Assessing the functions of aggression in psychiatric inpatients.

Abstract

Conflict is inevitable in psychiatric wards where patients are admitted and treated involuntarily. Moreover, in these wards aggression is common and most probably also inevitable. How staff understand the determinants of a patient's aggression impacts on their willingness to help the patient. Causal attributions also influence the nature of prevention, management and treatment strategies that are activated. Traditionally, the most common way of describing and classifying aggression has been according to the anger-mediated/ instrumental dichotomy. This is however, a flawed dichotomy that may limit options for prevention, management and treatment. This paper describes a behaviorally oriented classification and recording system that may be used to structure assessments of aggression in psychiatric wards. It also describes an aggressive behavior recording form that can be used by nursing staff to monitor and record the functions of aggression. The advantage of these two instruments is that they emphasize the adaptive value of aggression for the patient and encourage the identification of function, from which effective treatments may be derived. An indirect benefit associated with the focus on function is that the number of incidents classified as motiveless (having no obvious function) may be reduced. For ward staff, this may lessen fear and increase confidence in their management of aggressive patients. Future research needs and opportunities for clinical application are described. Keywords: Aggressive behavior, behavioural classification system, function of aggressive behavior, motivation ********** The aggressive behavior of psychiatric patients admitted for hospital treatment has a profound impact on patients, staff, and ward functioning. Research relating to aggression in psychiatric hospitals has primarily adopted a structural assessment framework. The focus of this work has been to describe the frequency and type of aggressive behavior in different settings. The delineation of individual patient characteristics, specifically the psychopathological features of aggressive patients, has also been a focus of attention (for review see Daffern & Howells, 2002). Recently, the interactional nature of aggression (Whittington & Richter, 2005) and situational variables influencing aggression (Gadon, Johnstone & Cooke, 2006), including the physical structure of the ward, the remit and regime of the ward, and the behavior of staff and other patients, has been the focus of empirical and scholarly inquiry. Published studies of inpatient aggression have rarely adopted the function analytic approach despite a long tradition of behavioral principles being used to understand, treat and manage aggression and other disruptive behavior within psychiatric hospitals (see for example Paul & Lentz, 1987). Consequently, few methods are available to support practitioners examine the determinants and functions of inpatient aggression. In the absence of systematic and structured methods for organising information and formulating hypotheses about the determinants and functions of aggression, the selection of management strategies commonly used to contain aggressive patients (e.g., seclusion, one to one supervision, and provision of prn medication) may be inconsistent, and biased by characteristics of the patient that are unrelated to those factors that activated or maintain the aggressive behavior. For example, numerous patient characteristics, including diagnosis (Ionno, 1983), age (Tardiff, 1983), ethnicity and victim status (Gudjonsson, Rabe Hesketh & Szmukler, 2004) have been shown to bias the type of management strategy selected. Furthermore, it is often argued that these interventions are aversive, that their use should reduce the incidence of aggression and contribute to more adaptive behavior (Goren, Singh & Best, 1993). There is however little evidence to support this proposition and some evidence that coercive staff behaviors may paradoxically maintain and exacerbate undesirable behavior in hospitalized patients (Garrison et al. …