CH-26 Anger, Aggression, and Violence – Varcaroliss Canadian Psychiatric Mental Health Nursing : Chapter Notes

Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 26: Anger, Aggression, and Violence Instructor’s Manual Thoughts About Teaching the Topic It seems logical to begin by giving learners strategies to de-escalate impending aggression and protocols to use when actual aggression takes place. Role-playing verbal interventions is helpful, and practising physical interventions is essential. Emphasizing the fact that fear is a normal response to dealing with an aggressive patient can be reassuring to beginning students. Discussion of feelings should be followed by reassurance that team intervention increases safety for both patients and staff. Information about the use of seclusion and restraint usually accompanies the information on aggression. Key Terms and Concepts aggression bullying de-escalation techniques locus of control (LOC) rage trauma-informed care violence Objectives Compare and contrast three theories that explore the determinants for anger, aggression, and violence. Distinguish between the emotions of anger and rage and the behavioural manifestations of aggression and violence. Identify precipitators to anger, aggression, or violence. Compare and contrast interventions for a patient with healthy coping skills with those for a patient with marginal coping behaviours. Identify four principles of de-escalation with a moderately angry patient. Describe two criteria for the use of seclusion or restraint. Chapter Outline Teaching Strategies Clinical Picture Anger and aggression are challenges for nursing intervention, particularly if the focus of a patient’s aggression is the nurse because they imply threat and elicit emotional and personal responses. Anger is an emotional response to the perception of frustration of desires, threat to one’s needs, or challenge. Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Anger and aggression are the last two stages of a response that begins with feelings of vulnerability followed by uneasiness. Intervention in the early stages is desirable. Nurses and other health care providers must practise the skills of critical thinking, problem solving, responsive communication and team work in the care of patients exhibiting anger and aggression. Passivity and force are both unhelpful, and learning about the character of anger and aggression is important to learn steps to deescalate a potentially disruptive situation. Epidemiology Anger and aggression are considered universal emotions and can be identified across cultures via facial expression. Both are responses to threat or loss of control. The health care environment readily causes feelings of lack of control in patients. Aggression and violence are usually a result of unchecked escalation of anger. There is evidence that checks on aggression may be less available now than they have been, leading to an increased incidence of violence. High rates of suicide and domestic violence give insight into the prevalence of violence in general. Violence is most frequent in psychiatric units, ERs, waiting rooms, and geriatric units. Co-Morbidity A correlation has been found between quickness to anger and hyperactivity, attention deficits, and impulsivity in male children. Violence also frequently coexists with substance use and addictions. In adults, incidence of anger is higher in the presence of unipolar depression, post-traumatic stress disorder (PTSD), mania, personality disorders, and Tourette’s disease. Anger and hostility are also risk factors for cardiovascular disease and CVA. Etiology Biological Factors Brain Abnormalities Many neurological conditions are associated with anger and aggression (e.g., Alzheimer’s disease, temporal lobe epilepsy, traumatic brain injury, brain tumours). Serotonin A relationship between low levels of serotonin and impulsive aggression has been shown in studies. Genetic and Environmental Factors Research findings indicate that violence is a function of both genetics and childhood environment. Some are more biologically predisposed than others. Psychological Factors Drive and instinct theories led to the view that anger was an innate driving force sometimes essential to survival and harmful if repressed. Later research has shown that expression of anger is not always beneficial and can lead to increased anger and negative physiological changes such as cardiac reactivity. Repression of anger, however, is shown to lead to essential hypertension in women and is associated with immunological problems in both sexes. Anger management techniques have been shown to be beneficial. Children learn aggression by imitating others and by repeating behaviour that has been rewarded. Anger and aggression learned in the family and from TV watching have two intrinsic rewards: keeping the angry person in control while intimidating others, and providing relief of pent-up distress. Research by Bandura suggests that emotional arousal has an increased probability of expression as aggression when the context is predisposed to aggression. Milieu therapy has found that rigid intolerance of affect and an authoritarian style by nurses have been associated with assault. Application of the Nursing Process Assessment General Assessment It is important to identify anxiety before it escalates to anger and aggression. Expressions of anxiety and anger look quite similar: increased rate and volume of speech, increased demands, irritability, frowning, redness of face, pacing, twisting hands, or clenching and unclenching of fists. Assessment should include taking an accurate history of the patient’s background, usual coping skills, and perception of the issue. Patients’ perceptions often provide a useful point of intervention. Self-Assessment The nurse’s ability to intervene safely in situations of anger and violence depends on self-awareness. Nurses’ responses to angry patients can escalate along a continuum similar to that of patients. The more a nursing intervention is prompted by emotion, the less likely it is to be therapeutic. The phenomenon of emotional contagion is explained. Nurses’ responses reflect norms from their families of origin, personal issues, and situational events. In addition to self-assessment, techniques such as deep breathing, muscle relaxation, empathetic interpretation of patients’ distress, and review of intervention strategies can be helpful. Assessment Guidelines: Anger and Aggression The single best predictor of future violence is a history of violence. