Caring for the Combative Client

Who is the “Combative” Client?

Combative or aggressive behavior may include verbal attacks, such as yelling, cursing, and making threats. Non-verbal or physical behaviors may include hitting, pinching, spitting, pushing, kicking, or throwing things. Often, a fairly predictable progression of behaviors can be seen. For example, the client may start by becoming tense and irritated, followed by verbal complaints, such as “You’re always after me to take a bath!” This may progress to cursing, threatening (“Get away from me or I’ll hit you.”), and finally to physical forms of aggression, such as hitting or kicking.

Preventing and Managing Combative Behavior

The best way to manage combative behavior is, of course, to prevent it. While this is not possible in every case, proper client management can often significantly decrease aggressive incidents. If you are working with a client who has a history of aggressive behavior, get as much information as you can.

• What triggers the aggressive behavior?
• What early signs of aggression does the client display?
• Does the client’s behavior progress to physical violence?
• What helps the client to calm down?

When working with your clients, maintain a constant awareness of their mood and affect. Even subtle reactions, like a stiffening of the body or clenching fists when you perform certain actions, can give you clues that they may have difficulty coping. Watch for these early signs of possible aggression:

• increased activity, such as pacing
• a frightened or angry look in the eyes
• tensing of the body, such as clenched fists
• increased respirations
• flushed face

The Caregiver’s Role

Your behavior toward clients can greatly reduce the risk of aggression. The vast majority of our communication with others, about 93%, occurs nonverbally. This means that our messages to others are conveyed mainly by factors such as our appearance, body language and tone of voice.

• Act in a kind, calm, manner toward your clients
• Handle them gently, and speak in a calm tone
• Avoid hurrying or pressuring clients, or appearing impatient or annoyed, as these behaviors may trigger a combative reaction
• Provide a predictable, calm environment
• Make sure that the client’s needs for food, rest, comfort, and social interaction are met
• When working with clients who have dementia, tell them frequently who you are, to avoid fear and possible mistaken identity.

Managing a Combative Situation

If a client you are working with becomes combative, your goal in this situation is de-escalation— attempting to reduce or “bring down” the client’s reaction. Verbal and non-verbal de-escalation techniques can be very effective in reducing agitation. Non-verbally, your goal is to project a calm, yet attentive, facial expression. Excitement is contagious, and the client is likely to become more agitated if you react by becoming agitated yourself.  Here are some tips on how to de-escalate a situation:

• Keep your body loose
• Avoid aggressive signals such as clenching your fists or crossing your arms
• Maintain caring eye contact, but don’t stare aggressively at the client.
• Remember to breathe slowly and deeply, as this will help you to relax
• Stand with your body at a slight angle, rather than fully facing the client. This not only puts you in a better position if you need to exit quickly, but protects your chest and abdomen if the client suddenly hits or kicks
• Stand at least two arm lengths from the client, so that he doesn’t feel as threatened by you and cannot hit or kick you
• Always keep the nearest door open, and position yourself between the client and the door, so that he is not blocking your exit if you need to leave quickly
• If possible, position yourself so that there is a piece of furniture between you two, for further protection
• Speak to the client in a firm, calm voice. Watch the tone and volume of your voice. Keep it low, as most people tend to raise both their tone and volume when excited or threatened, resulting in high-pitched yelling
• Say something that helps the client to know that you understand his feelings… “Mr. Jones, I can see that you’re very upset, and I want to help.”
• Treat the client with dignity and respect,
• Never threaten or belittle him for his behavior
• Do not argue or try to reason with the angry client, such as saying, “I do not always forget your coffee.”

If possible, try to “undo” whatever has made the client agitated. For example, if combative behavior resulted when you approached the client to give him a bath, back off and leave him alone for awhile. If the client has dementia, distracting him with a favored activity can also be effective… “Mr. Jones, your favorite TV show is on now—would you like to watch?” When trying to de-escalate a client’s it is helpful if only one person talks, to avoid confusing or frightening the client.

Proper Procedure

Safety is the top priority when dealing with a combative client. If your safety is threatened, leave the area immediately, and get any other persons to safety if needed, and immediately call for assistance. As always, be familiar with and follow agency policy in dealing with emergency situations. If the situation is extreme enough that you cannot effectively handle it, the police should be promptly called to assist.

By acting in a caring and compassionate manner, and staying attuned to your client’s reactions, you can help to prevent and effectively manage combative behavior..

Once the incident is over, be sure you document it in a clear, objective manner. Also, it is very important to report any type of combative behavior, as this may be a sign of illness or medication reaction.