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Psychiatric-Mental Health Nursing

9.3 Anger, Abuse, and Violence

Psychiatric-Mental Health Nursing9.3 Anger, Abuse, and Violence

Learning Objectives

By the end of this section, you will be able to:

  • Understand and define anger and aggression
  • Review the cycle of abuse and types of abuse and violence
  • Learn prominent risk factors for anger, abuse, and violence
  • Comprehend the social problems relating to anger, abuse, and violence
  • Discuss ways to handle anger, abuse, and violence in clinical settings

Anger is a universal human emotion. As a survival mechanism, it evolved to protect people from threats and to ensure existence. When misdirected or poorly managed, however, anger can lead to destructive outcomes, causing harm to oneself and others. The nursing profession brings individuals face-to-face with some of these destructive outcomes: abuse and violence.

Abuse and violence come in many forms and can occur in various contexts, ranging from domestic settings to institutions, such as hospitals or nursing homes. This issue can affect individuals across the life span, from children to older adults. It encompasses physical, emotional, psychological, and sexual abuse, as well as neglect, and often has severe consequences for the health and well-being of the affected individuals. Nurses are often the first to recognize signs of anger, abuse, and violence, making their role pivotal in preventing, identifying, and intervening in these issues. Nurses are not just caregivers but are also advocates for clients, which demands understanding these societal problems and their manifestations in the health context.

Anger and Aggression Defined

Anger and aggression are two interrelated yet distinct constructs in psychology. The subjective, emotional state characterized by antagonism toward someone or something perceived as causing harm or offense is called anger. By contrast, aggression pertains to behaviors intended to harm or assert dominance over others. Both can be triggered by external or internal stimuli, such as perceived threats, frustration, or chronic stress, and can manifest in various ways, including verbal or physical confrontations, destructive behaviors, or even internalized distress.

Anger does not always lead to aggression; it can be expressed and managed in healthy ways through strategies like cognitive restructuring, relaxation techniques, and problem-solving (Richard et al., 2022). In turn, aggression does not always originate from anger alone. While anger is a common emotion associated with aggressive behavior, aggression can also stem from various other sources or triggers. It might arise from frustration, fear, self-defense, protection of oneself or others, or even from learned behavior or societal influences. For instance, aggression can manifest in response to a threat. It can be a learned behavior from environmental factors or past experiences. Some individuals might display aggressive behavior as a result of neurological conditions or certain mental health issues (Kruglanski et al., 2023). There are multiple issues that can cause anger, including medications, emotional dysregulation, poor impulse control, trauma, depression, poor outcomes, and challenging diagnoses and symptoms.

The Cycle and Types of Abuse Defined

Anger and aggressive behavior can be precursors to violence and abuse. The cycle of abuse is a model developed to explain behavior patterns in abusive relationships; it encompasses four stages: tension building, acute violence, reconciliation or honeymoon, and calm (Focht & Chu, 2020). In the tension-building phase, stress and conflict begin to escalate, often accompanied by verbal abuse or other forms of psychological torment. This phase may last for minutes or months, with the abused partner often feeling as though they are “walking on eggshells” (Focht & Chu, 2020).

The acute violence phase follows, characterized by outbursts of aggressive, abusive behavior, which can include physical, verbal, emotional, sexual, or financial abuse. Most harm occurs in this stage, but it is usually shorter than the tension-building phase (Focht & Chu, 2020).

After the violent episode, the cycle enters the reconciliation or honeymoon phase. The abuser may feel guilty or afraid of consequences, leading them to apologize, promise change, or exhibit unusually kind behavior. This period gives the victim hope that their abuser has truly changed, making it less likely they will leave the abusive relationship (Focht & Chu, 2020).

The calm phase is the period of relative tranquility before the tension starts building again. During this phase, the abuser might deny or minimize the abuse or act as if it never occurred. This behavior can confuse the victim and keep them in the relationship (Focht & Chu, 2020). It is important to note that while the cycle of abuse model has been widely used, it does not fit all abusive relationships. The pattern and frequency of the cycle can vary drastically between relationships (Dutton, 2007).

Physical Abuse

The intentional use of physical force that results in injury, pain, or impairment is called physical abuse. This form of abuse can encompass a broad range of behaviors, including hitting, slapping, punching, kicking, burning, choking, and the use of weapons. It is important to understand that the injuries resulting from physical abuse are not always apparent and can be concealed by the abuser or the victim due to fear, shame, or efforts to protect the abuser (Warren et al., 2023).

Health-care professionals must be aware of the signs of physical abuse, which can include unexplained or inconsistently explained injuries, frequent visits to the emergency department, delayed treatment seeking, and symptoms of anxiety or depression (Hegarty et al., 2020). Nurses play a pivotal role in recognizing, documenting, and reporting instances of physical abuse. They are also instrumental in providing emotional support and resources to victims, such as information on safety planning, crisis intervention services, and legal options. Mandatory reporting for nurses is an ethical and legal obligation aimed at safeguarding vulnerable individuals from harm or potential harm. Nurses are ethically bound to advocate for clients’ well-being and safety. Mandatory reporting requirements vary by jurisdiction but commonly include instances of suspected child abuse or neglect, elder abuse, domestic violence, and certain communicable diseases (Thomas & Reeves, 2020). Failure to comply with mandatory reporting obligations can result in legal repercussions and may compromise client safety and well-being (Geiderman & Marco, 2020).

