Managing violence without coercion

Managing Violence Without Coercion Dan Harris and Eileen F. Morrison

Managing violence has become a priority for nurses working in health care settings (bAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Although psychiatric nurses have a long history of dealing with and managing violent situations, very little attention has been given to a critical analysis of our traditional methods of managing violence. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional style in patients, as well as to critically examine interventions for managing violence. It is hoped that an honest examination will assist nurses to re-evaluate current practices for managing potentially difficult situations. Copyright © 1995 by W.B. Saunders Company

T HERE IS NO doubt that the management of violence is becoming a priority for nurses

working in health care settings (AAN Expert Panel, 1993; Editorial, 1992; Lipscomb & Love, 1992). Psychiatric nurses in particular have a long history of dealing with and managing violent situations. Although an accurate estimate is not available because of inaccuracies in reporting (Lion, Snyder, & Merrill, 1981), it seems that aggression and low level violence are relatively common oc- currences in psychiatric hospital settings. Severe physical violence also occurs, but less frequently (Lewis-Lanza, 1992; Lion & Reid, 1983; Lips- comb & Love, 1992). As the amount of aggression and violence increases in health care settings, nurses must become more sophisticated in their assessment and management of potentially violent situations. The purpose of this paper is: (a) to present an interactional theory of aggression and violence that argues for the coercive nature of violence in persons with a mental illness (Morrison, 1990b, 1992b, 1993b), and (b) to propose a different approach to managing violent situations that emphasizes negotiation and collaboration, rather than control. Vignettes of violent situations provided by a clinical nurse specialist are used to highlight the presence of this coercive interactional

style in patients, as well as to critically examine interventions for managing violence.

LITERATURE REVIEW

The literature on violence focuses almost pre- dominantly on individual factors related to violence, such as age, sex and psychiatric diagnosis (Brizer & Crowner, 1989; Lion & Reid, 1983; Monahan, 1981, 1984; Mulvey & Lidz, 1984). The violent patient has been described as a young male with a history of violence and criminal activ- ities (Brizer & Crowner, 1989; Mulvey, 1993). Although the relationship of violence and diagnosis is controversial, substance abuse, seizure dis- orders, organic brain syndromes and schizophrenia have been associated with violence (Brizer & Crowner, 1989; Mulvey, 1993; Swanson, Holzer, Ganju, & Tsutumo, 1990). Because of considerable inconsistency of the research findings on individual patient factors, most scientists now argue

From the School of Nursing, The University of Alabama, Birmingham, AA, and the Medical College of Virginia Hos- pital & School of Nursing, Richmond, VA,

Address reprint requests to Dan Harris RN, MSN, 876 Glenvalley Dr, Birmingham, AL 35206-3524.

Copyright © 1995 by W.B. Saunders Company 0883-9417/95/0904-000653.00/0

Archives of Psychiatric Nursing, Vol. IX, No. 4 (August), 1995: pp. 203-210 203

204 HARRIS AND MORRISON

for an examination of the interaction of the person with his/her environment as an important area for future research (Brizer & Crowner, 1990; Monahan, 1984, 1992; Mulvey & Lidz, 1984). With a few exceptions, very little research has been conducted in psychiatry and/or nursing to provide a greater understanding of the interactional nature of violence. But many lessons can be learned from the research of other disciplines examining the interactional aspects of anger, aggression and violence (Newell & Dryden, 1991; Patter- son, 1982; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991).

The importance of reinforcement toward main- taining antisocial behavior in children has been studied by many, but most notably by Patterson (1982) looking at interaction patterns in families. Patterson carefully documented that children ini- tially learn to be antisocial from parents who un- knowingly reinforce such behavior. Nagging, scolding, or yelling are used in response to misbehavior. When the child continues to misbehave, the parents eventfully reach their boiling point and explode. Unfortunately, this acts as a reinforcer for the misbehavior because the parent still does not adequately discipline and/or expect compliance. In this way, the child readily learns the coercive effects of aggression and violence. Then the child uses coercion to shape the behaviors of those in his environment for his own benefit. Thus, social control is learned and becomes a primary way of re- lating with others.

