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Behavioural interventions to reduce aggression among psychiatric patients


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Title: Behavioural interventions to reduce aggression among psychiatric patients

Behavioural interventions to reduce aggression
among psychiatric patients
McMaster University Dept. of Psychiatry
Behavioural Neurosciences Research Day April 2,
  • Marnie E. Rice, Ph.D.
  • Scientific Director McMaster/Penetanguishene
    Centre for the Study of Aggression and Mental

  • Introduction
  • Measurement issues
  • Characteristics of assaulters, assaults,
    assaultive environments
  • Prediction of assaults
  • Interventions focusing on patients
  • Interventions focusing on staff
  • Interventions focusing on the ward environment
  • Ideal program for aggressive patients

Measurement issues
  • Inconsistent and unreliable operational
    definitions of aggression
  • Overt Aggression Scale (Silver Yudofsky, 1987)
  • 5 Subscales-- Verbal Physical against self,
    Others, Objects Severity, Total score
  • Daily interviews of staff patients (Quinsey
    Varney, 1977 Harris Varney, 1986)
  • Direct observation (Paul Lentz, 1977)
  • Videotape monitoring (Brizer, Crowner, Convit
    Volavka, 1988 Crowner, Peric, Stepcic Van-Oss,

Characteristics of assaulters
  • Young, extensive history of institutional
    violence, low functioning
  • Exhibit hostility anger short of aggression
  • Results regarding diagnosis and sex of aggressors
    is mixed

(Quinsey, 2000)
Assaulters (cont.)
  • Small minority of patients are involved in the
    vast majority of assaults
  • Psychopaths commit few assaults, but when they
    do, they are more serious
  • Some evidence that acute symptoms esp.
    persecutory delusions are related to assaults in

(Hunter Love, 1993 Quinsey, 2000)
Characteristics of assaults
  • Staff proportionally more likely than patients to
    be assaulted
  • especially nursing/ attendant/ inexperienced
  • assaults occur in context of setting limits or
    making requests
  • Victim vs. perpetrator explanations
  • Injuries usually minor vs. restraints
  • Serious assaults more likely to involve weapons,
    room extractions

(Hunter Love, 1993 Quinsey, 2000 Rice,
Harris, Varney Quinsey, 1989)
Characteristics of assaultive environments
  • Rapid turnover of young individuals with
    histories of institutional violence , acute
    psychotic symptoms and/or low functioning
  • Many individuals with extensive histories of
    minor criminal behaviour

(Rice, Harris, Varney Quinsey, 1989)
Characteristics of assaultive environments
  • Inexperienced staff who approach patients in an
    authoritarian manner and use primarily aversive
    or punitive consequences to control patient
  • Crowded (many patients, line-ups)
  • Little structured activity, poor supervision
  • Few or inconsistent consequences for aggressive

Rice et al., 1989
Predicting institutional assaults
  • Predicting who Actuarial prediction tools
  • McNiel Binder (1994)
  • Violence Risk Appraisal Guide (VRAG, Harris,
    Rice, Quinsey, 1993)
  • Predicting when
  • Threatening gestures yelling, arguing,
    fist-shaking, pointing by victim or assailant
  • Intrusive behaviours getting very close,
    touching by victim or assailant

(Crowner, 2000)
Implications for treatment
  • 3 sensible approaches to intervention
  • Treat small number of highly assaultive patients
  • Teach staff ways to prevent and control
  • Focus on changing assaultive environment

Treating highly aggressive patients
  • Anger Management Training (Novaco, 1975)
  • Assessment--Novaco Anger Scale (Novaco,1994)
  • Predicts violence in the community (Monahan et
    al., 2001)
  • Example items
  • Once something makes me angry, I keep thinking
    about it
  • Every week I meet someone I dislike
  • When someone yells at me, I yell back at them
  • When a person says something that offends me, I
    just stop listening
  • When someone makes me angry, I think about
    getting even
  • I feel like I am getting a raw deal out of life

Anger Management Training
  • Treatment Components- Stress inoculation
  • Education about anger, stress, aggression
  • Self-monitoring of anger frequency, intensity,
  • Construction of personal anger provocation

