What's the point? Towards a methodology for assessing the function of psychiatric inpatient aggression

VR-assisted aggression treatment in forensic psychiatry: a qualitative study in patients with severe mental disorders

Introduction

Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments.

Methods

The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis.

Results

Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations.

Discussion

The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT.

Aggressive Incidents by Incarcerated People With Psychiatric Illness and Their Relationship With Psychiatric Symptoms

AIM

A prospective design was used to investigate the relationship of current psychiatric symptoms of incarcerated people with serious mental illness (SMI) and aggressive behavior on a penitentiary ward for crisis intervention.

METHODS

One hundred sixty detainees with SMI, detained in a high-security penitentiary psychiatric facility, were screened every 2 weeks with the Brief Psychiatric Rating Scale-Extended (BPRS-E) by trained clinicians, to ensure that the data on psychiatric symptoms were up-to-date. Aggressive behavior was registered with the Staff Observation Aggression Scale-Revised. A binary logistic regression analysis was performed to examine the relationships between factor scores of the BPRS-E and aggressive behavior.

RESULTS

Significant relationships between the BPRS-E factor hostility, antisocial traits, and aggressive incidents were found, but not between the positive symptoms or manic factor scores and aggressive incidents.

DISCUSSION

Symptoms of SMI measured with the BPRS-E did not help to explain the occurrence of aggressive behavior. This is not in line with what is commonly found. The implication is that it can be expected that this population will display aggressive behavior but that symptoms do not help in predicting when this will occur. In addition, hostility and antisocial traits were related to aggressive behavior. For this specific population, an interactional approach might be more effective in the management of aggression than treatment of symptoms of SMI.

A critical analysis of stalking theory and implications for research and practice

This article comprehensively reviews and critiques theories providing an aetiological account of stalking. We evaluate applications of preexisting psychological theories to stalking (attachment theory, evolutionary theory, social learning theory, information processing models of aggression, coercive control theory, and behavioural theory) as well as the only novel theory of stalking to date: Relational goal pursuit theory. Our aim was to identify which are supported by research, identify gaps in theoretical scope and explanatory depth and examine how current theories might inform clinical practice. This evaluation suggests that theories of stalking are underdeveloped relative to other areas of forensic clinical psychology and the theoretical literature is relatively stagnant. Consequently, there is limited research into clinically meaningful constructs that can guide the assessment, formulation and treatment of this client group. We identify similarities across existing theories, discussing implications for future research and clinical practice with people who stalk.

Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services

WHAT IS KNOWN ON THE SUBJECT?: The Safewards model has been introduced to forensic mental health wards with mixed results. Research has identified a need to consider the addition of factors that may be relevant to forensic mental health services to enhance the introduction of Safewards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study elicits factors specific to forensic mental health settings missing from the original Safewards model, which have the potential to enhance nursing care, improve safety and improve adherence to Safewards in a forensic mental health setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides the adaptation required in a forensic mental health setting to enhance the implementation of the Safewards model of care, originally developed to assist nurses to prevent and manage conflict and containment in acute general mental health settings. The development of Safewards Secure has incorporated perspectives from expert Safewards and forensic mental health nurse leaders and healthcare clinicians and is inclusive of consumer and carer perspectives to ensure the model is applicable and broadly acceptable. ABSTRACT: Introduction Safewards is a model designed specifically for acute mental inpatient wards. Research investigating the introduction of Safewards has identified a need to consider factors relevant in forensic mental health services, such as offence and risk issues. Aim To identify adaptations needed to address gaps in the Safewards model to assist forensic mental health nurses to prevent and manage conflict and containment. Method A Delphi study was employed to engage a group of international Safewards and forensic mental health experts (n = 19), to elucidate adaptation of the Safewards model. Results Experts identified necessary elements and reached consensus on key considerations for Safewards interventions. To ensure the Safewards Secure model was robust and developed on a platform of research, all items suggested by Delphi experts were cross-referenced and dependent on empirical evidence in the literature. Discussion This study identified a number of key differences between civil and forensic mental health services, which informed the development of Safewards Secure, an adjunct to the original Safewards model. Implications for Practice The development of person-centred models of nursing care adapted to specific settings, such as forensic mental health, provides a potential solution to preventing and managing conflict and containment, and improving consumer outcomes. Relevance Statement Managing conflict and containment in mental health services remains an ongoing challenge for mental health nurses. Safewards is a model of care designed for acute mental health inpatient settings to prevent conflict and containment. To date, there has been mixed results when introducing Safewards in forensic mental health settings, and reported reluctance and scepticism. To address these issues, this study employed a Delphi design to elicit possible adaptions to the original Safewards model. From this study, Safewards Secure was developed with adaptations designed for forensic services, to enhance the management of conflict and containment, assist implementation and improve consumer outcomes.

