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An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients
Accepted Manuscript An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients
Susan Oehler, Ashleigh Berman, Cecilia Gay, Rose Manguso, Jessica Espinoza PII: DOI: Reference:
S0883-9417(17)30040-7 doi:10.1016/j.apnu.2017.09.012 YAPNU 50994
To appear in:
Archives of Psychiatric Nursing
Received date: Revised date: Accepted date:
17 January 2017 18 September 2017 19 September 2017
Please cite this article as: Susan Oehler, Ashleigh Berman, Cecilia Gay, Rose Manguso, Jessica Espinoza , An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yapnu(2017), doi:10.1016/j.apnu.2017.09.012
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ACCEPTED MANUSCRIPT Running head: CORRELATES OF AGGRESSION An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients Corresponding Author: Susan Oehler, PsyDi [email protected]
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Rose Manguso, PhD, ABPPi [email protected]
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Cecilia Gay, PsyDi [email protected]
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Ashleigh Berman, PsyDi [email protected]
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Jessica Espinoza, PsyDi [email protected]
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Abstract
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Purpose: This study aimed to examine the relationship between behavioral variables and aggression among severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility.
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Methods: Using archival data over a 24-month period, a total of 23 severely and chronically mentally ill inpatients comprised the sample in this study. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects).
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Results: Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. Discussion: Our findings provide valuable information regarding aggressive tendencies that can inform treatment planning. Specifically, our results suggested there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill inpatients. Rather,
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other individualized patient factors may be at play in the expression of aggressive impulses, emphasizing the importance of adequate staff-to-patient ratios so that care planning and implementation can be appropriately individualized.
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The issue of aggressive behavior among severely and persistently mentally ill psychiatric inpatients is of particular concern due to its potential to significantly interfere with nursing staff safety, patient progress in treatment, and patient adaptive functioning (Bellus, Vergo, Kost, Stewart, & Barkstrom, 1999; LePage et al., 2003; Newbill, Paul, Menditto, Springer, & Mehta, 2011). Additionally, a history of aggressive behaviors complicates discharge for those patients to less restrictive settings (Springer, Sloan, Benge, Spence, Carlo, & Teng, 2010). Historically managed through the use of seclusion, restraint, and PRN medications, research has demonstrated the effectiveness of social learning principles in reducing aggressive behavior in a variety of psychiatric populations (Beck, Menditto, Baldwin, Angelone, & Maddox, 1991; Bellus et al., 2003; Donat, 2003, 2005). Of particular interest is Paul and Lentz’s Social Learning Program (SLP), which was designed to “meet the specialized training needs of the most severely regressed and persistently psychiatrically disabled adults” (Bellus et al., 2003, p. 33). The SLP has been widely studied and implemented and has received recognition from a task force within the American Psychological Association (APA) as a highly efficacious treatment for psychosis within an inpatient setting (Newbill et al., 2011). There is evidence that the SLP, which includes nursing and psychology staff implementation of a token economy and response-cost system, has been effective in decreasing aggression, increasing attainment of self-care competencies, and increasing chances of successful community reintegration (Beck et al., 1991; Bellus et al., 2003; Goodness & Renfro, 2002).
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Social Learning Program Overview Although significant time has elapsed since its inception, the SLP continues to be recognized as an effective treatment approach (Newbill et al., 2011). The program was initially designed to address specific issues that were found to be contributing to failed discharges from institutions among severely and persistently mentally ill individuals. These issues were summarized in four categories, including “lack of self-maintenance and social skills, instrumental role performance, and community support; and…. high rates of bizarre behavior” (Liberman, 1980, p. 367). The SLP is an inpatient, psychosocial treatment approach based on Social Learning Theory and designed for the severely, persistently, and chronically mentally ill (Menditto, 2002). In particular, the SLP targets maladaptive and aggressive behaviors. Utilizing behavioral techniques and skills training, the SLP is a comprehensive system implemented by staff members. Treatment is provided through individual and group methodologies with the goal of increasing adaptive behaviors (Menditto, 2002). In addition to addressing adaptive behaviors, the SLP incorporates training in several domains, including coping skills, problem solving, medication management, cognitive skills, and academics. Patients who are unable to manage the demands of these treatment groups participate in shaping classes where the goal is for the patient to complete smaller approximations of desired behaviors (Menditto, 2002). The SLP focuses on altering specific behaviors through token economy and response-cost systems (Bellus et al., 2003). Token economies have demonstrated effectiveness in changing behaviors, helping patients acquire new skills, reducing undesirable behaviors, increasing treatment compliance, and improving overall unit management (LePage et al., 2003). Token economies are based on operant principles (LePage et al., 2003), with secondary reinforcers used 3
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to increase motivation for completing specific target behaviors or displaying incremental behaviors consistent with their target. Conversely, the token reinforcer is withheld if the treatment target is not reached (Society of Clinical Psychology, 2016). In addition to the token economy, the SLP utilizes a four-step level system in which patients must reach certain treatment targets to be promoted. Each level is tied to specific privileges, including an increase in weekly token deposits in individuals’ token banks (Menditto, 2002). While the SLP relies heavily on specific behavioral interventions, there is an underlying goal for staff to create a treatment milieu that fosters a skills training environment. Within the milieu, patients are constantly coached to identify and follow through with adaptive behaviors (Bellus et al., 2003). The underlying principle of the SLP is that anyone, despite his or her mental status or disability, is able to learn new behaviors and skills (Menditto, 2002). This orientation is consistent with findings from recent research by Berring, Pedersen, and Buus (2016) that patients can collaborate with staff to effectively de-escalate and manage aggressive behaviors.
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Adaptive Functioning and Aggression The importance of increasing adaptive functioning skills in individuals with severe and persistent mental illness is high. Although patients with severe and persistent mental illness are admitted to inpatient facilities for a variety of reasons, the goal for discharge is the same: to return patients to assisted or independent living permanently (Newbill et al., 2011; Sharfstein, 2009). Adaptive behavior deficits are a major reason why people either remain hospitalized for long periods or return to inpatient settings after being released (Newbill et al., 2011). Research has identified that those who are most prepared for discharge to the community have fewer instances of deviant behaviors and demonstrated higher levels of basic living skills (e.g., use of table manners, appropriate dress, and use of money) (Deane, Huzziff, & Beaumont, 1995). In a psychosocial treatment program where behavior was tied to reinforcers, Silverstein et al. (2006) determined that during the same time period in which aggressive behaviors decreased, patient compliance with basic ADLs significantly increased. Adaptive functioning has now been clearly recognized in the literature as being of high importance in successful recovery and maintenance in those who are severely and persistently mentally ill. However, there is scant research on factors that affect chronically and severely mentally ill patients’ ability to increase adaptive functioning skills.
