RSS 1.0Behaviour Change
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De-escalating aggression in acute inpatient mental health settings: A behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectivesBACKGROUND: De-escalation is often advocated to reduce harm associated with violence and use of restrictive interventions, but there is insufficient understanding of factors that influence de-escalation behaviour in practice. For the first time, using behaviour change and implementation science methodology, this paper aims to identify the drivers that will enhance de-escalation in acute inpatient and psychiatric intensive care mental health settings. METHODS: Secondary analysis of 46 qualitative interviews with ward staff (n = 20) and patients (n = 26) informed by the Theoretical Domains Framework. RESULTS: Capabilities for de-escalation included knowledge (impact of trauma on memory and self-regulation and the aetiology and experience of voice hearing) and skills (emotional self-regulation, distress validation, reducing social distance, confirming autonomy, setting limits and problem-solving). Opportunities for de-escalation were limited by dysfunctional risk management cultures/ relationships between ward staff and clinical leadership, and a lack of patient involvement in safety maintenance. Motivation to engage in de-escalation was limited by negative emotion associated with moral formulations of patients and internal attributions for behaviour. CONCLUSION: In addition to training that enhances knowledge and skills, interventions to enhance de-escalation should target ward and organisational cultures, as well as making fundamental changes to the social and physical structure of inpatient mental health wards. Psychological interventions targeting negative emotion in staff are needed to increase motivation. This paper provides a new evidence-based framework of indicative changes that will enhance de-escalation in adult acute mental health inpatient and PICU settings.
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Treatment approaches to trauma for those convicted of sexual crime: Interventions globallyThis chapter explores therapeutic approaches to working with trauma in people who have been convicted for sexual offences. The chapter examines accounts of interventions using neuropsychological, psychodynamic, attachment focussed, cognitive behavioural/schema focussed and cognitive analytic therapies. Feminism informed and restorative justice-based interventions with this population are also discussed. The chapter identifies common themes, such as the critical role of attachment with therapists in bringing about change and the importance of trauma-informed milieu. The question of whether exposure work is necessary and if so, what kinds of exposure work are useful is explored. The chapter also looks at the ways in which this kind of work can be inadvertently iatrogenic. Finally, a summary of the key factors for this work is offered.
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The effect of attitudes towards individuals with sexual convictions on professional and student risk judgmentsAttitudes towards individuals with sexual convictions is an area with growing research interest, but the effects of such attitudes on professional judgments is largely unexplored. What is known from the existing literature is that attitudes guide the interpretation of sexual crime related information, which cascade into potential biased or heuristically driven judgments. In this study we recruited samples of both students (n = 341) and forensic professionals (n = 186) to explore whether attitudes towards individuals with sexual convictions predicted risk judgments of hypothetical sexual offense scenarios, and whether this relationship is moderated by professional status or perpetrator characteristics. Forensic professionals expressed more positive attitudes overall, but the significant effect of attitudes on risk judgments was consistent between participant groups and was not moderated by perpetrator age or sex. We suggest that relying on attitudes as a basis for risk judgments opens the door to incorrect (and potentially dangerous) decision-making and discuss our data in terms of their potential clinical implications. An open-access preprint of this work is available at https://psyarxiv.com/rjt5h/.
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Therapeutic community work with people who have sexually offended: Responding to developments in research and practicePurpose This paper aims to review the clinical approach adopted in prison-based therapeutic communities (TCs) for working with residents who have committed sexual offences. It reviews recent research and practice developments and explores the implications for TCs. Design/methodology/approach This paper describes a “think tank” review process which explores and reviews practice. This paper discusses the current approach adopted by TCs when working with those who have sexually offended and explores changes in clinical approach which could be considered in the light of current developments. Findings This paper explores the implications for TCs of the recent research and wider practice developments in interventions for those who have sexually offended. Practical implications This paper presents clinical options for working with those who deny their offence and undertaking victim empathy and offence disclosure work. It makes recommendations regarding staff training and support. It also discusses the strengths of the TC approach and how these can be built upon. Social implications This paper makes recommendations concerning how practice could be improved which promotes safety and public protection and enhances resident well-being. Originality/value There has been no recent review of TC clinical practice for working with those who have sexually offended.
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How accurate and effective are screening tools and subsequent interventions for intimate partner violence in non-high-risk settings (IPV)? A rapid reviewPurpose The purpose of this paper is to estimate the accuracy and effectiveness of screening tools and subsequent interventions in the detection and treatment of intimate partner violence (IPV) in non-high-risk settings (defined here as those in which routine IPV screening does not take place in the UK, such as in general practice). Design/methodology/approach Rapid review as defined by Grant and Booth - it is used under time or financial constraint to assess what is known using systematic review methods. Medline, PsycINFO, Embase and Cochrane Library databases to May 2019 were searched for "intimate partner violence" and synonyms plus terms related to screening and interventions. A Medline update was performed in August 2020. Data were extracted with the help of a predesigned tool and were synthesised to answer the two study aims. Data were mixed quantitative and qualitative. Findings The search yielded 10 relevant papers on screening (6 on accuracy and 4 on effectiveness) and 13 on intervention. These showed evidence of the effectiveness of simple screening tools and of subsequent interventions. However, the evidence was insufficient to support a change in UK guidelines which currently do not recommend their use outside of current high-risk environments. Originality/value Clinicians outside of high-risk areas should consider the use of some IPV screening tools and interventions but only within research protocols to gather further evidence.