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

Mapping aggressive behavior of forensic psychiatric inpatients with self-report and structured staff-monitoring

Structured assessment of aggressive behavior in forensic psychiatry is needed. This study investigated staff-observed and self-reported measures to map prevalence and characteristics of aggressive behavior in forensic inpatients and aimed to identify early signs of aggressive outbursts. In this longitudinal study, 120 forensic psychiatric inpatients with a history of aggression were included. Staff monitored aggressive behavior for 30 weeks using the Social Dysfunction and Aggression Scale (SDAS). Patients completed baseline self-report measures on aggression, anger, and impulsivity. Staff monitoring showed that most inpatients displayed moderate (86%) or severe (65%) aggressive behavior at least once, and 37.5% showed physical aggression. Inpatients with a least one physical aggression incident differed from others in self-reported anger, (reactive) aggression, non-planning impulsivity, and sociodemographic and clinical characteristics (e.g., higher prevalence of cluster B personality disorders, and lower intelligence). Two-thirds of the physical aggression incidents were preceded by observations of increased non-physical aggression (SDAS). In forensic psychiatric inpatients with a history of aggression, more than a third of the patients demonstrated at least one occasion of physical aggression during 30 weeks of observation.

Individual differences, ADHD, adult pathological demand avoidance, and delinquency

BACKGROUND

Pathological Demand Avoidance (PDA) is a developmental disorder involving challenging behaviour clinically linked to Autism Spectrum Disorder (ASD). Many of the problematic features of PDA are often seen in persons with attention deficit hyperactivity disorder and impulsivity. ADHD and impulsivity are also common in the backgrounds of offenders.

AIMS

Method and procedure: We examined if self-reported ASD, ADHD, impulsivity, and general personality traits such as low conscientiousness and low emotional stability predicted self-reported PDA scores, and which constructs contributed to the prediction of delinquency, recruiting 132 participants (mean age 34.6 years, SD = 10.9, range 18-68), of whom 126 cases had complete data.

OUTCOMES AND RESULTS

Many of these constructs, but particularly ADHD (r = 0.71, p < 0.001) were significant correlates of PDA, the correlation between ASD and PDA was small, and did not predict PDA. Multiple regression indicated that a combination of higher attention deficit, antagonism, and lower emotional stability predicted 65 % of an individual's PDA score, but that their PDA score did not contribute to the prediction of delinquency.

CONCLUSIONS AND IMPLICATIONS

This research indicates that, for community adult populations, self-reported individual differences in ADHD, emotional instability, and antagonism appear to better predict PDA than ASD. The association PDA has with delinquency may reflect these constructs, which are also correlates of offending.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.

Intranasal administration of oxytocin decreases task-related aggressive responses in healthy young males

Aggression and distrust are often challenging problems in mental health treatment. Converging evidence reveals that oxytocin increases trust in social interactions and decreases fear of social betrayal. However, oxytocin has also been associated with protective behavior and, as such, might increase defensive aggressive reactions. In this randomized double-blind, placebo-controlled study, the effects of intranasal oxytocin (32IU) on task-related aggressive responses were measured using the Point Subtraction Aggression Paradigm (PSAP). Fifty-seven healthy males were enrolled and randomized to oxytocin (N = 30) or placebo (n = 27). Salivary oxytocin, cortisol and testosterone were measured serially prior to the intervention, and then before and after the PSAP, to evaluate the effects of oxytocin administration on hormonal functioning in relation to aggression. In addition, oxytocin was measured in urine collected directly after the experimental task, reflecting the 2 h period after oxytocin or placebo administration. The proportion of aggressive responses to the PSAP was significantly lower in participants receiving oxytocin versus placebo (β= -0.46, P = 0.01). No significant effect of oxytocin was found regarding defensive reactions. Urinary oxytocin was negatively associated with the proportion of aggressive responses to the PSAP in both the oxytocin and the placebo group (β= -0.02, P < 0.01), suggesting that higher levels of urinary oxytocin corresponded with reduced aggressive responding. Our results indicate that oxytocin administration reduces aggressive behavior in healthy young men. Moreover, increased endogenous urinary oxytocin is associated with less aggressive responding. Taken together, these findings suggest that oxytocin signaling has a causal influence on aggressive behavior.