Nurses must be mindful of potential cultural, linguistic, or societal barriers when addressing physical abuse. This includes respecting privacy, recognizing the influence of cultural norms on abuse disclosure, and acknowledging that all individuals, regardless of gender, age, or sexual orientation, can be victims of physical abuse (Arora et al., 2023).

Psychological Abuse

Subjecting or exposing another individual to behavior that can result in psychological harm, such as anxiety, chronic depression, decreased self-esteem, or even post-traumatic stress disorder, is called psychological abuse or emotional abuse (Dokkedahl et al., 2019). This form of abuse is often characterized by a pattern of behavior that can include belittling, constant criticism, manipulation, intimidation, humiliation, gaslighting, and coercive control. This form of abuse often aims to undermine an individual’s sense of self-worth and independence, making them more dependent on the abuser (Dokkedahl et al., 2019).

While psychological abuse does not leave physical marks, its effects can be long-lasting, influencing an individual’s emotional health and well-being. Victims may experience feelings of fear, confusion, and doubt about their perceptions of the events. They may also exhibit symptoms, such as withdrawal, low self-esteem, and depression (Heise et al., 2019). It can be challenging for health-care professionals to identify psychological abuse due to its nonphysical nature. Being aware of possible signs, such as changes in behavior, withdrawal from social activities, and an unusual degree of compliance or deference toward a partner, can be helpful (Radell et al., 2021). Addressing psychological abuse requires a sensitive and holistic approach, including providing emotional support, encouraging clients to speak about their experience, connecting them with appropriate community resources, and potentially involving social services or mental health professionals (Dokkedahl et al., 2019).

Risk Factors for Anger, Violence, and Abuse

Emotional factors play a significant role in triggering anger and aggression. Specifically, negative emotions, such as frustration, stress, anxiety, and fear, often serve as antecedents to anger. For example, frustration, when a person’s goals are thwarted, can readily precipitate feelings of anger. Stress, too, increases irritability and impairs coping mechanisms, leading to heightened anger. Anxiety and fear, particularly if they are chronic or pervasive, can contribute to anger and violence as defensive responses to perceived threats. The inability to manage or appropriately express emotions, or emotional dysregulation, is another significant factor, as individuals who struggle with this often resort to aggression as an inappropriate coping mechanism (Richard et al., 2022). Social, economic, and environmental factors also increase the risk of anger, abuse, and violent behavior.

There are also several mitigating factors that can lessen the likelihood that an individual will engage in or be a victim to abusive or violent behavior. This section briefly reviews several of these items as well.


Stress plays a crucial role in increasing the risk that a client will display anger. Stressful situations can distort cognitive processes, leading to increased hostility. Specifically, clients under stress might misinterpret social cues, perceive threats where none exist, and respond disproportionately with anger or aggression. Chronic or high-stress levels can also impair emotional regulation, making it challenging for clients to manage their anger appropriately (Chipidza et al., 2016). Furthermore, stress can exacerbate preexisting mental health conditions, such as depression, anxiety, or personality disorders, increasing the risk of aggressive behaviors (Neelam et al., 2021). Interventions that help clients manage stress, such as mindfulness, relaxation training, and cognitive behavioral therapies, can effectively reduce stress-induced anger and aggression (Chipidza et al., 2016).

Experiencing Abuse

Research has continuously shown a strong correlation between being abused and individuals’ subsequent development of anger and aggression (Auslander et al., 2016). Abusive experiences often cause complex emotional and psychological effects, including the manifestation of anger. Abuse can lead to a hostile worldview, creating a sense of perceived threat that may trigger defensive responses, including aggression (Dugal et al., 2016). Anger and aggression can be coping mechanisms used by victims to deal with the ongoing pain or trauma associated with their abusive experiences (Center for Substance Abuse Treatment, 2014). Exposure to abusive environments often leads to normalizing aggressive behavior as an adaptive response to perceived threats, thereby perpetuating a cycle of anger and aggression (Auslander et al., 2016).


Anger is a common emotional response to perceived injustice or unfairness and is often a precursor to aggression if the individual decides to act on this emotion (Archer & Mills, 2019). The appraisal theory of emotion reasons that not only does the experience of unfairness elicit these emotions but so does the individual’s interpretation and appraisal of the situation (Moors, 2017). Individuals are more likely to exhibit aggressive behavior when they perceive they have been treated unfairly and may be more prone to display aggression to rectify the perceived injustice (Qin & Zhang, 2022). Nurses may see this type of aggression in clients or family members if they feel they are not receiving the care they deserve.

