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An acceptance and commitment therapy based protocol for the management of acute self-harm and violence in severe mental illness

DOI:10.1017/S1742646412000258
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Russell Razzaque at North East London NHS Foundation Trust
Russell Razzaque
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Abstract

Though only engaged in by a minority of sufferers, self-harm and violence can nevertheless occur within the context of a variety of mental illnesses, from personality disorder to affective disorders, to schizophrenia and other psychoses. Violence to the self (both with and without suicidal intent) and others are not uncommon occurrences on psychiatric wards. This paper explores the utilisation of a new mindfulness centred therapeutic protocol based on acceptance and commitment therapy for the management of self-harm and violence. The protocol was piloted on three patients with a history of high levels of violence to self or others on a psychiatric intensive care unit in London. An outline of acceptance and commitment therapy is provided, together with a detailed description of the protocol for the intervention itself, and some of the outcomes achieved. Recommendations for further adaptations, studies and clinical trials are considered.
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Original Research Article
An acceptance and commitment therapy based protocol for
the management of acute self-harm and violence in severe
mental illness
Russell Razzaque
Consultant Psychiatrist, North East London NHS Foundation Trust, UK
Abstract
Though only engaged in by a minority of sufferers, self-harm and violence can nevertheless occur
within the context of a variety of mental illnesses, from personality disorder to affective disorders, to
schizophrenia and other psychoses. Violence to the self (both with and without suicidal intent) and
others are not uncommon occurrences on psychiatric wards. This paper explores the utilisation of a new
mindfulness centred therapeutic protocol based on acceptance and commitment therapy for the
management of self-harm and violence. The protocol was piloted on three patients with a history of high
levels of violence to self or others on a psychiatric intensive care unit in London. An outline of acceptance
and commitment therapy is provided, together with a detailed description of the protocol for the
intervention itself, and some of the outcomes achieved. Recommendations for further adaptations, studies
and clinical trials are considered.
Keywords
Self-harm; violence; acceptance and commitment therapy; severe mental illness; mindfulness
BACKGROUND
Self-harm among sufferers of severe mental
illness in the acute setting has consequences that
are both immediate and long term. According
to a recent report from the National Institute
for Clinical Excellence on self-harm, 1.8% of
those who commit self-harm manage to commit
suicide the same year and 8.5% will die by
suicide over a 22 year period (NICE, 2011).
Violence and aggression are also of significant
concern, particularly on psychiatric wards,
where 58% of violent attacks are found to be
serious and 78% are directed towards nursing
staff (Owen et al. 1998). Additional evidence
also points to a particular subset of individuals
perpetrating this violence. It tends to be young
males with a history of violence (El-Badri &
Mellsop, 2006) and it also tends to be the same
people (Lussier et al. 2009).
Third wave therapies
The so called ‘third wave’ of cognitive beha-
viour therapies is a relatively new area in the
field of mental health. They are said to include
dialectic behaviour therapy (DBT), mindfulness
based cognitive behaviour therapy (MCBT) and
acceptance and commitment therapy (ACT).
Correspondence to: Dr Russell Razzaque, Picasso Ward, Psychiatric
Intensive Care Unit, North East London NHS Foundation Trust, UK.
E-mail: russell.razzaque@nelft.nhs.uk
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Journal of Psychiatric
Intensive Care Journal of Psychiatric Intensive Care
Vol.00 No.0:1–5
doi:10.1017/S1742646412000258
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One of the common themes between them is
the utilisation of mindfulness based practises for
mental health problems (Baer, 2003). Such
interventions have started to show positive
results in the treatment of a variety of disorders
(Baer, 2005), and are now also incorporated into
NICE guidelines for treatments of these dis-
orders. DBT has already demonstrated consid-
erable success in dealing with both non suicidal
self-harm (Muehlenkamp, 2006), suicidal beha-
viours (Linehan et al. 2006) and violence
(Fruzzetti & Levensky, 2000).
One mechanism via which mindfulness based
techniques are postulated to have an impact
on such behaviours is through a reduction in
experiential avoidance (Chapman et al. 2006).