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Why Further Analysis of the Correlates of Aggression is Necessary Despite the known effectiveness of the SLP in meeting the daily needs of severely and persistently mentally ill patients, a review of the literature indicated research has largely overlooked identification of treatment program components that correlate with aggression, particularly within a forensic inpatient setting. A better understanding of the relationship between aggression and specific treatment program variables may help inform care planning – specifically by providing staff with information on aspects of programming that are related to aggression and therefore warrant special attention in order to deal with this problem proactively. Specifically, the current study attempted to answer the following questions: 1. What is the relationship between the number of aggressive episodes and the length of current hospitalization, length of stay on SLP, basic activities of daily living (ADLs), instrumental ADLs, attendance in programming, participation in programming, and the 4
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION number of minor (5-token), major (10-token), and intolerable (25-token) infractions received? Operational definitions for all of these variables can be found in Appendix A. 2. How well do the following variables - length of current hospitalization, length of stay on SLP, basic ADLs, instrumental ADLs, attendance in programming, participation in programming, and the number of minor, major, and intolerable infractions - predict the number of aggressive episodes among patients on SLP?
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Method Human Rights and Ethical Considerations In order to meet institutional requirements for conducting ethical research with human participants, a research proposal was submitted to and approved by the facility’s privacy and research review board. This study utilized de-identified archival data. In gathering the data, patient identification numbers were used to match demographic information with behavioral data points. As soon as the data were merged, the patient identification numbers were deleted from the data base, thereby maintaining patient confidentiality.
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Treatment Setting Data were collected from the SLP unit at a state psychiatric facility in southern Colorado. It is a 449-bed facility accredited by the Joint Commission. The SLP is a psychosocial treatment unit that is well established within the facility. The SLP is based on Paul and Lentz’s original treatment program, and utilizes a token economy and response cost system. In addition to reinforcers on the unit, patients are able to work towards gaining on and off grounds (both supervised and unsupervised) privileges. The facility’s disposition committee and the Colorado court system govern these privileges. Patients consistently receive informal treatment through skills coaching (including Activities of Daily Living) and milieu management. There are also several hours of formal treatment each day, including Occupational Therapy, Recreational Therapy, Academics, Community, Promotion, and Psychology groups (Dialectical Behavior Therapy, Shaping, Cognitive Skills, Problem Solving, and Symptoms Management). Total formal treatment hours are dependent on the highly individualized program of each patient.
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Participants The patients admitted to the SLP unit had been referred from other units throughout the hospital. Admission criteria for the unit included presence of severe negative symptoms; a history of chronic mental illness; primary diagnosis could not be a personality disorder; presence of severe deficits in functioning in the areas of self-care skills, social skills, and/or instrumental role performance; and a history of continuous hospitalizations and failed placements due to psychotic symptoms. In selecting study participants, eligibility criteria consisted of whether the patient was treated on the SLP unit between January 1, 2013 and December 31, 2015. This time frame was chosen based on the availability of archival data. A total of 23 patients were treated on the SLP unit during the 24-month period of investigation, resulting in a sample of 23 participants. While this sample size fell below the number which would normally be required for an effect size of .35, the size of the patient unit under investigation prohibited a larger sample size.
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Measures and Procedure Data points collected and used to describe the sample of participants included age, gender, educational level, and psychiatric diagnosis. Researchers also had access to a group tracking system which is used on the targeted treatment unit to collect data regarding compliance with unit rules (behavioral), activities of daily living, and attendance and participation in their treatment program, specifically, daily therapy groups. In the group tracking system, data are initially collected on paper and pencil rosters and then input into the group tracking system daily by line staff. Utilizing a correlational study design, variables of interest in the group tracking system included length of current hospitalization; length of stay on SLP; the percentage of basic and instrumental ADLs adequately achieved; attendance and participation in unit programming; and the number of minor, major, and intolerable infractions received. The number of aggressive episodes was calculated based on examination of the basis for receipt of a fine (see Appendix A).
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Using SPSS 24.0 (IBM), a multiple regression analysis was conducted to examine the relationship between the number of aggressive episodes among patients on SLP and the length of current hospitalization, length of current stay on SLP, basic and instrumental ADLs, the percentage of attendance and participation in treatment programming, and the number of minor, major, intolerable infractions received.
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Results As can be seen in Table 1, the sample was comprised of 23 individuals, of which 86.9% (n = 20) were male and 13.1% (n = 3) were female. Ranging in age from 27 to 65, the mean age of the participants in the study was 47.22 (SD = 12.76) years. The participants’ educational level ranged from 7 to 16 years, with a mean of 11.50 (SD = 1.95) years. The length of patients’ current hospitalization ranged from 0.66 to 39 years, with a mean of 6.51 (SD = 8.40) years. Participants’ length of stay on SLP ranged from 0.08 to 11 years, with a mean of 2.87 (SD = 3.05) years. The number of aggressive episodes ranged from 0 to 113, with a mean of 8.39 (SD = 23.06) aggressive episodes over the 24-month period of investigation. Within the sample, 69.6% (n = 16) participants carried a primary diagnosis of Schizophrenia, 26.1% (n = 6) were diagnosed with Schizoaffective Disorder, and 4.3% (n = 1) were diagnosed with Psychosis Not Otherwise Specified.
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A standard multiple regression analysis was conducted to determine which independent variables (length of stay on SLP; length of current hospitalization; basic ADLs; instrumental ADLs; attendance in programming; participation in programming; and number of minor, major, and intolerable infractions received) predicted number of aggressive episodes. Data screening did not reveal any outliers and the assumptions of linearity, normality, and homoscedasticity were met. The significance level was set at .05. Regression results indicated that the overall 2 model significantly predicted the number of aggressive episodes, 𝑅 2 = .957, 𝑅𝑎𝑑𝑗 = .927, F(9, 13) = 32.224, p < .001. This model accounted for 95.7% of the variance in the number of aggressive episodes. However, the only variables that were found to be significant predictors of number of aggressive episodes were number of intolerable infractions and instrumentals ADLs. A summary of the regression model is presented in Table 2. As can be seen in Table 3, the number of aggressive episodes was positively and significantly correlated with the number of intolerable infractions (r = .96, p < .01).