Strained Relationships

Strained relationships, characterized by conflict, discord, and a lack of positive communication, may predict anger and aggression in individuals. The strain or stressors arising from these relationships can elicit various negative emotional responses, with anger being a common outcome (Wang et al., 2022a). Interpersonal relationships can be strained by various factors, such as communication breakdown, where misinterpretation or lack of effective communication can escalate tension and frustration (Gratis, 2022). Additionally, unresolved conflicts and disagreements over fundamental issues, such as finances, values, or priorities, can create persistent strain (Gossman et al., 2023). Stressors external to the relationship, such as work-related pressures or family conflicts, can spill over and impact the dynamics within the relationship, contributing to heightened emotional responses, including anger (Lau et al., 2019). Furthermore, breaches of trust, such as infidelity or dishonesty, can severely strain relationships and evoke strong feelings of betrayal and anger (Rokach & Chan, 2023). These factors can contribute to the deterioration of relationships, fostering anger and animosity between individuals involved.

Anger often serves as a catalyst for aggressive behavior, violence, and abuse, particularly within interpersonal relationships where conflict is present (Chen et al., 2019). People may resort to psychological or physical aggression as a coping mechanism or a means to assert control in the face of ongoing strain in their relationships. Strained relationships can create conditions that foster feelings of anger, which, in turn, can lead to abuse (Soreff et al., 2023).

Disparities in Access to Care

Disparities in access to care compound the risk factor for violence and abuse. The availability of essential services, such as health care, psychosocial support, and legal assistance, often varies based on geographic location, socioeconomic status, race, and ethnicity, creating barriers to care for many people in need of psychosocial support and for victims of abuse. In rural areas, for instance, individuals often face limited access to services due to physical distance, lack of transportation, and a shortage of specialized service providers (Cyr et al., 2019). In low-income communities, a lack of resources can similarly inhibit access to needed care. These disparities underscore the systemic issues inherent in the provision of services for abuse and violence victims. They also underscore a lack of access for people for whom early intervention may prevent later violence. Racial and ethnic disparities in care also persist. Victims from marginalized racial and ethnic groups may face additional barriers [barriers such as] such as cultural insensitivity, language barriers, or fear of discrimination, that can deter them from seeking or receiving care.

Families and Communities

Families can both be a source of support and risk for individuals when it comes to anger, violence, and abuse. For example, family structure and dynamics, such as marital conflict, divorce, single-parent households, and large family size, have been associated with an increased risk of child abuse and neglect. Exposure to violence within the family normalizes violent behavior and may perpetuate intergenerational cycles of abuse (Almuneef et al., 2016). Conversely, a strong and supportive family environment can help prevent violence and mitigate its effects when it does occur (Mercy et al., 2017).

Communities, similarly, play a crucial role in either exacerbating or alleviating anger and violence. Factors, such as high levels of neighborhood violence, social disorder, and poverty, can increase anger and the risk of aggression. In contrast, supportive communities with strong social networks and institutions can foster resilience and protect against violence. Societal norms and attitudes within communities can discourage violent behavior (World Health Organization, 2022).

Factors Mitigating Anger and Violence

Prevention programs are key to mitigating violence generally, focusing on early intervention to deter violent behavior. These initiatives often center around enhancing at-risk individuals’ social skills and emotional intelligence, implementing anti-bullying initiatives, or teaching conflict resolution methods (Rivara & Le Menestrel, 2016). Furthermore, mental health support is a crucial component in reducing violent behavior, given that many individuals exhibiting such behaviors have mental health challenges. Mental health services, such as counseling and medication, can relieve these conditions and decrease instances of violence. Community outreach programs that actively engage community members can play a significant role in reducing violence. Such programs may include establishing secure spaces for at-risk youth, providing mentorship programs, or creating opportunities for positive social interaction (Sugimoto-Matsuda & Braun, 2013). Additionally, potent tools for violence prevention include school-based programs educating on the impacts of violence and professional training for individuals like teachers and police officers to identify and de-escalate potentially violent situations. Policy changes and legislation also contribute to violence reduction, with reforms like stricter gun control laws, shifts in the criminal justice system toward a focus on rehabilitation over punishment, or policies addressing systemic issues, such as poverty and inequality, which are frequently tied to violence (National Academies of Sciences, Engineering, and Medicine et al., 2018).

Therapeutic approaches, such as CBT and positive behavior support (PBS), can help individuals change destructive or disturbing thought patterns that negatively influence their behavior and emotions (Wilmots et al., 2020). In addition, conflict resolution skills training can foster connections within communities and encourage peaceful conflict resolution, significantly reducing instances of violence (Kamatsiko, 2021) (Figure 9.3).

Chart titled: Crisis Intervention: It Takes a Team. CIT Program team members include: Law Enforcement Agencies, Mental Health Providers, Hospitals, Emergency Services, and Public Officials.
Figure 9.3 Crisis intervention requires an interdisciplinary team. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Social Problems Related to Anger, Abuse, and Violence

Anger has long been associated with a range of social problems. This emotion, when unregulated, can damage interpersonal relationships, disrupt the workplace environment, and pose significant barriers to effective communication. When unmanaged, anger can escalate into aggression, leading to antisocial behaviors and even violence (Reilly & Shopshire, 2019). Abuse and violence within society have direct and indirect impacts that ripple through communities, affecting individuals’ physical, psychological, and emotional health and overall societal structures (Wessells & Kostelny, 2022). Exposure to violence can lead to trauma, contributing to various mental health conditions, such as depression, anxiety, and post-traumatic stress disorder (PTSD). These conditions can further exacerbate societal problems, as individuals dealing with these conditions may struggle with employment, relationships, and other areas of daily life (Dabaghi et al., 2023). Moreover, abuse and violence have significant economic implications. The Centers for Disease Control and Prevention (CDC) reported that the financial toll of violence, including the cost of medical care and loss of productivity, amounted to billions of dollars annually (CDC, 2019).