(Novaco, 1975)
Stress inoculation components (cont.)
  • Relaxation training
  • Cognitive restructuring
  • Behavioural coping skills- e.g., assertiveness
  • Actual and imaginary role-playing scenes from
  • Preparatory phase (5-7 sessions) may be necessary
    for forensic patients

(Novaco et al., 2000)
Empirical Support for AMT
  • Found to reduce self-reported anger, increase
    scores on role-play measures of anger control,
    and reduce blood pressure increases in response
    to provocations in outpatient clients with
    self-reported anger problems (Novaco, 1975 1976)
  • Found to reduce aggressive behaviour among
    institutionalized adolescent psychiatric patients
    (Feindler et al., 1986)
  • Promising preliminary results with violent
    maximum security psychiatric patients (Renwick et
    al., 1997)

Modified AMT plus other behavioural interventions
  • Becker, Love Hunter, 1997
  • 4 intractible aggressive males psychotic
    inpatients in a maximum secure hospital
  • Pretreatment observations showed that anger was
    related to violent behaviour
  • Individual behavioural programs including
    classical and operant conditioning approaches
    (pretreatment skill building, behaviour shaping,
    desensitization) plus other anger management

Becker, Love Hunter, 1997(cont.)
  • Results
  • All participants increased prosocial behaviours
    including anger management skills
  • Violent behaviour and hours in seclusion and
    restraint were eliminated in all 4 cases
  • All 4 patients were transferred to a less secure

Other behavioural treatments-
  • Begin with behavioural analysis
  • Must be prosocial activities available
  • Specific interventions
  • social skills training
  • differential reinforcement of other behaviour
  • timeout
  • mild aversives
  • overcorrection
  • contingent restraint
  • Evaluate results

eg. Wong, Slama Liberman, 1987
Other behavioural treatments the Snoezelen Room
  • Background- Promotional materials
  • Name comes from Dutch words for sniff and
  • Multisensory, stress-free environment
  • Person experiences it, like watching flames at
    a campfire
  • Worldwide interest--Snoezelen Foundation
  • Cost
  • Data

Evaluating the Snoezelen Room
  • Method
  • Participants- 4 chronically aggressive
    developmentally handicapped inpatients
  • Design- ABAB reversal design for 2 patients,
    AABAB for other 2
  • Differential reinforcement for other behaviour
  • Patients can use room for calm behaviour
  • Rationale and future plans

(McKee et al., in progress)
Behavioural programs targeting staff behaviour
  • Rationale
  • Staff vs. patient reasons for assaults
  • Staff over-represented as victims
  • Training Course
  • 5 days
  • Topics
  • Preventing critical incidents Calming, defusing
  • Interventions during critical incidents Manual
    restraint, seclusion, and self-defense

(Rice, Harris, Varney Quinsey, 1989)
Staff Training Course (cont.)
  • Following critical incidents Interviewing
    techniques, Conflict resolution skills
  • Training Methods
  • Classroom teaching, heavy reliance on
    role-playing in simulated crisis situations
  • Shaping of role-play skills- Began by using short
    role-plays in small groups in the classroom, then
    built to longer role-plays in larger groups in
    ward environment

Rice et al., 1986 1989
The Escalation Process
Risk of injury to staff and/or patients
Stages in Escalation
Empirical support for staff training
  • Study design
  • Participants
  • Multiple baseline plus control
  • Results
  • Measures of knowledge and skill
  • Verbal skills- Audio and video role play tests
  • Physical Skills
  • Staff self-report questionnaires
  • Patient affect and morale measures
  • Assaults and staff injuries

Total assaults Assaults on patients Assaults on
Number of assaults
Thirty Day Periods
Work Days Lost due to Patient-Caused Staff
Experimental Wards Control Wards
Number of days lost
Thirty day periods
Behavioural Programs focusing on the social
  • Social learning program
  • Paul Lentz (1977)
  • Beck et al. (1991)
  • Menditto et al. (1996)
  • Total quality management

