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Year : 2021  |  Volume : 30  |  Issue : 1  |  Page : 1-3  Table of Contents     

“SHAANT BHIM”: A simple algorithm for management of violent patients

1 Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Psychiatry, Dr DY Patil Medical College, Pune, Maharashtra, India

Date of Submission21-May-2021
Date of Acceptance13-Jun-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Prof. Jyoti Prakash
Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_112_21

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How to cite this article:
Prakash J, Yadav P, Chatterjee K, Chaudhury S, Srivastava K. “SHAANT BHIM”: A simple algorithm for management of violent patients. Ind Psychiatry J 2021;30:1-3

How to cite this URL:
Prakash J, Yadav P, Chatterjee K, Chaudhury S, Srivastava K. “SHAANT BHIM”: A simple algorithm for management of violent patients. Ind Psychiatry J [serial online] 2021 [cited 2023 Jan 31];30:1-3. Available from: https://www.industrialpsychiatry.org/text.asp?2021/30/1/1/318933

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. The steps are enumerated in [Figure 1].
Figure 1: SHAANT BHIM Algorithm

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   Sit Down With the Patient Top

Violent behavior can be best comprehended by Swiss–cheese model, where many factors need to come together and align for violence to manifest. The aim of this algorithm is to impede clustering of these factors and alignment, thus nip the violence in the trigger phase itself. This entails being with the patient, ensuring that he/she feels safe in the environment, and no harm is imminent. Simple gestures will be assuring to the patient. Greet the patient and offer a chair to sit. Maintain about two arm length distance, which not only provides safety but also gives the patient a personal space. A large room is preferable, as smaller room may give the patient a feeling of being trapped.

   Harm Causing Substances/Surroundings: Avoid Top

The next step to avoid trigger is to keep the surroundings clear of these, which ensure protection of the patient and staff. The presence of a weapon or any hard/sharp object which can be used as weapon, tends to fuel the aggression.[7] Further, the trigger is not limited to weapons per se. Studies have found that even pictures in surrounding vicinity displaying such instruments or emotions, threatening/unpleasant sounds, offensive smell, significant background noises, etc., have equal potential.[8] Thus, the interview area should be devoid of such provocations. A calming neutral environment addressing these concerns will help in the effective prevention of aggression.

   Assure Patient of Safety Top

Assuring that the patient has nothing to fear and is in a secure place, tends to mitigate the anger developing due to the hostile attribution bias. The root of anger is generally a fear or threat to security and thus the de-escalation of the aggression, starts when the patient starts feeling secure. A sense of insecurity keeps the patient aroused, which can precipitate aggression with minimal provocation as would other aversive stimuli such as humid conditions or constant pain.

   Ask Concerns in an Empathetic Manner Top

The fourth step continues the de-escalation process with correct communication to establish working relationship with the patient. The therapist acknowledges distress without accusations. A simple empathetic enquiry of his/her immediate concerns will be more fruitful in mellowing down the patient. Use communication strategy, which may lead to positive engagement, for example, asking the patient how therapist can help defuse the situation. Miller's law further emphasizes empathy, which states, “to understand what another person is saying, you must assume that it is true and try to imagine what it could be true of.”[9]

   Nonconfrontational/Nonthreatening Approach Top

Confronting or threatening approach toward these patients is often counterproductive, as it feeds more negative valence stimulus and will enrage them further. Staring look from the staff, prolonged intense eye contact could be misconstrued as threat. Concealed hands, folded arms can be avoided.[10] The content of the conversation should not be challenging or insulting to the patient. The pitch and tone of voice should be deliberated to show calm and concern. These will reinforce patient's belief of being in a safe secure environment where problems are dealt by professionals.

   Identify Triggers Top

As our aim is also to prevent further such incidents, it is a good to know, what triggers precipitated the episode. This step will go along while the patient is being reassured and is being asked of his concerns. The caregiver should be open to the issues expressed by the patient, even if the trigger appears trivial or annoying. The patient might be distressed of a Ryle's tube that was annoying him/her which was not paid heed to, an insulting remark or sleep deprivation.

   Building up the Rapport Top

Rapport ensures a good patient–therapist communication and fruitful continuity of effort. With the development of good rapport history would be easier to elicit and issues are prioritized and addressed with mutual satisfaction.

   History of Psychiatric Illness Top

Aggressive behavior might often be a result of a psychiatric illness. The distress of a delusional belief or annoyance due to auditory hallucination or persistent anxiety state can be all a precipitant for aggression. A relevant history, is important for remediation of illness which can cause recurrence of such violent episodes.