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Discussion Reduction of aggression among the severely and persistently mentally ill is an important area of concern for nursing and clinical staff members working in inpatient settings, and the SLP has been found to be an efficacious treatment for this population (Bellus et al., 1999; LePage et al., 2003; Newbill et al., 2011). However, to date there has been little information in the literature regarding the relationship between specific treatment program variables and aggressive behaviors. The goal of this study was to provide information to clinicians regarding the way in which specific aspects of programming may be related to aggression in order to better inform treatment planning and assist in evidence-based clinical practices.
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When analyzed as a group, data collected over a two year period found significant positive correlations between aggression and intolerable infractions. Most importantly, results of a multiple regression analysis indicated that the number of intolerable infractions and instrumental ADLs were the only significant predictors of the number of aggressive episodes. In contrast to results of Silverstein et al. (2006), our findings demonstrated no significant correlation between aggressive behaviors and patient compliance with basic ADLs. It is possible that this discrepancy is due to differences in how basic ADLs were operationally defined in these two separate investigations.
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Taken together, current findings suggest that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. Therefore staff members working with chronically and severely mentally ill inpatients need to be continually vigilant for the potential of aggression, as our data suggest that there may not be obvious warning signs for aggression such as decompensating ADLs or withdrawal from treatment groups. This finding is noteworthy as it is consistent with research conducted by Newbill et al. (2011), which demonstrated that attentiveness to individual patient variables is a key component to successfully maintaining adaptive behaviors over time. Exploration of other factors beyond ADLs and treatment attendance/participation may shed light on the origin of aggression in this population. In particular, environmental, internal, or social triggers outside the formal treatment context (such as interpersonal distress related to disagreements during unstructured time or internal distress related to Anniversary dates) may be related to the presence of aggressive acts. An important corollary is that understanding and awareness of such individualized, patient-centered factors is only possible when staff members have the time to establish and maintain rapport and trust with patients through meaningful interpersonal interaction in the context of delivering care. This was also demonstrated by Berring, Pedersen, and Buus (2016) who noted the importance of collaboration and shared problem-solving between staff and patients in reducing aggressive behavior. Although unrelated to the likelihood of a patient engaging in aggressive behaviors, there are important clinical implications regarding the significant correlations observed among the predictor variables. In particular, participation and attendance in treatment programming were both found to be positively and significantly correlated with activities of daily living. Clinically, these findings lend support to the efficacy of SLP in that patients who regularly attend and participate in treatment programming are more likely to appropriately attend to their ADLs. Similarly, the negative and significant correlations obtained between attendance and 7
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION participation and the number of major and minor infractions received suggests that patients are less likely to receive infractions when they are engaged in treatment programming.
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There are several limitations to the current study. First, due to the research being conducted in a clinical setting, the sample group was already identified based on patients who had been admitted to the unit, and therefore random selection of participants was unattainable. Second, due to the fact that some of the behaviors that result in a patient receiving a major or intolerable infraction are aggressive in nature, there was a certain amount of redundancy that could not be controlled for between the dependent variable (aggressive episodes) and two of the independent variables (major and intolerable infractions). Third, the sample size was limited to the number of patients on the selected treatment unit. Thus, future research may benefit from replication with a larger sample size.
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Despite these limitations, nursing staff and other unit clinicians can glean important information from this study. Perhaps of most significance, our results suggest there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill patients, such as decompensating basic ADLs or withdrawal from treatment groups. Such factors, although important for other therapeutic reasons, would not appear to be appropriate treatment targets for reducing aggression potential. Rather, our findings as well as our clinical experience suggest that other individualized patient factors may be at play in the expression of aggressive impulses. This emphasizes the importance of adequate staff-to-patient ratios so that staff members can truly get to know their patients and establish rapport and trust in the context of delivering care. Treatment providers may benefit from future research focusing on individual differences between patients that may predict aggression.
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References 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. Psychiatric Services, 42(7), 750-752. Bellus, S. B., Donovan, S. M., Kost, P. P., Vergo, J. G., Gramse, R. A., Bross, A., & Tervit, S. L. (2003). Behavior change and achieving hospital discharge in persons with severe, chronic psychiatric disabilities. Psychiatric Quarterly, 74(1), 31-42. Berring, L. L., Pedersen, L., & Buus, N. (2016). Coping with violence in mental health care settings: Patient and staff member perspectives on de-escalation practices. Archives of Psychiatric Nursing, 30, 499-507. Colorado Mental Health Institute at Pueblo. (2014). Psychosocial program manual: SLP. Pueblo, CO: Author. Deane, F. P., Huzziff, R., & Beaumont, G. (1995). Discharge planning: Levels of care and behavioral functioning in long-term psychiatric inpatients transferred to community placement. Community Mental Health in New Zealand, 9, 18-26. Donat, D. C. (2003). An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services, 54(8), 1119-1123. Donat, D. C. (2005). Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital. Psychiatric Services, 56(9), 1105-1108. Goodness, K. R., & Renfro, N. S. (2002). Changing a culture: A brief program analysis of a social learning program on a maximum-security forensic unit. Behavioral Sciences and the Law, 20, 495-506. doi:10.1002/bsl.489. LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murphy, J., Lewis, P., Aboraya, A., & Mogge, N. (2003). Reducing assaults on an acute psychiatric unit using a token economy: A two-year follow-up. Behavioral Interventions, 18, 179-190. Doi: 10.1002/bin.134 Liberman, R. P. (1980). A review of Paul and Lentz’s psychological treatment for chronic mental patients: Milieu versus social-learning programs. Journal of Applied Behavior Analysis, 13(2), 367-371. Menditto, A. A. (2002). A social-learning approach to the rehabilitation of individuals with severe mental disorders who reside in forensic facilities. Psychiatric Rehabilitation Skills, 6(1), 73-93. Newbill, W. A., Paul, G. L., Menditto, A. A., Springer, J. R., & Mehta, P. (2011). Sociallearning programs facilitate an increase in adaptive behavior in a forensic mental hospital. Behavioral Interventions, 26(3), 214-230. Sharfstein, S. S. (2009). Goals of inpatient treatment for psychiatric disorders. Annual Review of Medicine, 60, 393-403. Silverstein, S. M., Hatashita-Wong, M., Wilkniss, S., Bloch, A., Smith, T., Savitz, A., McCarthy, R., Friedman, M., & Terkelsen, K. (2006). Behavioral rehabilitation of the “Treatment Refractory” schizophrenia patient: Conceptual foundations, interventions, and outcome data. Psychological Services, 3(3), 145-169. doi: 10.1037/1541-1559.3.3.3.145 Society of Clinical Psychology. (2016). Social learning/token economy programs for schizophrenia. Retrieved from http://www.div12.org/psychologicaltreatments/treatments/social-learningtoken-economy-programs-for-schizophrenia/
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Springer, J. R., Sloan, P. A., Benge, J. F., Spence, M., Carlo, I., & Teng, E. J. (2010). From dangerous to discharged: An application of social-learning-based procedures in an acute hospital setting. Clinical Case Studies, 9(1), 41-52. doi:10.1177/153465010934858
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION APPENDIX A
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Basic ADLs An average of the following: Up on Time: patients are praised and given credit for getting out of bed following two separate wake-up calls. Bed and Area Checks: staff members survey the patient’s bedroom, looking for belongings put away, bed neatly made, bedding free of soil, furniture in appropriate places, and drawers and closet neat and tidy. Appearance Checks: patient's appearance is assessed based on cleanliness of fingernails, tidy hair, teeth brushed, appropriate clothing that is clean and tidy, has recently showered, free of body odor, has shaven or wearing appropriate make up. Laundry: patients are expected to sign up for and independently complete their laundry as needed. Showers and Hygiene: a patient’s ability to shower and address hygiene adequately is assessed by their demonstrating consistently washing all body areas (lack of odor) and putting on clean clothes after bathing.