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Spousal role expectations and marital conflict: Perspectives of men and womenIntimate partner violence (IPV) affects millions of people across the world and is associated with a significant impact on physical and mental health of the victim. IPV often takes place within the context of marriage, where gender role expectations can play an important part in shaping attitudes towards it. While there is much research carried out to understand the phenomenon of IPV, little relates to how a husband and wife's accounts of spousal role expectations of each other contribute to marital conflict. The issue of IPV within marriage is highly sensitive, particularly in a patriarchy such as Pakistan. The aim of this unique study was to explore the perspective of Pakistani men and women about a husband and wife's role expectations and how fulfillment of such spousal role expectations impacts on marital conflict, and thereby IPV. Using the community setting, data for this qualitative study were collected through 41 individual interviews, including 20 from Pakistan and 21 from the UK. The findings are presented in two main themes, each containing two subthemes. The theme "provider and protector" relates to the role expectations from a husband, whereas "caretaker and household manager" relates to the role expectations of a wife. Overall, husbands and wives have numerous expectations of each other, and these expectations are shaped by gender role attitudes alongside cultural and societal norms. Unmet expectations and deviation of behavior from the perceived norms can result in the development of marital conflict which can escalate to IPV. The significance of this study lies in understanding spousal role expectations from the perspectives of husbands and wives and how unmet expectations contribute to marital conflict and IPV is important for health care professionals within family health contexts. This article provides a detailed insight of this largely hidden phenomena.
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Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon) [In Press]Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation - stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure - if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon's psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.
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Nurse education and understanding related to domestic violence and abuse against women: An integrative review of the literatureAim: The aim of this study was to explore previous literature related to nurses understanding of Intimate partner violence (IPV) or domestic violence and abuse (DVA) against women and to identify the gaps in nursing education so as to use the findings as a baseline to inform potential intervention strategies, curriculum development and outline implications for future nursing practice. Design: An Integrative review of literature. Methods: Studies were extracted through a search of the electronic databases, such as Science direct, EBSCO host and PubMed, to identify relevant evidences published between January 2000–January 2017. “Joanna Briggs Institute (JBI) tool” was used to review primary research studies. Results: Seventeen empirical studies were analysed. Findings supported four themes including: educational and training experiences, identification of IPV/DVA, curriculum and communication skills of nurses. Continued efforts are further needed to highlight and address IPV/DVA in nursing education and training, to scale up nursing understanding to respond and identify IPV/DVA appropriately in a clinical environment. © 2018 The Authors. Nursing Open published by John Wiley & Sons Ltd.
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Sexual offenders against children: The influence of personality and obsessionality on cognitive distortionsSexual offenders against children are generally inadequate in their social functioning and diverse in their psychopathology. The degree to which this inadequate functioning and psychopathology influences therapeutic interventions brings into question the belief that generic nonclinical programmatic treatment work is always appropriate for such a cohort. The Sex Offenders Assessment Package (SOAP) measures inadequate social functioning and sexual deviance, but has not been linked to broader individual differences and generic psychopathology. We collected information examining the relationship between the SOAP and standard measures of personality (the NEO-FFI) and obsessive-compulsiveness (MOCI) in a sample of 200 sexual offenders against children seen by the Probation Service. Factor analysis was used to reduce the SOAP to three reliable factors: emotional distress, cognitions supporting sex with children, and concern for others. These factors correlated respectively with higher Neuroticism and lower Extroversion; greater obsessive-compulsiveness on the MOCI, and trait Agreeableness, irrespective of whether or not one corrected for socially desirable responding. When partial correlation controlled for the influence of Neuroticism on the correlation between cognitions supporting sex with children and the MOCI, there was no change in the association between these variables. These results show that negative affect and obsessional tendencies are important underlying influences on the feelings and behavior of sexual offenders, that the obsessionality of the group is not attributable to Neuroticism, and suggest useful additional foci to enhance the treatment of this diverse clinical group. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
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Epidemiology of offending in learning disabilityThis chapter provides a detailed account of the epidemiology of offending behaviour in people with learning disabilities. Personal and professional perspectives are offered, together with a foray into studies of prevalence, and personal and offending characteristics. The chapter goes on to outline a variety of therapeutic approaches.