Agression en milieu psychiatrique fermé : identification des déclencheurs qui précèdent les agressions contre les intervenants

Cette étude vise l’identification des déclencheurs qui précèdent les agressions survenues dans un hôpital psychiatrique fermé. Une analyse de contenu de 140 rapports d’incident visant l’identification du déclencheur qui précédait immédiatement les événements d’agression survenus entre 2012 et 2017 a été effectuée. Avec un accord interjuge de 0,87, les résultats concordent avec ceux retrouvés dans des études précédentes. Plus de 37 % des agressions surviennent à la suite d’une intervention verbale d’un intervenant, alors qu’un peu plus de 54 % ont lieu à la suite d’un contact physique entre un intervenant et un patient. Moins de 9 % des agressions subies par le personnel sont liées à des événements où il a été impossible d’observer un déclencheur. Ces résultats sont discutés dans le cadre d’une approche interactionnelle sur l’agression en psychiatrie légale et ils permettent de proposer des pistes pour réduire le risque d’agression.

Professional Boundaries of Nursing Staff in Secure Mental Health Services: Impact of Interpersonal Style and Attitude Toward Coercion

The current study explored the impact of nursing staff members' interpersonal style and attitudes toward coercion on the management of their professional boundaries. Researchers predicted that a combination of a particular interpersonal style, a specific attitude toward coercion, and self-reported engagement in boundary-crossing behavior would be associated with particular styles of boundary management as outlined by Hamilton's Boundary Seesaw Model. Sixty-three nursing staff members in secure inpatient mental health services completed measures of boundary management, boundary crossings, attitude toward coercion, and interpersonal style. Regression analyses showed that a submissive interpersonal style and fewer boundary-crossing behaviors were associated with a pacifier boundary management style. In contrast, a pragmatic attitude toward coercion predicted a negotiator style of boundary management. The regression model for controller boundary management style was not significant. Findings are explored, along with their impact and implications for research and practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 16-24.].

Violent incidents in a secure service for individuals with learning disabilities: Incident types, circumstances and staff responses

BACKGROUND

The issue of violence in secure services has long been recognized both in the UK and worldwide. However, there is currently scarce literature available about violence within learning disability (LD) secure settings.

METHODS

Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a 1-year period.

RESULTS

Physical assaults were the most frequent type of incident, and the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalized linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff.

CONCLUSIONS

These findings can inform staff training on violence prevention and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

Evaluating the Introduction of the Safewards Model to a Medium- to Long-Term Forensic Mental Health Ward

Care and treatment in forensic mental health wards can present with challenges when loss of hope and freedom, and aggression are present, which can then influence ward atmosphere and feelings of safety. Safewards is a model designed to address a range of conflict (e.g., aggression and self-harm) and containment (e.g., use of restrictive interventions) events and may provide a suitable approach to delivery of care in a forensic setting, while also addressing aggression, restrictive interventions, and ward atmosphere. The aim of this study was to evaluate the introduction of Safewards to a forensic mental health ward to determine suitability, and to explore if changes to conflict, containment, and ward atmosphere occurred. A mixed methods approach was used involving the collection of incident data related to conflict and containment, an assessment of the degree to which interventions were implemented, and an assessment of the social climate before and after implementation. Results suggested that there were fewer conflict events after Safewards was introduced; however, there did not appear to be any changes in the already low use of restrictive interventions. The Safewards interventions were implemented to a high degree of fidelity, and there was indication of an increase in a positive perception of ward atmosphere, supported by themes of positive change, enhanced safety, and respectful relationships. Safewards may assist in contributing to an improvement in the perception of ward atmosphere. To enhance implementation in a forensic mental health setting, there may be a need to consider additional elements to Safewards, pertinent to this setting.