The most common finding related to the interactional nature of violence in the psychiatric literature is that violence is a common response to limit setting (Anderson & Roper, 1991; Brizer & Crowner, 1989; Davis & Booster, 1988; Depp, 1984; Morrison, 1990ab, 1992a, 1993ab; Roper & Anderson, 1991). In addition, some scientists have found a coercive, dominant, or manipulative nature in the persons with mental illness who are also violent (Anderson & Roper, 1991; Depp, 1984; Esser, 1979; Feltous, 1984; Geller, 1980; Davis & Boster, 1988; Feltous, 1984; Morrison, 1990b, 1992a, 1994; Paul & Lentz, 1977; Roper & Ander- son, 1991). The literature suggests that persons use violence as a coercive or manipulative behavior to manage certain situations, especially limit setting situations.

Building on Patterson's (1982) research, Morri- son (1990b, 1992a) found that the psychiatrically

ill do learn aggressive and violent behavior and use it to control those in their environment. Patterson's cycle of coercion (1982) and escalation was ob- served on a relatively routine basis in hospital settings, except that interactions occurred between nurses and patients, not families. As minor rules were ignored/broken, the staff ignored the patient or nagged, hoping for compliance. Despite these attempts, compliance did not occur. Eventually, the staff intervened. The situation escalated and a "take down" occurred. This scenario is very sim- ilar to what Patterson noted in the parent-child relationship when the child is noncompliant with a parent's corrections. Just as Patterson (1982) noted that children learn coercion in this way, so Morri- son (1990b, 1992a) noted that a take down rein- forced a patient's perception that violence was a valid method of gaining social control. The staff's physical response in the form of a take down re- inforced the patient's image of himself as a tough guy and increased the likelihood of future violent confrontations. In fact, patients were more aggressive when nursing staff were in the dayroom than when they were not. Children have also been found to be more aggressive when supervised (Be- sevegis & Lore, 1983). To be consistent with Patterson (1982), Morrison labelled this interactive style coercive and identified it as a primary factor predictive of aggression and violence (1992a). Us- ing a causal modeling design, this coercive style did indeed predict 35% of the aggression and violence in hospitalized psychiatric patients. When combined with a history of violence and length of hospitalization, 60% of the aggression and violence was predicted (Morrison, 1992a). These re- suits strongly support the possibility of an interactional process tied to reinforcement patterns as an important cause of aggression and violence.

Although findings are inconsistent, some envi- ronmental factors have been related to aggression and violence, including staffing ratios, space, and staff provocation. Of these, staff provocation is the most important issue. Although limit setting, de- taining patients, and forcing medication are all cited as examples of staff provocation in the literature (Brizer & Crowner, 1989; Esser, 1970; Mor- rison, 1989), these can be understood within the context of a coercive interactional style (Morrison, 1992a). When patients who have made a practice of controlling their environment through aggression and violence are placed on a psychiatric unit

MANAGING VIOLENCE WITHOUT COERCION 205

where staff detain them involuntarily, force medication, and/or set limits, it is reasonable to assume that staff/patient conflicts resulting in violence will occur. These situations are highly coercive, since staff are trying to force something onto a patient who uses coercion and violence as a way to get control over others. Though not extensively documented, it has been shown that a generalized authoritarian or controlling attitude by staff increases violence (Morrison, 1992a, 1993b). Although re- cent interest in the effect of organizations on patient behavior has been minimal, with an increas- ing emphasis on quality of care and patient satisfaction, the effect of staff behaviors on patient outcomes is once again a priority (Fisher, 1993; Johnson & Morrison, 1993; Morrison, 1993b). The authoritarian aspects of institutions have been documented, but what is unclear is how much aggression and violence is caused by the controlling atmosphere.

Medication, seclusion, and restraints are advo- cated as interventions for violence (Brown & Tooke, 1992; Corrigan, Yudofsky, & Silver, 1993; Eichelman, 1988; Tardiff, 1992; Tupin, 1983). Despite the attention given to these interventions, most clinicians would argue that these interventions are inadequate in decreasing the tide of violence on psychiatric units and we must ex- plore other options for managing violence (Brown & Tooke, 1992; Soloff, Gutheil & Wexler, 1985).