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. Patients with a history of limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence. Assess self for personal triggers and responses likely to escalate patient violence, and assess personal sense of competence. Diagnosis Three especially useful diagnoses are Ineffective coping, Risk for self-directed violence, and Risk for other-directed violence. Ineffective coping is useful for individuals who have adequate dayto-day coping skills but are overwhelmed by the stresses of illness or hospitalization. Patients may have a pattern of maladaptive coping that is marginally effective and consists of strategies that have been developed to meet unusual or extraordinary situations such as abusive families. Ideally, intervention aborts the development of aggression. If anger is not resolved, the diagnoses of Risk for self-directed violence or Risk for other-directed violence may become relevant. Outcomes Identification Outcome criteria for aggression self-control are outlined in NOC. Planning Planning interventions necessitates having a sound assessment and determining what the situation calls for from among alternatives such as psychotherapeutic approaches to teach the patient new skills for handling anger or immediate intervention to prevent overt violence via de-escalation techniques, restraints or seclusion, or psychopharmacology. Implementation Psychosocial Interventions The patient becomes increasingly agitated. The staff need to be educated. The better educated the staff, the less chance for injury. Verbal interventions include the following: o Analyze the patient and situation. o Use verbal techniques of de-escalation. o Demonstrate respect for the patient’s personal space. o Interact with the patient. o Invest time in the process. o Pay attention to the environment. o Assure your safety. Pharmacological Interventions Antianxiety and antipsychotic agents are used in the treatment of acute symptoms of anger and aggression. During violent incidents, the traditional and typical antipsychotic medication, haloperidol (Haldol), has historically been the most widely used antipsychotic, but with the introduction of IM atypical antipsychotics, the use of these medications has become more widespread, in part because of the severe side effects of haloperidol. Diphenhydramine (Benadryl) or benztropine is added to the injection to reduce extrapyramidal side effects. It is the nurse’s role to assess for appropriateness of prn medications. It is important to remember that patients often feel traumatized by the use of IM injections, so oral medications should always be used, if appropriate (Gilbert, Rose, and Slade, 2008). Health Teaching and Health Promotion One of the most important roles a nurse plays is that of role modelling appropriate responses and ways to cope with anger. It is also helpful to assist the patient to identify triggers for angry or aggressive behaviours. Milieu Management A thorough consideration of the environment is important when considering anger and aggression on the inpatient unit. It is important to be proactive and not reactive. The nurse must examine the milieu as a whole and identify stressors patients have to deal with. Use of Restraints or Seclusion If the patient progresses to the assaultive stage, the staff must respond quickly and as a team. It is advisable to use five members of the team or more as indicated. One leader speaks with the patient and instructs members of the team. The intervention usually requires physical restraints and seclusion of the patient. The goal of the use of seclusion and restraints is safety of the patient and others. Seclusion and physical restraints cannot be used without a physician’s order and are used only after exhaustion of all other intervention alternatives have failed. The patient must have 24hour one-on-one observation. The circumstances for physical restraint include the following: patient is a clear and present danger to self or others, patient has been legally detained for involuntary treatment, or patient requests seclusion or restraints for his or her own safety. Post-Assaultive Stage Processing with the patient is an important part of the therapeutic process, but only after the patient no longer requires seclusion and restraints. This allows the patient to learn from the situation, to identify the stressors that precipitated the behaviour, and to plan alternative ways of responding in the future. Caring for Patients in General Hospital Settings Inpatients With Healthy Coping Who Are Overwhelmed Interventions are aimed at collaborating with the patient to find ways to re-establish or substitute similar means for dealing with the overwhelming situation. The nurse acknowledges the patient’s distress, validates it as understandable, and indicates willingness to search for solutions. Validation cannot occur unless nurses recognize their own self-protective responses to angry patients