1. Social learning program
  • Paul Lentz (1977)
  • Most impressive results for reductions in all
    inappropriate behaviours and increases in
    appropriate behaviours of psychiatric patients
    using any type of treatment
  • Contingencies for assaultive behaviour were
    embedded in complex token economy plus skills
    training program

Paul Lentz
  • Study Design
  • Random assignment to
  • Control ward Traditional custodial care
  • Experimental wards
  • Milieu therapy
  • Social learning program
  • Measures taken every 6 mo. for the 6 years of the
    study (4.5 yrs. in hospital, 18 mos. in
  • Extra measures taken on experimental wards

Paul Lentz SLP
  • Patients -24 per group with replacement
  • Staff (same numbers on all, same staff on 2)
  • Measures
  • Staff- Resident Interaction Chronograph
  • Time-Sampled Behaviour Checklist
  • Program
  • Tokens for appropriate behaviours
  • Fines for serious inappropriate behaviours
  • Modeling, prompting, shaping, skills training

General Findings
  • Both experimental wards superior to traditional
    ward in building prosocial, reducing
    inappropriate behviours
  • Social learning program (SLP) superior to milieu
  • Psychotropic drug use
  • Patients discharged to community care

Specific Procedures for Assaultive Behaviour in
  • Time-out
  • Began with maximum time of 45 minutes
  • Soon raised to maximum of 72 hours
  • Reduced to maximum of 48 hours
  • Fines
  • 25 points (approx. 1 days earnings)

Assaultive behaviour in 1st 2 yrs.
Weekly incidents
Mandated reduction in time-out
  • Statewide policy mandated 2 hr. maximum time-out
  • On SLP
  • Continued fines
  • Instituted overcorrection/restitution
  • Increased aversiveness of time-out
  • Noise
  • Temperature/humidity

Assaultive behaviour in next 2 years
Weekly incidents
Results of 2 hr. timeout on programs
  • Increased aggression upset entire system
  • Eventually decided to reinstate baseline and
    start over with max. 24 hr. timeout- ABCAB design
  • During baseline, handled aggression by heavy use
    of physical and chemical restraint, tepid baths,
    physical separation

Assaultive behaviour in last 6 months
Weekly incidents
General conclusions of Paul Lentz
  • All but 1 of original SLP patients achieved
    release to community
  • Use of psychotropic drugs considerably reduced
  • Data show that SLP is the treatment of choice for
    chronic psychiatric patients (many of whom are
    nonresponders to psychotropic drugs)

Beck, Menditto, Baldwin, Angelone Maddox (1991)
  • 19 maximum security psychotic, chronic male
  • Social learning program introduced over 3 month
  • Included 24 hour seclusion and fine of 1-days
    tokens for aggressive behaviours

Aggressive behaviours
Total number of intolerable behaviours
SLP Plus Novel Antipsychotics
  • Menditto et al., 1996- Clozapine
  • 11 SLP traditional neuroleptics
  • 11 SLP clozapine
  • Most aggressive patients assigned to clozapine
  • Some evidence that clozapine added to effect of
  • Beck et al., 1997- Risperidone

3. Total Quality Management
  • Hunter Love, 1996
  • Review of violent incidents showed violent
    incidents peaked at mealtimes and that silverware
    was frequently used as a weapon
  • Project aimed to reduce aggression in the dining
    rooms at a state forensic hospital
  • First gathered data about violent mealtime
    incidents, mealtime policy procedures, patient
    opinions preferences

Hunter Love (cont.)
  • Found incidents occurred while gathering patients
    together to go to the dining room, when denying
    extra portions, when patients cut in line, and
    when staff set limits for rule-breaking patients
  • Interventions
  • Gave patients the option of eating breakfast on
    the ward -- No effect
  • Replaced silverware with plastic disposable
    utensils, provided music, allowed
    highest-privilege patients to leave when finished
    (and go to the courtyard or gym if they wished),
    trained dining room staff in therapeutic

  • Violent events in dining room decreased from
    .53/day in year before implementation to .32/day
    after implementation (plt.001)
  • No downward trend prior to implementation
  • No weapons assaults involving eating utensils
    after change to plastic
  • Reduced workers compensation claims after
    project implemented
  • Savings in staff time, patients dining staff
    happy with changes