A fair amount of literature exists documenting the techniques for managing violent situations. In addition to the previously mentioned medications, restraints and seclusion, the following interventions are all emphasized: (a) being aware of own feelings; (b) allowing personal space; (c) using re- flective statements; and (d) using nonthreatening body language (Felthous, 1984; Lion, 1987; Tar- diff, 1992; Tupin, 1983). This literature base is fairly traditional and is loosely based on a variation of Freudian theory, which suggests that catharsis is therapeutic and that internal staff feelings will ad- versely influence patient behavior. However, very little empirical evidence exists to support these findings. In fact, research suggests that "venting" leads to increased anger (Tavris, 1989).

Other options for managing violent situations are available. One such option is behavioral approaches, which have been used successfully with managing anger and violence in the mentally ill and with others (Corrigan, Yudofsky, & Silver,

1993; Davis & Booster, 1988; Goren, 1991; New- ell & Dryden, 1991; Patterson, 1982; Paul & Lentz, 1977; Reiss & Roth, 1993; Tavris, 1989; Tulloch, 1991; Wong, Woolsey, Innocent, & Liberman, 1988; Wong, Slama & Liberman, 1987). Since this coercive style is learned through reinforcements, behavioral techniques are consistent with the understanding of violence posed here. For readers interested in behavioral techniques, the thoughtful review of behavioral techniques for managing violent psychiatric patients by Wong et al. (1988) or Tavris's (1989) book on managing anger are both recommended.

CASE STUDY

Clinical vignettes are used to examine both the nature of violence currently occurring in psychiatric hospitals and practices for managing violent situations. Some of the interventions used in the vignettes were effective, whereas others were not. It is hoped that an honest examination will encourage other nurses to re-evaluate their current practices for managing potentially difficult situations. Mr. M is a clinical nurse specialist, with a total of 9 years of clinical experience in psychiatry including 3 years as a nurse manager. He has a masters degree in psychiatric nursing and he started his nursing career in intensive care, where he worked for 1 year. The first vignette will clearly document the nature of violence in psychiatric settings, where violence is a learned response and used in a coercive way.

lnteractional Style

A male patient (Mr. S), in his early 30s, was transferred from the jail when his head banging couldn't be controlled. Criminal charges were pending for firing a shotgun into his girlfriend's house. He was frighteningly large and had a United States Marine Corps tatoo on his left fore- ann. He was not psychotic and had no previous psychiatric history, but he did have a history of abuse towards his girlfriend.

A female RN had been assigned to do his (Mr. S) admis- sion interview. He was very angry. When he became loud and verbally abusive toward her, she left his room, but he continued to follow her down the hall, threatening to throw her against the wall if she didn't let him out. My coworker continued to walk calmly away. As I approached, he began to be distracted from her and focus more on me. He began by telling me to back off, let him out. mind my own


business; all interlaced with profanity, sexually based curses, and threats of bodily harm. I stopped.., waited a moment for him to quit cursing me, and said, "My name is Mike. I'm a nurse here. What can I do to help things?" "Just open the door and get out of the fucking way." He said this angrily and was taking a step back. That worried me. I took a step backward, too. "I'm sorry Mr. S, I can't open the door. I could lose my job." "Just open the fucking door. You think you can keep me here, big man? You think you're tough? You better get some help. I'll kill you." Now he was approaching me with fists raised. I was backing away but running out of room. "Come on, chicken shit, tough guy," he s a id . . . By this time he was little more than an ann's length away and I was backed up to a locked door.

This incident is very typical of violent incidents in psychiatric settings. A patient profile of history of violence and no psychotic behavior is quite common, as is experience with the criminal justice system. At a superficial level, the patient wanted to get out of the hospital and was ready to fight with anyone who got in the way. One interpreta-

tion is that the violence was a response to limit setting. However, if you examine the underlying dynamics of the interactional processes, something else is also apparent, a coercive interactional style. When someone has a coercive interactional style, others are bull ied and intimidated into giving up and giving in. The patient wants something and the

situation escalates until he gets it. He repeatedly accused the nurse of being a " tough g u y " , but the tough guy image was his and is a common mech-

anism that aids in bullying others. Aggressive and violent behavior escalates until

the goat is achieved (Morrison, 1992b). In this case, anger gave way to yelling, raised fists, a threat to kill the nurse, and finally movement towards the nurse. The movement was another in- timidating behavior designed to suggest that Mr. S would take action on his threat and try to kill the nurse if he d idn ' t open the door. Although Mr. S 's stated goal was to get out of the hospital, it is also very possible that he was using his hospitalization to serve some goal related to his legal problems. It is not uncommon for patients to manipulate the system so that a jai l sentence could be served in the hospital or to build a case for being psychotic to minimize a jai l sentence. However, we do not know enough about this situation to answer this question. The patient did return to the criminal justice system and about 1 month later successfully committed suicide outside of the system.