to prevent negative cycles of staff–patient conflict. If the patient is unable to communicate the source of the anger, the nurse can often make an accurate guess. Naming the feeling can lead to dissipation of anger by helping the patient feel understood. Patients with Marginal Coping Skills Patients with marginal coping skills need different interventions from patients with basically healthy coping skills. They often achieve feelings of control or mastery via the use of anger and intimidation. Patients with chemical dependence and patients with personality styles that externalize blame are examples of patients who become angry at staff for not providing relief from discomfort or anxiety. Intervention requires a respectful approach that establishes a sense of mutual collaboration. The nurse can maintain respect by remembering that patients are doing the best they can, patients want to improve, and patient behaviours make sense within their world view. Other interventions: provide comfort items before they are requested, to build rapport; be clear about what you can and can’t do; offer distractions (e.g., magazines, games); provide predictable interactions with staff. When verbal abuse occurs, three interventions can be used: (1) Leave the room when abuse begins, stating you will return in a specific amount of time (e.g., 20 minutes). Be matter-of-fact. The alternative is to break off conversation and eye contact and finish the procedure before leaving the room. (2) Attend positively to nonabusive communication by the patient. (3) Schedule regular, frequent contacts with patient, giving attention that is not contingent on patient’s behaviour. Caring for Patients in Inpatient Psychiatric Settings Not all psychiatric patients are violent. Aggression appears to be correlated less with certain disorders than with patient characteristics. The best predictors of violence are previous violent behaviour and impulsivity. Conflict with staff and interactions with staff that involve limit setting are common reasons for violence. Limit-setting styles that are belittling or provide solutions without options and restrictions on freedom are more likely to precipitate anger and aggression. Studies show that cognitive-behavioural therapy can be helpful. Caring for Patients With Cognitive Deficits Patients with cognitive deficits (e.g., patients with Alzheimer’s disease, multi-infarct dementia, brain injury) are at risk for acting aggressively. Interventions include reality orientation; orientation aids such as calendars and clocks; simplified environment; a calm, unhurried approach; and identification of antecedents of anxiety. Validation therapy may be used to calm patients when reality orientation is not effective. Validation involves the patient’s describing the current situation and the nurse’s commenting on what appears to be underlying the distress. Sedation is often not the best solution because it may further cloud the patient’s sensorium, making disorientation worse. De-escalating techniques are common sense principles such as maintaining calmness; assessing the situation, identifying stressors and what the patient considers to be his or her need; using a calm voice and nonthreatening nonverbal communication, being empathetic, genuine, and honest; maintaining a large personal space; not arguing, giving options. Return to Baseline: Critical Incident Debriefing The staff processing of a critical incident is essential to ensure that quality care was provided to the patient and staff have an opportunity to examine their responses to the patient. Several questions to be answered are included in the text. Documentation of a Violent Episode There are several areas that are essential to document in situations where violence either was averted or actually occurred. The nurse must document the assessment of the behaviours that occurred during the pre-assaultive stage, the nursing interventions, the patient’s responses, and evaluation of the interventions used. Details should be included. See text for a list of areas to document. Evaluation An evaluation provides information about whether outcome criteria have been met. Concept Map Some students, especially those who are visually oriented, find use of a concept map is helpful in learning. On the following page is a concept map for aggression. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 27: Interpersonal Violence: Child, Older Adult, and Intimate Partner Abuse Instructor’s Manual Thoughts About Teaching the Topic The authors explore family violence in this chapter, thereby providing the instructor with a variety of examples to help students operationalize crisis theory. Because individual provinces and territories have specific laws regarding the reporting of abuse, instructors may wish to review the provisions of the law as part of this unit of material. For many students, this material evokes strong emotions. Be prepared for this in classroom discussions. Because some students have experienced family violence, it is wise to have an established referral system with student services or an outside agency. Key Terms and Concepts crisis situation ecological model economic abuse emotional abuse family violence neglect perpetrators physical abuse primary prevention safety plan secondary prevention sexual abuse survivor tertiary prevention typology of interpersonal violence vulnerable person Objectives Define interpersonal violence. Identify three indicators of (a) physical abuse, (b) sexual abuse, (c) psychological or emotional abuse, and (d) deprivation or neglect. Discuss the ecological model of violence in terms of etiology of abuse (e.g., stresses on the perpetrator, vulnerable person, and environment that could escalate anxiety to the point