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Instrumental ADLs An average of the following: Leisure Events: patients sign up for off unit, leisure events during Leisure Planning groups and pay the token cost for the events they choose to attend. Informal Interactions: patients are given the opportunity to learn and practice leisure skills during casual, informal activities. To earn a token, the patient must attend during the scheduled time and actively interact with their peers.
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Attendance in Programming Average percentage of attendance in assigned treatment groups during the 24-month period under investigation (for patients who had been on SLP less than 24 months, the average percentage of attendance across their length of stay). Patients are given credit for attending a group, and staying in the group through completion. Decisions to refuse attendance are noted by staff and patients are required to use their tokens to buy out of the group.
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Participation in Programming This included the average percentage of participation in treatment programming and activities of daily living during the 24-month period under investigation (for patients who had been on SLP less than 24 months, the average percentage of participation across their length of stay). Patients are given credit for attending groups through completion as well as for successful completion of activities of daily living. Decisions to refuse participation are noted by staff. Minor Infractions (5-Token fines) The sum of minor infractions received during the 24-month period under investigation. These included low-level, non-violent maladaptive behaviors, such as rummaging through garbage, and exchanging goods and services with other patients.
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Major Infractions (10-Token fines) The sum of major infractions received during the 24-month period under investigation. These included behaviors such as leaving the unit without approval, creating a fire hazard, and possession of contraband. Intolerable Infractions (25-Token fines) The sum of intolerable infractions received during the 24-month period under investigation. These included behaviors such as attempted escape and possession of weapons.
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Aggressive Episodes Utilizing the SLP Program Manual (CMHIP, 2014) definition, aggressive episodes include the following acts: yelling or cursing at someone, glaring at someone, excessive arguing, racial slurs, explicit sexual comments, inappropriate touching or gesturing (i.e., flipping someone off), inappropriate sexual touching, threats or acts of physical harm to others, any sexual act with a non-consenting partner, possession of weapons, spitting on others, urinating on others, and serious property destruction of an aggressive nature.
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Table 1
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SD
Age
47.22
12.76
Educational Level
11.50
1.95
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Participant Characteristics (N = 23) Characteristic
6.51
8.40
2.87
3.05
8.39
23.06
IP
Length of Current Hospitalization
CR
Length of Stay on SLP
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Number of Aggressive Episodes
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Table 2 Regression Analysis Summary for Patient Variables Predicting Number of Aggressive Episodes B
SE B
ß
t
p
-.022
.195
-.008
-.460
.653
Length of Stay on SLP
.209
.671
.028
.312
.760
Total Basic ADLs
.259
.177
.152
1.467
.166
Total Instrumental ADLs
-.493
.200
-2.459
.029*
Total Participation
.690
.456
.299
1.513
.154
Total Attendance
-.473
.391
-.205
-1.209
.248
Total 5 Token Fines
-.132
.254
-.053
-.522
.610
Total 10 Token Fines
.859
.730
.112
1.176
.261
.463
.936
13.179
.000**
6.096
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Note. 𝑅 2 = .957 (N = 23, p < .001). * p < .05. ** p < .01.
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-.297
CR
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Total 25 Token Fines
T
Length of Current Hospitalization
IP
Variable
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Second, the sample size was limited to the number of patients on the selected treatment unit. Thus, future research may benefit from replication with a larger sample size. It is encouraging, however, that despite our small sample size, our findings were consistent with results reported by Silverstein et al. (2006). Table 3
Patient Predictor Variables M
SD
1
2
3
4
5
8.39
23.06
.09
.43
-.003
-.08
1. Length of Current Hospitalization
2.87
3.05
-
.48*
2. Length of Stay on SLP
85.57
9.98
.48*
-
3. Basic ADLs
53.70
13.92
.22
4. Instrumental ADLs
69.10
13.54
.12
5. Participation
6.51
8.40
6. Minor Infractions
5.68
9.30
7. Major Infractions
1.52
8. Intolerable Infractions
2.23
Number of Aggressive Episodes
5.68
8
9
.05
-.08
.11
.96**
.058
.12
.22
-.31
-.25
.09
.25
.39*
.43*
.34
-.34
-.22
.47*
.32
AN
.22
-
.71**
.69**
-.65**
-.65**
.02
.66**
.43*
.71**
-
.80**
-.48*
-.40*
.01
.65**
M
.39*
.34
.69**
.80**
-
-.58**
-.43*
.09
.91**
-.31
-.34
-.65**
-.48*
-.58**
-
.74**
-.12
-.67**
ED
.22
-.25
-.22
-.65**
-.40*
-.43*
.74**
-
.05
-.52*
3.02
.09
.47*
.016
.01
.087
-.12
.05
-
.11
.25
.32
.66**
.65**
.91**
-.67**
-.52*
.11
-
9.30
AC
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*p < .05. ** p < .01.
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3.54
PT
9. Attendance
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Predictor Variable
6
CR
Variable
IP
T
Means, Standard Deviations, and Interrcorrelations for Number of Aggressive Episodes and
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Highlights
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IP
CR
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This study utilized archival data to examine the relationship between behavioral variables and aggression over a 24-month period among 23 severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects). Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. These data provide valuable information regarding aggressive tendencies that can inform treatment planning.
