Behavioral Management

• Withdrawn clients that are aloof, alone, catatonic (have the tendency to hold their breath)
• Active Friendliness approach to withdrawn clients
• In withdrawn clients, provide activities that are achievable and non-competitive e.g. folding linens and watering plants to increase self-worth
• In withdrawn clients, focus on emotional reward and NEVER give material rewards
• Kind Firmness or mothering role is the approach to depressed clients 
• In depressed clients, engage them in structured and scheduled activities to distract them e.g. arranging kitchen utensils, craft activities, gardening, baking
• Suicidal clients may give valuables, cancel appointments, be apologetic, and have sudden cheerfulness/increase in energy
• Increased energy (from antidepressant) puts a suicidal patient at the highest risk of suicide
• Most common time of suicide is early morning, monday, during endorsement
• In suicide, females are more likely to attempt while males are more likely to die
• In suicide, 15-24 years old are more likely to attempt while >75 years old are more likely to die
• Substance abuse the most important factor to consider in suicidal patients
• Single civil status of most suicidal patients
• The type of constant observation for suicidal patients is irregular checks
• The best type of supervision is for suicide patients is one on one supervision and the nurse should be less than 1 meter away from the patient
• Direct Confrontation approach to suicidal clients
• Passive Friendliness approach to paranoid clients
• In paranoid clients, food and medicine should be given in a sealed container
• In paranoid clients, the nurse should respect their personal space of not less than 4 feet
• In paranoid clients, maintain professional tone by using simple, direct, concise words e.g. “the food is not poisoned”
• Matter-of-fact approach in manic/manipulative client; set firm limits
• Matter-of-fact approach pointing out unaccepted behavior, and inform client of what is expected
• Matter-of-fact approach pointing out unaccepted behavior, and inform client of what is expected
• Manic/Manipulative clients should be place in a private room
• In Manic/Manipulative - clients, activity should be non-competitive, solitary, and gross motor e.g. writing journals, drawings, cleaning the room, arranging tables - No triggering activities
• In Manic/Manipulative clients, patients should use crayons when drawing
• In Manic/Manipulative clients, patients should eat high calorie, finger foods e.g. burger, banana, peanut butter sandwich
• Directive approach for aggresive client involves being calm, non-threatening e.g. "put the gun on the floor"
• In aggresive clients, nurses must decrease stimulation e.g. turning off television, let others leave the room
• In aggresive clients, deescalation involves expression of feelings, promoting assertive communication
• In aggressive clients, there should be a show of force which is the visibility 4-6 staff members
• In aggressive clients, only the nurse assigned is allowed to talk or touch the client
• The goal of management for assaultive clients is to strengthen patient’s impulse control
• Assault Cycle

  1. Triggering
  2. Escalation
  3. Crisis
  4. Recovery
  5. Post Crisis Depression
• Assault Cycle - Behavior

  1. Triggering - non-compliance
  2. Escalation - verbal aggression
  3. Crisis - physical violence
  4. Recovery -relaxation
  5. Post Crisis Depression - reconciliatory actions
• Assault Cycle - Intervention

  1. Triggering - acknowledgment; verbalization
  2. Escalation - time out
  3. Crisis - seclusion or restraint
  4. Recovery - assess for injury
  5. Post Crisis Depression - discuss alternative behavior
• Restraint is considered as the last resort when dealing with aggressive and assaultive patients
• Least to most restrictive principle of seclusion/restraint
• ALL procedures require informed consent including seclusion and restraints by informing the client and its purpose
• The purpose of seclusion is restorative, not punitive