Whether we work in health care, education, or any human services field, we might have to deal with angry, hostile, or noncompliant behavior on any day. Our appropriate response to defensive behavior is often the key to avoiding a physical confrontation with someone who has lost control of their behavior.
I. Definition: Acting out behavior refers to problem behavior that is physically aggressive, destructive to property, verbally aggressive, or otherwise more severe than simple misbehavior. Acting out behavior is disruptive in any setting and often requires formal behavior intervention to manage it.
II. Signs and Symptoms of Acting out Behavior
- Physical aggressiveness
- Verbal aggressiveness
- Angry outbursts
- Physically attacking people and/or objects
- Damaging property
- Verbal or physical threats
- Pacing, clenching fists
- Raising voices, yelling, staring.
- Self-destructive behavior
- Muscle tension
- Chest tightness
- Tightness in chest, feeling hot
- Low frustration tolerance
- Feeling a loss of control over one’s thoughts
- Racing thoughts
- Hostile, self-talk
- Delusions, paranoid ideations
- Feelings of rage
- Uncontrollable irritability
- Isolation or withdrawal
- Excessive talking.
III. Factors/Events That Trigger Acting-out Behavior
- Traffic congestion
- Crowded buses
- Being wrong directions
- Bad weather
- Poor academic performance
- Conflicts with professors, schoolmates
- Having an untidy roommate
Relationships with others
- A friend joking about a sensitive topic
- Being wrongly accused
- Having a neighbor who plays the stereo too loud.
Health Care Facilities
- Long wait to see Doctors, clinicians or get medications or other services.
- Misunderstanding between patients and Doctors, clinicians or administrative staff
- Conflicts with parents and/or siblings, partner, spouse
- Loudness & noise
- Parenting styles (Authoritarian, authoritative, Permissive, uninvolved)
IV.Causes of Acting-out Behavior
Genetic: It has been hypothesized that the traits that this disorder is composed of are passed down from parents to children; however, there is presently not any specific gene identified as having a prominent impact in the development of aggressive behaviors.
The Brain-Behavior Connection: Research suggests that aggressive behavior may occur as the result of abnormalities in the areas of the brain that regulate arousal and inhibition. Frontal lobes are associated with functions such as impulse control, behavioral inhibition, reasoning and decision making. If the frontal lobe is damaged, the result may be aggression may result. Serotonin, which works to send chemical messages throughout the brain, may be composed differently in people with intermittent explosive disorder.
Environmental: The environment in which a person grows up can have a large impact on whether or not he or she develops acting out behaviors. People who grow up in homes where aggression is a common expression of distress or impulsive reactions will follow the example set by their parents and will act out aggressively. In addition, watching violent movies or TV shows also contributes to violent behaviors.
Health Condition &Psychiatric Issues: Diabetes, conduct disorder, oppositional defiant disorder (ODD) bipolar disorder, ADHD, schizophrenia, intermittent explosive disorder, anxiety disorder, depression disorder, PTSD, antisocial personality disorder, delirium, mania, stoke, alcohol/drug overdose/withdrawal or traumatic brain injury.
V. How to Deal with Acting out Behaviors in Health Care Facilities
A. CPI Crisis Development Model
Providing a balanced behavior management system while maintaining Care, Welfare, Safety and Security for both the client and staff.
1. Anxiety (agitated state)…Supportive (show empathy)
2. Defensive …Directive (Give simple clear orders)
3. Acting out person…Non-violent physical crisis interventions (nonharmful control positions to be used as a last resort)
4. Tension reduction…Therapeutic rapport re-establish communication (de-escalated state)
Anxiety (Agitated state)
Noticeable increase or change in behavior such as rocking, fists, crying, sweating, clenched jaw etc)
Staff role to Anxiety
Supportive – Show empathy, be non-judgmental
Beginning stages of loss of rationality. Individual becomes belligerent &challenges authority.
Staff role to defensive
Staff takes control of potentially escalating situation by giving simple orders, remind client of goals or guidelines.
The total loss of control which often results in a physical acting out episode
Staff role to Acting-out person
Use safe nonharmful control and restraint positions used to safely control an individual until he can regain control of his own behavior. Only use as a last resort.
A decrease in physical and emotional energy that occurs after a person has acted out. Regaining a rational state.
Staff role in Tension Reduction
Therapeutic Rapport – re-establish communications with individual who is experiencing tension reduction.
B. CPI’s Top 10 De-Escalation Tips
These Top 10 De-Escalation Tips will help us respond to difficult behavior in the safest, most effective way possible.
Be empathic and nonjudgmental
When someone says or does something we perceive as weird or irrational, try not to judge or discount their feelings. Whether or not we think those feelings are justified, they are real to the other person. Pay attention to them.
- Keep in mind that whatever the person is going through, it may be the most important thing in their life at the movement.
Respect personal space.
If possible, stand 1.5 to 3 feet away from a person who’s escalating. Allowing personal space tends to decrease a person’s anxiety and can help us prevent acting-out behavior.
- If we must enter someone’s personal space to provide care, explain our actions so the person feel less confused and frightened.
The more a person loses control, the less they hear our words-and the more they react to our nonverbal communication. Be mindful of our gestures, facial expressions, movements, and tone of voice.
- Keep our tone and body language neutral will go a long way toward defusing the situation.
Remain calm, rational, and professional. While we can’t control the person’s behavior, how we respond to their behavior will have a direct effect on whether the situation escalates or defuses.
- Positive thoughts like “I can handle this” and “I know what to do” will help us maintain our own rationality and calm the person down.
Focus on feelings.
Facts are important, but how a person feels is the heart of the matter. Yet some people have trouble identifying how they feel about what’s happening to them. Watch and listen carefully for the person’s real message.
- Try saying something like “that must be scary.” Supportive words like these will let the person know that we understand what is happening-and we may get a positive response.
Ignore challenging questions.
Answering challenging questions often results in a power struggle. When a person challenges our authority, redirect their attention to the issue at hand.
- Ignore the challenge, but not the person. Bring their focus back to how we can work together to solve the problem.
If a person’s behavior is belligerent, defensive, or disruptive, give them clear, simple, and enforceable limits. Offer concise and respectful choices and consequences.
- A person who’s upset may not be able to focus on everything we say. Be clear, speak simply, and offer the positive choice first.
Choose wisely what you insist upon.
It’s important to be thoughtful in deciding which rules are negotiable and which are not. For example, if a person doesn’t want to shower in the morning, can we allow them to choose the time of day that feels best for them?
- If we can offer a person options and flexibility, we may be able to avoid unnecessary altercations.
Allow silence for reflection.
We have all experienced moments of awkward silence. While it may seem counterintuitive to let moments of silence occur, sometimes it’s the best choice. It can give a person a chance to reflect on what’s happening, and how he or she needs to proceed.
- Believe it or not, silence can be a powerful communication tool.
Allow time for decisions.
When a person is upset, they may not be able to think clearly. Give them a few minutes to think through what you’ve said.
- A person’s stress rises when they feel rushed. Giving them time will allow them to calm down.