Job Loss

Job loss due to anger and aggression in the workplace can have profound implications on an individual’s career trajectory and overall well-being. Frequent displays of anger and aggressive behavior can significantly contribute to strained interpersonal relationships, reduced team cohesion, and ultimately result in termination of employment. Such behaviors not only disrupt the work environment but also compromise productivity and morale among colleagues (Popa et al., 2023). The repercussions of job loss linked to anger management issues extend beyond the professional realm, impacting one’s financial stability and mental health (Adler et al., 2022).

Rates of abusive behavior tend to increase during periods of economic decline, where job loss is more common. Added stress from unemployment could lead to a rise in violent behaviors because job loss might lead to a reduced sense of self-worth and increased feelings of stress and anger (Schleimer et al., 2022).

Loss of Family or Significant Others

Anger and aggression can negatively affect personal relationships, leading to damaged and irreparable relationships. Persistent anger and aggressive behavior significantly contribute to domestic discord, often resulting in strained familial relationships and, in extreme cases, separation or divorce. This behavior pattern not only inflicts emotional distress, but also poses a threat to the safety and well-being of family members (Killgore et al., 2021). Children exposed to parental aggression face adverse psychological and developmental consequences, which can lead to lasting impacts on their mental health and future relationships. The loss of family ties due to unmanaged anger and aggression underscores the urgency of seeking appropriate interventions and support systems to foster healthy relationships and prevent further emotional turmoil (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023).


The psychological impact of aggression and abuse is profound, often manifesting as traumatic stress responses. Individuals who have experienced abuse or violence may develop trauma symptoms, ranging from intrusive memories of the traumatic event, avoidance of reminders of the event, changes in thoughts and mood, and changes in physical and emotional reactions to everyday life events (SAMHSA, 2019). Physically, victims might demonstrate heightened startle responses, increased vigilance, or hypervigilance in mundane situations. For instance, sudden loud noises may evoke intense fear or panic due to past trauma experiences, leading to an exaggerated startle reflex. Additionally, survivors might manifest altered emotional reactions, such as emotional numbing or dissociation when faced with stressors that remind them of their traumatic experiences. In these cases, individuals may disconnect from their emotions or surroundings as a coping mechanism to manage overwhelming feelings associated with past abuse or violence (SAMHSA, 2019).

It is essential to acknowledge the long-term consequences of these traumatic experiences. Literature establishes a correlation between adverse childhood experiences (such as abuse or violence) and health and well-being issues in adulthood, including mental health disorders and chronic physical health conditions (Chang et al., 2019). This indicates that the traumatic effects of abuse and violence can span a lifetime, leading to many health problems, anger, and aggression.

Furthermore, victims of abuse and violence may develop post-traumatic stress disorder (PTSD). Symptoms of PTSD include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event. The prevalence of PTSD underscores the severe psychological damage that abuse and violence can cause (National Institute of Mental Health, 2023).

Trauma-informed care is a framework that acknowledges the prevalence of trauma in individuals’ lives and seeks to create an environment sensitive to their experiences. It is grounded in understanding the profound impact of trauma on one’s mental, emotional, and physical health (Menschner & Maul, 2016). Trauma-informed care emphasizes safety, trustworthiness, collaboration, empowerment, and cultural humility. Its principles guide health-care providers in delivering compassionate, individualized care while respecting the autonomy and dignity of those who have experienced trauma (Ranjbar et al., 2020). See 6.5 Trauma-Informed Care for more information.

Substance Misuse

Substance misuse and violence are interconnected and often co-occurring. Substance misuse is not necessarily a result of violence—although sexual abuse victims, for example, do have higher rates of substance misuse (SAMHSA, 2022)—but is often a cause of it. It can impair judgment, reduce inhibition, and increase impulsivity, escalating the likelihood of violent behavior. Various substances, including alcohol, illicit drugs, and prescription drugs, can contribute to interpersonal violence, such as domestic violence, and self-directed violence, such as self-harm or suicide (Zhong et al., 2020).

Research indicates that individuals with substance use disorders are more likely to engage in violent behavior, including physical assault and the use of weapons. They are also at a heightened risk of becoming victims of violence themselves. This increased risk may be due to various factors, such as engagement in high-risk activities, association with violent peers, or being targeted due to perceived vulnerability (Zhong et al., 2020). Conversely, experiencing violence, particularly during formative years, can increase an individual’s susceptibility to substance misuse. Exposure to violence, trauma, and stress can lead to maladaptive coping strategies, such as substance use, to manage overwhelming emotional pain or distress (Edalati & Krank, 2016).