Experiential avoidance is a key construct in
ACT, and it is defined as the attempt to alter the
form, frequency, or situational sensitivity of
negative private events (e.g. thoughts, feelings,
and physiological sensations). An experiential
avoidance model of violence and self-harm
postulates that such acts are, in fact, attempts to
avoid experiences such as thoughts, feelings,
somatic sensations or other internal experiences
that are uncomfortable or distressing (Chapman
et al. 2006). A reduction in experiential avoidance
is therefore the fundamental goal of ACT.
An intervention, therefore, that focuses on a
reduction in such experiential avoidance, may
well have an impact on propensity towards self-
harm, violence and aggression in sufferers of
severe mental illness.
ACCEPTANCE AND COMMITMENT
THERAPY
According to the Association for Contextual
Behavioural Science (the professional organisa-
tion for acceptance and commitment therapy)
‘ACT illuminates the ways that language
entangles clients into futile attempts to wage
war against their own inner lives. Through
metaphor, paradox, and experiential exercises
clients learn how to make healthy contact with
thoughts, feelings, memories, and physical
sensations that have been feared and avoided.’
(Hayes, 2005). The theoretical framework that
underpins ACT is known as relational frame
theory (RFT). RFT posits that humans possess
an ability that is unique to our species; namely
the deployment of sophisticated language. We
do so by forming what are known as bidirec-
tional associations between words and their
meanings so that, over time, both a word and its
meaning will start to fuse. We also develop
complex and deep associations between differ-
ent words and concepts, ultimately forming
whole networks of such associations within our
minds, which we may trigger at any time, in
response to interactions with the environment,
so taking us out of the present moment. As a
result, we are particularly creative as a species,
but this also makes us vulnerable to emotional
distress due to the constant inner chatter that
such a continual process involves. In addition,
our tendency to then attempt to ‘fix’ this
distress, as we would any external problem,
leads us to devise methods of avoidance of that
emotional distress (experiential avoidance)
which, in the emotional terrain, only serves to
exacerbate the problem. This ultimately makes
us vulnerable to psychopathology (Fledderus
et al. 2010).
ACT’s techniques involve intentionally bring-
ing one’s attention to the internal and external
experiences occurring in the present moment.
Such interventions have been shown to be of
considerable value in a number of disorders,
including for psychosis in an acute ward setting
(Bach & Hayes, 2002).
A core technique within the ACT treatment
approach is cognitive defusion. Cognitive defu-
sion is defined in the ACT Skills Training Manual
for Therapists (Luoma et al. 2007) as follows:
‘ACT argues that the problem with human
suffering as it relates to thoughts, is not that we
have the wrong thoughts, but rather that we
spend too much time ‘in’ them or ‘looking
from’ them rather than simply looking at them
or observing them. Cognitive defusion attempts
to circumvent this problem by drawing the
client’s attention to thinking as an ongoing
behavioural process and helping clients to see
thoughts as thoughts, so those thoughts can be
responded to in terms of their workability,
rather than their literal truth.’
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PROTOCOL
The intervention was delivered to three patients
on Picasso Ward (the psychiatric intensive care
unit of Goodmayes Hospital in East London)
all of whom had a lengthy history of regular
bouts of violence towards themselves or others.
One had a primary diagnosis of schizoaffective
disorder, with frequent admissions (an average of
two to three per year) for psychotic relapses
involving significant self-harm including suicidal
intent. The other two had bipolar affective
disorder, with presentations including frequent
bouts of violence toward family members, carers
and ward staff.
The intervention was commenced with the
schizoaffective patient once his risk of imminent
self-harm had reduced. He was no longer
actively responding to auditory hallucinations
but continued to report them regularly with
consequent thoughts of self-harm. Similarly, in
the case of the two patients diagnosed with
bipolar affective disorder, their imminent risks
of violence had reduced before commencing the
therapy, but they continued to display aggressive
and abusive behaviour toward staff and/or
family members.
The treatment consisted of daily 20 minute
one to one sessions, provided over a period of
two to three weeks.
Phase one
Each session starts with a specific defusion
exercise in which the patient is asked to bring
a difficult (particularly emotive) thought or
feeling to mind and, instead of ruminating on
or turning them over, just to hold them and
notice how their bodies react to this for a few
moments. This is followed by a wider cognitive
defusion exercise, in the form of metaphor
based guided meditation. The script for this
rotates each day between 20 available scripts;
each script is based on the idea of watching
thoughts and feelings as the observer and
container of them, rather than going into their
content. The different metaphors used included
concepts such as fish in the sea; where each
thought or feeling is like a fish swimming in the
sea and the person is the sea itself. Other
metaphors included people in a busy office block
where, again, the thoughts and feelings are the
different people doing different jobs in the
building and the person experiencing them is
the building (the context) itself.
