A functional analysis of psychiatric inpatient aggression

Michael Daffern BSc(Psych) MPsych(Clin)

School of Psychology
The University of South Australia

Submitted in fulfilment of the requirements of the degree of Doctor of Philosophy

June 2004
 Table of Contents
Page
List of Figures iv
List of Tables v
Abstract vii
Notes on the Literature Review and Studies Reported in the Thesis ix
Appendices x
Candidate’s Declaration xi
Acknowledgements xii
CHAPTER 1: INTRODUCTION 1
1.0 A Review of Structural and Functional Assessment Approaches 1
1.1 The Assessment of Inpatient Aggression 5
1.2 Structural Approaches: Intrapersonal Factors 5
1.2.1 Hallucinations 6
1.2.2 Delusions 8
1.2.3 Formal Thought Disorder 9
1.2.4 Negative Symptoms 9
1.2.5 Substance Use 9
1.2.6 Physiological Arousal 10
1.2.7 Summary 10
1.3 Structural Approaches: Environmental Factors 11
1.3.1 Staff Factors 11
1.3.2 Ward Structure and Routine 13
1.3.3 Summary 15
1.4 Functional Approaches to Inpatient Aggression 15
1.4.1 Community Studies Examining Motives and Functions 17
1.4.2 Antecedents to Inpatient Aggression 18
1.4.3 Consequences for Inpatient Aggression 18
1.4.4 Summary 19
1.5 Conclusion and Recommendations for Future Research 20
CHAPTER 2: INITIAL STUDIES 24
2.0 A Preliminary Investigation into Patterns of Aggression in the Thomas Embling
Hospital 24
2.1 Aggression in Forensic Psychiatric Hospitals 24
2.2 Australian Research 25

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 Table of Contents (continued)
Page
2.3 Method 25
2.3.1 Procedure 26
2.4 Results 27
2.5 Discussion 30
3.0 A Prospective Assessment of Aggression within the Thomas Embling Hospital 34
3.1 Method 35
3.1.1 Setting 35
3.1.2 Procedure 35
3.2 Results 36
3.3 Discussion 41
4.0 Environmental Contributors to Aggression within the Thomas Embling Hospital 44
4.1 Method 44
4.1.2 Setting 44
4.1.3 Procedure 47
4.2 Results 47
4.3 Discussion 51
CHAPTER 3: A METHODOLOGICAL FRAMEWORK FOR THE STUDY OF
INPATIENT AGGRESSION 54
5.0 An introduction to functional analysis 54
5.1 How Might a Functional Analysis of Aggression be Used on a Psychiatric Ward? 55
5.2 Developing a System for Identifying the Purposes of Inpatient Aggression 60
5.3 Towards a Functional Analysis of Psychiatric Inpatient Aggression 62
5.4 Assessment of Predisposing Characteristics Related to Aggression in Psychiatric
Patients 64
5.5 Proximal Antecedents and Consequences: The Assessment of Purpose 65
5.6 Anger Mediated and Instrumental Aggression 66
5.7 An Assessment and Classification System Based Upon the Identification of
Purpose 68
5.8 Assessing Purpose 72
5.9 Accuracy and Reliability of the ‘Assessment and Classification of Purpose’
System: A Pilot Study 73
CHAPTER 4: MAIN STUDY 75
6.0 Method 75

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 Table of Contents (continued)
Page
6.0.1 Setting 75
6.0.2 Procedure 76
6.1 STAGE 1: The Assessment of Characteristics Predisposing Inpatients to
Aggressive Behaviour 76
6.2 STAGE 2: The Assessment of Purpose Through Examination of Proximal
Antecedents and Consequences 80
6.3 Hypotheses 82
7.0 Results 82
7.1 Admissions, Legal Status and Predisposing Characteristics 83
7.2 The Nature and Frequency of Aggression Within the Thomas Embling Hospital 90
7.3 Characteristics of Aggressive and Non-aggressive Patients 101
7.4 The Purpose of Aggression 107
8.0 Discussion 122
8.1 The Nature and Frequency of Aggression Within the Thomas Embling
Hospital 122
8.2 Characteristics of Aggressive and Non-aggressive Patients 128
8.3 The Purpose of Aggression 136
8.3.1 The Relationship Between Purpose and Patient’s Predisposing
Characteristics 140
8.4 Implications for the Prevention and Management of Inpatient Aggression 142
8.4.1 Individual Treatment 142
8.4.2 Interventions for Staff 145
8.4.3 Risk Assessment 146
8.5 Limitations of the Study 147
8.6 Implications for Future Research 150
CHAPTER 5: CONCLUSION 152
REFERENCES 155
APPENDICES 169

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 List of Figures
Page
Figure 1 Type of aggression and victim classification by ward 28
Figure 2 Verbal and physical aggression by ward and victim 37
Figure 3 Verbal and physical aggression by victim 39
Figure 4 Aggression by month and victim 40
Figure 5 Frequency of aggression by time and hospital 51
Figure 6: Schematic representation of the pathways to violence in the mentally
ill patient 63
Figure 7 The relationship between cumulative survival and aggression 92
Figure 8 Time of the day by frequency of aggressive behaviour 93
Figure 9 Type of aggression by location 96
Figure 10 Verbal and physical aggression towards staff and patients by location 97
Figure 11 Severity of verbal and physical aggression towards staff and patients 98
Figure 12 Frequency of aggressive behaviours by month 99
Figure 13 Frequency of aggressive behaviours by victim type and day of the week 100

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 List of Tables
Page
Table 1 Severity of Aggression 29
Table 2 Number of Aggressive Behaviours by Ward 37
Table 3 Frequency of Aggressive Incidents by Type and Location 48
Table 4 Rate of Aggression per Patient (Adjusted for Occupancy Rate and
Available Beds) per Annum by Type and Location 49
Table 5 Number of Substances Used by Patients in the Year Prior to Assessment
and Across the Lifetime 85
Table 6 Violence Rating of Index Offence 86
Table 7 Violence Rating for Previous Record 86
Table 8a Correlations Between Predisposing Characteristics 88
Table 8b Correlations Between Predisposing Characteristics 89
Table 9 Number of Aggressive Behaviours Recorded by Patients Across
the Hospital 90
Table 10 Number of Days Between Admission and First Aggressive Behaviour 91
Table 11 Frequency of Aggression by Type and Location 101
Table 12 Aggressive and Non-aggressive Patient Characteristics 102
Table 13 The Relationship Between Predisposing Characteristics and the Number
of Aggressive Behaviours 106
Table 14 The Relationship Between Predisposing Characteristics and the Number
of Aggressive Behaviours Using a Stepwise Multiple Regression 107
Table 15 The Relationship Between Selected Predisposing Characteristics and the
Number of Aggressive Behaviours 107
Table 16 Percentage of Aggressive Behaviours Towards Staff and Patients in
which each Purpose was Evident 108
Table 17 Percentage of Verbally and Physically Aggressive Behaviours in which
each Purpose was Evident 108
Table 18 Frequency of Aggressive Behaviours Precipitated by a Demand for
Activity by Victim and Aggression Type 109
Table 19 Frequency of Aggressive Behaviours Precipitated by the Denial of a
Request by Victim and Aggression Type 110
Table 20 Frequency of Aggressive Behaviours Precipitated by Provocation by
Victim and Aggression Type 110

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 List of Tables (continued)
Page
Table 21 Frequency of Aggressive Behaviours Precipitated by Frustration by
Victim and aggression type 111
Table 22 Frequency of Aggressive Behaviours Perpetrated for Instrumental
Purposes by Victim and Aggression Type 112
Table 23 Frequency of Aggressive Behaviours Perpetrated to Reduce Social
Distance by Victim and Aggression Type 112
Table 24 Frequency of Aggressive Behaviours Perpetrated to Enhance Status or
Social Approval by Victim and Aggression Type 113
Table 25 Frequency of Aggressive Behaviours that Followed Instruction by
Victim and Aggression Type 114
Table 26 Frequency of Aggressive Behaviours Perpetrated to Observe Suffering
by Victim and Aggression Type 114
Table 27 Total Types of Purposes 119
Table 28 Frequency of Patients by Victim Type 120
Table 29 Frequency of Patients by Aggression Type 120
Table 30 Frequency of Patients by Total Types of Victim Genders 121
Table 31 Correlations Between Outcome Variables 121
Table 32 Correlations Between Patient’s Predisposing Characteristics and
Outcome Variables 122
Table 33 Intervention Strategies Indicated by Purpose 143

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 Abstract
Aggression occurs frequently on many psychiatric wards; its assessment and
management are crucial components of inpatient care. Consequences to inpatient aggression
are profound, impacting on staff and patients, ward milieu and regime, and mental health
services in general. Despite considerable research, which has primarily focussed on the
assessment of demographic and clinical characteristics of aggressive patients, the nature of the
relationship between mental illness, inpatient treatment and aggression remains unclear.
Inconsistent risk assessment practices, management strategies and treatment plans, often
derived from idiosyncratic beliefs about the causes of aggression, follow.
Approaches to the assessment of inpatient aggression have been categorised as
structural, which emphasise form, or functional, which emphasise purpose. Studies of
inpatient aggression have primarily utilized a structural approach. These studies have resulted
in the identification of demographic, clinical and situational characteristics of high-risk
patients and environments. Resource allocation and actuarial assessments of risk have been
assisted by this research. Conversely, functional assessment approaches seek to clarify the
factors responsible for the development, expression and maintenance of inpatient aggression
by examining predisposing characteristics, in addition to the proximal antecedents and
consequences of aggressive behaviours. While functional analysis has demonstrated efficacy
in assessing and prescribing interventions for other problem behaviours, and has been
regarded a legitimate assessment approach for anger management problems, psychiatric
inpatient aggression has been relatively neglected by functional analysis.
Against this background, four studies focussing on the assessment of predisposing
characteristics, precipitants and consequences, and purposes of aggressive behaviour, were
undertaken to assist in the development of a functional analysis of psychiatric inpatient
aggression. All four studies were conducted within the Thomas Embling Hospital (TEH), a
secure forensic psychiatric hospital in Melbourne, Australia. The first of three initial studies
involved a retrospective review of Incident Forms relating to aggressive behaviours that
occurred within the first year of the hospital’s operation. The second involved a comparison
of prospective assessment of aggressive behaviours with retrospective review of Incident
Forms. The third involved a review of Incident Forms across two forensic psychiatric
hospitals, the Rosanna Forensic Psychiatric Centre, and the TEH, to allow for the study of
environmental contributors to aggression.
The fourth, and main study, focussed on the assessment of patients and aggressive
incidents, using a framework emphasising purpose, which was assessed using a classification
system designed and validated as part of this study. Demographic and clinical information in

vii
addition to social behaviour, history of aggression and substance use were collected on the
204 patients admitted to the hospital during 2002. One hundred and ten of these patients
completed an additional assessment of psychotic symptoms in addition to a battery of
psychological tests measuring anger expression and control, assertiveness, and impulsivity.
During 2002, the year under review, there were 502 incidents of verbal aggression,
physical aggression, and property damage recorded. Staff members who observed these
incidents were interviewed, and files were reviewed to record the severity, type, direction and
purpose of aggression. Following 71 aggressive behaviours patients also participated in the
assessment of purpose. Results from this, and the three initial studies, reinforced the
contribution to aggression of a number of individual characteristics, including a recent history
of substance use, an entrenched history of aggression, a recent history of antisocial behaviour,
and symptoms of psychosis, including thought disturbance, auditory hallucinations and
conceptual disorganisation. Somewhat surprisingly, a number of other characteristics shown
through previous research to have a relationship with aggression, including anger arousal and
control, impulsivity, and assertiveness did not show a relationship with aggression. Further,
and perhaps a consequence of the peculiar characteristics of some patients admitted to the
TEH, older patients and females were more likely to be repeatedly aggressive, yet neither age
nor gender differentiated aggressive from non-aggressive inpatients.
In this study acts of inpatient aggression were usually precipitated by discernible
events, or motivated by rational purposes. Rarely was aggression the consequence of a
spontaneous manifestation of underlying psychopathology occurring in isolation from
environmental precipitants. A number of proximal environmental factors, most particularly
staff-patient interactions associated with treatment or maintenance of ward regime, that were
considered provocative or that threatened status, were evident in incidents of aggression
perpetrated against staff. The perception of provocation and the need to enhance status were
common precipitants of aggression between patients. There was little evidence to suggest that
aggression was used instrumentally to obtain tangible items, to reduce social isolation, or to
observe the suffering of others in the absence of provocation. Results of these four studies
have implications for the prediction and prevention of inpatient aggression, and for the
treatment of aggressive inpatients. These are discussed, as are the limitations of this research
and suggestions for further research.

viii
 Notes on the Literature Review and Studies Reported in the Thesis
Parts of the introduction, including the literature review and the three initial studies
have been previously published as:

Daffern, M., & Howells, K. (2002). Psychiatric inpatient aggression: A review of structural
and functional assessment approaches. Aggression and Violent Behavior, 7, 477-497.
Daffern, M., Mayer, M., & Martin, T. (2003). A preliminary investigation into patterns of
aggression in an Australian forensic psychiatric hospital. The Journal of Forensic
Psychiatry and Psychology, 14, 67-84.
Daffern, M., Ogloff, J., & Howells, K. (2003). Aggression in an Australian forensic
psychiatric hospital. British Journal of Forensic Practice, 5, 18-37.
Daffern, M., Mayer, M., & Martin, T. (2004). Environment contributors to aggression in
two forensic psychiatric hospitals. International Journal of Forensic Mental Health,
3, 105-114.

Neither of the methodology or results of the main research study examining the
purposes of inpatient aggression has been previously published.

ix
 Appendices
Page

APPENDIX 1 Adapted Overt Aggression Scale (OAS) 169

APPENDIX 2 Scoring sheet for recording the purpose of aggression 171
APPENDIX 3 Information sheet for the pilot study 182
APPENDIX 4 Incidents for the pilot study 184
APPENDIX 5 Plain language statement for patients regarding Stage 1 of the research 196
APPENDIX 6 Consent form for patients for Stage 1 of the research 199
APPENDIX 7 Scoring sheet for recording demographic details 201
APPENDIX 8 Violence Rating Scale 203
APPENDIX 9 Novaco Anger Scale 205
APPENDIX 10 Adapted Rathus Assertiveness Scale 208
APPENDIX 11 PSYRATS and KGV prompt questions 211
APPENDIX 12 Functional and Dysfunctional Impulsivity scale 214
APPENDIX 13 Shortened Social Behaviour Schedule 217
APPENDIX 14 Record form for scoring details of aggressive incident 224
APPENDIX 15 Staff structured interview 227
APPENDIX 16 Plain language statement for staff regarding Stage 2 of the research 232
APPENDIX 17 Consent form for staff to participate in Stage 2 of the research 234
APPENDIX 18 Patient structured interview 236
APPENDIX 19 Plain language statement for patients regarding Stage 2 of the research 242
APPENDIX 20 Consent form for patients to participate in Stage 2 of the research 245
APPENDIX 21 Consent form for staff to access details of the patient’s responses to
Stage 2 of the research 247
APPENDIX 22 Results 249

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 Candidate’s Declaration

Thesis Title: A functional analysis of psychiatric inpatient aggression

Candidate’s name: Michael David Daffern

I declare that this thesis does not incorporate without acknowledgement any material
previously submitted for a degree or diploma in any university and that to the best of my
knowledge it does not contain and materials previously published or written by another
person except where due reference is made in the text.

Signed: _____________________________
Date: _____________________________

xi
 Acknowledgements
I wish to acknowledge the practical support and encouragement given to me by the
following people during the production of this thesis.
Firstly to Professor Kevin Howells, who provided the opportunity to conduct this PhD,
the inspiration to approach the study of inpatient aggression in the way I thought it should be
examined, and the patience to support me throughout. I would also like to thank Professor
James Ogloff who provided optimism, encouragement, energy, and practical support when it
was most needed. This research is a function of Kevin and Jim’s dedication, accessibility and
collegiality.
I would also like to acknowledge the patients and staff of the Thomas Embling
Hospital who gave up their time to assist with this research. In particular, I would like to
thank Dr Trish Martin who had a bountiful supply of optimism and interest in my research
and who encouraged me to present what I believed to be useful information to staff being
inducted into the hospital. I would also like to thank Maggie Mayer who was also a
significant support and contributor to two of the initial studies. Thanks must also go to Dr
Joseph Lee who assisted with the design of the study, Professor Robert Burton who provided
valuable feedback on an early draft of the literature review, Bronwyn McKeon who helped
with data collection, and members of Forensicare’s psychology department who generated
useful interpretations of the study’s results and who assisted with the pilot study. Thanks must
also go to the psychology department of Rampton Hospital, in particular Dr Mark Gresswell
and Professor Clive Hollin who nurtured my interest in behavioural assessment.
Lastly, but far from least, thanks must go Harvey and Billy, and to my wife, Lenore,
who shared my time with this thesis. Without Lenore’s love, support, encouragement, and
tolerance of the long nights and weekends I spent working on this thesis, this would surely
have been a more difficult task. With this research completed hopefully comes opportunities
we can all share.

xii
 CHAPTER 1: INTRODUCTION
1.1 A Review of Structural and Functional Assessment Approaches
There is a long-standing debate regarding the nature of the relationship between
mental illness and aggression. Early research on the relationship reinforced stereotypical
beliefs about the dangers posed by those with a mental illness (Lagos, Perlmutter &
Suefinger, 1977). Whilst the results of these studies were not uniformly accepted, the absence
of evidence to the contrary perpetuated the professional and general community’s stereotype.
In contrast, a number of publications emerged in the early 1980’s whose conclusions were
inconsistent with the hypothesis that mentally ill persons are dangerous. They suggested that
mental abnormality in itself does not contribute to an increased likelihood of acting
aggressively (Hafner & Boker, 1982; Monahan & Steadman, 1983). Recently, however, more
methodologically sophisticated studies have produced a body of evidence indicating an
association between certain symptoms of mental illness and aggression for some patients
(Link & Stueve, 1994; Monahan, 1992; Swanson, Holzer, Ganju & Jono, 1990). An
association between the two is now widely acknowledged (Mulvey, 1994; Patterson,
Claughan & McComish, 2004; Wallace et al., 1998; Wallace, Mullen & Burgess, 2004).
One environment in which there is much discussion about the relationship between
mental illness and aggression, and where aggression is frequently perpetrated by mentally ill
patients, is in psychiatric hospitals (Delaney, Cleary, Jordan & Horsfall, 2001; Fottrell, 1980;
McKenna, Poole, Smith, Coverdale & Gale, 2003; Tardiff, 1984). In 1980, Fottrell examined
the prevalence of violence among psychiatric patients in three British hospitals and reported
that approximately 10% of all patients were violent. A prevalence rate similar to this, 15% of
all patients committed at least one act of physical aggression, was noted in Yesavage’s (1983)
16-month study of an acute psychiatric intensive care unit. In forensic psychiatric hospitals
there may be a higher frequency of aggressive behaviours, and a higher proportion of
aggressive patients (Dietz & Rada, 1982; Larkin, Murtagh & Jones, 1988; Rasmussen &
Levander, 1996; Torpy & Hall, 1993). Torpy and Hall (1993), for example, reported that 75%
of patients admitted to a United Kingdom medium secure unit were aggressive.
That aggression is prevalent in general and forensic psychiatric inpatient wards is
unsurprising given one of the necessary criteria for admission and detention in an approved
mental health service as an involuntary patient in many countries is for the protection of the
public. The increased likelihood of aggression in forensic psychiatric hospitals is most likely a
consequence of forensic psychiatric hospitals primarily treating young men with a history of
criminal behaviour and substance use, many of whom have entrenched negative attitudes,
established repertoires of aggressive behaviour, and recent exposure to the prison

1
environment, where animosity towards staff is encouraged, where conflict with others is
resolved through aggression, and where aggressive individuals are afforded status.
Unfortunately, there is also evidence that the prevalence of aggression in psychiatric hospitals
has increased (James, Fineberg, Shah & Priest, 1990; Snyder, 1994). Again, this may be an
understandable finding given that service shortages have resulted in fewer acute hospital beds
so that only the most unwell and potentially dangerous patients are admitted to hospital for
treatment (Palmstierna & Wistedt, 1995).
Aggressive behaviour by patients on psychiatric wards has a profound impact on
patients and staff, ward atmosphere and routine, and the functioning of mental health services
in general (James et al., 1990; Wong, Slama & Liberman, 1987). Aggression may affect
patients’ treatment, access to rehabilitation programs, level of supervision, access to liberty
and privileges, and may result in aggressive patients being placed in isolation from others. A
further consequence of aggression may be prolonged hospitalisation. Injury to patients
engaging in aggression when they are restrained and secluded, and injury to patients and staff
who are the victims of aggression, are also frequent and undesirable consequences.
Aggression can result in significant costs to ward atmosphere, morale and functioning
(Monroe, Van Rybroek & Maier, 1988). Therapeutic programs may be abandoned or
disrupted by acts of aggression, particularly when members of staff are redirected from
facilitation of these programs to the containment or prevention of aggressive behaviour.
Organizational problems related to aggression include time lost from sick leave taken by staff
in response to aggression, problems with staff recruitment and retention, compensation for
injury, as well as the costs associated with official inquiries and litigation (Hillbrand, Foster &
Spitz, 1996).
As a result of its profound impact, psychiatric inpatient aggression has attracted
considerable international research attention. Characteristics of the aggressive incident, the
aggressive patient, the victims of aggression and the aggression prone environment have been
identified (Davis, 1991). However, despite the frequency of aggressive acts, the severity of
their impact upon staff and patients, the reasonably well-established link between psychosis
and aggression, and the considerable body of literature on inpatient aggression, the pathway
through which mental illness leads to inpatient aggression remains unclear. This lack of
clarity often leads to unstructured and varied methods of inquiry into the dynamics of
aggressive incidents. Without a systematic framework for organising information and
formulating hypotheses about the nature of aggression, the immediate management of the
aggressive incident and interventions aimed at reducing the likelihood of future aggression
may be inconsistent, absent, or inappropriately selected. Diagnosis (Ionno, 1983), age

2
(Tardiff, 1983), ethnicity and victim status (Gudjonsson, Rabe Hesketh & Szmukler, 2004;
Gudjonsson, Rabe Hesketh & Wilson, 1999) have all been shown to bias intervention
selection. Ionno (1983) found that seclusion was utilized more frequently for psychotic
patients and cold wet packs for non-psychotic patients. Tardiff (1983) found that patients with
non-psychotic disorders were likely to receive physical restraint, one to one supervision and
emergency medication, whereas psychotic patients were more likely to receive only
emergency medication and one to one supervision. Prn (pro re nata) medication, physical
restraint and increased supervision were all used less frequently with increasing age,
regardless of perceived dangerousness and physical strength. Gudjonsson et al. (1999) found
prn medication was administered more frequently when the victim of assault was a nurse
rather than a patient. They also found that Afro-Caribbean patients were more frequently
given prn medications after aggressive incidents, despite non-significant relationships
between ethnicity and frequency or severity of aggressive incidents.
In addition to the inconsistent, often idiosyncratic use of interventions designed to
contain aggressive behaviours, the traditional techniques most frequently utilized in the
immediate management of the aggressive patient (seclusion, one to one supervision and
provision of prn medication) may reinforce aggression for some patients (Drinkwater &
Gudjonsson, 1989). Furthermore, the implementation of these management strategies may
precipitate aggression, model aggressive ways of interacting with others, or reinforce
aggression. Aggression may therefore be maintained rather than eliminated through normal
ward practices.
Against this background, the aim of the present research was to develop a functional
analysis of psychiatric inpatient aggression to assist in the prediction and prevention of
aggressive behaviour, and to guide treatment of aggressive inpatients. The purpose of Chapter
1, the introduction, aspects of which have been previously published (Daffern & Howells,
2002; Daffern, Mayer & Martin, 2003; Daffern, Ogloff & Howells, 2003; Daffern, Mayer &
Martin, 2004), was to review the literature on psychiatric inpatient aggression, and to describe
three initial studies of inpatient aggression conducted by the author in collaboration with
others.
The first of these initial studies describes a review of Incident Forms documenting
incidents of aggression that occurred during the first year of operation of the TEH. At the
outset of this program of research it was evident that little Australian research on inpatient
aggression existed. Furthermore, no published research on aggression in an Australian
forensic psychiatric hospital was available prior to the publication of this study. Although
there are problems associated with the assessment of inpatient aggression through

3
retrospective review of Incident Forms (Lion, Snyder & Merrill, 1981; Rippon, 2000),
Incident Forms were available for review and they provided information on local patterns and
contributors that were able to be considered immediately. This review also contributed to the
refinement of the main study’s methodology. Furthermore, following notification by the
author and his colleagues to conduct this study, the TEH’s Human Resources Department
requested assistance in their attempt to understand an unequal distribution of WorkCover (a
Victorian state government workers’ compensation insurance scheme) claims between the
hospital’s two male acute wards. Review of these Incident Forms allowed for contributors to
this discrepancy to be identified and for some contributors to inpatient aggression to be
examined, particularly the contribution of staff members use of aggression management
strategies.
The purpose of the second study was to refine methodology to be used in the main
study, and to compare aggressive behaviours recorded prospectively using aggression specific
recording instrumentation with aggressive behaviours recorded on the hospitals Incident
Forms. This study also aimed to understand the extent to which staff members may tolerate
aggression. Research that compares aggressive behaviours recorded on aggression specific
instruments with standard Incident Forms may indicate what is considered an incident, and
reveal what proportion, and which type of aggressive behaviours are recorded on Incident
Forms. A further purpose of this study was to examine the relationship between aggression
and seclusion, specifically to examine whether seclusion was used to manage aggressive
patients following different types of aggressive behaviour, and whether patients who were
aggressive towards staff were more likely to be secluded when compared with patients who
were aggressive towards co-patients. Additionally, the study sought to clarify whether
recording aggressive behaviours would have some effect on the frequency of aggression
within the hospital. The third study examined the effects of aspects of the physical
environment and regime on aggression by comparing incidents of aggression recorded in the
last two years of operation of an old forensic psychiatric hospital, the Rosanna Forensic
Psychiatry Centre (RFPC) and the first two years of operation of the TEH, which was built to
replace the RFPC. A number of environmental contributors to aggression were identified,
most importantly the contribution to aggression of personal space.
The main study involved the assessment of patients and aggressive behaviours,
utilising a framework with an emphasis on purpose. This framework was informed by the
cognitive model of anger developed by Raymond Novaco (Novaco, 1976), the instigating and
maintaining mechanisms outlined by Albert Bandura in his social learning theory of
aggression (Bandura, 1973), and the antecedents to aggression identified through previous

4
research on inpatient aggression (Powell, Caan & Crowe, 1994). Assessment of predisposing
characteristics, precipitants and consequences, that assisted the identification of purpose, was
undertaken. The focus on purpose reflects the need to investigate and challenge the notion
that the aggression of psychiatric patients, particularly psychotic patients, is motiveless.
Identifying rationality in the bizarre behaviour of the psychotic patient may allow staff to
consider psychological models of anger and aggression developed to assist in the treatment of
non-mentally ill offenders, and reduce fear generated by the unknown:
Violence performed by psychotic patients is often surrounded by mystery. It is seen as
unpredictable and impossible to understand. As it is difficult to prepare oneself for anything
one cannot understand, this contributes to the fear people feel for this phenomenon (Linaker
& Busch-Iversen, 1995, p. 252).
The repertoire of possible responses to aggressive behaviour may be expanded as a
consequence of the focus on purpose. Interventions may shift from those directed exclusively
towards amelioration of psychotic symptoms and containment of aggressive individuals, to
the treatment of inpatient aggression.
1.1 The Assessment of Inpatient Aggression
A distinction can be made between structural assessment approaches, which
emphasise the correct classification of the form of a particular behaviour, and functional
assessment approaches, which emphasise the purpose of the behaviour (Haynes & O’Brien,
1990, as cited in Sturmey, 1996; Owens & Ashcroft, 1982). Considerable international
research on the prevalence of psychiatric inpatient aggression exists. Unfortunately for those
interested in aggression within forensic psychiatric facilities, this research has primarily been
conducted in general psychiatric hospitals. Further, these studies have, for the most part,
drawn upon structural assessment approaches, and have typically focussed on the
demographic and clinical characteristics of aggressive patients. Less emphasis has been
placed on the interpersonal context and environmental in which aggression occurs (Davis,
1991; Krakowski & Czobor, 1997; Rasmussen & Levander, 1996). Furthermore, when
clinical characteristics have been assessed, symptoms of psychosis, in particular delusions and
hallucinations, have been the focus of study. A number of other symptoms and individual
characteristics may however influence inpatient aggression.
1.2 Structural Approaches: Individual Factors
Many of the demographic characteristics associated with aggression in psychiatric
inpatients are also associated with aggression in the general population (Bonta, Hanson &
Law 1998; Krakowski, Volavka & Brizer, 1986). For example, younger patients are more
likely to be aggressive than older patients (Pearson, Wilmot & Padi, 1986; Tardiff &

5
Sweillam, 1982), and those with a history of aggressive behaviour are aggressive more
frequently (Depp, 1976; McNiel, Binder & Greenfield, 1988). Socio-economic status may be
related to aggression (Hiday, 1995). Inconsistent findings have been reported on the
relationship between gender and aggression (Krakowski & Czobor, 2004) with some studies
reporting no relationship (James et al., 1990; Tardiff, 1983), others reporting that women are
more frequently aggressive than men (Fottrell, 1980; Rasmussen & Levander, 1996), or that
men have been more aggressive than women (Depp, 1983). Inconsistent findings are reported
on the influence of race (Shah, Fineberg & James, 1991). A small number of patients are
responsible for a disproportionate number of incidents (Larkin et al., 1988), the majority of
which do not result in serious injury (Fottrell, 1980; Palmstierna & Wistedt, 1987).
Those studies focusing upon the relationship between clinical characteristics and
inpatient aggression have differentiated aggressive from non-aggressive patients on the basis
of diagnosis (Fottrell, 1980; McNiel & Binder, 1994). Specifically they have generally found
the diagnosis of schizophrenia (Depp, 1976; Fottrell, 1980; Hodgins, 1994; Sheridan, Herion,
Robinson & Baxter, 1990) and mania (McNiel & Binder, 1989) to be more often related to
aggression than other disorders or illnesses. Similarly, psychotic symptomatology (Krakowski
& Czobor, 1997), and the emotional concomitants of psychotic symptoms, particularly anger,
anxiety and sadness (Cheung, Schweitzer, Tuckwell & Crowley, 1996) have differentiated
aggressive and non-aggressive inpatients. Command auditory hallucinations (Junginger,
1995) and persecutory delusions may have a significant and direct influence on aggression
(Taylor et al., 1998).
Likelihood of aggression is influenced by the course of the illness (Davis, 1991) and
the nature of its treatment (Taylor & Schanda, 2000). Active symptomatology is more often
associated with aggression than is the diagnosis (Link & Stueve, 1994; McNeil & Binder,
1994; Mulvey, 1994). Consistent with this, associations between violent behaviour prior to
admission and violent behaviour during the early, but not later stages of acute inpatient
treatment have been reported (McNiel et al., 1988).
1.2.1 Hallucinations
Research on the relationship between hallucinations on aggression has focused almost
exclusively on command auditory hallucinations (Junginger, 1995). For such symptoms
hypothetical pathways are clear; the person responds to a command to harm another person.
There does exist, however, a number of alternative pathways through which aggression may
proceed during or after the experience of non-command type hallucinations. These pathways
are similar to the effect that hallucinations experienced through other senses may have on
aggression. A person may be primed for violence through physical arousal or agitation

6
resulting from their hallucinatory experience, and then become aggressive in response to a
minor unrelated provocation. Alternatively, if a delusional interpretation is placed on a
hallucination, a person may behave aggressively towards the perceived agent of the
hallucination. For example, a person who experiences pejorative auditory hallucinations (e.g.,
“You’re stupid”) may attack the individual whom they believe is responsible.
Research to date on the role of command hallucinations and aggression has been
mixed (Rogers, Watt, Gray, MacCulloch & Gournay, 2002). Despite the intuitive plausibility
of the notion that psychotic people comply with command auditory hallucinations and some
research suggesting that a small number of patients do act on such hallucinations (Rogers,
1986), the available evidence rarely reveals a clear association between hallucinations and
aggression (McNeil, 1994). Where significant associations have been found, this has usually
been in the context of the person experiencing other psychotic symptoms (Lowenstein, Binder
& McNiel, 1990; McNeil, 1994). Furthermore, of those patients who experience command
auditory hallucinations, there is only a small percentage whose hallucinatory content relates to
harming others (Hellerstein, Frosch & Koenigsberg, 1987). Very few comply with these
hallucinations (McNeil, 1994). Goodwin, Alderson and Rosenthal (1971) found that patients
who experienced auditory hallucinations mostly ignored them and none had committed
dangerous or destructive acts in response to them. Falloon and Talbot (1981), who reviewed
community psychiatric patients with chronic auditory hallucinations, found that although
patients often accepted the guidance offered by their voices, violence towards others in
response to auditory hallucinations was uncommon.
One of the reasons why research on the relationship between auditory hallucinations
and aggression has been mixed is that most studies have not differentiated subjects on the
basis of the content of their command hallucinations, some groups included patients who had
benign instructions with other patients who had violent instructions. In a recent investigation
into the role of command hallucinations and violence towards others, which considered the
content of the hallucination, a positive relationship between command hallucinations and
violence was found (McNiel, Eisner & Binder, 2000). Despite this finding, which reinforces
the need for future research to be more precise about the content of command hallucinations,
the available research is currently unable to clarify exactly how often, or which types of
auditory hallucinations contribute to aggression. The work of Chadwick, Birchwood and
Trower (1996) may, however, clarify the relationship between hallucinations and aggressive
actions. These authors suggest that emotional and behavioural responses to hallucinations are
not exclusively the consequence of content. They are a consequence of the individual’s beliefs
about the hallucination. When the content of auditory hallucinations consists of an instruction

7
to harm others, compliance may be more likely when the voices are perceived as benevolent,
rather than malevolent. However, even malevolent voices may be complied with when
pressure is extreme (Chadwick et al., 1996).
1.2.2 Delusions
The relationship between delusions and aggression is stronger than that between
hallucinations and aggression (Taylor 1985). In their Special Hospital review, Taylor et al.
(1998) showed that delusions were the most important psychotic symptom for the most
seriously violent of psychotic patients. In another study of factors motivating mentally ill
persons living in the community to commit both violent and non-violent offences, delusions
were found to be relatively common precipitants of offending (Taylor, 1985).
Epidemiological research conducted in community samples in the United States over
the last decade has also supported the role delusions may have in increasing the likelihood of
aggression in psychiatric patients (Swanson et al., 1990; Link & Stueve, 1994; Swanson,
Borum, Swartz & Monahan, 1996). In the first of two analyses using data from the National
Institute of Mental Health’s Epidemiologic Catchment Area (ECA) project, Swanson et al.
(1990) demonstrated that the presence of a major mental illness was a statistically significant
but modest risk factor for violence. In a subsequent analysis of self-reported psychotic
symptoms Link and Stueve (1994) reported that it was not psychotic symptoms in general
which were associated with violence but rather those psychotic symptoms that produced
feelings of personal threat, or involved intrusion of thoughts that override self control, the so
called Threat Control/Override (TCO) constellation of symptoms. In light of the identification
of the TCO symptoms' association with violence, Swanson et al. (1996) re-evaluated and
subsequently substantiated Link and Stueve’s (1994) findings using a comparable index of
TCO. Those people who reported feeling threatened by others, and unable to control their
own thoughts, were twice as likely to be violent when compared with those reporting other
psychotic symptoms. Link and Stueve (1994) hypothesised that other symptoms of mental
illness were not independently associated with violence, only in so far as they are commonly
associated with TCO symptoms. In an attempt to extend these findings to institutional
aggression, Steadman et al. (2000) incorporated TCO symptoms in an actuarial violence risk
assessment tool. A sample of 939 patients were assessed during acute psychiatric
hospitalisation and followed for 20 weeks post discharge. Contrary to previous research, TCO
symptoms were found to be negatively associated with violence. Given these mixed reports,
and the intuitive plausibility of this constellation of symptoms contributing to aggression,
their role continues to have widespread acceptance and is worthy of further research.

8
 Taylor et al. (1994) suggested that it is the content and strength of conviction that is
associated with delusional drive to commit violence, whereas Cheung, Schweitzer, Crowley,
and Tuckwell (1997) found that persecutory delusions and emotional responses, particularly
anger, determined the likelihood of aggressive behaviour. Similarly et al. (1993) found that
action was more likely in the presence of persecutory delusions and less likely in the presence
of delusions of guilt and grandiose delusions.
1.2.3 Formal Thought Disorder
Conceptual disorganisation, a measure of formal thought disorder, has been shown to
relate to inpatient aggression (Cheung et al., 1996; Yesavage, 1983). Formal thought disorder
might have contributed to aggression indirectly through confusion and frustration originating
from the patient’s inability to manage their environment or communicate their needs
effectively. Formal thought disorder may also be indicative of impaired neuropsychological
functioning, including frontal lobe impairment, a result of which may be an impaired ability
to resolve problems without aggression (Foster, Hillbrand & Silverstein, 1993).
1.2.4 Negative Symptoms
Few empirical studies have specifically examined the relationship between negative
symptoms and inpatient aggression. Of these, Cheung et al. (1996) found that aggressive
patients scored higher on the negative symptom scale on the Positive and Negative Syndrome
Scale (PANSS) (Kay, Opler & Lindenmayer, 1989), although this difference occurred within
the context of the aggressive group also scoring higher on the positive symptom, general
psychopathology and total PANSS scores. Conversely, McNiel and Binder (1994) found that
motor retardation, emotional withdrawal and blunted affect did not differentiate assaultive
from non-assaultive patients, and Kay Wolkenfield and Murrill (1988) found that over arousal
and motor excitement differentiated aggressive from non-aggressive patients. Aggressive
behaviour resulting from negative symptoms may seem incongruous. However, aggression
may occur indirectly as a result of negative symptoms (e.g., when staff request an amotivated
patient to attend a ward activity the patient may respond aggressively).
1.2.5 Substance Use
Despite alarmingly high rates of substance use amongst psychiatric patients, few
studies have examined the impact of substance use on inpatient aggression. Results from
reviews of psychiatric illness and substance use in community studies have shown a high rate
of co morbidity between substance use disorders and many mental illnesses (Regier, Farmer,
Rae, Locke, Keith, Judd & Goodwin, 1990). Further, recent studies have consistently found
that substance use significantly increases the likelihood that a person with a mental illness
will be aggressive (Mulvey, 1994). In their post discharge follow up study of 1136 patients,

9
Steadman et al. (1998) found the one year prevalence rate for violence to be 17.9% for
patients with a major mental illness only, and 31.1% for patients with major mental illness
and substance abuse diagnoses. In another study examining the degree of association between
dual diagnosis and aggression, 27 people with both a psychotic illness and substance use
disorder were compared with 65 people with a psychotic illness only (Scott, Johnson,
Menezes, Thornicroft, Marshall, Bindman, Bebbington & Kuipers, 1998). In this study
patients in the dual diagnosis group were more aggressive than those patients without a co
morbid substance use disorder.
The nature of the relationship between substance use, mental illness and aggression is
complex. A range of individual, situational and pharmacological factors most probably
interact to increase the likelihood of dually diagnosed individuals behaving aggressively.
Substance use may decrease the likelihood of internal restraints against aggressive impulses
or impair a range of cognitive abilities and judgements that make aggression more likely
(Graham, 1980). These include impairing basic coping skills, reducing the ability of the
individual to select more appropriate and sophisticated alternatives to aggression, biasing
interpretations of the behaviour of others, making other people’s actions appear more
provocative, narrowing time and perception, leaving the person’s behaviour more
situationally determined, and/or impairing the ability to consider the anticipated future
consequences of aggression. Substance use may compromise the way in which psychotic
patients are treated (Williams & Cohen 2000), may exacerbate symptoms directly, or through
a compromise of the efficacy of prescribed treatment. Furthermore, mental health staff may
treat substance users differently, even punitively.
1.2.6 Physiological Arousal
General physiological arousal facilitates aggression in the presence of provoking
situational factors or aggressive cues, particularly when the arousal is attributed to the
provoking event (Rule & Nesdale, 1976). Novaco (1994) hypothesised that the transfer of
physiological excitation/arousal, when guided by cues for anger or aggression, enhances or
intensifies the experience of anger. Physiological arousal generated by active psychotic
symptomatology, particularly symptoms of a threatening nature such as derogatory auditory
hallucinations, may prime a patient for anger and aggression.
1.2.7 Summary
Despite inconsistencies and individual patient variation, the literature reveals a
number of clinical characteristics of psychiatric inpatients that increase the likelihood of
aggression. Of these characteristics, delusions, particularly those of a persecutory nature,
which result in fear and anger, may have a significant and direct influence. Hallucinations

10
may have a relationship with aggression, although their role has been less evident, perhaps
due to methodological problems in the studies conducted. Disorder of thought and increased
physiological arousal may contribute to a lesser extent, and in a more indirect manner. Phase
of illness is crucial, as is the presence of co-existing substance use.
1.3 Structural Approaches: Environmental Factors
In addition to the characteristics of individual patients, environmental or contextual
factors may also contribute to aggression. Environmental contributors to aggression, whilst
often acknowledged, have received less attention and are therefore less well understood. This
dearth of research may be due to the relative ease of examining individual characteristics,
some bias amongst researchers that individual characteristics are the most important
contributors to aggression, the difficulty in quantifying and therefore empirically evaluating
environmental characteristics, a reluctance by staff to acknowledge their own contribution to
aggression, and a belief that these environmental factors are either resistant to, or more
difficult to change, when compared with individual characteristics.
The physical characteristics of the ward, the behaviour of its staff, the remit and
routine of the ward, the characteristics of co-patients, including their personality style,
symptoms, gender, age, and behaviour on the ward, may all influence aggression. Teasing,
insults and intrusive, irritating actions by other patients may all contribute to aggression.
Restrictions upon liberty, boredom, limited opportunities for privacy, poor physical facilities,
lack of effective therapy, the presence of weapons (Dietz & Rada, 1982), poor aesthetic
appeal of the ward, a lack of privacy, and the absence of recreational, psychotherapeutic,
educational, spiritual and occupational activities may all contribute. Drinkwater and
Gudjonsson (1989) argued that the nature of the ward environment, including its low level of
planned activities, low level and poor quality of staff patient interactions, staff management
problems and poor management of violent incidents may be conducive to violence on
psychiatric wards. Environmental contributors to inpatient aggression may be divided into
staff or ward factors.
1.3.1 Staff Factors
Poor motivation, lack of choice in working environment, low staff numbers, team
instability (Taylor & Schanda, 2000), poor therapeutic alliance (Beauford, McNiel & Binder,
1997), limited working experience (Perregaard & Bartels, 1992), young age (Whittington &
Wykes, 1994), and a denying, authoritarian, inflexible attitude (Blair, 1991) may all
contribute to aggression. Team stability (Taylor & Schanda, 2000), competent, committed and
accessible psychiatrists, and supportive interpersonal interactions between patients and staff
may reduce the likelihood of aggression (Katz & Kirkland, 1990).

11
 Aggression toward nursing staff is generally more frequent than aggression directed to
patients, visitors and staff other than nurses (Fottrell, 1980; Gudjonsson et al., 1999; James et
al., 1990), although some studies showing a higher incidence of aggression towards other
patients have been reported (Mortimer, 1995). Further, senior nursing staff and male nurses of
any grade may be injured at a rate higher than other nurses, as these groups are more actively
involved in the containment (restraining an actual or potentially aggressive patient) of
aggressive behaviour (Carmel & Hunter, 1989). For staff and patient victims, male patients
tend to assault males, and females in general assault females (Depp, 1976). Hypothesised
reasons for the high number of aggressive incidents directed towards nursing staff fall within
two domains: that aggression is a result of problematic communication by these staff, or that
nursing staff more frequently impose limits, enforce decisions, restrain and seclude patients
more frequently than other staff, and have, in general, the most contact with patients.
Evidence for both interpretations of this finding exist and will be discussed below.
Depp (1976) identified variation in the frequency of aggression for times of the day
and for days of the week, reporting that assaults peaked between 6:00am to 8:00am daily, and
that most assaults occurred on Mondays, a finding that led to the formulation of the activity
demand hypothesis. According to this hypothesis, aggression is the patient's attempt to
remove a demand or to demonstrate that they find the demand insulting, irritating,
unreasonable or provocative. Similarly, following their examination of seclusion room
practices, Plutchik, Karasu, Conte, Siegel and Jerrett (1978) noted that the highest frequency
of seclusion occurred during the day shift. They hypothesised that confrontation, challenges
and verbal interactions disturb or overstimulate patients, resulting in aggression. In
subsequent research the demand for activity, in addition to staff denial of a patient’s request,
have been shown to be common antecedents to aggression towards staff. For example,
Cheung et al. (1996) found that 34.3% of violent incidents followed staff/patient interaction
such as staff requesting patients to take medications or staff turning down patient’s demands.
Whittington and Wykes (1994) examined the precursors to 100 violent incidents and found
that over half had been preceded either by staff requesting an activity, a negative verbal
statement, or by staff acting in some way to prevent harm or absconding. In subsequent
research, Whittington and Wykes (1996) reported that 86% of 63 assaults by patients on
nursing staff were immediately preceded by an aversive stimulus delivered by the assaulted
nurse. These interactions included physical contact, an activity demand, or a frustrating
interaction.
Some research suggests that it is not only the content of the demand or the refusal of a
request that may influence the likelihood of aggression, but also the manner in which these

12
demands are made or requests denied. In one examination of limit setting style, Lancee,
Gallop and McCaye-Toner (1995) examined limit setting among nurses. They found that a
limit setting style characterized by belittlement generated significantly more anger than other
styles. Similarly, in their review of violence in psychiatric facilities in the United States and
Europe, Edwards and Reid (1983) identified anger and irritability as staff characteristics that
can provoke assaults by patients.
Results from some studies have also shown that a small number of nursing staff may
be involved in a disproportionately high number of violent incidents. This may indicate either
problematic relationships between certain staff members and patients, or may reveal the
presence of problematic staff members (Hodgkins, McIvor & Phillips, 1985). Similarly,
Sheridan et al. (1990), who examined events preceding 73 episodes of restraint, reported that
24% of their patients stated that better communication with staff could have prevented the
incident or future incidents. Other patients in this study reported that their rights had been
violated, or that they deserved more respect. James et al. (1990) found that an increase in
violent incidents on a 60 bed psychiatric unit in London was strongly associated with a
decline in permanent nursing staff, and an increase in agency staff, hypothesising that changes
in staffing resulted in a more custodial and less therapeutic relationship between staff and
patients.
Although it would be unreasonable and incorrect to suggest that staff cause
aggression, there is sufficient research available to suggest that staff behaviours, attitudes and
practices do contribute to inpatient aggression. This conclusion challenges the assumption that
staff members are benign in terms of their contribution to aggression. Exactly how staff
influence aggression is however unclear and is an area requiring further study.
1.3.2 Ward Structure and Routine
In considering the effect of environment on inpatient aggression it is naturally
important to pay attention to the role of ward structure and function. Unfortunately, whilst
intuitively plausible, most aspects of ward structure and function postulated to play a role in
inpatient aggression have not been subjected to empirical evaluation. Of the limited research
available, it has been noted that a positive, therapeutic atmosphere and the presence of
structured activities are associated with an absence of aggression (Moos, 1974; Shah et al.,
1991; Tardiff, 1983). Similarly, the majority of aggressive behaviours occur on the ward
rather than in occupational or psychotherapy areas (Shepherd & Lavender, 1999). Less
attractive presentation and poor maintenance of buildings, limited opportunities for privacy,
and the presence of weapons may all contribute to aggression (Dietz & Rada, 1982; Wong et
al., 1987).

13
 The function of the ward, for example, the pattern of ward usage in terms of admission
rates and bed occupancy (Fottrell, 1980), may also influence the likelihood of aggression.
Aggression is more common on acute wards rather than non-acute wards (Perregaard &
Bartels, 1992). In addition to disturbed mental state caused by acute psychiatric illness, acute
wards may reveal a higher frequency of aggressive behaviours due to the frequent admissions
and discharges that may result in less secure relationships between staff and patients. Depp
(1976) noted differences in rates of aggression between mixed and same gender wards, with a
greater frequency of aggression on mixed gender wards, noting that these wards were less
routine and subjected to more rapid changes in staff and patients.
Stress contributed to by over stimulation and overcrowding, or a lack of personal
space, has been a focus of limited study (Drinkwater & Gudjonsson, 1989; Edwards & Reid,
1983; Palmstierna, Huitfeldt & Wistedt, 1991). Brooks, Mulaik, Gilead and Daniels (1994)
cite the work of Sommer (1969) and Horowitz (1968), who identified withdrawal, agitation
and social isolation in schizophrenic patients when their spatial boundaries were invaded.
Brooks et al. (1994) assessed the relationship between the frequency of seclusion and capacity
in a public psychiatric hospital, noting that over capacity was significantly related to an
increase in violent incidents. Lanza, Kayne, Hicks and Milner (1993) noted a relationship
between aggression and “high traffic areas” and suggested that “assault frequency is simply
related to chance of occurrence: the presence of more patients in one area obviously increases
that chance” (p. 323). In contrast with those studies that have found a relationship between
crowding and aggression, Palmstierna and Wistedt (1995) found that when available beds on
an acute psychiatric intensive care unit were reduced from 19 to 10, without changes in the
size of the unit, that no significant difference in the number of incidents and frequency of
aggression from individual patients occurred.
The ward environment may affect a patient’s symptomatology and inclination to act
upon particular symptoms. Junginger (1995) found that only 25 of 370 patients under short-
term hospitalisation experienced command auditory hallucinations compared with 93 of 370
who experienced them during the two years prior to hospitalisation. Further, commands
experienced in the hospital tended to be specific to the hospital environment and were less
dangerous. Significantly fewer patients reported acting dangerously upon hallucinations,
suggesting environmental characteristics or stage of treatment may influence aggression.
In forensic hospitals the cultural norms surrounding the use of aggression may differ
from those of the community (Toch, 1989). In these settings aggression may be a socially
acceptable response to provocation, particularly when the consequences of aggression are
absent or insignificant. Some authors have speculated that psychiatric wards may promote an

14
acceptance of aggression (Durivage, 1989; Felthous, 1986) on a scale that would be
unacceptable within the broader community.
1.3.3 Summary
In the literature on inpatient aggression reviewed here, characteristics of the ward
environment are neglected. However, there is evidence that the physical characteristics of the
ward and the rules and regulations by which they operate, that contribute to aggression. Staff
characteristics, particularly their behaviour and style of interaction with patients, may also
contribute to aggression.
1.4 Functional Approaches to Inpatient Aggression
An alternative approach to the examination of inpatient aggression may be provided
by functional analysis, which Haynes and O’Brien (1990) define as the “identification of
important, controllable, causal functional relationships applicable to a specified set of target
behaviours for an individual client” (p. 654). Functional analyses attempt to identify the
purpose of behaviour. They seek to clarify the factors responsible for the development,
expression and maintenance of problem behaviours by assessing the behaviour itself, the
individual’s predisposing characteristics, the antecedent events, that are considered important
for the initiation of the behaviour, and the consequences of the behaviour, which maintain and
direct its developmental course (Haynes, 1998; Jackson, Glass & Hope, 1987). Assessment of
environmental, cognitive, physiological and behavioural variables is undertaken. Information
obtained from the assessment is then used to design an intervention, which introduces new
controlling variables, or modifies the original variables, so that the target behaviours can be
modified (Haynes & O’Brien, 1990). According to Owens and Ashcroft (1982), attempts to
analyse behaviour problems that omit any of these factors are “likely to produce incomplete
analyses” that can lead to ineffective interventions.
Analysis of individual cases is the most common application of functional analysis
(Sturmey, 1996). A number of published case studies have utilized functional analysis for
assessment of aggressive behaviour (Thompson, Fisher, Piazza & Kuhn 1998; Kern, Carberry
& Haidara, 1997). Gresswell and Hollin (1992, as cited in Sturmey, 1996) used a functional
analysis to clarify the development of offending behaviour in a man who had unsuccessfully
attempted to kill two people. Their analysis clarified the development of the problem,
suggested intervention strategies, and identified methods for managing future risk by
highlighting triggers for potentially violent episodes.
While functional analysis has demonstrated efficacy in sugesting interventions for
problem behaviours such as self injury (Iwata, Dorsey, Sliferer, Bauman & Richman, 1982),
and has been regarded by experts in the field to be a legitimate assessment approach for anger

15
management problems (Howells, 1998), there is only one report in the literature of its use for
the assessment of psychiatric inpatient aggression (Shepherd & Lavender, 1999). In this study
antecedents and aggression management strategies were examined for 130 incidents of
aggression. The majority of incidents in this study (60%) were preceded by external factors
such as staff refusal of a patient’s request, or when members of staff demanded an activity.
Hospital related matters such as ward restrictions and transfers between wards, or patient
conflict with fellow patients were also important. Forty percent of all incidents were attributed
to internal factors, such as the patient’s mental state or substance use. The purpose of the
aggressive behaviour was not clarified through the assessment of these precipitants and
consequences, although Shepherd and Lavender (1994) reiterated the antecedent interactions
previously noted by Whittington (1994): that aggression frequently occurs as a consequence
of social distance, or as a consequence of aversive stimulation.
Functional analysis has also been used in a study examining violent incidents in a
forensic adolescent unit. Using Incident Forms, nursing process records and accident reports,
McDougal (2000) retrospectively examined 219 incidents to identify, categorise and measure
antecedents and consequences. Antecedents included frustrating interactions, activity
demands, and interventions by others, perceived by the adolescent as an attack. Consequences
examined were restricted to aggression management strategies and included a range of
therapeutic or containment strategies in addition to the imposition of sanctions.
There are three fundamental reasons why exploration of inpatient aggression through
functional analysis, with its emphasis on purpose, may be limited. The first is definitional.
Function and purpose are commonly used interchangeably with motive, which is a subjective
rationalisation for a behaviour. Taylor (1985) notes the difficulty in identifying motives.
Motives are changeable over time and liable to non-deliberate misrepresentation by the
offender through ineffective recall of the offence, or deliberately in an effort to claim
mitigating factors. Confusion between terms and recognition of the difficulty in elucidating
reliable and valid motives may have generated a reluctance to study function.
A second reason for the absence of research employing functional analysis is the
commonly held assumption, noted by Taylor (1985), that a lack of motivation is the hallmark
of mentally abnormal offenders, in particular those with schizophrenia. In other words, why
examine purpose when the aggression of those with a mental illness is random and
unmotivated? Given that a basic premise of functional assessment approaches is that
behaviour is acquired and maintained because it is purposeful, exploration of function may
appear contradictory to the assumption that aggression is motiveless. Thorough assessment

16
based upon the assumption that all behaviour is functional is necessary prior to dismissing
bizarre or unreasonable behaviour as purposeless.
Finally, no instrument exists to assist the discrimination of differently motivated
aggression amongst psychiatric inpatients. In the absence of instruments designed for the
assessment of purpose, other instruments, incapable of identifying purpose, are sometimes
used, resulting in a high number of aggressive incidents being recorded as motiveless. The
time required to complete a functional analysis may also be prohibitive, resulting in a
preference for more simplistic, or structural assessments.
Functional analysis requires assessment of the predisposing characteristics of
aggressive individuals in addition to the assessment of proximal antecedents and
consequences, which may contribute to clarification of purpose (Howells, 1998). Many
individual characteristics that may predispose patients to aggression in the inpatient setting,
including anger arousal and control (Novaco, 1994), impulsivity (McNeil et al., 2003), a
history of aggression (Depp, 1976), a history of substance use (Steadman et al., 1998), and
psychotic symptoms (Taylor & Schanda, 2000) have been delineated. There have been fewer
investigations of proximal antecedents and consequences, from which the functions of
aggression may be identified. Three lines of research will therefore be reviewed: (a) research
examining motives for offending amongst mentally ill offenders living in the community, (b)
research focussing upon precipitants for inpatient aggression, and (c) examination of the
strategies utilized in the immediate management of aggressive incidents, which have provided
information regarding some of the consequences, or maintaining factors for aggression.
1.4.1 Community Studies Examining Motives and Functions
Two notable studies have examined the motives for aggression of mentally ill
offenders living in the community exist. Hafner and Boker (1973) examined motives for
aggression through a retrospective review of case notes in a sample of mentally abnormal
offenders and emphasised the complexity of the interaction between offender,
symptomatology, and external circumstances. Motiveless offences in this study were rare,
occurring in only 20% of cases. Violence was related to mental illness in many cases: a result
of command auditory hallucinations (17.5%); a result of acting upon a delusion when
threatened or persecuted (16%); in response to jealousy (15%), and upon motives of revenge
that were often influenced by delusions (40%).
Taylor (1985) identified motives for aggressive and non-aggressive offences in a
sample of 121 psychotic men. Through direct observation at interview and file review, Taylor
found that 75% of men in this study were actively symptomatic at the time of their offence.
However, only 46% of offences were either directly or probably driven by delusions or