One more point needs to be emphasized before discussing how this situation resolved. Consider- ing Mr. S ' s violent history towards his girlfriend, Mr. S should never have been assigned to a female nurse. The choice of victim is usually very stable; either vulnerable others (women/or children) or men (Morrison, 1990b). In this case, Mr. S had a

much greater l ikelihood of assaulting the female nurse, than he did of assaulting a male nurse.

The story continues as Mr. M discusses how this situation resolved.

By this time he was little more than an arm's length away and I was backed up to a locked door. Stop! I didn't shout, but I did speak loudly and firmly. "I don't work here to fight people. I'm a nurse. I take care of sick people. That's why I'm here. You want to win a fight? O.K.-You've won. I give up. Now what happens? . . . . "I just want out. I'm not crazy!" The situation deescalated.

This situation resolved after this exchange since Mr. M did not buy into the fight for control. He gave up control when he said " y o u want to win a fight . . . OK . . . you 've w o n " . This is a very

creative solution to the problem, since he gave up control without giving in, that is, without opening the door. Once the patient rea.lized that Mr. M would not let him out, there was no reason to continue the violence. Another way of looking at the situation is to say that the violence did not work, that is, violence was not rewarded. A second issue is that early on, Mr. M successfully removed the

intended victim (female) from the situation. A third possible factor might have influenced the re- suit. Mr. M also told the patient that he was frightening staff and patients. Although Mr. M does not usually intervene in this manner, he thought it was helpful in this case. In general, this intervention is risky because some patients want staff to be fright- ened and intimidated and if so, would increase their violence when given this information. To the author's knowledge there is no research that documents the effectiveness of this intervention.

In this next scenario, Mr. M provides us with another creative solution to a violent situation. A 20-year-old young man, an offensive l ineman of a major university football team, who was admitted for an acute schizophrenic break, was shouting at the top of his lungs.

He had turned over one chair. He held another chair in his hands at chest height. As he paused for a moment, I asked "Jim, what's happening?" I was standing several feet


away. "Jim, what's going on here?" My voice was some- what softer this time. Jim lowered the chair a bit, half crying and half shouting, he continued to talk about people pushing him around. "Jim, let's talk in your room," I said quietly. "What?" he said. I repeated myself and he began to look around as if he didn't know what to do next. "It's O.K. to put the chair down now," I said quietly. "Let's talk in your room." He put the chair down and we started toward his room.

In this case, Mr. M deliberately softened his

voice, almost to a whisper. The patient had to in- terrupt his outburst to hear what the staff was saying. Speaking in a quiet, soft tone seems to end verbal confrontations because the patient has to attend and listen carefully to what is being said. This intervention had a calming effect and fostered de-escalation. In addition, Mr. M ' s invitation to talk and permission to put the chair down contrib-

uted to a quick resolution. Although filing charges against psychiatric pa-

tients continues to be controversial, the following vignette provides an example in which a threat of taking legal action had a positive effect on the patient. Ms. P, a 25-year-old, attractive, electrical engineer, with a good job, was admitted to the unit on an involuntary basis.

Within 10 minutes she attacked staff. I and several other staff members responded to the scene to help subdue her. As we held her, she relaxed. She spoke more calmly. She agreed to rest on her bed for a while. As staff began to turn loose of her, she remained calm. Then, when she was no longer being held, she kicked a staff person in the face and laughed. She was again subdued, this time with leather restraints.

