This article delves into strategies that mental health clinicians can utilise when working with clients who exhibit aggressive behaviour during therapy sessions.
Related articles: Anger Management: De-escalating Anger, The Neuroscience of Anger, Assessing and Treating Problem Anger.
Introduction
Jamie’s court-mandated client abruptly shoved the small table between her chair and his toward her, knocking over the lamp and half-full coffee cups on it and splashing the contents all over her. “This is a f_____g waste of time and you’re full of s__t! The whole system is stupid.” He stood up, towering over Jamie, and demanded she support an end to his electronic monitoring. Jamie was aghast; she had no authority to do any such thing. Nervously, she eyed the door on the other side of the room. Her client stood between her and any escape. Now what, she thought?
If you have ever been in a situation of aggressive communication or behaviour from a client, you know the panic that can ensue when you, and possibly other staff members, are threatened. This article examines what aggressive behaviour/communication entails, what may trigger it, others’ reactions, and strategies for responding to it.
Aggression and the signs that it may be imminent
What are we calling “aggressive”?
Aggressive behaviour or communication is the use of confrontational, threatening, intimidating, or hostile language or behaviour which seeks to control or dominate others. It disregards the needs and feelings of others and prioritises the aggressive person’s agenda. Although it can be used by anyone in the “heat of the moment” when they lack the skills to handle feelings of being threatened or frustrated, aggressive behaviour is most often utilised by bullies and narcissists to manipulate (read this article for a case example of how narcissism may manifest in a relationship).
Signs that a person could potentially become aggressive or violent
These warning signs may indicate that things could escalate at any moment:
Appearance: bloodstained, dishevelled or dirty, intoxicated or high on drugs, bizarre appearance, or carrying anything that could be used as a weapon.
Mood: anxious, tense, distressed, irritable, angry, and has difficulty controlling emotions.
Physical activity: pacing, clenching jaw or fists, restless or agitated, hostile facial expressions with sustained eye contact, eye-rolling, or entering “off-limit” areas (e.g., “Employees only”).
Speech: cursing or sarcastic, loud, threatening (e.g., “Do this or you’ll regret it”), or even slurred. The person may throw insults, such as calling the therapist “stupid”, “incompetent”, or an “idiot”, or they may blame the therapist.
Reaction of others: Other personnel/individuals in the area react with fear, frustration, anger, anxiety, or unease.
What’s behind the aggression?
The inability to control oneself in a challenging situation occurs when people are emotionally dysregulated, without the appropriate skills to deal with the feelings of fear, anxiety, or frustration. You can appreciate how common aggressive outbursts are when you read this partial list of circumstances which often trigger such language or behaviour: acute or chronic pain, drug or alcohol withdrawal or being high on such substances, stroke, head injury, Alzheimer’s disease, medications (e.g., corticosteroids), neurological disorders, and comorbid substance abuse and mental disorders.
Mental health concerns associated with aggressive communication include anxiety, PTSD (post-traumatic stress disorder), adjustment disorder, psychosis (including responding to command hallucinations or delusions), borderline personality disorder, and narcissism.
Additionally, a client may be in a situation that has triggered memories of past trauma. They may have a history of dealing with frustration through violence, or they may genuinely not be getting effective treatment for their condition.
Reactions of others to aggressive behaviour
Naturally, when someone explodes in an angry outburst, they often appear to get their needs met as others may scurry around to accommodate them. But it is a short-term gain with long-term loss, especially of relationship and trust, as you can see below from these typical reactions nurses have reported to aggressive or violent behaviour in their patients:
Anger: Just as love begats love, anger begats anger, as the nurse being shown anger comes to resent the patient exploding at them. It doesn’t bode well for care of the angry one, as it generates an unconscious (or sometimes conscious) desire to punish the patient.
Desire to appease: Those who may have personal problems with anger (say, in their family of origin, where anger may have signalled danger or may not have been allowed at all) may opt for appeasing the aggressive person to “buy peace” at any price. Avoiding confrontation does not work for long, however, as the angry patient may become increasingly demanding and aggressive.
Avoidance: Fear of being hurt or spoken to aggressively can lead a health professional to avoid an angry client. However, if others do not intervene, the angry person can go from displaying aggressive language to becoming physically violent and out of control.