Patient characteristics associated with aggression in mental health units

Aggression in mental health units is a significant and pervasive problem. However, the characteristics of patients associated with increased aggression propensity remain unclear and there are few attempts to expand understanding of these characteristics by drawing upon contemporary aggression theory. This study assessed the influence of interpersonal (hostile-dominance) and personality (psychopathy), General Aggression Model-specified (aggressive script rehearsal, attitudes towards violence, and trait anger), and clinical (psychiatric symptoms) factors on aggression during psychiatric hospitalization in 200 inpatients (132 men and 68 women; 19-64 years, M=38.32 years, S.D.=11.13 years). Patient characteristics were assessed on admission using structured interviews and self-report psychological tests. Patients' files were reviewed and nurses were interviewed after patients were discharged to establish whether patients were aggressive during their hospital stay. Results of univariate analyses showed that higher levels of interpersonal hostile-dominance, psychopathy and aggressive script rehearsal, positive attitudes towards violence, trait anger, and disorganized and excited type psychiatric symptoms all predicted aggression. In the final multivariable logistic regression model, only hostile-dominance remained as a significant predictor of aggressive behavior. This important personality characteristic should be considered in violence risk assessments and aggression prevention strategies.

Observer Ratings of Interpersonal Behavior as Predictors of Aggression and Self-Harm in a High-Security Sample of Male Forensic Inpatients

Incidents of aggression and self-harm in forensic mental health inpatient settings present a significant challenge to practitioners in terms of safely managing and reducing the harm they cause. Research has been conducted to explore the possible predictors of these incidents and has identified a range of environmental, situational, and individual risk factors. However, despite the often interpersonal nature of the majority of aggressive incidents, few studies have investigated forensic inpatient interpersonal styles as predictors of aggression and even fewer have explored the potential interpersonal function of self-harming behaviors. The current study investigated the predictive validity of the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE) for incidents of verbal and physical aggression, and self-harm recorded from 204 high-secure forensic inpatients. Means comparisons, correlations, and receiver operating characteristics (ROC) were conducted on recorded incident data at 12, 24, and 48 months following baseline assessment using the CIRCLE. Dominant and coercive interpersonal styles were significant predictors of aggression, and a coercive interpersonal style was a significant predictor of self-harm, over the recorded time periods. When categorizing the inpatients on the basis of short- and long-term admissions, these findings were only replicated for inpatients with shorter lengths of stay. The findings support previous research which has demonstrated the benefits of assessing interpersonal style for the purposes of risk planning and management of forensic inpatients. The predictive value may be time-limited in terms of stage of admission.

Version 3 of the historical-clinical-risk management-20 (HCR-20V3): relevance to violence risk assessment and management in forensic conditional release contexts

The conditional release of insanity acquittees requires decisions both about community risk level and the contextual factors that may mitigate or aggravate risk. This article discusses the potential role of the newly revised Historical-Clinical-Risk Management-20 (HCR-20, Version 3) within the conditional release context. A brief review of the structured professional judgment (SPJ) approach to violence risk assessment and management is provided. Version 2 of the HCR-20, which has been broadly adopted and evaluated, is briefly described. New features of Version 3 of the HCR-20 with particular relevance to conditional release decision-making are reviewed, including: item indicators; ratings of the relevance of risk factors to an individual's violence; risk formulation; scenario planning; and risk management planning. Version 3 of the HCR-20 includes a number of features that should assist evaluators and decision-makers to determine risk level, as well as to anticipate and specify community conditions and contexts that may mitigate or aggravate risk. Research on the HCR-20 Version 3 using approximately 800 participants across three settings (forensic psychiatric, civil psychiatric, correctional) and eight countries is reviewed.

Motivational dimensions of inpatient aggression

BACKGROUND

Recent studies have suggested that functional classifications of aggression should be used to improve the understanding of the heterogeneity of aggression and its management, among inpatients in psychiatric hospitals.

AIMS

Our aim was to examine a theoretically derived three-factor model for conceptualising aggressive incidents by inpatients as irritable, instrumental or defensive.

