Aggression occurs frequently on many psychiatric wards; its assessment and management are crucial components of inpatient care. Consequences to inpatient aggression are profound, impacting on staff and patients, ward milieu and regime, and mental health services in general. Despite considerable research, which has primarily focussed on the assessment of demographic and clinical characteristics of aggressive patients, the nature of the relationship between mental illness, inpatient treatment and aggression remains unclear. Inconsistent risk assessment practices, management strategies and treatment plans, often derived from idiosyncratic beliefs about the causes of aggression, follow. Approaches to the assessment of inpatient aggression have been categorised as structural, which emphasise form, or functional, which emphasise purpose. Studies of inpatient aggression have primarily utilized a structural approach. These studies have resulted in the identification of demographic, clinical and situational characteristics of high-risk patients and environments. Resource allocation and actuarial assessments of risk have been assisted by this research. Conversely, functional assessment approaches seek to clarify the factors responsible for the development, expression and maintenance of inpatient aggression by examining predisposing characteristics, in addition to the proximal antecedents and consequences of aggressive behaviours. While functional analysis has demonstrated efficacy in assessing and prescribing interventions for other problem behaviours, and has been regarded a legitimate assessment approach for anger management problems, psychiatric inpatient aggression has been relatively neglected by functional analysis. Against this background, four studies focussing on the assessment of predisposing characteristics, precipitants and consequences, and purposes of aggressive behaviour, were undertaken to assist in the development of a functional analysis of psychiatric inpatient aggression. All four studies were conducted within the Thomas Embling Hospital (TEH), a secure forensic psychiatric hospital in Melbourne, Australia. The first of three initial studies involved a retrospective review of Incident Forms relating to aggressive behaviours that occurred within the first year of the hospital?s operation. The second involved a comparison of prospective assessment of aggressive behaviours with retrospective review of Incident Forms. The third involved a review of Incident Forms across two forensic psychiatric hospitals, the Rosanna Forensic Psychiatric Centre, and the TEH, to allow for the study of environmental contributors to aggression. The fourth, and main study, focussed on the assessment of patients and aggressive incidents, using a framework emphasising purpose, which was assessed using a classification system designed and validated as part of this study. Demographic and clinical information in addition to social behaviour, history of aggression and substance use were collected on the 204 patients admitted to the hospital during 2002. One hundred and ten of these patients completed an additional assessment of psychotic symptoms in addition to a battery of psychological tests measuring anger expression and control, assertiveness, and impulsivity. During 2002, the year under review, there were 502 incidents of verbal aggression, physical aggression, and property damage recorded. Staff members who observed these incidents were interviewed, and files were reviewed to record the severity, type, direction and purpose of aggression. Following 71 aggressive behaviours patients also participated in the assessment of purpose. Results from this, and the three initial studies, reinforced the contribution to aggression of a number of individual characteristics, including a recent history of substance use, an entrenched history of aggression, a recent history of antisocial behaviour, and symptoms of psychosis, including thought disturbance, auditory hallucinations and conceptual disorganisation. Somewhat surprisingly, a number of other characteristics shown through previous research to have a relationship with aggression, including anger arousal and control, impulsivity, and assertiveness did not show a relationship with aggression. Further, and perhaps a consequence of the peculiar characteristics of some patients admitted to the TEH, older patients and females were more likely to be repeatedly aggressive, yet neither age nor gender differentiated aggressive from non-aggressive inpatients. In this study acts of inpatient aggression were usually precipitated by discernible events, or motivated by rational purposes. Rarely was aggression the consequence of a spontaneous manifestation of underlying psychopathology occurring in isolation from environmental precipitants. A number of proximal environmental factors, most particularly staff-patient interactions associated with treatment or maintenance of ward regime, that were considered provocative or that threatened status, were evident in incidents of aggression perpetrated against staff. The perception of provocation and the need to enhance status were common precipitants of aggression between patients. There was little evidence to suggest that aggression was used instrumentally to obtain tangible items, to reduce social isolation, or to observe the suffering of others in the absence of provocation. Results of these four studies have implications for the prediction and prevention of inpatient aggression, and for the treatment of aggressive inpatients. These are discussed, as are the limitations of this research and suggestions for further research. / thesis (BPsychology(Hons))--University of South Australia, 2004.
| Identifer | oai:union.ndltd.org:ADTP/173365 |
| Date | January 2004 |
| Creators | Daffern, Michael |
| Source Sets | Australiasian Digital Theses Program |
| Language | English |
| Detected Language | English |
| Rights | © 2004 Michael Daffern |
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