Highly emotionally charged responses such as verbal abuse or plain rage can
be confusing and unsettling for the caregiver especially when the source of
these high energy acts are unknown.  If it is determined that the individual
becomes verbally threatening  to intimidate, refer to the intimidation section
of behavioral assessment. Take every threat very seriously and document
each time it occurs.  When an individual engages in verbal abuse by stating
demeaning, condescending or accusatory words, the care giver should assess
whether the individual lacks social skills or intends to manipulate.  When I
was working with a group of troubled youth one of the young men
approached me, made a fist and while slowly bringing it close to my face
stated, "My fist is as big as your face".  The act could have been interpreted
as a form of intimidation but it wasn't; it was lack of social skills.  An
individual may use demeaning words like, "you are stupid, incompetent or
weak" to provoke the caregiver and redirect him from the task at hand.  
Likewise, questioning one's authority has a tendency to distract the caregiver
if allowed.  At this stage the individual may be slightly irrational so,
caregiver should be aware of her body language and avoid words that may
be interpreted as threats.  These distractions should not be internalized, nor
should the caregiver respond to them.  Instead, the caregiver should redirect
the individual's attention to the task at hand.  Should the negative responses
continue, the caregiver states the positive and negative consequences of
individual's actions.  For example:
1-  The care giver approaches the individual and asks, "did you brush your
The individual responds by saying, "are you stupid?  It's my teeth."  
Caregiver ignores the responds and repeats the question by saying, "please
answer my question, did you brush your teeth?"  
The individual responds by saying "go to hell, you are not my boss".  
Care giver again ignores the respond and begins to describe the
consequences of breaking the rules (assuming the rules are already
established and consequences of breaking the rules are familiar to the
individual).  If the targeted behavior is verbal abuse, the care giver states, "If
you respond to me appropriately, I will leave you alone; if that's what you
want.  But if you continue to respond abusively, the rules say you will lose a
weekend privilege and I really want you to enjoy your weekend."  
The person may respond in three ways:
1-  Comply
2-  Continue with verbal abuse or challenges
3- Go into rage
When the person goes into rage, if she is not a harm to herself and or others,
allow her to let all that energy out of her system. Remember that the person
is probably irrational so,  shorten your verbal cues while being cognizant of
words that may be interpreted as  threats and increase body language.  By
focusing on what the person is saying and how she is acting, caregiver may
be able to gain some insight as to the cause of the rage being displayed.  
Look at the individual facial reaction, body movements including the lips to
determine whether the person is acting out of anger, frustration or other
emotional pain.  Be sure others are not around as this may traumatize them
and or add to the problem.  Normally, it takes a lot of energy output during
the rage therefore, it is difficult to maintain it for long period of time.  Allow
her to calm down before communicating as to what happened, why it
happened and what measures need to be put in place so the behavior does
not occur again.  
An act of rage may occur due to poor social skills such as not being able to
communicate one's frustrations verbally and regularly.  It may be the only
way the person has learned to cope with a mental illness or she may have
very low stress tolerance.  It could also be a learned behavior to get out of
things such as chores.  Once an individual has finished with his rage and has
regained his rationality, the caregiver should evaluate whether the person is
ready to talk.  My preference is to ask, "I would like to talk to you about
what happened, come and get me when you're ready".  This type of request
works for some population but not all; however, it allows the person to
determine for himself whether he is ready to talk or not.  Remember,
allowing personal autonomy creates personal responsibility.  Avoid starting
the conversation with words like, "you, how, why" instead use statements
like, "lets figure out what happened".  For the caregiver this communication
session is mostly about listening so, allow the individual to do most of the
talking and if possible most of the decision making.  Caregiver should allow
the person to describe what happened regardless of the variations from the
real event.  While the caregiver listens to the individual, he or she also
focuses on the feelings that are being manifested.  Are there signs of anger,
frustration, hopelessness?  For example, the individual may state:  " I hate
this place and its stupid rules, I can't wait to move out of here."  The
caregiver should be careful not to get redirected by such statements and
change his or her focus to what was said.  Talking about the environment,
the rules and plan of leaving will not resolve the behavior from reoccurring.  
Rather, the caregiver should state something like, "I can see that you are
very frustrated."  The caregiver becomes the listener once again and expects
the individual talk about his frustrations.  If some of the statements from the
individual appear to be confusing or questionable, the caregiver should
clarify by saying, "so, you are telling me that....?"  The caregiver role here to
figure out what happened, how it happened, why it happened.  Once the
caregiver has figured out the elements that led to the incident, then he or she
has something to work with.  If it is a personality conflict for example,
environmental and or schedule changes may help.  If it is caused by
stressors,  external stimuli such as noise, lighting and room colors can be
adjusted.  Social coping skills can help with relationship stressors.  
Objectives written for these behaviors mostly focus on preventive
techniques.  For example:  I will improve my personal and social skills by
verbalizing my frustration appropriately.
I will improve my personal and social skills by requesting staff for a 4
minutes private session to express my frustrations.
I will improve my personal and social skills by utilizing relaxation skill such
as breathing techniques to calm my self.
I will engage in 6 minutes of physical exercise twice a week to lower my
stress level.
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