Inconsistency of care: If some staff members are avoiding the person, some are getting angry in return, and others are appeasing the person, there may be inconsistency of care, leading to conflicts between staff members and overall reduced standards of care for the person.
Aggressive language or behaviour, at best, makes people feel like they are walking on eggshells, which makes it difficult to feel empathy for the client, thereby complicating any resolution of legitimate concerns. The reputation the aggressive individual gains for being unapproachable and disrespectful not only ruins their relationships; it also makes emotional burnout a more likely outcome for those interacting with them, as it is so draining.
How can you most effectively deal with aggressive client behaviour?
As a mental health professional interested in the best outcomes for your clients, you know that an ineffective response to aggression – even when you have done nothing to deserve the aggression – can derail the client’s progress. Equally, however, a helpful response may actually improve their treatment, as the client experiences – perhaps for the first time – being “held” by a nonjudgmental professional when they are out of control. Your effective response becomes a container big enough to hold their aggression.
Let’s look at the parts of that response, starting with a standardised list of dos and don’ts for the high-intensity moments when you first confront the anger/aggression.
Dos
- Adopt a passive, non-threatening body posture (e.g., hands by your side, palms upturned)
- Approach the client from the front
- Try to move the client to a no-audience place, keep others out of harm’s way, and reduce environmental stimulation
- Let the client vent, acknowledging their feelings
- Be flexible
- Ask open-ended questions
- Position yourself near the exit, for protection (safety mechanisms, such as alarms, should already be in place)
Don’ts
- Challenge or threaten the client through tone of voice, body posture, or eyes
- Yell, (even if you are being yelled at), say escalatory things, or argue with the client
- Turn your back on or rush the client
- Dismiss their delusional thoughts (real to them, after all)
- Ignore verbal threats or warnings of violence, but don’t tolerate violence, either
- Try to disarm an armed person
The longer-term preparations are just as vital for those awful moments of facing aggression.
Calm yourself: before, during, and after
Neuroscience tells us that the most recently evolved, logical part of our brain, the pre-frontal cortex (PFC) responsible for executive functions, can get overridden, or shut down quickly, when our older, limbic system detects threat. When you notice a racing heart, surging adrenaline, confusion, dread, and an emotional sense of panic in the middle of a confrontation, it’s time to ask for a timeout. That may not always be possible in the moment but slowing any response on your part and taking a few breaths can help you to restore the calm that enables you to bring your PFC back online, thinking more clearly about what needs to happen next.
You are more likely to be able to do this if your lifestyle contains regular calming practices, such as mindfulness or other meditations, body-feelings-mind meditations, or other stillness practices. Daily practice of mindfulness/meditation enhances your ability to nonjudgmentally tune into bodily sensations, emotions, and thoughts at the moment you are experiencing them, enabling a more considered, holistic response. Moreover, the capacity to operate from a calm inner space – despite provocation – enables you to consciously bring to mind the values that underpin your counselling efforts, and those can be a “guiding star” for those difficult moments.
Express empathy, even if it’s hard to feel like they deserve it
A non-defensive stance – that is, one excluding the making of excuses and arguing back – can go a long way toward de-escalation. You can first express empathy by validating the client’s feelings. The stance sounds something like: “You’re angry with me because _____; am I hearing/understanding that correctly?” You can add in the assertive skill of negative enquiry: “Is there anything else that you feel angry about?” “What about ____? Is that a problem?” You probably need to apologise (blatantly unfair, no?), acknowledging that something you said or did has made them angry, or perhaps they feel that you are not competent to provide the services they need.
A sincere expression of regret that the client is not having the hoped-for experience in therapy can help them see (perhaps for the first time) that it is possible to be criticised, have anger directed against one, and still respond with empathy to the client’s distress. Such response is de-escalatory and probably an eye opener for a client who may have had a lifetime of interactions in which empathy and non-defensiveness played no part, and as such, can provide a new model for how relationship can be.
It goes without saying that any expressions of empathy must be done “right”, or aggressive clients (already suspicious) may see you as “phony” or inauthentic. In a weird way, you may have to earn the right to express it with such clients, strictly avoiding cliched phrases.
Finally, here, note that empathy and any compassionate gestures on your part are not licence for your boundaries to be violated, or for you to fail to enforce them. Your acknowledgement of intense feelings on the client’s part is not permission for them to make threats, curse at you, or simply fail to show up without cancelling.