‘Self as context’ is an important concept in
ACT treatment (Luoma et al. 2007). It is seen as
a dimension of the self (the observer self) that is
an alternative to the self that is embroiled in and
fused to the world of thinking and doing,
known as ‘self as content’. Practicing experien-
cing one’s self from this perspective is a key
objective of each cognitive defusion exercise.
Phase two
The next phase is an exercise in the contempla-
tion of values (another core process in the ACT
schema; Luoma et al. 2007) via visual cues. Here,
the patient is asked to read to themselves a values
statement they prepared earlier in an introduc-
tory session, which lists their key life values in
terms of what kind of person they would like to
be in the areas of life most important to them
(e.g. a loving partner, a dedicated student). The
list is normally written within an outline drawing
of a person. They are asked to read through the
list, and then look upon the figure in soft focus as
if it were a mirror or photo in which they could
see themselves.
Phase three
Each session then finishes with a few minutes
of discussion around the patient’s experience of
the exercises. The clinician always guides the
discussion towards a highlighting of the experi-
ence of the thoughts and feelings within the
body during the exercise, rather than the
content of the thoughts themselves. This way,
through sharing of multiple examples, they will
learn to mindfully notice their thoughts and
feelings more, and become entangled in their
content less.
At every stage, the clinician engages in each
of the exercises together with the patient,
making it a collaborative exercise in personal
growth for them both.
An ACT-based protocol for the management of self-harm and violence
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Outcomes
Levels of aggressive and abusive behaviour
were determined for each patient based on
regular nursing shift reports, describing their
behaviour over the course of the day. Changes
in the levels of such behaviours were noted,
as were changes in expression of self-harm
or suicidal ideation as noted after interviews or
ward reviews.
In the patients with a diagnosis of bipolar
disorder, a clear reduction in aggressive and
abusive behaviour was observed during the
treatment period, and each developed an
increasing confidence in their ability to manage
such impulses in future. The Clinical Global
Index (CGI) is a rating scale that is routinely
used to determine clinical progress of patients
on the ward and, in each case, a consistent
reduction in severity of illness scores was
observed during the period of treatment.
Behaviours of an abusive and aggressive nature
towards staff were regularly reported for one
patient prior to commencement of therapy
and, during treatment, such outbursts consis-
tently reduced. At the end of the treatment,
reports of aggressive and abusive outbursts had
ceased entirely.
The patient with a diagnosis of schizoaffective
disorder experienced a mark reduction in self-
harm and suicidal ideation as well as a reduction
in derogatory auditory hallucinations. He too
showed a consistent reduction in severity of
illness CGI scores during the period of treat-
ment, and he also reported a more positive
mood and self esteem during formal ward
reviews.
The patient feedback regarding the interven-
tion was universally positive, with each feeling
that the ACT sessions contributed significantly
to a reduction in their impulsive and violent
behaviours. At the end of each course of
treatment, the patient asked for information
about the exercises so that continued mindfulness
practice might be facilitated in the community
after discharge. This was then provided in the
form of a print out describing self directing
exercises along the same lines.
DISCUSSION
Thereisaclearevidencebasefortheefficacy
of mindfulness based treatments across various
psychopathologies and there is some indication
that this may also translate to the use of treatments
such as ACT for the management of acute self-
harm or violence. This initial experience of
utilising ACT based treatments on a psychiatric
intensive care unit has produced some positive
results. The study, however, was not a controlled
one and each patient undergoing the intervention
was also subject to treatment as usual (i.e. standard
pharmacological therapies as appropriate to their
condition) which would also have an effect on
levels of aggressive and abusive behaviours and
self-harm ideation. More study is, therefore,
required to further verify the effect of such
interventions with controlled trials across wider
samples using validated outcome measures.
Currently under development is a group-based
intervention, based on this protocol, which is
designed to facilitate daily mindfulness practice for
both staff and patients together on psychiatric
wards, entitled Integrated Mutual Participation
Acceptance & Commitment Therapy (IMPACT)
groups. A study to examine more global change,
with outcome measures including use of PRN
medication, use of restraint, Clinical Global Index
(CGI)scoresandlengthsofstayiscurrently
underway. This is a historically controlled trial
and was launched in late 2011.
