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VIOLENT PATIENTS

The majority of violent patients are not medically ill in the true sense, but are people who under certain circumstances respond with violent behaviour. This is sometimes associated to alcohol or drug abuse. Major mental disorders are not the chief causes of violent behaviour, except in some cases of acute psychosis in which physical restraint is inevitable (see ACUTE PSYCHOSIS).

We can consider the subject as being able to develop violent behaviour when:

• They speak viciously, threateningly and in vulgar terms.
• Show elevated muscular tension; for instance, sit on the edge of their seats or hold their arms tensely.
• Find it impossible to remain still, are fidgety and distrustful.
• Slam or open and close doors, or constantly drum their fingers on furniture.
• Demonstrate an irritable attitude and easiness for arguing with those around them that reaches the stage of verbal threats.

Norms of action when dealing with violent patients

1. If the subject's state is not manifestly aggressive and they are willing to receive help, you should try to calm them down by talking to them. The aim of this conversation is to make them understand that you can help them to control their impulses if they wish to cooperate.


• Allow them to choose with whom and where they want to speak, and whether they prefer to stand or be seated.



• Avoid the presence of unnecessary people during the interview.



• Maintain a physical distance. Do not touch them or say things that may excite them.



• Do not humiliate them or make them feel rejected. Impose limits on their behaviour but never in a threatening way or showing anger towards them.



• Tell them about the possibility of consulting a doctor about their problem (MEDICAL ADVICE VIA RADIO ).



• If the subject suffers from hallucinations or believes someone is trying to kill or harm them, do not argue with them nor tell them they are delirious or lying, as this may excite them even more. Let them see that you are able to help them, though warning them that you will not speak to them while they adopt an aggressive attitude.


2. If the patient is openly aggressive and violent or brandishes a weapon, talking may anger them further, so physical restraint should be used, according to the following method:
   
   
   • A minimum of five people should work together, following a pre-established plan, take hold of the head (one person) and limbs (one person per limb). The action should start on the command "Now!" given by one of the participants (see figure 9-1).
     
     
     

     Figure 9-1: How to restrain a violent patient.

   
   
   • The action should take place while the subject is distracted, making sure that when someone else distracts the subject, the Group of five immobilises the subject acting at the same time.
   
   
   
   • Leather straps are the most secure (bands, belts etc.) and should be tested periodically. Straps with cords are also effective, although it should be ensured that these are not so fine as to injure the patient during the struggle and that the knot is not tied so tight as to stop the circulation. The Neil-Robertson stretcher may be employed. (OTHER MATERIAL NOT INCLUDED IN DRAWERS, Medical kit A) (see figure 9-2).
     
     
     
     
     Figure 9-2 physical restraints with the Neil-Robertson stretcher.
     
     
   • Ask for MEDICAL ADVICE VIA RADIO ; the doctor will indicate the appropriate method.
   
   
   
   • Do not release the straps except in the presence of sufficient people to repeat the action if the subject starts struggling again.
   
   
   
   • Calmly explain the reason for the restraint to the subject.