Behavioural interventions to reduce aggression among psychiatric patients

1
Behavioural interventions to reduce aggression
among psychiatric patients
McMaster University Dept. of Psychiatry
Behavioural Neurosciences Research Day April 2,
2003

• Marnie E. Rice, Ph.D.
• Scientific Director McMaster/Penetanguishene
  Centre for the Study of Aggression and Mental
  Disorder
• www.mhcp-research.com/present.htm
• riceme_at_mcmaster.ca

2
Outline

• 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

3
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,
  1994)

4
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)
5
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
  institutions

(Hunter Love, 1993 Quinsey, 2000)
6
Characteristics of assaults

• Staff proportionally more likely than patients to
  be assaulted
• especially nursing/ attendant/ inexperienced
  staff
• 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)
7
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)
8
Characteristics of assaultive environments

• Inexperienced staff who approach patients in an
  authoritarian manner and use primarily aversive
  or punitive consequences to control patient
  behaviour
• Crowded (many patients, line-ups)
• Little structured activity, poor supervision
• Few or inconsistent consequences for aggressive
  behaviour

Rice et al., 1989
9
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)
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Implications for treatment

• 3 sensible approaches to intervention
• Treat small number of highly assaultive patients
• Teach staff ways to prevent and control
  aggression
• Focus on changing assaultive environment

11
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

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Anger Management Training

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

.
(Novaco, 1975)
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Stress inoculation components (cont.)

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

(Novaco et al., 2000)
14
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)

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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
  techniques

.
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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
  setting

17
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
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Other behavioural treatments the Snoezelen Room

• Background- Promotional materials
• Name comes from Dutch words for sniff and
  doze
• Multisensory, stress-free environment
• Person experiences it, like watching flames at
  a campfire
• Worldwide interest--Snoezelen Foundation
• Cost
• Data

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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)
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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
  skills
• Interventions during critical incidents Manual
  restraint, seclusion, and self-defense

.
(Rice, Harris, Varney Quinsey, 1989)
21
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
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The Escalation Process
Assaultive
High
Hostile
Moderate
Risk of injury to staff and/or patients
Anxious
Low
Calm
Stages in Escalation
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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

24
Total assaults Assaults on patients Assaults on
staff
Course
Number of assaults
Thirty Day Periods
25
Work Days Lost due to Patient-Caused Staff
Injuries
Experimental Wards Control Wards
Number of days lost
Course
Pre-course
Post-course
Thirty day periods
26
Behavioural Programs focusing on the social
environment

• Social learning program
• Paul Lentz (1977)
• Beck et al. (1991)
• Menditto et al. (1996)
• Total quality management

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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

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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
  community)
• Extra measures taken on experimental wards

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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

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General Findings

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

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Specific Procedures for Assaultive Behaviour in
SLP

• 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)

32
Assaultive behaviour in 1st 2 yrs.
Weekly incidents
33
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

34
Assaultive behaviour in next 2 years
Weekly incidents
35
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

36
Assaultive behaviour in last 6 months
Weekly incidents
37
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)

38
Beck, Menditto, Baldwin, Angelone Maddox (1991)

• 19 maximum security psychotic, chronic male
  patients
• Social learning program introduced over 3 month
  period
• Included 24 hour seclusion and fine of 1-days
  tokens for aggressive behaviours

39
Aggressive behaviours
Before
During
After
Total number of intolerable behaviours
40
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
  SLP
• Beck et al., 1997- Risperidone

41
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

.
42
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
  communication

43
Results

• 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

44
Ideal program for aggressive patients

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

45
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
  implement
• Comprehensive treatment must include behavioural
  approaches and careful measurement

46
Behavioural Interventions to Reduce Aggression
Among Psychiatric Patients Marnie E. Rice,
McMaster Research Day, April Selected
References http//www.mhcp-research.com/mhcbib.ht
m riceme_at_mcmaster.ca 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
47
Behavioural Interventions to Reduce Aggression
Among Psychiatric Patients Marnie E. Rice,
McMaster Research Day, April Selected References
(continued)
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.