METHODS

As part of the routine assessments in a forensic psychiatric high security ward, staff filled out a questionnaire on motives for aggression after all violent incidents. A total of 1652 incidents from 28 patients were analysed by means of exploratory and confirmatory factor analyses.

RESULTS

Support was found for the three-factor model. For the most part, the scale items loaded on the factors as predicted, and the model was able to explain 61% of the data variance. Irritable incidents were the most common, but elevated scores for instrumental characteristics were found as well. High psychopathy scores were associated with incidents scoring high values on both irritable and instrumental dimensions, and low values on the defensive dimensions.

CONCLUSIONS

Confirming these three dimensions of inpatient aggressive incidents may help caregivers' understanding of aggressive behaviour. If confirmed in future studies, this dimensional approach may prove useful for the management of aggressive inpatients.

The short anger measure: development of a measure to assess anger in forensic populations

In this brief report we describe the development of a measure of anger that may be used by nurses and other professionals to assess anger and changes in anger with male offenders. The Short Anger Measure, a 12-item self-report measure of angry feelings and aggressive impulses, was administered to 73 male offenders. The measure showed sound psychometric properties (internal consistency reliability, test-retest reliability) and concurrent validity with an established measure of anger. The potential use of the measure by nurses working in forensic settings is discussed.

Examination of the predictive validity of the Dynamic Appraisal of Situational Aggression in two mental health units

Empirically derived structured violence risk assessment instruments are increasingly used by nurses in forensic mental health settings, typically demonstrating stronger predictive validity than unaided clinical risk assessments, and associated with reduced aggression and reduced restrictive practices including seclusion. However, these instruments are less often used in non-forensic mental health settings despite frequent aggression in these settings. This study represents the first test of the Dynamic Appraisal of Situational Aggression (DASA-IV), a structured instrument used to appraise risk for imminent aggression in a non-forensic mental health hospital. Predictive validity of DASA-IV, and unaided clinical and structured clinical judgements made after DASA-IV assessments were compared. Participants included 105 nurses at two mental health inpatient units in rural Victoria, Australia. During the study, 482 DASA-IV assessments and structured clinical judgements were compared with 997 unaided clinical risk judgements. DASA-IV total scores predicted aggression significantly better than unaided clinical risk ratings over the subsequent 24 hours and for the next shift. Nurses' structured clinical judgement ratings were more accurate than unaided clinical appraisals but less accurate than actuarial (DASA-IV derived) scores. The DASA-IV presents as a valid measure for appraising risk of imminent aggression in mainstream mental health inpatient settings.

Should clinicians use average or peak scores on a dynamic risk-assessment measure to most accurately predict inpatient aggression?

Recent advancements in risk assessment have led to the development of dynamic risk-assessment measures that are predictive of inpatient aggression in the short term. However, there are several areas within this field that warrant further empirical investigation, including whether the average, maximum, or most recent risk state assessment is the most valid for predicting subsequent aggression in the medium term. This prospective study compared the predictive validity of three indices (i.e. mean score, peak score, and most recent single time-point rating) of the Dynamic Appraisal of Situational Aggression (DASA) for inpatient aggression. Daily risk ratings were completed for 60 psychiatric inpatients (from the acute wards of a forensic psychiatric hospital) for up to 6 months; a total of 1054 DASA ratings were obtained. Results showed that mean and peak scores on the DASA were better predictors of interpersonal violence, verbal threat, and any inpatient aggression than the DASA single time-point most recent ratings. Overall, the results support the use of the prior week's mean and peak scores to aid the prediction of inpatient aggression within inpatient forensic psychiatric settings in the short to medium term. These results also have practical implications for clinicians considering risk-management strategies and the scoring of clinically-relevant items on risk-assessment measures.