From a health-care perspective, it is vital to recognize the intricate links between substance misuse and violence. Integrative approaches, including trauma-informed care, substance misuse treatment, mental health services, and violence prevention programs, have been effective (Center for Substance Abuse Treatment, 2014).


Individuals who commit aggressive, abusive, or violent behavior may face incarceration. At the same time, imprisonment can expose individuals to various abuses, including physical violence, sexual assault, and psychological trauma (Mears & Cochran, 2015). In other words, incarceration can contribute to and result from various forms of abuse, highlighting the complex relationship between the criminal justice system and abuse (Saxena & Messina, 2021). The experience of incarceration can also indirectly contribute to patterns of abuse. Post release, individuals often face significant social, economic, and psychological challenges, leading to high-stress environments that may increase the likelihood of violent or abusive behavior once released (Saxena & Messina, 2021). Incarceration can deeply affect familial relationships, leading to emotional trauma, economic hardship, and potentially a continuation of the cycle of abuse in the families affected (Massoglia & Pridemore, 2015).

Prevention and intervention strategies are essential in breaking the cycle, such as trauma-informed care within correctional facilities, support for reintegration post incarceration, and efforts to address the root causes of abuse and criminal behavior (Lehrer, 2021). Nurses employ assessment tools and techniques to identify trauma exposure and its potential effects on an individual’s health and well-being. Through comprehensive assessments, they gather information regarding trauma experiences, enabling them to develop personalized care plans that consider the unique needs of each person (Lehrer, 2021). They serve as frontline health-care providers who have direct and frequent interactions with incarcerated individuals. Their responsibilities encompass creating a safe and supportive environment conducive to healing while respecting the inherent dignity of the incarcerated individuals (Levenson & Willis, 2018).

Social and Emotional Concerns of Victims of Abuse and Violence

Abuse and violence can lead to a range of social and emotional concerns in victims, significantly affecting their psychological well-being and overall life quality. Immediate emotional responses to abuse and violence may include fear, anxiety, confusion, and anger. Over time, these can evolve into more chronic conditions, such as PTSD, depression, anxiety disorders, and complex trauma, characterized by difficulties with emotion regulation, relationship issues, and altered belief systems (Center for Substance Abuse Treatment, 2014).

Victims of violence and abuse often experience shame, guilt, and self-blame, which can exacerbate their emotional distress and hinder their help-seeking behavior (Ullman & Peter-Hagene, 2014). They may also suffer from diminished self-worth and develop a negative self-concept. They have an increased risk of resorting to substance misuse. In addition, experiencing violence can lead to chronic feelings of powerlessness and a persistent sense of threat, creating a state of hypervigilance and difficulty trusting others (Smith et al., 2019). These emotional concerns underscore the need for trauma-informed interventions that address the profound psychological impacts of violence and abuse.

Stigmatization and Discrimination

Stigmatization and discrimination compound the harm inflicted by abuse and violence. The social stigma attached to being a victim of abuse or violence often discourages victims from reporting these experiences, seeking help, or pursuing justice (Dahal et al., 2022). According to the World Health Organization (WHO), fear of stigma and discriminatory attitudes can deter individuals from seeking and receiving necessary medical, legal, and psychosocial support, potentially exacerbating trauma and health consequences (2021).

Furthermore, victims may face societal discrimination, often stemming from deeply ingrained societal norms that blame victims or trivialize the abuse or violence they experienced (UN Women, 2020). This discrimination can contribute to a culture of silence around abuse and violence, making it more difficult for victims to reach out for support and resources for recovery. It is common for victims to be ostracized or judged by their communities or certain cultures, which only amplifies the emotional toll of the abuse and violence they have suffered (Dahal et al., 2022) and places them at higher risk of secondary victimization or revictimization (Sabri et al., 2022).

Fear and Anxiety

Fear and anxiety are common psychological responses to abuse and violence and can lead to both acute and chronic mental health difficulties. Following a traumatic event, such as experiencing violence or abuse, individuals often report intense fear, which can stem from the immediate threat to their safety and well-being (Smith et al., 2019). This fear can continue long after the threat has passed, particularly if the individual experiences ongoing abuse or is constantly afraid of recurrence.

Anxiety is also frequently seen in survivors of abuse and violence. This anxiety may present as generalized anxiety disorder, characterized by excessive and persistent worry, or as PTSD (National Institute of Mental Health, 2023). Moreover, survivors may experience panic attacks and specific phobias related to the trauma, further compounding their distress (Cruz et al., 2022). Fear and anxiety can negatively impact an individual’s daily functioning, relationships, and quality of life. They may cause sleep disturbances, problems concentrating, and physical health issues, such as heart disease and chronic pain (Scott et al., 2013).

Shame and Guilt

Shame and guilt play critical roles in the dynamics of abuse and violence, affecting both the victim and the perpetrator. Abuse victims often report shame and guilt, as they may blame themselves for the abuse or believe they could have prevented it. This self-blame can exacerbate feelings of worthlessness and hopelessness, potentially leading to chronic emotional distress and contributing to the development of mental health disorders, such as depression and anxiety (McElvaney et al., 2022). Sometimes, these feelings can deter victims from seeking help and delay their recovery (Ullman & Peter-Hagene, 2014).