   Immediate Concerns Addressed First Top

With a feeling of being in control of self and surrounding, patient mellows down to a safe basal level. He feels comfortable to discuss his concerns and is willing to entertain nonviolent options for the solutions. His/her distress may be acknowledged, even if beliefs are unfounded; and simple behavioral or medical measures may be discussed for alleviation of the distress. Even giving a me time, respecting his/her personal space or avoiding remarks of personal significance, which he perceives as provocative, helps.

   Management Plan in Collaboration With the Patient Top

With adequate de-escalation of violence, establishment of rapport, relevant history, and remediation of immediate concerns; a definitive management plan for psychiatric/medical illness, if any, should be planned in consultation with the patient and instituted. Patient and family should be explained about nature and course of illness, known behavioral issues and available interventions. With the institution of definitive medication, the symptomatology leading to the violence is targeted and treated. Thus, not only the pain is addressed but also the thorn in the finger pulp, which was the source of pain, is addressed.

In patients with hyperactive delirium or acute psychosis, who are not receptive to verbal de-escalation; pharmacological/physical restrain may be more viable option. However, noncoercive de-escalation are recommended as the first line in all cases where ever it is possible to communicate clearly. Studies have shown restrained patients have a higher chance to land up in a psychiatry ward and have a much longer hospital stay.[11] De-escalation, on the other end, improves efficacy of both the staff and the patient; as both behave in a calmer manner during this process.[12]

Thus, de-escalation provides an optimal milieu of safety and facilitates empowerment of an individual to exercise his self-restraint to avert build-up of violence. This not only reinforces positive coping in the individual and negates requirement of physical/chemical restraint; but also exposes them to an emotionally positive and constructive therapeutic interaction. Using a mnemonic with EMIC perspective may prompt the professionals to practice notion of de-escalation in their patients and growing ease of comfort with use of de-escalation will finally negate the ease of comfort, professionals may have developed toward chemical/physical restraint.

   References Top

Iennaco JD, Dixon J, Whittemore R, Bowers L. Measurement and monitoring of health care worker aggression exposure. Online J Issues Nurs 2013;18:3.  Back to cited text no. 1
Maruna S, Butler M. Violent Self-Narratives and the Hostile Attributional Bias. In Youngs D, editor, Behavioural Analysis of Crime: Studies in David Canter's Investigative Psychology. Aldershot: Ashgate Publishing. 2013. p. 27-48.  Back to cited text no. 2
Hallett N, Dickens GL. De-escalation of aggressive behaviour in healthcare settings: Concept analysis. Int J Nurs Stud 2017;75:10-20.  Back to cited text no. 3
Allen JJ, Anderson CA, Bushman BJ. The general aggression model. Curr Opin Psychol 2018;19:75-80.  Back to cited text no. 4
National Institute for Health and Care Excellence. Violence and Aggression: Short-term Management in Mental Health, Health and Community Settings. National Institute for Health and Care Excellence; 2015. Available from: www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in- mental-health-health-and-community-settings-pdf-183726 4712389. [Last accessed on 2021 May 15].  Back to cited text no. 5
Bowers L. A model of de-escalation. Mental Health Pract 2014;17:36-7.  Back to cited text no. 6
Benjamin AJ, Bushman BJ. Retraction notice to “The weapons effect” [Curr. Opin. Psychol. 19 (2018) 93-97]. Curr Opin Psychol 2018;22:96.  Back to cited text no. 7
Sulikowski D, Burke D. Threat is in the sex of the beholder: Men find weapons faster than do women. Evol Psychol 2014;12:913-31.  Back to cited text no. 8
Schafer J. Psychological Narrative Analysis: A Professional Method to Detect Deception in Written and Oral Communications. 2nd ed. Illinois: Charles C Thomas Publisher; 2019.  Back to cited text no. 9
Fishkind A. Agitation II: De-escalation of the aggressive patient and avoiding coercion. In: Glick RL, Berlin JS, Fishkind AB, et al., editors. Emergency Psychiatry: Principles and Practice. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2008.  Back to cited text no. 10
Knutzen M, Mjosund NH, Eidhammer G, Lorentzen S, Opjordsmoen S, Sandvik L, et al. Characteristics of psychiatric inpatients who experienced restraint and those who did not: A case-control study. Psychiatr Serv 2011;62:492-7.  Back to cited text no. 11
Khademi Mofrad SH, Mehrabi T. The role of self-efficacy and assertiveness in aggression among high-school students in Isfahan. J Med Life 2015;8:225-31.  Back to cited text no. 12


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