at which abuse becomes the relief behaviour). Compare and contrast three characteristics of a perpetrator with three characteristics of a vulnerable person. Describe four areas to assess when interviewing a person who has experienced abuse. Formulate four nursing diagnoses for the survivor of abuse, and list supporting data from the assessment. Write out a safety plan with the essential elements for a victim of intimate partner abuse. Compare and contrast primary, secondary, and tertiary levels of intervention, giving two examples of intervention for each level. Discuss three psychotherapeutic modalities useful in working with abusive families. Chapter Outline Teaching Strategies Types of Abuse The World Health Organization has identified a typology of interpersonal violence which refers to violence between individuals and is subdivided into family and intimate partner violence which includes child abuse, intimate partner violence, and older adult abuse; and community violence which is broken down into acquaintance and stranger violence and includes youth violence, assault by strangers, violence related to property crimes, and violence in workplaces and other institutions. Five specific modes of abuse have been identified: (1) physical abuse, (2) sexual abuse, (3) psychological or emotional abuse, (4) deprivation or neglect, and (5) economic abuse. Cycle of Violence In the cycle of violence, periods of intense violence alternate with periods of safety, hope, and trust. This pattern is described in terms of escalation and de-escalation. Four stages have been identified: (1) Tension-building stage: includes minor incidents such as pushing and verbal abuse. The vulnerable person does NOT tell the perpetrator that abuse is unacceptable. The abuser rationalizes that abuse is acceptable; the abused person minimizes importance of incidents and may blame self. (2) Acute battering stage: a perpetrator releases built-up tension by beating a vulnerable person; the victim depersonalizes the incident. Both perpetrator and victim are in shock. (3) Honeymoon stage: perpetrator feels remorse and acts in kindly, loving ways by apologizing or bringing gifts; victim believes promises and apologies, may drop criminal charges. (4) Tension-building stage: abuse recurs, and cycle begins again. Epidemiology While the true prevalence of child, older adult, and intimate partner abuse is unknown (because of under-reporting and variability in reporting methods, instruments, sites, and reporters), it is clear that abuse is a significant problem. Child Abuse In a 2008 Canadian Incidence Study, there was a reported rate of 14.19 investigations per 1000 children. Thirty-four percent identified exposure to intimate partner violence as the primary type of abuse and another 34% identified neglect as the overriding concern, followed by physical abuse (20%), emotional abuse (9%), and sexual abuse (3%). There was some variation by age and sex in the incidence of investigated abuse, with rates being highest for infants. The rate of family-related sexual offences was more than four times higher for girls than for boys, and the rate of physical assault was similar for girls and boys (Statistics Canada, 2009). Intimate Partner Abuse According to Statistics Canada (2009), of the 19 million Canadians who had a current or former spouse, 6% reported being physically or sexually victimized by their partner or spouse in the preceding five years. Spousal violence was more likely to occur between ex-spouses or -partners than current spouses or partners. Of those reporting to police, the majority were women (83%), with 17% being men. Those who self-identified as gay or lesbian were more than twice as likely as heterosexuals to report having experienced spousal violence, while those who self-identified as bisexual were four times more likely than heterosexuals to self-report spousal violence. Household income and education levels were found to have had little impact on experiencing spousal violence. Those who self-identified as an Aboriginal person were almost twice as likely as those who did not to report being the victim of spousal violence (10% versus 6%) (Canadian Centre for Justice Statistics, 2009). Older Adult Abuse The rate of violent victimization for older adults was less than half that for adults aged 55 to 64 and more than eight times lower than the rate for adults aged 25 to 34 (Statistics Canada, 2009). Lower rates of family violence among older adults compared to their younger counterparts may be linked to differences in their living situations. Older adults aged 75 years and older are more likely to live alone or in an institutional setting than older adults under age 75 are (Turcotte & Schellenberg, 2007). Although the overall rate of violent victimization was higher for older adult men than for older adult women, family-related violent victimization was higher among older adult women. Older adult men were more likely to be victimized by an acquaintance or a stranger than a family member. Co-Morbidity Common long-term psychological and social effects of abuse include depression, suicidal ideation, chronic post-traumatic stress symptoms, dissociation, interpersonal disturbances, substance abuse, and revictimization. Family violence is common in the childhood histories of juvenile offenders, runaways, violent criminals, prostitutes, and those who in turn are violent toward others. Exposure to abuse has been associated with decrements in children’s optimal development in the areas of social behaviour, academic performance, physical health, and mental health (Graham-Bermann, Gruber, Girz, et al., 2009; Skopp, McDonald, Jouriles, et al., 2007). The increased occurrence of prolonged childhood sexual abuse in girls may