17
hallucinations. The majority of aggressive acts committed by people with a mental illness in
this study were motivated by the same social and psychological factors which motivate non-
mentally ill individuals to commit aggression. These motives may however have been
indirectly influenced by the illness. Immediate retaliation to perceived provocation was the
most common reason for offending.
1.4.2 Antecedents to Inpatient Aggression
Antecedents to aggression have frequently been identified to assist prediction of
imminent aggression. Powell et al. (1994) identified verbal and physical antecedents through
review of Incident Forms. A single antecedent was identified for the majority (82%) of
incidents: 52% were preceded by internal antecedents or characteristics of the patient, 48%
were preceded by external characteristics, hospital related or interpersonal. The most common
antecedents were: patients were generally agitated or disturbed, followed restrictions were
placed on patients due to hospital routines and regimes, and provocation by other patients,
relatives or visitors. In an examination of violent incidents in an adolescent forensic unit,
McDougal (2000) identified a number of personal (variations in mood, boredom, agitation,
anxiety, preoccupation, overactivity, and psychotic symptoms) and interactive (invasion of
personal space, touch, unfulfilled requests, limit setting, increased observation, hostility,
threats and anger) antecedents to aggression.
Sheridan et al. (1990) examined events preceding 73 episodes of restraint following
acts of aggression and attempted to interview all patients within 72 hours of their release from
restraint. Behavioural cues preceding the patient’s aggression were obtained from medical
records and interviews with staff. The origin of events leading to aggression was more
frequently categorised as external (existed outside the patient and involved another person)
rather than internal (when they were directly related to symptoms of the patient’s illness). The
most frequent external event precipitating restraint was patient staff conflict (e.g.,
enforcement of rules by staff, staff denying patient privileges, or staff denial of a patient’s
request). Of the 48 patients who agreed to an interview, 28 viewed the aggression as a
consequence of conflict with staff, 11 as a conflict with other patients and five as conflict with
family. Thirty one patients were able to identify their feelings before the incident: 12 were
angry, six were upset, five were depressed, five were nervous, two were frustrated, two felt
good, two were scared, one felt guilty and one felt worried.
1.4.3 Consequences for Inpatient Aggression
Management strategies designed to contain aggressive behaviour are the most
frequently examined consequences. Following assaults, staff may attend to the aggressive
patient, request reasons for their assault, touch, reason or reprimand, increase supervision,

18
escort patients to a quiet secluded area, provide physical restraint or prn medication.
Gudjonsson et al. (1999) recorded the frequency with which three of the most common
consequences were utilized following aggression; 67% of incidents resulted in physical
restraint, in 36% prn medication was administered, and in 11% of incidents the patient was
transferred to an intensive care area, seclusion room, bedroom or elsewhere. Prn medication
was utilized in 54% of occasions when patients were transferred and following 44% of
incidents in conjunction with physical restraint.
All interventions and management strategies may inadvertently reward aggression
(Drinkwater & Gudjonsson, 1989). In one study of seclusion room practices, a number of
staff recommended that a staff member should remain with the patient during seclusion and
that seclusion rooms should be comfortable and accessible when required for disturbed
patients (Plutchik at al., 1978). In this study secluded patients often received special attention
from staff. Efforts were made to avoid implications that the patient’s loss of control was bad.
The responses of other patients may also reinforce aggression. The aggressive patient
may be admired by other patients for standing up against the seemingly unreasonable
demands of staff, or may receive tangible rewards such as cigarettes and favours from
intimidated patients and staff. Further, aggression may enable the patient to avoid a program
or therapy session they do not wish to attend, or frighten annoying and intrusive fellow
patients who do not respond to verbal requests.
1.4.4 Summary
Despite methodological limitations, including the small number of studies involving
interviews with aggressive patients and the exclusive focus, in terms of consequences, on
aggression management strategies, the available literature reveals a number of possible
functions of inpatient aggression. Aggression may be a function of normal psychological
processes such as anger, revenge or jealousy, and may occur in response to perceived
provocation. Provocations may result from a misinterpretation of environmental stimuli
resulting from the patient’s psychiatric illness. On other occasions the provocation may be
‘real’, yet the patient’s social and psychological functioning, their ability to tolerate these
provocations or respond assertively, may be compromised due to psychiatric illness. In some
instances aggression may be a function of compelling psychotic symptomatology in which
compliance with symptoms alleviates frustration or assists patients in managing their
psychosis.
Aggression may also allow the patient to manage his or her environment. Many
aggressive incidents occur following demands by nursing staff or when requests are refused.
In an environment with few rewards and many expectations, aggression may be used to avoid

19
these demands, or to coerce staff into granting their requests. Aggression may be used
instrumentally to obtain sanctuary in the form of seclusion, physical attention during restraint,
or sedation following the provision of prn medication. Aggression may afford the aggressive
patient prestige, or may help him or her achieve material gain. Aggression may reduce social
isolation as staff intervention usually occurs as a consequence to aggression. For some
patients aggression may, in itself, be reinforcing.
1.5 Conclusion and Recommendations for Future Research
Although the literature reveals some inconsistencies, it is clear that psychiatric
inpatient aggression is linked to a wide range of clinical, psychological and environmental
variables. Any demographic, clinical or environmental characteristic may or may not be
significant for a particular patient. The experience of psychiatric illness and a patient’s
response to environmental demands vary considerably. It follows that pathways to aggression
may vary between patients.
The studies of inpatient aggression reviewed mainly involved structural assessment
approaches. The associations identified in these studies assist in the identification of high-risk
patients and problematic environments. Resource allocation and actuarial risk assessment are
enhanced through these studies. Identification of the correlates of aggression is however of
limited usefulness to clinicians interested in the design, implementation and evaluation of
psychological intervention plans. The crucial question of what is causing aggression and how
it can be changed is left unanswered by structural analyses, even when a number of associated
demographic and clinical variables are observed within the aggressive patient.
Functional analysis and examination of the purposes of psychiatric inpatient
aggression have been relatively neglected. Only two studies, one of which examined incidents
of aggression in an adolescent forensic unit, identified functional relationships influencing
aggression through analysis of proximal antecedents and consequences. Further research is
required to elucidate empirically the purposes or functions of aggression. This is achievable
through assessment of the antecedents and consequences for aggression to identify purpose, in
addition to assessment of the predisposing characteristics pertinent to aggression (e.g., anger
management and assertiveness skills), which clarify why aggression rather than some other
interpersonal conflict resolution strategy was selected. Once the range of possible purposes
for aggression are identified and operationalized, ward staff may be able to intervene at times
of aggression in an informed manner that considers the purposes of the aggression, and the
impact of their intervention on the course of the aggression.
Interventions may occur at the ward and individual patient levels. For example, should
a patient’s aggression always occur after demands are made of him, and the patient be found

20
to have inefficient assertion skills and poor anger control, then intervention programs may be
developed which assist the patient express their dissatisfaction with demands in more
appropriate and assertive means, whilst at the same time managing their anger. Similarly,
management strategies may be delivered which ensure aggression is not reinforced (i.e., that
demands are not avoided as a consequence to aggression). At the ward level, if patients were
aggressive during times of the day when no ward programs existed, and therefore considered
a consequence of frustration with the lack of stimulation and attention received from staff,
then ward programs could be introduced at these times.
With few exceptions the studies reviewed here were hampered by methodological
limitations, which compromise the ability to arrive at definitive conclusions about inpatient
aggression. These limitations include the wide variability in environments and populations,
the lack of appropriate recording systems, the retrospective nature of most studies, the lack of
a theoretical basis for examining inpatient aggression, and inconsistent definitions.
The research settings and populations examined varied in terms of: (a) the nature and
purpose of the ward environment, (b) the degree of psychosocial rehabilitation offered, (c)
admission and discharge policies, (d) whether wards were locked or not, (e) the aesthetic
appeal of the ward, (f) the experience of ward staff, (g) the nature of aggression management
strategies and practices utilized, (h) the ward’s tolerance of aggression, and (i) the
demographic and clinical characteristics of patients.
Standardised instruments designed to assist reporting of inpatient aggression have not
been developed. Most of the studies that were reviewed relied upon either retrospective
review of standard hospital Incident Forms, file review, or observation by staff to determine
the nature of aggression. Direct patient interviews were rare. Retrospective analysis of
aggressive incidents results in unreliable recording (Lion et al., 1981). Further, standard
Incident Forms are often isolated from a theoretical framework. Their content is restricted to
that information deemed pertinent by the author at that time. The perceptions and motives of
the aggressive patient may be neglected. The complex interaction of factors contributing to
aggression is generally unable to be understood through analysis of Incident Forms alone.
Furthermore, instruments designed to assess the frequency and severity of aggressive
incidents are neither sophisticated nor sensitive enough to elicit the purpose of aggression.
Most research reviewed did not consider theoretical pathways to aggression. This may
be due to the assumption that psychiatric patients' aggression is motiveless, or that the
experience of psychosis is discontinuous from normal experience. Few authors considered the
role of anger, despite its central and contributory role in the aggression of other populations
(Novaco, 1994). No study considered the anger mediated/instrumental distinction frequently

21
used to differentiate motives of aggressive behaviour in non-mentally ill offenders. Few
authors considered the influence of interpersonal characteristics, in particular the influence of
gender, personality styles and diagnostic categories of patients hospitalised together.
A further methodological problem was the lack of consistent definitions of psychosis
and aggression. Typically the narrowest definition of psychosis was utilized (i.e., the presence
of delusions and hallucinations). In terms of behavioural outcomes, some research examined
behaviours resulting in physical injury to a person whereas others focussed on verbal and
physical aggression. Some studies failed to differentiate violent from aggressive actions.
Blackburn (1993) defined violence as the intentional infliction of physical injury, and
aggression as the intentional infliction of harm, including psychological discomfort as well as
physical injury, which is unjustified from the victim’s perspective. In this program of research
these definitions were used.
Aggressive acts were infrequently differentiated on the basis of severity or frequency.
The considerable difference in harm caused by the frequently verbally aggressive patient and
the infrequently aggressive patient who, on the rare occasions acts aggressively, causes
physical injury or death, highlights the need for future research to take into account the
severity and frequency of aggression. Differentiating aggressive acts on the basis of form,
severity and frequency assists in risk management and resource allocation. Severity and
frequency of aggression may also be related to purpose. For example, the patient who, on a
daily basis, walks the ward articulating threats to kill may be left alone by other patients, the
intention of his behaviour. Conversely, the patient who acts aggressively infrequently yet in a
very severe manner may do so in response to misperceived provocation and may intend to
cause harm. In the only study that examined the relationship between antecedents and form of
aggression (McDougal, 2000) no significant correlation was found. However, given the
paucity of research into the relationship between purpose and severity, further inquiry appears
warranted. Such investigations may benefit risk management and prediction. Typically
dynamic (response to treatment) and static (gender, history of violence, relationship history,
socio-economic status, history of use of weapons and criminal history) factors form the basis
of actuarial risk assessment instruments. Should purpose correlate with severity it may
become a useful component of risk assessment tools.
An excessive reliance on the immediate and direct contributors to aggression with an
exclusive focus on individual characteristics promotes simplistic, linear models of aggression.
Distal (e.g., previously learned patterns of aggression) and proximal (e.g., provocative
interactions by staff), direct (e.g., fear of attack) and indirect (e.g., limited assertiveness)
contributors to aggression (demographic, clinical and situational characteristics) should be

22
considered prospectively within a framework grounded in theory if a comprehensive analysis
of inpatient aggression is to be achieved. The development of recording systems capable of
reliably classifying the purpose of aggression, and intervention guidelines corresponding to
these purposes may assist the treatment of aggressive inpatients and enhance risk assessment
and management.
Against this background, the aim of the current research was to develop a functional
analysis of inpatient aggression, which in part relied upon the assessment of purpose, using a
methodology designed by the author for this task. An assessment of predisposing
characteristics was also undertaken. The literature reviewed here, and that describing the
history and use of functional analysis, together with the results from three studies, undertaken
to assist the development of methodology for the main study and to examine other aspects of
inpatient aggression, are integrated into the final functional analysis.

23
 CHAPTER 2: INITIAL STUDIES
2.0 A Preliminary Investigation into Patterns of Aggression in the Thomas Embling
Hospital
There is little published research on aggression in Australian psychiatric hospitals,
and prior to the publication of this study (Daffern, Mayer & Martin, 2003) there was no
published research on aggression in an Australian forensic psychiatric hospital. To ensure
effective prevention and management of aggressive behaviour it is crucial that there is an
appreciation of the demographic and clinical characteristics associated with aggressive
behaviour, which are likely to be consistent across environments. It is also important to
understand local patterns of aggression, which may reflect the influence of environmental
contributors. This first study was therefore designed with this task in mind. Its aim was to
assess the frequency, direction and type of aggression within the TEH through retrospective
review of available documentation pertinent to aggressive behaviours that occurred within the
first year of the TEH’s operation. In addition to refinement of methodology for subsequent
studies, this review aimed to understand a discrepancy in the frequency of WorkCover (a
Victorian state government workers’ compensation insurance scheme) claims between wards,
noted by the hospital’s Human Resources Department. Staff injuries resulting from aggression
are a significant liability for the hospital. An unequal distribution of claims existed between
the two male acute wards, with 18 claims from one ward and two from the other. This study
was undertaken in collaboration with the hospital’s Senior Nurse, Dr. Trish Martin and a
Clinical Administrator, Maggie Mayer.
2.1 Aggression in Forensic Psychiatric Hospitals
Prior to the commencement of this study, a review of aggression in forensic
psychiatric hospitals was undertaken (see previous chapter). In summary, this review showed
that forensic hospital patients show a greater incidence of aggression when compared with
patients in general psychiatric hospitals (Dietz & Rada, 1982; Larkin et al., 1988; Rasmussen
& Levander, 1996; Torpy & Hall, 1993), with staff and patients the victims of aggression in
approximately equal proportions (Torpy & Hall, 1993). In these hospitals females tend to be
more aggressive than males (Larkin et al., 1988; Rasmussen & Levander, 1996). Consistent
with the results obtained in studies of general psychiatric hospitals, a small proportion of
patients are responsible for a disproportionately high number of incidents (Larkin et al., 1988;
Rasmussen & Levander, 1996), serious incidents are rare (Rasmussen & Levander, 1996),
aggressive patients are younger, and typically show more psychotic symptoms (Rasmussen &
Levander, 1996). Heilbrun, Golloway, Shoukry and Gustafson (1995) found forensic patients
to be more threatening and verbally hostile when compared with civil psychiatric patients.

24
Psychiatric patients with longer exposure to prison have been shown to be more exploitative
in their relationships when compared with patients without such prison exposure (Morrison,
1994).
2.2 Australian Research
Comparatively little research on psychiatric inpatient aggression has been conducted
in Australia. Findings from the few studies that do exist tend to be consistent with results
found in the international literature. Cheung et al. (1996) examined aggressive incidents in the
rehabilitation wards of a large psychiatric hospital in Melbourne, Victoria (including two
locked wards for chronically aggressive patients), and found aggression to be most frequently
directed to staff, then patients and property. Serious acts of aggression were rare and males
were more physically, but not verbally aggressive than females. Barlow, Grenyer and Ilkiw-
Lavalle’s (2001) investigation of aggression on four adult psychiatric units in Wollongong,
New South Wales, revealed that aggression was most likely to occur within two days of
admission, was more frequent on the day shift, and involved only a small proportion of
patients, who were younger and actively psychotic. Aggressive patients were more likely to
have a history of both substance misuse and aggression, and to have diagnoses of either
schizophrenia or bipolar affective disorder. Owen, Tarantello, Jones and Tennant (1998)
investigated aggression in five psychiatric units in Sydney, New South Wales, and reported
that aggression was most frequently directed towards staff, followed by property and other
patients.
2.3 Method
The setting for this project was the TEH, the secure inpatient hospital of the Victorian
Institute of Forensic Mental Health, which was opened on 27th April 2000. The TEH provides
psychiatric assessment and treatment for mentally disordered offenders. The patients are
remanded or sentenced prisoners with a serious mental illness requiring secure hospital
treatment, people detained as being unfit to plead or not guilty because of mental impairment,
offenders or alleged offenders referred by courts for psychiatric assessment and/or treatment,
selected high-risk offenders referred by releasing authorities, and people with serious mental
illness referred from general mental health services who are a risk to the community.
During the first year of operation, the TEH encompassed an acute care program and a
continuing care program. The acute care program comprised 40 beds, two 15-bed wards for
acutely ill males (Argyle and Atherton), and a 10-bed ward for acutely ill women (Barossa).
The acute care program offered extensive assessment and early treatment. The continuing care
program comprised 40 beds in two wards. The program aimed to assist patients gain and
maintain independent living. One 20-bed extended care ward (Canning) offered supported

25
living for patients in a high/medium security environment. It was primarily directed towards
patients who required long-term care and treatment due to chronic symptomatology, and/or
behaviours that represented a risk to the community. The program was designed to reflect the
normal life patterns of work, rest and recreation, with an emphasis on patients creating an
existence for themselves from which they could derive meaning and a sense of fulfilment.
Staff worked with patients on individual, long-term projects aimed at reducing the effects of
institutionalisation, reducing the likelihood of reoffending, maintaining mental well being,
and improving overall quality of life. Educational, therapeutic, recreational and work related
groups were conducted on the ward. The other rehabilitation ward (Bass) was a 20-bed
intensive rehabilitation, independent living ward for patients in a medium security
environment. It was primarily directed towards patients whose mental state had been
stabilised and who were working towards reintegration into the community. Emphasis was
placed upon personal autonomy, responsibility, and the attainment of the skills necessary to
make a successful transition from the hospital to the community. Patients were encouraged to
take advantage of the educational, vocational and recreational opportunities available on
campus, as well as establish community-based networks. In addition to ward based care and
programs, the hospital provided patients with access to a range of campus based therapeutic,
educational, recreational and leisure programs.
2.3.1 Procedure
Incident Forms that reported acts of aggression by patients between 27th April 2000
and 26th April 2001 were reviewed. Information extracted from these forms included the time
of day and month of aggressive incident, ward, type of aggression (verbal or physical
aggression or property damage), characteristics of the aggressive patient (gender and age),
characteristics of the victim (gender, whether staff or patient, and the discipline if staff
victim), and the severity of aggression. Severity of aggression was rated retrospectively
according to information on the Incident Forms by Maggie Mayer, a Clinical Administrator,
according to an adapted version of the Overt Aggression Scale (OAS) (Silver & Yudofsky,
1987) (see Appendix 1). This scale categorises aggressive behaviour into verbal aggression,
physical aggression against objects, physical aggression against self and physical aggression
against other people. In the adapted version of the OAS, modified for this program of
research, items relating to physical aggression against self were eliminated. On the adapted
version, like the original scale, each category of aggressive behaviours arranged four different
aggressive behaviours hierarchically according to severity. In this study, the severity of an
aggressive behaviour was ranked, with physical aggression towards others the most severe
form of aggression, followed by verbal aggression and property damage. In this first study,

26
sexual aggression was also recorded. Where several forms of aggression occurred during one
incident (e.g., verbal and physical aggression), the most severe form of aggression was rated.
The Seclusion Register was also reviewed. This register recorded details of the
frequency and length of all incidents of seclusion. DINMA (Disease/Injury/Near Miss and
Accident) forms were also reviewed. DINMA forms are completed when the health of a staff
member is compromised. A completed DINMA form is required before any WorkCover
claim is processed. These forms may therefore provide information on those incidents of
aggression that resulted in the most physical or psychological harm. These forms were
reviewed to add additional information on the severity of aggression, to identify acts of
aggression not recorded on Incident Forms, and to classify incidents of physical aggression as
either containment or direct assault. Containment assaults were those that occurred within the
context of restraint and seclusion. Direct assault incidents were those that occurred prior to
any attempt to restrain or seclude the patient. Data were analysed using SPSS for windows
version 10.0. Approval to conduct the research was granted by the Department of Human
Services Human Research Ethics Committee.
2.4 Results
One hundred and ninety seven incidents of aggression were reported within the
hospital during the 12 months under review. Physical aggression was the most common form
of aggression recorded (88 or 44.7% of incidents), followed by property damage (68 or
34.5%), verbal aggression (38 or 19.3%) and sexual aggression (3 or 1.5%). Differences in
the frequency of aggression existed between wards. The three acute wards recorded 90% of
all incidents of aggression, with the two male acute wards recording the majority of these
(73.1%); Argyle (male acute) recorded 83 incidents, Atherton (male acute) 61, and Barossa
(female acute) 35. Rehabilitation wards accounted for 16 (8.1%) incidents. Two incidents
occurred off-ward. Sixty-six patients, 51 males and 15 females, from a total of 193 patients
admitted to the hospital during the study period, were responsible for the 197 incidents.
Twenty-seven patients were aggressive on one occasion. Twelve patients were aggressive on
five or more occasions. One patient was responsible for 15 incidents. On Argyle 24 (50%),
from a total of 48 patients were aggressive; on Atherton, 25 (46.3%), from a total of 54
patients were aggressive; on Barossa, 15 (35.7%), from a total of 42 patients were aggressive;
on Bass, one (3.6%), from a total of 28 patients were aggressive, and on Canning, seven
(33.3%), from a total of 21 patients were aggressive. Six patients were aggressive across more
than one ward due to within-hospital transfers.
Given the small sample of aggressive patients, only descriptive statistics are presented
in this study. Variation in the type of aggression and characteristics of the victim existed

27
across wards (see Figure 1). Physical aggression occurred mostly on the male acute wards.
Both Atherton (30) and Argyle (34) recorded a similar frequency of physical aggression,
although a marked difference existed when characteristics of the victim were taken into
account. On Argyle, staff and patients were the victims of aggression at an equal rate (17
incidents), whereas on Atherton, patients (26) were more frequently the victims of physical
aggression when compared to staff (4).

Figure 1: Type of aggression and victim classification by ward location

35

30
Number of Incidents

25

20

15

10

ARGYLE ATHERTON BAROSSA BASS CANNING OFF WARD

Ward location

Physical Aggression Staff victim Physical Aggression Patient victim Verbal Aggression Staff victim
Verbal Aggression Patient victim Property Damage Sexual

Severity
Table 1 shows the frequency of aggressive behaviours according to the adapted OAS.
The most common forms of aggression included ‘Breaks objects, smashes windows’ (40
incidents), and ‘Physical aggression resulting in mild-moderate injury such as bruises, sprains
or welts’ (40 incidents). No incidents of the most severe type of aggression ‘Attacks others
causing severe physical injury such as broken bones deep lacerations or internal injuries’ were
recorded, although ‘Striking, kicking, pushing or pulling hair’ (29) and ‘Makes threatening
gestures, swings at people or grabs at clothes’ (19) were common. Verbal aggression (all
types) was infrequently recorded. The three incidents of sexual aggression were not recorded
in terms of severity, and a further seven incidents, all of which involved verbal aggression,
were unable to be rated retrospectively on the adapted OAS due to insufficient information.

28
 Table 1: Severity of Aggression

Type of aggressive incident Total number of

incidents

Slams door, scatters clothing, makes a mess 5

Throws objects down, kicks furniture without breaking it, marks the wall 23

Breaks objects, smashes windows 40

Sets fires, throws objects dangerously

Makes loud noises, shouts angrily 7

Yells mild personal insults, e.g., “You’re stupid!” 3

Curses viciously, uses foul language in anger, makes moderate threats to others or self 9

Makes clear threats of violence towards others (“I’m going to kill you”) or requests 12

help to control self

Makes threatening gesture, swings at people, grabs at clothes 19

Strikes, kicks, pushes, pulls hair (without injury to the victim) 29

Attacks others, causing mild-moderate physical injury (bruises, sprain, welts) 40

Attacks others, causing severe physical injury (broken bones, deep lacerations,

internal injury)

Sexual aggression 3

Missing/unable to be coded 7

Total 197

Aggressor and Victim Characteristics

Aggressive patients ranged in age from 18 to 61 years (M = 32.16, SD = 13.77;
Median = 29). Males were responsible for 82.2% of all recorded incidents. Patients (68
incidents) and nursing staff (48 incidents) were the most frequent victims of verbal and
physical aggression. Cleaning/food handling (4), medical (1), allied health (1), administration
(1) YMCA (staff employed to work within a recreation facility in the secure campus) (1) and
visitors (1) were also the victims of aggression. Physical aggression against patients (56) was
recorded more frequently than verbal aggression against patients (18). Physical aggression
against staff (30) was more common than verbal aggression (23) or sexual aggression (3).
Males (84 incidents) were the victims of aggression more frequently than females (37
incidents). On 11 occasions both males and females were the victims of aggression. Patients
were aggressive towards other patients of the same gender, and on all but two occasions,
patients were both verbally and physically aggressive towards staff of the same gender.
Female members of staff were exclusively the victims of sexual aggression.

29
Time of Incident
No fewer than 10 incidents occurred every month. The most incidents occurred in
September (33) with the least in October (10). All other months recorded between 14 and 19
incidents. An even distribution of aggressive incidents existed between 9:00am and 11:00pm.
At least 8 (between 9:00pm and 10:00pm), and no more than 17 incidents (between 9:00am
and 10:00am), were recorded every hour between 9:00am and 11:00pm across the 12-month
period of the study. No aggression occurred between midnight and 5:00am.
Containment and Assault: Seclusion Register and DINMA Forms
Thirty-two incidents of physical aggression towards staff were recorded. Review of
Incident Forms and DINMA forms showed that 20 incidents occurred within the context of
restraint or seclusion and 12 occurred within the context of direct assault. Frequency and
duration of seclusion were identified through review of the Seclusion Register. Seclusion
episodes lasting more than 1000 minutes (3 episodes) were removed, as these were considered
extraordinary. Seclusion episodes used to prevent absconding or to prevent self-harm were
also removed. Two hundred and fifty three seclusion episodes remained. Considerable
differences existed between wards. Argyle recorded 123 episodes compared with 62 in
Atherton. Bass ward did not use seclusion at all and Canning, the slow stream rehabilitation
ward, recorded only five episodes. Barossa recorded 62 episodes of seclusion. Duration of
seclusion also varied. Atherton ward recorded the longest duration of seclusion (324 minutes),
followed by Argyle (276 minutes), Barossa (225 minutes) and Canning (137 minutes).
2.5 Discussion
The aim of this first study was to investigate the frequency and pattern of aggression
in the TEH, so as to contribute to the development of methodology for the main study in this
program of research, and to understand a discrepancy in WorkCover claims between male
acute wards. Similar to the results obtained in previous research in both general and forensic
psychiatric hospitals, aggression was common although severe acts of aggression were rare.
In this study there were no recorded incidents of ‘Attacks others, causing severe physical
injury’. Nursing staff were more frequently the victims of aggression than other staff groups.
This probably reflects their greater numbers within the hospital, the tendency of all staff to
rely on nurses to restrain and seclude aggressive patients, the time they spend with patients,
and the fact that nursing staff more frequently impose limits on patients or demand that they
attend to an activity possibly considered aversive by the patient. Few staff members of other
disciplines were the victims of aggression. When they were, the type of aggression was
usually verbal.

30
 Compared to staff, patients were more frequently the victims of physical aggression.
One explanation for this may be that forensic hospital patients are mostly admitted from
prison, where cultural norms surrounding aggression differ from those in the general
community. Aggression in prisons is affected by the status, social dominance or privilege
afforded to those prisoners who both respond to provocation with aggression, and who use
aggression to achieve material gain (Toch, 1989). Further, patients were aggressive towards
other patients of the same gender, and on all but two occasions, patients were both verbally
and physically aggressive towards staff of the same gender.
Clarification of the discrepancy in WorkCover claims emanating from patient
aggression between the two male acute wards was assisted by the review. The majority of
WorkCover claims were a consequence of physical aggression against staff, resulting in
injury. Although the total number of aggressive incidents varied between the two wards; 83
incidents on Argyle, the ward with 18 WorkCover claims, and 61 incidents on Atherton, with
only two claims, the frequency of physical aggression in the two wards varied marginally; 34
incidents on Argyle, and 30 on Atherton. When the type of victim was considered, differences
appeared. On Argyle, staff and patients were equally the victims of physical aggression,
recording 17 incidents each. However, on Atherton many more incidents of physical
aggression against patients (26), when compared to physical aggression towards staff (4) were
recorded. Whilst the small number of subjects and incidents precluded statistical analysis, it
was clear that different patterns of aggression existed.
Examination of the DINMA forms showed that most incidents of physical aggression
towards staff occurred within the context of restraint and seclusion (20 of 32, or 62.5% of
incidents). Review of the Seclusion Register showed that Argyle used seclusion almost twice
as often as Atherton. One explanation for the discrepancy in WorkCover claims may therefore
be that staff on Argyle had a lower tolerance for aggression and secluded potentially
aggressive patients more readily than Atherton. Restraint and seclusion may exacerbate
aggression, expose staff to a greater likelihood of injury, and impair the therapeutic
relationship staff share with patients. Whilst patients may be verbally aggressive or damaging
property prior to restraint and seclusion, staff may not be the initial targets of physical
aggression. As staff on Argyle secluded potentially aggressive patients more frequently than
staff on Atherton, this may have also contributed to the smaller number of incidents of
physical aggression between patients on Argyle compared to Atherton. That is, patients at risk
of behaving aggressively may have been removed from the presence of co-patients prior to
physical aggression against them. These results suggest that some aspects of staff behaviour,

31
in particular the management of risk and staff member’s propensity to use restraint and
seclusion, may contribute to the frequency and direction of aggression on psychiatric wards.
The interpretation of these findings in this manner may have implications for the
management of aggressive patients and for the prevention of injury to ward staff. If the goal
of hospital administrators is to reduce staff injury, and the method identified to achieve this
goal is to reduce restraint and seclusion, then the risk of aggression between patients may be
increased. The relative merits of secluding potentially aggressive patients to avoid aggression
towards other patients, with the concomitant risks to staff involved in restraint and seclusion,
require careful consideration. Further, distinguishing physically aggressive incidents
emanating from restraint and seclusion from incidents occurring outside of this type of
provocation may be helpful for future studies of inpatient aggression.
The methodological problems inherent in previous research on psychiatric inpatient
aggression are relevant to this study. As retrospective analysis of Incident Forms may result in
unreliable assessment (Lion et al., 1981), the 197 incidents identified in this review most
likely represents an underestimate of aggression within the TEH. Incident Forms should be
completed following any event considered inconsistent with routine operation. Considerable
variability exists in definitions of incident, and routine operation. Verbal aggression between
patients was rarely recorded and probably represents both the acceptance amongst staff that
such events are not inconsistent with the manner in which forensic patients interact, and the
fact that recording such incidents serves little purpose. Staff familiar with forensic psychiatric
wards would acknowledge that verbal aggression towards staff in particular is common and
appears in this study to have been underreported. The higher rate of physical aggression when
compared to verbal aggression against both staff and patients may well have been a
consequence of the recording procedure. Additional evidence for the failure of retrospective
review of Incident Forms to provide an accurate assessment of aggressive behaviour may be
found in the review of the Seclusion Register. Approximately half of the 253 episodes of
seclusion resulting from aggression had no corresponding Incident Form.
This study identified the use of restraint and seclusion as one particular environmental
contributor to inpatient aggression that has received little attention in the literature. The
contribution of restraint and seclusion to the observed variation in the direction of aggression
may in part explain the discrepancy in WorkCover claims. This research also highlights the
need to use prospective measures of recording incidents on instrumentation specifically
designed for measuring inpatient aggression. Given problems with underreporting of
aggressive behaviours and the need to identify a means of more accurately recording incidents
of aggression, a further study, focusing on comparison of aggressive behaviours recorded on

32
Incident Forms, with those recorded prospectively on aggression specific recording
instrumentation, was undertaken.

33
 3.0 A Prospective Assessment of Aggression within the Thomas Embling Hospital
This second study describes a prospective assessment of aggression. As noted in the
previous study, assessment of inpatient aggression has traditionally relied on retrospective
analysis of institutional records, including Incident Forms. However, almost as soon as
research on inpatient aggression appeared in the literature, Lion et al. (1981) reported that
such methodology results in unreliable assessment, with approximately five times as many
aggressive episodes documented in daily ward reports when compared with incident reports.
Underreporting of aggressive behaviours may occur because: (1) of the effort required to
complete an Incident Report, (2) staff tolerate or accept aggression as a “matter of course” (p.
497), (3) many staff may view violence as an indication of performance failure and therefore
fail to record it, and (4) if staff report aggression they may fear investigation into whether or
not they had assaulted the patient in self defence (Lion et al., 1981).
Other contributors to underreporting include: (1) staff may accept anger and
aggression as an acceptable occupational hazard because both are common in psychiatric
hospitals, (2) staff may become inured to aggressive behaviour because it is so common, (3)
hospitals may utilise ineffective or non-specific reporting mechanisms, such as standard
Incident Forms which have unclear or vague definitions of incident or aggression, and do not
direct staff to complete such a form for all acts of aggressive behaviour and then define what
constitutes aggressive behaviour, (4) paperwork, policies and procedures may be considered
excessive and burdensome, (5) some staff willing to tolerate aggression may exert peer
pressure on other staff, preventing them from officially recording incidents, and (6) there may
be few or limited responses by hospital administrators to minor incidents of aggression so that
staff are discouraged, or become apathetic in relation to notifying administrators of minor
incidents of aggression through official recording procedures (Rippon, 2000).
When specific aggression recording instruments such as the Overt Aggression Scale
(Silver & Yudofsky, 1987) are used to record aggressive behaviours, considerably more
aggressive incidents are recorded. For example, Silver and Yudofsky (1987) reported that the
OAS recorded 87% and 98% of documented aggressive incidents at two psychiatric centres
whereas other hospital documentation recorded only 27% and 53% of aggressive incidents.
The 197 incidents of aggression in the first year of operation of the TEH identified in the first
study may have represented an underestimate of the frequency, and misrepresent the form and
direction of aggressive behaviours. Although it could be argued that the most serious
incidents of aggression are recorded on Incident Forms, the lack of any corroborative
aggression monitoring system suggests such conclusions may be premature.

34
 Few studies since that by Lion et al.’s (1981) initial observations have compared
prospective assessment of aggressive behaviours with those identified through review of
Incident Forms. Prospective research that compares aggressive behaviours recorded on
specific instruments with standard Incident Forms may indicate what is considered an
untoward incident and reveal what proportion, and which type of aggressive behaviours, are
recorded on Incident Forms. In addition to ascertaining a more accurate assessment of the
frequency, type and direction of aggression within the TEH, and to assess staff perceptions of
incident, the second study also aimed to pilot recording procedures and methodology
designed for recording aggressive incidents in the main study. A further purpose was to
identify when seclusion was used to manage aggressive patients, and to clarify whether
recording incidents of aggression would have some effect on the frequency of aggression
within the hospital.
3.1 Method
3.1.1 Setting
The setting for this project was the TEH, a description of which may be found in the
method section of the first study.
3.1.2 Procedure
All five wards within the hospital were provided with a folder containing copies of an
adapted version of the Overt Aggression Scale (OAS) (Silver & Yudofsky, 1987) (see
Appendix 1). A description of this scale may be found in the procedure section of the first
study. Members of ward staff were trained in how to record incidents of aggression by the
author. They were instructed to record aggressive behaviours either after they occurred, or
when reviewing patients at the completion of a shift. Where several forms of aggression
occurred during one incident (e.g., verbal and physical aggression), the most severe form of
aggression was rated. The name of the aggressive patient, the date aggression occurred,
whether the victim of aggression was a patient or a member of staff, and the ward location
were also recorded. The study began on 1st October 2001 and ended on 31st March 2002.
The author visited each ward three times every week to provide support and
encouragement for staff, to ensure they remained mindful of the project, and to ensure acts of
aggression were recorded. The Seclusion Register and Incident Form data base were also
reviewed at the completion of the study to identify incidents of aggression not recorded on the
adapted OAS and to determine which type of incidents were recorded on Incident Forms, and
which incidents resulted in the patient being secluded. Data were analysed using SPSS for
windows version 10.0. Approval to conduct the research was granted by the Department of
Human Services Human Research Ethics Committee.

35
 3.2 Results
Using the recording procedure described above, 331 incidents of aggression were
reported within the hospital during the six months under review. Verbal aggression was the
most common form of aggression recorded (n = 205, 61.9% of incidents), followed by
physical aggression (n = 98, 29.6%), and property damage (n = 28, 8.5%). Differences in the
frequency of aggression existed between wards (see Table 2). The three acute wards recorded
95.5% of all incidents of aggression. Argyle (male acute) recorded 135 incidents, Atherton
(male acute) 93, Barossa (female acute) 88, Canning (slow stream rehabilitation) 14, and Bass
(intensive rehabilitation) one incident. Across the three acute wards, physical aggression was
recorded in similar proportions, with Argyle and Atherton, the two male acute wards
recording 31 incidents and Barossa recording 30 incidents. Canning recorded six incidents of
physical aggression and Bass did not record any. Property damage was recorded in similar
proportions across the three acute wards with Argyle and Barossa recording nine incidents
each, and Atherton 10. No incidents of property damage occurred on the rehabilitation wards.
Fewer incidents of verbal aggression were recorded on Atherton (52) and Barossa (49)
compared to Argyle (95). The rehabilitation wards recorded few incidents of verbal
aggression; Bass recorded one incident and Canning eight. Accounting for differences in the
number of patients in the acute wards, female patients (Barossa) were slightly more likely (M
= 8.8 incidents per bed for the study period) to be aggressive than male acute (Atherton and
Argyle) patients when the aggressive behaviours across the two male acute wards were
combined (M = 7.6 incidents per bed). Males, who represented 75% of acute patients and
85% of all patients, were responsible for 73.4% of recorded incidents.

Variation in the frequency of aggression towards staff and patients occurred across the
five wards (see Figure 2). On Argyle, patients were verbally aggressive to other patients (17)
almost twice as often as they were physically aggressive (8), whereas on Atherton, patients
were physically aggressive to other patients (17) almost twice as often as they were verbally
aggressive (9). On both male acute wards patients were verbally aggressive towards staff
approximately four times as often as they were physically aggressive (Argyle 77 and 22;
Atherton 40 and 14). On Barossa, patients were equally as likely to be verbally aggressive (5),
as physically aggressive (5) to other patients. Barossa staff members were the victims of
verbal aggression approximately twice as often (44) as they were victims of physical
aggression (25). On the rehabilitation wards, patients and staff were the victims of both
physical and verbal aggression in similar proportions. Bass recorded one incident of verbal
aggression against a patient, and Canning reported three incidents of physical aggression
against patients and staff and four incidents of verbal aggression against staff and patients).

36
 Table 2: Number of Aggressive Behaviours by Ward

Male Acute Female Acute Continuing Care Total

(30 beds) (10 beds) (40 beds)

Argyle Atherton Barossa Bass Canning

(15 patients) (15 patients) (10 patients) (20 patients) (20 patients)

Property 9 10 9 0 0 28

Verbal 95 52 49 1 8 205

Physical 31 31 30 0 6 98

Total 135 93 88 1 14 331

Figure 2: Verbal and physical aggression by ward and victim

120

100
Number of incidents

80

60

40

20

0
Staff Patient Staff Patient Staff Patient Staff Patient Staff Patient

Argyle Atherton Barossa Bass Canning

Victim type by ward

Physical aggression Verbal aggression

Sixty-four of 145 (44.14%) patients admitted to the hospital during the study period
were aggressive. Twenty-nine patients from Argyle (74.34% of patients admitted to Argyle),
20 patients from Atherton (51.28%), 14 patients from Barossa (53.85%), one patient from
Bass (4.76%) and four patients from Canning (18.18%) were aggressive. Twenty-one patients
were aggressive on one occasion. Eighty eight (60.7%) were aggressive on more than one
occasion. Eight patients were responsible for more than 10 incidents, including two patients

37
who were aggressive on 25 occasions. These eight patients accounted for 142 (42.9%) of
incidents.
The most common forms of aggression involved the most severe forms of verbal
aggression, ‘Curses viciously, uses foul language in anger, makes moderate threats to others
or self’ (109 incidents) and ‘Makes clear threats of violence towards others (“I’m going to kill
you”) or requests help to control self’ (63). Less severe verbal aggression was infrequent,
‘Makes loud noises, shouts angrily’ (11), ‘Yells mild personal insults, e.g., “You’re stupid!”’
(20). Physical aggression was recorded frequently, ‘Makes threatening gesture, swings at
people, grabs at clothes’ (39), ‘Strikes, kicks, pushes, pulls hair (without injury to the victim)’
(44), and ‘Attacks others, causing mild-moderate physical injury (bruises, sprain, welts)’ (17).
No incidents of the most severe form of aggression, ‘Attacks others, causing severe physical
injury (broken bones, deep lacerations, internal injury)’ were recorded. Property damage was
relatively rare, ‘Slams door, scatters clothing, makes a mess’ (4), ‘Throws objects down, kicks
furniture without breaking it, marks the wall’ (10), ‘Breaks objects, smashes windows’ (10),
and ‘Sets fires, throws objects dangerously’ (4).
Irrespective of differences across wards, members of staff were more frequently the
victims of both verbal (165), and physical (64) aggression, when compared with patients
(verbal, 36, and physical, 33). The average severity of aggression towards patients (M =
4.638, SD = 1.639) was significantly higher (t(296) = 13.264, p = .000) than the average
severity of aggression where members of staff were victims (M = 3.8638, SD = 1.359) (see
Figure 3). Patients were, in terms of the total number of aggressive behaviours in which
patients were victims, more likely to be the victims of physical aggression when compared
with verbal aggression, whereas members of staff were less likely to be the victims of
physical aggression when compared with verbal aggression (χ2(1) = 9.543, p = .002).

38
 Figure 3: Verbal and physical aggression by victim

100
90
Number of incidents 80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8
Severity

Staff victim Patient victim

Note: 1 = Makes loud noises, shouts angrily; 2 = Yells mild personal insults, e.g., “You’re stupid!”; 3 = Curses viciously, uses foul language
in anger, makes moderate threats to others or self; 4 = makes clear threats of violence towards others (“I’m going to kill you”) or requests
help to control self; 5 = Makes threatening gesture, swings at people, grabs at clothes; 6 = Strikes, kicks, pushes, pulls hair (without injury to
the victim); 7 = Attacks others, causing mild-moderate physical injury (bruises, sprain, welts); 8 = Attacks others, causing severe physical
injury (broken bones, deep lacerations, internal injury)

Month, Time of Day and Day of Week

The frequency of aggression varied by month (see Figure 4). The highest number of
incidents was recorded in October (80), followed by November (81), March (54), December
(45), February (41) and January (30). There was no difference between the average number of
incidents per month during the first three months of assessment (M = 68.667, SD = 20.502)
when compared with the latter three months (M = 41.667, SD = 12.014) (t(4) = -3.330, p =
n.s.). During the first three months, 42 incidents of physical aggression against staff were
recorded, and 22 during the latter three months. There were 105 incidents of verbal aggression
towards staff during the first three months and 56 in the latter three months. The difference in
the total number of aggressive behaviours towards staff during the first three months of
assessment (M = 49, SD = 15.621) when compared with the latter three months (M = 27.333,
SD = 5.686) approached, but did not reach significance (t(4) = 2.258, p = n.s.). There were 18
incidents of verbal aggression against patients recorded during the first and second three-
month periods. Seventeen incidents of physical aggression against patients were recorded
between October and December, and 16 between January and March. There was no
significant difference in the frequency of incidents towards patients during the first three
months of assessment (M = 11.667, SD = 2.08) when compared with the latter three months
(M = 11.333, SD = 4.041) (t(4) = .127, p = n.s.).

39
 Figure 4: Aggression by month and victim

90
80
70
Number of incidents

60
50
40
30
20
10
0
October November December January February March
Month

Property Verbal aggression/patient victim

Verbal aggression/staff victim Physical aggression/patient victim
Physical aggression/staff victim

Aggressive Behaviours Recorded Using Incident Forms Versus Adapted OAS Ratings
In contrast to the 331 incidents recorded by staff on the adapted OAS, only 101
Incident Forms were completed (30.2% of aggressive behaviours) during the six-month study
period. Incident Forms were completed for 42.9% of incidents of property damage, 14.8% of
all incidents of verbal aggression and 59% of all incidents of physical aggression. Incident
Forms were only completed for the more severe forms of property damage (χ2(3) = 9.217, p =
.027), and verbal aggression (χ2(3) = 12.433, p = .006). Incident Forms were completed for
all levels of severity of physical aggression (χ2(2) = 1.829, p = n.s). Incident Forms were
more likely to be completed when patients rather than staff were the victims of aggression
(χ2(1) = 3.977, p = .046). There was no relationship between the number of aggressive
behaviours recorded for individual aggressive patients during the previous week and whether
or not an Incident Form was completed (t(329) = 1.469, p = n.s).
Seclusion
Of the 331 incidents, 20.6% resulted in the patient being secluded. Patients were
secluded following five incidents of property damage (17.1% of all incidents of property
damage), 35 incidents of verbal aggression (17.1% of all incidents of verbal aggression), and
48 incidents of physical aggression (40.9 of all incidents of physical aggression). Patients
were more likely to be secluded following incidents of physical aggression when compared to
verbal aggression and property damage (χ2(6) = 45.071, p = .0001). Seclusion was used most

40
frequently on Argyle (35), then Barossa (30), Atherton (18) and Canning (5). Aggressive
patients were secluded in 26.9% of occasions when staff were the victims of aggression and in
37.3% of occasions when patients were the victims of aggression. This difference was not
statistically significant difference (χ2(6) = 4.47, p = n.s.). There was no statistically significant
difference in the number of aggressive behaviours recorded in the week leading to an
aggressive incident between aggressive behaviours resulting in seclusion and in those that did
not (t(308) = .521, p = n.s).
3.3 Discussion
In this second study, aggression against property, verbal aggression and physical
aggression against both patients and staff were recorded frequently on the adapted OAS. In
contrast to the previous study of Incident Forms, verbal aggression was the most frequently
recorded type of aggression, followed by physical aggression, and then property damage.
Compared with the 197 incidents in the retrospective study, 331 aggressive behaviours were
recorded during the six months of this study. Only 101 (30.2%) of aggressive behaviours
identified in this study were recorded on the hospital’s standard Incident Forms. This finding
provides support for the use of prospective assessment of aggressive behaviours using
instrumentation specifically designed for assessing inpatient aggression, rather than review of
such behaviours through analysis of Incident Forms alone.
In contrast with the previous retrospective study, verbal aggression towards staff was
recorded frequently. Verbal aggression towards staff may not be recorded on Incident Forms
as a consequence of any of the reasons identified by Lion et al. (1981) and Rippon (2000).
Incident Forms may however provide a more accurate assessment of property damage and
physical aggression. Property damage may be recorded more reliably as staff members are
expected to complete an Incident Form in these situations in order to alert managers of
damage to property to ensure it is repaired or replaced. Physical aggression may be recorded
more reliably to assist in the processing of claims for compensation and sick leave.
Furthermore physical aggression may be considered more serious, severe or untoward, than
verbal aggression. As in the first study, and consistent with international research, all types of
aggression were more common on the acute wards. Severe forms of aggression were
relatively rare however, most likely as a consequence of the high level of support, structure
and vigilance by staff, assertive pharmacological treatment, and the restricted availability of
weapons in hospital. Similarly to other forensic facilities (Rasmussen & Levander, 1996),
aggression was reported at a similar frequency for both males and females, with females
recording a slightly higher number of incidents per bed throughout the study period.
Interestingly, differences existed between the two male acute wards, in particular for the

41
frequency of verbal aggression, but also for the direction of physical aggression. Similar to
the previous study, aggression towards staff was more frequently recorded on Argyle
compared with Atherton. In the first study this difference was hypothesised to be a
consequence of the more frequent use of restraint and seclusion. It is possible that the use of
seclusion again contributed to differences in the frequency and pattern on aggression in this
study. In the six months under review, seclusion was used more frequently on Argyle
compared with Atherton. An additional contributor to the variation in frequency of aggression
may have been that the author worked as a psychologist on Argyle during the period of this
study. The author’s presence may have resulted in staff being more responsive to the project
and more reliably recording verbal aggression when compared with Atherton staff.
Patients were almost as likely to be the victims of physical as of verbal aggression,
whereas members of staff were more likely to be the victims of verbal, as opposed to physical
aggression. In general, members of staff were the victims of less severe forms of aggression.
The reasons for these differences are unclear although they may be a consequence of the
recording procedure. Staff may not have witnessed some episodes of verbal aggression
between patients or they may have been less willing to record verbal aggression between
patients.
Consistent with previous research (Nijman, Merckelbach, Allertz & á Campo, 1997)
aggression decreased in frequency over the course of the study, although this difference was
not statistically significant. The systematic monitoring of aggression may have contributed to
a reduction in verbal and physical aggression, particularly towards staff, during the latter three
months. As other possible contributors to aggression were uncontrolled in this study, the
contribution of systematic recording to this reduction is unclear. However, given previous
findings consistent with this observation, and the lack of known adverse affects to the
introduction of such monitoring, systematic recording to identify patterns of aggression and to
assist in the reduction of aggressive behaviour could be considered.
As might be expected, because physical aggression is in general considered more
harmful than other forms of aggression, patients in this study were secluded more frequently
following incidents of physical aggression when compared with property damage and verbal
aggression. That seclusion was as likely to occur following incidents of aggression towards
staff as to patients may indicate that staff did not consider harm to their colleagues as more
severe than aggression towards patients. This finding may also indicate that staff did not use
seclusion preferentially as a punishment for those patients who behaved aggressively towards
their colleagues.

42
 In addition to the aforementioned findings, which allowed for more information on
inpatient aggression within the hospital to be obtained, this second study allowed for
methodology designed for use in the main study to be successfully piloted. Ward staff quickly
became familiar with the recording practices and a high level of enthusiasm for the project
emerged, a consequence of staff concern about aggression, their awareness of the lack of
research on inpatient aggression within the hospital, and recognizable problems with the
Incident Forms as a method of recording aggressive behaviours. Given the success of this
pilot, the main study began as planned on 1st January 2002. As this study was underway an
opportunity arose for a third study, an examination of the environmental contributors to
inpatient aggression through review of Incident Forms detailing aggressive behaviours across
two forensic psychiatric hospitals. This study is detailed in the subsequent chapter.

43
 4.0 Environmental contributors to aggression within the Thomas Embling Hospital
This third study used available information, specifically Incident Forms, to examine
the role of a number of environmental factors on inpatient aggression. The opportunity to
examine these characteristics arose from the closure of an old forensic psychiatric hospital,
the Rosanna Forensic Psychiatry Centre (RFPC) in April 2000, and the transfer of its patients
to the TEH. In this study Incident Forms relating to aggressive behaviours during the final
two years of operation of the Rosanna Forensic Psychiatry Centre and the first two years of
operation of the TEH were compared. It was hypothesized that the rate of aggression, by bed
per annum when adjusted for annual occupancy rates, would be lower at the TEH when
compared with the RFPC. This reduction was considered likely due to a number of factors
affecting patient satisfaction with their admission, not the least of which was the aesthetic
appeal of the TEH, the increase in personal space, improved access to occupational,
recreational and educational activities, and a less restrictive regime. Like the first study, this
study was undertaken in collaboration with the hospital’s Senior Nurse, Dr. Trish Martin and
a Clinical Administration, Maggie Mayer.
4.1 Method
4.1.2 Setting
The settings for this project were the TEH and the RFPC. Like the TEH, the RFPC
provided psychiatric assessment and treatment for mentally ill offenders. Patients included
remanded and sentenced prisoners with a serious mental illness who required immediate
inpatient treatment, people detained as being unfit to plead or not guilty because of mental
impairment, offenders referred by courts for psychiatric assessment and treatment, selected
high-risk offenders referred by releasing authorities, and people with serious mental illness
who were a risk to the community and were referred by general mental health services.
The history of the RFPC began in 1989 when two adjoining wards of an existing
psychiatric hospital, built in 1917, were refurbished to become an acute ward and a
rehabilitation ward comprising the forensic program for the hospital. The 18 bed acute ward,
named M6, opened in August 1989 and the 20-bed rehabilitation ward, named M5, opened in
October 1991. In 1999, following the closure of a rural forensic psychiatry centre, a third
ward was refurbished and subsequently became a 20-bed, male continuing care ward, named
Ellery. Wards M6 and M5 were mixed gender wards although the vast majority of patients
were male.
On the acute admission ward, M6, intervention primarily focused on symptom
alleviation. Most patients were psychotic and treatment was targeted at the resolution of
symptoms so that patients could either be returned to prison or to the community depending

44
upon the nature and length of their legal disposition. The intensive rehabilitation ward, M5,
was an independent living program for patients in a medium security environment. Its
program was primarily directed towards patients whose mental state had been stabilized and
who were working towards reintegration into the community. Ellery offered supported living
for patients requiring long-term care and treatment due to chronic symptomatology, and/or
behaviours that represented a risk to the community.
In each ward the day amenities, comprising the television lounge, recreation and
program areas, were downstairs, and the bedrooms and bathrooms were upstairs. Each ward
had an enclosed courtyard garden although on M6 and Ellery this was accessible only when
there were two members of staff available for supervision. In Ellery and M5 a number of the
bedrooms were shared, and in M6 and Ellery the bedrooms were unable to be accessed during
the day, although depending on staff availability, patients could visit the bedrooms for short
periods of time. Each ward had a fenced courtyard but access to the hospital’s grounds was
limited as there was no perimeter fence. On M6 and Ellery during the week, the patients were
required to shower and be downstairs before 8.00am. On weekends patients did not come
downstairs until 10.00am. All patients were required to go upstairs at 9.00pm. There was no
access to downstairs areas during the night. The corridor leading to the downstairs female
toilet in M6 was locked to provide safety for female patients in the mixed gender ward.
Whilst increasing safety this resulted in female patients having to ask staff to open the door
every time they wished to use the toilet. They then rang a bell to be let out and had to wait
until a staff member came to open the door. The limitations of the architecture in M6 and
Ellery resulted in a restrictive environment, characterized by a rigid regime, with few
opportunities for privacy, and limited access to rehabilitation facilities.
In April 2000 the inpatient services were moved from the 58 beds at RFPC to the
purpose built TEH, with 80 beds. During the two years under review, the TEH encompassed
an acute care program and a continuing care program. The acute care program comprised two
15-bed male acute wards (Argyle and Atherton) and a 10-bed ward for acutely ill women
(Barossa). At the time of completion of this study, the continuing care program was one 20-
bed extended care ward (Canning) and a 20-bed rehabilitation ward (Bass). When the TEH
opened, the M6 patients were allocated to Argyle, Atherton and Barossa, the M5 patients
moved to Bass, and the Ellery patients moved to Canning. The patient profiles did not change.
Bed occupancy in both hospitals was high, vacancies were filled quickly and any drop in
occupancy was generally explained by beds being held for acute patients who had been
admitted to a general hospital for medical treatment or for continuing care patients on short
rehabilitation leaves.

45
 The number of admissions and length of admission across the two hospitals were
similar. There were 401 admissions (including only involuntary civil admissions and
sentenced or remanded prisoners admitted involuntarily for psychiatric treatment), 192 at the
RFPC and 209 at the TEH. Patients admitted after being found not guilty by reason of mental
impairment were not included in this analysis as these patients tended to have
disproportionately lengthy admissions when compared with the other categories of admission.
Given these exclusions, there was no significant difference in the length of admission between
patients admitted and discharged at the RFPC (M = 96.41, SD = 173.78) compared to patients
admitted and discharged to the TEH (M = 84.66, SD = 85.31) (t(399) = .870, p = n.s.).
Using ICD-10, the discharge diagnoses of all patients admitted to both hospitals varied
little between the two hospitals over the four years of study. In the RFPC 187 (82.01%) of the
228 patients admitted for whom a discharge diagnosis was recorded experienced some type of
psychotic illness, including Schizophrenia (172), Drug Induced Psychosis (3), Delusional
Disorder (3), Schizoaffective Disorder (2), Depression with Psychosis (4), and Bipolar
Affective Disorder with Psychosis (3). Other disorders were less common and included
Depression or Dysthymia (13), Adjustment Disorder (4), Personality Disorder (11), Bipolar
Affective Disorder (6), Hypomania (3), Acute Alcohol Intoxication (1), Delirium (1), Drug
Dependence (1), and Malingering (1). In the TEH, 166 (75.45%) of the 220 patients admitted
for whom a discharge diagnosis was recorded also experienced some type of psychotic illness,
including Schizophrenia (150), Drug Induced Psychosis (3), Delusional Disorder (6),
Schizoaffective Disorder (3), Depression with Psychosis (3), Bipolar Affective Disorder with
Psychosis (1). Other disorders were less common and included Depression or Dysthymia (20),
Adjustment Disorder (20), Personality Disorder (8), Bipolar Affective Disorder (3),
Hypomania (1), Huntington’s disease (1), and Post Traumatic Stress Disorder (1). There was
no significant difference across the two hospitals in diagnosis when patients’ diagnoses were
recoded into either psychotic or non-psychotic illness (χ2(46) = 58.00, n.s.).
Despite considerable differences in physical environment and changes to routine,
given the changes in physical structure, treatment approaches and goals for intervention were
consistent across the two hospitals. Ward programs were consistent. One significant outcome
of the move to the TEH was that all patients had access to their bedrooms throughout the day
and increased access to the grounds.
Unlike the RFPC, the TEH was built on substantial grounds, with perimeter security.
Within the grounds is a Technical and Further Education campus (TAFE) with a variety of
facilities and programs including hospitality, woodwork and horticulture, and a YMCA with
an indoor basketball court, swimming pool and gymnasium. In the TEH patients are

46
encouraged to utilize the campus facilities in addition to participation in psychotherapeutic
activities coordinated on both the wards and across the campus.
The composition of disciplines was consistent across the two hospitals. A consultant
psychiatrist, psychiatric registrar or medical officer, a clinical psychologist, social worker,
occupational therapist, and nursing staff were employed on each ward. All staff employed at
the RFPC at the time of its closure continued their employment at the TEH. The additional
members of staff, required due to the expansion in services, were recruited prior to the move
from the RFPC. This allowed all staff to participate in the extensive orientation and
commissioning activities that were necessary for the opening of TEH. There were no
discernable differences in the characteristics of staff across the two hospitals.
4.1.3 Procedure
Incident Forms reporting acts of aggression by patients between 27th April 1998 and
26th April 2002 were reviewed. Information extracted from these forms included the time of
day the aggressive incident occurred, the month of aggression, the ward, the type of
aggression (verbal or physical aggression or property damage), characteristics of the
aggressive patient (gender and age), and characteristics of the victim (gender, whether staff or
patient). Where several forms of aggression occurred during one incident (e.g., verbal and
physical aggression), the most severe form of aggression was rated. Physical aggression was
rated the most severe form of aggression followed by verbal aggression and then property
damage. There were no organizational directives or formal changes to the procedures relating
to the reporting of incidents during the period of the study. As all new members of staff were
oriented to the existing system of incident reporting, and as senior staff responsible for the
processing of incident reports remained with the service over the four years of study it was
unlikely that there was any difference in reporting practices. Data were analysed using SPSS
for windows version 10.0. Approval to conduct the research was granted by the Department
of Human Services Human Research Ethics Committee.
4.2 Results
Using the recording procedure described above, 756 incidents of aggression were
reported during the four years under review. At the RFPC 289 incidents were reported
whereas 467 were reported at the TEH (see Table 3). Given differences in the number of
available beds in each hospital and differences in bed occupancy rates, a rate of aggression
(per patient per annum) was calculated by dividing the frequency of aggressive behaviours by
the number of beds in each hospital, multiplied by the annual percentage occupancy, and then
dividing by two. The incidents of aggression across the two hospitals therefore correspond to
a rate of 3.03 incidents per patient per annum at the TEH, and 2.98 incidents per patient per

47
annum at the RFPC (see Table 4). To compare rates of aggression between the two hospitals,
the monthly frequency of aggressive behaviour, adjusted for number of available beds and
annual average occupancy rates, was compared. Using this procedure, the difference in the
total rate of aggression between the two hospitals was found to be not statistically significant
(t(22) = -.145, p = n.s.).