Clearly, this patient was aware of and delighted in her fight with the staff. The injured nurse and the hospital decided to pursue criminal assault charges against the patient. On hearing this, Ms. P calmed considerably. She apologized and asked the nurse not to press charges. The nurse agreed. In this case, the threat of assault charges accomplished three goals. First, the message was communicated that violence would not be tolerated and that consequences existed for breaking this rule. Although this expectation is stated in most psychiatric units, it is rarely enforced. Second, a threat of legal action clearly communicated that she was re- sponsible for her behavior. When this message was given, she responded by acting in a more respon- sible manner . Third , a threat of legal act ion changes the reward system for the violence and effectively acts as a negative consequence. How-

ever, improvement in her behavior was only tem- porary. Shortly after discharge, she was fired from her job as an electrical engineer after more disrup- tive behavior at work. It is possible, that the tem- porary improvement in her behavior was manipulative, so that the hospital would drop the assault

charges. Perhaps it would have been more effective if the hospital had successfully filed charges.

The following situation describes how behavior-

al techniques can be used to change socially inappropriate behavior. A young woman (Ms. M), in her early 30s, in the manic phase of a bipolar illness, was admitted to the hospital. She exhibited considerable hypersexual behavior, cozying up to male patients and staff, grabbing crotch 's and rub-

bing their chests.

Ms. M approached me while I was seated on the couch. She stopped a couple of feet directly in front of me. I said hello. She raised her dress above her head. She wore no underclothes. When she lowered her dress there was a defiant look on her face. Instead of commenting on her behavior, I introduced myself and asked if she would like to join a card game we were forming. She declined the game. Later that evening I asked her to help as I walked an elderly woman in the hall. She helped and I thanked her. Before she was discharged she sought me out and said thank you so much. "You've helped me a lot" She seemed sincere.

This intervention was effective since Ms. M never again approached the CNS in a sexual manner, although she continued this behavior with

many others. Ignoring the behavior accomplished two things with respect to reinforcement principles

(Morrison, 1990b). First, in cases such as these, patients use inappropriate social behavior to gain attention. Staff comply by giving negative attention; telling her that her behavior is inappropriate or telling her to put her dress down. Both of these responses reinforce the inappropriate behavior by providing attention, albeit negative. The second accomplished goal was that Mr. M did not allow the patient to control the interaction and create dis- tance through intimidation. While ignoring the behavior, he asked her to join in a card game. This intervention implicitly communicated a set of appropriate expectations; not the response she hoped for, but an appropriate intervention that worked at eliminating the behavior while she interacted with Mr. M. However, if others in the environment continue to reinforce the inappropriate behavior it will continue. In addition, without the support of those outside the hospital who will be in the im-


portant role o f caretaking, the behavior will con-

tinue.

Staff Provocation A second contributor to violence in institutional set-

tings that must be addressed is the effect of staff provocation through excess control and authority. Several investigators (Depp, 1984; Fisher, 1993; Morrison, 1990a, 1993b) described a process in psychiatric settings where administration and staff defined psychiatric nursing in terms of managing patients and their psychotic behavior. When a unit's philosophy is based on control or the management of patients, then physical techniques take on a predominant role (Lion, 1987), especially with respect to managing violent situations. Mr. M has a unique perspective since he is 6 ft. and 6 in. and weighs in the 300-1b range. In the following two scenarios, he describes how he was received on two different psychiatric units.

Unit 1: My HN let me know that I may have a built-in disadvantage in working with seriously mentally ill clients. My new supervisors were concerned that my size would be frightening to some clients or simply offsetting to others. I became very self-conscious about being as respectful and nonthreatening to clients as I could.

On this unit, Mr. M was a very successful nurse

because he focused on learning how to relate with

patients, how to communica t e a car ing attitude,

and how to show respect for patients. In contrast,

Mr. M worked on a second unit, which has a phi-

losophy emphas iz ing control. On this unit, he was

valued because o f his pe rce ived ability to physi-

cal ly manage patients.

Unit 2: A few nurses made the comment to me that they were glad to see a large male RN working on the unit. I often heard remarks like "It 's about time," or "We're glad to see you," or "This is more like it." All such remarks were made in reference to my size. On my first day at my new job a loud banging and commotion was heard down the hall. I rushed to the scene with the rest of the staff. As the newest team member I waited to be given directions on what to do. I looked at the rest of the team to see who was going to be talking to the disturbed client who was in the process of trashing his room. No team member made a move. Finally I said, "Who's going to talk to him?" They all looked at me and one said, "You are. You're the biggest."

