Inpatient aggression has been increasingly problematic in psychiatric facilities across the United States and around the world. Psychological assessment measures, such as the Rorschach Inkblot Method, are often used in psychiatric facilities to clarify a patient's diagnostic issues and assist in treatment planning. An assessment measure that could provide information about the type, intensity, and direction of a patient's aggressive impulses would therefore be clinically useful. The current method for scoring aggression on the Rorschach provides limited information about a patient's aggressive drives; Gacono & Meloy have proposed a broader system for scoring Rorschach aggressive content. Thus far, research on this new aggression scoring system has neglected to examine patients with Axis I disorders. The purpose of this dissertation was to explore the differences between the types and frequencies of these newer aggression variables, as well as the utility of these scores in predicting aggression in an inpatient sample of depressed and paranoid patients. This sample was chosen based on psychoanalytic conceptualization of aggressive dynamics in these patients. Results of Poisson and negative binomial regressions indicated that there were no differences between the depressed and paranoid groups in terms of the types or frequencies of Rorschach aggressive content. Kruskal-Wallis tests indicated that there were some differences between the groups in terms of the type and severity of behavioral manifestations of aggression. Finally, a logistic binomial regression showed that Rorschach variables did not add significantly to the prediction of the presence of aggressive behavior in this population. Clinical implications, limitations of the study, and directions for future research are examined. / text

This thesis comprises a rigorous and coherent body of work related to the use of the HCR-20 and the START to inform risk assessment and management of secure mental health inpatients. The thesis contributes significant theoretical and applied knowledge by: 1) investigating the extent to which these tools can be generalised beyond restricted validation samples to the full range of individuals in contact with secure services, 2) determining whether they can aid assessment and management of adverse outcomes beyond aggression, and 3) offering practical, empirically-derived advice for clinicians regarding management strategies that may reduce the occurrence of adverse events. This collection of papers has used considerably novel methods, such as rocreg analysis in risk assessment of behavioural outcomes, and high quality, routinely collected data to gain a more realistic representation of what occurs in clinical practice. Further, the papers draw on larger sample sizes than have previously been reported in this area, allowing for more complex statistical analysis. This thesis has helped clarify the contexts in which these instruments perform effectively and therefore has important implications for clinical risk assessment in inpatient settings. Specifically, there is evidence that the HCR-20 and the START may aid assessment and management of aggression for the majority of groups examined, and that both tools have some efficacy for predicting self-harm among female populations. However, the HCR-20 should not be used to inform prediction and management of aggression and self-harm for individuals with developmental and organic disorders and is unlikely to be beneficial at informing risk management strategies targeting self-harm among males; the START should not be used to inform prediction and management of substance abuse, victimisation, or unauthorised leave. Finally, this thesis highlights a number of directions for future research to continue advancement in this area.