Intended for healthcare professionals

Career Focus

Handling aggressive patients

BMJ 2006; 333 doi: (Published 12 August 2006) Cite this as: BMJ 2006;333:s63
  1. Anita Houghton, consultant and coach
  1. London ( anita.houghton{at}


Anita Houghton suggests using non-violent communication when confronted with anger

Something we all have to deal with from time to time is aggression from patients. It may be someone who is angry because they've had to wait for an appointment longer than they think is appropriate, or some other perceived shortfall in the service you provide, or it may be out and out violence, as experienced in accident and emergency and psychiatric departments on a regular basis.

Feeling your way

Each situation is different, so the following strategies are not prescriptive for every occasion. They are useful, though, for just about any situation in which emotions are running high.

There are three main rules:

  • Resist your instinctive responses. They usually make things worse

  • Manage your own mental and emotional state. You need to be calm to be effective

  • Get curious about the other person's feelings and needs. Here lies the answer.

Resist your instinctive responses

When someone is aggressive, our instinctive reactions are flight or fight. As a sophisticated professional, you probably don't run out of the consulting room or punch your patient although you might be tempted. What you are more likely to do is a more subtle form of flight or fight, which is to defend yourself, or get quietly aggressive by telling the patient what you think of their behaviour, or calling security. Underlying these responses is a simple need—to stop experiencing the aggression.

Common ways of responding to aggression

  • Saying “but” (“but you are fit to work”)

  • Explaining (“the thing is that two of our nurses are off sick, one of the consultants is on maternity leave, and the secretary of state for health has banned the use of temporary staff in order to alleviate the NHS cash crisis”)

  • Blaming (“you ungrateful louse, can't you see I'm rushed off my feet?”)

  • Fighting back (“right, I'm removing you from my list”).

None of these are likely to reduce the patient's aggression, and may actually increase it. Why? Because the person, in their clumsy and inept way, needs something from you.

Manage your own mental and emotional state

If you're going to avoid making these very understandable responses, you need to manage the emotions and thoughts that drive them. These fall mainly into the two categories of fear (provoking flight reactions) and anger (provoking fight reactions)

To experience these feelings you have to be what is called “associated,” your attention focused inside yourself. To reduce these feelings you need to be “dissociated,” your attention focused outside of yourself.

To see what this means, try this:

  • Think of a situation in your life that regularly causes you to feel bad (angry, upset, irritated, frustrated, sad, whatever)

  • Imagine that you are in that situation and re-experience the feelings you get

  • Notice how you feel, and give the feeling a name

  • Now imagine you are a fly on the wall, watching what is going on from a distance. Notice what happens to the way you feel.

Take yourself out of the situation

When you're experiencing a feeling, you are associated—your perspective is from inside your head/body. When you look at it as an observer, those feelings will usually reduce in intensity dramatically, and may disappear altogether.

The next time you are in a difficult situation and you notice the very first signs of feeling bad, flip yourself out of the situation and imagine you are observing it. Ask yourself, what is going on here? Practise and you will become aware earlier and earlier of negative feelings—if you leave it until you are too emotional, you will find it difficult to recover. In those circumstances the best resort may well be to leave the room, or call for help.


“Never say no to an angry person”Marshall Rosenberg

Become curious about the other people's feelings and needs

Marshall Rosenberg was the founder of non-violent communication, a system of communication based on the premise that negative emotions arise from unmet needs.1 Understanding a person's feelings, and the needs that drive them, allows you to empathise, rather than fight. As a result they feel understood, and anger melts away.

You bitch, don't lie to me

Rosenberg tells a story about a woman who was undergoing training in non-violent communication, and whose job was at a Chicago detox centre. One night a drug user came in and asked for a room for the night. She told him that there were no rooms free. At that, he pushed her to the ground, and whipped out a knife that he held at her throat, shouting, “You bitch, don't lie to me, you do have a room!” About to say, “But I don't have a room,” she remembered her training, took some deep breaths, and then said, “It sounds like you're really angry and you want to be given a room.” He shouted back, “I may be an addict, but I deserve some respect! I'm tired of no one giving me respect.” “Are you fed up not getting the respect you want...?” she asked. After 35 minutes of feeding back his feelings and needs, he got off her, she gave him the address of another centre, and off he went. She said afterwards, “I could see how people who seem like monsters are simply human beings whose language and behaviour sometimes keep us from seeing their humaneness.”

Fly on the wall

Try these techniques in minor, safe situations first. When your partner or flatmate or child gets ratty at the end of a working day, notice how you react, flip out of the situation to fly on the wall, then focus on the other person and ask yourself, what's going on for them? Reflect back their feelings and needs in a kindly tone. “Are you feeling fed up because you need some peace and quiet?” When you see the other person relax, and they stop talking, you know you're done. ■


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