Reframe resistance
Even when clients say that they want to change, they can resist “tooth and nail”, fighting even small changes that would improve their lives. That’s frustrating for the therapist, but if you find that happening with your client and you resist their resistance, therapy has ended. Two parties are resisting each other, and war has begun. Instead, you can try reframing the situation, giving them a compliment on their persistence, noting that if they tried as hard to improve their life as they do to make sure nothing changes in it, they would be consummately successful. Likewise, when you get resistance in the form of negative feedback (which could be about anything from how you run the sessions to how you dress), you can ask them to say more about it. Whether the feedback is valid (or genuine) or not, at least the client is talking; chances are they talk to others this way, too. Eventually, you can help them explore how their interactional style may be putting other people off, leading to unsatisfying relationships.
Patience is a wonderful virtue; cultivate it
A challenging, aggressive client is not likely to do a 180-degree change in just one, or even a few, sessions. Patience is needed here. They may have had a lifetime of being let down, treated disrespectfully, or even being abused. It will take time for them to accept respectful, hope-holding overtures. Maybe they never get to that point. Either way, the other stream of patience is the one you direct toward yourself. Again, stillness practices and, particularly here, loving-kindness meditations in which you direct good wishes toward yourself, friends and family, even enemies and aggressive clients, can help you to re-align with your vision and mission in therapy. You have entered a profession where you volunteer to bear the burden of others’ pain. Can you affirm how encounters with aggression are helping you to build patience and resilience as a therapist?
Get support
As therapists, most of us passionately desire to be helpful and competent, so when things go awry, it is easy to blame ourselves, judge ourselves to be a “lousy” therapist, and feel ashamed to tell any colleagues what has occurred, but that is just when we most need to share our experience. Everyone has those days – and those clients. You are not alone and need to follow the advice you have probably given to many clients before: don’t isolate! Seek out professional peers and your supervisor. A second pair of eyes and ears may pick up what you missed while your PFC was offline in panic mode. They can help you go from rattled to growth mode, where you can ask: what can I learn from this for my future practice? Another consideration is to seek therapy for yourself.
This client may not be right for you
Just as every therapist is not right for a given client, so, too, not every client will be appropriate for you. When the client calms down, it may be time to have a conversation about what you each take on as your expectations from and responsibilities to the other party. After you have detailed what you expect to give to and do for the client, you can ask if the client believes that you are meeting their expectations. You can say what you need from the client. The match may not be a good one, and you may need to consider referring the person on.
Dealing with angry, aggressive behaviour is no fun, but with preparation and practice you can transform it from “the day from hell” to “the day when I learned so much.”
Key takeaways
- The appearance, mood, physical activity, and speech of an agitated person hold warning signs that violence or aggression could be imminent.
- Many health conditions render a person incapable of dealing with their frustration appropriately.
- You can most effectively deal with aggression through calm, non-threatening responses which do not challenge or ignore the angry person, while protecting yourself.
- The skills to be developed in the longer-term include learning to stay calm and express empathy in tense situations, reframe resistance, cultivate patience, get collegial support, and consider referring on a client not well matched with you.
References
- Clay, R. (2017). Coping with challenging clients. American Psychological Association. Retrieved on 28 May 2024 from: https://www.apa.org/monitor/2017/07-08/challenging-clients
- Comorbidity Guidelines. (2024). Aggressive, angry, or violent behaviour. Author. Retrieved on 28 May 2024, from: https://comorbidityguidelines.org.au/other-conditions/aggressive-angry-or-violent-behaviour-6
- NSW Health. (2020). How can I work with someone who may be violent? Author. Retrieved on 28 May 2024 from: https://www.health.nsw.gov.au/mentalhealth/psychosocial/strategies/Pages/managing-violence.aspx
- Queensland Mind Essentials. (n.d.). Caring for a person who is aggressive or violent. Author. Retrieved on 28 May 2024 from: Caring for a person who is Aggressive or Violent (health.qld.gov.au)
- Rausch, A. (2023). Aggressive Communication: Definition, Examples, & Tips. Choosing Therapy. Retrieved on 29 May 2024, from: https://www.choosingtherapy.com/aggressive-communication/