As data accumulates on the efficacy of such
measures, implementation of similar protocols,
in either a one to one or group setting, may
become a viable treatment option across PICUs
and forensic units for the management of self-
harm or violent behaviour. It will require
engagement and cooperation from the patient
and so will not have universal applicability, but
where patients are amenable, such interventions
may serve as a useful additional medium term
tool at the disposal of clinicians.
References
Bach, P. and Hayes, S.C. (2002) The use of Acceptance and
Commitment Therapy to prevent the rehospitalization of
psychotic patients: a randomized controlled trial. Journal of
Consulting and Clinical Psychology. 70(5): 1129–1139.
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Baer, R. (2005) Mindfulness-Based Treatment Approaches:
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Academic Press.
Chapman, A., Gratz, K. and Broan, M. (2006) Solving the
puzzle of deliberate self-harm: the experiential avoidance
model. Behavior Research and Therapy. 44(3): 371–394.
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... Harvey, Henrickson, Bimler, and Dickson (2017) Overall, these studies suggested that ACT interventions offer a promising approach to addressing aggressive behavior (Donahue et al., 2017;Harvey et al., 2017;Razzaque, 2012) and its occurrence in intimate partner relationships (Berta & Zarling, In Press ;Zarling et al., 2015;Zarling et al., 2017a;Zarling & Berta, 2017b). ...
... Scholars have examined the impact of ACT on anger and aggression. ACT appears to decrease engagement in aggressive behavior (Donahue et al., 2017;Harvey et al., 2017;Razzaque, 2012) and intimate partner violence (Zarling et al., 2015;Zarling et al., 2017a;Zarling & Berta, 2017b;Berta & Zarling, In Press). ...
... easure compared to TAU at posttreatment (η2=0.54, p=0.02) and at three month follow up (η2=0.73, p=0.02). No other differences were obtained. Scholars suggested that changes in values consistency, rather than psychological inflexibility, may have been reflective of greater focus on values over the course of the intervention(Eisenbeck et al., 2017).Razzaque (2012) studied the effectiveness of an ACT intervention on three patients in a British psychiatric intensive care unit using a case study design. The intervention included defusion, self as context, values, and mindfulness delivered via 20-minute daily sessions over the course of two to three weeks. Participants had lengthy histories of self-h ...
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A growing body of literature has begun to examine anger, hostility, and aggression using the psychological flexibility model among both youth and adults. This manuscript provides the first overview of this research. Papers were included in this review if they were published in English, peer-reviewed, published throughDecember 8th 2017 on PsycInfo and PubMed, or were recommended during the review process. The research reviewed examines anger, hostility, and aggression in a variety of contexts, such as interpersonal difficulties, emotional difficulties (e.g., depression, posttraumatic stress disorder), impulse control, and externalizing. The article also reviews Acceptance and Commitment Therapy-based interventions targeting problems related to anger and aggression. Generally, there is support for the psychological flexibility model in this domain and treatment studies have been demonstrated a beneficial impact of ACT on aggression and domestic violence in adults. The literature in youth is extremely limited, although some supportive findings were demonstrated. More extensive and methodologically stronger examinations would strengthen this area of study and are discussed.
... Five distinct interventions were delivered by professionals that had specific qualifications to treat patients. Three of these were different forms of psychotherapy: animal assisted psychotherapy [30], acceptance and commitment therapy [31] and narrative group therapy [32]. Two interventions were similar to the psychotherapies in that the people delivering them had specific training, but they were not forms of psychotherapy. ...
... The designs varied greatly, ranging from RCTs [30,34], to a cluster-level controlled pre-post study [31] and case series [32,33]. ...
... The design of the study assessing the group narrative therapy intervention [32] makes drawing conclusions difficult, as only aggregate ward-level data that was routinely collected at admission and discharge is available from all patients, and it is not known whether they attended the group or not. However the wards on which narrative group therapy was offered showed a significant improvement in symptom scores compared to the control wards, suggesting the intervention may have provided some benefits. ...