Ideal program for aggressive patients
  • Ward environment promoting prosocial behaviour
    and with serious consequences for antisocial
  • Staff trained in social learning techniques and
    assault prevention and management
  • Specific interventions for highly assaultive
  • Constant monitoring and analysis of assaultive

Conclusions and future research
  • Evidence for efficacy of all 3 approaches
  • Need for stronger designs, more studies using
    harder measures of aggressive behaviour, more
    studies of seriously aggressive patients,
    especially adults
  • Although empirical evidence is strong,
    pharmacological treatments are much easier to
  • Comprehensive treatment must include behavioural
    approaches and careful measurement

Behavioural Interventions to Reduce Aggression
Among Psychiatric Patients Marnie E. Rice,
McMaster Research Day, April Selected
References http//
m Beck, N.C., Menditto,
A.A., Baldwin, L., Angelone, E., Maddox, M.
(1991). Reduced frequency of aggressive behavior
in forensic patients in a social learning
program. Hospital and Community Psychiatry, 42,
750-752. Becker, M., Love, C.C., Hunter, M.E.
(1997). Intractability is relative Behaviour
therapy in the elimination of violence in
psychotic forensic patients. Legal and
Criminological Psychology, 2, 89-101. Crowner,
M.L. (Ed.). (2000). Understanding and treating
violent psychiatric patients. Washington, DC
American Psychiatric Press Inc. - Contains
chapters by Menditto and colleagues as well as
another chapter on behaviour therapy for
aggressive psychiatric patients Hunter, M.E.,
Love, C.C. (1996). Total quality management and
the reduction of inpatient violence and costs in
a forensic psychiatric hospital. Psychiatric
Services, 47, 751-754. Menditto, A.A., Beck,
N.C., Stuve, P., Fisher, J.A., Stacy, M., Logue,
M.B., Baldwin, L.J. (1996). Effectiveness of
clozapine and a social learning program for
severely disabled psychiatric inpatients.
Psychiatric Services, 47, 46-51. Novaco, R.W.
(1975). Anger control. Toronto D.C.
Heath. Novaco, R.W. (1994). Anger as a risk
factor for violence among the mentally
disordered. In J. Monahan H.J. Steadman (Eds.),
Violence and mental disorder Developments in
risk assessment. Chicago University of Chicago
Press. Novaco, R.W., Ramm, M., Black, L.
(2001). Anger treatment with offenders. In C.R.
Hollin (Ed.), Handbook of offender assessment and
treatment (pp. 281-296). New York John Wiley
Sons Ltd. - Contains many of the earlier
references regarding anger management training
Continued on next slide
Behavioural Interventions to Reduce Aggression
Among Psychiatric Patients Marnie E. Rice,
McMaster Research Day, April Selected References
Paul, G.L., Lentz, R.J. (1977). Psychosocial
treatment of chronic mental patients Milieu
versus social-learning programs. Cambridge, MA
Harvard University Press. -Hard going, but worth
it! Quinsey, V.L. (2000). Institutional
violence among the mentally ill. In S. Hodgins
(Ed.), Violence among the mentally ill (pp.
213-235). Netherlands Kluwer Academic
Publishers. - Good review that contains many of
the references from this presentation Quinsey,
V.L., Harris, G.T., Rice, M.E., Cormier, C.A.
(1998). Violent offenders Appraising and
managing risk. Washington, DC American
Psychological Association. Rice, M.E., Harris,
G.T., Varney, G.W., Quinsey, V.L. (1989).
Violence in institutions Understanding,
prevention, and control. Toronto Hans
Huber. Rice, M.E., Helzel, M.F., Varney, G.W.,
Quinsey, V.L. (1985). Crisis prevention and
intervention training for psychiatric hospital
staff. American Journal of Community Psychology,
13, 289-304. Wong, S.E., Slama, K.M.,
Liberman, R.P. (1987). Behavioral analysis and
therapy for aggressive psychiatric and
developmentally disabled patients. In L.H. Roth
(Ed.), Clinical treatment of the violent person
(pp. 20-53). New York Guilford Press.