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Colorado Mental Health Institute at Pueblo 1600 W 24th Street Pueblo, CO 81003
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Susan Oehler, Ashleigh Berman, Cecilia Gay, Rose Manguso, Jessica Espinoza PII: DOI: Reference:
S0883-9417(17)30040-7 doi:10.1016/j.apnu.2017.09.012 YAPNU 50994
To appear in:
Archives of Psychiatric Nursing
Received date: Revised date: Accepted date:
17 January 2017 18 September 2017 19 September 2017
Please cite this article as: Susan Oehler, Ashleigh Berman, Cecilia Gay, Rose Manguso, Jessica Espinoza , An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yapnu(2017), doi:10.1016/j.apnu.2017.09.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running head: CORRELATES OF AGGRESSION An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients Corresponding Author: Susan Oehler, PsyDi [email protected]
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Rose Manguso, PhD, ABPPi [email protected]
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Cecilia Gay, PsyDi [email protected]
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Ashleigh Berman, PsyDi [email protected]
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Jessica Espinoza, PsyDi [email protected]
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Abstract
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Purpose: This study aimed to examine the relationship between behavioral variables and aggression among severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility.
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Methods: Using archival data over a 24-month period, a total of 23 severely and chronically mentally ill inpatients comprised the sample in this study. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects).
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Results: Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. Discussion: Our findings provide valuable information regarding aggressive tendencies that can inform treatment planning. Specifically, our results suggested there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill inpatients. Rather,
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other individualized patient factors may be at play in the expression of aggressive impulses, emphasizing the importance of adequate staff-to-patient ratios so that care planning and implementation can be appropriately individualized.
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The issue of aggressive behavior among severely and persistently mentally ill psychiatric inpatients is of particular concern due to its potential to significantly interfere with nursing staff safety, patient progress in treatment, and patient adaptive functioning (Bellus, Vergo, Kost, Stewart, & Barkstrom, 1999; LePage et al., 2003; Newbill, Paul, Menditto, Springer, & Mehta, 2011). Additionally, a history of aggressive behaviors complicates discharge for those patients to less restrictive settings (Springer, Sloan, Benge, Spence, Carlo, & Teng, 2010). Historically managed through the use of seclusion, restraint, and PRN medications, research has demonstrated the effectiveness of social learning principles in reducing aggressive behavior in a variety of psychiatric populations (Beck, Menditto, Baldwin, Angelone, & Maddox, 1991; Bellus et al., 2003; Donat, 2003, 2005). Of particular interest is Paul and Lentz’s Social Learning Program (SLP), which was designed to “meet the specialized training needs of the most severely regressed and persistently psychiatrically disabled adults” (Bellus et al., 2003, p. 33). The SLP has been widely studied and implemented and has received recognition from a task force within the American Psychological Association (APA) as a highly efficacious treatment for psychosis within an inpatient setting (Newbill et al., 2011). There is evidence that the SLP, which includes nursing and psychology staff implementation of a token economy and response-cost system, has been effective in decreasing aggression, increasing attainment of self-care competencies, and increasing chances of successful community reintegration (Beck et al., 1991; Bellus et al., 2003; Goodness & Renfro, 2002).
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Social Learning Program Overview Although significant time has elapsed since its inception, the SLP continues to be recognized as an effective treatment approach (Newbill et al., 2011). The program was initially designed to address specific issues that were found to be contributing to failed discharges from institutions among severely and persistently mentally ill individuals. These issues were summarized in four categories, including “lack of self-maintenance and social skills, instrumental role performance, and community support; and…. high rates of bizarre behavior” (Liberman, 1980, p. 367). The SLP is an inpatient, psychosocial treatment approach based on Social Learning Theory and designed for the severely, persistently, and chronically mentally ill (Menditto, 2002). In particular, the SLP targets maladaptive and aggressive behaviors. Utilizing behavioral techniques and skills training, the SLP is a comprehensive system implemented by staff members. Treatment is provided through individual and group methodologies with the goal of increasing adaptive behaviors (Menditto, 2002). In addition to addressing adaptive behaviors, the SLP incorporates training in several domains, including coping skills, problem solving, medication management, cognitive skills, and academics. Patients who are unable to manage the demands of these treatment groups participate in shaping classes where the goal is for the patient to complete smaller approximations of desired behaviors (Menditto, 2002). The SLP focuses on altering specific behaviors through token economy and response-cost systems (Bellus et al., 2003). Token economies have demonstrated effectiveness in changing behaviors, helping patients acquire new skills, reducing undesirable behaviors, increasing treatment compliance, and improving overall unit management (LePage et al., 2003). Token economies are based on operant principles (LePage et al., 2003), with secondary reinforcers used 3
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to increase motivation for completing specific target behaviors or displaying incremental behaviors consistent with their target. Conversely, the token reinforcer is withheld if the treatment target is not reached (Society of Clinical Psychology, 2016). In addition to the token economy, the SLP utilizes a four-step level system in which patients must reach certain treatment targets to be promoted. Each level is tied to specific privileges, including an increase in weekly token deposits in individuals’ token banks (Menditto, 2002). While the SLP relies heavily on specific behavioral interventions, there is an underlying goal for staff to create a treatment milieu that fosters a skills training environment. Within the milieu, patients are constantly coached to identify and follow through with adaptive behaviors (Bellus et al., 2003). The underlying principle of the SLP is that anyone, despite his or her mental status or disability, is able to learn new behaviors and skills (Menditto, 2002). This orientation is consistent with findings from recent research by Berring, Pedersen, and Buus (2016) that patients can collaborate with staff to effectively de-escalate and manage aggressive behaviors.
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Adaptive Functioning and Aggression The importance of increasing adaptive functioning skills in individuals with severe and persistent mental illness is high. Although patients with severe and persistent mental illness are admitted to inpatient facilities for a variety of reasons, the goal for discharge is the same: to return patients to assisted or independent living permanently (Newbill et al., 2011; Sharfstein, 2009). Adaptive behavior deficits are a major reason why people either remain hospitalized for long periods or return to inpatient settings after being released (Newbill et al., 2011). Research has identified that those who are most prepared for discharge to the community have fewer instances of deviant behaviors and demonstrated higher levels of basic living skills (e.g., use of table manners, appropriate dress, and use of money) (Deane, Huzziff, & Beaumont, 1995). In a psychosocial treatment program where behavior was tied to reinforcers, Silverstein et al. (2006) determined that during the same time period in which aggressive behaviors decreased, patient compliance with basic ADLs significantly increased. Adaptive functioning has now been clearly recognized in the literature as being of high importance in successful recovery and maintenance in those who are severely and persistently mentally ill. However, there is scant research on factors that affect chronically and severely mentally ill patients’ ability to increase adaptive functioning skills.