Table 3: Frequency of Aggressive Incidents by Type and Location

Property Verbal aggression Physical aggression Total incidents

damage Staff victim Patient victim Other Staff victim Patient victim per ward and

hospital

TEH Argyle 66 51 11 1 45 47 221

Atherton 35 13 6 1 17 51 123

Barossa 18 12 6 2 35 10 83

Bass 1 1 1 0 0 1 4

Canning 2 5 4 0 9 13 33

Off ward 0 1 0 0 2 0 3

122 83 28 4 108 122

122 115 230 467

Total (TEH)

RFPC M5 0 0 0 0 1 1 2

Ellery 8 6 1 2 17 36 70

M6 36 20 9 0 41 110 216

Off ward 0 0 0 0 0 1 1

Total 44 26 10 2 59 148 289

(RFPC)

Total (TEH and RFPC) 166 153 437 756

Physical aggression was the most frequently recorded type of aggression (437
incidents) followed by property damage (166) and verbal aggression (153) (see Table 3). The
difference between the rate of verbal aggression recorded at the TEH and the RFPC
approached statistical significance (t(22) = 2.077, p = .05). The TEH recorded a higher rate of
property damage (t(22) = -2.691, p = .013) when compared to the RFPC. Similar rates of
physical aggression (t(22) = 1.928, p = n.s.) were recorded across the two hospitals. At the
TEH there were 1.49 incidents of physical aggression per patient per annum compared with a
rate of 2.14 at the RFPC. Property damage occurred at the rate of 0.79 incidents per patient

48
per annum at the TEH, and 0.45 at the RFPC. Verbal aggression was recorded at the rate of
0.75 incidents per patient per annum at the TEH, and 0.39 at the RFPC.

Table 4: Rate of Aggression per Patient (Adjusted for Occupancy Rate and Available Beds)
per Annum by Type and Location

Property damage Verbal aggression Physical aggression Total incidents

Staff Patient Other Staff Patient victim per ward and

victim victim victim hospital

TEH Argyle 2.25 1.74 0.38 0.03 1.54 1.60 7.54

Atherton 1.24 0.46 0.2 0.04 0.6 1.81 4.36

Barossa 1.01 0.67 0.34 0.11 1.97 0.56 4.67

Bass 0.03 0.03 0.03 0 0 0.03 0.1

Canning 0.05 0.13 0.1 0 0.23 0.33 0.84

0.79 0.54 0.18 0.03 0.70 0.79

Total (TEH) 3.03
0.79 0.75 1.49

RFPC M5 0 0 0 0 0.03 0.03 0.07

Ellery 0.24 0.18 0.03 0.06 0.5 1.06 2.06

M6 1.07 0.59 0.27 0 1.22 3.26 6.4

Total 0.45 0.27 0.1 0.02 0.61 1.53

2.98
(RFPC) 0.45 0.39 2.14

Differences in the rate of aggression per patient per annum existed when type of
aggression, hospital location and characteristics of the victim were taken into account (see
Table 4). Patients were more often the victims of physical aggression at the RFPC (1.53
incidents per patient per annum) when compared with the TEH (0.79). This difference
approached statistical significance (t(22) = -2.713, p = .05). Physical aggression towards staff
remained relatively constant across the two hospitals (TEH, 0.70; RFPC, 0.61) (t(22) = .542, p
= n.s.). Patients were the victims of verbal aggression at similar rates across the two hospitals
(TEH, 0.18; RFPC, 0.1) (t(22) = -1.527, p = n.s.). Staff members were the victims of verbal
aggression at a higher rate at the TEH (0.54) when compared with the RFPC (0.27) (t(22) = -
2.713, p = .013).
Across both hospitals, aggression was recorded at a higher rate on the acute wards
(5.54) when compared with the rehabilitation wards (0.94) (t(22) = 14.289, p = .0001). There
was no significant difference (t(22) = .993, p = n.s.) in the rate of incidents on acute wards
across the hospitals, with 6.4 incidents per patient per annum on M6, and 5.34 incidents per
patient per annum when the three acute wards of the TEH (Argyle, Atherton and Barossa)

49
were combined. There was a significant difference (t(22) = 3.234, p = .004) in the rate of
incidents on the rehabilitation wards between the two hospitals, with 0.9 incidents per patient
per annum at the RFPC (M5 and Ellery), and 0.46 incidents per patient per annum at the TEH
(Canning and Bass).
Characteristics of Aggressive Patients and their Victims
A total of 176 patients were aggressive during the study period. Twelve patients were
responsible for more than 10 incidents of aggression, four were responsible for more than 20
incidents and one patient, who resided in both hospitals for the four years under review, was
responsible for 57 incidents. Sixty-five patients were each responsible for one incident of
aggression. Aggressive patients ranged in age from 17 to 81 although they were generally
young (M = 32.82, SD = 14.49, Median = 29). There was no significant difference in the ages
of aggressive patients at the RFPC (M = 32.55, SD = 10.66) when compared with the TEH (M
= 30.71, SD = 9.62) (t(399) = 1.810, p = n.s.).
Time of Day
The frequency of aggressive incidents increased from 8:00am through to 7:00pm at
both hospitals (see Figure 5). At both the RFPC and the TEH the most number of incidents
(27 at the RFPC and 42 at the TEH) were recorded between 6:00pm and 7:00pm. Irrespective
of hospital, aggression was most frequently recorded during the evening. Between 5:00pm
and 10:00pm, 284 incidents were recorded. In the afternoon, between 12:00pm and 5:00pm,
228 incidents were recorded. Between 7:00am and 12:00pm, 157 incidents were recorded.
Between 10:00pm and 7:00am 81 incidents were recorded.

50
 Figure 5: Frequency of aggression by time and hospital

45
40
Number of incidents 35
30
25
20
15
10
5
0
12pm-1am
1-2am
2-3am
3-4am
4-5am
5-6am
6-7am
7-8am
8-9am
9-10am
10-11am
11-12pm
12-1pm
1-2pm
2-3pm
3-4pm
4-5pm
5-6pm
6-7pm
7-8pm
8-9pm
9-10pm
10-11pm
11-12pm
Time of day

Rosanna Forensic Psychiatric Centre Thomas Embling Hospital

4.3 Discussion
In this review of the environmental contributors to inpatient aggression, the total rate
of aggression across the two hospitals was similar. However, when the type of aggression and
victim characteristics were taken into account, differences were evident. Although the overall
rate of physical aggression was similar across the two hospitals, a decreased rate of physical
aggression towards patients at the TEH was noted. Property damage and verbal aggression
towards staff occurred at a higher rate at the TEH.
Methodological problems, including the lack of control for other variables known to
contribute to inpatient aggression such as the acute symptoms of psychotic illness, history of
substance use and previous violent behaviour, prohibit definitive conclusions being drawn
from this research. However, this comparison of aggression in two hospitals with essentially
similar patients and staff revealed clear differences in the type and direction of aggressive
behaviour from which some tentative conclusions may be drawn.
The absence of a reduction in the overall rate of aggression was the first striking result
of this research and was contrary to the author’s expectations. Several possible explanations
for this finding exist. Across both hospitals incidents of aggression were reported at a higher
rate on the acute wards. Patients are more likely to be aggressive during the acute phase of
their illness when, in addition to more acute symptoms, they are exposed to environment
instability created by frequent admissions and discharges, stress contributed to by incomplete
legal matters, and cultural support of aggression in patients transferred from prison. The TEH
had twice the number of acute beds compared with the RFPC. It is therefore possible that the

51
higher number of acute ward patients contributed to the absence of a reduction in the overall
rate of aggression at the TEH.
The absence of a reduction in aggression was also, in part, a consequence of an
increase in the rates of property damage and verbal aggression towards staff. The increase in
property damage at the TEH may have been a consequence of an increase in the fragility of
ward property. The TEH was designed as a ‘residential standard’ facility so as to avoid an
institutional appearance and atmosphere. Reported incidents of property damage often
included damage to walls, where a patient punched a hole in a wall, or when a window was
broken by a patient throwing an object against it. At the RFPC the walls were brick and the
windows were unbreakable. Furthermore, to increase privacy, patients at the TEH had access
to their bedrooms during the day. A considerable number of incidents of property damage at
the TEH occurred in the bedrooms, out of sight of staff. Due to limited accessibility of
bedrooms at the RFPC this type of incident was less likely. The increase in verbal aggression
towards staff at the TEH may have been a consequence of increased intolerance of verbal
aggression towards staff, given the improved, aesthetic environment.
There was a change in the pattern of physical aggression across the two hospitals
when characteristics of the victim were considered. The rate of physical aggression towards
patients decreased at the TEH, whereas the rate of physical aggression against staff remained
relatively constant across the two hospitals. The inability of RFPC patients to retire to their
rooms when irritated by the noise, teasing, insults, and intrusions into personal space by other
patients may have contributed to the higher rate of aggression between patients at the RFPC.
Given their inability to remove themselves from intrusive or annoying co-patients, patients at
the RFPC may have relied upon aggression to keep other patients at distance, or to punish
them for their ‘provocative’ behaviour.
In contrast to the overall stability in aggression between hospitals, there was a
decreased rate of aggression on the rehabilitation wards at the TEH compared to the
rehabilitation wards of the RFPC. Several explanations for this observation exist. Firstly, a
small number of chronically psychotic and frequently aggressive patients who had been on
the rehabilitation wards at the RFPC were admitted to the acute wards of the TEH to preserve
the milieu of the TEH rehabilitation wards. Further, the increased variety and access to
rehabilitation programs at the TEH may have reduced frustration for rehabilitation ward
patients.
Individual characteristics alone are incapable of explaining the different patterns of
aggression identified in this review. Whilst the greater number of acute beds may have
contributed to the absence of a reduction in the rate of aggression at the TEH, it is unlikely

52
that it accounts for the variation in patterns of aggressive behaviour that have been identified.
This study has hypothesised that the physical structure of the ward, access to personal space,
and different recording practices may also contribute to an understanding of the observed
differences. Whilst these are plausible contributors, there can be no definitive conclusion due
to the descriptive and retrospective nature of the research. Unfortunately however, it may
always be difficult to precisely identify the environmental contributors to inpatient aggression
because of the inability to create methodologically irrefutable studies. For example, it would
be difficult to build two different psychiatric hospitals and randomly admit patients to each
simply to observe the effects of environment and regime on inpatient aggression.
Nevertheless, aspects of the environment, including the frequency with which members of
staff use restraint and seclusion, and patients access personal space, have an influence on
aggression and are amenable to change. They are therefore potential targets for intervention.

53
 CHAPTER 3: A METHODOLOGICAL FRAMEWORK FOR THE STUDY OF
INPATIENT AGGRESSION
5.0 An introduction to functional analysis
The principle aim of any psychological assessment is to explain an individual’s
presenting problem by clarifying why the behaviour has occurred in this individual, at this
time, and in this form. The assessment should also assist in the development of a treatment
plan that contributes to the resolution of the problem. A number of approaches to the
assessment of an individual’s presenting problem may be taken, with a distinction often made
between structural and functional approaches (Sturmey, 1996). Structural assessment
approaches emphasise the correct classification of the behaviour’s form. They seek to locate
the enduring, underlying traits assumed to cause the behaviour. In contrast, functional
assessment approaches emphasise situational determinants, examine the co variation between
topography and controlling variables, and focus on the purpose of the behaviour (Bellack &
Hersen, 1998; Haynes & O’Brien, 1990; Owens & Ashcroft, 1982). Within functional
assessment approaches, the integration of assessment information into a hypothesised account
of the patient’s behavioural problems is often referred to as functional analysis (Haynes,
1990). Whilst functional analysis can be considered independent of any particular theoretical
orientation (Owens & Ashcroft, 1982), in clinical practice it is generally associated with the
behavioural approach (Lee-Evans, 1994).
Functional analysis serves a number of purposes, including description, classification
and measurement, assessment of treatment outcome, understanding the causes of behaviour,
developing hypotheses about purpose, and generating predictions about future behaviour. Its
core function however is to gather information relevant to planning interventions (Lee-Evans,
1994). Owens and Ashcroft (1982) suggested it is a strategy for problem solving: “functional
analysis approaches a problem or a phenomenon seeking to answer questions regarding the
function of the phenomenon to the system as a whole” (p. 188). After the factors responsible
for the initiation and maintenance of the problem behaviour are identified, new controlling
variables can be introduced so that the problem behaviour’s functional value is reduced, or
that new adaptive behaviours, which achieve the same purpose, are reinforced (Lee-Evans,
1994).
An important assumption of functional assessment approaches is that of aetiological
heterogeneity (Lee-Evans, 1994). According to this assumption, the same behaviour in
different individuals may have different determinants (Lee-Evans, 1994); an individual’s
behavioural problems result from a complex interaction between biological make-up,
previous learning history and current situational influences. As such, an idiographic approach

54
is the most common application of functional analysis to clinical psychology (Haynes &
O’Brien, 1990; Sturmey, 1996).
According to Lee-Evans (1994), the key to identifying the precise determinants of
problem behaviour lies in a second key assumption of the functional assessment approach, the
principle of adaptation to environment:

explanations of behaviour should be sought in terms of the functions it serves

in a particular context. Thus behaviours that appear structurally or topographically
similar (e.g., different variations of verbal abuse) may require quite different
explanations because they serve different functions for different individuals (e.g.,
demand avoidance or instrumental gain), or even different functions for the same
individual in different contexts. Conversely, behaviours that appear to be
topographically dissimilar (e.g., verbal abuse and crying) may have a similar
explanation if the individual has learned that they can have the same functional value
(Lee-Evans, 1994, p. 19).

5.1 How Might Functional Analysis be used to Understand Psychiatric Inpatient

Aggression?
Typically, assessment approaches to psychiatric inpatient aggression, and risk
assessment generally, have adopted a structural approach (Daffern & Howells, 2002).
Functional analysis may be a useful alternative. In particular, the principle of adaptation to
environment, that behaviour is purposeful, or has adaptive value, has particular relevance to
the study of inpatient aggression. Frequently, perhaps because of a bias in interpreting the
actions of inpatients as a consequence of illness, or due to an absence of systems to assist staff
understand the reasons for unacceptable or unreasonable behaviour, aggression in psychiatric
wards is often considered purposeless, a direct manifestation of disorganised thinking
generated by psychotic illness. However, problematic or bizarre behaviour, including
psychiatric inpatient aggression, may, despite the presence of psychosis, be purposeful in that
it satisfies some need for the individual that is either unable be satisfied in an adaptive, pro-
social manner, or because it is perceived by the individual to be the most effective behaviour
for that environment at that time.
Through the identification of purpose, bizarre behaviour may be understood and
opportunities for intervention generated. Identifying rationality in the aggressive behaviour of
the psychiatric inpatient may allow staff to consider psychological models of anger and

55
aggression developed to understand and treat non-mentally ill offenders. An additional
consequence may be that fear, generated by an inability to understand aggression, is reduced.
The repertoire of potential responses to aggressive behaviour may be expanded as a
consequence of the focus on purpose. Interventions may shift from a restricted range, usually
incorporating strategies directed exclusively towards sedation or amelioration of psychiatric
symptoms and containment of the aggressive patient, to treatment of the aggressive
behaviour. For example, two patients may assault staff in an identical manner, by punching
them with a closed fist. Based on a topographical analysis, the two acts are identical. If staff
members consider seclusion and sedation to be reasonable responses to aggression, then both
patients would be managed using a combination of these responses. However, the purpose of
the aggressive behaviour may vary for the patients. One patient may behave aggressively
because he is frightened in the company of his fellow patients and has learned that when he is
aggressive he is taken to seclusion, which provides sanctuary. Based on an assessment of
purpose, interventions that are likely to result in a decrease of aggressive behaviour may
include teaching the patient assertion skills, addressing his fears, providing safety, and not
secluding him. The second patient may behave aggressively because he is acutely psychotic
and believes members of staff poison his food. Interventions other than containment may
include stabilising his mental state through pharmacological and cognitive behavioural
interventions. Seclusion may also be warranted in this case to manage the immediate risk, as
may sedation to lower arousal.
Traditionally, aggressive behaviours have been considered purposeless, bizarre, or
pathological because they break social mores and have profoundly negative consequences
(Layng & Andronis, 1984). Indermaur (1999) notes however that legitimacy of aggression is
often confused with purpose, and that aggression is often conceptualised as purposeless
because it is illegitimate. However, whilst illegitimate, aggression most usually serves some
purpose, even if motivated by illogical beliefs that are a direct consequence of psychiatric
illness. In psychiatric wards, staff members are vulnerable to interpreting the aggressive
behaviour of patients as either a function of a problematic personality, or as a direct
consequence of psychiatric illness. Aggressive behaviour may then be classified as either
‘illness related’ or ‘behavioural’, or even ‘mad’ or ‘bad’. Such classifications have limited
value in explaining aggressive behaviour, or for indicating treatment. Functional analysis
assumes that all behaviour, irrespective of how topographically bizarre, is acquired and
maintained because it is purposeful and has meaning. It may be helpful for staff to accept that
bizarre behaviour, including unacceptable behaviour such as aggression, may still be adaptive,

56
or rational, when considered within the context of the aggressive patient’s limitations,
tendencies, skills, or pre-existing vulnerabilities (Goldiamond, 1975a & b).
There are few examples in the literature of functional analysis being utilised for the
assessment of psychotic patients. However, this type of analysis is consistent with the work of
Layng and Andronis (1984) who assumed that behaviour, in their case delusional speech and
hallucinatory behaviour, is operant, in that its frequency is a function of its contingent
consequences. As an example they report on the case of a psychiatric patient who complained
of how hard it was for her to go to the nurse’s station and ask to talk to staff.

When the unit staff observed that this patient’s discussions with them were
becoming less frequent, one staff person suggested that the patient was “withdrawing
further into herself”. One day, while sitting in the dayroom, the same patient began
exclaiming that her head was falling off and acted convincingly frightened. A staff
person then went and sat with her to “calm her down”. The delusion became more
pronounced, and the woman also reported hearing “popping noises” preceding
feelings that her head was falling off. Later, one of the authors was asked to consult on
this case. He discussed this delusion with the patient, and together they analysed the
pattern. It was noted that a not-to-hidden cost of approaching staff at the nursing
station entailed a possible interruption of an ongoing conversation among them,
sometimes incurring hostile responses. Her delusion was an immediately less onerous,
but ultimately very costly, alternative to the more difficult task of going to the nurse’s
station to seek out unit staff. Both patterns, it was noted, appeared to produce the same
maintaining consequences, i.e., conversations with staff. Viewed in terms of the
consequential alternatives available to the person, this woman’s delusional behaviour
now made sense. A program was subsequently implemented to train the client to
approach an engage others in prolonged conversations which would maintain their
interest as well as hers. As predicted from the foregoing analysis, the program in fact
resulted in her delusional speech being altogether replaced by ‘normal’ conversation
(Layng & Andronis, 1984, p. 142).

Like delusional speech and hallucinatory behaviour, aggression may result in

considerable costs to the individual (e.g., seclusion, restraint, restriction in privileges, physical
injury, isolation and rejection). Aggression is however likely to be maintained by its
anticipated or achieved positive reinforcement contingencies (e.g., avoiding or punishing
irritating staff or patients, instrumental gains, and increased status). Layng and Andronis

57
(1984) suggest a cost/benefit type analysis can be extended to patterns of behaviour not only
considered irrational, but also to those behaviours whose costs are:

so dramatic and immediate that they might completely obscure the clinician’s
view of any possible benefits. When the benefits of the disturbing pattern are so
overlooked, the search for available alternatives is effectively precluded; moreover, a
program to establish patterns that produce the same benefits but at less personal or
social cost is never undertaken (p. 141).

Take, for example, the following incident of aggression perpetrated by Avi, a young
man from Iran, detained involuntarily and indefinitely on an acute psychiatric ward of a high
security hospital within the TEH. During his admission Avi frequently engaged in acts of
severe aggression. He threatened staff and patients and has broke furniture. On two occasions
he broke a pool cue and threatened staff. Avi’s comprehension of English was poor and he
required an interpreter to communicate effectively. He believed staff did not give him
effective treatment, as they did not wish to release him. Early one afternoon Avi requested the
ward’s doctor take three tubes of blood from him to ease his chest pain. He believed his chest
pain was caused by bad blood contaminated by antipsychotic medication. He insisted that if
blood were removed, his pain would ease. He approached nursing staff on a number of
occasions requesting blood be taken from him. This request was repeatedly refused. Avi was
informed that the removal of blood would not alleviate any chest pain and was told that his
chest pain had been investigated, that he was not suffering a life threatening condition, and
that worrying about his chest pain would probably cause him further distress.
Avi would not accept this explanation nor would he accept prn medication, which he
did not believe would help. Despite his frustration with staff’s reluctance to take blood from
him, Avi remained relatively settled for the majority of the afternoon. However, at
approximately 4:00 pm Avi picked up a chair in the music room and attempted to smash a
window separating the music room from the kitchen by throwing the chair against the
window. Nursing staff entered the music room and Avi attempted to punch a nurse. He was
restrained, escorted to the seclusion area and given intra-muscular sedation. At approximately
7:00 pm Avi settled and agreed that he would no longer attempt to assault anyone or damage
property. He was released from seclusion.
The ward doctor and psychologist interviewed Avi the following day. During this
interview Avi acknowledged being very angry and distressed by problems with his heart. He
stated that he was angry that staff dismissed his concerns and that they did not meet his

58
request for blood to be taken from his body. Avi also said that around 4:00 pm he knew the
doctor was about to go home and thought that once the doctor had left the ward he would
have no opportunity for blood to be taken from him. In an attempt to force the doctor to do
something Avi smashed the window. During the interview there were no signs of lingering
animosity towards staff, in fact he smiled mischievously during the interview. It is clear in
this example that aggression was used in an angry and distressed patient to coerce staff action,
namely to take blood from him. The aggression, whilst unacceptable, and motivated in part by
delusional beliefs, had functional value or purpose.
Goldiamond’s (1974, 1975a & b) comments on constructional tactics are also
consistent with the notion that bizarre behaviour may be purposeful. Constructional tactics are
methods of intervention which arise from a belief that problematic behaviour is “behaviour
which, although distressful to the client or significant others, successfully produces desirable
and logical consequences which the person’s adaptive behaviour does not” (Sturmey, 1996, p.
7). Accordingly, the focus of intervention is “not to treat the target behaviour directly, but to
support and increase functionally equivalent alternate behaviours” (Sturmey, 1996, p. 7).
In addition to assessment for treatment, functional analyses may also have inplications
for risk assessment. For example, in an attempt to enhance risk assessment strategies for
prisoners serving long sentences for serious violent offences, Clark, Fisher & McDougall
(1994) demonstrated through functional analysis that a prisoner’s index offence often showed
functional equivalence to behaviour in prison. These authors used this finding to justify
assessment of prison behaviour to assist prediction of violent re-offending. Following from
this assumption, it may be possible that the treatment of a patient’s aggression in hospital, if
demonstrated through functional analysis to be the equivalent of prior aggressive offending,
may have some effect on recidivism. For example, a patient admitted for psychiatric treatment
may, in the community, be verbally aggressive over the telephone whenever he is asked to
attend for an appointment with his treating team. The patient may have been admitted after
going to a supermarket whilst unwell and assaulting a checkout assistant who asked him to
open his bags for inspection. Analysis of this patient’s aggression may conclude that the
patient becomes angry when a demand is placed on them, that they are aggressive due to a
limited range of behavioural resources to cope more adaptively with these perceived
provocations without recourse to aggression. It may be predicted that within the inpatient
setting the person is likely to behave aggressively when a demand is made on him, for
example, when he is requested to attend meetings, or to take medication. To avoid aggression,
staff may teach the patient more assertive ways of displaying his annoyance and ensuring the
patient’s aggression is not reinforced by allowing him to avoid the demand, providing an

59
aversive consequence instead. Staff might model adaptive ways of expressing anger, problem
solve, and reward adaptive behaviours. If the patient’s behavioural repertoire in hospital or
prison is expanded to include more adaptive strategies then this may have an impact on their
likelihood of recidivism upon discharge. Howells (1996, 1998) has indicated the usefulness of
the functional analysis for assessment and treatment of offenders with anger management
problems:
Such a formulation would form the basis of all interventions and rehabilitation, and
would dictate what changes in behaviour needed to be produced and what outcome measures
of improvement should be used. It would also form the basis for any statement of future risk
(Howells, 1996, p. 74).
The identification of common antecedents to aggressive behaviour may also assist in
the prediction of inpatient aggression by identifying situations in which aggressive behaviour
is likely. For example, in their study of inpatient aggression, Shepherd and Lavender (1999)
noted that the majority of aggressive incidents towards staff members were preceded by a
staff member’s refusal of a patient’s request, a staff member’s demands for activity, ward
restrictions, or transfers between wards. Given the identification of these triggers,
interventions could be instituted so these antecedent-interactions became less provocative.
Alternatively, when these interactions were necessary, staff members would be prepared to
manage aggression, possibly decreasing the severity of the aggressive behaviour if and when
it does occur.
5.2 Developing a System for Identifying the Purposes of Inpatient Aggression
Although the idiographic approach is emphasised in functional analysis, for staff
considering interventions in response to aggressive behaviour, such an approach may be
unworkable. The time required to collate the information required for an adequate analysis is
often unavailable, and many ward staff confronted by an aggressive inpatient may have
insufficient expertise in behavioural assessment to stop and assess the likely purposes of
aggression. An alternative approach, behavioural diagnostics, may have utility (Sturmey,
1996). The behavioural diagnostics approach simplifies the decision making process by
identifying some of the common purposes of a particular behaviour. After these are identified,
guidelines may be:

given to the clinician on how to recognize these common functions. In this way the
assessment process is simplified in a number of ways. First, the number of potential
functions that the target behavior can have is reduced. Second, the information that is
necessary for the clinician to discriminate between the options is specified. This can

60
 act as a structure that needs to be collected…. Finally it can guide the clinician as to
the treatment options that are appropriate for each of the functions of the target
behavior. It should also specify those treatments that are contra-indicated (pp. 64-65).

An example of the behavioural diagnostics approach is that derived from Carr’s

(1977) review of the motivations for self-injurious behaviour. Carr (1977) noted three main
motivations for self-injury; positive reinforcement (e.g., tangibles or social contact), negative
reinforcement (e.g., the removal of a demand, pain or discomfort), and internal stimulation. In
one application of Carr’s (1976) framework, 152 cases of self-injury were assessed (Iwata et
al., 1994). Almost every case in this review could be assigned to one of the three motivations.
Similarly, for inpatient aggression, using a behavioural diagnostics approach, ward staff could
be trained to identify the common purposes of aggression and instructed in methods for
responding to incidents that contribute, if possible, to the treatment of the patient’s aggressive
behaviour, in addition to its containment.
A focus on purpose rather that the identification of antecedents that commonly
precede aggression is emphasised primarily because the antecedents to aggressive behaviour
on psychiatric wards are too numerous. It may not be possible to identify all possible
antecedents and then prescribe interventions for each. A problem with limiting the range of
antecedents is that incidents that occurred that were not associated with these particular
antecedents would not be classifiable, they may therefore be considered unpredictable or
motiveless. For example, the Staff Observation of Aggression Scale (SOAS) (Palmstierna &
Wistedt, 1987), which has been used to study the frequency of aggressive behaviour on
psychiatric wards, and which has the advantage of categorising precipitants (No
understandable provocation, Provoked by other patients, Helping the patients with Activities
of Daily Life, Staff demanding patient to take medication, Patient denied something, or
Other), has failed in several studies to adequately allow classification of many aggressive
behaviours. In one Australian study examining aggression in a large psychiatric hospital with
the SOAS, Cheung et al. (1996) found that in approximately 324 of 806 (40.2%) incidents, no
provoking factors could be identified. As a consequence, Cheung et al. (1996) concluded that
since the majority of the patients within this study experienced persistent psychotic
symptoms, that the unprovoked incidents were most likely caused by "severe
psychopathology rather than environmental factors” (p. 261). A behavioural diagnostics
approach with an emphasis on purpose may allow for a higher frequency of behaviours to be
classified.

61
 5.3 Towards a Functional Analysis of Psychiatric Inpatient Aggression
One frequently documented problem with functional analysis is that methods for
integrating data obtained through assessment are not delineated (Haynes, 1998). However,
models for integrating information relevant to a functional analysis do exist. Each of these
models is based around the core assumption that behaviour can be understood in terms of its
relationship to its antecedents and consequences (Lee-Evans, 1994). One model that has
received considerable attention is the SORC (Goldfried & Sprafkin, 1976; in Lee-Evans,
1994). According to this model, S refers to antecedent stimuli, O to organism factors, R refers
to response, and C to consequences. The inclusion of organism factors allows for the
incorporation of individual factors (e.g., inherited dispositions and physical capabilities) that,
with situational variables, interact to influence the person’s behaviour in the presence of
antecedent stimuli.
Based on the assessment of antecedents, behaviour and consequences, yet
incorporating a number of specific environmental and organism factors, Howells (1998) has
collated a list of variables requiring consideration in a functional analysis of aggressive
behaviour. These include, the: (a) frequency, intensity, duration and form of aggression, (b)
environmental triggers (including background stressors); (c) cognitive antecedents (including
biases in appraisal of events, dysfunctional schemata, underlying beliefs and values
supporting aggression), (d) affective antecedents (emotions preceding aggressive acts, e.g.,
anger or fear), (e) physiological antecedents, (f) coping problem-solving skills, (g) personality
dispositions (e.g., anger proneness, impulsivity, psychopathy, general criminality, over-
control, under-control), (h) mental disorder variables (mood, brain impairment, delusions,
hallucinations, personality disorders, (i) consequences/functions of aggressive acts (for
perpetrator and others, short term and long term, including emotional consequences such as
remorse and peer group or institutional reinforcement), (j) buffer factors (good relationships,
family support, achievement in some area), (k) opportunity factors (weapons, victim
availability, restrictions), and (l) disinhibitors (alcohol, drugs).
Consistent with the SORC, and general behavioural assessment methods, there can be
seen within Howells’ (1998) list a requirement to assess antecedents to the behaviour of
interest (environmental triggers, cognitive, affective and physiological antecedents), a
description of the behaviour (frequency, intensity, duration and form of aggression), and the
consequences to the behaviour, in addition to a description of organism variables (personality
dispositions, mental disorder, buffer factors and disinhibitors). Furthermore, this list requires
assessment of environmental and opportunity factors (e.g., access to weapons, the presence or
absence of observers who may intervene should aggression be initiated, and the availability

62
and type of potential victims) that may explain why aggressive behaviour takes a particular
form. For example, the availability of weapons may result in an angry person picking up a
knife and stabbing a person, leading to their injury or death. In the absence of the knife the
angry person may punch the person.
The variables identified by Howells are consistent with a model developed by Mullen
(2000) to assess the probability of violence in the mentally ill. The primary focus of this
model is the patient’s state of mind, which may be influenced by a range of factors including
pre-existing vulnerabilities such as age, gender, personality, intellectual functioning, and
history of abuse or disruption in childhood, mental disorder, substance abuse, the social and
interpersonal environment, and the presence of situational triggers. According to this model,
environmental events become situational triggers when, due to the patient’s state of mind,
these events are perceived as threatening or provocative (Mullen, 2000). A schematic
representation of Mullen’s (2000) model is shown in Figure 6.

Figure 6: Schematic representation of the pathways to violence in the mentally ill patient

Pre-existing
vulnerabilities Social and
interpersonal
stressors
Mental
disorder
Current state
of mind Social and
interpersonal
Substance protectors
abuse

Situational
triggers

Violent
behaviour

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 5.4 Assessment of Predisposing Characteristics Related to Aggression in Psychiatric
Inpatients
A functional analysis of psychiatric inpatient aggression requires assessment of the
predisposing characteristics (organism variables) of aggressive individuals, in addition to the
assessment of proximal antecedents and consequences that assist in the identification of
purpose (Howells, 1998). Many variables may contribute to aggression in psychiatric
inpatients, yet only some have been emphasized in this study. It was beyond the scope of this
study to investigate the role of all possible contributors to inpatient aggression. The
predisposing characteristics of aggressive inpatients assessed in this study: anger, impulsivity,
assertiveness, history of aggression, history of substance use, and psychotic symptoms, were
chosen because of previous research demonstrating their relationship with aggression, their
face validity, and the ability to measure these variables in a reliable and valid manner.
Anger
Anger is a “significant activator of, and has a mutually influenced relationship with
aggression” (Novaco 1994, p. 33). Problems with anger control often contribute to violent
behaviour (Howells, Watt, Hall, & Baldwin, 1997). Kay et al. (1988) found anger to be the
strongest predictor of physical aggression in the clinical and diagnostic profiles of 208
psychiatric inpatients, and Novaco (1994) found that clinicians’ ratings of anger were
significantly related to physically assault. Further, McNiel, Eisner and Binder (2003) found
that an aggressive attributional style increases the risk of violence in mentally ill patients, and
Mullen (2000) has noted that on admission to a psychiatric ward “the best predictors of
violence are a combination of the general level of disturbance in the mental state, particularly
when manifesting in fear, agitation, and anger, combined with a history of prior violence” (p.
2075).
Impulsivity
Impulsivity has been defined as the tendency to deliberate less than most people of
equal ability before taking action (Dickman, 1990). The consequences of this lack of
deliberation are generally negative, with impulsivity and sensation seeking showing an
association with violent behaviour (Barratt, 1994). Impulsiveness, together with a “learned
underlying predisposition” (Barratt, 1994, p. 73) to respond to certain stimuli with angry
feelings, increases the likelihood of angry responses. That is, impulsiveness interacting with
an aggressive attributional style may increase the likelihood of aggression (McNeil et al.,
2003).

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Assertiveness
Aggression is almost always a response to perceived threat “for which at that moment
no alternative response seems safe or possible” (Mullen, 2000, p. 2074). Inpatient aggression
is frequently precipitated by a demand being made of the patient, following a request being
refused by staff, or when patients are socially isolated, and consider such isolation aversive
(Shepherd & Lavender, 1999; Sheridan et al., 1990; Whittington, 1994). The ability to resolve
conflict assertively and to satisfy the need for attention without recourse to aggression
requires assertion.
History of Aggression
Patients with a history of aggressive behaviour are in general more likely to be
aggressive than those with no history of aggression (Depp, 1976; McNiel, Binder &
Greenfield, 1988).
History of Substance Use
Substance use is a significant factor in acts of violence among non-mentally ill people
(Regier et al., 1990). Further, there is a high rate of co-morbidity between substance use
disorders and schizophrenia; recent studies have consistently found that substance use
significantly increases the likelihood that a person with a mental illness will be aggressive
(Mulvey, 1994; Steadman et al., 1998)
Psychotic Symptoms
Aggressive inpatients have been differentiated from non-aggressive inpatients on the
basis of clinical characteristics such as diagnoses, psychotic symptomatology, and the
emotional (e.g., anger, anxiety and sadness) concomitants of psychotic symptoms. Whilst
symptoms of other forms of mental illness may contribute to aggression, for example, frontal
lobe impairment (Krakowski & Czobor, 1997) and mania (McNiel & Binder, 1989), given the
trend to preferentially admit people with a psychotic illness to psychiatric hospitals (Taylor &
Schanda, 2000), and findings that these psychotic patients are over represented amongst
aggressive patients, symptoms of psychosis were the focus of this research.
5.5 Proximal Antecedents and Consequences: The Assessment of Purpose
If the principle of adaptation to environment is accepted, and the bizarre behaviour of
psychiatric patients is considered purposeful, one problem for clinicians is to determine the
adaptive value, or purpose, of aggressive behaviour. Unfortunately there are no guidelines
available for assisting clinicians in this task. To assist in the development of procedures to
identify the purpose of inpatient aggression, frameworks developed to explain the aggressive
behaviour of non-mentally ill people were reviewed. The use of these frameworks was
supported by Bonta et al. (1998), who suggested that in “addition to psychopathological

65
explanations, theories formulated to explain the conduct of rational offenders may have
significant relevance to understanding mentally disordered offenders” (p. 124).
5.6 Anger Mediated and Instrumental Aggression
For non-mentally ill people, acts of aggression have typically been divided into those
that are motivated by anger (also referred to as reactive, affective, hostile, impulsive,
retaliatory or emotional aggression), and those motivated by instrumental goals (Blackburn,
1993; Buss, 1961). According to Bushman and Anderson (2001), there are three differences
between anger mediated and instrumental aggression: (a) the primary goal of the behaviour,
(b) the presence of anger, and (c) the extent of thought and planning involved. For anger-
mediated aggression, harming the agent of provocation is the end goal, whereas for
instrumental aggression harm to others is the means to another goal. The second characteristic
usually assisting the discrimination of anger and instrumental aggression is the presence of
anger. Anger mediated aggression is characterised by the presence of anger, and instrumental
aggression by its absence. With regard to the extent of thought or degree of planning
involved, anger mediated aggression is considered impulsive or unplanned, whereas
instrumental aggression is typically considered premeditated or planned.
Cornell (1996) described a scale for coding aggressive acts according to the anger
mediated/instrumental dichotomy using the following offence characteristics: planning, goal-
directedness, provocation, arousal, relationship to victim, intoxication, psychosis, and severity
of aggression. In a reliability study, which reported on the classification of 50 forensic clinic
defendants, no single offence characteristic was synonymous with either instrumental or anger
mediated aggression (Cornell, 1996). The characteristics most strongly associated with
instrumental aggression were the presence of a clearly defined goal, little or no provocation
by the victim, and comparatively low levels of emotional arousal at the time of the offence. In
contrast, anger mediated aggression was associated most strongly with a lack of goal
directedness, little or no planning, provocation by the victim, and comparatively greater
emotional arousal at the time of the offence.
Despite widespread utilisation, classification of aggressive behaviour according to the
anger-mediated/instrumental dichotomy has been criticised (Bushman & Anderson, 2001;
Cornell, 1996; Indermaur, 1999; Tedeschi & Felson, 1994). Bushman and Anderson (2001)
suggested that the anger mediated/instrumental dichotomy, whilst useful to the early
development of aggression theories and interventions, may have “outlived its usefulness” (p.
274). Their criticisms included: classification ignores the possibility that aggression may have
multiple purposes, similar purposes may manifest in topographically different forms of
behaviour, or conversely, different purposes may result in similar forms of aggressive

66
behaviour (Bushman & Anderson, 2001). Further, aggression might initially have
instrumental objectives but the aggressor may become angry with the victim and engage in
anger-mediated aggression (Cornell, 1996). Similarly, instrumental offences are often not
devoid of anger. They may have complex affective antecedents (Bushman & Anderson, 2001;
Indermaur, 1999). Furthermore, aggressive individuals may have a history of both
instrumental and reactive violent offences, compromising the usefulness of separating the two
types for treatment (Cornell, Warren, Hawk, Stafford, Oram & Pine, 1996).
Some authors suggested that all aggression is instrumental in that it achieves, or seeks
to achieve, desired outcomes (Bandura, 1973; Tedeschi & Felson, 1993, 1994). Tedeschi and
Felson (1993, 1994) argued that aggression is rational, the result of a decision making process
motivated by various goals. Many instances of anger mediated aggression have identifiable
instrumental purposes including the reestablishment of self esteem, self-image, or public
image, to express grievance or discontent publicly, to right a perceived wrong, and to obtain
benefits such as information, goods, services or safety. The fact that instrumental acts have
more identifiable (material gain) objectives does not detract from the functionality of hostile
aggression (Tedeschi & Felson, 1994). Similarly, Novaco (1976) stated that anger and
aggression are functional and that one of their instrumental values is their ability to modify
aversive events, energising or increasing the vigour with which people act. Anger and
aggression may enhance communication, assist impression management, protect against
feelings of vulnerability, and enhance the person’s sense of control. Further, anger and
aggression may show strength, determination and resolve, attributes particularly important
within an inpatient ward where displays of weakness may be seized upon by other patients.
Social learning approaches to aggression emphasise a number of instigating
mechanisms, including aversive instigators (aggression may follow aversive events such as
physical assaults, verbal threats and insults, adverse reductions in conditions of life, or
thwarting of goal-directed behaviour, that may prompt anger mediated aggression), and
incentive instigators (aggression may be prompted by anticipated positive consequences)
(Bandura, 1979). Modelling instigators (modelling influences may generate similar behaviour
in observers particularly when the observer is angry, if the modelled behaviour is perceived as
socially justified, if the demonstrated aggression is successful in securing a reward, and if the
victim invites attack through prior association with aggression), and instructional instigators
(directives issued in the form of authoritative commands often elicit obedient aggression) may
also precipitate aggression.

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 5.7 An Assessment and Classification System to Aid in the Identification of Purpose
Given criticism of the anger mediated/instrumental dichotomy, a classification system
that assists identification of the purposes for aggression was been developed by the present
author, the ‘Assessment and classification of purpose’ system. This system is informed by the
cognitive model of anger developed by Raymond Novaco, and the instigating mechanisms
outlined by Albert Bandura in his social learning theory of aggression. Furthermore, this
system has considered the antecedent interactions to aggression identified through previous
research. The purposes and antecedent-interactions included in this system include:
Demand Avoidance
Demands by co-patients and staff to cease an activity or to complete a task are
frequent precipitants to aggression (Cheung et al., 1996; Depp, 1976; Shepherd & Lavender,
1999; Whittington & Wykes, 1994). Aggression may occur after a demand because the
patient perceives the demand as aversive and acts aggressively to avoid it. For example, a
patient who is asked by a nurse to have a shower may tell the nurse who has made the request
to “fuck off” so that they do not have to take the shower. Alternatively, aggression may occur
following a demand because the patient perceives the demand to be insulting, unreasonable or
irritating, and acts aggressively to punish the person responsible for the demand. As members
of staff impose demands on patients more frequently than patients, it was anticipated that
demand avoidance would be a more common precipitant of aggression towards staff
compared to patients.
Denial of Request
Aggression often occurs following the denial of a request, made by the aggressive
patient (Cheung, et al., 1996; Powell et al., 1994; Shepherd & Lavender, 1999; Sheridan et al.,
1990). For example, a patient may make a request to attend a program, access leave from the
unit, obtain medication, or receive information about their treatment. Aggression may occur
after a request is refused (pending discussion, pending appropriate behaviour, or after the
completion of some task) because the patient believes aggression will ensure the request
refuser grants the request. Again, the patient may behave aggressively at these times because
they perceive the refusal of the request insulting, unreasonable or irritating, and act
aggressively to punish the person responsible for the refusal of their request. Again, as
members of staff deny patients’ requests more frequently when compared with patients, it was
anticipated that this would be a more common precipitant of aggression towards staff
compared to patients.

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Following Provocation
Aggressive behaviour by psychiatric inpatients often follows provocation (Powell, et
al. 1994; Shepherd & Lavender, 1999). This antecedent interaction is synonymous with
anger-mediated aggression. According to the cognitive/information-processing model of
anger proposed by Novaco (1975), provocations are mediated by cognitive factors (appraisal,
attributions, expectations and internal speech). Novaco and Welsh (1989) identified five types
of external events that may be perceived as provocative: disrespectful treatment (perceived
disrespect having ego-threat implications: e.g., a patient may feel that staff look down on
them and treat them punitively); unfairness/injustice (e.g., a patient may feel that rules are
imposed on them to which other patients are not subjected); frustration/interruption (the
blocking of goal directed behaviour, particularly when the thwarting is viewed as arbitrary,
repetitive or inconsistent: e.g., a patient may feel frustrated that other patients get in the way
of a task they were attempting to complete); annoying traits (finding fault with others: e.g., a
patient may be irritated by co-patients who have poor hygiene or who have the volume on the
television set turned up loudly), and irritations (incidental annoyances and aggravations: e.g.,
a patient becomes annoyed by the poor hygiene of their co-patients). Provocation may also
include physical assault or threat by other patients. It was anticipated that there would be no
difference in the proportion of aggressive behaviours preceded by provocation when incidents
of aggression towards staff were compared with incidents of aggression towards patients.
A Consequence of Frustration
Many patients behave aggressively following a period of irritability, tension, or
frustration. A patient may be frustrated by their inability to convince medical staff that they
are not mentally ill, by their detention, or by the lack of staff availability. Aggression resulting
from frustration may occur against another person following a minor, yet unrelated
provocation, or may result in property damage because there is either no provoking agent, or
because the patient is motivated to reduce frustration without harming another person. Again,
it was anticipated that there would be no difference in the proportion of aggressive behaviours
that occurred as a consequence of frustration when incidents of aggression towards staff were
compared with incidents of aggression towards patients.
Instrumental
Aggression may be used to obtain tangible items, social and/or psychological
reinforcers (Buss, 1961). For example, a patient may threaten another patient to make sure the
patient gives them cigarettes or money. Aggression also serves to keep others away when
solitude is preferred. A patient may behave aggressively so that they are placed in seclusion to
avoid the intrusive and irritating behaviours of their co-patients, in order to receive sedating

69
medication. Although seclusion is used as an aversive consequence for aggression and is
intended to reduce the likelihood of repeated aggressive behaviour, several authors have noted
the potential reinforcement value of seclusion (Plutchik et al., 1978; Wells, 1972). Plutchik at
al. (1978) noted in their review of seclusion room practices that recommendations were made
for a member of staff to remain with the patient during seclusion, and that seclusion rooms
should be comfortable for disturbed patients. “Every secluded patient received special
attention from members of staff. Frequent contacts with these patients regularly included
sympathetic, encouraging conversation and behaviour…. An effort was made to avoid
implications that his lack of control was bad” (Plutchik et al., 1978, p.412). Some patients
may find the experience of isolation from the intrusive behaviour of co-patents and the
demands of staff to be pleasurable. Medication is also commonly administered to agitated or
aggressive patients considered at risk of aggressive behaviour. The sedating effect of these
medications may be reinforcing for some patients.
Most patients are restrained prior to seclusion, which typically involves staff holding
the patient and escorting them to seclusion. If a patient struggles excessively during restraint,
staff may guide the patient to the floor and hold them on the ground until they no longer
struggle. This may involve as many as five staff holding the patient’s head, legs and arms.
Whilst in seclusion, staff may restrain a patient by holding their arms to reduce the likelihood
of aggression when medical staff review the patient. Whilst the majority of patients regard
restraint and seclusion as frightening and uncomfortable, it is reinforcing for some. Consider
the following example of a man who regarded the process of aggression and restraint highly
reinforcing: Barry, a 40 year-old psychotic man was repeatedly aggressive towards prisoners
and staff in prison prior to his admission to an acute forensic psychiatric ward, and then
towards staff during a four-week period whilst he was managed in the seclusion suite. During
this period in seclusion Barry would strike out at staff with his fists. His aggression never
caused injury to staff as the punches he attempted to deliver had little power behind them. He
later suggested he did not wish to harm staff and did not dislike them. Barry never made
threats towards staff and did not ever swear at staff whilst being aggressive. After his
psychotic symptoms resolved and his aggressive behaviour subsided Barry collaborated in
psychological assessment that uncovered a number of purposes for his aggressive behaviour.
Barry acknowledged his homosexuality during these sessions and reported that assaulting
others not only “prevented” others from referring to him as weak because of his sexual
orientation, but also assisted his sexual arousal and functioning because male staff would hold
him firmly in the seclusion room to prevent him from being aggressive. Barry also reported
that a consequence of his treatment with anti-psychotic medication was an inability to sustain

70
an erection and to masturbate. He reported that following aggression he was able to attain an
erection and ejaculate. As Barry did not hurt anybody during his aggressive behaviours, he
did not feel guilty about his behaviour. Again, it was anticipated that there would be no
difference in the proportion of aggressive behaviours perpetrated for instrumental reasons
when incidents of aggression towards staff were compared with incidents of aggression
towards patients.
To Reduce Social Distance
Depp (1983) reported that aggressive patients sought either high levels of supervision
and/or competed more frequently for staff attention than non-aggressive patients. Whittington
(1994) suggested that some socially isolated patients behaved aggressively to reduce social
distance. For example, patients who are lonely and whose only contact with staff occurs after
aggression, may behave aggressively to facilitate physical and social contact. Following
aggression, patients may receive increased physical contact through the restraint process.
They may also receive increased attention when staff ask them the reasons for their
aggression, or support and thank them when they apologise or promise not to behave
aggressively again.
To prevent aggression, patients may be subjected to increased supervision. Increased
supervision limits the ability of patients to access weapons, and optimises the likelihood of
staff intervening quickly, prior to serious injury, should a patient behave aggressively. At
times, supervision might involve close observation by a nurse. Another common method of
increasing supervision is by reducing access to liberty by restricting a patient’s leave from the
ward. Whilst increasing supervision may frustrate patients who feel their personal space is
invaded, the availability of staff to talk with, provide comfort, and assist where necessary,
may be reinforcing for some patients, particularly those who are socially isolated. As staff are
more likely to provide attention for patients who are aggressive it was anticipated that this
purpose would more frequently precipitate acts of aggression towards staff, when compared
to acts of aggression towards patients.
To Enhance Status or Social Approval
Humiliating affronts and threats to reputation are common precipitants of aggression
(Toch, 1989). Toch (1989) noted that the likelihood of aggression in prisons is influenced by
the social dominance and privilege afforded to prisoners who respond to provocation with
aggression, and who use aggression instrumentally to achieve material gain. In psychiatric
wards, although many patients punish aggressive patients, some co-patients reinforce
aggressive behaviour. This may particularly be the case in forensic psychiatric hospitals
where, like prison, animosity towards staff and patients is occasionally encouraged. For

71
example, the aggressive patient who verbally abuses staff when he is requested to give a urine
sample for drug screening may be revered by other patients for his bravado, and for standing
up against the seemingly unreasonable demands of staff. These patients may obtain tangible
rewards such as cigarettes and favours from other patients, in addition to avoiding the
demand. It was anticipated that there would be no difference in the proportion of aggressive
behaviours perpetrated to enhance status or social approval when incidents of aggression
towards staff were compared with incidents of aggression towards patients.
Compliance with Instruction
Aggression may occur following a command auditory hallucination or following
instruction by another person (e.g., a visitor or inpatient). For example, a powerful patient on
the ward may instruct a young or vulnerable patient to act aggressively against staff. The
patient being instructed to act aggressively may then comply with this request because they
fear the consequences of non-compliance. Alternatively, they may comply because they wish
to develop an alliance with the patient giving the instruction. Again, i was anticipated that
there would be no difference in the proportion of aggressive behaviours preceded by
instruction when incidents of aggression towards staff were compared with incidents of
aggression towards patients.
To Observe Suffering
Some patients may be motivated to act aggressively by the observation of suffering in
their victim. Although many patients will show intent to harm, or a disregard for the pain of
others, this category is designed to assess the extent to which the patient’s primary motivation
for acting aggressively was to see pain or suffering where there was no evidence of
provocation. It was anticipated that there would be no difference in the proportion of
aggressive behaviours perpetrated by a desire to observe suffering when incidents of
aggression towards staff were compared with incidents of aggression towards patients.
5.8 Assessing Purpose
Whilst a single purpose may initially precede aggression, several purposes may be
achieved, some of which may be unintended and influence the likelihood of subsequent
aggressive behaviour. As such, aggression may serve several purposes. For example, an
inpatient who behaves aggressively following a demand to attend to an activity may be
secluded and therefore succeed in avoiding the activity. An unintended function may be that
the patient is revered amongst his peers, who similarly dislike ward-based activities. He may
experience an increase in status or receive tangible rewards, such as cigarettes. Given the
possibility of several purposes being served by one incident, a range of purposes may be
identified for each incident through this classification system.

72
 Although it is argued here that all behaviour is functional, it is possible that this
contention is incorrect, and that some aggressive behaviour is indeed purposeless. Further,
this classification system may be insensitive to a range of other purposes of aggressive
behaviour. As such, a final category of purposeless aggression was included where there were
no indications that the other nine purposes were evident. To avoid a frequently observed
problem with previous research, which divides the reasons for inpatient aggression into either
external (environmental) or internal (mental state) categories, the current classification system
ignores the need for this distinction. Ultimately, the purpose of the behaviour is a
consequence of the individual’s perception of environmental events. Regardless of the
accuracy of perception, and the influence of psychiatric illness on perception and appraisal,
aggression may still be purposeful. Prior to the start of the main study it was important to
assess the accuracy and reliability of this classification system. A pilot study was undertaken
and is detailed below.
5.9 Accuracy and Reliability of the ‘Assessment and Classification of Purpose’ System: A
Pilot Study
The quality of a behavioural observation is determined by three characteristics:
accuracy, validity and reliability (Cone, 1998). In “the psychometrics of behavioural
assessment, accuracy and reliability are … the two most important characteristics” (Cone,
1998, p. 33). Accuracy may be defined as “the extent to which observations are sensitive to
objective topographic features and dimensional quantities (i.e., frequency, latency, duration,
magnitude) of behaviour” (Cone, 1998, p. 29). If an observation of behaviour is the result of
the behaviour’s occurrence, then the observation can be said to be accurate. To establish
accuracy, clear rules and procedures for measuring behaviour are required (Cone, 1998). To
achieve accuracy in this project written procedures for identifying purpose according to the
‘Assessment and classification of purpose’ system were established (APPENDIX 2).
Some antecedents, such as a request by the patient that is denied, or the demand for
activity, are observable. Therefore, their identification is likely to be accurate. The
identification of purpose at these times is however, likely to be less accurate, as purpose may
be determined in part by assumptions made by the observer. For example, a patient who is
aggressive following a request being denied may be attempting to avoid the task by behaving
aggressively. Alternatively, the patient may be responding with aggression at what they
perceive as an unjust or unreasonable refusal and a desire to harm the person responsible for
the denial without regard for whether staff will acquiesce. The accuracy of the ‘Assessment
and classification of purpose’ system, with its focus on purpose, is less than it would be if
there were an exclusive focus on the identification of clearly observable antecedents and

73
consequences. However, as discussed, an emphasis on purpose may be more meaningful than
a focus on antecedents and may avoid incidents being misclassified because they do not
appear on an exhaustive list of antecedents.
If an instrument remains accurate it is said to be reliable. In behavioural assessment,
reliability is used to characterise the consistency of observations of behaviour (Cone, 1998).
In other words, if comparable scores result from multiple observations, then the scoring
system may be considered reliable. When accuracy and reliability cannot be ascertained, the
concept of believability may be useful (Johnston & Pennypacker, 1993). Inter-observer
agreement is one method of enhancing believability. The intra-class correlation coefficient
(Bakeman & Gottman, 1986) may be used to demonstrate inter-observer agreement and
believability (Cone, 1998).
To assess the inter-observer agreement of the ‘Assessment and classification of
purpose’ system’, six clinical forensic psychologists and two clinical psychology doctoral
students were provided with a copy of the classification and scoring system (APPENDIX 2), a
brief presentation highlighting the rationale for assessing the purpose of aggression, and an
information sheet regarding the pilot study (APPENDIX 3). They were then provided with a
one-hour lecture on how to score purpose according to the classification system. Ten vignettes
(APPENDIX 4), consisting of 300 word descriptions of aggressive behaviour perpetrated by
patients on a male acute ward within the TEH were given for classification. Psychologists and
students were requested to read and score each vignette. Results from this pilot study were
then analysed using SPSS for windows version 10.0. Results revealed an inter-item
correlation coefficient mean of .65, with a minimum of .30. The single measure intra-class
correlation coefficient was .64. The average measure intra-class correlation coefficient was
.94.
According to Cone (1998), maximum replicability, an objective of accurate recording
systems, is achieved when explicit written instructions accompany scoring instruments. In this
pilot project verbal instructions included only a brief outline of the reason for the project and
a brief overview of the scoring system. Participants therefore relied upon their written
instructions to classify purpose. Given these results it was concluded that the classification
system was acceptably believable and the main study could begin.

