Often times, I will make a tad more sustained eye contact when I tell the angry person, "I am listening" or " You said, I am upset over the food and nobody cares. I hear you." I use my own eyes to emphasize that I am listening and am present.

Once the angry patient has had time to express his/her fears/needs/concerns, if they are reasonable and doable to be addressed, briefly state so. Inform the patient what you are willing or capable of doing for him/her. If only some of the request is reasonable or doable, offer to the patient what is possible by you. Demonstrate your willingness to collaborate. Offer this to the patient.

After the angry patient has diffused his/her anger by your listening and addressing his/her expressed fears, it is now time for you to offer your own invitation. Your invitation could be open ended, such as, "Anytime you feel this way and I am here, ask for me, I will come" or "What can I do for you the next time you feel this way?" Your invitation could also be tailored with more structure added, such as: "I will check on you during the course of my shift, and if you should need me, we can talk again." After you have extended the invite, ask for a sign of collaboration, like : "Would this be alright?" or "Thank you for sharing your concern with me." or "I am happy we had this chance to talk." These expressions offers the angry patient a chance to form an agreement with you by having the last words, such as: "Yes, that would be OK." or "You're welcome" or "I am (happy) too." Even a silent head nod counts.

So, the crisis is resolved at the moment...for this moment. How well did you do? Use this time to reflect upon the scenario, upon yourself, and upon the patient. What worked well? What needs some additional work by you? If you were to rate yourself on a 0-10 scale....how did you rate? How well were you to keep your own emotions in check? What behaviors in you escalated or deescalated the patient? How long did it take?

So far, we have spent quite a bit of time on energy...it's spread, it's build up, it's expression, it's explosion, and how to diffuse the ticking time bomb. Now, it is time to explore some options available in preventing future occurrences. Again, let's go back to the base fuel, anxiety. What are some things that may cause anxiety and fuel the pump towards fear or anger? Many things, actually.

In and of itself, the hospital/clinical setting is very much anxiety producing. Much of this hospital anxiety is caused by "the unknown" or "by not knowing what to expect." You as a psychiatric nurse can be most effective here. One of the best ways to reduce anxiety in patients is by providing this information or "structure." Keep the patient in the loop and keep him/her informed about the daily events. When you start your shift with a patient, introduce yourself and who you are. Inform the patient what to expect (meds, tests, procedures, assessments, et cetera) while you are there. Providing structure reduces anxiety. If the patient is asking questions, it simply means the patient is asking for more structure.

Also, being in the hospital/clinical setting, a patient can often feel helpless and powerless. Everyone else seems to be making the decisions for him/her. For a patient who prides independence, this can be devastating. For a paranoid patient, this can be threatening. This is not good. By encouraging collaboration and exploring choices together, the patient becomes less anxious by believing him/herself as a partner. As a partner, the patient is encouraged to ask questions. Answers are provided, clearing up mysteries and dispelling any doubts that the patient may have.

The psychiatric nurse can reduce patient anxiety by the use of humor. This can be accomplished by inviting a patient to explore something funny or in a different light. Getting the patient to smile or laugh is an excellent way in reducing anxiety. The heartier the laugh, the better the discharge of anxiety.

Meeting the patient's biological needs are also effective. If the patient is in pain, providing comfort measures and medications are often helpful. If the patient is tired, encouraging periods of rest. Adequate, restful sleep is key to reducing stress and anxiety. If hungry, nutritional foods to eat at meal times and for snacks are provided. Paying attention to daily hygiene, grooming, and toileting are also crucial. It is difficult to feel well if one feels unkempt and dirty. As nurses, we pay attention to these aspects of general well being.

Much can be done to reduce patient anxiety. However, if not addressed, anxiety may concentrate up to higher levels of emotion, like fear and anger. And if ignored or left unattended, explosions of emotion or behavior may occur. When you are approached by an angry patient, don't become shaken by it. Instead, begin addressing the immediate fear linked to the anger. If you address the immediate fear, you often come to address the immediate anger. As psychiatric nurses, we can help diffuse the concentration of energy that leads to anger. By paying attention to our own internal emotions and by being observant to our patients, we can become aware of the spread of toxic energies. And once aware, intervene.

[LethaChristina]

Exactly so! What we often don't expect from "psych patients" is often the cause of anger (even on-going anger) are problems within the very system expected "to heal." Had we only listened (so adroitly and expressively explained here), these issues do not have to go "on and on" nor reach the "boiling point." Sometimes patients are angry for excellent reasons (meaning here, not that all anger isn't justified, but that the reasons may well be something from which WE, as clinicians, can learn. I've met so many well-informed and thoughtful psych patients even on the streets of Seattle--whom have been shoved off into "no man's land" with no identity/ability to self-care thanks to the very treatment imposed upon them by biological psychiatry and medicine. Fear of emotion in this culture is also rampant, along with such a lack of trust in each other, we simply do not believe what is told us at all... by almost anyone. We ARE in "survival" mode as a culture, obviously--but we as healthcare professionals cannot fall into the same kind of traps--or we will be useless to others and ourselves. We have the "educational advantage"... as well as the life experience... we owe it to society to be "change agents."