Anger and Loss of Trust

Anger and loss of trust are significant emotional consequences frequently associated with experiences of abuse and violence. Victims often experience anger toward their perpetrators, which can be a normal and healthy response to injustice but also a potential source of chronic distress if not appropriately addressed. In some instances, this anger may be internalized and misdirected toward the self, leading to feelings of self-loathing and perpetuating a cycle of victimization (Avdibegovic et al., 2017).

In addition to anger, victims of abuse often experience a profound loss of trust, particularly when the perpetrator is a close family member, partner, or friend. This loss of trust can extend beyond the perpetrator, affecting the victim’s relationships with others and their ability to form new, healthy relationships. Victims may develop a pervasive sense of insecurity, expecting others to harm or betray them, leading to social withdrawal and isolation (Radell et al., 2021). Furthermore, loss of trust can significantly hinder the healing process because it may reduce the likelihood of victims seeking or accepting help from others, including professionals (Ullman & Peter-Hagene, 2014).

Isolation and Loneliness

Abuse and violence can lead to feelings of isolation and loneliness in victims, worsening the traumatic impacts of the experiences. Perpetrators of abuse often employ tactics of control and manipulation, which may include isolating the victim from their social networks in an attempt to increase their dependence on the abuser. This isolation can leave victims feeling alone and unsupported, contributing to hopelessness and despair (Harsey et al., 2017). At times, the stigma and shame associated with being a victim of abuse can lead individuals to isolate themselves out of fear of judgment or misunderstanding by others (Ullman & Peter-Hagene, 2014). This self-imposed isolation can compound feelings of loneliness and exacerbate mental health issues, such as depression and anxiety (Birken et al., 2023).

Anger, Abuse, and Violence in Clinical Settings

When dealing with anger and aggression in clinical situations, understand that these emotions may stem from fear, frustration, or a loss of control related to clients’ medical conditions (Llor-Esteban et al., 2017). Nurses most often encounter types of verbal aggression in clinical settings. This type of aggression involves hostile communication or threats without physical harm. Clients might become verbally aggressive due to frustration with treatment, communication barriers, or feelings of powerlessness (BCcampus, 2014). It is important first to ensure safety for staff and clients, and then to consider all of the institutional, legal, and ethical implications. After all, in clinical settings, anger and aggression can manifest in various forms, each presenting distinct characteristics and consequences.

Causes of Anger and Violence in the Clinical Environment

Anger and aggression within the clinical environment are often categorized as client-related, health-care provider-related, or systemic (Vento et al., 2020). From the client’s perspective, certain medical conditions, including chronic pain and mental health disorders, such as dementia, personality disorders, schizophrenia, delirium, and substance misuse, can precipitate aggressive behaviors (Pekurinen et al., 2017). Severe psychiatric symptoms, a history of violence, and substance misuse can contribute to the risk of violence in health settings as well. It is important to stress, however, that most individuals with mental health disorders are not violent, and mental illness alone does not predict violence (DeAngelis, 2021).

Additionally, the stress induced by hospitalization, diagnoses of serious illnesses, limited opportunities for meaningful activities, and the need for medical procedures can often lead to heightened fear and anxiety, which may manifest as anger or aggression (Center for Substance Abuse Treatment, 2014). A nurse may encounter impulsive aggression, which often occurs quickly in response to perceived provocation or threat. For instance, a client might exhibit this type of aggression if they feel misunderstood or subjected to intrusive procedures, leading to an outburst of anger or violence (BCcampus, 2014).

Provider-related factors can also motivate aggressive behaviors. These may include poor communication skills, lack of empathy, perceived neglect, and rushed consultations that may frustrate clients and their families. An unfriendly and unsupportive attitude from the health-care provider can trigger defensive mechanisms, such as anger and aggression (Pekurinen et al., 2017).

Systemic issues within the health-care system likewise can be catalysts for anger and aggression. These systemic problems often include long waiting times, inadequate resources, overworked staff, and poor hospital conditions (Lim et al., 2022). Such conditions may exacerbate client-related factors, creating a stressful environment leading to anger and violence.

Handling Anger and Violence in Clinical Settings

Addressing anger and aggression in mental health settings requires a comprehensive, person-centered approach, acknowledging the individual’s unique psychological state and needs (Välimäki et al., 2022). Nurses must approach these situations with empathy, validation, and nonjudgmental attitudes, which can help defuse tension and foster a therapeutic relationship. Safety should be the primary concern, however. At the group level, teamwork and good interpersonal relationships among health-care providers can contribute to a less stressful environment, potentially reducing the occurrence of anger and aggression. Regular team meetings, supervision, and stress management workshops can support the health-care staff, further alleviating workplace stress (Pollock et al., 2020). At the organizational level, hospitals and health-care institutions should prioritize creating a safe, respectful, and supportive environment for clients and staff. This may involve reducing waiting times, improving resources, and ensuring appropriate staffing levels. Clear policies on managing aggression and violence and a zero-tolerance approach to such behaviors are crucial (Rosen et al., 2018). In situations where violence occurs, a thorough risk assessment ensures the safety of all involved and helps in developing appropriate management strategies for future incidents. The implementation of restrictive measures, such as seclusion and restraint, should be used as a last resort and only when less invasive strategies are ineffective and safety is at immediate risk. It is more appropriate to handle aggressive/escalating behaviors by employing client engagement through therapeutic communication, respecting the wishes and personal space of the client, and suggesting alternative physical activities such as walking.