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 CHAPTER 4: MAIN STUDY
There have been few applications of functional analysis, with its emphasis on purpose,
to the study of inpatient aggression. The reasons for this are unclear although probably
reflects a bias amongst mental health staff that aggression is either purposeless and a direct
manifestation of psychiatric illness, or that knowledge of purpose contributes little to the
prediction, prevention, and treatment of aggressive behaviour. These assumptions are
however untested. Prior to any assessment of the role of purpose in prediction, prevention and
treatment, a system for assessing purpose was required. As discussed in Chapter 1 there does
not currently exist a system for adequately analysing and integrating information relating to
acts of inpatient aggression that has an emphasis on purpose. The ‘Assessment and
classification of purpose’ system was developed in response to this need. The aim of the main
study was to assess a range of individual characteristics shown through previous research to
predispose psychiatric patients to aggression, to assess purpose using the ‘Assessment and
classification of purpose’ system, and to determine the relationship between purpose and
these predisposing characteristics with aggression.
6.0 Method
6.0.1 Setting
The setting for this project was the TEH, a description of which may be found in the
method section of the first study (see p. 26). Importantly, at the commencement of the study,
on 31st October 2001, the TEH encompassed an acute care program and a continuing care
program. The acute care program comprised 40 beds, two 15-bed units for acutely ill males
(Argyle and Atherton) and a 10-bed unit for acutely ill women (Barossa). The continuing care
program comprised 40 beds in two units: Canning, a 20-bed extended care unit, and Bass, a
20-bed intensive psychosocial rehabilitation unit. On 9th October 2002 a third rehabilitation
ward, Daintree, was opened. Patients from Bass unit were transferred to Daintree and the
intensive psychosocial rehabilitation program on Bass was replicated on Daintree. Several
patients, whose mental state had been stable, were then transferred to Bass from the two male
acute wards. A small number of patients, considered a low risk of violence within the
hospital, were transferred from Canning to Bass. Patients remaining on Canning, or
transferred there from the acute wards, were generally chronically unwell and either at risk of
violence within the hospital, or unwilling and/or incapable of participating in the
rehabilitation programs on either Daintree or Bass. Between 9th October 2002 and 31st
December 2002 only male patients were admitted to Bass.

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 6.0.2 Procedure
Consistent with the underlying framework emphasised by functional analysis,
whereby predisposing characteristics or organism variables are assessed in addition to
proximal antecedents and consequences, two phases of assessment were undertaken: Stage 1,
the assessment of predisposing characteristics, and Stage 2, the assessment of the purposes for
aggression, through examination of antecedents to, and consequences of, aggressive
behaviours. Stage 1 began on 1st October 2001 and continued until 31st December 2002. Stage
2 began on 1st January and continued until 31st December 2002.
Prior to the commencement of Stage 1, a research proposal was developed and
submitted to the University of South Australia. Approval to conduct the research was granted
by the Victorian Department of Human Services Human Research Ethics Committee, the
University of South Australia’s Human Research Ethics Committee, and the Forensicare
research committee.
In September 2001, subsequent to ethics approval from all committees, the author
attended the Community Meeting of each unit within the hospital to introduce himself and to
talk about the study to staff and patients. Essentially, staff and patients were told that the
author was conducting a study of inpatient aggression that comprised two stages. The first
(Stage 1), involved an assessment of each patient on a range of historical, demographic and
clinical characteristics, and the second, involved the recording and assessment of aggressive
behaviours occurring within the hospital. A presentation describing the study was also
provided for the hospital’s Consumer Advisory Group, a forum consisting of patient
representatives that meets regularly to advocate on the behalf of patients. A presentation was
also made to each ward at their team meetings.
6.1 STAGE 1: The Assessment of Characteristics Predisposing Inpatients to Aggressive
Behaviour
The aim of Stage 1 was to assess a range of historical, demographic and clinical
characteristics of patients admitted to the TEH between 1st January 2002 and 31st December
2002, so that the relationship between these characteristics and aggression could be
determined. Assessments were conducted between 1st October and 31st December 2002 on
patients in the hospital during this period where it was likely that these patients would be in
the hospital on 1st January 2002. All patients admitted during 2002 were approached for
assessment of Stage 1 characteristics as soon as possible after admission. An attempt was
made to approach patients within the first week of admission. Whether patients agreed to
participate or not, staff were approached at this time to complete a shortened version of the
Social Behaviour Schedule (SBS) (Wykes & Sturt, 1986) and a short version of the Brief

76
Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962), both of which will be described
below.
To reduce the likelihood of patients feeling coerced into participation, the author
initially approached the Case Coordinator for the patient, or a senior nurse on the ward, to ask
whether or not the patient was able to provide informed consent. If the patient was considered
capable, and permission was granted to approach the patient, the author was then introduced
to the patient. At this time the author then requested an opportunity to talk to the patient about
the study. An information sheet (APPENDIX 5) was provided and patients were informed that
participation was voluntary, that they could withdraw their consent to participate at any time,
and that details of their assessment would be treated with confidence. If the patient agreed to
participate, the author and patient retired to an interview room and the patient was provided a
consent form to sign (APPENDIX 6). After the patient consented in writing to participate,
Stage 1 assessment began.
Participation in Stage 1 of the project involved patients completing a semi-structured
interview and a number of self-report inventories. Assessment lasted approximately one hour.
A range of demographic and clinical information including date of birth, gender, date of
admission, date of discharge, and primary diagnosis was obtained during this interview
(APPENDIX 7). The use of several types of legal and illegal substances (alcohol, marijuana,
cocaine, heroin, and amphetamines) was recorded by asking patients whether they had used
these substances in the preceding year and during the lifetime. The patient’s history of
aggression was recorded using the Violence Rating Scale (Robertson, Taylor & Gunn, 1987)
(see APPENDIX 8). The Violence Rating Scale has been used in studies of the violence
history of other forensic psychiatric hospital patients, for example patients in Broadmoor
Hospital (Wong, Lumsden, Fenton & Fenwick, 1993), and has been described as a useful
screening instrument to describe the violence profile of an offender population (Wong et al.,
1993). Essentially, the Violence Rating Scale is a combination of ratings of violence
associated with the index offence (the offence that resulted in the current
admission/incarceration) and ratings derived from previous convictions. Information from
case notes and from interview with patients was used to score violence from the index offence
(range: 0 - 4) and previous criminal records (range: 0 – 4). A total score was obtained from
the sum of these two scores (range: 0 – 8). Files were also reviewed to assist data collection.
For those patients who refused to participate, files were reviewed and available data was used
to record the required historical, demographic and clinical details.

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 After the historical, demographic and clinical information had been obtained from
those patients consenting to participation in Stage 1 a number of questionnaires were
administered. These questionnaires included:
The Novaco Anger Scale (Novaco, 1994) (APPENDIX 9)
The NAS is a self-report measure of anger arousal and control that has Cognitive,
Behavioural and Arousal dimensions. In addition to these three domain scales a Total anger
score may be calculated by summing the three subscales. The NAS was developed and
validated for use with mentally disordered as well as non mentally disordered populations so
was therefore considered applicable for assessment of patients in this study. Its statistical
properties are well established. In studies with psychiatric patients in California state hospitals
(Novaco, 1994), the NAS was found to have an internal reliability of .95 and a test-retest
reliability of .84. Further, it was significantly related to a number of anger and aggressive
behaviour criteria evaluated in concurrent, retrospective, and prospective analyses, which also
included comparative measures.
A revised version (1998) of the NAS was obtained from Western Psychological
Services for use in the study. The most recent version of the NAS has parts A and B. Part A
comprises the Arousal, Cognitive and Behavioural scales. Part B comprises a Provocation
Inventory. For this study Part B was not able to be obtained from Western Psychological
Services and was therefore not used.
The NAS was chosen to assess anger arousal and control as it has demonstrated
efficacy. The NAS was reported by McNiel et al. (2003) to be a useful measure to assess the
risk of violent behaviour, consistent with the MacArthur Study of Mental Disorder and
Violence, which found the NAS to predict risk of future violence after patients had been
stabilized and discharged from civil psychiatric hospitals (Monahan, Steadman, Silver,
Appelbaum, Robbins & Mulvey, 2001).
The Simplified Version of the Rathus Assertiveness Scale (RAS) (McCormick, 1984)
(APPENDIX 10)
For this study, the simplified version of the Rathus Assertiveness Scale (McCormick,
1984) was selected to measure assertiveness. The simplified version of the RAS consists of 30
items that are scored on a six-point scale from 0 (very unlike me) to 6 (very much like me).
The range of scores is therefore 30 to 180.The utility of the simplified RAS was, when
compared with the original RAS, considered high, with 97% of 64 offenders completing the
simplified RAS, compared with only 7% who were able to complete the original RAS
(McCormick, 1984). Statistical properties were reportedly acceptable with a mean inter-item

78
correlation between the simplified and the original RAS of .79, and a total score correlation of
.94 on the two tests (McCormick, 1984).
The Psychotic Symptom Rating Scales (PSYRATS) (Haddock, McCarron, Tarrier, &
Faragher, 1999) (APPENDIX 11)
The PSYRATS was chosen because it comprises two scales designed to rate aspects of
auditory hallucinations and delusions. The auditory hallucinations subscale is an 11-item
scale. Items included in this subscale measure frequency, duration, severity and intensity of
distress, controllability, loudness, location, negative content, degree of negative content,
beliefs about the origin of voices, and disruption. A five point ordinal scale is used to rate
symptom scores (0 – 4). The delusions subscale is a six-item scale that assesses dimensions of
delusions. The items include preoccupation, distress, duration, conviction, intensity of distress
and disruption. The items are rated on a five-point ordinal scale (0 – 4). According to a factor
structure derived by Haddock et al. (1999), three auditory hallucinations and two delusions
factors can be calculated. The three auditory hallucinations factors include an emotional
characteristics factor (factor 1), a physical characteristics factor (factor 2) and a cognitive
interpretation factor (factor 3). The two delusions factors include a cognitive interpretation
factor (factor 1) and an emotional characteristics factor (factor 2).
The Functional and Dysfunctional Impulsivity Scale (Dickman, 1990) (APPENDIX 12)
The Functional and Dysfunctional Impulsivity scale (Dickman, 1990) is a self-report
instrument that provides a measure of dysfunctional and functional impulsivity. Dickman
(1990) suggested that impulsivity may be characterised as either functional, where impulsivity
benefits the individual, or dysfunctional, where impulsivity disadvantages the individual. The
Functional and Dysfunctional Impulsivity scale has acceptable statistical properties with a
reported internal reliability coefficient for the functional scale of 0.74 and 0.85 for the
dysfunctional scale. The correlation between the two is relatively low (Dickman, 1990).
At the time of patients being approached for participation in Stage 1 assessment, the
patient’s Case Coordinator, Primary Nurse or shift leader was asked to complete a shortened
version of the Social Behaviour Schedule (SBS) (Wykes & Sturt, 1986) (APPENDIX 13),
rating the patient’s social behaviour in the week prior to assessment.
Social Behaviour Schedule (SBS)
The SBS covers 21 behaviour areas exhibited by patients with long-term impairments
cause by psychiatric illness. Most of the items are rated on a scale of 0 (no problem or
acceptable behaviour) to 4 (serious problem). In the current study only those items derived
from a four behavioural syndrome classification system developed by Curson, Duke, Harvey,
Pantelis and Barnes (1999), were used. Using the results of a principal components analysis of

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SBS items, Curson et al. (1999) identified four behavioural syndromes: Social Withdrawal,
Thought Disturbance, Antisocial Behaviour and Depressed Behaviour. For the purpose of this
study each behavioural syndrome was scored in addition to a Total SBS score, a measure of
total impairment in social behaviour, which was calculated by summing the aforementioned
four subscales.
At this time, the patient’s Psychiatric Registrar was also asked to complete a short
version of the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962). For patients
admitted to the hospital prior to October 1st 2001, registrars completed the short version of the
BPRS on mental state examination during the last week of December 2001.
Brief Psychiatric Rating Scale (BPRS)
The BPRS is a clinician based rating scale that provides a means to evaluate a range of
psychiatric symptom constructs. Each item is measured according to a seven-point scale that
runs on a continuum from 0 (not present) to 6 (extremely severe). The short version of the
BPRS developed for this study included three subscales taken from the original BPRS:
Conceptual Disorganisation, Hallucinatory Behaviour and Unusual Thought Content. A Total
BPRS score was also calculated by summing each of the three items assessed. The BPRS has
been used in numerous studies examining psychiatric illness and has been shown to be a
reliable and effective measure of psychiatric symptoms. In a previous study of inpatient
aggression, Krakowski et al. (1986) reported that BPRS Conceptual Disorganisation, Unusual
Thought Content and Hallucinatory Behaviour scales differentiated aggressive from non-
aggressive patients. Similarly, Yesavage (1983) found that the severity of “schizophrenic
symptoms” (p. 356), Conceptual Disorganisation, Unusual Thought Content and
Hallucinatory Behaviour, was related to aggression.
6.2 STAGE 2: The Assessment of Purpose
Between 1st January and 31st December 2002 staff members were asked to record
aggressive behaviours using an adapted version of the Overt Aggression Scale (OAS) (Silver
& Yudofsky, 1987) that was renamed for the purpose of this study, the ‘Record of Aggressive
Behaviours’ (APPENDIX 1).
Prior to 1st October 2001, as discussed in the second study, staff were informed of the
project and trained to record incidents of aggression using the ‘Record of Aggressive
Behaviours’. In the ‘Record of Aggressive Behaviours’ the name of the patient behaving
aggressively, the date and time of the incident, the ward where the incident occurred, and in
the case of physical and verbal aggression, whether the victim was a staff member or a co-
patient was recorded. A folder containing blank record forms was left in a prominent position
within the nursing station on each ward. An instruction sheet was left with the folder and the

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author visited the ward at least three times every week to collect completed Incident Forms,
review the recording process and maintain staff interest in the project. The author also
assisted in the completion of forms where they had not been completed by asking staff
whether there had been aggressive behaviours that had gone unreported.
Following every act of aggression an attempt was made to identify purpose, and to
obtain additional information including victim characteristics, and the month, day of week,
and location of each aggressive behaviour according to a record form developed for the study
(APPENDIX 14). In a semi-structured interview (APPENDIX 15) conducted by the author,
the staff member who had recorded the incident, or another staff member who was aware of
details of the aggressive behaviour, and who was familiar with the aggressive patient, was
asked to provide a description of the incident, its antecedents and consequences. Prior to this
interview an information sheet describing the project (APPENDIX 16) and the nature of the
interview was provided for staff. Staff members were then requested to provide written
informed consent (APPENDIX 17) before participation in the study. Following completion of
the staff interview the aggressive inpatient was approached to participate in a similar semi-
structured interview (APPENDIX 18) providing they were not in seclusion, were able to
provide informed consent (determined by ward staff), and staff believed an approach to
participate in the research would not increase the likelihood of further aggression. A thorough
explanation of the research project was provided for patients. An information sheet
(APPENDIX 19) describing the research project was provided prior to a request for
participation and written consent (APPENDIX 20). In addition to the semi-structured
interview the patient’s rationale for his or her aggressive behaviour was elicited and if
delusional or a consequence of command auditory hallucination, as assessed by the author,
then the delusion and/or hallucination was rated using the PSYRATS (Haddock et al., 1999).
Where the aggression was directed towards the author, or in those cases where the
author participated in the aggressive patient’s restraint or seclusion, the patient was not
approached for interview. However, the incident was recorded on the ‘Record of Aggressive
Behaviours’. In those cases where assessment of the patient’s aggression through semi-
structured interview was determined by the patient’s treating team to be reinforcing, or where
previous assessments had contributed to an escalation in the patient’s aggression, the patient
was excluded from participation in the semi-structured interview in subsequent aggressive
incidents.
Treating teams were informed that assessment details were to be used exclusively for
research purposes. Only at the patient’s request and with his or her written consent (see
APPENDIX 21) were details of the assessment made available to the treating team.

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 6.3 Hypotheses
The main aim of the current research was to describe the nature and frequency of
aggression in the TEH, identify the purposes for aggression, and determine whether these
purposes varied according to the type, direction and severity of aggression. Specifically, with
regard to purpose, every act of aggression was hypothesised to have at least one purpose
identified, in contrast with the view that inpatient aggression is motiveless. Further, when the
victim of aggression was another patient, ‘Following provocation’ was considered the most
likely purpose. When the victim of aggression was a member of staff, the following purposes
were considered most likely: (a) ‘Following provocation’ (b) ‘Denial of request’, (c) ‘Demand
Avoidance’, and (d) ‘To reduce social distance’. The current research also aimed to examine
the relationship between inpatient aggression and a range of predisposing characteristics,
including psychotic symptoms, impulsivity, assertiveness, social behaviour and anger. A
further aim was to determine whether these individual characteristics predisposed inpatients
to behave aggressively for different purposes. According to a review of the literature, it was
assumed that all of the predisposing characteristics examined would show a relationship with
inpatient aggression. There were no clear hypotheses developed with regard to the
relationship between patients predisposing characteristics and purpose, except for socially
isolated and unassertive patients. These patients were hypothesised to more frequently behave
aggressively to reduce social distance.
7.0 Results
Results are presented in the following sections:
The first section provides a description of admission and discharge information,
including length of admission and legal status of patients on admission. Also included in this
section is a description of patients’ predisposing characteristics including age, diagnosis,
substance use history, and history of aggression. A description of the relationships between
age, substance use history, history of aggression, social behaviour, anger, impulsivity,
assertiveness, and psychotic symptoms is also provided in a correlation matrix.
The second section provides a description of the nature and frequency of aggressive
behaviours occurring during 2002. Included are the number of days between admission and
first aggressive behaviour, time of day aggression occurred, type of aggression, ward where
aggression occurred, severity of the aggressive behaviour towards staff and patients, day of
week and month of aggressive behaviour, type of aggression by day of the week, victim type,
victim type by day of the week, gender of victim, details of property damage, and whether
physically aggressive behaviours towards staff occurred within the context of restraint or
seclusion.

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 The third section describes the relationships between aggression and age, gender,
diagnosis, legal status, substance use history, history of aggression, social behaviour, anger,
impulsivity, assertiveness, and psychiatric symptoms. Included in this section are the results
of a multiple regression analysis examining the relationship between patients’ predisposing
characteristics and aggressive behaviour.
The final results section describes the purposes for aggression and the relationship
between purpose and the type, direction and severity of aggression. Also included is a
description of the relationships between purpose and age, diagnosis, gender, social behaviour,
history of aggression, substance use, anger, impulsivity, assertiveness and psychiatric
symptoms. Results of the mental status assessment conducted after the aggressive behaviour,
using the PSYRATS, which evaluated the influence of aspects of delusions and hallucinations
on the patient’s aggressive behaviour is also reported. The relationship between the total
number of different types of purposes, the total number of different types of victims, and the
total number of types of aggression used by each aggressive patient is described, as is a
description of the relationships between these outcome variables. Also reported are the
relationships between patients’ predisposing characteristics, including age, substance use,
history of aggression, social behaviour, anger, impulsivity, assertiveness and psychotic
symptoms, with the number of aggressive behaviours, total types of aggressive behaviours,
total types of victims, total types of gender, and total number of different types of purposes
for aggression, used by each patient.
To make results more accessible, in several sections, a summary of the results is
provided with an emphasis on significant results. In these sections a full description of the
results is included in APPENDIX 22.
7.1 Admissions, Legal Status and Predisposing Characteristics
Including the 80 patients who were admitted prior to, but residing in the hospital on 1st
January 2002, there were 232 admissions to the TEH between 1st January 2002 and 31st
December 2002. Two hundred and four patients, 167 males and 37 females were admitted
during the study period. Twenty-four patients were admitted on two occasions and two
patients were admitted on three occasions. A total of 133 patients were discharged from the
TEH during the study period. Ninety-four patients were admitted and discharged during 2002.
Length of admission for these 94 patients ranged from one to 177 days (M = 50.77, SD =
40.06).
The majority of patients who resided in the hospital on 1st January 2002, or were
admitted during 2002, were admitted from prison under Section 16(3)(b) of the Mental Health
Act, 1986 (n = 159 or 68.5% of admissions). There were 41 patients (17.7% of admissions)

83
admitted under the Crimes (Mental Impairment and Unfitness to be Tried) Act, 14 (6%)
admitted under Section 93(1)(e) of the Sentencing Act, and three (1.3%) admitted under
Section 93(1)(d) of the Sentencing Act. Fifteen (6.5%) patients were, at the time of
assessment, held under Section 12 of the Mental Health Act, 1986.
Age
Age was determined by calculating age at the time of admission, if admitted during
2002, or age as at the 1st January 2002 for those patients admitted prior to this date. Age was
recorded for all 232 admissions. Patients ranged in age from 17 to 83 years (M = 34.52, SD =
12.6, Median = 31.10 years).
Diagnosis
The diagnosis to which the patient’s presenting problem was attributed was identified
from discharge summaries. For patients remaining in the hospital on 31st December 2002, the
provisional diagnosis was obtained through interview with the Psychiatric Registrar
responsible for the patient’s care. Diagnosis was recorded for 229 admissions. The most
common diagnosis was Schizophrenia (n = 173 or 74.57%). Disorders characterised by the
presence of psychotic symptoms, including Schizophrenia (n = 173 or 74.57%), Paranoid
Psychosis (n = 2 or 0.87%), Schizoaffective Disorder (n = 8 or 3.49%), Delusional Disorder
(n = 3 or 1.31%), Brief Reactive Psychosis (n = 1 or 0.44%), Drug Induced Psychosis (n = 4
or 1.75%), Depression with Psychotic Features (n = 5 or 2.18%), Psychosis Not Otherwise
Specified (n = 3 or 1.31%), and Psychosis of Organic origin (n = 2 or 0.87%), were most
common (n = 201 or 86.64%). Affective disorders (not including Schizoaffective Disorder),
including Bipolar Affective Disorder (n = 4 or 1.75), Hypomania (n = 1 or 0.44%),
Depression (n = 7 or 3.06%) and Dysthymia (n = 2 or 0.87%) were recorded on 14 (6.11%)
occasions. Personality disorders including Borderline Personality Disorder (n = 5 or 2.18%)
and Antisocial Personality Disorder (n = 4 or 1.75%), were recorded on nine (3.93%)
occasions. A number of other diagnoses were also recorded, including Adjustment Disorder
(n = 1 or 0.44%), Asperger’s disorder (n = 2 or 0.87%), Huntington’s disease (n = 1 or
0.44%), and Dementia (n = 1 or 0.44%). No diagnosis was recorded for three patients.
Substance Use
As part of the study, patients were asked whether they had used alcohol, marijuana,
heroin, cocaine or amphetamines in the year prior to assessment, and in the course of their
lifetime. The number of substances used in the year prior to assessment and during the course
of the lifetime was calculated. As each patient’s substance use history is assessed routinely on
admission, details of substance use for patients who refused to participate in the study were

84
able to be taken from file. Details of substance use were therefore available for all 232
admissions.
One hundred and fifty one (65.1%) patients had used alcohol in the year prior to
assessment, 128 (55.2%) had used marijuana, 19 (8.2%) had used cocaine, 64 (27.6%) had
used heroin and 75 (32.3%) had used amphetamines. Two hundred and eighteen patients
(94%) had used alcohol during their lifetime, 185 (79.7%) had used marijuana, 39 (16.8%)
had used cocaine, 101 (43.5%) had used heroin, and 120 (51.7%) had used amphetamines.
Sixty-three patients (27.2%) had used no substances in the year prior to assessment, 39
(16.8%) had used one substance, 38 (16.4%) had used two different substances, 38 (16.4%)
had used three, 42 (18.1%) had used four, and eight (3.4%) had used five. Six patients (2.6%)
reported never using any substances during their lifetime, 31 (13.4%) had used one substance,
53 (22.8%) had used two different substances, 44 (19%) had used three, 61 (26.3%) had used
four, and 30 (12.9%) had used five. Table 5 shows the number of substances used by patients
in the year prior to assessment and across the lifetime.

Table 5: Number of Substances Used by Patients in the Year Prior to Assessment and Across
the Lifetime
Total substances used In previous year In lifetime
0 63 (27.2%) 6 (2.6%)
1 39 (16.8%) 31 (13.4%)
2 38 (16.4%) 53 (22.8%)
3 38 (16.4%) 44 (19%)
4 42 (18.1%) 61 (26.3%)
5 8 (3.4%) 30 (12.9%)

History of Aggression
As each patient’s history of aggression and details of prior offences are recorded on
file, patients who refused to participate in the study had details of their history of aggression
taken from file. The severity of aggression of the index offence was calculated for 226
(97.41%) admissions. The history of aggression was calculated for 224 (96.55%) admissions.
According to the Violence Scale, the violence level of the index offence for 33
patients (14.2%) was categorised as completely non-violent. The violence level of another 33
patients (14.2%) was categorised as minimal, the violence level of 64 patients (27.6%) was
categorised as moderate, and the violence level of 96 patients (41.4%) was categorised as
severe. Table 6 shows the violence rating of patient’s index offence.

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 Table 6: Violence Rating of Index Offence

Violence rating for index offence Total (percentage)

Completely non violent 33 (14.2%)
Minimal violence 33 (14.2%)
Moderate violence 64 (27.6%)
Severe violence 96 (41.4%)

With regard to previous violence, which did not include the index offence, 57 (24.6%)
patients had never been convicted of a violent offence and reported never getting into fights,
70 (30.25%) patients reported some evidence of violence (e.g., getting into occasional fights),
53 patients (22.8%) had one or two convictions for minor assaults or damage to property, 30
(12.9%) had three or more convictions for violence, none of which involved someone’s health
or life being seriously endangered, and 14 (6.25%) had one or more episodes of violence in
which someone’s life or health was seriously endangered. Table 7 shows patients’ previous
violence record.
Table 7: Violence Rating for Previous Record

Violence rating for previous record Total (Percentage)

Never convicted of violence 57 (24.6%)
Some evidence of violence 70 (30.25%)
One or two convictions for minor assaults or damage to property 53 (22.8%)
Three or more convictions for violence 30 (12.9%)
One or more severly violent episodes 14 (6.25%)

Psychotic Symptoms (Brief Psychiatric Rating Scale (BPRS)- Short Version)

Fifty-seven patients (24.5%) showed no Conceptual Disorganisation. Thirty-three
patients (14.3%) experienced very mild Conceptual Disorganisation. Forty patients (17.2%)
experienced mild Conceptual Disorganisation. Thirty patients (12.9%) experienced moderate
Conceptual Disorganisation. Thirty patients (12.9%) experienced moderate to severe
Conceptual Disorganisation. Twenty patients (8.6%) experienced severe Conceptual
Disorganisation. Two patients (0.9%) experienced extremely severe Conceptual
Disorganisation.
Ninety-eight patients (42.3%) showed no Hallucinatory Behaviour. Nineteen patients
(8.2%) experienced very mild Hallucinatory Behaviour. Thirty-two patients (13.8%)
experienced mild Hallucinatory Behaviour. Twenty-eight patients (12.1%) experienced
moderate Hallucinatory Behaviour. Sixteen patients (6.9%) experienced moderate to severe

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Hallucinatory Behaviour. Twenty patients (8.6%) experienced severe Hallucinatory
Behaviour. Two patients (0.9%) experienced extremely severe Hallucinatory Behaviour.
Thirty-eight patients (16.4%) showed no Unusual Thought Content. Nineteen patients (8.2%)
experienced very mild Unusual Thought Content. Thirty-three patients (14.2%) experienced
mild Unusual Thought Content. Forty-one patients (17.7%) experienced moderate Unusual
Thought Content. Thirty-one patients (13.4%) experienced moderate to severe Unusual
Thought Content. Forty-five patients (19.4%) experienced severe Unusual Thought Content.
Five patients (2.2%) experienced extremely severe Unusual Thought Content. The mean Total
BPRS-adapted version, with a minimum of zero and maximum of 21, was 9.42 (SD = 4.41).
Relationships between patient’s predisposing characteristics
The relationships between patient’s age, substance use, prior aggression, social behaviour,
anger, impulsivity, assertiveness, and psychotic symptoms were assessed. Significant
correlations are reported in Tables 8a and 8b.

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 Table 8a: Significant Pearson Correlations Between Predisposing Characteristics

NAS (Co) NAS (B) NAS (A) NAS (T) Impulsivity (F) Impulsivity (D) RAS PSYRATS (H1) PSYRATS (H2)

Age

Violence

Substances (I)

Substances (II)

SBS (SW)

SBS (TD)

SBS (AB)

SBS (DB)

SBS (T)

NAS (Co)

NAS (B) .660*** (n =110)

NAS (A) .697*** (n =110) .730*** (n =110)

NAS (T) .874*** (n =110) .901*** (n =110) .904*** (n =110)

Impulsivity (F)

Impulsivity (D) .301** (n =110) .426*** (n =110) .354*** (n =110) .406*** (n =110)

RAS .230* (n =108) .368*** (n=111) -.196* (n =111)

PSYRATS (H1) .226* (n =107) .296** (n =107) .248* (n =107) .346*** (n =111)

PSYRATS (H2) .226* (n =109) -.364*** (n =113) .189* (n =110) .866*** (n =111)

PSYRATS (H3) .232* (n =109) .369*** (n =113) -.199* (n =110) .910*** (n =111) .959*** (n =114)

PSYRATS (D1) .228* (n =102) .213* (n =102) .239* (n =102) .284** (n =106) .432*** (n =104) .495*** (n =106)

PSYRATS (D2) .225* (n =105) .210* (n =105) .205* (n =105) .242* (n =105) .310** (n =109) .440*** (n =107) .446*** (n =109)

BPRS (T) .278** (n =105) .290** (n =105) .266** (n =105) .312** (n =105) .275** (n =108) .322** (n =109)

*p < .05, **p < .01, ***p<.001

NOTE: Abbreviations: Violence = Total Violence Scale score, Substances (I) = Number of substances used in the year prior to assessment, Substances (II) = Number of substances used in the lifetime, SBS (SW) = SBS
Social Withdrawal, SBS (TD) SBS Thought Disturbance, SBS (AB) SBS Antisocial Behaviour, SBS (DB) = SBS Depressed Behaviour, SBS (T) = SBS Total, NAS (Co) = NAS Cognitive, NAS (B) = NAS Behavior,
NAS (A) = NAS Arousal, NAS (T) = NAS Total, Impulsivity (F) = Functional Impulsivity, Impulsivity (D) = Dysfunctional Impulsivity, RAS = Rathus Assertiveness Schedule, PSYRATS = Psychotic Symptom
Rating Scales (H1 = Hallucinations (Emotional Characteristics), H2 = Hallucinations (Physical Characteristics), H3 = Hallucinations (Cognitive Interpretation), D1 = Delusions (Cognitive Interpretation), D2 =
Delusions (Emotional Characteristics), BPRS = Brief Psychiatric Rating Scale (Total)

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 Table 8b: Significant Pearson Correlations Between Predisposing Characteristics

NAS (Co) NAS (B) NAS (A) NAS (T) Impulsivity (F) Impulsivity (D) RAS PSYRATS (H1) PSYRATS (H2) PSYRATS (H3) PSYRATS (D1) PSYRATS (D2) BPRS (T)

NAS (Co)

NAS (B) .660*** (n =110)

NAS (A) .697*** (n =110) .730*** (n =110)

NAS (T) .874*** (n =110) .901*** (n =110) .904*** (n =110)

Impulsivity (F)

Impulsivity (D) .301** (n =110) .426*** (n =110) .354*** (n =110) .406*** (n =110)

RAS .230* (n =108) .368*** (n=111) -.196* (n =111)

PSYRATS (H1) .226* (n =107) .296** (n =107) .248* (n =107) .346*** (n =111)

PSYRATS (H2) .226* (n =109) -.364*** (n =113) .189* (n =110) .866*** (n =111)

PSYRATS (H3) .232* (n =109) .369*** (n =113) -.199* (n =110) .910*** (n =111) .959*** (n =114)

PSYRATS (D1) .228* (n =102) .213* (n =102) .239* (n =102) .284** (n =106) .432*** (n =104) .495*** (n =106) .491*** (n =106)

PSYRATS (D2) .225* (n =105) .210* (n =105) .205* (n =105) .242* (n =105) .310** (n =109) .440*** (n =107) .446*** (n =109) .451*** (n =109) .747*** (n =107)

BPRS (T) .278** (n =105) .290** (n =105) .266** (n =105) .312** (n =105) .275** (n =108) .322** (n =109) .328** (n =109) .451*** (n =103) .247* (n =105)

*p < .05, **p < .01, ***p<.001

NOTE: Abbreviations: Violence = NAS Cognitive, NAS (B) = NAS Behavior, NAS (A) = NAS Arousal, NAS (T) = NAS Total, Impulsivity (F) = Functional Impulsivity, Impulsivity (D) = Dysfunctional Impulsivity,
RAS = Rathus Assertiveness Schedule, PSYRATS = Psychotic Symptom Rating Scales (H1 = Hallucinations (Emotional Characteristics), H2 = Hallucinations (Physical Characteristics), H3 = Hallucinations (Cognitive
Interpretation), D1 = Delusions (Cognitive Interpretation), D2 = Delusions (Emotional Characteristics), BPRS = Brief Psychiatric Rating Scale (Total)

89
 7.2 The Nature and Frequency of Aggression within the Thomas Embling Hospital
Five hundred and two aggressive behaviours were recorded during 2002.
Overall, 105 of the 232 patients admitted (45.26%) were aggressive on at least one occasion.
Of those patients who were aggressive, 36.2% were aggressive on one occasion. Most
(81.9%) aggressive patients were aggressive on fewer than six occasions. A small number of
patients (8) were aggressive on 15 or more occasions. These patients were responsible for 216
(43.03%) aggressive behaviours. The mean length of admission for non-aggressive patients
(M = 34.8, SD = 36.26) was almost half that for aggressive patients (M = 65.43, SD = 38.02)
(t(92) = 4, p = .0001). Table 9 shows the number of aggressive behaviours and the number of
patients across the various wards within the hospital that were responsible for these acts of
aggression.

Table 9: Number of Aggressive Behaviours Recorded by Patients Across the Hospital

Number of incidents Argyle Atherton Barossa Bass Canning Daintree Total (Cumulative frequency)
1 12 15 7 7 5 1 38 (36.2)
2 14 6 3 1 1 23 (58.1)
3 3 3 2 4 10 (67.6)
4 3 1 2 1 6 (73.3)
5 5 2 2 1 1 9 (81.9)
6 1 1 2 (83.8)
7 1 1 2 (85.7)
8 1 1 (86.7)
9 1 1 (87.6)
11 1 1 2 (89.5)
12 1 1 (90.5)
13 2 1 2 (92.4)
15 1 1 1 (93.3)
17 1 1 (94.3)
18 1 1 (95.2)
26 1 1 (96.2)
28 1 1 1 (97.1)
29 1 1 (98.1)
30 1 1 (99)
53 1 1 (100)

Days Between Admission and First Aggressive Behaviour

The number of days between admission date and first aggressive behaviour was
calculated for those patients admitted during 2002. Patients who were admitted prior to 1st
January 2002 were excluded because information about aggression prior to the 1st January
2002 was unavailable. Seventy three patients admitted after 1st January 2002 were aggressive.
The average number of days between admission and first aggressive behaviour was 23.27 (SD
= 36.18). The median number of days was eight. Almost half (43.8%) of all aggressive

90
patients were aggressive during their first week of admission. Table 10 shows the days
between admission and first aggressive behaviour.

Table 10: Number of Days Between Admission and First Aggressive Behaviour

Number of days Frequency Total (Cumulative frequency)

0 3 4.1
1 4 9.6
2 3 13.7
3 9 26
4 3 30.1
5 6 38.4
6 2 41.1
7 2 43.8
8 5 50.7
10 2 53.4
11 3 57.5
12 1 58.9
15 1 60.3
16 3 64.4
17 1 65.8
18 1 67.1
22 1 68.5
24 1 69.9
25 1 71.2
26 1 72.6
29 1 74
30 3 78.1
32 1 79.5
35 2 82.2
40 1 83.6
43 1 84.9
50 2 87.7
52 1 89
54 1 90.4
56 1 91.8
62 1 93.2
82 1 94.5
86 1 95.9
138 1 97.3
146 1 98.6
214 1 100

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Survival Function for Aggressive Behaviour
A survival analysis was conducted to determine the relationship between number of
days between admission and first aggressive behaviour. Figure 7 presents the estimates of
survival probabilities for aggressive behaviour for patients admitted to and discharged from
the hospital during 2002. The survival curve is relatively steep, suggesting that aggressive
patients are first aggressive during the early stages of their admission.

Figure 7: The relationship between cumulative survival and aggression

Survival Function
1.2

1.0

.8

.6

.4

.2
Cum Survival

0.0

-.2
-20 0 20 40 60 80 100 120 140

Days between admission and first aggressive incident

Time of Aggressive Behaviour

Figure 8 shows the time of the day by frequency of aggressive behaviours. There was
no significant effect of time of day on type of aggressive behaviour (χ2(41) = 54.56, n.s.).
Similarly, there was no significant effect on time of day and type of victim (staff or patient)
(χ2(46) = 58.00, n.s.).

92
 Figure 8: Time of the day by frequency of aggressive behaviour

60

frequency of aggressive incidents 50

40

30

20

10

0
m

am

pm

pm

m
m

m
1a

2a

3a

4a

5a

6a

7a

8a

9a

1a

2p

1p

2a
2p

3p

4p

5p

6p

7p

8p

9p
10

-1

10
0-

1-

2-

3-

4-

5-

6-

7-

8-

-1

-1
1-

2-

3-

4-

5-

6-

7-

8-
-1

-1
12
9-

9-
10

11
11

10
Time of day

Victim Characteristics
Of the 463 aggressive behaviours in which characteristics of the victim were recorded,
320 (n = 69.11%) involved verbal or physical aggression towards staff, and 139 (30.02%)
involved verbal or physical aggression towards patients. Staff and patients were the victims of
aggression on four occasions. There was a statistically significant difference (χ2(2) = 31.309,
p = .001) for type of aggression (verbal or physical) and victim type (staff, patient or both
staff and patients). Members of staff were more likely to be the victims of verbal aggression
when compared with patients. Patients were more likely to be the victims of physical
aggression. One hundred and ninety six verbally aggressive (61.25% of all aggressive
behaviours towards staff), and 124 (38.75%) physically aggressive behaviours towards staff
were recorded. Forty-eight verbally aggressive (34.53% of all aggressive behaviours towards
patients), and 91 (65.47%) physically aggressive behaviours towards patients were recorded.
When the four behaviours in which staff and patients were excluded, a statistically significant
difference (χ2(1) = 27.781, p = .001) for type of aggression between victim types existed.
Of the 320 aggressive behaviours towards staff, 275 (85.94%) were directed towards
nursing staff. Members of nursing staff were the most frequent victims of physical (n = 107
aggressive behaviours), and verbal aggression (n = 168 aggressive behaviours). On 11
occasions patients were aggressive towards Psychiatric Registrars (two physical and nine
verbal) and on eight occasions the aggression (four physical and four verbal) was directed
towards Consultant Psychiatrists. Twelve aggressive behaviours (eight physical and four
verbal) were directed towards ward managers and three (all verbal) were directed towards
Psychiatric Services Officers, who are untrained ward staff. Seven incidents of aggression

93
(one physical and six verbal) were directed towards Psychologists. Occupational Therapists
and Social Workers were victims of aggression on one (both verbal) occasion each. Ward
cleaners were the victims of aggression on two (one physical and one verbal) occasions.
Gender of Victim
Of the 458 aggressive behaviours in which the gender of the victim was recorded, 213
(46.50%) involved aggression towards males. One hundred and seventy four (37.99%)
involved aggression towards females, and 71 (15.5%) involved aggression towards both
males and females. There was a significant interaction between gender of aggressive patient
and gender of victim when property damage and aggression towards both males and females
were excluded (χ2(1) = 122.844, p = .0001). Males were more likely to be aggressive towards
males (n = 189 or 75.9% of aggressive behaviours) and females were more likely to be
aggressive towards females (n = 114 or 82.6% of aggressive behaviours).
When only verbal and physical aggression towards staff was considered (excluding
aggressive behaviours where both males and females were victims) there was still a
significant interaction between gender of patient and gender of victim (χ2(1) = 33.222, p =
.0001). Male patients were more likely to be aggressive towards male staff (103 or 51.5%)
when compared with female staff (n = 55 or 27.5%). Conversely, female patients were more
likely to be aggressive towards female staff (n = 65 or 56.5%) when compared with male staff
(n = 24 or 20.9%).
There was a significant interaction between gender of patient and gender of victim
when aggression towards other patients was considered (χ2(1) = 119.122, p = .0001). When
males were the perpetrators of aggression towards patients they were much more likely to be
aggressive towards males (n = 85 or 94.4%) rather than females. When females were
aggressive towards patients they were always aggressive towards females (n = 49 or 100%).
When males were the perpetrators of aggression there was a significant interaction
between gender of victim and type of aggression (χ2(6) = 337.400, p = .0001). Males were
slightly more likely to be verbally (n = 102 or 54.0%), rather than physically (n = 87 or 46%),
aggressive towards males. Males were much more likely to be verbally (n = 49 or 81.7%),
rather than physically aggressive towards females (n = 11 or 18.3%). When males were
aggressive towards both males and females they were much more likely to be verbally (n = 35
or 79.5%), rather than physically aggressive (9 or 20.5%).
When females were the perpetrators of aggression there was a significant interaction
between gender of victim and type of aggression (χ2(6) = 172.771, p = .0001). Females were
equally as likely to be verbally (n = 12 or 50%), as physically aggressive towards males (n =
12 or 50%), whereas they were more likely to be physically (n = 79 or 69.3%), rather than

94
verbally (n = 35 or 30.7%) aggressive towards females. When females were aggressive
towards males and females, they were almost as likely to be verbally (n = 11 or 40.7%), as
physically aggressive (n = 16 or 59.3%).
Aggression by Type and Location
The acute wards accounted for the highest frequency of aggressive behaviours: Argyle
(n = 185 or 36.9%), Barossa (n = 175 or 34.9%), and Atherton (n = 105 or 21%). The long
stay unit, Canning, recorded 34 (6.8%) aggressive behaviours and one (0.2%) act of
aggression was recorded on Daintree and in the YMCA.
Barossa, the female acute unit, recorded the highest frequency of physical aggression
(n = 108 or 49.8% of all physical aggression; 61.7% of all aggression on Barossa), followed
by Argyle (n = 54 or 24.9% of all physical aggression; 29.2% of all aggression on Argyle),
Atherton (n = 34 or 15.7% of all physical aggression; 32.4% of all aggression on Atherton),
Canning (n = 20 or 9.2% of all physical aggression; 58.8% of all aggression on Canning), and
the YMCA (n = 1 or 0.5% of all physical aggression; 100% of all aggression on the YMCA).
Argyle recorded the highest frequency of verbal aggression (n = 118 or 45.7% of all
verbal aggression; 63.8% of all aggression on Argyle), followed by Barossa (n = 63 or 24.4%
of all verbal aggression; 36% of all aggression on Barossa) and Atherton (n = 63 or 24.4% of
all verbal aggression; 60% of all aggression on Atherton), Canning (n = 13 or 5.0% of all
verbal aggression; 38.2% of all aggression on Canning), and Daintree (n = 1 or 0.4% of all
verbal aggression; 100% of all aggression on Daintree).
Argyle recorded the highest frequency of property damage (n = 13 or 50% of all
property damage; 7% of all aggression on Argyle), followed by Atherton (n = 8 or 30.8% of
all property damage; 7.6% of all aggression on Atherton), Barossa (n = 4 or 15.4% of all
property damage; 2.3% of all aggression on Barossa) and Canning (n = 1 or 3.8% of all
property damage; 2.9% of all aggression on Canning). There was a significant difference in
the type of aggression depending upon location (χ2(10) = 51.03, p = .0001). Figure 9 shows
the type of aggression by location.

95
 Figure 9: Type of aggression by location

200
180
Frequency of aggressive behaviours 160

140
120
100
80
60
40
20
0
Argyle Atherton Barossa Canning Daintree Off campus
Location

Physical aggression Verbal aggression Property damage

Verbal and Physical Aggression Towards Staff and Patients by Location

Physical aggression towards staff was most frequently recorded on Barossa (n = 69 or
55.65% of all physical aggression towards staff), followed by Argyle (n = 28 or 22.58%),
Atherton (n = 15 or 12.1%) and Canning (n = 12 or 9.68%). Physical aggression towards
patients was most frequently recorded on Barossa (n = 38 or 41.76% of all physical
aggression towards patients), followed by Argyle (n = 26 or 28.57%), Atherton (n = 19 or
20.88%), Canning (n = 7 or 7.7%) and the YMCA (n = 1 or 1.1%).
Verbal aggression towards patients was most frequently recorded on Argyle (n = 21 or
43.75% of all verbal aggression towards patients) followed by Atherton (n = 14 or 29.17%),
Barossa (n = 9 or 18.75%), Canning (n = 3 or 6.25%) and Daintree (n = 1 or 2.08%). Verbal
aggression towards staff was most frequently recorded on Argyle (n = 90 or 45.92% of all
verbal aggression towards staff), followed by Atherton (n = 48 or 24.49%), Barossa (n = 48 or
24.49%), and Canning (n = 9 or 4.59%). There was a significant difference between ward
location and type of aggression (verbal or physical) (χ2(5) = 45.139, p = n.s.), but no
significant difference between ward location and characteristics of the victim (whether staff or
patient) (χ2(5) = 5.872, p = n.s.). When only the acute wards were taken into account there
was a significant difference between ward location and type of aggression (verbal or physical)
(χ2(2) = 40.140, p = .0001), but no significant difference between ward location and
characteristics of the victim (whether staff or patient) (χ2(2) = 1.337, p = n.s.). Figure 10
shows the frequency of verbal and physical aggression towards staff and patients by location.

96
 Figure 10: Verbal and physical aggression towards staff and patients by location

180
Frequency of aggressive behaviours
160
140
120
100
80
60
40
20
0
Argyle Atherton Barossa Canning Daintree Off campus
Location

Physical aggression Patient victim Physical aggression Staff victim

Verbal aggression Patient victim Verbal aggression Staff victim

Severity of Verbal and Physical Aggression Towards Staff and Patients

The average severity of aggression towards patients (M = 8.98, SD = 1.48) was higher
than the average severity of aggression towards staff (M = 7.93, SD = 1.58), (t(457) = -6.699,
p = .0001). Figure 11 shows the frequency of verbal and physical aggression towards staff
and patients.

97
 Figure 11: Severity of verbal and physical aggression towards staff and patients

140

120
Frequency of aggressive behaviours

100

80

60

40

20

0
5 6 7 8 9 10 11 12
Severity of aggression

Staff victim Patient victim

Note: 5 = Makes loud noises, shouts angrily; 6 = Yells mild personal insults, e.g., “You’re stupid!”; 7 = Curses viciously, uses foul language
in anger, makes moderate threats to others or self; 8 = makes clear threats of violence towards others (“I’m going to kill you”) or requests
help to control self; 9 = Makes threatening gesture, swings at people, grabs at clothes; 10 = Strikes, kicks, pushes, pulls hair (without injury
to the victim); 11 = Attacks others, causing mild-moderate physical injury (bruises, sprain, welts); 12 = Attacks others, causing severe
physical injury (broken bones, deep lacerations, internal injury)

Aggression by Month
The frequency of aggressive behaviour increased steadily from January to June (82
aggressive behaviours), then decreased in July (20) before maintaining a similar frequency
between August (37) and December (25). The average number of aggressive behaviours per
month was significantly lower for the second six months of assessment (July until December)
(M = 31, SD = 6.84) when compared with the first six months (January until June) (M =
52.67, SD = 17.88) (t(10) = 2.77, p = .020). Figure 6 shows the frequency of aggressive
behaviours by month. There was no significant difference in the type of aggression by month
(χ2(33) = 40.913, p = n.s.), neither was there a significant difference in the type of victim by
month (χ2(22) = 32.462, p = n.s.).
Aggression by Day of the Week
There was a relatively even distribution of aggressive acts across days of the week.
The lowest frequency of aggressive behaviours occurred on Saturdays (56 or 11.2% of all
aggressive behaviours). The highest frequency of aggressive behaviours occurred on
Tuesdays and Wednesdays (80 or 16%), followed by Thursdays (78 or 15.6%), Fridays (70 or
15.2%), Sundays (66 or 13.2%), and Mondays (65 or 3%).

98
 Figure 12: Frequency of aggressive behaviours by month

90

80

70
Frequency of aggression

60

50

40

30

20

10

0
ry

ly

r
il

t
ne

er
ay
y

ch

us

be
be

be
ar

pr

Ju

ob
ua

Ju
ar

ug

em

em

em
nu

A
M
br

ct
A
Ja

ov

ec
pt

O
Fe

Se

D
N
Month

Type of Aggression by Day of the Week

Differences in the type of aggression by day of the week were statistically significant
(χ2(12) = 23.936, p = .021). The highest frequency of property damage occurred on Friday (n
= 9 or 34.62% of all behaviours of property damage), followed by Tuesday (n = 4 or 15.38%)
and Wednesday (n = 4 or 15.38%), Sunday (n = 3 or 11.54%), Monday (n = 2 or 7.69%),
Tuesday (n = 2 or 7.69%), and Saturday (n = 2 or 7.69%). Verbal aggression was recorded
most frequently on Tuesdays (n = 52 or 20.97% of all behaviours of verbal aggression),
followed by Thursday (n = 44 or 17.74%), Wednesday (n = 40 or 16.13%) and Friday (n = 52
or 16.13%), Monday (n = 33 or 13.31%), Sunday (n = 25 or 10.08%) and Saturday (n = 25 or
10.08%). Physical aggression was most frequently recorded on Sunday (n = 38 or 17.67% of
all behaviours of physical aggression), followed by Wednesday (n = 36 or 16.74%), Thursday
(n = 32 or 14.88%), Monday (n = 30 or 13.95%) and Saturday (n = 30 or 13.95%), Friday (n =
27 or 12.56%) and Tuesday (n = 24 or 11.16%).
Victim Type by Day of the Week
Aggression towards staff was most frequently recorded on Thursday (n = 56 or
17.54% of all behaviours of aggression towards staff), followed by Tuesday (n = 54 or
16.88%), Friday (n = 50 or 15.63%), Wednesday (n = 47 or 14.69%), Monday (n = 45 or
14.06%), Sunday (n = 37 or 11.56%) and Saturday (n = 30 or 9.37%). Aggression towards
patients was most frequently recorded on Saturday (n = 23 or 16.55% of all behaviours of
aggression towards patients) and Sunday (n = 23 or 16.55%), followed by Wednesday (n = 22
or 15.83%), Tuesday (n = 21 or 15.11%), Thursday (n = 19 or 13.67%), Monday (n = 17 or
12.23%), and Friday (n = 14 or 10.07%). There was no significant difference between type of

99
victim and day of the week (χ2(18) = 21.538, p = n.s.). Figure 13 shows the frequency of
aggressive behaviours by victim type and day of the week.

Figure 13: Frequency of aggressive behaviours by victim type and day of the week

90

80
Frequency of aggressive behaviours

70

60

50

40

30

20

10

0
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Day of the week

Patient victim Staff victim Property damage

Location of Aggressive Behaviour

Most (n = 253 or 40.2%) aggressive behaviours occurred in the lounge room. The
seclusion room (n = 41 or 6.5%), smokers’ room (n = 38 or 6%), courtyard (n = 37 or 5.9%),
dining room (n = 36 or 5.7%), and patients’ own bedrooms (n = 31 or 4.9%) were also
common locations for aggressive behaviours. Differences in the frequency of aggression by
location within the ward were statistically significant (χ2(38) = 66.898, p = .003). Table 11
shows the frequency of aggression by type and location.

100
 Table 11: Frequency of Aggression by Type and Location

Location on ward Property damage Verbal aggression Physical aggression Total

Lounge room 9 127 117 253
Music room 1 2 4 7
Interview room 0 1 4 5
Art room 0 2 1 3
Dining room 2 22 12 36
OT kitchen 0 0 1 1
Bedroom (own) 7 13 11 31
Bedroom (other) 1 3 4
Courtyard 2 22 13 37
Smokers room 4 20 14 38
Bathroom 0 0 3 3
Seclusion room 0 27 14 41
Bedroom corridor 4 4 7 15
At telephone 0 1 0 1
Surgery 0 2 0 2
Visitors room 0 1 0 1
Nurses station 0 0 1 1
Programme corridor 0 0 1 1
Campus 0 6 3 9
YMCA 0 0 2 2

Property Damage
There were 25 incidents where details of ownership of the property damaged by
aggressive patients were available. Damage to hospital walls was the most frequently
recorded type of property damage (n = 8 or 20.5%), followed by damage to windows (n = 4 or
16%) and doors (n = 4 or 16.67%). The ward’s stereo (n = 3 or 12%), television (n = 2 or 8%)
and telephone (n = 2 or 8%), a chair (n = 1 or 4%), and table (n = 1 or 4%) were also
deliberately damaged. Property damaged was either owned by the patient responsible for the
aggression (3 or 12%), or owned by the hospital (22 behaviours or 88% of property damage).
Containment or Direct Assault
One hundred and thirteen of the 122 physically aggressive behaviours towards staff
were differentiated on the basis of direct or containment (occurring within the context of
restraint and seclusion) assaults. Acts of aggression classified as assault were more common
(77 incidents) than containment (36 incidents). There was no significant difference in the
average severity of direct assault (M = 9.58, SD = 0.73), compared with containment assault
(M = 9.75, SD = 0.65) (t(111) = -1.160, n.s.).
7.3 Characteristics of Aggressive and Non-aggressive Patients
Patients who provided consent and completed the Stage 1 assessment of predisposing
characteristics were no more likely to be aggressive than patients who did not consent to
participate (χ2(1) = .482, p = n.s.). Of those patients who did not consent to participate, 41.9%

101
were aggressive, whereas 53.5% of patients who consented to participate were aggressive.
Table 12 shows the predisposing characteristics for aggressive and non-aggressive patients’.

Table 12: Aggressive and Non-aggressive Patient Characteristics

Patient characteristics M (SD )
Aggressive Not aggressive Total
Age 33.19 (11.9) 35.54 (13.23) 34.52 (12.6)
Substance use (previous year) 2.24 (1.51) 1.65 (1.6)*** 1.92 (1.58)
Substance use (lifetime) 3.09 (1.37) 2.83 (1.34) 2.95 (1.36)
Severity of index offence 1.95 (0.98) 2.02 (1.15) 1.99 (1.08)
Severity of previous violence 1.77 (1.31) 1.16 (0.9)*** 1.44 (1.19)
Total violence 3.73 (1.56) 3.18 (1.45)*** 3.43 (1.52)
SBS (Social withdrawal) 3.41 (2.69) 3.18 (2.91) 3.29 (8.20)
SBS (Thought disturbance) 3.88 (2.3) 2.88 (2.39)** 3.35 (2.39)
SBS (Antisocial behaviour) 3.51 (2.83) 1.67 (2.08)*** 2.53 (2.63)
SBS (Depressed behaviour) 1.14 (1.70) 1.03 (1.66) 1.08 91.68)
SBS (Total) 11.93 (5.96) 8.76 (6.17)*** 10.25 96.26)
NAS (Cognitive) 40.68 (8.28) 39.24 (5.82) 39.92 (7.11)
NAS (Arousal) 39.00 (6.37) 37.13 (6.31) 36.98 (6.97)
NAS (Behavior) 37.51 (7.33) 36.5 (6.64) 36.98 (6.97)
NAS (Total) 117.84 (18.18) 112.87 (16.54) 115.22 (17.44)
Impulsivity (Functional) 5.34 (2.64) 5.91 (2.66) 5.64 (2.65)
Impulsivity (Dysfunctional) 5.05 (2.89) 5.23 (2.98) 5.14 (2.92)
Assertiveness 106.15 (24.13) 108.55 (19.81) 107.42 (21.89)
PSYRATS (Hallucinations Factor 1) 2.56 (5.89) 2.91 (5.25) 2.74 (5.06)
PSYRATS (Hallucinations Factor 2) 2.81 (4.48) 2.72 (4.61) 2.76 (4.53)
PSYRATS (Hallucinations Factor 3) 3.22 (5.22) 2.93 (4.91) 3.07 (5.04)
PSYRATS (Delusions Factor 1) 7.10 (5.52) 6.12 (5.45) 6.58 (5.48)
PSYRATS (Delusions Factor 2) 2.86 (3.11) 2.49 (2.97) 2.66 (3.03)
BPRS (Conceptual disorganisation) 3.44 (1.57) 2.71 (1.78)** 3.06 (1.72)
BPRS (Hallucinory behaviour) 2.95 (1.89) 2.3 (1.67)** 2.61 (1.80)
BPRS (Unusual thought content) 3.93 (1.70) 3.63 (1.91) 3.77 (1.82)
BPRS (Total) 10.33 (4.25) 8.59 (4.41)*** 9.42 (4.41)
*p < .05, **p < .01, ***p<.001

Age
There was no statistically significant difference between the ages of aggressive and
non-aggressive patients (t(230) = 1.407, n.s.).
Gender
Eighty-three of 192 males (43.2%) and 22 of 39 females (56.4%) were aggressive.
There was no significant difference in the proportion of males who were aggressive when
compared to females (χ2(1) = .152, p = n.s.), although aggressive females had a higher
frequency of aggressive behaviours (i.e., were more often repeatedly aggressive) (M = 4.51,
SD = 10.31) when compared to males (M = 1.69, SD = 3.98) (t(226) = -2.898, p = .004).