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Why Further Analysis of the Correlates of Aggression is Necessary Despite the known effectiveness of the SLP in meeting the daily needs of severely and persistently mentally ill patients, a review of the literature indicated research has largely overlooked identification of treatment program components that correlate with aggression, particularly within a forensic inpatient setting. A better understanding of the relationship between aggression and specific treatment program variables may help inform care planning – specifically by providing staff with information on aspects of programming that are related to aggression and therefore warrant special attention in order to deal with this problem proactively. Specifically, the current study attempted to answer the following questions: 1. What is the relationship between the number of aggressive episodes and the length of current hospitalization, length of stay on SLP, basic activities of daily living (ADLs), instrumental ADLs, attendance in programming, participation in programming, and the 4
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION number of minor (5-token), major (10-token), and intolerable (25-token) infractions received? Operational definitions for all of these variables can be found in Appendix A. 2. How well do the following variables - length of current hospitalization, length of stay on SLP, basic ADLs, instrumental ADLs, attendance in programming, participation in programming, and the number of minor, major, and intolerable infractions - predict the number of aggressive episodes among patients on SLP?
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Method Human Rights and Ethical Considerations In order to meet institutional requirements for conducting ethical research with human participants, a research proposal was submitted to and approved by the facility’s privacy and research review board. This study utilized de-identified archival data. In gathering the data, patient identification numbers were used to match demographic information with behavioral data points. As soon as the data were merged, the patient identification numbers were deleted from the data base, thereby maintaining patient confidentiality.
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Treatment Setting Data were collected from the SLP unit at a state psychiatric facility in southern Colorado. It is a 449-bed facility accredited by the Joint Commission. The SLP is a psychosocial treatment unit that is well established within the facility. The SLP is based on Paul and Lentz’s original treatment program, and utilizes a token economy and response cost system. In addition to reinforcers on the unit, patients are able to work towards gaining on and off grounds (both supervised and unsupervised) privileges. The facility’s disposition committee and the Colorado court system govern these privileges. Patients consistently receive informal treatment through skills coaching (including Activities of Daily Living) and milieu management. There are also several hours of formal treatment each day, including Occupational Therapy, Recreational Therapy, Academics, Community, Promotion, and Psychology groups (Dialectical Behavior Therapy, Shaping, Cognitive Skills, Problem Solving, and Symptoms Management). Total formal treatment hours are dependent on the highly individualized program of each patient.
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Participants The patients admitted to the SLP unit had been referred from other units throughout the hospital. Admission criteria for the unit included presence of severe negative symptoms; a history of chronic mental illness; primary diagnosis could not be a personality disorder; presence of severe deficits in functioning in the areas of self-care skills, social skills, and/or instrumental role performance; and a history of continuous hospitalizations and failed placements due to psychotic symptoms. In selecting study participants, eligibility criteria consisted of whether the patient was treated on the SLP unit between January 1, 2013 and December 31, 2015. This time frame was chosen based on the availability of archival data. A total of 23 patients were treated on the SLP unit during the 24-month period of investigation, resulting in a sample of 23 participants. While this sample size fell below the number which would normally be required for an effect size of .35, the size of the patient unit under investigation prohibited a larger sample size.
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Measures and Procedure Data points collected and used to describe the sample of participants included age, gender, educational level, and psychiatric diagnosis. Researchers also had access to a group tracking system which is used on the targeted treatment unit to collect data regarding compliance with unit rules (behavioral), activities of daily living, and attendance and participation in their treatment program, specifically, daily therapy groups. In the group tracking system, data are initially collected on paper and pencil rosters and then input into the group tracking system daily by line staff. Utilizing a correlational study design, variables of interest in the group tracking system included length of current hospitalization; length of stay on SLP; the percentage of basic and instrumental ADLs adequately achieved; attendance and participation in unit programming; and the number of minor, major, and intolerable infractions received. The number of aggressive episodes was calculated based on examination of the basis for receipt of a fine (see Appendix A).
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Using SPSS 24.0 (IBM), a multiple regression analysis was conducted to examine the relationship between the number of aggressive episodes among patients on SLP and the length of current hospitalization, length of current stay on SLP, basic and instrumental ADLs, the percentage of attendance and participation in treatment programming, and the number of minor, major, intolerable infractions received.
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Results As can be seen in Table 1, the sample was comprised of 23 individuals, of which 86.9% (n = 20) were male and 13.1% (n = 3) were female. Ranging in age from 27 to 65, the mean age of the participants in the study was 47.22 (SD = 12.76) years. The participants’ educational level ranged from 7 to 16 years, with a mean of 11.50 (SD = 1.95) years. The length of patients’ current hospitalization ranged from 0.66 to 39 years, with a mean of 6.51 (SD = 8.40) years. Participants’ length of stay on SLP ranged from 0.08 to 11 years, with a mean of 2.87 (SD = 3.05) years. The number of aggressive episodes ranged from 0 to 113, with a mean of 8.39 (SD = 23.06) aggressive episodes over the 24-month period of investigation. Within the sample, 69.6% (n = 16) participants carried a primary diagnosis of Schizophrenia, 26.1% (n = 6) were diagnosed with Schizoaffective Disorder, and 4.3% (n = 1) were diagnosed with Psychosis Not Otherwise Specified.
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A standard multiple regression analysis was conducted to determine which independent variables (length of stay on SLP; length of current hospitalization; basic ADLs; instrumental ADLs; attendance in programming; participation in programming; and number of minor, major, and intolerable infractions received) predicted number of aggressive episodes. Data screening did not reveal any outliers and the assumptions of linearity, normality, and homoscedasticity were met. The significance level was set at .05. Regression results indicated that the overall 2 model significantly predicted the number of aggressive episodes, 𝑅 2 = .957, 𝑅𝑎𝑑𝑗 = .927, F(9, 13) = 32.224, p < .001. This model accounted for 95.7% of the variance in the number of aggressive episodes. However, the only variables that were found to be significant predictors of number of aggressive episodes were number of intolerable infractions and instrumentals ADLs. A summary of the regression model is presented in Table 2. As can be seen in Table 3, the number of aggressive episodes was positively and significantly correlated with the number of intolerable infractions (r = .96, p < .01).