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Psychopathy, impulsiveness and violence: How are they linked?This paper attempts to elucidate possible relationships between three multifaceted constructs: psychopathy, impulsiveness and violence. A recently developed and validated quadripartite violence typology is described which parses violence into two motivationally distinct types according to whether it is appetitively or aversively driven. Nested within each type are 2 sub-types which depend on whether the violence is impulsive or premeditated/controlled. An attempt is then made to link each type and subtype of violence with, firstly, psychopathy as viewed through the prism of the Triarchic Psychopathy Model (TPM) which parses psychopathy into the three phenotypic components of Meanness, Boldness and Disinhibition; and secondly, impulsiveness parsed using the UPPS model into Urgency, (lack of) Perseverance, (lack of) Premeditation, and Sensation seeking. It is suggested that violence that is appetitively driven and controlled/premeditated (motivated by a desire for self-gratification) is related to Boldness; that violence that is appetitively driven and impulsive (motivated by a desire for excitement) is related to the combination of Boldness and Meanness; and that violence that is aversively driven and impulsive (motivated by a desire to protect oneself from a perceived and immediate threat) is related to the combination of Meanness and Disinhibition. It remains unclear whether, or how, the fourth violence type motivated by a desire for vengeance relates to the triarchic psychopathy components. While the suggested relationships are hypothetical, they provide a platform for empirical verification in future studies.
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Evaluation of the use of pharmacological treatment with prisoners experiencing high levels of hypersexual disorderAbstract: This paper presents an evaluation of the impact of pharmacological treatment in reducing hypersexual disorder in adult males who have been incarcerated following conviction for a sexual offence. The evaluation compares two types of pharmacological treatment, one of which is part of the current NICE guidance for treatment of hypersexuality (Antiandrogens), whilst the other type (SSRIs) is off-label use in the UK for hypersexuality. The participant pool comprised 127 adult male prisoners serving sentences for sexual offences in a UK prison. Participants had been voluntarily referred for pharmacological treatment to manage hypersexual disorder. The results demonstrated a significant reduction of hypersexual disorder pre- and post-medication and contribute to the evidence base for the use of pharmacological treatment with individuals for whom hypersexual disorder may be a salient factor in their offending. Limitations of the current research are discussed.
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Violent offender treatment in a medium secure unitPurpose - The purpose of this paper is to conduct a preliminary evaluation of a Violent Offender Treatment Program (VOTP) adapted for use in a medium secure unit (MSU). The patient population is adult male mentally disordered offenders. Design/methodology/approach - Patient outcomes are explored using the Reliable Change Index and Clinical Significance Criterion. Outcomes are assessed using VOTP facilitators violence risk assessment (VRS), multi-disciplinary team violence risk assessment (HCR-20 and GAS-V), and patient self-report using two measures (FAVT and STAXI-2). Findings - There was evidence of improved outcomes for some participants in some areas related to risk of violence. Research limitations/implications - Consideration is given to using varied risk assessments to evaluate outcomes of an adapted VOTP for a MSU. Originality/value - There is limited development and evaluation of psychological treatment programmes that aim to reduce risk of violence for male offenders within MSUs. Outcomes of this evaluation could influence treatment delivery and evaluation in other services. Copyright © 2018 Emerald Publishing Limited.
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Challenging behaviour and insecure attachmentThe present authors previously investigated a database about people with severe intellectual disability (ID) to explore whether secure/insecure attachment plays a role in challenging behaviour. This study took the form of a survey of staff and carers involved with a cohort of 54 school-leavers with severe ID. 34% percent of students were rated by placement staff as "overinvesting in one or a few relationships which become a source of jealousy". Students without such problems were significantly less likely to show challenging behaviours, while those with them were significantly more likely to be living outside the family home. These preliminary results justify more detailed and longitudinal research into the relationship between attachment status and challenging behaviour. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Droperidol and midazolam, alone or combined, have similar effects on duration of violent and acute behaviour disturbance in emergency department patientsComment on: Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. [Ann Emerg Med. 2010]
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WITHDRAWN: Psychological interventions for those who have sexually offended or are at risk of offendingBACKGROUNDSexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.OBJECTIVESTo evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.SEARCH STRATEGY33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.SELECTION CRITERIARandomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.DATA COLLECTION AND ANALYSISIndependent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.MAIN RESULTSWe included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).AUTHORS' CONCLUSIONSLimited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.
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Rapid tranquillisation: a global perspectiveViolence and aggression among patients suffering from mental health problems undoubtedly pose a challenge to healthcare professionals, families and carers. Aggressive behaviours affect all aspects of clinical care. The goal of professionals is to ensure safety while effectively managing behavioural emergencies. ‘Rapid tranquillisation’ implies prescribing pharmacological agents to manage these behaviours. This article highlights changing prescription trends. Appraisal of global guidelines suggests that factors other than scientific evidence dictate their evolution. Highquality randomised controlled trials are needed to develop a global guideline.
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The utility of post-conviction polygraph testing among sexual offendersIt is often difficult to ascertain the true extent and nature of sexually deviant behavior, as much relies on self-report or historic information. The polygraph has been proposed as a useful tool in the treatment and supervision of sex offenders. The current review aims to provide a coherent, objective, and recent synthesis of evaluation studies exploring the utility of the post-conviction polygraph (PCSOT) in the treatment and management of sexual offenders. This was assessed based on offense recidivism rates and disclosure; self-reported utility was also considered. Nineteen studies were identified from the United States, the United Kingdom, and the Netherlands with no randomized controlled trials identified. Overall, there was a significant increase in relevant disclosures associated with the polygraph. The impact on reoffending rates was significant for violent but not sexual offenses. A number of methodological factors introduced the potential for bias in a significant number of studies reviewed in this review.