102
Diagnosis
Patients with a disorder characterised by the absence of psychotic symptoms were
more likely to be aggressive (n = 20 or 64.5%) when compared to patients with a disorder
characterised by the presence of psychosis (n = 85 or 42.5%) (χ2(1) = 5.247, p = .022).
Legal status
Patients held under Section 12 of the Mental Health Act, 1986 were responsible for
6.9% of all aggressive behaviours. These patients were almost equally likely to be aggressive
(n = 7 or 46.7%), as non-aggressive (n = 8 or 53.3%). Similarly, 52.2% (n = 83) of patients
held under Sections 16(3)(b) of the Mental Health Act, 1986, were aggressive. These patients
were responsible for 79% of aggressive behaviours. Only a small proportion of Forensic
Patients (n = 8 or 19.5%) were aggressive. These patients were responsible for 7.6% of all
aggressive behaviours recorded. Two thirds (n = 2 or 66.7%) of patients held under Section
93(1)(d) were aggressive. These patients accounted for 1.9% of all aggressive behaviours.
Five (35.7%) Section 93(1)(e) patients were aggressive, and accounted for 4.8% of all
aggressive behaviours.
Substance Use
Patients who were aggressive on at least one occasion during 2002 used a significantly
higher total number of substances in the year prior to assessment when compared to non-
aggressive patients (t(226) = 2.871, p = .004). No significant difference was found between
aggressive and non-aggressive patients on the total number of substances used over the
lifetime (t(223) = 1.426, p = n.s.).
History of Aggression
There was no significant difference between aggressive and non-aggressive patients
(t(222) = 2.75, n.s.) on the severity of the index offence. There was a significant difference
between aggressive and non-aggressive patients according to the previous violence record
(t(222) = 3.96, p = .0001). There was a significant difference between aggressive and non-
aggressive patients on Total Violence (t(222) = 2.75, p = 0.006).
Shortened Social Behaviour Schedule
Staff recorded the social behaviour of 221 of the 232 (95.26%) admissions.
Aggressive patients scored significantly higher on SBS Thought Disturbance when compared
with non-aggressive patients (t(219) = 3.146, p = .002), SBS Antisocial Behaviour when
compared with non-aggressive patients (t(219) = 5.566, p = .0001), and SBS Total when
compared with non-aggressive patients (t(218) = 3.866, p = .0001). No significant differences
existed between aggressive and non-aggressive patients on SBS Social Withdrawal (t(219) = -

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.619, p = n.s.), and between aggressive and non-aggressive patients on SBS Depressed
Behaviour (t(218) = -.449, p = n.s.).
Given that SBS Antisocial Behaviour was expected to be higher for aggressive
patients it was eliminated from the SBS Total on a modified SBS Total. When it was
removed, a statistically significant difference between aggressive (M = 8.42, SD = 4.5) and
non-aggressive (M = 7.09, SD = 5.22) patients remained (t(218) = 2, p = .047).
Novaco Anger Scale
One hundred and ten patients (47.41%) completed the NAS. There were no significant
differences between aggressive and non-aggressive patients on NAS Cognitive (t(128) = -
1.157, n.s.), NAS Behavior (t(127) = -.820, n.s.), NAS Arousal (t(127) = -1.671, n.s.), and
NAS Total (t(127) = -1.625, n.s.).
The Functional and Dysfunctional Impulsivity Scale
One hundred and fifteen patients (49.57%) completed the Dickman Functional
Impulsivity scale and 114 (49.14%) completed the Dickman Dysfunctional Impulsivity scale.
There was no significant difference between aggressive and non-aggressive patients on
Functional Impulsivity (t(132) = 1.246, n.s.) and Dysfunctional Impulsivity (t(132) = 1.246,
n.s.).
Simplified Rathus Assertiveness Schedule
One hundred and ten patients (47.41%) completed the simplified version of the RAS.
No significant difference was found between aggressive and non-aggressive patients on the
simplified RAS (t(128) = .623, n.s.).
Psychotic Symptom Rating Scales
Psychotic symptoms were recorded on the PSYRATS for 130 admissions (56.03%).
There was no significant difference between aggressive and non-aggressive patients on all
five PSYRATS scales. No significant difference was found between aggressive and non-
aggressive patients on PSYRATS Hallucinations Factor 1 (Emotional Characteristics) (t(128)
= .398, n.s.), Hallucinations Factor 2 (Physical Characteristics) (t(129) = -.112, n.s.),
Hallucinations Factor 3 (Cognitive Interpretation) (t(129) = -.334, n.s.), Delusions Factor 1
(Cognitive Interpretation) (t(123) = -1.002, n.s.), and Delusions Factor 2 (Emotional
Characteristics) (t(127) = -.706, n.s.).
Brief Psychiatric Rating Scale- Short Version
A measure of each patient’s symptoms according the three BPRS subscales and a
Total BPRS was obtained for all 232 admissions. There were statistically significant
differences between aggressive and non-aggressive patients on BPRS Conceptual
Disorganisation, BPRS Hallucinatory Behaviour and the BPRS Total, but not BPRS Unusual

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Thought Content (t(210) = -1.222, n.s.). Aggressive patients scored higher on BPRS
Conceptual Disorganisation (t(210) = 3.132, p = .002), higher on BPRS Hallucinatory
Behaviour (t(210) = 2.641, p = .009), and higher on BPRS Total (t(209) = 2.91, p = .004).
Psychotic Symptom Rating Scales Assessment Conducted After Aggressive Incidents
Following 71 aggressive behaviours, patients consented to an interview to determine
the purpose of aggression. The PSYRATS was also administered during these interviews.
During these interviews the key purposes for the aggressive behaviour were identified and the
PSYRATS was administered if these purposes for aggression were considered by the author
to be directly related to a delusion or hallucination.
For the 71 aggressive behaviours no patient reported an auditory hallucinations in their
explanation for the aggressive behaviour. In approximately 37% of aggressive behaviours
there was evidence of a direct relationship between a delusional belief and the aggressive
behaviour. Scores on PSYRATS Delusions Factor 1 (Cognitive Interpretation) ranged from
zero to 12. Scores on PSYRATS Delusions Factor 2 (Emotional Characteristics) ranged from
zero to eight.
The Relationship Between Patient’s Predisposing Characteristics and Aggression
A simultaneous multiple regression analysis was used to examine the effect of age,
social behaviour, total types of substances used in the year prior to assessment, total types of
substances used in the lifetime, history of aggression, anger, functional and dysfunctional
impulsivity, assertiveness, and psychotic symptoms on the number of aggressive behaviours.
The analysis showed that the variables explained 40.4% of the variance in aggressive
behaviours (adjusted R2 = .234). Table 13 shows the results. Most of the explained variance
could be attributed to the unique effects of only two variables; SBS Antisocial Behaviour and
PSYRATS Hallucination Factor 1, although the variable, PSYRATS Delusions Factor 1
approached significance (p = .067).
Stepwise multiple regression analysis with the same variables resulted in a model
including only two variables. At step 1, SBS Antisocial Behaviour was added to the model
(R2 = .203: adjusted R2 = .195). Table 14 shows the results of this multiple regression.
The Relationship Between a Selection of Predisposing Characteristics and the Number of
Aggressive Behaviours
A multiple regression analysis was conducted using readily accessible information
that did not require patient participation, and that can be routinely obtained on admission.
Immediately following admission it is often not possible to administer a range of
psychological tests as patients are often either unwilling or unable to participate in assessment
to determine their level of risk for aggressive behaviour. Therefore, only those items of

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information that are readily accessible and that do not rely on patient participation were
included for this multiple regression. The variables included the SBS Antisocial Behaviour
scale, total types of substances used in the year prior to assessment, prior history of violence,
and the four BPRS scales. The analysis showed that the variables explained 13.7% of the
variance in aggressive behaviours (adjusted R2 of.106). Table 15 shows the results of this
multiple regression.
A further multiple regression including the SBS Antisocial Behaviour scale, the total
types of substances used in the year prior to assessment, and the four BPRS scales was
conducted. This combination does not rely on a description of the patient’s past history of
convictions for aggressive behaviour. The analysis showed that the variance explained 13.6%
of the variance in aggressive behaviours (adjusted R2 of.110).

Table 13: The Relationship Between Predisposing Characteristics and the Number of
Aggressive Behaviours

B SE B ß t Sig
Age 0.031 0.045 0.04 0.34 0.733
Total drugs(previous year) 0.128 0.375 0.04 0.34 0.733
Total drugs (lifetime) 0.433 0.464 0.13 0.93 0.353
Violence level (index offence) -0.023 0.616 0 0 0.997
Violence level (prior history) Excluded
Violence level (Total) 0.193 0.407 0.06 0.47 0.638
SBS (Social withdrawal) -0.051 0.192 -0.03 -0.27 0.792
SBS (Thought disturbance) 0.278 0.246 0.14 1.13 0.262
SBS (Antisocial behaviour) 0.646 0.189 0.37 3.42 0.001
SBS (Depressed behaviour) 0.161 0.253 0.07 0.64 0.525
SBS (Total) Excluded
NAS (Cognitive) 0 0.097 0 0 0.999
NAS (Behavior) -0.017 0.106 -0.03 -0.16 0.874
NAS (Arousal) 0.026 0.112 0.04 0.23 0.819
NAS (Total) Excluded
Impulsivity (Functional) -0.167 0.177 -0.1 -0.95 0.347
Impulsivity (Dysfunctional) -0.02 0.177 -0.06 -0.55 0.587
Assertiveness 0.02 0.024 0.1 0.85 0.398
Hallucinations (Factor 1) -0.608 0.199 -0.68 -3.06 0.003
Hallucinations (Factor 2) -0.018 0.325 -0.02 -0.06 0.956
Hallucinations (Factor 3) 0.505 0.346 0.58 1.46 0.148
Delusions (Factor 1) 0.251 0.135 0.31 1.85 0.067
Delusions (Factor 2) -0.185 0.216 -0.12 -0.86 0.395
BPRS (Conceptual disorganisation) 0.688 2.534 0.25 0.27 0.787
BPRS (Hallucinatory behaviour) 1.029 2.556 0.43 0.4 0.688
BPRS (Unusual thought content) 0.478 2.565 0.2 0.19 0.853
BPRS (Total) -0.787 2.55 -0.79 -0.309 0.758

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 Table 14: The Relationship Between Predisposing Characteristics and the Number of
Aggressive Behaviours Using a Stepwise Multiple Regression

Variable B SE B ß t Sig
Model 1
SBS (Antisocial behaviour) 0.796 0.153 0.45 5.21 0.0001
Model 2
SBS (Antisocial behaviour) 0.787 0.146 0.44 5.4 0.0001
PSYRATS (Delusion factor 1) 0.229 0.068 0.28 3.38 0.001

Table 15: The Relationship Between Selected Predisposing Characteristics and the
Number of Aggressive Behaviours

B SE B ß t Sig
Total drugs (previous year) -0.33 0.275 -0.09 -1.2 0.231
Violence level (prior history) 0.204 0.368 0.04 0.55 0.58
SBS (Antisocial behaviour) 0.75 0.16 0.33 4.68 0.0001
BPRS (Conceptual disorganisation) -2.349 1.649 -0.68 -1.43 0.156
BPRS (Hallucinatory behaviour) -2.265 1.589 -0.69 -1.43 0.156
BPRS (Unusual thought content) -2.758 1.608 -0.84 -1.71 0.088
BPRS (Total) 2.506 1.601 1.86 1.57 0.119

7.4 The Purpose of Aggression

The Relationship Between Purpose and the Type and Direction of Aggression
Four hundred and seventy six, from a total of 502 aggressive behaviours (94.82%),
were rated for purpose by the author. For all except 16 aggressive behaviours (3.36%; 3.6% in
which staff were victims, and 5.3% when patients were victims) at least one purpose was
identified. Very few patients (16) were willing to provide written consent to discuss the
aggressive behaviour.
Results of the assessment of purpose are summarised in Table 16, which shows the
percentage of aggressive behaviours towards staff and patients in which there was some
indication that each purpose was evident. Table 17 shows the percentage of verbally and
physically aggressive behaviours in which there was some indication that each purpose was
evident. Following these two tables a detailed description of the frequency of each purpose by
type of victim (whether staff or patient) and type of aggression (verbal or physical aggression)
is provided. To assess whether differences existed between type of victim and type of
aggression, the three-point purpose scale used to record the presence of each purpose
according to the ‘Assessment and classification of purpose’ scale was modified into a
dichotomous variable and scored as either no evidence at all of the purpose contributing to the

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aggressive behaviour, or some evidence that the purpose contributed to the aggressive
behaviour, by collapsing the ‘possibly indicated’ and ‘definitely indicated’ categories.
The relationships between purpose, type (verbal or physical) and direction (staff or
patient victim) of aggression are presented. Incidents of property damage and incidents of
aggression towards staff and patients are excluded. There were no incidents of physical
aggression in which both staff and patients were victims.

Table 16: Percentage of Aggressive Behaviours Towards Staff and Patients in which each
Purpose was Evident

Purpose % of aggressive behaviours towards staff % of aggressive behaviours towards patients

Demand avoidance*** 43.9 6
Request denial*** 46.9 12
Following provocation*** 72.8 86.5
Frustration release*** 64.4 36.1
To enhance status*** 25.1 54.1
Following instruction* 2.3 6.8
Instrumental 12.2 15.8
To reduce social distance 9.9 5.3
To observe suffering 3.6 5.3
*p < .05, **p < .01, ***p<.001

Table 17: Percentage of Verbally and Physically Aggressive Behaviours in which each
Purpose was Evident

Purpose % of verbally aggressive behaviours %of physically aggressive behaviours

Demand avoidance* 36.8 27.2
Request denial*** 44.4 26.7
Following provocation 79.5 74.1
Frustration release* 61.1 49.5
To enhance status 33.3 34.7
Following instruction* 1.7 5.9
Instrumental 14.6 11.8
To reduce social distance 8.1 9.8
To observe suffering 2.4 5.9
*p < .05, **p < .01, ***p<.001

Demand Avoidance
A demand for activity frequently precipitated both verbal (43.85%) and physical
(43.96%) aggression towards staff (43.9% of all aggressive behaviours towards staff). When
patients were victims, a demand for activity was less frequently identified (6% of all
aggressive behaviours towards patients). A demand for activity had been made in 8.51% of all
of verbally aggressive behaviours, and 4.66% of physically aggressive behaviours towards
patients. Seventy five percent of verbally aggressive behaviours in which both staff or patients

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were victims occurred after a demand for activity had been made. Twelve percent of property
damage was preceded by a demand for activity.
Members of staff were significantly more likely to be the victims of aggression
following a demand for activity when compared with patients (χ2(1) = 60.610, p = .0001).
Verbal (36.8%) aggression was more likely to occur following a demand for activity when
compared with physical (27.2%) aggression (χ2(1) = 4.495, p = .034). Table 18 shows the
frequency of aggressive behaviours precipitated by a demand for activity by victim and
aggression type.

Table 18: Frequency of Aggressive Behaviours Precipitated by a Demand for Activity by

Victim and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 105 56.15% 35 18.72% 47 25.13%
Staff
Physical aggression 65 56.03% 16 13.79% 35 30.17%
Verbal aggression 43 91.49% 3 6.38% 1 2.13%
Patient
Physical aggression 82 95.35% 2 2.33% 2 2.33%
Staff and patients Verbal aggression 1 25.00% 2 50.00% 1 25.00%
Property 22 88.00% 2 8.00% 1 4.00%

Denial of Request
Aggression was preceded by the denial of a request in 46.9% of all aggression towards
staff, and in 12% of all aggression towards patients. The denial of a request was made in
approximately half of all verbally (51.34%) and physically (39.66%) aggressive behaviours
towards staff. When patients were the victims of verbal aggression, a denial of request was
made in 17.03% of all aggressive behaviours towards patients. The denial of a request was
made in 9.3% of physically aggressive behaviours in which patients were victims. When both
staff and patients were the victims of verbal aggression 50% of aggressive behaviours
occurred after the denial of a request. Thirty six percent of property damage was preceded by
the denial of a request.
Members of staff were significantly more likely to be the victims of aggression
following the denial of a request when compared with patients (χ2(1) = 48.540, p = .0001).
Verbal (44.4%) aggression was more likely to occur following the denial of a request when
compared with physical (26.7%) aggression (χ2(1) = 14.719, p = .0001). Table 19 shows the
frequency of aggressive behaviours precipitated by the denial of a request by victim and
aggression type.

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 Table 19: Frequency of Aggressive Behaviours Precipitated by the Denial of a Request by
Victim and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 91 48.66% 34 18.18% 62 33.16%
Staff
Physical aggression 70 60.34% 18 15.52% 28 24.14%
Verbal aggression 39 82.98% 2 4.26% 6 12.77%
Patient
Physical aggression 78 90.70% 4 4.65% 4 4.65%
Staff and patients Verbal aggression 2 50.00% 1 25.00% 1 25.00%
Property 16 64.00% 4 16.00% 5 20.00%

Following Provocation
Aggression was preceded by provocation on 72.8% of all aggressive behaviours
towards staff and 86.5% of all aggressive behaviours towards patients. Provocation had been
perceived in 77.54% of all verbal aggression directed towards staff and 65.22% of physical
aggression towards staff. Provocation had been perceived in 87.23% of all verbally aggressive
and 86.04% of physically aggressive behaviours in which patients were victims. When both
staff and patients were the victims of verbal aggression, 50% of aggressive behaviours had
occurred after provocation had been perceived. Forty four percent of property damage
incidents were preceded by provocation.
Patients were significantly more likely to be the victims of aggression following
provocation when compared with staff (χ2(1) = 23.008, p = .0001). There was no significant
difference in the proportion of verbal (79.5%) and physical (74.1%) aggression that occurred
as a consequence of provocation (χ2(1) = 1.753, n.s.). Table 20 shows the frequency of
aggressive behaviours precipitated by provocation by victim and aggression type.

Table 20: Frequency of Aggressive Behaviours Precipitated by Provocation by Victim and

Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 42 22.46% 101 54.01% 44 23.53%
Staff
Physical aggression 40 34.78% 53 46.09% 22 19.13%
Verbal aggression 6 12.77% 13 27.66% 28 59.57%
Patient
Physical aggression 12 13.95% 16 18.60% 58 67.44%
Staff and patients Verbal aggression 2 50.00% 0 0.00% 2 50.00%
Property 14 56.00% 10 40.00% 1 4.00%

A Consequence of Frustration
Aggression occurred as a consequence of frustration in 64.4% of all aggressive
behaviours towards staff, and 36.1% of all aggressive behaviours towards patients. Frustration
was observed in 65.24% of all verbal aggression, and 62.93% of all physical aggression in

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which staff were victims. Frustration was observed in 44.68% of all verbal aggression and
31.39% of physical aggression towards other patients. Every (100%) incident of verbal
aggression towards staff and patients occurred following frustration. Ninety six percent of
property damage was preceded by frustration
Members of staff were significantly more likely to be the victims of aggression as a
consequence of frustration when compared with patients (χ2(1) = 29.933, p = .0001). Verbal
(61.1%) aggression was more likely to occur as a consequence of frustration when compared
with physical (49.5%) aggression (χ2(1) = 5.919, p = .015). Table 21 shows the frequency of
aggressive behaviours precipitated by frustration by victim and aggression type.

Table 21: Frequency of Aggressive Behaviours Precipitated by Frustration by Victim and

Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 65 34.76% 111 59.36% 11 5.88%
Staff
Physical aggression 43 37.07% 67 57.76% 6 5.17%
Verbal aggression 26 55.32% 21 44.68% 0 0.00%
Patient
Physical aggression 59 68.60% 26 30.23% 1 1.16%
Staff and patients Verbal aggression 0 0.00% 4 100.00% 0 0.00%
Property 1 4.00% 14 56.00% 10 40.00%

Instrumental
Aggression occurred for instrumental purposes in 12.2% of all aggressive behaviours
towards staff and in 15.8% of all aggressive behaviours towards patients. Instrumental
purposes were observed in 14.44% of all verbal aggression and in 8.62% of physical
aggression in which staff were victims. Instrumental purposes had been observed in 14.89%
of all verbal aggression and 16.28% of physical aggression towards patients. When both staff
and patients were the victims of verbal aggression no instrumental purposes were observed.
Twenty percent of property damage was preceded by instrumental purposes.
There was no significant difference in the proportion of aggressive behaviours
between staff and patients that were perpetrated for instrumental purposes (χ2(1) = 1.026,
n.s.). Further, there was no significant difference in the proportion of verbal (14.5%) and
physical (11.9%) aggression that occurred for instrumental purposes (χ2(1) = .659, n.s.). Table
22 shows the frequency of aggressive behaviours perpetrated for instrumental purposes by
victim and aggression type.

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 Table 22: Frequency of Aggressive Behaviours Perpetrated for Instrumental Purposes by
Victim and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 160 85.56% 23 12.30% 4 2.14%
Staff
Physical aggression 106 91.38% 10 8.62% 0 0.00%
Verbal aggression 40 85.11% 4 8.51% 3 6.38%
Patient
Physical aggression 72 83.72% 13 15.12% 1 1.16%
Staff and patients Verbal aggression 4 100.00% 0 0.00% 0 0.00%
Property 20 80.00% 4 16.00% 1 4.00%

To Reduce Social Distance

Aggression occurred to reduce social distance in 9.9% of all aggressive behaviours in
which staff were victims and in 5.3% of all aggressive behaviours in which patients were
victims. An attempt to reduce social distance precipitated 8.55% of all of verbal aggression,
and 12.06% of all physical aggression in which staff were victims. An attempt to reduce
social distance precipitated 2.13% of all verbal aggression, and 6.98% of all physical
aggression. When both staff and patients were the victims of verbal aggression, 25% of
aggressive behaviours were preceded by an attempt to reduce social distance. Four percent of
property damage was preceded by an attempt to reduce social distance.
There was no significant difference in the proportion of aggressive behaviours against
staff and patients that were preceded by an attempt to reduce social distance (χ2(1) = 1.026,
n.s.). There was no significant difference in the proportion of verbally (7.3%) and physically
(9.9%) aggressive behaviours perpetrated to reduce social distance (χ2(1) = .970, n.s.). Table
23 shows the frequency of aggressive behaviours perpetrated to reduce social distance by
victim and aggression type.

Table 23: Frequency of Aggressive Behaviours Perpetrated to Reduce Social Distance by

Victim and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 171 91.44% 13 6.95% 3 1.60%
Staff
Physical aggression 102 87.93% 7 6.03% 7 6.03%
Verbal aggression 46 97.87% 0 0.00% 1 2.13%
Patient
Physical aggression 80 93.02% 6 6.98% 0 0.00%
Staff and patients Verbal aggression 3 75.00% 1 25.00% 0 0.00%
Property 24 96.00% 0 0.00% 1 4.00%

To Enhance Status or Social Approval

Aggression occurred to enhance status in 25.1% of all aggressive behaviours towards
staff and in 54.1% of all aggressive behaviours towards patients. An attempt to enhance status
precipitated 27.28% of all verbal aggression and 21.55% of all physical aggression in which
staff were victims. An attempt to enhance status precipitated 57.44% of all verbal aggression,

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and 52.33% of all physical aggression in which patients were victims. When both staff and
patients were the victims of verbal aggression there were no aggressive behaviours that
occurred to enhance status. Twenty percent of property damage occurred as an attempt to
enhance status.
Patients were significantly more likely to be the victims of aggression to enhance
status or social approval when compared with staff (χ2(1) = 34.794, p = .0001). There was no
significant difference in the proportion of verbal (33.3%) and physical (34.7%) aggression
perpetrated to enhance status or social approval (χ2(1) = .084, n.s.). Table 24 shows the
frequency of aggressive behaviours perpetrated to enhance status or social approval by victim
and aggression type.

Table 24: Frequency of Aggressive Behaviours Perpetrated to Enhance Status or Social

Approval by Victim and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 136 72.73% 37 19.79% 14 7.49%
Staff
Physical aggression 91 78.45% 24 20.69% 1 0.86%
Verbal aggression 20 42.55% 24 51.06% 3 6.38%
Patient
Physical aggression 41 47.67% 35 40.70% 10 11.63%
Staff and patients Verbal aggression 4 100.00% 0 0.00% 0 0.00%
Property 20 80.00% 5 20.00% 0 0.00%

Compliance with Instruction

Aggression followed instruction in 2.3% of all aggressive behaviours towards staff
and in 6.8% of all aggressive behaviours towards patients. An instruction to behave
aggressively had been made in 1.6% of verbal aggression and 3.45% of physical aggression
towards staff. An instruction to behave aggressively had been made in 2.13% of all verbal
aggression and 9.3% of physical aggression in which patients were victims. When both staff
and patients were the victims of verbal aggression, no aggressive behaviours occurred
following instruction. Four percent of property damage occurred following instruction.
Patients were significantly more likely to be the victims of aggression following
instruction when compared with staff (χ2(1) = 5.193, p = .023). Physical (5.9%) aggression
was more likely to occur following instruction when compared with verbal (1.7%) aggression
(χ2(1) = 5.490, p = .019). Table 25 shows the frequency of aggressive behaviours that
followed instruction by victim and aggression type.

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 Table 25: Frequency of Aggressive Behaviours that Followed Instruction by Victim and
Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 184 98.40% 3 1.60% 0 0.00%
Staff
Physical aggression 112 96.55% 3 2.59% 1 0.86%
Verbal aggression 46 97.87% 1 2.13% 0 0.00%
Patient
Physical aggression 78 90.70% 8 9.30% 0 0.00%
Staff and patients Verbal aggression 4 100.00% 0 0.00% 0 0.00%
Property 24 96.00% 0 0.00% 1 4.00%

To Observe Suffering
Aggression occurred to observe suffering in 3.6% of all aggressive behaviours towards
staff and in 5.3% of all aggressive behaviours towards patients. An attempt to observe
suffering was identified in 2.67% of verbal aggression and in 5.17% of all physical aggression
towards staff. A desire to observe suffering was identified in 2.13% of verbal aggression, and
in 6.98% of physical aggression towards patients. When both staff and patients were the
victims of verbal aggression, and when property damage occurred, there were no aggressive
behaviours that occurred within the context of the patient being motivated to observe
suffering.
There was no significant difference in the proportion of aggressive behaviour in which
staff or patients were the victims of aggression to observe suffering (χ2(1) = 1.026, n.s.).
When patients were motivated by an attempt to observe suffering, physical aggression (5.9%)
was more likely when compared with verbal aggression (2.6%) (χ2(1) = 3.123, p = .077).
Table 26 shows the frequency of aggressive behaviours perpetrated to observe suffering by
victim and aggression type.

Table 26: Frequency of Aggressive Behaviours Perpetrated to Observe Suffering by Victim

and Aggression Type

Victim type Type of aggression Definitely not indicated Possibly indicated Definitely indicated
Verbal aggression 182 97.33% 5 2.67% 0 0.00%
Staff
Physical aggression 110 94.83% 6 5.17% 0 0.00%
Verbal aggression 46 97.87% 1 2.13% 0 0.00%
Patient
Physical aggression 80 93.02% 6 6.98% 0 0.00%
Staff and patients Verbal aggression 4 100.00% 0 0.00% 0 0.00%
Property 25 100.00% 0 0.00% 0 0.00%

The Relationship Between Purpose and Patient’s Predisposing Characteristics

To ascertain whether relationships existed between predisposing characteristics and
purpose, each patient’s aggressive behaviours were reviewed to determine whether they had
been aggressive for any of the 10 purposes (including purposeless aggression) during any of
their aggressive behaviours. Each aggressive inpatient then had a record, on a dichotomous

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scale, as to whether there was evidence that any of their aggressive behaviours were
motivated by each purpose.
The relationship between purpose and the following predisposing characteristics were
examined: age, whether the patient’s illness was characterised by the presence of psychosis,
gender, history of aggression, history of substance use, Shortened SBS, NAS, Dickman
Dysfunctional Impulsivity scale, simplified RAS, PSYRATS and BPRS – short version.
Only significant relationships between patients’ predisposing characteristics are
reported here. A complete summary of the relationships between patients’ predisposing
characteristics and each purpose is reported in Appendix 22.
Age
Patients who were aggressive on at least one occasion to reduce social distance were
significantly older (M = 38.45, SD = 16.68) when compared to those who did not (M = 31.93,
SD = 10.41) (t(100) = -2.070, p = .0001). Patients who were aggressive on at least one
occasion when there was no purpose evident were significantly older (M = 44.68, SD =
20.20) when compared to those who did not (M = 31.82, SD = 10.07) (t(100) = -2.070, p =
.0001).
Psychotic Disorder
Aggressive patients who had a psychotic illness were almost equally likely to be
aggressive following a demand for activity (41 of 83, or 49.4% of individuals with a
psychotic illness who were aggressive), whereas those who did not have a psychotic illness
were more likely to be aggressive in response to a demand for activity (16 of 19, or 84.2% of
patients who did not have a psychotic illness) (χ2(1) = 7.600, p = .006).
Patients who had a psychotic illness were less likely to be aggressive as a consequence
of frustration (52 or 62.7% of individuals with a psychotic illness who were aggressive) when
compared to patients who did not have a psychotic illness (17 or 89.5% of patients who did
not have a psychotic illness) (χ2(1) = 5.083, p = .024).
Patients who had a psychotic illness were less likely to be aggressive for instrumental
purposes (19 or 22.9% of individuals with a psychotic illness who were aggressive) when
compared to patients who did not have a psychotic illness (9 or 47.44% of patients who did
not have a psychotic illness) (χ2(1) = 4.651, p = .031).
Patients who had a psychotic illness were less likely to be aggressive to reduce social
distance (8 or 9.6% of individuals with a psychotic illness who were aggressive) when
compared with patients who did not have a psychotic illness (8 or 42.1% of patients who did
not have a psychotic illness) (χ2(1) = 12.322, p = .000).

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Gender
Females (17 or 81%) were more likely to be aggressive following the denial of a
request when compared to males (32 or 48.5%) (χ2(1) = 6.827, p = .009). Females (19 or
90.5%) were more likely to be aggressive as a consequence of frustration when compared to
males (40 or 60.6%) (χ2(1) = 6.512, p = .011). Females (11 or 52.4%) were more likely to be
aggressive for instrumental purposes when compared to males (11 or 16.7%) (χ2(1) = 10.725,
p = .001). Females (8 or 38.1%) were also more likely to be aggressive to reduce social
distance when compared to males (6 or 9.1%) (χ2(1) = 9.926, p = .002).
Violence Scale
Patients who were aggressive on at least one occasion following instruction (M =
4.58, SD = 1.88) scored higher on Total Violence when compared to those who did not (M =
3.57, SD = 1.49) (t(96) = -2.134, p = .035).
Substance Use
There were no significant differences between the number of substances used in the
year prior to assessment and the total number of substances used over the lifetime with any of
the 10 purposes for aggression.
Shortened Social Behaviour Schedule
Patients who were aggressive on at least one occasion following a demand for activity
had a higher SBS Social Withdrawal (M = 3.56, SD = 2.82) when compared to those who did
not (M = 3.25, SD = 2.57) (t(99) = -.572, p = n.s.). Patients who were aggressive on at least
one occasion following a demand for activity had a higher SBS Thought Disturbance (M =
4.00, SD = 2.35) when compared to those who did not (M = 3.64, SD = 2.23) (t(99) = -.787, p
= .035). Patients who were aggressive on at least one occasion following a demand for
activity had a higher SBS Antisocial Behaviour (M = 3.82, SD = 2.87) when compared to
those who did not (M = 2.91, SD = 2.68) (t(99) = -1.638, p = .007).
Patients who were aggressive on at least one occasion following the denial of a request
had a higher SBS Antisocial Behaviour (M = 4.00, SD = 2.99) when compared to those who
did not (M = 2.71, SD = 2.41) (t(99) = -2.343, p = .007).
Patients who were aggressive on at least one occasion as a consequence of frustration
had a higher SBS Antisocial Behaviour (M = 3.88, SD = 2.95) when compared to those who
did not (M = 2.48, SD = 2.52) (t(99) = -2.401, p = .018). Patients who were aggressive on at
least one occasion as a consequence of frustration had a higher SBS Depressed Behaviour (M
= 1.36, SD = 1.92) when compared to those who did not (M = 0.61, SD = 0.97) (t(98) = -
2.118, p = .037).

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 Patients who were aggressive on at least one occasion for instrumental purposes had a
higher SBS Antisocial Behaviour (M = 4.79, SD = 3.01) when compared to those who did not
(M = 2.90, SD = 2.56) (t(99) = -3.145, p = .007).
Patients who were aggressive on at least one occasion to reduce social distance had a
higher SBS Depressed Behaviour (M = 2.56, SD = 2.45) when compared to those who did not
(M = 0.83, SD = 1.37) (t(98) = -4.004, p = .0001). Patients who were aggressive on at least
one occasion to reduce social distance had a higher SBS Total (M = 15.06, SD = 6.85) when
compared to those who did not (M = 11.18, SD = 5.61) (t(98) = -2.450, p = .016).
Patients who were aggressive on at least one occasion following instruction had a
higher SBS Antisocial Behaviour (M = 5.25, SD = 3.17) when compared to those who did not
(M = 3.18, SD = 2.68) (t(99) = -2.457, p = .016). Patients who were aggressive on at least
one occasion following instruction had a higher SBS Total (M = 15.83, SD = 7.64) when
compared to those who did not (M = 11.25, SD = 5.52) (t(98) = -2.570, p = .012.).
Patients who were aggressive on at least one occasion to observe suffering had a
higher SBS Antisocial Behaviour (M = 6.20, SD = 3.46) when compared to those who did not
(M = 3.12, SD = 2.57) (t(99) = -3.468, p = .001).
Patients who were aggressive on at least one occasion when there was no purpose
evident had a higher SBS Social Withdrawal (M = 5.33, SD = 3.24) when compared to those
who did not (M = 3.24, SD = 2.59) (t(99) = -2.263, p = .026). Patients who were aggressive
on at least one occasion when there was no purpose evident had a higher SBS Total (M =
16.63, SD = 5.53) when compared to those who did not (M = 11.38, SD = 5.83) (t(98) = -
2.448, p = .016).
Novaco Anger Scale
There were no significant differences between any of the four NAS scales for any of
the 10 purposes for aggression.
Functional and Dysfunctional Impulsivity Scale
There were no significant differences between the two impulsivity scales for any of
the 10 purposes for aggression
Simplified Rathus Assertiveness Schedule
There were no significant differences on Simplified RAS for any of the purposes.
Psychotic Symptom Rating Scales
Patients who were aggressive on at least one occasion when there was no purpose
evident had a higher PSYRATS Hallucinations Factor 2 (Physical Characteristics) (M = 9.50,
SD = .707) when compared to those who did not (M = 2.68, SD = 4.43) (t(59) = -2.161, p =
.035). Patients who were aggressive on at least one occasion when there was no purpose

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evident had a higher PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (M =
13.00, SD = 0.00) when compared to those who did not (M = 3.00, SD = 5.04) (t(59) = -
2.783, p = .007).
Brief Psychiatric Rating Scale – Short Version
Patients who were aggressive on at least one occasion following instruction had a
higher Hallucinatory Behaviour score (M = 4.17, SD = 1.90) when compared to those who
did not (M = 2.78, SD = 1.85) (t(95) = -2.432, p = .017).
The relationship Between Purpose and Psychotic Symptoms at the Time of the Aggressive
Behaviour
Only significant results are described in this results section. For a full description of
the relationship between purpose and psychotic symptoms at the type of the aggressive
behaviour see APPENDIX 22.
Following 71 aggressive behaviours patients consented to be interviewed and the
PSYRATS was administered. On 67 occasions the Hallucinations factors were scored. No
patients reported that hallucinations directly influenced their aggressive behaviour. On 71
occasions Delusions Factor 2 (Emotional Characteristics) was calculated and on 70 occasions
Delusions Factor 1 (Cognitive Interpretation) was calculated. There was a significant
difference in PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = 2.249, p =
.028) between those behaviours of aggression occurring in response to a demand for activity
(M = 1.73, SD = 3.81) when compared with those that did not (M = 4.38, SD = 4.88). There
was a significant difference in PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68)
= 2.107, p = .039) between those aggressive behaviours occurring to enhance status or social
approval (M = 2.04, SD = 4.33) when compared with those that did not (M = 4.43, SD =
4.74).
The Relationship Between Purpose and Severity of Aggressive Behaviour
Aggressive behaviour following the denial of a request had a lower mean level of
severity (M = 7.48, SD = 1.983) than when it did not (M = 8.17, SD = 1.952) (t(474) = 3.711,
p = .0001). Aggression following provocation had a higher mean level of severity (M = 8.07,
SD = 1.854) than when it did not (M = 7.50, SD = 2.294) (t(473) = -2.724, p = .007).
Aggression occurring as a consequence of frustration had a lower mean level of severity (M =
7.55, SD = 2.183) than when it did not (M = 8.45, SD = 1.533) (t(473) = -2.724, p = .0001).
Aggression to enhance status or social approval had a higher mean level of severity (M =
8.28, SD = 1.764) than when it did not (M = 7.75, SD = 2.070) (t(474) = -2.709, p = .007).
Aggression following instruction had a higher mean level of severity (M = 9.24, SD = 1.954)
than when it did not (M = 7.88, SD = 1.976) (t(474) = -2.787, p = .006). Aggression used to

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observe suffering had a lower mean level of severity (M = 9.33, SD = 1.940) than when it did
not (M = 7.87, SD = 1.973) (t(474) = -3.091, p = .002).
When only acts of verbal and physical aggression towards staff and patients were
compared the following differences were noted: Aggressive behaviour following the denial of
a request had a lower mean level of severity (M = 7.75, SD = 1.644) than when it did not (M
= 8.46, SD = 1.563) (t(449) = 4.558, p = .0001). Aggression occurring as a consequence of
frustration had a lower mean level of severity (M = 8.00, SD = 1.689) than when it did not (M
= 8.47, SD = 1.504) (t(449) = 3.125, p = .002). Aggression to enhance status or social
approval had a higher mean level of severity (M = 8.45, SD = 1.500) than when it did not (M
= 8.08, SD = 1.675) (t(449) = -2.309, p = .021). Aggression following instruction had a
higher mean level of severity (M = 9.56, SD = 1.459) than when it did not (M = 8.15, SD =
1.613) (t(449) = -3.441, p = .001). Aggression to observe suffering had a higher mean level of
severity (M = 9.33, SD = 1.940) than when it did not (M = 8.16, SD = 1.598) (t(449) = -
3.033, p = .003).
Total Number of Purposes
The total number of purposes used by every patient was calculated by summing the
different purposes used during all of their aggressive behaviours. As can be seen from Table
27, most patients (81%) who were aggressive used less that five different types of purpose. A
small number (n = 19 or19%) showed evidence of six or more purposes for aggression. Table
27 shows the total types of purposes used by patients.

Table 27: Total Types of Purposes

Total types of purposes Number of patients (Percent)

1 4 (4%)
2 21 (20.8%)
3 24 (23.8%)
4 12 (11.9%)
5 21 (20.8%)
6 6 (5.9%)
7 5 (5.0%)
8 5 (5.0%)
9 3 (3.0%)

Total Types of Victims

The total types of victims was calculated to determine whether patients were selective
according to type of victim during their aggressive episodes. This was calculated by
determining whether each patient was aggressive towards the three groups of victims; staff,
patients and property. As can be seen from Table 28, most patients were aggressive to only

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one group of victim, patients (29.6%), staff (23.5%) and property (3.1%). Very few patients
were aggressive towards staff, patients and property (7.1%). Twenty seven (27.6%) patients
were aggressive towards staff and patients. There were very few patients who were aggressive
towards both staff and property (6.1%), or patients and property (3.1%).

Table 28: Frequency of Patients by Victim Type

Victim types Number of patients (Percent)

Patients only 29 (29.6%)
Staff only 23 (23.5%)
Property only 3 (3.1%)
Staff and patients only 27 (27.6%)
Staff and property only 6 (6.1%)
Patients and property only 3 (3.1%)
All types of victims 7 (7.1%)

Total Types of Aggression

The total types of aggression was calculated to determine whether patients were
selective in their type of aggression. This was calculated by determining whether each patient
was aggressive across the three types; verbal aggression, physical aggression, and aggression
towards property. As can be seen from Table 29, most patients either used one type of
aggression, verbal aggression (32.3%), physical aggression (19.2%), or aggression towards
property (2%). Very few patients used all types of aggression (1.1%). Thirty patients used
verbal and physical aggression (30.3%) Few patients were aggressive towards property and
were verbally aggressive (3%), or were aggressive towards property and physically aggressive
(3%).

Table 29: Frequency of Patients by Aggression Type

Aggression types Number of patients (Percent)

Property damage only 2 (2%)
Verbal aggression only 32 (32.3%)
Physical aggression only 19 (19.2%)
Property and verbal aggression only 3 (3%)
Property and physical aggression only 3 (3%)
Verbal and physical aggression only 30 (30.3%)
All types of aggression shown 10 (10.1%)

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Aggression Towards Males, Females and Property (Total Number of Victim Genders)
The total number of victim genders was calculated to determine whether patients were
selective in their type of victim when they were aggressive. The total number of victim
genders was calculated for each patient by determining whether each aggressive patient was
aggressive across the three victim gender types, including males, females and property. As
can be seen from Table 30, most patients were aggressive towards either males (28.9%), or
females (17.5%), or towards both males and females (35.1%). Few patients were aggressive
towards property only (4.1%), males and property (4.1%), females and property (1%), or
males and females and property (9.3%).

Table 30: Frequency of Patients by Total Types of Victim Genders

Gender types Number of patients (Percent)

Males only 28 (28.9%)
Females only 17 (17.5%)
Property only 4 (4.1%)
Males and females only 34 (35.1%)
Males and property only 4 (4.1%)
Females and property only 1 (1%)
Males, females and property 9 (9.3%)

Correlations Between the Number of Aggressive Behaviours, Total Types of Aggressive

Behaviours, Total Types of Victims, Total Types of Victim Gender, and Total Number of
Different Types of Purposes for Aggression
Significant correlations between the number of aggressive behaviours, total types of
aggressive behaviours, total types of victims, total types of victim gender, and total number of
different types of purposes for aggression are reported in Table 31.

Table 31: Correlations Between Outcome Variables

Number of aggressive behaviours Number of types of aggression Number of victim types Number of victim gender types Number of different purpoises

Number of aggressive behaviours 1

Number of types of aggression .497*** (n = 98) 1

Number of victim types .381*** (n = 96) .696*** (n = 95) 1

Number of victim gender types .705*** (n = 100) .523*** (n = 97) .351*** (n = 95) 1

Number of different purpoises .478*** (n = 76) .833*** (n = 95) .756*** (n = 93) .552*** (n = 95) 1
*p < .05, **p < .01, ***p<.001

Table 32 shows the correlations between the number of aggressive behaviours, total
types of aggressive behaviours, total types of victims, total types of gender, and total number
of different types of purposes for aggression, and the following predisposing variables: age,

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substance use (total types of substances used in year prior to assessment and total types of
substances used over the lifetime), prior violence (total violence), SBS (Social Withdrawal,
Thought Disturbance, Antisocial Behaviour, Depressed Behaviour, and Total), NAS
(Cognitive, Behavior, Arousal, Total), impulsivity (Functional and Dysfunctional),
assertiveness (simplified RAS), the five PSYRATS factors, and BPRS Total. Only significant
relationships are reported.

Table 32: Correlations Between Patient’s Predisposing Characteristics and Outcome

Variables

Age Substances SBS (AB) SBS (T) PSYRATS (D1) NAS (A)

Number of aggressive incidents .391*** (n = 104) -.225* (n = 100) .290** (n = 103) .275** (n = 102) .266* (n = 58)

Number of victim types .301** (n = 98)

Number of victim gender types .211* (n = 95) .271* (n = 58)

Number of different purpoises .385*** (n = 99) .305** (n = 98) .290* (n = 56)

Total types of aggressive behaviours .385*** (n = 99) .268** (n = 94)

*p < .05, **p < .01, ***p<.001

NOTE: Abbreviations: Substances = Total types of substances used across the lifetime, SBS (AB) SBS Antisocial Behaviour, SBS (T) = SBS Total, PSYRATS (D1) = Psychotic Symptom

Rating Scales Delusions Factor 1 (Cognitive Interpretation), NAS (A) = NAS Arousal.

8.0 Discussion
Reducing the likelihood of aggression in psychiatric wards relies upon accurate
predictions of risk, preventative strategies based on knowledge of the individual and
contextual contributors to aggression, and effective treatment programs that are informed by
these individual and environmental contributors. In addition, such strategies and programs
may benefit from an understanding of the reasons why psychiatric patients are aggressive
within the inpatient setting. The task of predicting, preventing, and treating aggressive
inpatients is advanced by this research.
Within the following discussion a review of aggressive behaviours is presented,
followed by a review and discussion of the relationship between aggression and the
personality and behavioural characteristics assessed in this study. Also considered are the
purposes for aggression and an examination of the relationships between patient
characteristics and purpose. Following a discussion of these results, implications for the
prevention and management of inpatient aggression, limitations of the study and opportunities
for future research are presented. An integration of the results of this research and the initial
studies undertaken as part of this program of research is presented in the conclusion.
8.1 The Nature and Frequency of Aggression Within the Thomas Embling Hospital
The following section provides a description of the aggressive behaviours that
occurred during 2002 and a review of these findings. Results are considered in the following

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order: (a) when aggression occurred as a function of the number of days following admission,
the time of day, day of the week, and month, (b) where aggression occurred, in terms of
location within the hospital, and on the ward, (c) and the victims of aggression.
Previous research on inpatient aggression (Daffern, Ogloff and Howells, 2003; Lion,
Snyder & Merrill, 1981) has identified problems with under-reporting of aggressive
behaviours that probably reflects a tolerance of aggression, as well as doubts about the
usefulness of recording aggressive acts. The need for prospective assessment of aggressive
behaviours on instruments specifically designed for this task has been universally indicated.
The method for assessing inpatient aggression in this study is consistent with this
recommendation. The current results are therefore considered a reliable indication of the true
frequency and nature of aggression within the TEH.
In the year under review, aggression occurred frequently, although, consistent with
previous research (Gudjonsson, Rabe-Hesketh & Wilson, 2000; Rasmussen & Levander,
1996), most incidents were minor, in that staff and patients were not often physically harmed
as a consequence of aggression. That aggression was common is probably a reflection of
several factors: patients with active psychotic illnesses were preferentially admitted for
treatment, most patients were admitted from prison, an environment that supports aggression,
and most patients had a history of aggression, recent antisocial behaviour and substance use,
known correlates of ongoing aggressive behaviour.
Almost half of all patients who were aggressive during the course of their admission to
the TEH were aggressive during their first week of admission, although the median number of
days between admission and first aggressive incident was eight. Previous research has
demonstrated a relationship between aggression and acute symptoms of psychotic illness
(Krakowski et al., 1986; McNeil & Binder, 1994; Mulvey, 1994), and between aggression and
the early stages of acute admissions (Barlow et al., 2001; Beauford et al., 1997). In addition to
acute symptoms of psychiatric illness, aggression during the early stages of admission is more
likely because relationships with staff, which often form a powerful barrier to aggression, are
typically unstable (Whittington, 1994). Although aggression is most likely during the early
stages of acute treatment, there is variability in the average number of days between
admission and aggression across studies of inpatient aggression. Barlow et al (2001) reported
that aggression was most likely to occur during the first two days of admission whereas Tam,
Engelsmann and Fugere (1996) found that the majority of aggressive episodes occurred after
the first week of admission. Identifying the most common times for aggression has obvious
implications for risk assessments and the development of strategies directed towards the
prevention of aggressive behaviour. If patients are at risk of aggression during their first week

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of admission then increased supervision, care, and treatment to prevent aggression may be
required during this time.
Although patients in this study were likely to be aggressive during their first week of
admission, there were few patients who were aggressive during their first two days of
admission. Given the relationship between acute psychotic symptoms and aggression it was
anticipated that aggression would occur most frequently during the earliest stages of
admission, when patients were presumably most unwell. Whilst patients were frequently
aggressive during the first two weeks of admission few were aggressive on the first day or
two following admission. Social, psychological and environmental protectors may have
contributed to the lack of aggression immediately following admission. For example, patients
may have been reluctant to behave aggressively immediately after admission due to concern
about the possible consequences of aggression within the hospital. Alternatively, patients may
initially have been satisfied with their transfer to hospital and only later become irritated by
the demands of the hospital, particularly the enforced psychiatric treatment and increased
scrutiny. Patients may also have been subject to increased scrutiny during their first few days
of admission, when they were confined to the ward, and placed under constant observation.
These interventions, which were often removed after the first few days of admission if there
has been an absence of problematic behaviour, may have restricted opportunities for
aggressive behaviour.
Neither type nor direction of aggression was related to time of day, although
consistent with the first two studies, and previous research (Fottrell, 1980), aggression was
more common during the day when compared with the night. There were very few acts of
aggression recorded between 10pm and 7am. This is probably a reflection of the increased
number of demands placed on patients during the day, the decreased interaction between
patients during the night, and because patients were in general, asleep at night. The highest
frequency of aggressive behaviours was recorded between 9am and 10am. Depp (1976) first
noted a relationship between peak periods of aggression and time of day, and considered these
elevated frequencies a result of increased demands on patients at these times. Between 9am
and 10am patients are expected to be out of bed, and attend to meetings or programs with
allied health and medical staff. This is also the time when patients are asked to attend a
community meeting, where patients and staff are able to raise concerns and discuss the
activities that are available during the day. It is also the time when patients may expect to be
able to leave the ward to participate in activities across the hospital’s campus. In contrast with
those studies that have found an elevated frequency of aggressive behaviours during meal
times (Gudjonsson et al., 1999), which might reflect the fact that medication is provided at

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mealtimes in some hospitals, there were few incidents of aggression recorded during lunch
and dinner. In contrast, there were generally increases in aggression in the hour periods
immediately following meal times. The reason for this may be that patients are typically
required to take their medication following meals in the TEH.
There was a relatively even distribution of aggression across days of the week. The
lowest frequency of aggressive behaviours occurred on Saturdays and the highest frequency
occurred on Tuesdays and Wednesdays. It was expected that weekdays would have a higher
average number of incidents when compared with the weekends, due to the increased
demands made of patients during the week, and on the basis of previous research where these
patterns have been identified (Gudjonsson et al., 1999). Although not statistically significant,
slight differences in the frequency of aggression were identified when characteristics of the
victim were considered. Aggression towards staff was more frequently recorded on weekdays
when compared with weekends, whereas aggression towards patients was more frequently
recorded on the weekends. Weekends are typically more relaxed on the wards, there are less
demands for activity, expectations of program participation, and review by medical and allied
health staff. The reason for the increase in aggression between patients on the weekend is
unclear although this may be contributed to by the lack of structure and programs offered. It
may also be a consequence of there being fewer staff present to intervene at times of conflict
between patients. Medical and allied health staff do not work on the weekends and there are
fewer nursing staff working over the weekend.
Consistently with previous research (Nijman et al., 1997), aggression decreased in
frequency over the course of the study. The average number of aggressive behaviours per
month was significantly lower for the second six months (July until December) when
compared with the first six months (January until June). This finding may be due to recording
fatigue, with staff tiring of the study. Alternatively, this reduction in aggression may have
been a consequence of the systematic monitoring of aggression that contributed to an
increased awareness and understanding of aggressive behaviour, which in turn lead to
changes in risk assessment and management. As other possible contributors to aggression
were uncontrolled in this study, the role of systematic recording in these observed changes is
unclear.
Aggression was more common on the acute wards when compared with the
rehabilitation wards, although, as was found in the first two studies, there was a discrepancy
in reported incidents of aggression between the two male acute wards. The reason for this
discrepancy is unclear, although a similar observation made in the first study was considered
a consequence of differences in the management of aggression, particularly the use of

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seclusion. It is possible that these practices, again, contributed to the observed differences,
although the precise reasons remain unclear. Another possible contributor to the discrepancy
was that the author worked as a psychologist on Argyle throughout the study. As a result of
his location on Argyle, other staff on this ward may have been more attentive to the study and
recorded aggressive behaviours more reliably. However, as the first study relied on Incident
Forms completed prior to the author’s involvement in aggression research within the TEH,
there is probably more to this discrepancy than a recording bias.
On the ward, most aggressive behaviours occurred in the lounge room (n = 253 or
40.2%). Previous authors (Lanza et al., 1993) have noted that the presence of more patients in
one area necessarily increases the chance of aggression. Patients spend most of their waking
hours congregating in the lounge room. As such, this is the area where staff members demand
activity, and where patients make requests of staff. The lounge room is where the television,
pool table and table tennis table are located, which are often sources of conflict. Shepherd and
Lavender (1999) noted a lack of incidents in therapeutic contexts and suggested that planned,
structured activity, of which there is generally few in the lounge room except for pool and
table tennis, and the opportunity for positive interpersonal contact, may reduce the likelihood
of aggressive incidents. Consistent with this finding, Haller and Deluty (1988) reported that
violence is more likely to occur when patients are gathered together with little structured
activity, as they are in the lounge room.
As in previous research (Barlow et al., 2001; Fottrell, 1980; James et al., 1990; Larkin
et al., 1988) members of staff were more frequently the victims of both verbal and physical
aggression when compared to patients. This demonstrates the inherent dangers mental health
staff are exposed to whilst working in psychiatric wards. Patients were more likely to be
verbally, rather than physically aggressive to staff, and more likely to be physically, rather
than verbally aggressive to patients. Again, consistent with previous research (Pearson et al.,
1986), aggression towards patients was on average more severe than aggression towards staff.
This may be due to norms supporting the use of physical aggression during conflict between
patients. Alternatively, less severe incidents towards staff may be a consequence of the early
intervention by other members of staff when their colleagues are being assaulted, and staff
training in the prevention and management of aggression. The purpose for aggression towards
staff and patients may also, in part, explain the different levels of severity of aggression, with
evidence coming from this study that some purposes for aggression showed a relationship
with the type and severity of aggression. Most commonly, demands for activity, or denials of
requests precipitated aggression towards staff. Aggression between patients typically occurred
following provocation. Aggression towards staff may have been on average, less severe

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because staff demands for activity and denials of requests are considered less provocative than
the swearing, threatening behaviour and intimidation that commonly precipitated aggression
between patients. Aggression may have also been less severe towards staff because patients
had some appreciation that whilst staff are irritating, unfair, unjust or annoying, that they are
simply trying to do their job. Consistent with previous research (Gudjonsson et al., 2000;
James et al., 1990; Larkin et al., 1988), and most likely a consequence of the fact that they
more frequently impose limits, enforce decisions, demand activity, deny requests, and have
the most contact with patients, nurses were the most frequent victims of aggression when
compared with other staff groups.
When incidents of physical aggression towards staff were classified according to
whether or not they occurred within the context of restraint and seclusion, or as a consequence
of direct assault, there was no significant difference in the average severity of aggressive
incidents. Although focussing on injuries rather than incidents of aggressive behaviour,
Carmel and Hunter (1989) reported that injuries to staff involved in the containment of
aggression were more frequent, but less severe, than those which occurred as a consequence
of direct assault. Further, the frequency of physically aggressive behaviours towards staff that
occurred within the context of restraint and seclusion were less common when compared with
physically aggressive behaviours that occurred as a consequence of direct assault. These
contrasting results highlight the need to differentiate between incidents of aggression and
incidents that result in injury.
The process of classifying incidents of aggression according to whether or not they
occurred within the context of restraint or whether they were a consequence of direct assault
was problematic, in that the distinction between setting limits and restraining patients was
sometimes difficult to establish. For example, a nurse may have approached a patient and told
him that he should stop behaving in a particular manner. The patient may have resisted, begun
swearing and then attempted to assault the staff. During this process the patient may have
been restrained and taken to seclusion. This entire episode may be considered limit setting or
containment. As most aggressive behaviours towards staff occurred subsequent to demands
for activity or following denials of request, and both involve limit setting or instructions to
behave in particular ways, the distinction between direct assault and containment is
sometimes difficult to establish. In this study physical aggression towards staff was classified
as containment if it occurred subsequent to staff attempting to physically restrain a patient.
All other incidents were classified as assault. Future studies should carefully consider how to
differentiate between the two types of aggressive behaviour and establish written guidelines to
assist classification.