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Discussion Reduction of aggression among the severely and persistently mentally ill is an important area of concern for nursing and clinical staff members working in inpatient settings, and the SLP has been found to be an efficacious treatment for this population (Bellus et al., 1999; LePage et al., 2003; Newbill et al., 2011). However, to date there has been little information in the literature regarding the relationship between specific treatment program variables and aggressive behaviors. The goal of this study was to provide information to clinicians regarding the way in which specific aspects of programming may be related to aggression in order to better inform treatment planning and assist in evidence-based clinical practices.
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When analyzed as a group, data collected over a two year period found significant positive correlations between aggression and intolerable infractions. Most importantly, results of a multiple regression analysis indicated that the number of intolerable infractions and instrumental ADLs were the only significant predictors of the number of aggressive episodes. In contrast to results of Silverstein et al. (2006), our findings demonstrated no significant correlation between aggressive behaviors and patient compliance with basic ADLs. It is possible that this discrepancy is due to differences in how basic ADLs were operationally defined in these two separate investigations.
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Taken together, current findings suggest that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. Therefore staff members working with chronically and severely mentally ill inpatients need to be continually vigilant for the potential of aggression, as our data suggest that there may not be obvious warning signs for aggression such as decompensating ADLs or withdrawal from treatment groups. This finding is noteworthy as it is consistent with research conducted by Newbill et al. (2011), which demonstrated that attentiveness to individual patient variables is a key component to successfully maintaining adaptive behaviors over time. Exploration of other factors beyond ADLs and treatment attendance/participation may shed light on the origin of aggression in this population. In particular, environmental, internal, or social triggers outside the formal treatment context (such as interpersonal distress related to disagreements during unstructured time or internal distress related to Anniversary dates) may be related to the presence of aggressive acts. An important corollary is that understanding and awareness of such individualized, patient-centered factors is only possible when staff members have the time to establish and maintain rapport and trust with patients through meaningful interpersonal interaction in the context of delivering care. This was also demonstrated by Berring, Pedersen, and Buus (2016) who noted the importance of collaboration and shared problem-solving between staff and patients in reducing aggressive behavior. Although unrelated to the likelihood of a patient engaging in aggressive behaviors, there are important clinical implications regarding the significant correlations observed among the predictor variables. In particular, participation and attendance in treatment programming were both found to be positively and significantly correlated with activities of daily living. Clinically, these findings lend support to the efficacy of SLP in that patients who regularly attend and participate in treatment programming are more likely to appropriately attend to their ADLs. Similarly, the negative and significant correlations obtained between attendance and 7
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION participation and the number of major and minor infractions received suggests that patients are less likely to receive infractions when they are engaged in treatment programming.
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There are several limitations to the current study. First, due to the research being conducted in a clinical setting, the sample group was already identified based on patients who had been admitted to the unit, and therefore random selection of participants was unattainable. Second, due to the fact that some of the behaviors that result in a patient receiving a major or intolerable infraction are aggressive in nature, there was a certain amount of redundancy that could not be controlled for between the dependent variable (aggressive episodes) and two of the independent variables (major and intolerable infractions). Third, the sample size was limited to the number of patients on the selected treatment unit. Thus, future research may benefit from replication with a larger sample size.
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Despite these limitations, nursing staff and other unit clinicians can glean important information from this study. Perhaps of most significance, our results suggest there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill patients, such as decompensating basic ADLs or withdrawal from treatment groups. Such factors, although important for other therapeutic reasons, would not appear to be appropriate treatment targets for reducing aggression potential. Rather, our findings as well as our clinical experience suggest that other individualized patient factors may be at play in the expression of aggressive impulses. This emphasizes the importance of adequate staff-to-patient ratios so that staff members can truly get to know their patients and establish rapport and trust in the context of delivering care. Treatment providers may benefit from future research focusing on individual differences between patients that may predict aggression.
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References 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. Psychiatric Services, 42(7), 750-752. Bellus, S. B., Donovan, S. M., Kost, P. P., Vergo, J. G., Gramse, R. A., Bross, A., & Tervit, S. L. (2003). Behavior change and achieving hospital discharge in persons with severe, chronic psychiatric disabilities. Psychiatric Quarterly, 74(1), 31-42. Berring, L. L., Pedersen, L., & Buus, N. (2016). Coping with violence in mental health care settings: Patient and staff member perspectives on de-escalation practices. Archives of Psychiatric Nursing, 30, 499-507. Colorado Mental Health Institute at Pueblo. (2014). Psychosocial program manual: SLP. Pueblo, CO: Author. Deane, F. P., Huzziff, R., & Beaumont, G. (1995). Discharge planning: Levels of care and behavioral functioning in long-term psychiatric inpatients transferred to community placement. Community Mental Health in New Zealand, 9, 18-26. Donat, D. C. (2003). An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services, 54(8), 1119-1123. Donat, D. C. (2005). Encouraging alternatives to seclusion, restraint, and reliance on PRN drugs in a public psychiatric hospital. Psychiatric Services, 56(9), 1105-1108. Goodness, K. R., & Renfro, N. S. (2002). Changing a culture: A brief program analysis of a social learning program on a maximum-security forensic unit. Behavioral Sciences and the Law, 20, 495-506. doi:10.1002/bsl.489. LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murphy, J., Lewis, P., Aboraya, A., & Mogge, N. (2003). Reducing assaults on an acute psychiatric unit using a token economy: A two-year follow-up. Behavioral Interventions, 18, 179-190. Doi: 10.1002/bin.134 Liberman, R. P. (1980). A review of Paul and Lentz’s psychological treatment for chronic mental patients: Milieu versus social-learning programs. Journal of Applied Behavior Analysis, 13(2), 367-371. Menditto, A. A. (2002). A social-learning approach to the rehabilitation of individuals with severe mental disorders who reside in forensic facilities. Psychiatric Rehabilitation Skills, 6(1), 73-93. Newbill, W. A., Paul, G. L., Menditto, A. A., Springer, J. R., & Mehta, P. (2011). Sociallearning programs facilitate an increase in adaptive behavior in a forensic mental hospital. Behavioral Interventions, 26(3), 214-230. Sharfstein, S. S. (2009). Goals of inpatient treatment for psychiatric disorders. Annual Review of Medicine, 60, 393-403. Silverstein, S. M., Hatashita-Wong, M., Wilkniss, S., Bloch, A., Smith, T., Savitz, A., McCarthy, R., Friedman, M., & Terkelsen, K. (2006). Behavioral rehabilitation of the “Treatment Refractory” schizophrenia patient: Conceptual foundations, interventions, and outcome data. Psychological Services, 3(3), 145-169. doi: 10.1037/1541-1559.3.3.3.145 Society of Clinical Psychology. (2016). Social learning/token economy programs for schizophrenia. Retrieved from http://www.div12.org/psychologicaltreatments/treatments/social-learningtoken-economy-programs-for-schizophrenia/
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Springer, J. R., Sloan, P. A., Benge, J. F., Spence, M., Carlo, I., & Teng, E. J. (2010). From dangerous to discharged: An application of social-learning-based procedures in an acute hospital setting. Clinical Case Studies, 9(1), 41-52. doi:10.1177/153465010934858
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION APPENDIX A
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Basic ADLs An average of the following: Up on Time: patients are praised and given credit for getting out of bed following two separate wake-up calls. Bed and Area Checks: staff members survey the patient’s bedroom, looking for belongings put away, bed neatly made, bedding free of soil, furniture in appropriate places, and drawers and closet neat and tidy. Appearance Checks: patient's appearance is assessed based on cleanliness of fingernails, tidy hair, teeth brushed, appropriate clothing that is clean and tidy, has recently showered, free of body odor, has shaven or wearing appropriate make up. Laundry: patients are expected to sign up for and independently complete their laundry as needed. Showers and Hygiene: a patient’s ability to shower and address hygiene adequately is assessed by their demonstrating consistently washing all body areas (lack of odor) and putting on clean clothes after bathing.