contribute to the increased prevalence of stress disorders reported in women (Carter-Snell & Hegadoren, 2003). Etiology The ecological model (see Figure 27-3) recognizes and identifies personal history and characteristics of the victim or perpetrator, other family members, the immediate social context (often referred to as community factors), and the characteristics of the larger society. Perpetrator The abuse of power and control is the foundational etiology of relationship violence (see Figure 27-4), with additional ecological risk and resiliency factors determining the typology. Because of extreme pathological jealousy, many perpetrators of relationship violence maintain control through possessiveness, intimidation, restriction of social and economic resources, and other forms of abuse and violence. Vulnerable Person The vulnerable person is an adult or child who, as a result of illness, physical condition, or experiences is at greater risk than the general population for being harmed. Pregnancy increases the risk of violence. Violence also escalates when the wife makes a move toward independence. The risk for violence is greatest when the spouse attempts to leave the relationship. Children are most likely to be abused if they are under 3 years old, perceived as “different,” remind the parents of someone they do not like, are the product of an unwanted pregnancy, or do not meet parental fantasy expectations. Adolescents are also at risk for abuse, at least as frequently as children. Older adults are particularly vulnerable when in poor mental or physical health or are disruptive. Abused older adults may be either male or female, being cared for by a spouse or child who was a victim of abuse. Crisis Situation A crisis situation is an event that puts stress on the family with a violent member. Social isolation contributes to ineffective coping during a crisis situation. Application of the Nursing Process Assessment General Assessment Nurses will see people experiencing violence in every health care setting. Complaints may be vague and need exploration. Assessments should include a history of sexual abuse, family violence, and drug use or abuse. History should be conducted with only the nurse and patient present. Interview Process and Setting Assessment requires privacy and interviewer tact in questioning. The following techniques are useful: Sit near patient, establish rapport, reassure patient that he or she did nothing wrong, allow patient to tell story without interruption, be nonjudgemental. In verbal approaches, use open-ended techniques if possible: “Tell me what happened to you.” “What happens when you do something wrong?” “Describe how you discipline your child.” Determine need for further help by assessing violence indicators, levels of anxiety and coping responses, family coping patterns, support systems, suicide potential, and drug and alcohol use. Once trust has been established, openness and directness about the situation can strengthen the relationship. Maintaining Accurate Records For legal reasons, records should contain an accurate, detailed history; descriptions of findings; verbatim statements of who caused injury and when injury occurred; a body map to indicate information about injuries; photos; and physical evidence of sexual abuse acquired by carefully following legal protocols. Self-Assessment Working with those experiencing violence gives rise to strong emotions on the part of the nurse. Professional or peer supervision is a necessary part of dealing with these responses. Types of Abuse Physical Abuse Overt signs of battering include bruises; scars; burns; wounds around head, face, chest, arms, abdomen, back, buttocks, and genitalia; injuries in various stages of healing. Covert minor complaints often heard include “accidents,” “back trouble,” “falls.” Sexual abuse may be suspected with bruising or injury around genitalia and presence of urinary tract infection. Also be suspicious if explanations do not fit the injury; patient minimizes the seriousness of the injury; a child under 6 months has bruises; or respiratory problems are present in young child (may suggest shaken baby syndrome). Ask patients directly, but in a nonthreatening way, whether the injury has been caused by someone close to them. Observe nonverbal response for hesitation or lack of eye contact. Then ask specific questions about the last time abuse occurred, how often it happens, in what ways the patient is hurt. Sexual Abuse Victims often display various psychopathologies, including depression. Remember that sexual abuse of boys appears to be common but is under-reported, under-recognized, and less treated. Emotional Abuse Wherever physical or sexual violence is occurring, emotional violence occurs. It may also exist alone when low self-esteem, anguish, and isolation are instilled in place of love and acceptance. Neglect Signs include appearing undernourished, dirty, and poorly clothed. Inadequate medical care is a form of neglect. Economic Abuse Economic abuse is the failure to provide for the needs of the victim even when adequate funds are available. Level of Anxiety and Coping Responses Nurses should note nonverbal responses, hesitation, lack of eye contact, vague statements, vigilance, inability to relax, sleep deprivation, physical signs of chronic stress. Note defensiveness about loved ones, even if they perpetrate violence. Family Coping Patterns Nurses should show a willingness to listen and avoid use of a judgemental tone. Living with children and older adults in the same household can cause frustration, stress, and anger. Support Systems Is patient in a dependent position, relying on perpetrator for basic needs? Is patient isolated from others? Suicide Potential Suicide may