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 Consistent with some previous research (Depp, 1976; Torpy & Hall, 1993), male
patients were more likely to be aggressive towards males, and females were more likely to be
aggressive towards females. This was an unsurprising finding as the acute wards, where
aggression occurs most frequently, are single gender wards. Patients who are restricted to the
ward are therefore only able to behave aggressively towards patients of the same gender.
However, when aggression towards staff was considered, a similar pattern was identified.
Male patients were more likely to be aggressive towards male staff, and female patients were
more likely to be aggressive towards female staff. Furthermore, when type of aggression
towards both staff and patients was considered, male patients were slightly more likely to be
verbally aggressive towards males, whereas they were much more likely to be verbally
aggressive towards females. Similarly, females were much more likely to be physically, rather
than verbally aggressive towards females. They were equally as likely to be verbally, as
physically aggressive towards males. These findings indicate that opposite gender may protect
against severe acts of aggression.
8.2 Characteristics of Aggressive and Non-aggressive Patients
The following section describes characteristics of aggressive patients and contrasts
these with the characteristics of non-aggressive patients. In particular, the following
characteristics are discussed: (a) age and gender, (b) history of substance use, (c)
assertiveness, anger and impulsivity, and (e) symptoms of psychosis. Results of the multiple
regression analysis are also discussed.
As anticipated, a high proportion, almost half (45.26%), of all patients admitted to the
TEH during 2002 were aggressive on at least one occasion. This proportion is higher than that
reported in studies of inpatient aggression in mainstream psychiatric hospitals. For example,
Barlow et al. (2001) found in their review of aggressive behaviour, which included aggression
to self, in four mainstream acute psychiatric wards, that 13.7% of patients had been
aggressive. The proportion of patients who were aggressive in the TEH is lower however than
that reported in some forensic services, including a medium secure unit in England
(Gudjonsson et al., 1999), where 59% of patients were aggressive. The proportion identified
in this study is however higher that that reported by Heilbrun, Hart, Hare, Gustafson, Nunez
and White (1998), who examined inpatient aggression in the Forensic Service, Florida State
Hospital, and reported that 22.5% of patients were involved in at least one incident of verbal
aggression, and 11.9% were physically aggressive. One reason for these differences may be
the procedure with which incidents of aggression were identified, the definition of aggression
used, and the length of the study period. For example, Heilbrun et al. (1998) reviewed only
the first and last two months of admission and relied on review of hospital charts, a method

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known to result in an underreporting of aggressive behaviours (Lion et al., 1981). Similarly,
Barlow et al. (2001) relied on review of incident report forms. Methodological differences
render comparison of aggression across psychiatric hospitals problematic. If there is to be
comparison of aggressive incidents then equivalent recording procedures must be adopted.
Consistent with previous research (Barlow et al., 2001), most patients were aggressive
infrequently (36.2% were aggressive once and only eight were aggressive on 15 or more
occasions). Further, and again consistent with previous research (Barlow et al., 2001; James et
al., 1990; Larkin et al., 1988; Rasmussen & Levander, 1996), a small number of patients were
repeatedly aggressive. In this study eight patients were responsible for almost half of all
aggressive behaviours reported. Larkin et al. (1988) reported that 4% of patients were
responsible for 60% of incidents, and Fottrell (1980) reported that 3% of patients were
responsible for 70% of incidents. In the current study, repeatedly aggressive patients were
typically aggressive towards males, females and property, were physically and verbally
aggressive, and were aggressive towards staff, patients and property. This finding suggests
that repeatedly aggressive patients are indiscriminate with regard to their targets and type of
aggression. It also suggests that broad strategies should be implemented for repeatedly
aggressive patients that protect against a variety of aggressive behaviours.
As patients admitted to the hospital during 2002 were as likely to be aggressive as not,
the adoption of universal strategies for preventing and managing aggression is indicated.
However, as only a small number of patients are repeatedly aggressive, the identification of
these patients, in addition to the identification of patients at risk of severe aggressive
behaviour is critical so that restrictive strategies aimed at eliminating aggression are
selectively implemented. Frustration generated by unnecessarily restrictive conditions may
increase the risk of aggressive behaviour.
Patients admitted to the hospital ranged in age from 17 to 83 years although most were
young, with an average age of 34 years (Median = 31). This average age is younger than other
samples studied; Beauford et al. (1997) recorded a mean age of 41.9 years. In contrast to
some previous research (Fottrell, 1980; Heilbrun et al., 1998; James et al., 1990; Pearson et
al., 1986; Tardiff & Sweillam, 1982), which has shown that aggressive patients are younger
than non-aggressive patients, there was no significant difference between the average ages of
aggressive and non-aggressive patients. Previous research has generally shown that
aggressive patients are predominantly under the age of 40 (Bjorkly, 1995). Results of the
current study are consistent with this finding. That lack of a significant difference between
aggressive and non-aggressive patients observed in the current study is most likely a
consequence of the fact that most patients admitted for treatment to the TEH were young.

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 In contrast with the lack of significant difference between aggressive and non
aggressive patients on age, there was a positive correlation between age and the number of
aggressive behaviours, with older patients more likely to be repeatedly aggressive. This
finding was maintained when the most repeatedly aggressive patient, an 83-year-old woman
responsible for 53 incidents, was removed from the analysis. This result is consistent with
Noble and Rodgers (1989), who found that patients in their seventies were involved in a
disproportionate number of assaults. The current finding probably reflects the fact that the
TEH provides long term care for a small number of chronically unwell, treatment resistant
patients, who continue to behave aggressively despite treatment.
In the present study, males and females were equally likely to be aggressive although
females were repeatedly aggressive more often than males. However, when the 83 year old
patient who was responsible for 53 incidents was removed from the analysis, this difference
approached, but did not reach significance (t(228) = -1.916, n.s.). These findings are similar to
previous research in forensic psychiatric hospitals (Larkin et al., 1988; Rasmussen &
Levander, 1996). A small number of women are incarcerated in prison when compared with
men and the number of beds available for treatment at the TEH for women is also small. This
results in only the most unwell and difficult to manage female prisoners being transferred for
assessment and treatment. Rasmussen and Levander (1996), who similarly noted a
disproportionate number of incidents accounted for by women, considered this a result of a
selection bias in admitting patients to a maximum security psychiatric hospital unit,
suggesting that “females are more grossly disturbed before being admitted” (p. 386). Another
reason for the increased frequency of aggressive behaviours amongst female patients may be
the size of the sample responsible for repeated aggressive behaviour. There were only a small
number of repeatedly aggressive patients. It may be that this small sample of repeatedly
aggressive patients was, during the study period, biased by a disproportionate number of
repeatedly aggressive women.
Substance use in the year prior to assessment and across the lifetime was commonly
reported. Alcohol and marijuana were used by over half of all patients in the year prior to
assessment, with amphetamines, heroin and cocaine used less frequently. Nearly all patients
had used alcohol, most had used marijuana, and almost half had used either heroin or
amphetamines across the lifetime. There were only a small number of patients who had never
used drugs or alcohol at some time during the lifetime. These findings are consistent with a
more thorough examination of substance use conducted within the TEH during 2002 by
Ogloff, Lemphers and Dwyer (in press). Results from their study indicated that almost 75% of
patients had a diagnosis of substance abuse or dependence at some point in their life, and all

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of the remanded prisoners and most of the sentenced prisoners had a diagnosis of substance
abuse or dependence.
The prevalence of substance use in this study indicates the need for assessment and
intervention of substance use problems in the forensic psychiatric context, particularly as
patients who were aggressive on at least one occasion during 2002 used a significantly higher
total number of substances in the year prior to assessment. Regarding treatment, there is now
increasing evidence for the effectiveness of treatment for substance misuse, with
improvement in outcomes in approximately 30% of treated patients (Crome, 1999).
Whilst the prevalence of substance use disorders has received some empirical
attention, the relationship between substance use and inpatient psychiatric treatment remains
unclear. In mainstream acute wards, patients may be admitted directly from the community,
and occasionally return to the ward from leave, intoxicated. Where patients’ leaves and visits
are less restrictive and absconding is possible, substance use, intoxication and disinhibition is
more common; the risk of aggression presumably increases. Available evidence suggests that
there is infrequent use of illegal substances within the TEH. Although intoxication was not
investigated directly during the course of this study, there was not one occasion when an
aggressive patient was reported by staff to be intoxicated at the time of their aggression. It
cannot therefore be claimed that substance use contributes to inpatient aggression exclusively
through intoxication.
Although the mechanism by which substance use and psychiatric symptoms interact to
contribute to aggression remains unclear, given that a relationship between aggression and
substance use exists, and evidence supportive of treatment, interventions should occur. In
terms of identifying correlates of inpatient aggression, recent drug and alcohol use may be a
useful indicator of inpatient aggression, rather than the total number of substances used over
the lifetime. This finding may also indicate that recent disturbance in social or psychological
functioning caused by intoxication, withdrawal or dependence, rather than a history of
substance use, which may indicate long-standing personality dispositions towards both
substance use and aggressive behaviour are related to aggression.
As in a study of aggression in an English high security psychiatric hospital (Wong et
al., 1993), most patients admitted to the TEH had a history of aggressive behaviour, and many
had committed a seriously aggressive offence prior to admission. In approximately 50% of
occasions the index offence resulted in the victim being killed or having their health seriously
endangered. Only 14.2% of patients’ index offences were completely non-violent. Not
including a patient’s index offence, only a small proportion of patients (24.6%), reported that
they never became involved in fights and had never been convicted of a violent offence.

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These results indicate that patients in this hospital have a disposition towards aggression that
increases the likelihood of aggressive behaviour.
There was no significant difference between aggressive and non-aggressive inpatients
on the severity of their index offence, as measure by the Violence Scale. This is similar to the
results of Doyle, Dolan and McGovern (2002), who studied the risk of violence in a British
medium secure unit and found that patients with an index offence of homicide were less likely
to be violent in the inpatient setting. The current results may also have been influenced by the
large number of patients found not guilty by reason of mental impairment, most of whom
committed murder or attempted murder, who were asymptomatic during much of 2002, had
been in hospital for many years, so therefore had not used drugs or alcohol in the previous
year, and who were located in a settled environment in the rehabilitation wards, where
aggression was uncommon.
There was a significant difference between aggressive and non-aggressive patients on
the history of aggression, indicating that the length or extent of a patient’s history of
aggression, rather than the severity of a recent aggressive act, as measured by the index
offence, may be a better marker for the risk of inpatient aggression. Recent antisocial
behaviour, as measured by the SBS Antisocial Behaviour scale, which measures recent
hostility, socially unacceptable habits and destructive behaviour, also differentiated
aggressive from non-aggressive patients. This finding is consistent with the results of Watts,
Leese, Thomas, Atakan and Wykes (2003), who examined the likelihood of aggression within
two weeks of admission to two locked psychiatric units in England. These authors found that
recent pre-admission violence was significantly related to aggression, results that are also
similar to those of McNiel and Binder (1989), who noted a relationship between preadmission
threats of violence and violence within the psychiatric ward, particularly for patients
diagnosed with schizophrenia. These findings lend support to the need to assess recent
antisocial behaviour and the entire history of aggressive behaviour to assess the likelihood of
inpatient aggression, rather than an exclusive focus on the severity of the index offence,
particularly if it occurred several years previously.
There were no significant differences between aggressive and non-aggressive patients
on the Simplified RAS and the Functional and Dysfunctional Impulsivity scale. The lack of
significant differences on the Functional and Dysfunctional Impulsivity scale is similar to the
results of Cherek, Moeller, Dougherty and Rhoades (1997) who examined the relationship
between criminal history and impulsivity in parolees. They reported that parolees did not
differ on either the functional or dysfunctional dimensions of the Functional and
Dysfunctional Impulsivity scale. Cherek at al. (1997) did however find an association

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between criminal history and impulsivity when impulsivity was measured using the Barratt
Impulsivity Scale (Barratt, 1985). One possible explanation for the current findings may have
been that patients underreported their dysfunctional impulsivity. However, the mean
dysfunctional impulsivity score for both aggressive (M = 5.05; SD = 2.89) and non-aggressive
(M = 5.23; SD = 2.98) patients was higher than that reported by Cherek et al. (1997) (M =
3.78; SD = 1.4). Given these findings, it may be concluded that impulsivity either does not
play a dominant role in inpatient aggression, or that the Functional and Dysfunctional
Impulsivity scale is insensitive with this population.
In contrast with the results of Kay et al. (1988) and Novaco (1994), there was no
relationship between inpatient aggression and any of the Novaco Anger Scales. This finding is
also inconsistent with the findings of McNiel et al. (2003), who reported a relationship
between aggression and several indicators of aggressive attributional style. The lack of
significant differences on the NAS in the current study was unexpected, given these previous
findings, and clear evidence that most acts of inpatient aggression reviewed during this study
were precipitated by a perception of provocation. Again, one possible explanation for this
finding was that the assessment procedure might have allowed patients to underreport anger
problems. However, the levels of anger reported in this study were high, even when compared
with similar populations. The average scores on the four NAS scales for patients admitted to
the TEH were: NAS Cognitive, M = 39.92, SD = 7.11; NAS Arousal, M = 36.98, SD = 6.97;
NAS Behavior, M = 36.98, SD = 6.97; NAS Total, M = 115.22, SD = 17.44. These results
are similar to a sample of outpatients referred for anger management training to a clinical
psychology department of a regional secure unit in England (Jones, Thomas-Peter & Trout,
1999): (NAS Cognitive, M = 34.12, SD = 4.99; NAS Arousal, M = 34.42, SD = 6.25; NAS
Behavior, M = 34.63, SD = 7.19; NAS Total, not reported). Although the NAS did not
differentiate between aggressive and non-aggressive inpatients, the high levels of anger
reported by both aggressive and non-aggressive patients in the current study indicate that this
sample clearly has problems with anger arousal and control, which necessitates universal
implementation of anger management programs across the hospital.
As in many other studies of contemporary psychiatric hospitals (Bhui et al., 2001),
most patients in this study were admitted for treatment of disorders characterised by the
presence of psychotic symptoms, with schizophrenia the most common diagnosis. Previous
research focusing upon the relationship between diagnosis and inpatient aggression have
sometimes found the diagnosis of schizophrenia to be more often related to aggression than
other disorders (Depp, 1976; Fottrell, 1980; Sheridan et al., 1990). In contrast with these
findings, patients in the current study with a disorder characterised by the absence of

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psychotic symptoms were more likely to be aggressive, and more likely to be repeatedly
aggressive, than those patients with a psychotic illness, even when the 83-year-old woman
responsible for 53 incidents who had a disorder characterised by the absence of psychotic
symptoms, was removed from the analysis. One reason for this finding may be that the small
number of patients with non-psychotic illnesses and severe behavioural problems admitted to
the hospital during the study period were repeatedly aggressive. Three of the repeatedly
aggressive patients had diagnoses of Asperger’s disorder, Dementia, and Huntington’s
disease. These are disorders of a chronic and often treatment resistant nature; hence, for these
individuals, the course of aggression, if related to their disorder, is longer.
This suggestion is consistent with the findings of Krakowski and Czobor (1997), who
differentiated between persistently violent patients (patients whose violence did not
substantially decrease within 10 days following an initial assault) and transiently violent
patients (patients whose violence substantially decreased within 10 days following an initial
assault). Persistently violent patients showed less resolution of psychiatric symptoms and
more impaired frontal lobe functioning than transiently violent patients. They noted that both
groups were more impaired during the early stages of admission, consistent with the positive
association noted between violence and positive psychotic symptoms. However, transiently
violent patients showed better resolution of positive psychotic symptoms, whereas
persistently violent patients were more impaired in their ability to follow ward routine and
regulations, to interact socially with other patients and to control their temper. They also
showed poorer frontal functioning, the authors noting that patients “are more likely to be
persistently violent when poor frontal functioning is accompanied by little improvement in
positive symptoms” (p. 234).
In previous studies of inpatient aggression (Krakowski et al., 1986; Yesavage, 1983)
the BPRS Conceptual Disorganisation, Unusual Thought Content and Hallucinatory
Behaviour have differentiated aggressive from non-aggressive patients. In the current study,
aggressive patients scored higher on BPRS Conceptual Disorganisation, Hallucinatory
Behaviour, and Total BPRS. There was no significant difference between aggressive and non-
aggressive patients on BPRS Unusual Thought Content, an unexpected finding given (a) the
results of the aforementioned studies, (b) previous research supporting the role of delusions in
aggression (Swanson et al., 1990; Link & Stueve, 1994; Swanson et al., 1996), (c) the fact
that 37% of patients revealed a delusional belief that directly related to their aggression, and
(d) a significant difference between aggressive and non-aggressive patients on SBS Thought
Disturbance. However, with regard to differences between BPRS Unusual Thought Content
and SBS Thought Disturbance, the BPRS Unusual Thought Content measures the extent to

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which a patient’s speech is odd, unusual or bizarre, the unusualness of the content of the
patient’s speech, whereas the SBS Thought disturbance is a broader measure, incorporating
assessment of the patient’s incoherence of speech, oddness or inappropriateness of
conversation, and problems with attention. It may be that this broader measure of thought
disturbance is more useful when considering the relationship between delusions and
aggression. Further research comparing the two measures is required to clarify the most useful
measure for assessing the relationship between thought disorder and inpatient aggression.
The PSYRATS was incorporated into the current study because of its ability to assess
various dimensions of delusions and hallucinations, and to determine the relationship between
these dimensions of delusions and hallucinations with aggression. Neither of the PSYRATS
delusions factors, cognitive interpretation (amount and duration of preoccupation, and
conviction) and emotional characteristics (amount and intensity of distress, and disruption)
was related to aggression. Similarly, there were no significant differences between aggressive
and non-aggressive patients on any of the PSYRATS hallucinations factors, Emotional
Characteristics (amount and degree of negative content, and amount and intensity of distress),
Physical Characteristics (frequency, duration, location and loudness), and Cognitive
Interpretation (location, beliefs regarding origin, disruption and control). The most likely
reason for the lack of significant differences was that patients might have underreported their
symptoms during the PSYRATS interview.
Despite a positive relationship between BPRS Hallucinatory Behaviour and
aggression, on the 71 occasions that patients consented to interview for assessment of the
relationship between delusions, hallucinations and aggression after they had behaved
aggressively, no patient recalled the influence of an auditory hallucination. Research to date
on the role of command hallucinations and aggression has been mixed (Rogers et al., 2002),
although McNiel et al., (2000) recently reported a positive relationship between command
hallucinations and violence towards others, a consequence of controlling for content of
command hallucinations. McNiel et al. (2000) established the relationship by studying
symptoms and aggression in a period preceding inpatient treatment. In the current study,
assertive treatment in a secure environment may have affected the likelihood of command
hallucinations, their content, and the behavioural manifestations of these symptoms. Further,
as assessment of command hallucinations relied on subjective report from patients, and as
most patients were unwilling to discuss their motivations for aggression, it may be that
command hallucinations did precede some episodes of aggressive behaviour.
Multiple regression showed that recent antisocial behaviour, as measured by SBS
Antisocial Behaviour either on its own, or in combination with the PSYRATS Delusions

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Factor 1, Cognitive Interpretation (amount and duration of preoccupation and conviction),
accounted for the most variance in this study. Both of these items correlated positively with
the number of aggressive behaviours. Although the PSYRATS Delusions Factor 1 did not
differentiate aggressive from non-aggressive patients, it was correlated with a number of other
characteristics that did, for example, substances used in the last year, and SBS Total. Results
of the multiple regression are consistent with the work of Mullen (2000) who stated that the
best predictor of inpatient aggression is a combination of the general level of disturbance in
the mental state, particularly when manifesting in fear, agitation and anger, combined with a
history of prior violence. Both the PSYRATS Delusions Factor 1 and the SBS Antisocial
Behaviour scale may be efficient means of assessing the likelihood of inpatient aggression
and could be completed for each patient on admission, or prior to transfer. Although the
PSYRATS Delusions Factor 1 required the consent of patients in this study, it is easily scored
from mental state examination. The use of the entire SBS, rather than the Antisocial
Behaviour scale is supported by the usefulness of several of its scales in discriminating
between different types of purpose. This scale may therefore be able to identify individuals
with a sensitivity to behave aggressively for different purposes. Information from this
assessment may then be incorporated into management and preventative strategies. For
example, patients who were more depressed, as measured by SBS Depressed Behaviour, were
more likely to be aggressive to reduce social distance. These patients may then be targeted to
either ensure they do not become socially isolated, or that they are introduced on admission to
appropriate means of responding to feelings of isolation without recourse to aggression.
8.3 The Purpose of Aggression
The following section discusses results pertaining to the assessment of purpose: (a) the
proportion of aggressive behaviours observed in which there was some evidence of purpose,
and (b) the nature of these purposes.
In clear contrast with previous studies that have failed to the identify antecedent-
interactions or purposes for a considerable proportion of aggressive behaviours (Bhui et al.,
2001; Cheung et al., 1996), and therefore assumed that these behaviours are a manifestation
of severe psychopathology and therefore motiveless (Cheung et al., 1996), the current study
found that most incidents of inpatient aggression had identifiable antecedents or purposes.
The relative success in identifying purposes is consistent with the work of Whittington and
Wykes (1996) who found that aversive stimuli, delivered by the assaulted nurse, could be
identified in 86% of incidents. In only 16 of the 502 aggressive behaviours recorded in the
current study was an antecedent or purpose not identified. The high proportion of identifiable
antecedents and purposes is most likely a consequence of adopting the functional analytic

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perspective, where the presence of function is assumed. Further, the use of a tool, the
‘Assessment and Classification of Purpose’ system, developed specifically for the task of
identifying purpose, may have also contributed to the high rate of purposes being identified.
Studies that have failed to identify purpose or antecedents have relied upon instruments
developed to assess the frequency and type of aggression. These instruments are probably
inadequate when the assessment of purpose is required.
On the basis of these results it can reasonably be argued that motiveless aggression
amongst psychiatric inpatients is rare. The few instances of motiveless aggression, where
purpose was unable to be identified, may be due to other less common purposes that the
current classification system was incapable of assessing, or due to the same purposes
identified by this system but that were unable to be classified because of a lack of
information, or because the purposes manifested in an uncharacteristic manner.
A number of purposes were present in most acts of aggression. Further, there was
evidence for a range of purposes. Previously, aggression has been considered a consequence
of instrumental objectives, frustration, or anger, which is used to either obtain property, to
express anger or frustration, or to inflict injury or harm on another person. The wide variety of
purposes identified in this study supports the need to broaden aggression classification
systems beyond the anger mediated and instrumental dichotomy. Attempts to classify
offenders as either anger mediated or instrumental is challenged by the current results on the
basis that patients were often aggressive for a number of purposes across incidents, and the
finding that a range of purposes often existed within any one aggressive incident. Rather than
attempt to classify individual patients according to the anger mediated-instrumental
dichotomy, it may be more profitable to determine the purposes for which aggression is used,
and then determine the conditions or individual deficits that permit these purposes to be
expressed in an aggressive manner.
As expected, and consistent with previous research that has focused on antecedent
interactions (Cheung et al., 1996; Shepherd & Lavender, 1999; Whittington & Wykes, 1994),
and with the activity-demand hypothesis (Depp, 1976), a demand for activity was a common
precipitant of inpatient aggression, observed in almost half of all aggressive behaviours
towards staff. Aggression towards patients following a demand for activity was less
frequently recorded, probably a consequence of patients requiring less activity from their
peers. Similarly, and again consistent with previous research (Cheung et al., 1996; McDougal,
2000; Powell et al., 1994; Shepherd & Lavender, 1999; Sheridan et al., 1990), the denial of a
request was a common precipitant of aggression towards staff, although an infrequent
precipitant of aggression between patients. When aggression occurred as a consequence of a

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demand for activity or the denial of a request, verbal, rather that physical aggression was
more likely. The reason for these findings may be that these precipitants were more common
in aggressive incidents in which members of staff, rather than patients, were victims.
Aggression towards staff and patients was frequently precipitated by a perception of
provocation. The high proportion of aggressive behaviours in which provocation was evident
is consistent with previous research on the motivations for aggression between patients
(Powell et al., 1994; Shepherd & Lavender, 1999), and is consistent with the view that
aggression often occurs within the context of anger arousal (Novaco, 1994), or follows the
perception of threat (Mullen, 1988). The large proportion of aggressive behaviours towards
staff precipitated by perceived provocation was a surprising finding. Although most patients
were unwilling to participate in assessment, and provocation was assessed through interview
with staff, patients commonly claimed that members of staff were annoying, unfair,
disrespectful, unjust, frustrating or irritating. Although it was never reported that staff
threatened patients, it seems evident that staff do things, such as refuse requests or demand
activity that are perceived by patients as provocative. This finding is consistent with the work
of Blackburn (1988), who argued that in an institutional setting the perception of unfairness
was a common precipitant of anger and conflict. This finding indicates the need for a review
of practices so that the performance of routine tasks becomes less provocative and therefore
less likely to contribute to aggression. Further discussion of the role of staff communication
and implications for the prevention of aggressive behaviour may be found in the implications
for the prevention and management of inpatient aggression section. Although many acts of
aggression were precipitated by perceived provocation, and the intentions of patients in these
incidents may well have been to harm, aggressive behaviour rarely occurred simply to
observe suffering in the absence of provocation or the arousal of anger. Although infrequent,
aggression motivated by a desire to observe suffering was typically severe.
Acts of instrumental aggression were rare, consistent with Indermaur (1999) who
noted that most apparently instrumental-like behaviours are often not devoid of emotional
arousal. This finding is also consistent with the work of Heilbrun et al. (1998), who noted that
aggressive behaviours in mentally ill patients are more likely a consequence of anger and
provocation rather than instrumental acts, which are more often a consequence of
psychopathy. Similarly, Appelbaum, Robbins and Monahan (2000) suggested that
instrumental violence is less likely for persons with delusions.
Aggression towards staff and patients was commonly precipitated by frustration. In
almost all episodes of property damage the patient was perceived to be frustrated. Verbal
aggression was more likely to occur as a consequence of frustration when compared with

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physical aggression. Similarly, acts of aggression used to discharge frustration were in general
less severe. The reason for this finding may be that patients who were feeling frustrated may
have simply wanted to discharge tension rather than harm another person. The high
proportion of incidents precipitated by frustration is similar to that found by Powell et al.
(1994), who identified verbal and physical antecedents through review of Incident Forms.
These authors found that one of the most common antecedents was that the patient was
generally agitated or disturbed, the equivalent in this study to ‘frustrated’. Similarly, in an
examination of violent incidents in an adolescent forensic unit, McDougal (2000) found that
agitation, anxiety, and overactivity were common antecedents to aggression. In the current
study, this category of purpose was intended to identify patients who were aggressive in a
conscious attempt to reduce physiological arousal in a cathartic manner. However, rather than
a conscious attempt to discharge arousal, it is more likely that in those cases where frustration
was evident, the patient was irritable, resulting in increased sensitivity to perceived
provocation. This interpretation is consistent with the work of Rule and Nesdale (1976), who
noted that general physiological arousal facilitates aggression in the presence of provoking
situational factors or aggressive cues, particularly when the arousal is attributed to the
provoking event.
Aggression was rarely precipitated by social distance. Further, SBS Social Withdrawal
did not differentiate aggressive from non-aggressive inpatients. This finding is in contrast to
previous reports indicating that a reduction in social distance is a common motivation for
inpatient aggression (Whittington, 1994). The present study is one of the first to empirically
investigate the relationship between social distance and aggression. Given that the findings
from this study are in contrast with these previous hypotheses these is a clear need for further
research examining the relationship between social distance and aggression, particularly as
there does exist evidence suggesting that patients behave aggressively when bored, or when
they are not involved in therapeutic activities (James et al., 1990).
Attaining status or preventing a detioration in status was a common motivation for
aggression between patients. Further, aggression precipitated by a desire to enhance status
was typically severe. This was not an unexpected finding, given that patients are usually
transferred to the TEH from prison, where there is cultural support of aggression as a strategy
for resolving conflict and attaining status (Toch, 1989). In a qualitative study of aggressive
behaviour in a public psychiatric hospital Morrison (1990) also found that some patients were
aggressive to build their reputation. What was most surprising was the identification of status
as an important contributor to aggression towards staff, occurring in 25.1% of all aggressive
behaviours in which members of staff were victims. This indicates that patients may not only

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perceive the actions of staff to be provocative, but that they may believe their status has been
challenged. This finding further challenges the view that the staff-patient relationship is
benign in terms of its influence on inpatient aggression, and suggests the need for
consideration of communication style when relating to patients.
Aggression towards both staff and patients rarely followed instruction. This supports
the case of those authors who have suggested that few acts of inpatient aggression are
preceded by command auditory hallucinations (Lowenstein et al., 1990; McNeil, 1994). It is
also in contrast with those views that inpatient aggression is frequently the result of patients
conspiring with, or encouraging each other to be aggressive. Assessing the contribution of this
purpose was compromised however by the fact that visible evidence for instruction was often
unavailable, as patients may have been unwilling to encourage their fellow patients to be
aggressive whilst in the company of staff. Further, patients may not have told staff about other
patients instructing them to behave aggressively for fear of repercussions from these other
patients. Additionally, auditory hallucinations were unobservable, and most patients did not
consent to participation in assessment immediately following their aggression, when they
might otherwise have disclosed the contribution of auditory hallucinations. Furthermore,
those patients who did participate may not have told staff about the presence of auditory
hallucinations for fear that their medication would be increased or their admission prolonged.
Although aggression rarely followed instruction, when it was, physical aggression was
more likely to occur. These incidents of aggression were typically severe. The reason for this
finding is unclear although it may be due to a perceived omnipotence of voices or powerful
co-patients that leads to a greater determination to harm others. These hypotheses are however
speculative and further research is required to determine the relationship between purpose,
psychopathology, and severity of aggression. Other factors that might influence this finding
were that patients who were aggressive on at least one occasion following instruction had a
more substantial history of aggression and had committed a more severe index offence, when
compared to those who patients who did not act aggressively following instruction.
The Relationship Between Purpose and Patients’ Predisposing Characteristics
The following section discusses results pertaining to the relationship between patients
predisposing characteristics and the purpose of aggression. In general, there were few
individual characteristics that predisposed individuals to be aggressive for particular purposes.
There was no difference in the average age of patients who were aggressive for any of
the purposes except for those patients who were aggressive on at least one occasion to reduce
social distance, or when there was no purpose evident. In both cases, patients were
significantly older. That is, elderly patients were more likely to be aggressive to attract the

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attention of staff, and for motiveless reasons, or reasons that the classification system was not
equipped to identify. Compared to males, females were more likely to be aggressive
following the denial of a request, as a consequence of frustration, for instrumental purposes
and to reduce social distance. This finding indicates the need for aggression and anger
management programs to be mindful of the possibility that males and females may use
aggression for different reasons.
Patients who were aggressive following a demand for activity, the denial of a request,
as a consequence of frustration, for instrumental purposes, following instruction, and to
observe suffering, showed a higher level of recent antisocial behaviour, as measured by the
SBS Antisocial Behaviour scale. Patients who were more socially withdrawn, as measured by
the SBS Social Withdrawal scale were more likely to be aggressive following a demand for
activity. This may indicate that these patients may enjoy social isolation and act aggressively
to maintain social distance, in addition to avoiding activity. Patients who were more thought
disturbed, as measured by the SBS Thought Disturbance scale were more likely to be
aggressive following a demand for activity, possibly indicating that thought disordered
patients may find additional stimulation, in this case demands for activity, stressful or
provocative and act aggressively to avoid the demand. Patients who were more depressed, as
measured by the SBS Depressed Behaviour scale were more likely to be aggressive as a
consequence of frustration, and to reduce social distance. Patients who showed a higher
overall disturbance in social behaviour, as measured by the SBS Total scale were more likely
to be aggressive to reduce social distance. This suggests that profoundly disturbed patients
may have fewer resources to gain attention in appropriate ways, a suggestion consistent with
Drinkwater (1982), who suggested that more disturbed patients are avoided by staff because
interaction with them is difficult and stressful, and that these patients use aggression to gain
the attention of staff. Patients who showed a higher overall disturbance in social behaviour
were also more likely to be aggressive when there was no purpose evident. This may indicate
that more disturbed social behaviour leads to incomprehensible acts of aggression. Patients
with more severe auditory hallucinations, as measured by the PSYRATS Hallucinations
Factor 2 (physical characteristics: frequency, duration, location and loudness), and
Hallucinations Factor 3 (cognitive interpretation: location, beliefs regarding origin, disruption
and control) were more likely to be aggressive when there was no purpose evident.
Patients who showed a higher overall disturbance in social behaviour were also more
likely to be aggressive following instruction, indicating a vulnerability to the instructions of
other patients, an inability to ignore or reject these instructions. This finding may also indicate
that patients with auditory hallucinations who were socially withdrawn, disturbed in thought

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and depressed may have less ability to cope with, or reject command auditory hallucinations.
As would be expected, patients who were aggressive on at least one occasion following
instruction had a higher BPRS Hallucinatory Behaviour score. Together, these findings
suggest that severity of hallucinations and severity of social behaviour disturbance increases
the likelihood of aggression as a consequence to instruction.
8.4 Implications for the Prevention and Management of Inpatient Aggression
The following section discusses implications for the prevention and management of
inpatient aggression. In particular: (a) indications for individual treatment based on the
assessment of purpose, (b) interventions for staff, and (c) implications for risk assessment, are
discussed.
Unfortunately, there is little published research evaluating interventions directed at the
reduction of aggressive behaviour in psychiatric hospitals. Reported interventions, primarily
based on a social learning approach, do indicate the possibility of a reduction of aggressive
incidents (Beck, Menditto, Baldwin, Angelone & Maddox, 1991; Paul & Lentz, 1987). The
results of the current study may contribute to the development of intervention programs, and
assist in the prevention and management of inpatient aggression. In general, interventions
need to be multifaceted and should focus on treatment for individual patients and changes to
the way in which staff interact with patients.
8.4.1 Individual Treatment
Although the arousal of anger and its relationship to aggression was not evaluated at
the time of the aggressive behaviour, anger typically occurs in response to external events that
are perceived as provocative. In this study, only a few categories of purpose assumed an
absence of anger arousal, specifically instrumental aggression and aggression perpetrated to
observe suffering. Aggression motivated by these purposes was rare. Therefore, programs
assisting patients manage or reduce emotional arousal, behave assertively, communicate
adaptively, relax, avoid high risk situations and restructure dysfunctional or distorted beliefs,
particularly where these beliefs consist of appraisals of events as malevolent and deliberate,
may be of benefit. Although there was no relationship between the NAS items and aggression
in this study, the aggressive attributional style (McNiel et al., 2003) offers a conceptual
framework that may help staff understand the cognitive mediators of aggressive behaviour.
Although there have been few evaluations of anger management interventions in forensic
psychiatry, Stermac (1987) reported significantly lower levels of anger in forensic patients
who participated in a cognitive-behavioural anger control program, as did Renwick, Black,
Ramm and Novaco (1997), who reported modest but significant gains in the treatment of
mentally disordered patients with an inability to control their anger.

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 Aside from strategies focussing on anger management, which may be of benefit to
aggressive patients irrespective of purpose (with the exception of patients who are aggressive
for instrumental reasons or to observe suffering), specific interventions based on the purpose
of the aggressive behaviour may be indicated. Table 33 presents a summary of interventions
suggested by the author to correspond to each purpose.

Table 33: Intervention Strategies Indicated by Purpose

Purpose Intervention
Demand for activity Increase assertion; enhance anger management skills and develop more adaptive
communication. Reinforce adaptive expression of dissatisfaction with treatment.
Minimise reinforcement of aggression by allowing avoidance of demand. Ensure
patients understand why demands are required. Identify less provocative means
of demanding activity.
Denial of a request Increase assertion; enhance anger management skills and develop more adaptive
communication. Reinforce adaptive expression of dissatisfaction with treatment.
Minimise reinforcement of aggression by acquiescing to requests. Explain why
requests cannot be granted. Identify less provocative means of denying requests.

Following Provide anger management programs that reduce or help patients manage
provocation emotional arousal, challenge beliefs supporting the use of aggression, and
increase assertion. Develop adaptive communication skills. Challenge
dysfunctional or distorted beliefs, particularly where these beliefs consist of
appraisals of events as malevolent and deliberate.
Following frustration Teach and encourage the use of adaptive methods for reducing arousal.
Encourage alternative means of discharging tension or preventing tension.
To observe suffering Assist patients identify more adaptive and pro social means through which they
can gain pleasure. Punish aggression, so that the reinforcement potential of
observing suffering comes at significant and certain cost.
To enhance status Encourage alternative means of enhancing status, and punish aggression. Where
ward culture supports the use of aggression then these values need to be
challenged.
For instrumental Punish aggressive behaviour; ensure aggression is not reinforced. Challenge
purposes individual and community views about the legitimacy of aggression, and teach
more adaptive means of securing needs. Avoid reinforcement of aggression by
allowing patients to receive tangible rewards.
To reduce social Teach and reinforce adaptive, assertive methods to socialise through social skills
distance training. Differentially reinforce prosocial attempts to elicit attention. Avoid
reinforcement of aggression by providing attention following aggression.
Provide individual time for patients vulnerable to aggression if socially isolated.

Following Develop assertion skills so that patients can resist instructions to harm others.
instruction

Patients who are typically aggressive in response to a demand for activity or following
the denial of a request, may benefit from interventions which foster the ability to act
assertively, and adaptively express dissatisfaction with treatment. To reduce uncertainty and
conflict, expectations and ward rules should be discussed with patients on admission and
implemented consistently. Providing forums, including staff-patient meetings, for patients to
discuss expectations may be beneficial. Staff behaviour should be explained and justified

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wherever possible to avoid appraisal of rule enforcement as arbitrary or malicious
(Whittington, 1994). To avoid unintentional reinforcement of aggression, motivated to avoid a
demand or in response to the denial of a request, where patients are attempting to coerce staff
into granting their requests, it would be important for staff to ensure that patients do not avoid
demands nor have their requests granted as a consequence of aggression.
Patients whose aggression typically occurs after the development of frustration may be
taught and encouraged to use adaptive means of reducing physiological arousal. Encouraging
activities that allow patients to discharge tension, or prevent the development of tension, such
as relaxation training and exercise, may also be of assistance.
Patients who are aggressive to observe suffering may be assisted to identify more
adaptive, pro social means through which they can gain pleasure. Aversive consequences
should also occur, so that the reinforcement potential of observing suffering comes at
significant and certain cost. However, whilst psychopathy was not directly measured in this
study, individuals who are aggressive solely to observe suffering may well be psychopathic.
Treatment for these patients will be difficult. Cornell et al. (1996) and Heilbrun et al. (1998)
note that instrumental aggression is often associated with psychopathy; “the capacity to inflict
serious injury on a person for goal directed purposes is made possible by the relative lack of
well-internalized social standards and associated feelings of concern and respect for others
that otherwise would inhibit the offender” (Cornell et al., 1996, p. 788). Although these
appraisals of others could well be targets for intervention, some of the characteristics often
associated with psychopathy, including dishonesty, impulsivity, manipulativeness and
irresponsibility are characteristics that impair the therapeutic relationship and compromise
treatment. Nevertheless, patients who use aggression instrumentally should be shown the
negative consequences to aggression. Effort must be made to ensure aggression is not
reinforced. Where communities, wards or cultures support the use of aggression to obtain
tangible items then these community values need to be challenged. Changing individual and
community views about the legitimacy of aggression, and teaching more adaptive means of
securing needs should also be considered. To prevent other patients learning that aggression is
an acceptable means through which goals can be attained, observable consequences,
specifically punishment, is required.
In addition to the fact that status is afforded to aggressive individuals within the prison
system and in some psychiatric hospitals, patients who use aggression to enhance status may
do so because they have few alternative resources from which to maintain status. Again,
although psychopathy was not measured in this study, it may be that patients who rely on
aggression to secure status may have higher levels of psychopathy than other types of

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aggressive patients. The aforementioned considerations for treating psychopathic inpatients
should be observed. Intervention for patients who are aggressive to enhance status is required
at the individual and community levels. Patients relying on aggression must be encouraged to
use alternative means of enhancing status, and must be shown aversive consequences to
aggression. Ward communities need to ensure that status is not reinforced.
Where aggression is used to attract attention or narrow social distance, patients could
be taught and encouraged to use more adaptive, assertive methods to socialise through social
skills training. Assertive attempts to elicit attention should be reinforced. Further, maladaptive
methods, including aggression should not be reinforced. The provision of individual time for
patients vulnerable to aggression if socially distant could be considered.
Patients who are aggressive following instruction from other patients should be
differentiated from patients who are aggressive in response to instructions from auditory
hallucinations, as there may be different contributors to aggression within these two groups.
The reasons for compliance and consequences for non-compliance should be examined.
Assertion training in both cases may be of benefit. Interventions, both psychological and
pharmacological, could be considered for individuals with intrusive and problematic
command auditory hallucinations.
8.4.2 Interventions for Staff
Many incidents of aggression occurred subsequent to a demand for activity or the
denial of a request, interactions that were considered provocative or that challenged status.
Given that many of these demands and denials are necessary components of inpatient
treatment it is crucial that less provocative methods of communicating with patients are
found. Several authors have identified aspects of staff communication style that may affect
the likelihood of aggression. Morrison (1994) noted that a coercive interaction style was more
likely to lead to aggression, and James et al. (1990) noted that staff with a custodial rather
than therapeutic relationship, may contribute to aggression. Lancee et al. (1995) suggested
that a style of limit setting characterised by affective involvement with the provision of
options is likely to provoke the least anger. Similarly, Kahneman (1981) showed that losses
are in general more important and have a greater impact on people than possible gains. On
this basis, Tversky and Kahneman (1981) proposed that limits should be framed in terms of
choices, and that a choice in terms of a loss should always be avoided, a choice that
emphasizes a gain is preferable. For example, when a patient is required to take medication,
rather than state that privileges will be lost, emphasize the possibility of securing rewards.
Training staff in less problematic styles of communication as well as encouraging staff
to consider the possibility that psychiatric wards are demanding environments that contribute

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to frustration, irritability and aggression (Shepherd & Lavender, 1999; Whittington, 1994;
Whittington & Wykes, 1996) should be considered. Understanding patient perspectives
(Ilkiw-Lavalle & Grenyer, 2003), training staff in empathic communication skills (Smoot &
Gonzales, 1995), improving the quality of the therapeutic relationship (Beauford et al., 1997),
and asking patients to contribute to education sessions for new staff, may enhance
collaboration and understanding, and foster empathic communication between staff and
patients.
In the current study, males were more likely to be aggressive towards males and
females were more likely to be aggressive towards females. These findings may have
particular relevance to the prevention of aggressive behaviour. If patients are less likely to
behave aggressively towards staff of the opposite gender, then male staff could be called upon
to approach irritable or frustrated female patients or allocated responsibility for their care
during a day when members of staff consider the risk of aggressive behaviour elevated.
Similarly, female staff may be allocated irritable male patients, or called upon to negotiate
with potentially aggressive male patients. It is likely that other staff characteristics influence
the likelihood of inpatient aggression and that examination of these characteristics will
enhance our understanding of the characteristics that protect against aggression.
Aggression decreased in frequency over the course of the study, consistent with
previous research examining the effects of systematic monitoring. Given the absence of
known adverse effects following the introduction of such monitoring, systematic recording
may be a useful method for understanding local patterns of aggression, and a simple
intervention that requires little staff training and that may result in significant reductions in
aggressive behaviour.
8.4.3 Risk Assessment
Identification of antecedent interactions and consideration of purpose may enhance
risk assessment by locating the events that commonly precipitate aggression, allowing staff to
avoid these events or prepare for them. Typically, dynamic (response to treatment) and static
(gender, history of violence, relationship history, socio-economic status, history of use of
weapons and criminal history) factors form the basis of actuarial risk assessment instruments.
There have been few examinations of the relationship between antecedents and form of
aggression, the exception being that of McDougal (2000), who found no significant
correlation. Given the results of the current study, the purposes of aggression and antecedent
interactions identified may be usefully incorporated into risk assessment schemes.
In one attempt to develop risk assessment practices for inpatient aggression, Ogloff
and Daffern (2003) included items derived from the antecedent interactions and purposes

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examined in the current study (‘sensitivity to perceived provocation’, ‘unwillingness to follow
direction’, and ‘easily angered when requests are denied’) and compared these with the Broset
Violence Checklist (Almvik, Woods & Rasmussen, 2000), and items taken from the clinical
and risk scales of the HCR-20 (Webster, Douglas, Eaves & Hart, 1997). Results of this study
showed that the three items derived from the current study performed as well as, or better than
many of the other items from the HCR-20 and Broset Violence Checklist, with AUC statistics
of .76 for ‘unwillingness to follow direction’, .75 for ‘sensitivity to perceived provocation’,
and .74 for ‘easily angered when requests are denied’. Only irritability (.77) and impulsivity
(.77) had better AUC’s. As a result of this research, these three items were integrated into the
Dynamic Appraisal of Inpatient Aggression, a risk assessment system that is currently being
piloted within the TEH to assist in the assessment of imminent aggression. Further research in
other settings is required to validate these findings. However, these results suggest that
consideration of purpose or precipitants of aggression may assist risk assessment.
Idiographic risk assessments for patients at risk of frequent or severe aggression may
also be enhanced by analysis of a patient’s purpose for aggression, in a similar manner to that
developed by Clark, Fisher and McDougall (1993) for assessing the risk of violence in long-
term prisoners. Clark et al. (1993) drew on Zamble and Porporino’s (1990) research showing
that prisoners responded similarly to a range of prison difficulties as they had to problems
outside of prison. They then proposed that an accumulation of knowledge regarding the
behaviours, characteristics and situational aspects that contributed to the individual’s index
offence would manifest in similar, or functionally equivalent, patterns of behaviour in the
institutional setting. Clark et al. (1993) suggested that if:

one is aware of the types of behaviour shown at the time of the offence, one can look
for similar behaviours in prison. If the frequencies of these monitored behaviours
continue at a similar rate or increase over time, one might reasonably assume that no
change has taken place in the individual’s behavioural repertoire and that he remains
just as much at risk or re-offending as he was at the time of conviction…Alternatively,
if the criminological behaviour patterns decrease over a period of incarceration, one
might assume that changes have taken place, especially if alternative behaviour were
to be exhibited in similar situations (p. 440).

8.5 Limitations of the Study

Several issues limit the usefulness of the current research. The single most critical
limitation of the study’s attempt to identify the purposes of inpatient aggression was that very

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few patients were willing to participate in interview following their aggressive behaviour. The
identification of purpose relied heavily on staff descriptions of aggressive behaviour. Other
studies that have inquired into patient’s perspectives have reported a greater level of
cooperation (Fagan-Pryor et al., 2003). However, these studies generally requested verbal
consent and did not ask specific questions about the patient’s involvement in recent
aggressive incidents. Although the reasons for non-participation in the current study were not
systematically recorded, patients often refused to participate when informed that written
consent was required. Patients may have been unwilling to provide written consent because
they feared legal consequences to their aggression. Further, patients were often angry or
resentful after their aggressive behaviour and refused participation because they were angry
with staff in general. Several patients were unable to provide consent due to the severity of
their psychiatric illness, intellectual disability, or difficulties speaking English. Although most
patients were unwilling to provide written consent and therefore contribute formally to the
research project, patient’s perceptions were often included in the reviews, as members of staff
were able to report what patients said before, during and after their aggressive behaviour.
Obtaining patients’ perceptions of aggressive behaviour is crucial to improving our
understanding of inpatient aggression. Continued effort must be made to better understand
patient perceptions of treatment and aggression.
In addition to endeavours to include patients’ perspectives in future studies of
inpatient aggression, it may be also be advantageous to ask more than one staff member for a
description of aggressive behaviours. In the current study, witnesses or victims of aggressive
behaviour may have been vulnerable to bias in their description of the aggressive behaviour,
its precipitants and consequences. The reliability of patient and staff views about incidents
was not assessed. In future studies it may be more worthwhile focussing on a smaller number
of incidents, interviewing several staff about the incident and accessing patient perspectives.
Further, it may be worthwhile interviewing other patients who observed the patient behave
aggressively. Interviewing these patients may identify beliefs that support aggression in the
psychiatric ward.
A further limitation concerns the generalisability of these results to other forensic and
mainstream facilities. Every psychiatric hospital has different environmental characteristics
and operational guidelines, practices and issues that contribute to, or protect against
aggression. One remarkable characteristic of the environment examined in this research that
should be reviewed when considering the application of these findings to other hospitals,
particularly mainstream acute psychiatric wards, was the average length of admission, which,
at 50 days, was of considerably longer duration than the average length of admission reported

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in other published studies of inpatient aggression. For example, Beauford et al. (1997)
reported a mean length of admission of 16 days, and Hyde and Harrower-Wilson (1995)
reported an average length of admission of 12.3 days. In the current study, patients who were
aggressive tended to have a longer length of admission, a finding that is consistent with
previous research on inpatient aggression conducted in mainstream acute wards (Barlow et
al., 2001; Beauford et al., 1997). In one of few attempts to understand the nature of the
relationship between aggression and length of hospitalisation, Greenfield, McNiel and Binder
(1989) noted the relationship to be mediated by diagnosis, with aggressive schizophrenic
patients more likely to have an extended admission than other aggressive patients. They
suggested that the “difficulty in clinical management of violent schizophrenic patients,
delayed or incomplete responsiveness to medication by these patients, and resistance of
community treatment providers to accepting such patients” (p. 814) might explain the
relationship between aggression and length of admission.
Caution should also be exerted before generalising these findings to other psychiatric
hospitals and their patients. The extent and severity of patients’ previous aggressive
behaviour, their history of substance use, and the disproportionate number of males admitted
to the hospital during the study period are characteristics likely to differ from mainstream
psychiatric hospitals. Another important issue that may limit gereralisability is that all wards
during the course of the study were single gender, with the exception of Daintree where there
was no aggression recorded. Most mainstream psychiatric wards are mixed gender. The
impact of gender of co-patients has received little empirical scrutiny and is an area of
opportunity for further research.
Another notable finding in this study and one that may differ from mainstream
psychiatric hospitals was the high rate of aggression towards other patients. The cultural
support for aggression evident in prison populations and some forensic psychiatric wards may
have affected the overall frequency of aggression. It may also have affected the severity of
aggressive incidents, as patients in this study were more severely aggressive towards other
patients when compared with staff. Further, it may also be the case that some of the purposes
identified in this study are less evident in mainstream psychiatric populations. Instrumental
aggression, aggression to enhance status and aggression motivated to observe suffering may
be less common in mainstream rather than forensic psychiatric facilities. A better
understanding of the nature of aggression and its purposes within different contexts is
required.
Regarding instrumentation, the adapted Overt Aggression Scale (OAS) used in this
study proved to be a useful method for recording incidents of aggressive behaviour. One

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minor problem was that this adapted scale might not have been sensitive to the severity of
some incidents. The method used to record the severity of aggressive behaviour was
developed for this study and differs from that of Silver and Yudofsky (1991), primarily
because the adapted scale excluded self-harm. In the absence of severity weightings available
for this adapted OAS, the current means of measuring severity was adopted. A particularly
serious incident highlights the problems with the assessment of severity adopted for the study.
On one occasion a patient broke into the nursing station, obtained a large knife and threatened
staff. Although nobody was harmed in this incident, it was potentially life threatening and was
generally considered to be the most traumatic incident since the opening of the hospital.
Nevertheless, according to the adapted OAS, this incident was not considered the most
serious of incidents and was recorded as “Makes threatening gesture, swings at people, grabs
at clothes”. Victims generally determine severity subjectively. Some incidents of property
damage and verbal aggression may have been as distressing for staff as some physical threats.
It may be that the manner in which the adapted OAS was used in this study to measure
severity was flawed.
Further, the method by which aggression was recorded may not have allowed for the
greatest number of incidents to be recorded. In general, staff recorded incidents after they
occurred. One problem with this method was that the study was an additional administrative
task for ward staff and not part of their routine. A more accurate assessment of aggression
may have been obtained if staff at the end of their shift completed a record of aggression for
their allocated patients, rather than complete a form immediately after an incident when they
also have to complete mandatory paperwork, often when in a state of emotional arousal.
8.6 Implications for Future Research
Results from this study should be regarded as preliminary, particularly because of the
novel method for assessing purpose. Although the current system may be useful for
psychologists to assist in the case formulation of severely or repeatedly aggressive patients, it
is a system requiring an understanding of functional analysis. It may also include too many
categories of purpose. The process used for determining purposes in this study is also time
consuming. Further research would profit from the development of a more parsimonious
method of classifying purpose that is able to be used in the real task of recording and
classifying inpatient aggression as it occurs on the ward. Specifically, in the forensic setting,
the range of purposes could be reduced to five and would include demand avoidance, denial
of a request, following provocation, to enhance status, and following frustration. Replication
of this study in mainstream psychiatric hospitals and with patients living in the community, to
determine the presence and frequency of different purposes is warranted. Through comparison

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of the purposes for aggression in different settings, environmental contributors to aggression
may be identified.
Future research must be conducted that examines the prevention and management of
aggression and the treatment of aggressive individuals. In particular, further research may
consider the effectiveness of interventions that are informed by an analysis of the purposes of
inpatient aggression. These interventions may occur with individual patients, and at the ward
and organisation levels. One intervention that is indicated by the current results is the need to
examine staff communication style, particularly around the denial of requests and demands
for activity. Provocation by staff is a critical issue and further research must be undertaken to
assess the nature of the provocations. Rules, routine and staff behaviours that are considered
provocative should be investigated so that problematic communication styles and practices
can be amended. Further examination of patients’ appraisals of staff behaviours, particularly
those behaviours that are common and considered necessary, such as the provision of
medication, is warranted. The contribution to aggression of staff characteristics including
gender, size, attitudes and skill may assist the development of effective interventions and help
identify characteristics of staff that protect against aggression.
Although there were few relationships between the predisposing characteristics
examined and purpose, this is an area worthy of future study. The list of demographic and
clinical characteristics examined in this study was not exhaustive. There remains opportunity
for analysis of other individual contributors and their relationship to the perception of
provocation, and aggression. Investigating methods for assessing sensitivity to particular
provocations by examining relationships between predisposing characteristics with purpose,
and determining the effects of management strategies derived from the identification of these
particular sensitivities is required.

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 CHAPTER 5: CONCLUSION
Aggression has a profound impact on psychiatric inpatient treatment, particularly for
staff and patients, whose physical and psychological wellbeing is frequently compromised.
Unfortunately, conflict in psychiatric wards, where patients are often admitted involuntarily,
is logical and should be expected: “even high-quality care of psychiatric patients sometimes
inevitably involves doing things to the patient that they might not welcome and occasionally
actually causing pain, e.g., giving an injection” (Whittington & Wykes, 1996, p. 12).
Aggression may also be inevitable in the forensic setting, a consequence of providing
psychiatric treatment for patients who have limited resources to manage the anger that is
aroused by the restrictions and expectations of inpatient treatment. Many patients admitted to
forensic psychiatric hospitals have entrenched negative attitudes and established repertoires of
aggressive behaviour. Most have recently been exposed to the prison environment where
animosity towards staff is encouraged, where conflict with others is resolved through
aggression, and where status is afforded to those who are aggressive. Patients are typically
admitted for treatment during the acute phase of a psychotic illness and they often have a
proximal history of antisocial behaviour and substance use. Furthermore, in the forensic
psychiatric ward aggression is tolerated to a greater extent than would be accepted in the
general community.
The current program of research reinforced the notion that some individual
characteristics contribute to an increased likelihood of aggression. These include recent
substance use, an entrenched history of aggression and a recent history of antisocial
behaviour, and symptoms of psychosis including thought disturbance, hallucinations, and
conceptual disorganisation. Somewhat surprisingly, and perhaps a consequence of the
peculiar characteristics of patients admitted to the TEH, a number of other characteristics
shown in previous research to have a relationship with aggression, including age, diagnosis,
gender, anger arousal and control, impulsivity and assertiveness, were not related to whether
or not a patient was aggressive.
As inpatient aggression results from an interaction between the environment and the
individual, the role of some environmental factors was also examined. Comparison of the
Rosanna Forensic Psychiatric Centre and the TEH allowed for exploration of the relationship
between inpatient aggression and physical structure of the ward, recording practices, and
access to personal space and privacy. The relationship between personal space and aggression
between patients was particularly noteworthy. The retrospective review of Incident Forms
identified one aspect of the staff-patient relationship that may contribute to aggression,
specifically the frequency with which staff restrain and seclude patients. The findings from

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these two studies have implications for the management of aggressive inpatients, the
prevention of injury to staff, and the design of psychiatric wards. Furthermore, these findings
reinforced the need to consider aspects of the environment in future research on inpatient
aggression.
A number of proximal contextual factors were also identified, specifically provocative
staff-patient interactions associated with treatment or maintenance of ward regime.
Aggression towards co-patients was most commonly preceded by a perception of provocation
and threatened status. Frustration, which may have affected the ability of patients to manage
the demands of inpatient treatment, was evident prior to many episodes of aggressive
behaviour. There was little evidence supporting the proposition that aggression was frequently
used instrumentally to obtain tangible items, sanctuary in the form of seclusion, physical
attention during restraint, or sedation through provision of prn medication. Neither was
aggression used frequently to reduce social isolation or to observe others suffering. How
symptoms of psychiatric illness, personality and behavioural characteristics contribute to the
perception of provocation or limit a patient’s ability to manage the demands of psychiatric
inpatient treatment without recourse to aggression remains unclear. Although some
relationships between psychotic symptoms, behavioural characteristics and purpose were
identified, this is an area requiring future research. It is only through examination of the inter-
relationships among environmental context, a patient’s behavioural repertoire and presenting
psychopathology, that the reasons for aggression within the context of these situational
precipitants can be understood.
This research has shown that inpatient aggression almost always serves some function.
It is commonly precipitated by identifiable events, is not completely unpredictable, and only
very rarely is it the result of a spontaneous manifestation of underlying psychopathology
isolated from environmental precipitants. Further, aggression is likely to serve different
functions for different individuals, even while acutely psychotic. Whilst there may be some
benefit in providing generic aggression reduction programs such as anger management, the
current research indicates that individualised case conceptualisation or functional analysis
may be required prior to treatment, particularly for repeatedly aggressive inpatients, or those
at risk of severe forms of aggressive behaviour. The use of functional analysis and the focus
on purpose remains a viable method for the study of inpatient aggression. However, further
research must determine whether there are alternative methods for assessing the determinants
of aggressive behaviour, or more effective ways of integrating assessment data into a
functional analysis. The time and expertise required to conduct a functional analysis in the
acute setting, which influences its cost effectiveness and utility, are also unclear. Further

153
research is required to determine the efficacy of interventions that are informed by functional
analysis, and to ascertain whether this approach assists risk assessment and management
beyond the contribution already made by structuralist approaches.