'He did what? Well, that wasn't handed over!' Communicating risk in mental health

Mental health inpatient units are dynamic, complex environments that provide care for patients with heterogeneous ages, diagnoses and levels of acuity. These environments commonly expose clinicians and patients to many potential risks. Despite extensive research into risk assessment, prediction and management, no study has investigated how risk information is communicated at handover in acute mental health settings. Given the pivotal role handover plays in informing risk management, this evidence gap is significant. This paper reports on a study that investigated the practices of communicating risk at handover in an Australian acute mental health inpatient unit. The aim of this research was to identify the frequency and type of risk information communicated between nursing shifts, and the methods by which this communication was performed. A secondary aim was to identify effective and ineffective risk communication practices. This study involved an observational design method using a 14-item Clinical Audit Tool derived from handover principles outlined by World Health Organization. Five hundred occasions of patient handover were observed. Few risk information items were observed to be communicated in any method. Risk communication practice was inconsistent, and a key recommendation from the study is the use of standardized handover tools that ensures risk information is adequately reported.

Understanding inpatient violence in a New Zealand child and adolescent psychiatric setting

This paper describes the rate of violent episodes at a youth psychiatric unit, identifies significant clinical and demographic differences between service users who had admissions with violent episodes and those who did not, and describes characteristics of violent incidents, including antecedents, consequences, victim type, and severity of violence. A retrospective file audit over a 2-year period reviewed 303 admissions. Characteristics of violent incidents (n = 242) and service users (violent/non-violent) were recorded. Of 263 service users, 21.7% exhibited violent behaviour. Significant differences between admissions with and without violent episodes were found in terms of ethnicity, legal status, length of admission, and diagnosis. Staff were the most frequent victims and less severe incidents were most common. The most frequent antecedents to violence were positive symptoms of psychosis, hostility, and agitation, while the most common consequences were seclusion, physical restraint and 'as-required' medication. This study has identified that violent incidents are a common and significant issue. The findings might help staff in reviewing current management approaches. Future areas of study have been identified.

Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory

Although interpersonal style is a defining feature of personality and personality disorder and is commonly identified as an important influence on aggressive behavior, treatment completion, and the development of an effective therapeutic alliance, it is rarely considered in practice guidelines for preventing, engaging, and managing patients at risk of aggression. In this article, the authors consider three potential applications of interpersonal theory to the care and management of patients at risk of aggression during hospitalization: (a) preventing aggression through theoretically grounded limit setting and de-escalation techniques, (b) developing and using interventions to alter problematic interpersonal styles, and (c) understanding therapeutic ruptures and difficulties establishing a therapeutic alliance. Interpersonal theory is proposed to offer a unifying framework that may assist development of intervention and management strategies that can help to reduce the occurrence of aggression in institutional settings.

Assessing the risk of imminent aggression in institutionalized youth offenders using the dynamic appraisal of situational aggression

Aggressive behavior in incarcerated youth presents a significant problem for staff, co-residents and the functioning of the institution. This study aimed to examine the predictive validity of an empirically validated measure, designed to appraise the risk of imminent aggression within institutionalized adult psychiatric patients (Dynamic Appraisal of Situational Aggression; DASA), in adolescent male and female offenders. The supervising staff members on the residential units rated the DASA daily for 49 youth (29 males and 20 females) over two months. The results showed that DASA total scores significantly predicted institutional aggression in the following 24 and 48 hrs; however, the predictive validity of the DASA for institutional aggression was, at best, modest. Further analyses on male and female subsamples revealed that the DASA total scores only predicted imminent institutional aggression in the male subsample. Item analyses showed that negative attitudes, anger when requests are denied, and unwillingness to follow instructions predicted institutional aggression more strongly as compared with other behavioral manifestations of an irritable and unstable mental state as assessed by the DASA.

Safety issues on British mental health wards

BACKGROUND

Assuring patient safety on inpatient psychiatric units is a complex issue that involves mitigating risks as well as promoting safety by building an environment that supports engagement and constructive activity.

OBJECTIVES

To review the concerns surrounding inpatient psychiatric units in the United Kingdom that led to a service user-designed program, Star Wards. The essential elements of the program are outlined along with a rationale for how Star Wards' 75 ideas effectively build greater engagement, address boredom, and enhance safety on inpatient psychiatric wards.

DESIGN

This article reports on the development and dissemination of Star Wards. Included is information on the program's effectiveness; data were drawn from an evaluation of Star Wards conducted by a U.K. university.

RESULTS

Psychiatric wards that have adopted Star Wards have demonstrated improvements in patient satisfaction, staff morale, levels of boredom, and incidents of aggression.