seem the only answer for one who feels trapped in a relationship he or she is desperate to leave. Suicide threats by a perpetrator may be used to manipulate the victim: “If you leave, I’ll kill myself.” Homicide Potential A vulnerable person is at greater risk for homicide if there is a gun in the home; when alcohol or drugs are used; if the perpetrator has been violent previously; or when the perpetrator is jealous and obsessive about the relationship and tries to control all of victim’s daily activities. Inquire whether the patient feels safe about going home. Drug and Alcohol Use A person experiencing violence may self-medicate. If a battered person presents in an intoxicated state, allow him or her to become sober before making a referral. Such a patient should not be discharged to the spouse. Diagnosis Diagnoses are focused on the underlying causes and symptoms of family violence. Useful diagnoses include Risk for injury, Anxiety, Fear, Ineffective coping, Disabled family coping, Powerlessness, Caregiver role strain, Chronic low self-esteem, Interrupted family processes, and Impaired parenting. Pain related to physical injury would take a high priority. Table 273 Outcomes Identification The Nursing Outcomes Classification (NOC) is used to identify criteria for abuse cessation. Table 27-4 Planning Plans should centre on patient safety and also take into consideration the needs of the abuser if he or she seems willing to learn violence-free alternatives to aggression. Implementation Reporting Abuse There is no mandatory obligation to report woman abuse to the police. It is the woman’s right to choose if she wishes to have police involvement, and she must consent to this involvement prior to the nurse’s initiating contact with authorities (Registered Nurses’ Association of Ontario, 2005). According to provincial or territorial legislation, any suspected or actual cases of child abuse must be reported to the official social service agency. Competency may be a consideration in a situation of older adult abuse. Competent older adults have the right to selfdetermination. Unless the individual is found to be incompetent, help can be offered but cannot be forced upon the person. In Canada, there is no general test of competency. Counselling Counselling involves crisis intervention and promotion of growth. The role of the nurse is to support the victim, counsel about safety (having a plan for escape and use of a safe house), and facilitate access to other resources as appropriate. Case Management Case management should include coordination of community, medical, criminal justice, and social systems to provide comprehensive services for the family. Milieu Management Interventions are geared toward stabilizing the home situation and maintaining a violence-free environment. It often involves providing economic support or job opportunities, social support from public health nurse, social worker, and others, and family therapy. Promotion of Self-Care Activities The goal of promoting self-care is empowerment. Examples include provision of referral numbers for other agencies, legal counselling, vocational counselling, parenting resources, and other support information. Health Teaching and Health Promotion Teaching topics include normal developmental and physiological changes (explanation is geared to helping the family members gain a more positive view of the victim and the crisis situation), coping skills, risk factors for violence, and parenting skills. Candidates for special attention are new parents whose behaviour toward an infant is rejecting, hostile, or indifferent; teenage parents; parents with developmental disabilities; parents who grew up watching their mother being beaten. Prevention of Abuse Primary Prevention This consists of measures taken to prevent the occurrence of abuse: identifying individuals and families at high risk, providing health teaching, and coordinating supportive services to prevent crises. Secondary Prevention This involves early intervention in abusive situations to minimize their disabling or long-term effects. Tertiary Prevention This involves nurses facilitating the healing and rehabilitative process by counselling and providing support for survivors of violence to achieve optimal level of safety. Advanced-Practice Interventions An advanced-practice nurse carries out some type of psychotherapy after the crisis intervention when the situation is less chaotic. It is aimed at empowerment, communication, validation, support, and respect for individual autonomy. Individual Psychotherapy This is aimed at helping the victim recognize feelings about experiencing violence, about self, and about options. For the perpetrator who meets criteria for intermittent explosive disorder, therapy is most effective if court-ordered. Nurse therapists working with perpetrators have a duty to warn potential victims. Family Psychotherapy If violence is recent and both partners agree to be involved, family therapy may be used. Desired outcomes: perpetrator will recognize inner states of anger and use alternative coping strategies; family members will listen to each other and communicate openly. Group Psychotherapy Provides assurances that the person is not alone and that positive change is possible. Self-help groups are also effective for many people. Nurses engaged in therapy with perpetrators have a duty to warn potential victims. Evaluation Evaluation of brief interventions can be based on whether the survivor acknowledges the violence and is willing to accept intervention or is removed from the violent situation. Evaluation of long-term processes should note reduction in incidence of violence and healthier coping patterns. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400