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Abstract Background Observational research has found that involuntary treatment provides limited benefits in terms of long-term clinical outcomes. Our aim was to review literature on existing interventions in order to identify helpful approaches to improve outcomes of involuntary treatment. Methods This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement guidelines. Seven databases (AMED, PsycINFO, Embase Classic, Embase 1974–2017, CINAHL, MEDLINE, and BNI) were searched and the results were analysed in a narrative synthesis. Results Nineteen papers describing fourteen different interventions were included. Using narrative synthesis the interventions were summarised into three categories: a) structured patient-centred care planning; b) specialist therapeutic interventions; c) systemic changes to hospital practice. The methodologies used and outcomes assessed were heterogeneous. Most studies were of low quality, although five interventions were tested in randomised controlled trials (RCTs). Preliminary evidence supports structured patient-centred care planning interventions have an effect on long-term outcomes (such as readmission), and that specialist therapeutic interventions and systemic changes to hospital practice have an effect on reducing the use of coercive measures on wards. Conclusions This review shows that it is possible to conduct rigorous intervention-testing studies in involuntary patients, including RCTs. Yet, the overall evidence is limited. Structured patient-centred care planning interventions show promise for the improvement of long-term outcomes and should be further evaluated.
... The authors of this trial concluded that ACT may help reduce the intensity and frequency of SI due to increases in acceptance, valued action and a reduction in risk factors such as hopelessness and psychological pain [36]. The two casestudies measured and reported a reduction in both SI and DSH [44,45]. ...
... Walser et al [32] reported a 32% reduction in depression scores for the cohort of veterans that recorded SI at baseline. This study also reported a 40% [44,45]. Both studies report impressive reductions in SI for all five individuals studied; however the studies had many limitations, including lack of specificity around how SI and self-harm reports were measured (apart from hospital ward reports). ...
... Tighe et al's [27] trial showed significant reductions for depression and distress on standardised measures and a 30% reduction in SI scores (although this was non-significant between groups). All five participants whose case studies were presented improved significantly with marked reductions in SI/DSH [44,45]. In addition to the significant results for SI in the two pre-post studies, both of these studies showed improvements on the AAQ, a measure of psychological flexibility [32,36]. ...
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Background: Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH). Objective: The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT. Methods: We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes. Results: After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre-post studies, and 1 mHealth randomized controlled trial. Conclusions: The review found that ACT is effective in reducing SI in the 2 pre-post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH.
... It trains the person not to ponder or overthink it. They understand the thought, accept it, and move on in the present moment [76]. They make a commitment to focus on the future at hand and not let their thoughts hold them down. ...
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... Beyond those included in this study, this may include the ASI-3-SCC (Smith et al., 2020), Suicide Cognitions Scale (Ellis & Rufino, 2015), or Suicide Rumination Scale (Rogers, Law et al., 2021). Psychological inflexibility is a target of interventions like Acceptance and Commitment Therapy (ACT; Hayes et al., 2012), which has shown promise as a treatment for depression, and subsequently SI (Ducasse et al., 2014;Kumpula et al., 2019;Razzaque, 2013;Walser et al., 2015;Zettle, 2007). Pertinent to the present investigation, two of these studies provided evidence, albeit without establishing causality via mediation, that reductions in psychological inflexibility broadly are associated with reductions in suicidality (Ducasse et al., 2014;Walser et al., 2015). ...
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... There are over 75 randomized controlled trials (RCTs) and ACT is recognized as empirically supported by the American Psychological Association, Division 12 and the Substance Abuse and Mental Health Services Administration (APA, 2012;SAMHSA, 2012). Although there are no published data with suicidal behaviors specifically, there is strong evidence supporting ACT for depression (Ruiz, 2012), and preliminary evidence demonstrating some success with self-harm (Gratz & Gunderson, 2006;Razzaque, 2013). This model is flexible in addressing multiple age groups, and similar interventions have been adapted for the treatment of children, adolescents, and parents (Coyne & Murrell, 2009;Greco & Hayes, 2008, Murrell, Coyne, & Wilson, 2004. ...
... There currently exists a clear evidence base for the efficacy of mindfulness based treatments across various psychopathologies, as well as an apparent indication that this may also translate into the use of mindfulness-based therapy for management of acute self-harm (Luoma & Villatte, 2012;Razzaque, 2013). Research suggests that mindfulness underpinnings may prove to be the principal component of future therapies for selfinjury (Martin, 2010) and that when incorporated with other therapies such as, dialectical behaviour therapy, trials of this therapy show significant reductions in the repetition of self-harming behaviour (Verheul et al., 2003). ...