CONCLUSION

Boredom and poor staff-patient engagement on psychiatric wards may contribute to aggression and violence. Drawing on Star Wards ideas, nurses and service users can work together to enhance safety via an active ward program and greater staff-patient engagement. The innovations suggested by Star Wards are practical ways to build programming and create platforms for dialogue with service users, particularly around what they need to move toward recovery.

Relationship between aggression, interpersonal style, and therapeutic alliance during short-term psychiatric hospitalization

Aggression during psychiatric hospitalization is frequent, problematic, and a major challenge for nurses and mental health services more generally. The strength of the therapeutic alliance between nursing staff and patients has been posited as an important protective factor that can limit the likelihood of aggression. This study examined the relationship between interpersonal style, perceived coercion, and psychiatric symptoms on the therapeutic alliance between patients and staff, and how each, in turn, is related to aggression. Participants in this study were 79 patients admitted to an acute psychiatric hospital. Each participant was interviewed to determine perceived coercion, symptoms of psychiatric illness, interpersonal style, and therapeutic alliance. Incidents of aggression were recorded at discharge through a review of incident forms, file review, and interviews with unit nursing staff. The results showed that a hostile-dominant interpersonal style and symptoms of paranoia predicted poor therapeutic alliance, contributing 14% of the variance in therapeutic alliance scores. A dominant interpersonal style predicted aggression towards staff. Therapeutic alliance, perceived coercion, and symptoms of psychiatric illness did not predict aggression. Implications for engagement in treatment and the prevention of aggression are discussed.

Restraint and seclusion use in U.S. school settings: recommendations from allied treatment disciplines

Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.

Officer attitudes towards intra-group aggression in young people and young adults: does the reported motivation of an aggressor impact on intervention and support?

The present study aims to assess whether global and context specific attitudes influence the ability to correctly identify the motivation for aggression and selection of appropriate intervention strategies. A sample of 105 prison officers completed a measure assessing global attitudes towards prisoners, one assessing context specific attitudes towards aggression, and also a case vignette. Officers were asked to consider the motivation for aggression and to select an appropriate intervention. It was predicted that sex, age and level of experience would impact on global and context specific attitudes. Officers expressing positive global attitudes and non-aggressive context specific attitudes were expected to be more able to identify the motivation for aggression and more likely to adopt a rehabilitative approach. There was evidence to indicate sex differences in global and context specific attitudes but no impact of age. Level of experience of aggression impacted both on global and context specific attitudes. Global or context specific attitudes did not influence the ability to interpret aggression, but aggression type did. Limitations and directions for future research are discussed.

The Short- to Medium-Term Predictive Accuracy of Static and Dynamic Risk Assessment Measures in a Secure Forensic Hospital

Although violence risk assessment knowledge and practice has advanced over the past few decades, it remains practically difficult to decide which measures clinicians should use to assess and make decisions about the violence potential of individuals on an ongoing basis, particularly in the short to medium term. Within this context, this study sought to compare the predictive accuracy of dynamic risk assessment measures for violence with static risk assessment measures over the short term (up to 1 month) and medium term (up to 6 months) in a forensic psychiatric inpatient setting. Results showed that dynamic measures were generally more accurate than static measures for short- to medium-term predictions of inpatient aggression. These findings highlight the necessity of using risk assessment measures that are sensitive to important clinical risk state variables to improve the short- to medium-term prediction of aggression within the forensic inpatient setting. Such knowledge can assist with the development of more accurate and efficient risk assessment procedures, including the selection of appropriate risk assessment instruments to manage and prevent the violence of offenders with mental illnesses during inpatient treatment.