Setting Boundaries

Setting boundaries with angry and aggressive clients is critical to effective clinical practice. It protects the safety of the health-care professional and the client, supports the therapeutic relationship, and fosters an environment conducive to effective client care. A crucial first step is maintaining a calm, nonthreatening demeanor and utilizing active listening to understand the client’s frustrations and fears. Validating the client’s feelings without condoning aggressive behavior can help to de-escalate the situation. It is essential to set clear and explicit behavioral expectations, such as respect for personal space and nonviolence, and to be consistent with consequences for violations of these boundaries. Providing clients with choices where possible can also help them regain control and reduce anger and aggression (Adeniyi & Puzi, 2021).

Trauma-Informed Approach

In clinical situations, addressing abuse and violence with sensitivity, awareness, and a trauma-informed approach is crucial. This entails understanding the widespread impact of trauma, recognizing signs and symptoms of trauma in clients, and responding by integrating knowledge about trauma into treatment planning. It is important to ensure that the environment is safe, trustworthy, and nurturing for individuals who have experienced abuse. Health-care professionals should respect clients’ decisions about when and how much to disclose about their experiences because forcing the issue can lead to further traumatization. Finally, health-care professionals should empower survivors of abuse and violence by facilitating self-efficacy and resilience, encouraging them to take an active role in their recovery process (Doyle et al., 2022). This client-centered approach recognizes the individual as the expert on their experience and is key in fostering healing and growth.

Client Engagement

Client engagement is a critical component of effectively mitigating violent incidents in health-care settings. Active engagement involves creating a respectful and therapeutic relationship with the client, which can help lessen feelings of distress and fear that often contribute to escalating behaviors (Pomey et al., 2015).

Client engagement entails involvement in the decision-making process. When clients are included in decision-making about their care, it can foster a sense of control, reduce feelings of powerlessness, and minimize the likelihood of agitation or aggression. Shared decision-making can involve explaining procedures, discussing treatment options, and seeking the client’s input and preferences (Pomey et al., 2015).

Client engagement in developing a personalized de-escalation plan may enhance the effectiveness of these strategies. This plan would include the client’s triggers, signs of escalation, and preferred de-escalation techniques. Client engagement is a critical part of de-escalation, with key components of open communication, shared decision-making, and personalized care planning (Crisis Prevention Institute, 2022).


The concept of de-escalation involves recognizing early signs of agitation or aggression, such as changes in a client’s body language, tone of voice, or behavior to prevent an escalating situation from becoming harmful or violent by reducing the intensity and reestablishing communication with the individual involved (Spencer et al., 2018). De-escalation in health-care settings is vital in managing anger, aggression, and potential violence.

Techniques for de-escalation include using a calm, reassuring tone of voice, maintaining appropriate body language, actively listening, and demonstrating empathy. Health-care providers should communicate empathetically and nonjudgmentally, validating the individual’s feelings and concerns. It is crucial to ensure the individual’s safety and the safety of others. This might involve creating physical space, reducing environmental stimuli, or calling for additional assistance in more severe cases (Goodman et al., 2020).

More specifically, de-escalation involves employing active listening and empathy to understand the client’s perspective. By actively listening without judgment and acknowledging their feelings, nurses can establish rapport and defuse escalating tension. Additionally, utilizing nonthreatening body language, such as maintaining a calm posture and speaking in a soft tone, helps convey a sense of reassurance and safety. Redirecting attention away from the source of agitation to a more calming topic or environment can further aid in de-escalation. These techniques, when combined with a comprehensive understanding of individualized client triggers, contribute significantly to the creation of a safer and more supportive care environment (Khan et al., 2021). Creating a therapeutic environment that promotes resilience and adherence to the rights and dignity of clients, even in the face of aggression, is paramount in mental health settings.

Training Staff

Staff training is essential to preventing and managing abuse and violence in health-care settings. Structured de-escalation training programs, such as the Crisis Prevention Institute’s Nonviolent Crisis Intervention Program, have effectively taught health-care providers these de-escalation techniques and are recommended for all health-care staff (Crisis Prevention Institute, 2020). Regular debriefing sessions after such incidents can help staff cope with their emotions and understand that such incidents reflect not their clinical competence but a part of the complex human behavior in stressful circumstances (Richardson et al., 2019).