W h e n the tradit ion o f toughness exists, staff are

e m p l o y e d s imply for their abil i ty to physical ly

manage patients (Morr ison, 1990b). Those with an

addit ional advantage such as size or knowledge o f

martial arts are part icularly we lcomed . These em-

p loymen t strategies do not necessari ly improve the

therapeut ic e n v i r o n m e n t ( Johnson & Morr i son ,

1993). Mr. M tells a story about a part icularly bad

day when unstable e lder ly patients were walking

around, patients were arguing, and staffing was

short. His interactions were part icularly direct ive.

A 30-year-old woman, working as a paralegal, with a diagnosis of bipolar, approached me from behind and struck me in the head very harshly with her shoe. I was so star- tled, I whirled around drawing back my fist. When I saw her standing there, she made no attempt to duck or with- draw. Stunned, "I s a id . . , what on earth are you doing?" She said "you can't treat us like this! We're not your slaves!"

Later, Mr. M came to real ize that the patient

was responding to his direct ive interactions with

the other patients which she perce ived as " b o s s y . "

As Mr. M ref lected on his exper ience , he told o f

another incident that he d idn ' t handle very well .

However , other staff in tervened and managed the

situation in a thoughtful and caring manner .

Several years ago at mealtime on a locked unit, I noticed that a male schizophrenic patient had removed the stainless steel dinner knife off his tray and placed it in his back pocket. I attempted to sneak up on him and grab it from his pocket. He saw me, quickly jumped up and brandished the knife pushing me into a comer. A psychiatric technician, spoke in a calm voice to the patient saying, "It 's O.K. to put the knife down. You've proved yourself. There's no need to carry this any further."

The CNS acted inappropriately, but the situation

resolved when the psychiatr ic technic ian told the

patient what he needed to hear, that is, " y o u ' v e

proved you r se l f " e l iminat ing the need to cont inue

the fight. Mr. M learned f rom this exper ience to

give up when possible. He was fortunate to have

such good role models who interacted with patients

in a thoughtful and caring manner and e l imina ted

the need for a power struggle. These situations are

not u n c o m m o n and most nurses work ing on psy-

chiatr ic units can descr ibe s imi lar incidents in

which staff acted in control l ing ways in response to

patients who were chal lenging.

DISCUSSION

Several examples of cl inical ly violent situations

have been rev iewed and analyzed. S o m e o f the

interventions were effect ive , whi le a few were not.

Throughout the analysis, an interactional theory o f

aggression and v io lence was proposed that argues

for the coerc ive nature o f v io lence in persons with

a mental i l lness (Morrison, 1990b, 1992b, 1993b).

Clearly, prevent ion o f escalat ing events is the

key to the management o f v io lence in psychiatr ic

settings. Seclusion is used far too often and tech-


niques that have insufficient empirical support should be re-examined (Morrison, 1993a). Litera- ture does exist to provide direction for understanding the interactional nature of violence and we must begin the process of examining our own behaviors and responses to patient behaviors and changing those responses when necessary. It is hoped that an honest examination of these vignettes will encourage nurses to re-evaluate their practice.

Many hospital nurses are concerned about violence and are demanding that administration institute additional controls regarding safety. The underlying problem with this approach, however, is that as hospitals become more controlling, violence will increase. This is not an effective solution for the problem! The health care system must become less controlling and more responsive and user-friendly for both nurses and patients (Johnson & Morrison, 1993).

Nurses are encouraged to focus on the preven- tion of violence before it starts and to manage potentially violent situations using some of the principles outlined earlier in this article. Avoid power struggles; allow patients to win struggles for control without giving in to unrealistic demands. Ask patients what is important while they are in the hospital and give it to them if possible. Make them true partners in their care. Teach them verbal skills of negotiation and collaboration. Encourage in- volvement in decision-making and show respect when they are able to act independently. Institute consequences for violent or threatening behavior.

Lore and Schultz (1993) argued that Americans believe that aggression either cannot or should not be controlled. It is true that those of us in psychiatry are a good example of this since we want to believe that violence is an impulsive behavior. This interpretation comes from our adherence to out- dated theories that have limited explanatory power, A norm against violence must be estab- lished in every aspect of society, including psychiatric units and enforced when necessary (Feltous, 1984; Johnson & Morrison, 1993; Lore & Schultz, 1993). If violence occurs, clinical staff must take action; consequences must occur!

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Managing violence without coercion