Personality traits as predictors of inpatient aggression in a high-security forensic psychiatric setting: prospective evaluation of the PCL-R and IPDE dimension ratings

The Dangerous and Severe Personality Disorder (DSPD) initiative in England and Wales provides specialized care to high-risk offenders with mental disorders. This study investigated the predictive utility of personality traits, assessed using the Psychopathy Checklist-Revised (PCL-R) and the International Personality Disorder Examination, with 44 consecutive admissions to the DSPD unit at a high-security forensic psychiatric hospital. Incidents of interpersonal physical aggression (IPA) were observed for 39% of the sample over an average 1.5-year period following admission. Histrionic personality disorder (PD) predicted IPA, and Histrionic, Borderline, and Antisocial PDs all predicted repetitive (2+ incidents of) IPA. PCL-R Factor 1 and Facets 1 and 2 were also significant predictors of IPA. PCL-R Factor 1 and Histrionic PD scores were significantly associated with imminence of IPA. Results were discussed in terms of the utility of personality traits in risk assessment and treatment of specially selected high-risk forensic psychiatric patients in secure settings.

An empirical evaluation of reasons for non-completion of treatment in a dangerous and severe personality disorder unit

BACKGROUND

Individuals deemed to be of high risk to others, and diagnosed with severe personality disorders have become the focus for developing clinical services in England. Such services often require highly secure accommodation and labour-intensive therapeutic interventions. There is, however, uncertainty about the capacity to engage such patients effectively in therapies.

AIM

Here, we examine service evaluation monitoring data to identify the level of completion of therapeutic programmes in a high secure severe personality disordered population, and analyse reasons for failure to complete.

METHOD

Guidelines for classifying reasons for non-completion were developed, based on the multifactorial offender readiness model (MORM). Electronic case notes were searched for references to non-completion, and recorded reasons for non-completion were classified.

RESULTS

Non-completion was at a relatively modest level. The main reasons for non-completion were: (1) affective: general distress of the patient or specific emotional reactions to previous offending, e.g. shame; (2) volitional: pursuing goals other than treatment; and (3) cognitive: negative self-efficacy beliefs and negative evaluations (low trust) of staff and the programme. External factors included exclusion from treatment and transfer to another unit.

CONCLUSION

This study identifies specific readiness areas that might need to be addressed in efforts to improve engagement and retention in treatment. A wider range of methodologies is required for future studies.

The prediction of imminent aggression in patients with mental illness and/or intellectual disability using the Dynamic Appraisal of Situational Aggression instrument

Objective: The aim of this paper was to determine whether imminent aggression in psychiatric inpatients can be accurately predicted using a structured risk assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA). Methods: This prospective validation study involved 10 013 DASA risk assessments of patients residing in a psychiatric hospital. Twenty-four hours after the risk assessment, psychiatric nurses documented whether patients had behaved aggressively towards others or whether they had deliberately damaged property. They also noted the target of aggression, whether towards staff, patients or property. Results: The predictive validity of the DASA varied according to the type and target of aggression. The prediction of any aggressive behaviour, irrespective of type of aggression or target, was significantly greater than chance (AUC = 0.69). The strongest predictive accuracy (AUC = 0.80) was for physical aggression towards staff. Conclusions: These results suggest that imminent aggression in psychiatric hospitals may be able to be accurately predicted by psychiatric nurses using a structured risk assessment instrument.

Assessing treatment readiness in violent offenders

Although violent offenders are widely considered to be difficult to engage in therapeutic change, few methods of assessing treatment readiness currently exist. In this article the validation of a brief self-report measure designed to assess treatment readiness in offenders who have been referred to violent offender treatment programs is described. The measure, which is an adaptation of a general measure of treatment readiness developed in a previous work, displayed acceptable levels of convergent and discriminant validity and was able to successfully predict treatment engagement in violent offender treatment. These results suggest that the measure has utility in the assessment of treatment readiness in violent offenders.

A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements

This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.

The function of aggression in personality disordered patients

It has been suggested that psychological interventions for personality disorders should focus on improving adaptive expression of the functional needs expressed through problematic behaviors such as aggression. The measurement of function is a necessary condition for devising a function-based treatment approach. Two studies that employ a method for assessing the functions of aggressive behavior in personality disordered patients are described by: (a) a retrospective analysis, through file review of inpatient aggressive behaviors and of the index offenses of patients admitted for treatment, and (b) an analysis of inpatient aggressive incidents where staff and patients were interviewed to elicit functions. Results showed that most aggression had the function of expressing anger, although other functions were also evident. The profile of functions observed in the inpatient studies was somewhat dissimilar to that observed in the studies of predominantly psychotic patients. Therapeutic implications of these findings are discussed.