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Article
  • Feb 2021
Objectives ACT for Life was developed to guide the application of Acceptance and Commitment Therapy (ACT) to maximize recovery from suicidal crises. The current study tested the acceptability of ACT for Life and evaluated the feasibility of the research design for a future efficacy trial. Method Seventy veterans were randomized to treatment as usual (TAU) or ACT for Life plus TAU. Participants were assessed at baseline, post-treatment, and one- and three-months post enrollment. Results The mean Client Satisfaction Questionnaire-8 score was 29.1 (SD = 4.2; 95% CI: 27.6, 30.8). Qualitative data further supported acceptability. Feasibility was demonstrated by 74.3% of participants completing the treatment per protocol and clinicians delivering the treatment with 95% fidelity. Preliminary data suggest that ACT for Life may improve recovery following suicidal crises. Conclusions ACT for Life was highly acceptable and feasible. Future research is warranted to establish the efficacy of ACT for Life.
Chronic Violent Patients in an Inpatient Psychiatric Hospital
Article
Full-text available
This study examines the prevalence and the individual characteristics of chronically violent patients (CVPs) in a psychiatric hospital during inpatient treatment. The study is based on a 1-year follow-up investigation of all violent episodes committed by a sample of 527 patients in a forensic psychiatric hospital in British Columbia, Canada. Sociodemographic, legal and criminological, historical, and clinical factors were analyzed using a risk assessment scheme. Approximately 10% of the sample was responsible for more than 60% for all violent episodes recorded during the study period. Those CVPs were characterized by historical, but mostly clinical, risk factors. Moderate to good predictive accuracy was achieved when defining CVPs as individuals who perpetrated 15 or more violent episodes. Important limitations of the actuarial approach were also highlighted by the presence of two qualitatively different groups of CVPs. The results are discussed in light of the scientific literature on the risk management of inpatient violence.
Aggressive behaviour in an acute general adult psychiatric unit
Article
Full-text available
Aims and Method The study aimed to identify the correlates of aggressive behaviour in an adult acute psychiatric ward. Over a period of 9 months, all incidents of verbal and physical aggressive behaviour exhibited by in-patients were routinely assessed using the Overt Aggression Scale. Results Of the 535 patients admitted during the study period, 80 (15%) were involved in a total of 124 aggressive incidents. Of these 80, 44 (55%) had a history of previous violence and 54 (68%) had a history of substance misuse. The majority of events occurred early in the hospital stay and in most cases aggression was against staff. There were significant differences between aggressive and non-aggressive patients in terms of gender and ethnicity, with the lowest rate occurring in European females. Clinical Implications These results reinforce clinical impressions, and empirical evidence, and allow risk assessment to be performed with greater confidence. The relevance of ethnicity (or more likely culture) highlights the difficulties of a ‘one size fits all’ approach to risk assessment.
Dialectical behavior therapy for domestic violence: Rationale and procedures
Article
Full-text available
Domestic violence is a significant social problem with significant psychological and medical consequences for its victims and their children. In part because treatments for domestic violence are often not effective, and in part because of the hypothesized similarities between the problems of chronically aggressive men and chronically suicidal women (e.g., emotion dysregulation), a rationale for applying Dialectical Behavior Therapy (DBT) to domestic violence is provided. This new application of DBT, designed to treat aggression and violence in families, is described. Aggression assessment procedures and conceptualization issues are presented, along with a case to illustrate treatment principles and intervention strategies. Typically targeting men who batter their partners, this new application includes the four essential functions of DBT, including attending to client motivation, skill acquisition, skill generalization, and team/therapist consultation. In addition, a number of new treatment developments are presented to target reducing and eliminating aggression: validation and empathy skill training; a focus on reconditioning anger responses to be more normative (including identifying alternative emotions and their associated effective coping responses); skills training on accurate interpersonal emotional expression; and understanding the functions of aggression and teaching skills in how formerly aggressive partners can get relationship and self-management needs met skillfully. A brief overview of the other strategies and components of DBT, and how they are applied to treating domestic violence, is also provided. Particular attention is devoted to therapists maintaining a nonjudgmental stance by utilizing mindfulness practice and team consultation.