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Instrumental ADLs An average of the following: Leisure Events: patients sign up for off unit, leisure events during Leisure Planning groups and pay the token cost for the events they choose to attend. Informal Interactions: patients are given the opportunity to learn and practice leisure skills during casual, informal activities. To earn a token, the patient must attend during the scheduled time and actively interact with their peers.
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Attendance in Programming Average percentage of attendance in assigned treatment groups during the 24-month period under investigation (for patients who had been on SLP less than 24 months, the average percentage of attendance across their length of stay). Patients are given credit for attending a group, and staying in the group through completion. Decisions to refuse attendance are noted by staff and patients are required to use their tokens to buy out of the group.
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Participation in Programming This included the average percentage of participation in treatment programming and activities of daily living during the 24-month period under investigation (for patients who had been on SLP less than 24 months, the average percentage of participation across their length of stay). Patients are given credit for attending groups through completion as well as for successful completion of activities of daily living. Decisions to refuse participation are noted by staff. Minor Infractions (5-Token fines) The sum of minor infractions received during the 24-month period under investigation. These included low-level, non-violent maladaptive behaviors, such as rummaging through garbage, and exchanging goods and services with other patients.
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Major Infractions (10-Token fines) The sum of major infractions received during the 24-month period under investigation. These included behaviors such as leaving the unit without approval, creating a fire hazard, and possession of contraband. Intolerable Infractions (25-Token fines) The sum of intolerable infractions received during the 24-month period under investigation. These included behaviors such as attempted escape and possession of weapons.
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Aggressive Episodes Utilizing the SLP Program Manual (CMHIP, 2014) definition, aggressive episodes include the following acts: yelling or cursing at someone, glaring at someone, excessive arguing, racial slurs, explicit sexual comments, inappropriate touching or gesturing (i.e., flipping someone off), inappropriate sexual touching, threats or acts of physical harm to others, any sexual act with a non-consenting partner, possession of weapons, spitting on others, urinating on others, and serious property destruction of an aggressive nature.
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Table 1
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SD
Age
47.22
12.76
Educational Level
11.50
1.95
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Participant Characteristics (N = 23) Characteristic
6.51
8.40
2.87
3.05
8.39
23.06
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Length of Current Hospitalization
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Length of Stay on SLP
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Number of Aggressive Episodes
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Table 2 Regression Analysis Summary for Patient Variables Predicting Number of Aggressive Episodes B
SE B
ß
t
p
-.022
.195
-.008
-.460
.653
Length of Stay on SLP
.209
.671
.028
.312
.760
Total Basic ADLs
.259
.177
.152
1.467
.166
Total Instrumental ADLs
-.493
.200
-2.459
.029*
Total Participation
.690
.456
.299
1.513
.154
Total Attendance
-.473
.391
-.205
-1.209
.248
Total 5 Token Fines
-.132
.254
-.053
-.522
.610
Total 10 Token Fines
.859
.730
.112
1.176
.261
.463
.936
13.179
.000**
6.096
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Note. 𝑅 2 = .957 (N = 23, p < .001). * p < .05. ** p < .01.
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-.297
CR
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Total 25 Token Fines
T
Length of Current Hospitalization
IP
Variable
ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Second, the sample size was limited to the number of patients on the selected treatment unit. Thus, future research may benefit from replication with a larger sample size. It is encouraging, however, that despite our small sample size, our findings were consistent with results reported by Silverstein et al. (2006). Table 3
Patient Predictor Variables M
SD
1
2
3
4
5
8.39
23.06
.09
.43
-.003
-.08
1. Length of Current Hospitalization
2.87
3.05
-
.48*
2. Length of Stay on SLP
85.57
9.98
.48*
-
3. Basic ADLs
53.70
13.92
.22
4. Instrumental ADLs
69.10
13.54
.12
5. Participation
6.51
8.40
6. Minor Infractions
5.68
9.30
7. Major Infractions
1.52
8. Intolerable Infractions
2.23
Number of Aggressive Episodes
5.68
8
9
.05
-.08
.11
.96**
.058
.12
.22
-.31
-.25
.09
.25
.39*
.43*
.34
-.34
-.22
.47*
.32
AN
.22
-
.71**
.69**
-.65**
-.65**
.02
.66**
.43*
.71**
-
.80**
-.48*
-.40*
.01
.65**
M
.39*
.34
.69**
.80**
-
-.58**
-.43*
.09
.91**
-.31
-.34
-.65**
-.48*
-.58**
-
.74**
-.12
-.67**
ED
.22
-.25
-.22
-.65**
-.40*
-.43*
.74**
-
.05
-.52*
3.02
.09
.47*
.016
.01
.087
-.12
.05
-
.11
.25
.32
.66**
.65**
.91**
-.67**
-.52*
.11
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9.30
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*p < .05. ** p < .01.
7
3.54
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9. Attendance
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Predictor Variable
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Variable
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Means, Standard Deviations, and Interrcorrelations for Number of Aggressive Episodes and
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ACCEPTED MANUSCRIPT CORRELATES OF AGGRESSION Highlights
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This study utilized archival data to examine the relationship between behavioral variables and aggression over a 24-month period among 23 severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects). Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. These data provide valuable information regarding aggressive tendencies that can inform treatment planning.
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Colorado Mental Health Institute at Pueblo 1600 W 24th Street Pueblo, CO 81003
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