154
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 APPENDIX 1

Adapted Overt Aggression Scale (OAS)

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 Record of aggressive behaviours

1. Name of patient behaving aggressively: _______________________________

2. Date of incident: _____ / ______/____ 3. Time of day incident occurred: _____
4. Ward/Location if not on ward: ________________________________
5. Patient or staff victim: _______________________________________

Please circle the type of aggression observed: If several types of aggressive behaviour occur,
circle each behaviour.

Physical Aggression Against Objects

1. Slams door, scatters clothing, makes a mess.
2. Throws objects down, kicks furniture without breaking it, marks the wall.
3. Breaks objects, smashes windows.
4. Sets fires, throws objects dangerously.
Verbal Aggression
5. Makes loud noises, shouts angrily.
6. Yells mild personal insults, e.g., “You’re stupid!”
7. Curses viciously, uses foul language in anger, makes moderate threats to others or
self.
8. Makes clear threats of violence towards others (“I’m going to kill you”) or requests
help to control self.
Physical Aggression Against Other People
9. Makes threatening gesture, swings at people, grabs at clothes.
10. Strikes, kicks, pushes, pulls hair (without injury to the victim).
11. Attacks others, causing mild-moderate physical injury (bruises, sprain, welts).
12. Attacks others, causing severe physical injury (broken bones, deep lacerations,
internal injury).

Other (if the type of aggression does not fit into the above categories please describe
aggressive act):
___________________________________________________________________________
___________________________________________________________________________
Please direct any questions or concerns about this research project to Michael Daffern on
x207.

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 APPENDIX 2

Scoring sheet for recording the purpose of aggression

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 Scoring sheet for recording the purpose of aggression

1. Demand avoidance

Rate the degree to which the behaviour was motivated by a desire to avoid a demand.

Aggression often occurs following a demand where the patient is motivated to avoid
the demand. Co-patients and staff make demands of patients. Demands may be either to cease
an activity or to complete a task. For example, patients may be requested to adhere to hospital
routine or treatment, to cease an inappropriate behaviour, or to attend to an activity such as
taking a shower.
The principle components in the identification of this purpose are: (a) a demand is
made by other patients or staff, (b) the patient is dissatisfied with the demand, and (c) the
patient wishes to avoid the demand.
Aggression may occur after a demand because the patient does not wish to attend to
the demand and acts aggressively to avoid it. Alternatively, aggression may occur because the
patient not only finds the demand aversive and acts aggressively to avoid it, but may also find
the demand insulting, unreasonable, irritating and provocative. If the patient finds the request
to attend to a demand insulting, unreasonable, irritating or provocative also score ‘3.
Following Provocation.’ If the patient is not motivated to avoid the demand but simply finds
the demand insulting score 0 for ‘1. Demand avoidance’ and then score ‘3. Following
Provocation.’
To score this purpose identify whether a demand was evident. The demand may be
either recalled by staff or patient or evident from review of the patient’s daily
activities/program? If a demand is not recalled by either staff or patient but it is thought that
the patient is behaving aggressively to avoid a scheduled activity then the scheduled activity
assumed to be a demand must be an activity the patient (a) is usually expected to attend and
(b) is considered aversive by the patient.

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Scoring key:

1. Definitely not the result of demand avoidance. There is no demand or expectation

evident, which is considered aversive by the patient.

2. Possibly the result of demand avoidance. No demand is recalled by patient or staff,

although there is an activity or program evident, which the patient either has a history of
finding aversive.

3. Definitely the result of demand avoidance. A demand was made prior to the
aggression. Clear desire articulated by the patient to avoid the demand.

2. Denial of request

Rate the degree to which the behaviour followed the refusal of a request.

Aggression may occur following the denial of a request made by the patient. For
example a patient who makes a request to make a telephone call, attend a program, access
leave from the unit, obtain medication, receive information about their treatment, may be
refused. He may then become aggressive. The principle components in the identification of
this purpose are: (a) the patient makes a request, (b) it is refused, (c) the patient is dissatisfied
with the request being refused, and/or (d) is motivated to use aggression to force the request
refuser to change their mind and grant their request.
Aggression may occur after a request is refused because the patient believes
aggression will force the request refuser to grant the request. Alternatively, aggression may
also occur because the patient finds the refusal of the request insulting, unreasonable,
irritating or provocative. If, in addition to a motivation to force the request refuser into grating
the request the patient also finds the request refusal insulting, unreasonable, irritating or
provocative also score ‘3. Following Provocation’ If the patient is not motivated to avoid the
demand but simply finds the demand provocative score 0 for ‘1. Demand avoidance’ and then
score ‘3. Following Provocation’
To score this purpose: Did the patient make a request that was either denied or delayed
(pending discussion, pending appropriate behaviour or completion of some task, etc)?

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Scoring key:

1. Definitely not the result of request refusal. No request made.

2. Possibly the result of the denial of a request. No request made immediately prior to
the aggressive incident but the patient had made a recent request of staff, which was refused
or not responded to immediately.

3 Definitely the result of a request being refused. The patient made a request and it
was either denied or delayed. The patient was dissatisfied or angry following the request
being refused. The content of the patient’s speech indicates the refusal of a request resulted in
aggression.

3. Following Provocation

Rate the degree to which the behaviour was motivated by provocation from others.

Aggression often occurs following provocation by other patients or staff. The principle
components in the identification of this purpose are: (a) an external event, (b) an
interpretation of the event as provocation (disrespectful treatment; unfairness/injustice;
frustration/interruption; annoying traits; and irritations), and (c) a desire to punish the agent of
provocation, or a belief in the need for self-defence.
To score this purpose: Was there any provocation evident? Did the person cite being
treated unfairly? Did they report feeling disrespected? Did they report somebody directly
intimidated them, got in their way, or annoyed them?
Provocation is likely to be subjectively determined by the patient as their appraisal of,
or sensitivity to particular provocations may differ from others.
This category will often be scored in addition to other motivations.

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Scoring key:

1. Definitely not the result of provocation.

2. Possibly the result of provocation. No provocation cited by the patient although

staff are of the opinion that the patient’s aggression was in response to provocation by others.

3. Definitely the result of provocation. Aggression resulted from a belief that the other
person had provoked the person. Content of speech indicates anger with provoking agent.

4. A consequence of frustration

Rate the degree to which the aggressive behaviour followed a period of frustration.

Frustration with life circumstances may precipitate aggression. Aggression may occur
against a random person to discharge tension or may result in property damage because there
is either no provoking agent or the patient is motivated to discharge tension without hurting
another person. Frustration may prime a patient for aggression and lead them to behave
aggressively towards a person who acts in a provocative manner.
To score this purpose: Did the person complain of frustration prior to the aggressive
incident or did they appear tense or agitated in the period leading to the incident? As many
patients may appear agitated immediately prior to an act of aggression only score ‘4. A
consequence of frustration’ if the patient was more frustrated than usual in the week before
aggression.

Scoring key:

1. Definitely not the result of a desire to release frustration.

2 Possibly the result of frustration. Some evidence of frustration in the week before
the aggression.

3. Definitely the result of frustration. The patient was frustrated or tense in the week
prior to aggression and appeared to act aggressively to reduce the tension, possibly reporting
that they felt more relaxed after the aggressive incident.

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5. Instrumental

Rate the degree to which the behaviour was used in an attempt to obtain instrumental
objectives.

Aggression may be used to obtain tangible items or other positive reinforcers. The
principle components in the identification of this demand are: (a) something tangible exists,
(b) the patient believes the item has positive reinforcement potential, and (c) there is a request
for the item.
To score this purpose: Was a demand for tangibles made?
Aggression may be used instrumentally to achieve many different objectives, such as
getting somebody to comply with a request or to achieve status. Only rate ‘5. Instrumental’ if
the desired objective is tangible (e.g., cigarettes, clothing or money). If the patient acts
aggressively in an attempt to coerce a fellow patient or staff into granting a request then score
‘2. Denial of request (thwarting of goal-directed behaviour)’. If the patient acts aggressively
to enhance status then score ‘7. To enhance status or social approval’. If a patient acts
aggressively in an instrumental manner to reduce social distance score 0 on ‘5. Instrumental’
and then score ‘6. To reduce social distance’.

Scoring key:

1. Definitely no demand for, or observed attainment of tangible reward.

2. Possibly not the result an attempt to obtain tangible reinforcers. No demand for
tangibles, or access to privileges made, although possibly as an unintended by-product of
aggression some rewards obtained.

3. Definitely the result of instrumental objectives. A demand for tangible items made.

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6. To reduce social distance

Rate the degree to which the behaviour occurred to reduce social distance.

Some patients who report social isolation behave aggressively to reduce social
distance. The principle components in the identification of this purpose are: (a) the patient is
socially isolated, (b) the patient wants to be socially connected, and (c) the patient believes
that aggression will reduce social isolation. If the patient acted aggressively to force others to
interact with them but also reported provocation by their victim also score ‘3. Following
Provocation’.
To score this purpose: Was the person socially isolated prior to the aggression and
dissatisfied with this isolation? Is there any evidence that aggression was used by the patient
to secure interactions with staff or other patients?

Scoring key:

1 Definitely not the result of an attempt to reduce social distance. The patient was not
dissatisfied with social isolation or was not socially isolated.

2 Possibly the result of social isolation.

3. Definitely the result of social isolation. The patient was clearly isolated. The patient
was frustrated or angry as a consequence of their isolation and there were suggestions that
they deliberately acted aggressively so they would have either physical contact with staff
during the restraint process or increased interaction with staff during or after seclusion.

7. To enhance status or social approval

Rate the degree to which the behaviour was designed to enhance social approval or
status.

Humiliating affronts and threats to reputation and manly status are common
precipitants of violence. A high sensitivity to devaluation combined with deficient verbal
skills for resolving disputes and restoring self-esteem are common in men who use violence.
The principle components in the identification of this purpose are: (a) a perception of

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inadequate social status or threat to status, and (b) a belief that aggression increases social
status.
Differentiate from ‘5. Instrumental’ by the type of reward expected. If tangible, then
score ‘5. Instrumental’. If status score ‘7. To enhance status or social approval’. If both
tangibles and status are sought then score both.
To score this purpose: Was there any evidence that the patient was dissatisfied with
their status amongst staff or co-patients prior to the aggression? Was there evidence that the
person behaved aggressively to enhance their image amongst other patients or that their status
was enhanced after the incident? Was there a challenge to the patient’s status preceding the
aggressive incident?

Scoring key:

1. Definitely not the result of attempts to enhance status or social approval.

2. Possibly motivated by a desire to enhance status or prevent a detioration in status.

3 Definitely the result of a desire to enhance status or social approval. The patient was
clearly behaving aggressively to obtain status or protect their image.

8. Compliance with instruction

Rate the degree to which the behaviour was motivated by instruction.

Aggression may occur following instruction by another person (e.g., a visitor or

patient). It is also possible that compliance with auditory hallucinations may result in
aggression. The principle components in the identification of this purpose are an instruction
by somebody to act aggressively, or a command auditory hallucination instructing the person
to act aggressively.
To score this purpose: Was the person instructed to behave aggressively?

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Scoring key:

1 Definitely not the result of instruction. No instruction evident.

2. Probably the result of instruction to act aggressively (e.g., the patient may have
been encouraged to behave aggressively during the incident).

3 Definitely the result of instruction from another person or auditory hallucination.

9. To observe suffering

Rate the degree to which the behaviour was motivated by a desire to observe suffering
in somebody.

Aggression may be instigated by a desire to witness suffering in others. This may

occur following provocation or may occur in the absence of provocation. The principle
components in the identification of this purpose are: (a) a belief that suffering will be
positively reinforced, and (b) a disregard for the suffering felt by others.
Score ‘9. To observe suffering’ rather than ‘3. Following Provocation’, during which
there may also be motivation to see the provoking person suffer, when there is no immediate,
direct provocation. If there is a clear provocation articulated by the aggressive patient then
score ‘3. Following Provocation’. If both provocation and a clear desire to see the victim in
pain or suffering exist then score both, although only score 2 for ‘9. To observe suffering’.
Differentiate ‘9. To observe suffering’ from ‘5. Instrumental’ by the objective
expected. If the expected outcome of the aggression is to observe suffering in the victim then
score ‘9. To observe suffering’. If the expected outcome is tangible then score ‘5.
Instrumental’.
To score this purpose: Was aggression exclusively committed to observe suffering in
the victim.

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Scoring key:

1. Definitely not the result of motivation to observe suffering (does not describe
arousal or reinforcement in witnessing suffering). Ceased aggression when the victim was
either in pain, pleading for the aggressor to stop, or made attempts to escape. Describes clear
provocation even if provocation appears minor. May describe remorse after the incident.

2. Possibly the result of motivation to observe suffering. The aggressor was

unconcerned by the victim’s suffering or continued acting aggressively when the victim was
obviously in pain of distressed.

3 Definitely the result of motivation to observe suffering. No evidence of any

provocation and no attempt to cease aggression when the victim was either in pain, pleading
for the aggressor to stop or making attempts to escape. Possibly increased intensity of
aggression when evidence of pain in the victim.

10. Motiveless aggression

If no motive can be identified for an act of aggression (the patient scores one on all
nine categories of purpose) score:

Scoring Key:

1. At least one motive identified

2. No motive identified

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 Rating form

1. Demand avoidance: 1 2 3

2. Request by patient: 1 2 3

3. Following Provocation: 1 2 3

4. A consequence of frustration: 1 2 3

5. Instrumental: 1 2 3

6. To reduce social distance: 1 2 3

7. To enhance status or social approval: 1 2 3

8. Compliance with instruction: 1 2 3

9. To observe suffering: 1 2 3

10. No motivation evident 1 2

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 APPENDIX 3

Information sheet for the pilot study

182
 The purpose of psychiatric inpatient aggression:
A pilot study

Psychiatric inpatient aggression serves a variety of purposes. For example, aggression

may be used by patients to coerce staff into fulfilling requests, may allow patients to avoid
demands, or may reduce frustration. Whilst a single motive may initially precede aggressive
behaviour, motives may change during the course of an incident. Furthermore, aggression
may serve a variety of purposes. For example, an inpatient who behaves aggressively
following a request to attend an activity that he does not wish to attend may be secluded and
therefore succeed in avoiding the activity. An unintended function may be that the person is
revered amongst his co-patients who similarly dislike attending ward-based activities. He may
experience an increase in status when seclusion is terminated and staff may not ask the person
to attend the activity again because they fear another act of aggression.
A project investigating the purpose of psychiatric inpatient aggression is to begin at
the Thomas Embling Hospital in January 2002. As investigations into the purpose of
psychiatric inpatient aggression are scarce, structured interview forms and a classification
system to record the purpose of aggression have been developed for this study. To assess the
efficiency and reliability of these instruments a pilot study has been designed. Ten acts of
aggression, including acts of verbal and physical aggression in addition to acts of aggression
against property, have been documented. Transcripts of these ten interviews are to be
presented to eight clinical and forensic psychologists for assessment of interrater reliability.
Participants in this pilot study are to read over each transcript and then, using the
attached scoring keys rate the purposes of each act of aggression. Each purpose is scored on a
scale of 1 to 3 indicating the degree to which the purpose has contributed to the aggressive
behaviour. A scoring sheet is included. Thank you for your help.

Michael Daffern
Psychologist
12th November 2001

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 APPENDIX 4

Incidents for the pilot study

184
Incident 1: Andrew, 17th June 2001

Andrew is a 48 year-old man with a long history of criminal behaviour and psychiatric
care. He was admitted to hospital on an indeterminate sentence on the 13th June 2001. During
the first week of his admission he was irritable and demanding. He frequently complained
about his treatment, the inconsistencies and inadequacies of psychiatry, and the “disgusting”
behaviour of his fellow patients.
On the morning of 17th June 2001 Andrew attended the ward’s community meeting.
At this community meeting Andrew was irritable and demanding. He angrily complained
about several aspects of ward hygiene and cleanliness, such as co-patients spitting in the
smoker’s room and urinating on the bathroom floor. He also complained that several
recommendations he had made to enhance the running of the ward during his last admission
had not been attended to. He demanded staff escort him to the trust office to obtain some
money immediately after the meeting. Staff told him to wait until after the meeting.
Whilst making his complaints to the community meeting Andrew became irritated by
Dave, a co-patient, who repeatedly asked Roy, an older patient on the ward, for cigarettes.
Andrew told Dave to leave Roy alone and swore at him. The two men approached each other
and continued to threaten. Dave lunged at Andrew, grabbing him by the neck with both hands.
Staff attending the meeting immediately separated the two men and Dave was escorted to
seclusion. After a short period in seclusion Dave was allowed to return to the ward. As he left
seclusion and walked down the corridor to his bedroom Andrew walked towards him and
punched him in the abdomen. Andrew was restrained by members of staff who then escorted
him to seclusion.
When interviewed two days after the incident to identify the reasons for the assault
Andrew complained that he was frustrated by his environment and angry with being
interrupted during the community meeting. He also said that he had become irritated that
Dave was intimidating Roy. He said that having been assaulted he was determined that he was
not going to be stood over by other patients. He also acknowledged a number of other issues
had been bothering him since his admission such as the uncertainty of his discharge date.
Furthermore, he feared that other patients were ganging up on him and that he was in danger
of being seriously assaulted. Andrew said nobody had asked him to do anything before the
assault and that although he had asked to go to the trust after the community meeting the
delay in meeting this request had not made him angry. He denied assaulting Dave to obtain
anything tangible. Nobody told Andrew to be aggressive. He denied enjoying seeing others in
pain. Rate Andrew’s assault upon Dave.

185
Incident 2: Peter, 19th June 2001

Peter is an 18 year-old man admitted to the hospital from the Juvenile Justice system.
He is serving a long sentence following conviction for murder. Prior to his admission to
hospital he had complained of “voices”. Following assessment a diagnosis of schizophrenia
was discounted. His diagnosis is that of Borderline Personality Disorder. Since admission
Peter has been involved in several incidents of both verbal and physical aggression. He has
told staff that he does not want to be transferred to prison. He is fearful of other prisoners. On
the ward he has tried to create a good impression with the other patients. With their support he
has made complaints about staff during the ward’s morning community meeting.
Late in the evening of Friday 19th June 2001 several nurses sitting in the staff station
witnessed a fight in the smoker’s room. Nursing staff rushed to the smoker’s room and
observed Peter and Andrew, a co-patient, fighting. The two were separated and Peter verbally
threatened staff. Andrew told staff that he had been sitting down having a cigarette when
Peter started punching him. Peter was escorted to seclusion. Whilst in seclusion Peter
continued to hit his hands against the wall and yell threats towards staff. He was offered and
accepted prn sedation although continued to punch the walls for approximately one hour
before settling to sleep.
In the few hours prior to this incident Peter had appeared relaxed on the ward, playing
the guitar and singing with staff. He did not appear to be particularly agitated, frustrated or
angry.
During an interview after this incident Peter revealed that a co-patient, Mario, a large
man with a reputation for aggression whom Peter describes as a friend, had encouraged Peter
to taunt and then attack Andrew. In the days leading up to the assault Peter had knocked on
Andrew’s door whilst Andrew slept and had also turned the lights of Andrew’s bedroom on
and off. Peter stated that there was nothing personal in the attack upon Andrew; that he had
“nothing against him”. He simply stated that Mario had told him to attack Andrew. He denied
that Mario was going to give him anything for attacking Andrew. Peter said nobody had made
a demand of him before the assault. He denied enjoying seeing others in pain. Peter said
nobody had denied him a request before the assault. He denied that Andrew had provoked
him. Rate Peter’s attack upon Andrew.

186
Incident 3: Wayne, 20th June 2001

Wayne is a 30 year-old man with a long history of difficult and aggressive behaviour.
He is well known to his treating team as he has been incarcerated on many occasions since
turning 18 and has been transferred for psychiatric care frequently during these periods of
imprisonment. His convictions are predominantly for theft, drug dealing and violence. He is
currently serving a one-year sentence for a violent offence during which he assaulted a nurse
from another hospital. Wayne has a diagnosis of schizophrenia. Many staff dislike Wayne. He
is considered manipulative, deceitful and untrustworthy.
Late in the evening of 20th June 2001, Wayne was in the smoking room with two co-
patients. Several nurses sitting in the staff office noticed that Wayne and Andrew were
punching Mario, a co-patient. Staff rushed to the scene and separated the three men. Mario
claimed that Wayne and Andrew had assaulted him. Wayne did not deny that he had assaulted
Mario. Wayne was escorted to the seclusion room where he remained until the following
morning. Andrew and Mario were separated and allowed to remain on the ward.
During interviews with staff subsequent to the assault it became clear that Andrew, the
patient who had assisted Wayne with his assault upon Mario, had assaulted Mario that
morning. The reason for this assault was that Andrew had discovered that Mario had
encouraged another patient (Peter) to taunt Andrew by knocking on his door and switching his
bedroom light on and off whilst he was trying to sleep. Furthermore, Andrew had been
assaulted by Peter the previous night after being told to do so by Mario.
On interview Wayne stated that he assaulted Mario because he was angry that Mario
had encouraged Peter to assault Andrew, a friend of his. Wayne said that he had to protect
himself and to assault Mario before Mario either assaulted him, or encouraged somebody else
to attack him. He also thought Mario was being unfair and disrespectful; that he provoked the
assault, and deserved to be attacked. He denied feeling agitated or tense in the week prior to
the incident; denied the intention to obtain any tangible reinforces and denied being instructed
to assault Mario by Andrew.
Wayne was observed to brag about his assault to other patients in the week after the
assault, stating that Mario was “getting too big for his own good”, and “getting out of
control”. Furthermore, Wayne stated that Andrew probably appreciated his assistance with
assaulting Mario. Nursing staff reported that Wayne often creates alliances with other patients
to meet his own needs and that Wayne may have assaulted Mario to strengthen his
relationship with Andrew. Wayne stated that Mario had been hurt as a consequence of his
assault but hat the assault was proportional to the provocation and was necessary. He reported

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that he does not generally enjoy seeing people in pain and denied assaulting people just to see
them suffer.

Incident 4: Wayne, 21st July 2001

Wayne is a 30 year-old man with a long history of difficult and aggressive behaviour.
He is well known to his treating team as he has been incarcerated on many occasions since
turning 18 and has been transferred for psychiatric care frequently during these periods of
imprisonment. His convictions are predominantly for theft, drug dealing and violence. He is
currently serving a one-year sentence for a violent offence during which he assaulted a nurse
from another hospital. Wayne has a diagnosis of schizophrenia. Many staff dislike Wayne. He
is considered manipulative, deceitful and untrustworthy. In the week leading to this act of
aggression there had been several incidents of aggression in which Wayne had been involved.
A number of new patients had been admitted and ward staff considered the atmosphere
“tense”.
In the early evening of Friday 21st July 2001 Wayne was verbally abusive to a nurse
when they would not telephone Wayne’s mother for him. The victim of the verbal abuse
reported that as he walked past the patient’s telephone Wayne was attempting to make a call.
Wayne asked if the nurse would call his mother, as he was unable to make contact. He said
his mother was deliberately not answering her mobile phone because she knew it was him. He
said the patient’s phone number would “flash up” on her mobile phone. He said she was
trying to avoid him. Wayne appeared frustrated as he pleaded with the nurse to make the call.
The nurse told Wayne that he would not telephone his mother because he did not wish
to interfere with family business. He encouraged Wayne to keep calling, that his mother may
not be ignoring his calls, that she may in fact have the phone turned off, or that she may just
be busy. The nurse suggested that he would eventually get through. Wayne became angry and
told the nurse to “fuck off” and gestured for them to leave. The nurse walked away.
During interview Wayne said that his mother and sister had visited him earlier that day
and that he had given them $100 because they were in financial hardship. He asked them
whether they would be able to return later that day with approximately $10 worth of take-
away food. According to Wayne they agreed to bring back this food. At approximately
5:00pm when they had not returned Wayne became frustrated. He was annoyed that he had
given his family a large amount of money and they had not been bothered with what he
considered a reasonable request to return with his food. At the time of verbal aggression
Wayne was attempting to contact his mother to see when she was going to return with his

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food. Wayne stated that the nurse should have assisted him as staff are employed to assist
distressed patients. He said that he often worries that staff and family do not respect, trust or
like him, and his family often let him down. He said nobody had asked him to do something
before the assault and did not think other people would give him tangible things after the
assault. He denied being told to be aggressive and does not generally enjoy seeing other
people suffer.

Incident 5: Peter, 30th July 2001

Peter is an 18 year-old man admitted to the hospital from the Juvenile Justice system.
He is serving a long sentence following conviction for murder. Prior to his admission to
hospital he had complained of “voices”. Following assessment a diagnosis of schizophrenia
was discounted. His diagnosis is that of Borderline personality Disorder. Since admission
Peter has been involved in several incidents of both verbal and physical aggression.
Late in the afternoon of Monday 30th July 2001 Peter was observed speaking on the
telephone when he became agitated, pacing and speaking in a loud, desperate manner. Staff
noticed him hang up the phone by slamming it against the wall. He picked up a chair and
threw it against the wall. Some nursing staff who had heard Peter on the telephone and then
seen him throw the chair approached Peter. Peter told them he had just had a “bad”
conversation with his girlfriend. He said “I’ve just had bad news from my girlfriend. She’s
upset me.” He was shaking.
Staff attempted to engage Peter in some discussion about the telephone conversation
to find out what had happened and whether they could offer some support. Peter did not wish
to talk any further about the incident. He said, “I want to go to seclusion.” Rather than place
him immediately in seclusion it was suggested that he go to his room and try to relax. He
pleaded with staff to allow him to go to seclusion as he felt angry and could not trust himself.
He threatened to “smash” the ward if he was not put in the seclusion room.
Staff decided that to prevent further property damage Peter would be allowed to stay
in the seclusion room until he felt relaxed. He was escorted to seclusion. Upon arrival in
seclusion he lay down. After two minutes he requested that staff allow him out of the
seclusion room. He was told to wait for 30 minutes and then allowed to leave the seclusion
room.
Upon interview some days after the incident Peter said that he was worried his family
and girlfriend were deserting him. Staff interviewed after the incident said that Peter had been
fearful since his admission as this was his first time in adult custody. They said that he

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seemed worried about the prospect of spending the next ten years in prison. He also expressed
concerns that his family may not support him during his sentence, that they may stop visiting
him, and that he would be alone when he was eventually released. They said he was also
fearful of going to prison as other prisoners might hurt him. He said nobody had asked him to
do anything for him before the act of aggression. He also said that he had not made a request
of anybody. He said nobody had told him to be aggressive. Rate Peter’s property damage.

Incident 6: Peter, 2nd August 2001

Peter is an 18 year-old man admitted to the hospital from the Juvenile Justice system.
He is serving a long sentence following conviction for murder. Prior to his admission to
hospital he had complained of “voices”. Following assessment a diagnosis of schizophrenia
was discounted. His diagnosis is that of Borderline personality Disorder. Since admission
Peter has been involved in several incidents of both verbal and physical aggression. He
described to staff upon admission his fears of the adult prison system and is concerned that he
will be attacked. On the ward he has tried to create a good impression with the other patients.
With their support he has made complaints about staff during the ward’s morning community
meeting.
During the afternoon of Tuesday 2nd August 2001 Peter was observed by staff to be
sitting near the patient’s telephone in a distressed state. He was crying and holding his head in
his hands. Staff approached him and he said that his ex-girlfriend and family were “backing
out on him”. Staff tried to reassure him. As he appeared agitated despite their reassurances he
was offered prn medication. Peter accepted the medication, which appeared to help him relax.
Peter went to his room where he rested.
Later in the afternoon and just prior to dinner Peter returned to the living room. He sat
for a while on his own and when the dining room door was not opened for dinner at 6:00pm
as it usually is, he loudly demanded that the dining room door be opened. He yelled “dinner,
dinner”. A nurse whom had seen and heard Peter approached him to ask him what the
problem was. Peter stated angrily that it was “dinner-time” and that staff should open the
dining room door. Peter was told that dinner was not ready and that he should wait patiently
and quietly. Peter joked with the nurse, a short female, saying, “relax”, and rubbed her hair
with his hands.
Taken by surprise, the nurse told Peter not to touch her and told him to go away. Peter
walked away, cursing loudly at the nurse. He walked to the smoker’s room, which he entered.
He then smashed one of the smoker’s room windows by kicking and punching it. Several staff

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who had been watching the incident rushed to the smoker’s room and instructed Peter to stop
kicking the glass windows. He was restrained and escorted to seclusion. Whilst in seclusion
Peter continued to kick, punch and head butt the seclusion room walls and door. He bit his
wrist, causing it to bleed. He continued to abuse and threaten staff. He blamed staff members
for the injuries sustained while in seclusion where he remained overnight. Peter did not wish
to talk about these incidents. Rate the property damage (breaking the smoker’s room
window).

Incident 7: Avi, 11th October 2001

Avi is a 24 year-old man from Iran. This is his second admission to hospital. Avi is
detained indefinitely. During this admission Avi has frequently engaged in acts of severe
aggression. He has threatened staff and patients. On two occasions he has broken a pool cue
in half and threatened staff. He has also broken furniture. Avi’s comprehension of English is
poor and he requires an interpreter to communicate effectively. He believes staff do not give
him effective treatment as they do not wish to release him.
Early in the afternoon of 11th October 2001 Avi requested the ward’s doctor take three
tubes of blood from him to ease his chest pain. He believed his chest pain was caused by bad
blood contaminated by antipsychotic medication. He insisted that if the blood were removed
his pain would ease. He approached nursing staff on a number of occasions requesting blood
be taken from him. This request was repeatedly refused. Avi was informed that the removal of
blood would not alleviate any chest pain and told that his chest pain had been investigated,
that he was not suffering a life threatening condition and that worry about his chest pain
would probably cause him further distress.
Avi would not accept this explanation nor would he accept prn medication, which he
did not believe would help. Despite his frustration with staff’s reluctance to take blood from
him Avi remained relatively settled for the majority of the afternoon. However, at
approximately 4:00pm Avi picked up a chair in the music room and attempted to smash a
window separating the music room from the kitchen by throwing the chair against the
window. Nursing staff entered the music room and Avi attempted to punch a nurse. He was
restrained, escorted to the seclusion area and given intra-muscular sedation. At approximately
7:00pm Avi settled and agreed that he would no longer attempt to assault anyone or damage
property. He was released from seclusion at approximately 9:30pm.
The ward doctor and psychologist interviewed Avi the following day. During this
interview Avi acknowledged being very angry and distressed by problems with his heart

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during the previous day. He stated that he was angry that staff dismissed his concerns and that
they did not meet his request for blood to be taken from his body. Avi also said that around
4:00pm he knew the doctor was about to go home and thought that once the doctor had left
the ward he would have no opportunity for blood to be taken from him. In an attempt to force
the doctor to do something Avi smashed the window. During the interview there were no
signs of lingering animosity towards staff. Avi minimised the seriousness of his attempted
assault and his anger. Avi said that nobody had told him to do anything in particular before
the incident and said that he had been getting on well with other patients this last week, that
they had treated him well. He denied being told to be aggressive. Rate Avi’s property damage.

Incident 8: Avi, 4th September 2001

Avi is a 24 year-old man from Iran. This is his second admission to hospital. Avi is
detained indefinitely. During this admission Avi has frequently engaged in acts of severe
aggression. He has threatened staff and patients. On two occasions he has broken a pool cue
in half and threatened staff. He has also broken furniture. Avi’s comprehension of English is
poor and he requires an interpreter to communicate effectively. He believes staff do not give
him effective treatment as they do not wish to release him.
Earlier this day the ward psychologist and medical officer interviewed Avi. Avi
requested an injection to alleviate problems with his heart. During this interview the doctor
attempted to identify the precise nature of Avi’s heart problems whilst the psychologist
explored Avi’s anxiety. Avi’s treating team was of the belief that Avi’s problems with his
heart were primarily delusional. He has had many tests on his heart, none of which have
revealed abnormality. He has a long history of somatic delusions. Occasionally Avi has
accepted the contribution of psychological factors to his physical symptoms although in the
interview with the doctor and psychologist on this day Avi became angry that he was not
going to receive the injection he thought would alleviate his problems. Avi said that only an
injection would help him. He became angry with the psychologist and told him not to
interfere with the doctor’s attempt to prescribe medication. Attempts to reassure Avi during
the interview were ineffective. Avi walked out of the interview room and slammed the door.
Nursing staff were informed that Avi was angry, that he believed staff were
withholding effective treatment and that the risk of Avi behaving aggressively was high. Avi
refused to accept prn medication.
Later that afternoon, whilst the psychologist was talking with another client in the
lounge room Avi approached him and yelled at him, accusing him of interfering with his

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treatment. The psychologist offered to talk with Avi and to see whether there was any way of
resolving this problem. Avi agreed and they walked to the courtyard accompanied by two
nurses. The psychologist and Avi then talked about possible solutions and Avi accepted prn
medication (an injection). Avi then stood up and gestured to assault both the psychologist and
the nurse. He was restrained and escorted to seclusion where he was given injectable
antipsychotic medication. He remained angry and surly for several hours, refusing to leave the
seclusion room until approximately 10:00pm Avi remained angry with the psychologist, the
doctor and some nursing staff for several days. Rate Avi’s threatening behaviour towards the
psychologist and nurses.

Incident 9: Geoff, 18th October 2001

Geoff is a 24 year-old man serving a 18-month sentence following conviction for

assault. He has a diagnosis of schizophrenia and remains unwell. Staff describe him as
belligerent and argumentative. He often swears and has repeatedly threatened staff. On
occasions he has banged his head and hands against the wall.
On the 18th October 2001 Geoff slept for much of the morning, as he usually does,
rising only for lunch. He did not appear to be particularly distressed by his psychosis. As is
usually the case, Geoff was reluctant to engage in conversation with staff. Whilst sitting at a
table with other patients and staff that afternoon Geoff began banging on the table that his
hands. When staff asked him to stop, Geoff banged louder and louder. He was asked again to
stop but grinned, then walked away whilst yelling at staff to “fuck off”. He was told such
language and behaviour was “inappropriate”.
Later that afternoon when discussing his unescorted leave Geoff was informed that he
would have to return to the ward after one hour so that staff would know he had not
absconded. Geoff became angry and objected to what he believed was unfair treatment by
staff. He said nobody else had to abide by such rules and that he had never before been
subjected to such conditions. Nevertheless, he was allowed leave and told to return within the
hour. Geoff returned from leave within the hour. After he returned from leave Geoff did not
talk with staff.
During interview the following morning Geoff acknowledged that he had been angry
throughout the previous day and thought that he should have handled the situation in a calm
manner and walked away when the note was held against the window. He complained about
the inconsistent rules imposed by staff. He thought that nurses deliberately provoke him and
that they treat him differently to other patients. He felt the aggression was a result of

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provocation but also recognised that the note may have been a light-hearted reaction to his
insults as he generally gets on well with this nurse. Geoff said that he had not asked anybody
to do anything for him before the incident and that he did not think he would obtain anything
tangible. He thought that he had been getting on well with other patients. He denied being told
to be aggressive.

Incident 10: Geoff, 19th October 2001

Geoff is a 24 year-old man serving a 18-month sentence following conviction for

assault. He has a diagnosis of schizophrenia and remains unwell. Staff describe him as
belligerent and argumentative. He often swears and has repeatedly threatened staff. On
occasions he has banged his head and hands against the wall.
On the evening of 19th October 2001 immediately prior to the dining room being
opened for dinner Geoff began complaining that the dining room had not been opened on
time. He swore and abused staff. Staff told him that his swearing was unreasonable, that they
were busy, and would open the dining room within minutes. He was asked to wait patiently.
Geoff became abusive, telling staff he would do what he liked. A decision was made by staff
to suspend Geoff’s unescorted leave from the ward until further review. Two nurses requested
Geoff attend an interview to discuss his behaviour and his leave. Geoff did not tolerate the
interview and walked out swearing at staff, calling them “maggots”, “arseholes”, and other
obscenities. He also gestured in an obscene manner to staff.
Upon interview Geoff acknowledged being angry at staff and stated he had generally
been irritable since his admission because he feels staff do not respond to his needs when
required and do not live by the same rules as patients. Earlier in the week, Geoff had his leave
entitlements reduced, which was a considerable source of frustration for him. He had recently
begun a relationship with one of the female patients on another ward. Once staff became
aware of this relationship discussions were held with the other ward’s staff who decided that
the female patient was not in a position to consent to a sexual relationship with Geoff. A
consequence of this decision was that neither patient was allowed unescorted leave at the
same time. Geoff complained repeatedly during the last week that staff intrude upon his rights
and have interfered in his relationship. Furthermore, Geoff appeared in court during the
previous day to appeal the severity of his sentence. This appeal was declined. Geoff expressed
disappointment that his appeal would not proceed.
Geoff was unwilling to accept responsibility for his verbal abuse and thought his
aggression was a reasonable response to his inconsistent treatment. He threatened within

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interview that staff had not witnessed the full extent of his aggression. He did however
acknowledge that his rumination over past problems combined with his proneness to anger
leaves him vulnerable to aggression. Geoff said that he had been getting on well with other
patients on the ward and that patients but not staff had been treating him respectfully. He
denied being encouraged or told to be aggressive. He said that in general he does not enjoy
seeing people suffer but he does not really care about upsetting staff because he is treated
badly on the ward. Rate Geoff’s verbal aggression.

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 APPENDIX 5

Plain language statement for patients regarding Stage 1 of research

196
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

This project has been designed to investigate the reasons why inpatients of psychiatric
hospitals are aggressive. All patients of this hospital are being approached to participate in
this study.
The investigators of this study are Mr Michael Daffern, Psychologist, Forensicare and
University of South Australia and Professor Kevin Howells from the University of South
Australia. This research is being conducted as part of Mr Daffern’s PhD.
If you agree to participate in this research you will be required to complete a brief
interview in which I shall ask you some questions about your thinking. Then I will ask you to
complete a few self-report questionnaires. These questionnaires are designed to assess how
well you are able to manage your anger, how assertive you are, how impulsive you are and
how well you get along with other people. This assessment should take approximately one
hour although you can take longer if you wish. You may withdraw from the research at any
time without this decision affecting your treatment. If you wish to withdraw all information
collected from you will be destroyed.
Taking part in this study is entirely voluntary. Whether you agree to participate or not
will not influence your treatment and care at this hospital. Your responses to these
questionnaires are completely confidential. No information that could identify you as a
participant in this research will be available to anybody but Mr Daffern. Your treating team
will not be made aware of your responses to these questionnaires or the interview asking you
about your thinking. When you have completed the study the questionnaires they will be kept
in my office in a locked filing cabinet. Questionnaires and results of interviews will be coded
and kept for seven years.
Results from this research will be published through professional journals and
presented at conferences although no individual patients responses will be identifiable.
If you have any complaints about the assessment process you may make a complaint
to myself. Alternatively you can make a complaint to your Case Manager or Unit Manager
who will then inform the research team. If you do not feel comfortable making a complaint to
any of these people you may make a confidential complaint to Anne Hems, the Consumer

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Consultant who will pass on the complaint to Mr Daffern or Professor Howells. Alternatively,
you could contact the Ethics Officer of the Human research Ethics Committee at the
University of South Australia on (08) 83023956.
If you would like to discuss your responses to the research I will be happy to provide
you with feedback.

Michael Daffern Professor Kevin Howells

Argyle Ward University of South Australia
Thomas Embling Hospital 08 83020777
Ph 03 94959207

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 APPENDIX 6

Consent form for patients for Stage 1 of research

199
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

I ……………………………………………. understand that I have been asked to

participate in this study and I give my consent to participate by signing this form. I understand
that:

1. My consent to participate is voluntary and I may withdraw at any time. I do not

have to give a reason for the withdrawal of my consent.
2. If there are particular questions I do not wish to answer I do not have to do so.
3. I understand that all information will be handled in the strictest confidence and that
my participation will not be individually identifiable in any reports.

Signature:………………………………… Date:……………………………………

Signature:………………………………… Date:……………………………………

Michael Daffern
Forensicare and University of South Australia

200
 APPENDIX 7

Scoring sheet for recording demographic details

201
 Scoring sheet for recording demographic details
Name of patient: _____________________

1. Date of Birth: _____/_____/_____

2. Legal status:

1. Section 12
2. Forensic Patient
3. Section 16 (3) (b)
4. Security Patient 93(1)(e)
5. Security Patient 93(1)(d)

3(a). Date of admission: _____/_____/_____

3(b). Date of discharge: ____/_____/_____

4. Primary diagnosis: ___________________

5. Sex:

1. Male
2. Female

6. Ward:

1. Argyle
2. Atherton
3. Barossa
4. Bass
5. Canning
6. Daintree

7. Substance use:

Used in the last year: Used ever:

Alcohol Yes/No Yes/No

Marijuana Yes/No Yes/No
Cocaine Yes/No Yes/No
Heroin Yes/No Yes/No
Amphetamines Yes/No Yes/No

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 APPENDIX 8

Violence Rating Scale

203
 Violence Rating Scale

1. Violence rating for admission offence

Completely non-violent 0

Minimal violence 1
(e.g., verbally aggressive, shouting or gesturing, even if this
was not obviously directed at others)

Moderate violence 2
(e.g., attack on a person resulting in no serious injury, fighting
or brawling or damage to property when this was the main
intent)

Severe violence 3
(victim died or life and health seriously endangered)

2. Violence rating for previous record

Never been convicted of violence – never gets into fights 0

Some evidence of violence (occasional fights but no convictions) 1

One or two convictions for minor assaults or damage to property 2

Three or more convictions for violence, but none serious in the 3

sense of ‘4’ below

One or more severely episode in which someone’s life or health has 4

been seriously endangered

Total score:___________

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 APPENDIX 9

Novaco Anger Scale

205
206
207
 APPENDIX 10

Simplified version of the Rathus Assertiveness Scale

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 ASSERTIVENESS SCHEDULE

WHAT TO DO: Read each sentence carefully. Write down on each line whatever number is
correct for you.

6 Very Much Like Me

5 Rather Like Me
4 Somewhat Like Me
3 Somewhat Unlike Me
2 Rather Unlike Me
1 Very Unlike Me

_____ 1. Most people stand up for themselves more than I do.*

_____ 2. At times I have not made or gone on dates because of my shyness.*

_____ 3. When I am eating out and the food I am served is not cooked the way I
like it, I complain to the person serving it.

_____ 4. I am careful not to hurt other people’s feelings, even when I feel hurt.*

_____ 5. If a person serving in store has gone to a lot of trouble to show me

something which I do not really like, I have a hard time saying “No.”*

_____ 6. When I am asked to do something, I always want to know why.

_____ 7. There are times when I look for a good strong argument.

_____ 8. I try as hard to get ahead in life as most people like me do.

_____ 9. To be honest, people often get the better of me.*

_____ 10. I enjoy meeting and talking with people for the first time.

_____ 11. I often don’t know what to say to good looking people of the opposite
sex.*

_____ 12. I do not like making phone calls to businesses or companies.*

_____ 13. I would rather apply for jobs by writing letters than by going to talk to
the people.*

_____ 14. I feel silly if I return things I don’t like to the store that I bought them
from.*

_____ 15. If a close relative that I liked was upsetting me, I would hide my
feelings rather than say that I was upset.*

_____ 16. I have sometimes not asked questions for fear of sounding stupid.*

_____ 17. During an argument I am sometimes afraid that I will get so upset that
I will shake all over.*

209
_____ 18. If a famous person were talking in a crowd and I thought he or she was
wrong, I would get up and say what I thought.

_____ 19. I don’t argue over prices with people selling things.*

_____ 20. When I do something important or good, I try to let others know about
it.

_____ 21 I am open and honest about my feelings.

_____ 22. If someone has been telling false and bad stories about me, I see him
(her) as soon as possible to “have a talk” about it.

_____ 23. I often have a hard time saying “No.”*

_____ 24. I tend not to show my feelings rather than upsetting others.*

_____ 25. I complain about poor service when I am eating out or in other places.

_____ 26. When someone says I have done very well, I sometimes just don’t
know what to say.*

_____ 27. If a couple near me in the theatre were talking rather loudly, I would
ask them to be quiet or to go somewhere else and talk.

_____ 28. Anyone trying to push ahead of me in a line is in for a good battle.

_____ 29. I am quick to say what I think.

_____ 30. There are times when I just can’t say anything.*

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 APPENDIX 11

PSYRATS and KGV prompt questions

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 DELUSIONS – KGV Prompt Questions

Can you think quite clearly or is there any interference with your thoughts? Are you in full
control of your thoughts? Do you sometimes feel people can read your mind? Is anything like
hypnotism or telepathy going on?

Are thoughts put into your head which you know are not your own? Where do they come
from?

Do you ever seem to hear your own thoughts spoken aloud in your head, so that someone
standing near might be able to hear them? Are your thoughts broadcast so that other people
know what you are thinking? How do you explain it?

Do you ever seem to hear your own thoughts repeated or echoed? What is that like? How do
you explain it? Where does it come from?

Can anyone read your thoughts? How do you know? How do you explain it?

Do you ever feel under the control of some force or power other than yourself? As though you
were possessed by someone or something else? What is that like? Does this force make your
movements for you without your willing it, or use your voice, or your handwriting? Does it
replace your personality? What is the explanation?

Do people seem to drop hints about you, or say things with double meaning, or do things in a
special way so as to convey a meaning? Does everyone seem to gossip about you? Do people
follow you about, or check up on you, or record your movements? How do they do it? Are
people about who are not what they seem to be?

Do things seem to be specially arranged? Does it ever seem there is an experiment going on,
to test you out? Do you see any reference to yourself on TV or in the papers? Do you ever
seem to see special meanings in advertisements, or shop windows, or in the ways things are
arranged? How do you explain this?

Is anyone deliberately trying to harm you, eg trying to poison or kill you? How? Is there any
other kind of persecution? How do you explain this?

Is there anything special about you? Do you have special abilities or powers? Can you read
people’s thoughts? Is there a special purpose or mission to your life? Are you specially clever
or inventive? How do you explain this?

Are you a very prominent person, or related to someone prominent, like Royalty? Are you
very rich or famous?

Are you a very religious person? Are you especially close to Christ or God? Can God
communicate with you? Are you yourself a saint? How do you explain this?

Do you ever feel anything like electricity, or X-rays or radio waves affecting you? In what
way? What is the explanation?

Do you feel you have committed a crime, or sinned greatly, or deserve punishment? Is
anything the matter with your body?

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 HALLUCINATIONS – KGV Prompt Questions

Do you ever seem to hear noises or voices when there is no one about, and nothing else to
explain it? Do you ever seem to hear your name being called?

Do you hear noises like tapping or music? What does the voice say? Does it sound like
muttering or whispering? Can you make out the words?

Do you every hear a voice talking? What does the voice say? Do you hear your name being
called?

Do you hear several voices talking about you? Do they refer to you as ‘he’ or ‘she’? What do
they say? Do they comment on what you are thinking or doing?

Do they speak directly to you? Are they threatening or unpleasant? Do they call you names?
Do they give you orders? Do you obey?

Can you carry on a two way conversation with them? Do you see anything or smell anything
at the same time as you hear the voices? Who is it you are talking to? What is the
explanation? Do you know anyone else who has this kind of experience?

Are these voices in your mind or can you hear them through your ears? Where do the voices
come from? Do they come from in the room?

How do you explain these experiences?

Have you had any unusual visual experiences, for example have you seen people or things
which other people cannot see? What did you see?

Did you see these things with your eyes or in your mind?

Were you half asleep at the time? Has it occurred when you were fully awake?

Did the vision seem to arise out of a pattern on the wallpaper or a shadow?

How do you explain these experiences?

Do you ever notice anything unusual in the ways things feel, or taste, or smell?

Do you sometimes notice strange smells that other people don’t notice?

Do you ever feel that someone is touching you, but when you look there is nobody there?

Do you sometimes get strange feelings in your body?

213
 APPENDIX 12

The Functional and Dysfunctional Impulsivity scale

214
 Impulsivity Scale
(Circle the appropriate answer)

1. I don’t like to make decisions quickly, even simple decisions, such as

choosing what to wear, or what to have for dinner*. YES NO

2. I am good at taking advantage of unexpected opportunities, where you

have to do something immediately or lose your chance. YES NO

3. Most of the time I can put my thoughts into words very rapidly. YES NO

4. I am uncomfortable when I have to make up my mind rapidly. YES NO

5. I like to take part in really fast-paced conversations, where you really don’t have much
time to think before you speak. YES NO

6. I don’t like to do things quickly, even when I am doing something that is not very
difficult*. YES NO

7. I would enjoy working at a job that required me to make a lot of split-second

decisions. YES NO

8. I like sports and games in which you have to choose your next move very quickly.

YES NO

9. I have often missed out on opportunities because I couldn’t make up my mind fast
enough*. YES NO

10. People have admired me because I can think quickly. YES NO

11. I try to avoid activities where you have to act without much time to think first.
YES NO

215
 Impulsivity Scale

1. I will often say whatever comes into my head without thinking first.
YES NO

2. I enjoy working out problems slowly and carefully. YES NO

3. I frequently make appointments without thinking about whether I will be able to keep
them. YES NO

4. I frequently buy things without thinking about whether or not I can really afford them.
YES NO

5. I often make up my mind without taking the time to consider the situation from all
angles. YES NO

6. Often, I don’t spend enough time thinking over a situation before I act.
YES NO

7. I often get into trouble because I don’t think before I act. YES NO

8. Many times the plans I make don’t work out because I haven’t gone over them
carefully enough in advance. YES NO

9. I rarely get involved in projects without first considering the potential problems*.
YES NO

10. Before making any important decisions, I carefully weigh up the pros and cons.*
YES NO

11. I am good at careful reasoning*. YES NO

12. I often say and do things without considering the consequences. YES NO

216
 APPENDIX 13

Shortened Social Behaviour Schedule

217
 SHORTENED SOCIAL BEHAVIOUR SCHEDULE

Patient’s name: ________________________ Date: ___/___/___

Circle the appropriate answer for each patient.

COMMUNICATION: TAKING THE INITIATIVE

Does S. initiate conversations: Will he or she approach a member of staff either to ask a
question or to start a conversation? If S. approaches will he or she carry on the conversation
after the initial comments?

0. Good range of spontaneous contacts. Can initiate a conversation and keep it going by
spontaneous contributions. If someone else initiates a conversation, S. responds appropriately
and quite often keeps the conversation going (i.e., active as well as passive response).

1. Can sometimes initiate or maintain a conversation but this is infrequent or the range of
topics is very limited. If another person initiates contact S. usually responds appropriately, but
only for a short time and then ceases to respond.

2. Occasionally speaks spontaneously, but this is unusual, and limited to greetings, brief
factual exchanges etc. Quite often ignores another person's attempt at contact, or turns away.

3. Usually responds negatively to attempts to initiate conversation (e.g., turns away, walks out
of the room). Only spontaneous contact initiated by S. himself is non-verbal (e.g., smiling,
taking hand or aggressive contact).

4. S. says virtually nothing. He does not respond when greeted or spoken to. He initiates
extremely few verbal or non-verbal contacts.

CONVERSATION: INCOHERENCE

How far is S. handicapped in engaging in conversation with others through incoherence of

speech? (NB: this rating is NOT concerned with how articulate S. is or how intelligently
he/she can express himself/herself. The incoherence of speech rated here is that associated
with the psychotic illness - e.g., flight of ideas, knight's move)

0. No incoherence of speech.

1. Some occasional incoherence of speech (e.g., once or twice a month).

2. Incoherence of speech occurs more frequently (e.g., once a week). Most speech is coherent.

3. Frequent incoherence of speech (e.g., more than once a week).

4. S's conversation is always or almost always characterised by incoherence of speech. Very

difficult to understand anything he says.

218
CONVERSATION: ODDITY / INAPPROPRIATENESS

How far does S's conversation show a preoccupation with bizarre or eccentric topics, which
most people (not only specialists) would regard as extremely odd.

0. Above behaviour does not occur.

1. Above behaviour occasionally present (e.g., once or twice a month).

2. Above behaviour occurs more frequently (e.g., once a week) but most speech contains no
such examples.

3. Above behaviour occurs very frequently (e.g., daily).

4. Virtually all S's conversation is as described above.

The following rating is concerned with aspects of S's ability to mix with others. This rating
gives some picture of the extent to which people have to make allowances for S's handicaps or
social difficulties in order to interact with S. Thus S's rating on this question indicates how far
he or she is restricted by his or her handicaps to relating only to immediate family or to
professional carers.

(4) SOCIAL MIXING: PROPORTION OF SOCIAL CONTACTS WHICH ARE

HOSTILE IN NATURE

This rating is concerned with the sorts of contacts S. makes with other people. The emphasis
in this rating is on verbal or physical hostility. Only rate hostility if it is inappropriate or more
extreme than the situation demands. Verbal hostility includes swearing etc. but does not
include apathy or failures to respond to a social approach. Only rate physical hostility if S. has
had physical contact with another person, which was of a hostile nature.

0. Contacts are nearly all appropriately friendly.

1. Mostly friendly contacts. Occasionally contacts are inappropriately hostile (e.g., one or two
incidents in past month or more than this but of a relatively minor nature).

2. More frequent incidents of inappropriately hostile contact or a serious incident involving

threatening behaviour in past months, but most contacts have been friendly.

3. Most contacts are verbally hostile (e.g., swears, accuses etc. more than once a week).

4. Contacts are frequently verbally hostile, or S. has at any time in past month been physically
hostile.

219
(5) SUICIDAL AND SELF HARMING IDEAS AND BEHAVIOUR

Ratings on this item should be made conservatively. A rating of 3 or more should only be
made if the informant was sure that injuries which were sustained were intended by S. to be of
a suicidal nature.

0. S. has not spoken of suicide or made any attempt.

1. S. has alluded to suicide indirectly in the past month.

2. S. has spoken of suicide directly in past month.

3. S. has made some kind of suicidal gesture in past month (eg. scratching wrists). Or S. has
spoken of suicide several times in past month.

4. S. has made a serious attempt at suicide or injured himself or herself seriously in past
month.

(6) SOCIALLY UNACCEPTABLE HABITS OR MANNERS

This rating concerns unacceptable habits e.g., scratching genitals, passing loud flatus, picking
nose etc. Ask particularly about problems at meal times such as poor table manners.

0. Has good manners and behaviour is socially acceptable.

1. Behaviour is not markedly unacceptable but S. has positive qualities in manner.

2. Occasional unacceptable behaviour (e.g., markedly unattractive habit, surliness,

uncouthness). However much of the time S is passively acceptable.

3. Frequent episodes of unacceptable behaviour as in (2) (e.g., once a week).

4. Behaviour is markedly unacceptable most of the time.

220
(7) DESTRUCTIVE BEHAVIOUR

Under this item only rate behaviour which results in destruction of property only. If an
incident included some threatening behaviour to others as well as destruction of property then
rate under item 5 only.

0. S. has reasonable tolerance for provocation, is in control of angry feelings and acts in a
socially appropriate manner.

1. Threatens to destroy property occasionally but has not actually done so.

2. Frequently threatens to destroy property.

3. Has damaged property in anger during past month e.g., broken windows, torn clothes.

(8) DEPRESSION

This rating concerns periods spend in S. sitting with his/her head in his or her hands looking
miserable, remarks such as “I wish I had never been born” or “life is pointless” etc. Do not
assume suicidal behaviour is an indication of depression other signs need to be present to
make a rating here.

0. No such behaviour.

1. Such behaviour occurs occasionally (e.g., one or two brief incidents in past month).

2. Such behaviour occurs fairly often or for fairly long periods (e.g., once a week).

3. Such behaviour occurs frequently (e.g., daily).

221
(9) PERSONAL APPEARANCE AND HYGEINE

In making this rating, consider cleanliness, hair, changing underwear, incontinence. Also
consider bizarre appearance. Take into account the amount of supervision S. receives. If, for
example, S. is in a Hostel, consider how S. would care for himself or herself if not in a
supervised situation. (Do not consider “fashionable” disorder in dress).

0. Able to look after appearance and cleanliness adequately.

1. Usually appearance is satisfactory but occasionally needs reminding. Or takes an interest in

certain aspects of appearance but neglects others.

2. Quite often needs reminding about appearance (e.g., three times in past month). Or attends
to appearance but in an inappropriate manner so that appearance is bizarre.
Considerable self-neglect most of the time. Needs frequent reminding (e.g., more than once a
week) and some supervision.

3. Gross self-neglect. No spontaneous care of clothes (e.g., clean underwear), washing hair,
hygiene. Needs supervision in all aspects. Would smell if unsupervised. Would be incontinent
if not reminded.

(10) SLOWNESS

This item is concerned with abnormal slowness e.g., S. sits abnormally still, walks abnormally
slowly or is delayed when performing movements. Make allowances for age and physical
condition.