Violence and Aggression in Psychiatric Units
Article
Full-text available
  • Dec 1998
To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored. Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values. A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence. Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.
The use of Acceptance and Commitment Therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial
Article
Full-text available
  • Nov 2002
The present study examined the impact of a brief version of an acceptance-based treatment (acceptance and commitment therapy; ACT) that teaches patients to accept unavoidable private events; to identify and focus on actions directed toward valued goals; and to defuse from odd cognition, just noticing thoughts rather than treating them as either true or false. Eighty inpatient participants with positive psychotic symptoms were randomly assigned to treatment as usual (TAU) or to 4 sessions of ACT plus TAU. ACT participants showed significantly higher symptom reporting and lower symptom believability and a rate of rehospitalization half that of TAU participants over a 4-month follow-up period. The same basic pattern of results was seen with all participant subgroups except delusional participants who denied symptoms.
Empirically Supported Treatments and General Therapy Guidelines for Non-Suicidal Self-Injury
Article
  • Apr 2006
Mental health counselors are facing increased demand to treat both adolescents and adults who present with repetitive non-suicidal self-injurious behaviors, yet there are few empirically supported treatments or general treatment guidelines available. I will review the research on problem-solving and dialectical behavior therapy, two cognitive-behavioral treatments that have the most empirical support for reducing self-injurious behavior. I conclude by providing specific treatment recommendations drawn from the literature that can be of use to mental health counselors working with individuals who self-injure.
Mindfulness-Based Treatment Approaches: Clinician's Guide to Evidence Base and Applications
Book
  • Jan 2006
This edited volume provides chapters on the leading evidence-based mindfulness interventions as of 2006: mindfulness-based stress reduction, mindfulness-based cognitive therapy, dialectical behavior therapy, and acceptance and commitment therapy. Applications for clinical, medical, and nonclinical but stressed populations, as well as children, adolescents, and older adults, are described. Each chapter includes a detailed case study illustrating how the intervention is implemented, conceptual background, empirical support, and a discussion of practical issues that clinicians wishing to use these treatments must consider. A second edition (2014) focusing on MBSR, MBCT, and related treatment programs is also available.
Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical Review
Article
Interventions based on training in mindfulness skills are becoming increasingly popular. Mindfulness involves intentionally bringing one's attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises. This review summarizes conceptual approaches to mind-fulness and empirical research on the utility of mindfulness-based interventions. Meta-analytic techniques were incorporated to facilitate quantification of findings and comparison across studies. Although the current empirical literature includes many methodological flaws, findings suggest that mindfulness-based interventions may be helpful in the treatment of several disorders. Methodologically sound investigations are recommended in order to clarify the utility of these interventions.
Does Experiential Avoidance Mediate the Effects of Maladaptive Coping Styles on Psychopathology and Mental Health?
Article
  • Nov 2010
Experiential avoidance (EA) is considered a risk factor for psychopathology.This study explores whether EA mediates the relationship between maladaptive coping styles (palliative, avoidance, and passive coping) and psychopathology and positive mental health. A total of 93 adults with mild to moderate psychological distress completed measures assessing coping styles, psychopathology (depression, anxiety, and alcohol use), and mental health (emotional, psychological, and social well-being). Results showed that EA mediated the effects of passive coping on both increased anxiety and depression and decreased emotional and psychological well-being. These results suggest that a person who is prone to use EA or has learned EA in stressful situations has a higher risk of developing psychopathology and lower mental health.This indicates that early interventions that aim at people with high levels of EA are highly relevant.
Solving the puzzle of deliberate self-harm: The Experiential Avoidance Model
Article
Despite increasing attention to the phenomenon of deliberate self-harm (DSH), the literature currently lacks a unifying, evidence-based, theoretical framework within which to understand the factors that control this behavior. The purpose of the present paper is to outline such a framework-the Experiential Avoidance Model (EAM) of DSH. The EAM poses that DSH is primarily maintained by negative reinforcement in the form of escape from, or avoidance of, unwanted emotional experiences. Literature on factors that may lead to experiential avoidance is reviewed, along with the mounting empirical evidence that DSH functions to help the individual escape from unwanted emotional experiences. The EAM integrates a variety of research on emotions, experiential avoidance, and DSH within a clinically useful framework that sparks novel research directions.