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INTRODUCTION

“Darkness cannot drive out darkness: Only light can do that. Hate cannot drive out hate; only love can do that.”

–Dr. Martin Luther King, Jr.

OBJECTIVES

  • Explore the aggression continuum and escalation cycle

  • Map out the assault cycle

  • Identify triggers of aggressive or violent behavior

  • Identify escalating behaviors

  • Assess the patient’s behavior for signs of agitation

  • Grasp the importance of early intervention

In any tense situation, assessment is a critical practice. Correctly assessing a situation enables you to determine whether escalation has occurred or is likely to occur and to quickly intervene. Based on your assessment, you can develop strategies to de-escalate the situation. That’s what this chapter is about. It discusses the aggression continuum and the escalation cycle, identifies common causes of escalation and common escalation behaviors, and discusses the importance of early intervention.

THE AGGRESSION CONTINUUM AND THE ESCALATION CYCLE

Tense situations often escalate into incidents involving aggression. Aggression is defined as an intense physical or verbal reaction that indicates rage. Aggression may in turn escalate to physical or verbal destruction that can harm self or others (Simon & Tardiff, 2008).

The escalation of aggression occurs on a continuum. Absent the initiation of de-escalation interventions, the aggression will likely progress along the continuum. As it does, anxiety and emotion are heightened, and anger is often the result. Being aware of this continuum can help you correctly assess a tense situation.

As shown in Figure 3.1, this continuum has three phases:

  1. The trigger phase. In this phase, a catalyst event that causes stress starts the escalation process (Byrnes, 2000).

  2. The escalation phase. During this stage, anxiety builds, arousing angry emotions.

  3. The crisis phase. In this phase, the person loses control of the ability to speak and eventually experiences a total loss of reason and self-control (Byrnes, 2000). An individual may act violently toward others in this phase.

FIGURE 3.1

Loss of self-control into violence.

As individuals progress through the aggression continuum, their emotions often escalate in a predictable cycle (see Figure 3.2):

  1. Calm. Individuals are in this stage before a catalyst event triggers them.

  2. Anxious. This stage occurs after a triggering event. People in this stage of the cycle may exhibit behaviors such as a tense posture, fidgeting, pacing, hand-wringing, foot-tapping, and irritability. They rarely verbalize their anxiety, choosing to bottle it up instead. This sometimes causes them to explode—quickly advancing from anxiety through the remaining phases of the cycle.

  3. Agitated. As the situation escalates, the person may become agitated. Behavioral signs of agitation may include clenching one’s teeth or fists, cursing, and shouting.

  4. Aggressive. An aggressive person might display any number of telling behaviors. These might include insulting, intimidating, or threatening other patients or staff; ...

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