Citation

Prakash J, Yadav P, Chatterjee K, Chaudhury S, Srivastava K. Ind. Psychiatry J. 2021; 30(1): 1-3.

Copyright

(Copyright © 2021, Association of Industrial Psychiatry of India)

DOI

10.4103/ipj.ipj_112_21

PMID

34483515

Abstract

The presumed unpredictability in patients suffering from psychiatric disorders and the prevalent notion of violence being synonymous with these patients has often led to hasty and unhealthy use of restraints and tranquilizers. Though there can be varied reasons for patients to manifest with violence, restraints may not to be a lasting or constructive solution. While a tranquilizer may appear an effective intervention in psychiatric emergencies, it is merely like addressing the pain without taking out thorn from the finger pulp. Counter-aggressive measures toward a violent patient, who is already afraid of things imagined or real, can be counterproductive in the long run, and maleficent in practice. It has been seen that most of the aggressions are either instrumental or verbal in nature and may not culminate in physical violence at all.[1] A noncoercive approach to target aggression before it builds up beyond a tipping point manifesting in violence, appears to be the best coping and the most effective intervention.

Violence has been theorized to often occur in the backdrop of misinterpretation of a benign percept as a hostile one.[2] The "assault cycle" describes violence as build-up of various phases, starting from trigger phase followed by escalation phase, crisis phase, recovery phase, and the final phase of depression.[3] Timely recognition of these phases and early intervention may be preventive or therapeutic. The General Aggression Model[2],[4] explains that the aggression is shaped significantly by the "knowledge structure" in a person and each subsequent episode leads to further learning and reinforcement of aggressive behavior. Thus, a therapeutic milieu which diffuses the situation before the build up of aggression beyond the tipping point, is definitely the need of the hour.

De-escalation comes recommended by the NICE guidelines for management of aggressive behavior, which entails calming down the patient by halting the cycle at escalation phase.[5] Precise procedure or "on-ground" techniques, however, have not been clearly brought out in various guidelines.[6] More so a cultural perspective has often been lacking. We propose a step-wise approach toward management of violent behavior, which can be used in various settings, be it primary health care, emergency department, or a specialty ward. This has been titled as mnemonic-"SHAANT BHIM" - the oft-used phrase by the eldest Pandava, Yudhishthir, during a spoof in the popular Hindi movie "Jaane bhi do yaaro," to placate his younger brother Bhima, who was shown to be aggressive during challenging situations...

Language: en