In addition, staff should receive training in recognizing and managing traumatic responses often seen in clients who have experienced abuse. This requires education on trauma-informed care principles emphasizing understanding, empathy, and respect for the client’s trauma history (Muskett, 2014). Training should also include clear instructions on organizational policies and procedures related to managing violence and abuse, such as reporting incidents and implementing safety measures like medication, seclusion, or restraints, should they be necessary (NICE, 2015). Training should also address staff well-being and self-care, including strategies for coping with the emotional impact of encountering violence and abuse in the workplace (Nowrouzi-Kia et al., 2019).

The Use of PRN Medication to Manage Violent Clients

The primary purpose of using pro re nata (PRN) medications is to ensure the safety and comfort of the client, other clients, and staff. The most commonly used PRN medications include antipsychotics, benzodiazepines, and antihistamines, which have sedative effects (van Schalkwyk et al., 2018). Antipsychotic medications, such as haloperidol or risperidone, can be administered when the client exhibits violent behavior or aggression linked to psychotic symptoms (Einberger et al., 2020). Benzodiazepines, such as lorazepam or diazepam, are frequently used in managing acute agitation due to their rapid onset of action (Amore et al., 2021). Atypical antipsychotics and antihistamines may also be administered for their calming effects, especially when traditional methods are insufficient or contraindicated (Garakani et al., 2020). It is critical to note, however, that while PRN medications can be useful, they should be used cautiously and in conjunction with a broader therapeutic strategy. Overreliance on PRN medications can lead to unnecessary sedation, mask underlying conditions, or result in physical dependence (Mardani et al., 2022).

Clinical Safety and Procedures (QSEN)

Safety: Procedures for Initiating PRN to Manage Behavioral Crises

Pro re nata (PRN): This Latin term refers to medication taken “as needed.” It is frequently used in psychiatric settings to manage behavioral crises, including violent or aggressive behavior.

Common PRN medications: The most commonly used PRN medications for managing violent behavior include antipsychotics (e.g., haloperidol, risperidone), benzodiazepines (e.g., lorazepam, diazepam), and antihistamines. These medications often have calming or sedative effects.

Role of PRN medication: PRN medication is crucial in ensuring the safety and comfort of the client, other clients, and staff members. It can help de-escalate acute episodes of aggression or violence often associated with psychotic symptoms or agitation.

Cautious use: PRN medications should be used judiciously; overreliance can lead to unnecessary sedation, mask underlying conditions, or result in physical dependence. They are not a substitute for a comprehensive treatment plan but a part of it.

Broad therapeutic strategy: PRN medications should be incorporated into a broader therapeutic strategy that includes regular medication management, psychological therapies, and environmental modifications to reduce the frequency of behavioral crises. It is essential to have a health-care professional involved in any decisions regarding PRN medications.

The Use of Seclusion and Restraint to Intervene with Violent Clients

Seclusion and restraint are occasionally used interventions in health-care settings to manage violent or aggressive behavior and to ensure the safety of the client, other clients, and staff. These techniques should be used as last-resort measures, when all less restrictive interventions have been ineffective, and only used as long as necessary (Fletcher et al., 2019).

Confining a client in a room from which the client cannot freely exit, called seclusion, is used when the client poses an immediate danger to themselves or others. It provides the client with a safe, quiet environment to de-escalate without causing harm (Oostermeijer et al., 2021). The technique where physical or mechanical means restrict a client’s movement is called restraint. Physical restraint involves health-care staff physically holding a client to prevent harm, while mechanical restraint devices, such as straps or belts, restrict movement (Chieze et al., 2019). While these interventions can be necessary in some cases, they are not without risks and ethical concerns. They can be traumatic experiences for clients, potentially resulting in physical injury, emotional distress, and undermining therapeutic relationships (Chieze et al., 2019). As a result, their use should always be accompanied by a thorough risk assessment, clear documentation, and follow-up care.

Professional guidelines and policies often suggest that seclusion and restraint should only be used in emergency situations as a last resort and should be discontinued as soon as the client is no longer a danger to themselves or others. Furthermore, there should be a commitment to restraint-free care, and efforts should be made to develop and implement preventative strategies to manage aggressive behavior and reduce the use of these interventions (American Psychiatric Nurses Association, 2018).

Psychosocial Considerations

Controversy Surrounding the Use of Seclusion and Restraint in Clinical Environments

Seclusion and restraint are considered last-resort interventions to manage violent or aggressive behavior in health-care settings. They are only to be used (1) when all less restrictive methods have proven ineffective, and (2) for as short a duration as possible. These methods can be traumatic for clients. They might cause emotional distress and physical injury, negatively impacting therapeutic relationships. The potential for harm raises ethical concerns about client rights and autonomy. For these reasons, there is ongoing debate about the efficacy of these interventions (Hodel, 2023). Some studies suggest that these methods do not necessarily decrease the frequency of violent incidents and may even lead to increased agitation in some clients. In fact, the use of seclusion and restraint has been criticized as a potential violation of clients’ human rights. Concerns about misuse or overuse, particularly in vulnerable populations, have led to calls for stricter regulation and oversight. The growing emphasis on restraint-free care focuses on preventive strategies, such as de-escalation techniques, crisis intervention training, and client-centered care plans. The goal is to reduce reliance on these measures and promote a more humane approach to managing aggressive behavior (Hodel, 2023).


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