0. No abnormal slowness.

1. Moderately slow on occasions, but most of the time is not slow.

2. Moderately slow most of the time, even when stimulated.

3. Moderately slow most of the time with periods of extreme slowness as in (4).

4. Extremely slow. Will sit or lie doing nothing if not stimulated, and even then very slow to
move.

222
(11) UNDERACTIVITY

This rating concerns underactivity only. Bear in mind that S. may be slow (item 18) and
underactive or underactive only. Underactivity here is defined as lack of spontaneous activity.
If S. not stimulated will sit and do nothing (moderate underactivity). When it is not possible to
stimulate S. into carrying out a task then rate as extreme underactivity.

0. No abnormal underactivity.

1. Moderately underactive on occasions, but most of the times keeps active.

2. Moderately underactive most of the time even when stimulated.

3. Moderately underactive most of the time, with periods of extreme underactivity as in (4).

4. Extremely underactive. Will sit or lie doing nothing if not stimulated, and even then very
slow to move.

(12) CONCENTRATION

Suggested prompts: Does S. find it difficult to concentrate on a task even wen he really wants
to do so? On watching a T.V. program? On reading a book? Is S. distractible? Can S. set his
mind to something and do it, or does he find it impossible to concentrate long enough to do
this?

0. S. does not have problems with his ability to concentrate.

1. S. has periods when he is unable to concentrate.

2. S. can only concentrate for a few minutes at a time.

223
 APPENDIX 14

Record form for scoring details of aggressive incident

224
1. Total days between admission and aggressive incident: ___________

2. Month: 3. Day of week:

1. January 1. Monday
2. February 2. Tuesday
3. March 3. Wednesday
4. April 4. Thursday
5. May 5. Friday
6. June 6. Saturday
7. July 7. Sunday
8. August
9. September
10. October
11. November
12. December

4. Location of incident: 5. Time of day incident occurred:

1. Lounge room 1. 12:00am – 6:00am

2. Music room 2. 6:00am – 8:00 am
3. Interview room 3. 8:00am – 10:00am
4. Art room 4. 10:00am – 12:00am
5. Dining room 5. 12:00am – 2:00pm
6. OT kitchen 6. 2:00pm – 4:00pm
7. Bedroom (own) 7. 4:00pm – 6:00pm
8. Bedroom (other) 8. 6:00pm – 8:00pm
9. Courtyard 9. 8:00pm – 10:00pm
10. Smoker’s room 10. 10:00pm – 12:00am
11. Bathroom
12. Campus (grounds)
13. Campus (YMCA)
14. Campus (TAFE)

6. Ward:

1. Argyle
2. Atherton
3. Barossa
4. Bass
5. Daintree
6. Canning

7. Victim characteristics:

1. Staff
2. Patient
3. Property

225
8. Designation if staff victim: 9. Gender of victim:

1. Nurse 1. Male
2. PSO 2. Female
3. Ward Manager
4. Clerical
5. Consultant
6. Registrar
7. Psychologist
8. Social Worker
9. Occupational Therapist
10. Domestic
11. Staff visitor to ward

10. Property damaged: 11. Ownership of property

1. Chair 1. Own
2. Table 2. Other patient’s
3. Television 3. Hospital owned
4. Stereo
5. Window
6. Door
7. Wall
8. Sporting equipment
9. Computer
10. Other

12. Assault or containment

1. Assault (violence occurred out of context of restraint/containment or seclusion)

2. Containment (violence occurred out of context of restraint/containment or seclusion)

226
 APPENDIX 15

Staff structured interview

227
 Staff structured interview

Introduction: This project’s aim is to identify the motivations people have for being
aggressive. The purpose of this interview is to try to get an idea of what caused the
patient to ………. (substitute for actual behaviour). I will be asking you questions about
some of the things that happened before, during and after the incident as a way of
finding out what may have been the motive for the patient’s (substitute name)
aggression.

Perhaps you could start by telling me your version of the incident.

BEHAVIOUR:

What did the patient do during the incident?

Did the patient say anything during the incident?

ANTECEDENTS:

What was the patient doing prior to the incident?

Was there anything going on around the ward that you think contributed to the incident?

How did other patients influence the aggression?

CONSEQUENCES:

What stopped the aggression?

How did staff intervene during the incident?

How did the patient respond to staff intervention?

What did other patients do during and after the incident?

228
1. Demand avoidance:

Did anybody ask the patient to do something or to stop doing something prior to the incident?

If no, what is the patient generally expected to do at the time of the incident?

If yes, does the patient generally complain about having to do these things?

2. Denial of request:

Had the patient asked for anything prior to the aggression?

What did they want?

Was their request granted?

Was there a delay in fulfilling the request?

3. Provocation by others (including physical assault):

How does the patient generally get along with the victim of their aggression?

Were you aware of any interactions the patient had with other people which could be
construed as provocation, in particular the victim of their aggression, prior to the incident?

Do you think the patient felt provoked or threatened by their victim?

229
4. To reduce frustration:

Has the patient appeared, or complained of being tense or frustrated this last week?

5. To obtain tangible reinforcers/instrumental objectives (including prn medication and

seclusion):

Did the person appear motivated to act aggressively by some goal or objective?

Did they make a request for anything prior to the incident?

Did the person receive anything from staff or patients that they might not have obtained had
they not acted aggressively?

6. To reduce social distance:

Does the patient interact with other people more or less than other patients?

Is the patient rejected or ignored by other patients on the ward?

Does aggression occur with this patient when they have been left alone for long periods of
time?

Does the patient seem to crave contact with other people or seek attention from staff more
than other patients?

Was the person given attention as a result of aggression (physical attention/comfort/restraint)

or talked to?

230
7. To enhance status or social approval:

Did the patient report being treated badly or disrespectfully by other people before the
incident?

Do you think the patient is treated badly or stood over by other patients on this ward?

Do you think other patients will treat the person differently now that they have been
aggressive?

How has aggression helped the person?

8. Following instruction (by others or through command type auditory hallucinations):

Are you aware of anybody telling the person to be aggressive or did they report that auditory
hallucinations were responsible for the aggression?

Does the patient have a history of auditory command hallucinations?

Has the person ever acted on these instructions in the past?

9. To observe suffering in others:

Did the person seem to enjoy hurting the victim?

Did the patient stop their aggression when it was clear the other person had given up or was in
pain?

231
 APPENDIX 16

Plain language statement for staff regarding Stage 2 of research

232
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

The project has been designed to investigate the reasons why psychiatric inpatients are
aggressive. After each aggressive incident in this hospital patients and staff are being
approached to participate in this study. The investigators of this study are Mr Michael
Daffern, Psychologist, Forensicare and University of South Australia and Professor Kevin
Howells from the University of South Australia. This research is being conducted as part of
Mr Daffern’s PhD.
If you agree to participate you will be required to complete a brief interview asking
you about the aggressive incident which occurred on this ward recently. This should take you
approximately half an hour although we can take longer if you wish.
Taking part in this interview is entirely voluntary. If you agree to participate the
results of this assessment will be entirely confidential. Results of the interview will be kept in
a locked filing cabinet in my office. Results of interviews will be coded and kept for seven
years. You can withdraw from this study at any time. If you wish to withdraw all information
collected from you will be destroyed.
Results from this research will be published through professional journals and
presented at conferences although no individual patients responses will be identifiable.
If you have any complaints about the assessment process you may make a complaint
to myself. Alternatively you can make a complaint to your Unit Manager who will then
inform the research team. Alternatively, you could contact the Ethics Officer of the Human
research Ethics Committee at the University of South Australia on (08) 83023956.

Michael Daffern Professor Kevin Howells

Argyle Ward University of South Australia
Thomas Embling Hospital Ph 08 83020777
Ph 03 94959207

233
 APPENDIX 17

Consent form for staff to participate in Stage 2 of the research

234
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

I ……………………………………………. understand that I have been asked to

participate in this study and I give my consent to participate by signing this form. I understand
that:

1. If I do not volunteer or decide to withdraw from the study at any time that my
decision will be accepted.
2. My consent to participate is voluntary and I may withdraw at any time. I do not
have to give a reason for the withdrawal of my consent.
3. If there are particular questions I do not wish to answer I do not have to do so.
4. I understand that all information will be handled in the strictest confidence and that
my participation will not be individually identifiable in any reports.

Signature:………………………………… Date:……………………………………

Signature:………………………………… Date:……………………………………

Michael Daffern
Forensicare and University of South Australia

235
 APPENDIX 18

Patient structured interview

236
 Patient structured interview
Introduction: I’m interested in the reasons people are aggressive. The purpose of this
interview is to try to get an idea of what caused you to ……….(substitute for actual
behaviour). I will be asking you questions about some of the things that happened
before, during and after the incident; like how you were feeling, what you were doing
and what you were thinking.

Perhaps you could start by telling me your version of the incident. (If the patient does not
describe their behaviour prompt with a summary of the incident as provided by staff).

How were you feeling during the incident?

What were you thinking about?

ANTECEDENTS:

What were you doing before the incident?

What were you thinking about?

How were you feeling?

Was there anything else that had been going on before the incident that you think contributed
to the incident or affected the way you were thinking or feeling at the time?

CONSEQUENCES:

How did the incident stop?

What happened to you after the incident?

How were you feeling after the incident?

237
Do you think your aggression was fair?

NOTE: This interview form is a guide only. The following pages include a number of
prompts designed to elicit the purposes of aggression. Whilst it is important to ascertain
the full range of purposes all questions will not need to be asked. Assessment should be
non-intrusive and brief.

1. Demand avoidance:

Had anybody asked you to do something you didn’t want to do or to stop doing something
you were enjoying prior to the incident?

If yes, what did they want you to do?

Did you act aggressively (substitute for actual behaviour) so that you would not have to do…?

Would your day have been any different if you had not been aggressive?

Did you miss out on anything (groups/programs/activities) because you were aggressive?

2. Denial of request:

Had you asked somebody to do something for you before the incident?

If yes, what did you ask for?

Did they do that for you?

If no, how did that make you feel?

238
3. Provocation by others (including physical assault):

Did you feel provoked or threatened by somebody before the incident?

What did they do?

Why do you think they did this?

Did you feel the need to protect yourself?

What would have happened if you had not been aggressive?

4. Frustration release-reduction of tension:

Would you say you have been feeling calm and relaxed this past week?

Have you been feeling wound up, stressed or tense this last week?
What’s been happening to make you feel this way?

How was the victim of your aggression contributing to your frustration?

Are you feeling less frustrated now?

5. To obtain tangible reinforcers/instrumental objectives (including prn medication and

seclusion):

What did other people give you or do for you after the incident?

239
What were you expecting other people would do after the incident?

Do you think other people will give you things or treat you differently because you have been
aggressive?

6. To reduce social distance:

How have you been getting on with other patients and staff on the ward?

Do you have many friends or people you can talk to on the ward?

If no, does that bother you?

Do you have more or less contact with staff when compared with other patients?

Are you satisfied with the amount of time you get to spend with staff on the ward?

7. To enhance status or social approval:

Have other patients and staff been treating you with respect this last week?

Do you feel other patients or staff look down on you?

Do people who stand up for themselves or who act aggressively get treated differently on this
ward?

240
What would have happened if you had not been aggressive?

Would other patients have treated you differently?

Do you think people will treat you differently now?

8. Following instruction (by others or through command type auditory hallucinations):

Had anybody told you to be aggressive?

If yes, what did they tell you to do?

Did you hear any voices telling you to be aggressive?

What would happen if you did not obey these voices?

Would you have missed out on something or would something bad have happened to you if
you did not obey the instruction?

9. To observe suffering in others:

Was the victim of your aggression hurt?

Do you feel bad about hurting them?

Do you enjoy seeing other people in pain?

241
 APPENDIX 19

Plain language statement for patients regarding Stage 2 of research

242
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

This project has been designed to investigate the reasons why people are aggressive.
After each aggressive incident in this hospital patients are being approached to participate in
this study.
The investigators of this study are Mr Michael Daffern, Psychologist, Forensicare and
University of South Australia and Professor Kevin Howells from the University of South
Australia. This research is being conducted as part of Mr Daffern’s PhD.
If you agree to participate you will be required to complete a brief interview asking
you about the incident you were involved in. This should take approximately half an hour
although we can take longer if you wish.
Taking part in this interview is entirely voluntary. Whether you agree to participate or
not will not influence your treatment and care at this hospital. You can withdraw from this
study at any time. If you wish to withdraw all information collected from you will be
destroyed. Your decision to withdraw will be respected and will not affect your treatment or
care at this hospital.
If you agree to participate the results of this assessment will be entirely confidential.
Results of the interview shall be kept in a locked filing cabinet in my office. If you would like
the details of this interview to be made available to your treating team this is possible.
Results from this research will be published through professional journals and
presented at conferences although no individual patient’s responses will be identifiable.
Questionnaires and

243
 If you have any complaints about the assessment process you may make a complaint
to myself. Alternatively you can make a complaint to your Case Manager or Unit Manager
who will then inform the research team. If you do not feel comfortable making a complaint to
any of these people you may make a confidential complaint to Anne Hems, the Consumer
Consultant who will pass on the complaint to Mr Daffern or Professor Howells. Alternatively,
you could contact the Ethics Officer of the Human research Ethics Committee at the
University of South Australia on (08) 83023956.

Michael Daffern Professor Kevin Howells

Argyle Ward University of South Australia
Thomas Embling Hospital Ph 08 83020777
Ph 03 94959207

244
 APPENDIX 20

Consent form for patients to participate in Stage 2 of research

245
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

I ……………………………………………. understand that I have been asked to

participate in this study and I give my consent to participate by signing this form. I understand
that:

1. If I do not volunteer or decide to withdraw from the study at any time that my
decision will be accepted.
2. My consent to participate is voluntary and I may withdraw at any time. I do not
have to give a reason for the withdrawal of my consent.
3. If there are particular questions I do not wish to answer I do not have to do so.
4. I understand that all information will be handled in the strictest confidence and that
my participation will not be individually identifiable in any reports.

Signature:………………………………… Date:……………………………………

Signature:………………………………… Date:……………………………………

Michael Daffern
Forensicare and University of South Australia

246
 APPENDIX 21

Consent form for staff to access details of the patient’s responses to Stage 2 of the research

247
 A study of the purpose, causes, and consequences of psychiatric inpatient aggression

I ……………………………………………. hereby give permission for the details of

this research project to be shared with my treating team.

Signature:………………………………… Date:……………………………………

Witness:…………………………………. Date:……………………………………

Michael Daffern
Forensicare and University of South Australia

248
APPENDIX 22

Results

249
The Relationship Between Purpose and Predisposing Characteristics
Age
Patients who were aggressive to reduce social distance were older (M = 38.45, SD =
16.68) when compared to those who did not (M = 31.93, SD = 10.41) (t(100) = -2.070, p =
.0001). Patients who were aggressive when there was no purpose evident were older (M =
44.68, SD = 20.20) when compared to those who did not (M = 31.82, SD = 10.07) (t(100) = -
2.070, p = .0001).
There was no significant difference in the ages of patients who were aggressive
following a demand for activity (M = 32.84, SD = 11.76) when compared to those who did
not (M = 33.26, SD = 12.29) (t(100) = .190, p = n.s.). There was no significant difference in
the ages of patients who were aggressive following the denial of a request (M = 32.33, SD =
12.1) when compared to those who did not (M = 33.93, SD = 11.81) (t(100) = .366, p = n.s.).
There was no significant difference in the ages of patients who were aggressive following
provocation (M = 32.67, SD = 11.93) when compared to those who did not (M = 35.28, SD =
12.83) (t(99) = .981, p = n.s.). There was no significant difference in the ages of patients who
were aggressive as a consequence of frustration (M = 34.16, SD = 12.11) when compared to
those who did not (M = 30.64, SD = 11.39) (t(100) = -1.315, p = n.s.). There was no
significant difference in the ages of patients who were aggressive for instrumental purposes
(M = 35.49, SD = 14.52) when compared to those who did not (M = 32.19, SD = 10.92)
(t(100) = -.878, p = n.s.). There was no significant difference in the ages of patients who were
aggressive to enhance status or social approval (M = 35.49, SD = 14.52) when compared to
those who did not (M = 32.19, SD = 10.92) (t(100) = .866, p = n.s.). There was no significant
difference in the ages of patients who were aggressive following instruction (M = 38.05, SD
= 17.86) when compared to those who did not (M = 32.45, SD = 11.07) (t(100) = -1.194, p =
n.s.). There was no significant difference in the ages of patients who were aggressive to
observe suffering (M = 31.89, SD = 9.01) when compared to those who did not (M = 33.14,
SD = 12.23) (t(100) = .141, p = n.s.).
Psychotic Disorder
Patients who did not have a psychotic illness were more likely to be aggressive in
response to a demand for activity (16 of 19, or 84.2%) when compared with patients with a
psychotic illness (41 of 83, or 49.4%) (χ2(1) = 7.600, p = .006). Patients with a psychotic
illness were less likely to be aggressive as a consequence of frustration (52 or 62.7%) when
compared to patients who did not have a psychotic illness (17 or 89.5%) (χ2(1) = 5.083, p =
.024). Patients with a psychotic illness were less likely to be aggressive for instrumental
purposes (19 or 22.9%) when compared to patients who did not have a psychotic illness (9 or

250
47.44%) (χ2(1) = 4.651, p = .031). Patients with a psychotic illness were less likely to be
aggressive to reduce social distance (8 or 9.6%) when compared with patients who did not
have a psychotic illness (8 or 42.1%) (χ2(1) = 12.322, p = .000).
There was no significant difference in the proportion of patients with a psychotic
illness being aggressive following the denial of a request (46 or 55.4%), when compared to
those patients who did not have a psychotic illness (11 or 57.9%) (χ2(1) = .038, p = n.s.).
There was no significant difference in the proportion of patients with a psychotic illness being
aggressive following provocation (75 or 90.4%), when compared to those patients who did
not have a psychotic illness (14 or 77.8%) (χ2(1) = 2.237, p = n.s.). There was no significant
difference in the proportion of patients with a psychotic illness being aggressive to enhance
status or social approval (48 or 57.8%), when compared to those patients who did not have a
psychotic illness (13 or 68.4%) (χ2(1) = .721, p = n.s.). There was no significant difference in
the proportion of patients with a psychotic illness being aggressive following instruction (9 or
10.8%), when compared to those patients who did not have a psychotic illness (3 or 15.8%)
(χ2(1) = .364, p = n.s.). There was no significant difference in the proportion of patients with a
psychotic illness being aggressive to observe suffering (7 or 8.4%), when compared to those
patients who did not have a psychotic illness (4 or 21.1%) (χ2(1) = 2.559, p = n.s.). There was
no significant difference in the proportion of patients with a psychotic illness being aggressive
when there was no purpose evident (7 or 8.4%), when compared to those patients who did not
have a psychotic illness (2 or 10.5%) (χ2(1) = .084, p = n.s.).
Gender
Females (17 or 81%) were more likely to be aggressive following the denial of a
request when compared to males (32 or 48.5%) (χ2(1) = 6.827, p = .009). Females (19 or
90.5%) were also more likely to be aggressive as a consequence of frustration when compared
to males (40 or 60.6%) (χ2(1) = 6.512, p = .011). They were also more likely (11 or 52.4%) to
be aggressive for instrumental purposes when compared to males (11 or 16.7%) (χ2(1) =
10.725, p = .001), and more likely (8 or 38.1%) to be aggressive to reduce social distance
when compared to males (6 or 9.1%) (χ2(1) = 9.926, p = .002).
There was no significant difference in the proportion of males (58 or 89.2%) who
were aggressive following provocation when compared with females (18 or 85.7%) (χ2(1) =
.191, p = n.s.), and no significant difference in the proportion of males (41 or 62.1%) who
were aggressive to enhance status or social approval when compared with females (10 or
47.6%) (χ2(1) = 1.381, p = n.s.). There was no significant difference in the proportion of
males (5 or 7.6%) who were aggressive following instruction when compared with females (4

251
or 19%) (χ2(1) = 2.261, p = n.s.). There was also no significant difference in the proportion of
males (6 or 9.1%) who were aggressive to observe suffering when compared with females (2
or 9.5%) (χ2(1) = .004, p = n.s.), and no significant difference in the proportion of males (4 or
6.1%) who were aggressive when there was no purpose evident when compared with females
(3 or 14.3%) (χ2(1) = 1.457, p = n.s.).
History of Violence
There was no significant difference (t(96) = -.366, p = n.s.) between patients who
were aggressive on at least one occasion following a demand for activity (M = 3.75, SD =
1.51) when compared to those who were not (M = 3.63, SD = 1.66) for Total Violence. There
was no significant difference (χ2(3) = 1.096, p = n.s.) between patients who were aggressive
on at least one occasion following a demand for activity when compared to those who were
not on the severity of the index offence, with 12.7% patients (7) who scored zero being
aggressive, 10.9% patients (6) who scored one being aggressive, 47.3% patients (26) who
scored two being aggressive, and 29.1% patients (16) who scored three being aggressive.
There was no significant difference (χ2(4) = 3.533, p = n.s.) between patients who were
aggressive on at least one occasion following a demand for activity when compared to those
who were not on previous violence, with 20.0% patients (11) who scored zero being
aggressive, 23.6% patients (13) who scored one being aggressive, 21.8% patients (12) who
scored two being aggressive, 25.5% patients (14) who scored three being aggressive, and
9.1% patients (5) who scored four being aggressive.
There was no significant difference (t(96) = .668, p = n.s.) between patients who were
aggressive on at least one occasion following the denial of a request (M = 3.60, SD = 1.56)
when compared to those who were not (M = 3.81, SD = 1.59) for Total Violence. There was
no significant difference (χ2(3) = 3.346, p = n.s.) between patients who were aggressive on at
least one occasion following the denial of a request when compared to those who were not on
the severity of the index offence, with 16.4% patients (9) who scored zero being aggressive,
12.7% patients (7) who scored one being aggressive, 45.5% patients (25) who scored two
being aggressive, and 25.5% patients (14) who scored three being aggressive. There was no
significant difference (χ2(4) = 2.102, p = n.s.) between patients who were aggressive on at
least one occasion following the denial of a request when compared to those who were not on
previous violence, with 18.2% patients (10) who scored zero being aggressive, 27.3% patients
(15) who scored one being aggressive, 23.6% patients (13) who scored two being aggressive,
18.2% patients (10) who scored three being aggressive, and 12.7% patients (7) who scored
four being aggressive.

252
 There was no significant difference (t(95) = -.504, p = n.s.) between patients who
were aggressive on at least one occasion following provocation (M = 3.71, SD = 1.54) when
compared to those who were not (M = 3.45, SD = 1.86) for Total Violence. There was no
significant difference (χ2(3) = .412, p = n.s.) between patients who were aggressive on at least
one occasion following provocation when compared to those who were not on the severity of
the index offence, with 12.8% patients (11) who scored zero being aggressive, 11.6% patients
(10) who scored one being aggressive, 43.0% patients (37) who scored two being aggressive,
and 32.6% patients (28) who scored three being aggressive. There was no significant
difference (χ2(4) = 1.405, p = n.s.) between patients who were aggressive on at least one
occasion following provocation when compared to those who were not on previous violence,
with 20.9% patients (18) who scored zero being aggressive, 27.9% patients (24) who scored
one being aggressive, 18.6% patients (16) who scored two being aggressive, 20.9% patients
(18) who scored three being aggressive, and 11.6% patients (10) who scored four being
aggressive.
There was no significant difference (t(96) = -1.408, p = n.s.) between patients who
were aggressive on at least one occasion as a consequence of frustration (M = 3.85, SD =
1.54) when compared to those who were not (M = 3.38, SD = 1.60) for Total Violence. There
was no significant difference (χ2(3) = 1.980, p = n.s.) between patients who were aggressive
on at least one occasion as a consequence of frustration when compared to those who were
not on the severity of the index offence with 13.6% patients (9) who scored zero being
aggressive, 9.1% patients (6) who scored one being aggressive, 47.0% patients (31) who
scored two being aggressive, and 30.3% patients (20) who scored three being aggressive.
There was no significant difference (χ2(4) = 4.696, p = n.s.) between patients who were
aggressive on at least one occasion as a consequence of frustration when compared to those
who were not on previous violence, with 15.2% patients (10) who scored zero being
aggressive, 27.3% patients (18) who scored one being aggressive, 22.7% patients (15) who
scored two being aggressive, 22.7% patients (15) who scored three being aggressive, and
12.1% patients (8) who scored four being aggressive.
There was no significant difference (t(96) = -1.341, p = n.s.) between patients who
were aggressive on at least one occasion for instrumental purposes(M = 4.04, SD = 1.77)
when compared to those who were not (M = 3.56, SD = 1.48) for Total Violence. There was
no significant difference (χ2(3) = 2.717, p = n.s.) between patients who were aggressive on at
least one occasion for instrumental purposes when compared to those who were not on the
severity of the index offence, with 11.1% patients (3) who scored zero being aggressive, 3.7%
patients (1) who scored one being aggressive, 51.9% patients (14) who scored two being

253
aggressive, and 33.3% patients (9) who scored three being aggressive. There was no
significant difference (χ2(4) = 1.972, p = n.s.) between patients who were aggressive on at
least one occasion for instrumental purposes when compared to those who were not on
previous violence, with 14.8% patients (4) who scored zero being aggressive, 29.6% patients
(8) who scored one being aggressive, 14.8% patients (4) who scored two being aggressive,
25.9% patients (7) who scored three being aggressive, and 14.8% patients (4) who scored four
being aggressive.
There was no significant difference (t(96) = .538, p = n.s.) between patients who were
aggressive on at least one occasion to reduce social distance (M = 3.50, SD = 1.37) when
compared to those who were not (M = 3.73, SD = 1.61) for Total Violence. There was no
significant difference (χ2(3) = 2.605, p = n.s.) between patients who were aggressive on at
least one occasion to reduce social distance when compared to those who were not on the
severity of the index offence, with 18.8% patients (3) who scored zero being aggressive,
12.5% patients (2) who scored one being aggressive, 25.0% patients (4) who scored two being
aggressive, and 43.8% patients (7) who scored three being aggressive. There was no
significant difference (χ2(4) = .863, p = n.s.) between patients who were aggressive on at least
one occasion to reduce social distance when compared to those who were not on previous
violence, with 25.0% patients (4) who scored zero being aggressive, 31.3% patients (5) who
scored one being aggressive, 18.8% patients (3) who scored two being aggressive, 12.5%
patients (2) who scored three being aggressive, and 12.5% patients (2) who scored four being
aggressive.
There was no significant difference (t(96) = -.311, p = n.s.) between patients who
were aggressive on at least one occasion to enhance status or social approval (M = 3.73, SD =
1.57) when compared to those who were not (M = 3.63, SD = 1.58) for Total Violence. There
was a statistically significant difference (χ2(3) = 10.215, p = .017) between patients who were
aggressive on at least one occasion to enhance status or social approval when compared to
those who were not on the severity of the index offence, with 16.7% patients (10) who scored
zero being aggressive, 16.7% patients (10) who scored one being aggressive, 31.7% patients
(19) who scored two being aggressive, and 35.0% patients (21) who scored three being
aggressive. There was no significant difference (χ2(4) = 4.103, p = n.s.) between patients who
were aggressive on at least one occasion to enhance status or social approval when compared
to those who were not on previous violence with 18.3% patients (11) who scored zero being
aggressive, 25.0% patients (15) who scored one being aggressive, 18.3% patients (11) who
scored two being aggressive, 26.7% patients (16) who scored three being aggressive, and
11.7% patients (7) who scored four being aggressive.

254
 There was a statistically significant difference (t(96) = -2.134, p = .035) between
patients who were aggressive on at least one occasion following instruction (M = 4.58, SD =
1.88) when compared to those who were not (M = 3.57, SD = 1.49) for Total Violence. There
was no significant difference (χ2(3) = 4.132, p = n.s.) between patients who were aggressive
on at least one occasion following instruction when compared to those who were not on the
severity of the index offence, with 8.3% patients (1) who scored zero being aggressive, 8.3%
patients (1) who scored one being aggressive, 25.0% patients (3) who scored two being
aggressive, and 58.3% patients (7) who scored three being aggressive. There was no
significant difference (χ2(4) = 4.400, p = n.s.) between patients who were aggressive on at
least one occasion following instruction when compared to those who were not on previous
violence, with 8.3% patients (1) who scored zero being aggressive, 33.3% patients (4) who
scored one being aggressive, 8.1% patients (1) who scored two being aggressive, 25.0%
patients (3) who scored three being aggressive, and 25.0% patients (3) who scored four being
aggressive.
There was no significant difference (t(96) = -.685, p = n.s.) between patients who
were aggressive on at least one occasion to observe suffering (M = 4.00, SD = 1.73) when
compared to those who were not (M = 3.66, SD = 1.55) for Total Violence. There was no
significant difference (χ2(3) = 1.466, p = n.s.) between patients who were aggressive on at
least one occasion following a to observe suffering when compared to those who were not on
the severity of the index offence, with 18.2% patients (2) who scored zero being aggressive,
9.1% patients (1) who scored one being aggressive, 54.5% patients (6) who scored two being
aggressive, and 18.2% patients (2) who scored three being aggressive. There was no
significant difference (χ2(4) = 4.529, p = n.s.) between patients who were aggressive on at
least one occasion following a to observe suffering when compared to those who were not on
previous violence with 0% patients (0) who scored zero being aggressive, 27.3% patients (3)
who scored one being aggressive, 27.3% patients (3) who scored two being aggressive, 36.4%
patients (4) who scored three being aggressive, and 9.1% patients (1) who scored four being
aggressive.
There was no significant difference (t(96) = .276, p = n.s.) between patients who were
aggressive on at least one occasion when there was no purpose evident (M = 3.56, SD = 2.30)
when compared to those who were not (M = 3.71, SD = 1.49) for Total Violence. There was
no significant difference (χ2(3) = 4.522, p = n.s.) between patients who were aggressive on at
least one occasion when there was no purpose evident when compared to those who were not
on the severity of the index offence, with 22.2% patients (2) who scored zero being
aggressive, 11.1% patients (1) who scored one being aggressive, 11.1% patients (1) who

255
scored two being aggressive, and 55.6% patients (5) who scored three being aggressive. There
was no significant difference (χ2(4) = 2.827, p = n.s.) between patients who were aggressive
on at least one occasion when there was no purpose evident when compared to those who
were not on previous violence, with 22.2% patients (2) who scored zero being aggressive,
44.4% patients (4) who scored one being aggressive, 0% patients (0) who scored two being
aggressive, 22.2% patients (2) who scored three being aggressive, and 11.1% patients (1) who
scored four being aggressive.
Substance Use
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion following a
demand for activity (M = 2.27, SD = 1.43) when compared to those who were not (M = 2.34,
SD = 1.57) (t(98) = .243, p = n.s.). There was no significant difference between the total
number of substances used over the lifetime for patients who were aggressive on at least one
occasion following a demand for activity (M = 3.11, SD = 1.33) when compared to those who
were not (M = 3.14, SD = 1.39) (t(96) = .110, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion following the
denial of a request (M = 2.27, SD = 1.54) when compared to those who were not (M = 2.34,
SD = 1.43) (t(98) = .243, p = n.s.). There was no significant difference between the total
number of substances used over the lifetime for patients who were aggressive on at least one
occasion following the denial of a request (M = 3.09, SD = 1.36) when compared to those
who were not (M = 3.16, SD = 1.35) (t(96) = .110, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion following
provocation (M = 2.38, SD = 1.50) when compared to those who were not (M = 1.67, SD =
1.30) (t(97) = -1.561, p = n.s.). There was no significant difference between the total number
of substances used over the lifetime for patients who were aggressive on at least one occasion
following provocation (M = 3.17, SD = 1.33) when compared to those who were not (M =
2.73, SD = 1.56) (t(95) = -1.030, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion as a
consequence of frustration (M = 2.24, SD = 1.47) when compared to those who were not (M
= 2.44, SD = 1.54) (t(98) = .632, p = n.s.). There was no significant difference between the
total number of substances used over the lifetime for patients who were aggressive on at least

256
one occasion as a consequence of frustration (M = 3.11, SD = 1.36) when compared to those
who were not (M = 3.16, SD = 1.35) (t(96) = .172, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion for instrumental
purposes (M = 1.93, SD = 1.59) when compared to those who were not (M = 2.44, SD =
1.43) (t(98) = 1.540, p = n.s.). There was no significant difference between the total number
of substances used over the lifetime for patients who were aggressive on at least one occasion
for instrumental purposes (M = 2.92, SD = 1.38) when compared to those who were not (M =
3.19, SD = 1.34) (t(96) = .878, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion to reduce social
distance (M = 1.81, SD = 1.38) when compared to those who were not (M = 2.39, SD = 1.50)
(t(98) = 1.438, p = n.s.). There was no significant difference between the total number of
substances used over the lifetime for patients who were aggressive on at least one occasion to
reduce social distance (M = 2.88, SD = 1.67) when compared to those who were not (M =
3.17, SD = 1.28) (t(96) = .801, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion to enhance
status or social approval (M = 2.38, SD = 1.50) when compared to those who were not (M =
2.17, SD = 1.48) (t(98) = -.684, p = n.s.). There was no significant difference between the
total number of substances used over the lifetime for patients who were aggressive on at least
one occasion to enhance status or social approval (M = 3.25, SD = 1.36) when compared to
those who were not (M = 2.92, SD = 1.33) (t(96) = -1.192, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion following
instruction (M = 2.67, SD = 1.78) when compared to those who were not (M = 2.25, SD =
1.45) (t(98) = -.910, p = n.s.). There was no significant difference between the total number of
substances used over the lifetime for patients who were aggressive on at least one occasion
following instruction (M = 3.58, SD = 1.68) when compared to those who were not (M =
3.06, SD = 1.30) (t(96) = -1.267, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion to observe
suffering (M = 2.80, SD = 1.69) when compared to those who were not (M = 2.24, SD =
1.46) (t(98) = -1.122, p = n.s.). There was no significant difference between the total number
of substances used over the lifetime for patients who were aggressive on at least one occasion

257
to observe suffering (M = 3.50, SD = 1.43) when compared to those who were not (M = 3.08,
SD = 1.34) (t(96) = -.933, p = n.s.).
There was no significant difference between the number of substances used in the year
prior to assessment for patients who were aggressive on at least one occasion when there was
no purpose evident (M = 1.63, SD = 1.51) when compared to those who were not (M = 2.36,
SD = 1.48) (t(98) = 1.344, p = n.s.). There was no significant difference between the total
number of substances used over the lifetime for patients who were aggressive on at least one
occasion when there was no purpose evident (M = 2.38, SD = 1.92) when compared to those
who were not (M = 3.19, SD = 1.28) (t(96) = 1.650, p = n.s.).
Shortened Social Behaviour Schedule
There was no significant difference between patients who were aggressive on at least
one occasion following a demand for activity (M = 3.56, SD = 2.82) when compared to those
who were not (M = 3.25, SD = 2.57) for SBS Social Withdrawal (t(99) = -.572, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion following a demand for activity (M = 1.16, SD = 1.93) when compared to those who
were not (M = 1.05, SD = 1.36) for SBS Depressed Behaviour (t(98) = -.323, p = n.s.), and
no significant difference between patients who were aggressive on at least one occasion
following a demand for activity (M = 12.54, SD = 5.93) when compared to those who were
not (M = 10.81, SD = 5.92) for SBS Total (t(98) = -1.445, p = n.s.). Patients who were
aggressive on at least one occasion following a demand for activity had a higher SBS Thought
Disturbance (M = 4.00, SD = 2.35) when compared to those who were not (M = 3.64, SD =
2.23) (t(99) = -.787, p = .035). Patients who were aggressive on at least one occasion
following a demand for activity also had a higher SBS Antisocial Behaviour (M = 3.82, SD =
2.87) when compared to those who were not (M = 2.91, SD = 2.68) (t(99) = -1.638, p = .007).
There was no significant difference between patients who were aggressive on at least
one occasion following the denial of a request (M = 3.23, SD = 2.54) when compared to those
who were not (M = 3.67, SD = 2.90) for SBS Social Withdrawal (t(99) = .802, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion following the denial of a request (M = 3.91, SD = 2.25) when compared to those
who were not (M = 3.76, SD = 2.38) for SBS Thought Disturbance (t(99) = -.336, p = n.s.),
and no significant difference between patients who were aggressive on at least one occasion
following the denial of a request (M = 1.20, SD = 1.66) when compared to those who were
not (M = 1.00, SD = 1.77) for SBS Depressed Behaviour (t(98) = -.572, p = n.s.). There was
no significant difference between patients who were aggressive on at least one occasion
following the denial of a request (M = 12.54, SD = 5.81) when compared to those who were

258
not (M = 11.11, SD = 6.14) for SBS Total (t(98) = -1.021, p = n.s.). Patients who were
aggressive on at least one occasion following the denial of a request had a higher SBS
Antisocial Behaviour (M = 4.00, SD = 2.99) when compared to those who were not (M =
2.71, SD = 2.41) (t(99) = -2.343, p = .007).
There was no significant difference between patients who were aggressive on at least
one occasion following provocation (M = 3.38, SD = 2.60) when compared to those who
were not (M = 3.83, SD = 3.56) for SBS Social Withdrawal (t(98) = .546, p = n.s.). There
was also no significant difference between patients who were aggressive on at least one
occasion following provocation (M = 4.01, SD = 2.31) when compared to those who were not
(M = 2.75, SD = 1.96) for SBS Thought Disturbance (t(98) = -1.802, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion
following provocation (M = 3.36, SD = 2.87) when compared to those who were not (M =
3.58, SD = 2.31) for SBS Antisocial Behaviour (t(98) = .254, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion
following provocation (M = 1.11, SD = 1.71) when compared to those who were not (M =
1.18, SD = 1.72) for SBS Depressed Behaviour (t(97) = .124, p = n.s.), and no significant
difference between patients who were aggressive on at least one occasion following
provocation (M = 11.86, SD = 6.02) when compared to those who were not (M = 11.27, SD =
5.97) for SBS Total (t(97) = -.307, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion as a consequence of frustration (M = 3.34, SD = 2.57) when compared to those
who were not (M = 3.61, SD = 2.99) for SBS Social Withdrawal (t(99) = .465, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion as a consequence of frustration (M = 3.94, SD = 2.41) when compared to those who
were not (M = 3.64, SD = 2.07) for SBS Thought Disturbance (t(99) = -.624, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion as a
consequence of frustration (M = 12.52, SD = 6.38) when compared to those who were not (M
= 10.33, SD = 4.75) for SBS Total (t(98) = -1.745, p = n.s.). Patients who were aggressive on
at least one occasion as a consequence of frustration had a higher SBS Antisocial Behaviour
(M = 3.88, SD = 2.95) when compared to those who were not (M = 2.48, SD = 2.52) (t(99) =
-2.401, p = .018). Patients who were aggressive on at least one occasion as a consequence of
frustration had a higher SBS Depressed Behaviour (M = 1.36, SD = 1.92) when compared to
those who were not (M = 0.61, SD = 0.97) (t(98) = -2.118, p = .037).
There was no significant difference between patients who were aggressive on at least
one occasion for instrumental purposes (M = 3.36, SD = 2.48) when compared to those who

259
were not (M = 3.45, SD = 2.80) for SBS Social Withdrawal (t(99) = .157, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion for
instrumental purposes (M = 3.82, SD = 2.36) when compared to those who were not (M =
3.85, SD = 2.29) for SBS Thought Disturbance (t(99) = .054, p = n.s.). There was also no
significant difference between patients who were aggressive on at least one occasion for
instrumental purposes (M = 1.50, SD = 1.82) when compared to those who were not (M =
0.96, SD = 1.64) for SBS Depressed Behaviour (t(98) = -1.439, p = n.s.), and no significant
difference between patients who were aggressive on at least one occasion for instrumental
purposes (M = 13.46, SD = 5.83) when compared to those who were not (M = 11.15, SD =
5.92) for SBS Total (t(98) = -1.760, p = n.s.). Patients who were aggressive on at least one
occasion for instrumental purposes had a higher SBS Antisocial Behaviour (M = 4.79, SD =
3.01) when compared to those who were not (M = 2.90, SD = 2.56) (t(99) = -3.145, p = .007).
There was no significant difference between patients who were aggressive on at least
one occasion to reduce social distance (M = 4.19, SD = 3.35) when compared to those who
were not (M = 3.28, SD = 2.56) for SBS Social Withdrawal (t(99) = -1.232, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion to reduce
social distance (M = 4.25, SD = 2.44) when compared to those who were not (M = 3.76, SD
= 2.28) for SBS Thought Disturbance (t(99) = -.774, p = n.s.). There was no significant
difference between patients who were aggressive on at least one occasion to reduce social
distance (M = 4.06, SD = 3.42) when compared to those who were not (M = 3.31, SD = 2.69)
for SBS Antisocial Behaviour (t(99) = -.989, p = .007). Patients who were aggressive on at
least one occasion to reduce social distance had a higher SBS Depressed Behaviour (M =
2.56, SD = 2.45) when compared to those who were not (M = 0.83, SD = 1.37) (t(98) = -
4.004, p = .0001). Patients who were aggressive on at least one occasion to reduce social
distance had a higher SBS Total (M = 15.06, SD = 6.85) when compared to those who were
not (M = 11.18, SD = 5.61) (t(98) = -2.450, p = .016).
There was no significant difference between patients who were aggressive on at least
one occasion to enhance status or social approval (M = 3.50, SD = 2.76) when compared to
those who were not (M = 3.32, SD = 2.65) for SBS Social Withdrawal (t(99) = -.332, p =
n.s.), and no significant difference between patients who were aggressive on at least one
occasion to enhance status or social approval (M = 3.87, SD = 2.29) when compared to those
who were not (M = 3.80, SD = 2.34) for SBS Thought Disturbance (t(99) = -.132, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion to enhance status or social approval (M = 3.63, SD = 3.04) when compared to those
who were not (M = 3.12, SD = 2.44) for SBS Antisocial Behaviour (t(99) = -.898, p = n.s.),

260
and no significant difference between patients who were aggressive on at least one occasion
to enhance status or social approval (M = 0.86, SD = 1.53) when compared to those who were
not (M = 1.46, SD = 1.89) for SBS Depressed Behaviour (t(98) = 1.752, p = n.s.). There was
no significant difference between patients who were aggressive on at least one occasion to
enhance status or social approval (M = 11.86, SD = 6.25) when compared to those who were
not (M = 11.71, SD = 5.59) for SBS Total (t(98) = -.129, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following instruction (M = 4.50, SD = 2.97) when compared to those who were
not (M = 3.28, SD = 2.65) for SBS Social Withdrawal (t(99) = -1.475, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion
following instruction (M = 4.50, SD = 2.43) when compared to those who were not (M =
3.75, SD = 2.28) for SBS Thought Disturbance (t(99) = -1.059, p = .035). There was no
significant difference between patients who were aggressive on at least one occasion
following instruction (M = 1.58, SD = 1.88) when compared to those who were not (M =
1.05, SD = 1.67) for SBS Depressed Behaviour (t(98) = -1.029, p = n.s.). Patients who were
aggressive on at least one occasion following instruction had a higher SBS Antisocial
Behaviour (M = 5.25, SD = 3.17) when compared to those who were not (M = 3.18, SD =
2.68) (t(99) = -2.457, p = .016). Patients who were aggressive on at least one occasion
following instruction had a higher SBS Total (M = 15.83, SD = 7.64) when compared to
those who were not (M = 11.25, SD = 5.52) (t(98) = -2.570, p = .012.).
There was no significant difference between patients who were aggressive on at least
one occasion to observe suffering (M = 4.20, SD = 3.16) when compared to those who were
not (M = 3.34, SD = 2.66) for SBS Social Withdrawal (t(99) = -.954, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion to
observe suffering (M = 3.30, SD = 2.16) when compared to those who were not (M = 3.90,
SD = 2.31) for SBS Thought Disturbance (t(99) = -.784, p = n.s.). There was also no
significant difference between patients who were aggressive on at least one occasion to
observe suffering (M = 0.80, SD = 1.14) when compared to those who were not (M = 1.14,
SD = 1.75) for SBS Depressed Behaviour (t(98) = .606, p = n.s.), and no significant
difference between patients who were aggressive on at least one occasion to observe suffering
(M = 14.50, SD = 7.55) when compared to those who were not (M = 11.50, SD = 5.73) for
SBS Total (t(98) = -1.521, p = n.s.). Patients who were aggressive on at least one occasion to
observe suffering had a higher SBS Antisocial Behaviour (M = 6.20, SD = 3.46) when
compared to those who were not (M = 3.12, SD = 2.57) (t(99) = -3.468, p = .001).

261
 There was no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident (M = 5.00, SD = 2.06) when compared to
those who were not (M = 3.73, SD = 2.30) for SBS Thought Disturbance (t(99) = -1.598, p =
n.s.), and no significant difference between patients who were aggressive on at least one
occasion when there was no purpose evident (M = 5.00, SD = 2.40) when compared to those
who were not (M = 3.27, SD = 2.81) for SBS Antisocial Behaviour (t(99) = -1.781, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion when there was no purpose evident (M = 0.75, SD = 1.39) when compared to those
who were not (M = 1.14, SD = 1.73) for SBS Depressed Behaviour (t(98) = .623, p = n.s.).
Patients who were aggressive on at least one occasion when there was no purpose evident had
a higher SBS Social Withdrawal (M = 5.33, SD = 3.24) when compared to those who were
not (M = 3.24, SD = 2.59) (t(99) = -2.263, p = .026), and a higher SBS Total (M = 16.63, SD
= 5.53) when compared to those who were not (M = 11.38, SD = 5.83) (t(98) = -2.448, p =
.016).
Novaco Anger Scale
There was no significant difference between patients who were aggressive on at least
one occasion following a demand for activity when compared to those who were not for NAS
Cognitive (M = 42.50, SD = 7.56, and M = 39.86, SD = 6.43) (t(46) = -1.287, p = n.s.), NAS
Behavior (M = 39.96, SD = 7.11, and M = 36.23, SD = 7.80) (t(46) = -1.734, p = n.s.), NAS
Arousal (M = 40.23, SD = 6.66, and M = 37.73, SD = 6.33) (t(46) = -1.327, p = n.s.) and
NAS Total (M = 122.69, SD = 18.85, and M = 113.82, SD = 19.01) (t(46) = -1.619, p = n.s.).
There was no significant differences between patients who were aggressive on at least
one occasion following the denial of a request when compared to those who were not for NAS
Cognitive (M = 40.61, SD = 7.82, and M = 42.25, SD = 6.07) (t(46) = .785, p = n.s.), NAS
Behavior (M = 38.71, SD = 7.95, and M = 37.60, SD = 7.21) (t(46) = -.497, p = n.s.), NAS
Arousal (M = 38.46, SD = 7.38, and M = 39.95, SD = 5.29) (t(46) = .770, p = n.s.) and NAS
Total (M = 117.79, SD = 21.00, and M = 119.80, SD = 16.95) (t(46) = .354, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following provocation when compared to those who were not for NAS
Cognitive (M = 41.61, SD = 7.212, and M = 37.75, SD = 5.50) (t(46) = -1.040, p = n.s.),
NAS Behavioral (M = 38.61, SD = 7.686, and M = 34.25, SD = 5.74) (t(46) = -1.103, p =
n.s.), NAS Arousal (M = 39.34, SD = 6.62, and M = 36.25, SD = 6.02) (t(46) = -.900, p =
n.s.) and NAS Total (M = 119.57, SD = 19.33, and M = 108.25, SD = 17.15) (t(46) = -1.129,
p = n.s.).

262
 There was no significant difference between patients who were aggressive on at least
one occasion as a consequence of frustration when compared to those who were not for NAS
Cognitive (M = 41.07, SD = 7.106, and M = 41.63, SD = 7.32) (t(46) = .265, p = n.s.), NAS
Behavior (M = 37.97, SD = 6.90, and M = 38.68, SD = 8.73) (t(46) = .318, p = n.s.), NAS
Arousal (M = 38.83, SD = 6.55, and M = 39.47, SD = 6.75) (t(46) = .330, p = n.s.) and NAS
Total (M = 117.86, SD = 18.10, and M = 119.79, SD = 21.34) (t(46) = .336, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion for instrumental purposes when compared to those who were not for NAS
Cognitive (M = 40.36, SD = 6.82, and M = 41.57, SD = 7.28) (t(46) = .488, p = n.s.), NAS
Behavior (M = 37.64, SD = 9.16, and M = 38.43, SD = 7.20) (t(46) = .302, p = n.s.), NAS
Arousal (M = 38.82, SD = 8.07, and M = 39.16, SD = 6.18) (t(46) = .151, p = n.s.) and NAS
Total (M = 116.82, SD = 22.57, and M = 119.16, SD = 18.47) (t(46) = .351, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion to reduce social distance when compared to those who were not for NAS
Cognitive (M = 40.25, SD = 7.0, and M = 41.50, SD = 7.21) (t(46) = .450, p = n.s.), NAS
Behavior (M = 36.75, SD = 7.23, and M = 38.55, SD = 7.72) (t(46) = .608, p = n.s.), NAS
Arousal (M = 37.75, SD = 7.25, and M = 39.35, SD = 6.49) (t(46) = .625, p = n.s.) and NAS
Total (M = 114.75, SD = 19.32, and M = 119.40, SD = 19.39) (t(46) = .620, p = n.s.).
There were no significant difference between patients that were aggressive on at least
one occasion to enhance status or social approval when compared to those who were not for
NAS Cognitive (M = 41.42, SD = 6.96, and M = 41.00, SD = 7.71) (t(46) = -.189, p = n.s.),
NAS Behavior (M = 38.33, SD = 6.54, and M = 38.07, SD = 9.79) (t(46) = -.122, p = n.s.),
NAS Arousal (M = 38.76, SD = 5.56, and M = 39.80, SD = 8.56) (t(46) = .506, p = n.s.) and
NAS Total (M = 118.52, SD = 16.42, and M = 118.87, SD = 21.05) (t(46) = .058, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following instruction when compared to those who were not for NAS Cognitive
(M = 42.33, SD = 3.98, and M = 41.14, SD = 7.48) (t(46) = -.380, p = n.s.), NAS Behavior
(M = 38.17, SD = 3.43, and M = 38.26, SD = 8.04) (t(46) = .028, p = n.s.), NAS Arousal (M
= 39.50, SD = 4.89, and M = 39.02, SD = 6.82) (t(46) = -.164, p = n.s.) and NAS Total (M =
120.00, SD = 9.21, and M = 118.43, SD = 20.35) (t(46) = -.185, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion to observe suffering when compared to those who were not for NAS Cognitive
(M = 43.33, SD = 6.81, and M = 41.16, SD = 7.19) (t(46) = -.509, p = n.s.), NAS Behavior
(M = 40.33, SD = 9.29, and M = 38.11, SD = 7.57) (t(46) = -.487, p = n.s.), NAS Arousal (M

263
= 40.00, SD = 7.00, and M = 39.02, SD = 6.61) (t(46) = -.247, p = n.s.) and NAS Total (M =
123.67, SD = 22.86, and M = 118.29, SD = 19.24) (t(46) = -.465, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident when compared to those who were not for
NAS Cognitive (M = 41.00, SD = 0.00, and M = 41.30, SD = 7.20) (t(46) = .041, p = n.s.),
NAS Behavior (M = 34.00, SD = 0.00, and M = 38.34, SD = 7.65) (t(46) = .562, p = n.s.),
NAS Arousal (M = 37.00, SD = 0.00, and M = 39.13, SD = 6.63) (t(46) = .318, p = n.s.) and
NAS Total (M = 112.00, SD = 0.00, and M = 118.77, SD = 19.43) (t(46) = .345, p = n.s.).
Functional and Dysfunctional Impulsivity Scale
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion following a demand for activity (M = 5.80, SD
= 2.92) when compared to those who were not (M = 4.81, SD = 2.15) (t(60) = -1.472, p =
n.s.). There was no significant difference on dysfunctional impulsivity between those patients
who were aggressive on at least one occasion following a demand for activity (M = 5.23, SD
= 2.73) when compared to those who were not (M = 4.81, SD = 3.10) (t(60) = -.557, p =
n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion following the denial of a request (M = 5.22, SD
= 2.53) when compared to those who were not (M = 5.58, SD = 2.82) (t(60) = .519, p = n.s.).
There was no significant difference on dysfunctional impulsivity between those patients who
were aggressive on at least one occasion following the denial of a request (M = 5.25, SD =
2.53) when compared to those who were not (M = 4.77, SD = 3.34) (t(60) = -.645, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion following provocation (M = 5.44, SD = 2.65)
when compared to those who were not (M = 4.60, SD = 2.70) (t(60) = -.679, p = n.s.). There
was no significant difference on dysfunctional impulsivity between those patients who were
aggressive on at least one occasion following provocation (M = 5.05, SD = 2.91) when
compared to those who were not (M = 5.00, SD = 2.83) (t(60) = -.039, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion as a consequence of frustration (M = 4.97, SD =
2.75) when compared to those who were not (M = 6.04, SD = 2.35) (t(60) = 1.560, p = n.s.).
There was no significant difference on dysfunctional impulsivity between those patients who
were aggressive on at least one occasion as a consequence of frustration (M = 5.26, SD =
2.84) when compared to those who were not (M = 4.70, SD = 2.99) (t(60) = -.737, p = n.s.).

264
 There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion for instrumental purposes (M = 4.76, SD =
2.61) when compared to those who were not (M = 4.81, SD = 2.15) (t(60) = 1.114, p = n.s.).
There was no significant difference on dysfunctional impulsivity between those patients who
were aggressive on at least one occasion for instrumental purposes (M = 5.24, SD = 2.56)
when compared to those who were not (M = 4.98, SD = 3.02) (t(60) = -.311, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion to reduce social distance (M = 5.40, SD = 2.37)
when compared to those who were not (M = 5.37, SD = 2.71) (t(60) = -038, p = n.s.). There
was no significant difference on dysfunctional impulsivity between those patients who were
aggressive on at least one occasion to reduce social distance (M = 4.20, SD = 2.10) when
compared to those who were not (M = 5.21, SD = 3.00) (t(60) = 1.017, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion to enhance status or social approval (M = 5.70,
SD = 2.53) when compared to those who were not (M = 4.63, SD = 2.79) (t(60) = -1.481, p =
n.s.). There was no significant difference on dysfunctional impulsivity between those patients
who were aggressive on at least one occasion to enhance status or social approval (M = 5.35,
SD = 3.02) when compared to those who were not (M = 4.37, SD = 2.45) (t(60) = -1.240, p =
n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion following instruction (M = 4.00, SD = 2.12)
when compared to those who were not (M = 5.60, SD = 2.66) (t(60) = -1.713, p = n.s.). There
was no significant difference on dysfunctional impulsivity between those patients who were
aggressive on at least one occasion following instruction (M = 5.67, SD = 3.28) when
compared to those who were not (M = 4.94, SD = 2.33) (t(60) = -.693, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion to observe suffering (M = 4.17, SD = 2.32)
when compared to those who were not (M = 5.50, SD = 2.66) (t(60) = 1.180, p = n.s.). There
was no significant difference on dysfunctional impulsivity between those patients who were
aggressive on at least one occasion to observe suffering (M = 7.00, SD = 2.53) when
compared to those who were not (M = 4.84, SD = 2.86) (t(60) = -1.776, p = n.s.).
There was no significant difference on functional impulsivity between those patients
who were aggressive on at least one occasion when there was no purpose evident (M = 4.00,
SD = 2.83) when compared to those who were not (M = 5.42, SD = 2.64) (t(60) = .744, p =
n.s.). There was no significant difference on dysfunctional impulsivity between those patients

265
who were aggressive on at least one occasion when there was no purpose evident (M = 8.00,
SD = 1.41) when compared to those who were not (M = 4.95, SD = 2.87) (t(60) = -1.487, p =
n.s.).
Simplified Rathus Assertiveness Schedule
There was no significant difference on the simplified RAS between those patients who
were aggressive on at least one occasion following a demand for activity (M = 109.18, SD =
26.98) when compared to those who were not (M = 103.15, SD = 20.61) (t(57) = -.942, p =
n.s.). There was no significant difference on the simplified RAS between those patients who
were aggressive on at least one occasion following the denial of a request (M = 106.74, SD =
27.35) when compared to those who were not (M = 106.21, SD = 19.80) (t(57) = -.082, p =
n.s.). There was no significant difference on the simplified RAS between those patients who
were aggressive on at least one occasion following provocation (M = 106.69, SD = 25.07)
when compared to those who were not (M = 104.80, SD = 16.66) (t(57) = -.164, p = n.s.).
There was no significant difference on the simplified RAS between those patients who were
aggressive on at least one occasion as a consequence of frustration (M = 104.00, SD = 26.47)
when compared to those who were not (M = 110.77, SD = 20.23) (t(57) = 1.033, p = n.s.).
There was no significant difference on the simplified RAS between those patients who were
aggressive on at least one occasion for instrumental purposes (M = 106.00, SD = 30.39) when
compared to those who were not (M = 106.74, SD = 21.90) (t(57) = .104, p = n.s.).
There was no significant difference on the simplified RAS between those patients who
were aggressive on at least one occasion to reduce social distance (M = 96.70, SD = 30.61)
when compared to those who were not (M = 108.53, SD = 22.75) (t(57) = 1.411, p = n.s.).
There was no significant difference on the simplified RAS between those patients who were
aggressive on at least one occasion to enhance status or social approval (M = 108.65, SD =
25.62) when compared to those who were not (M = 102.05, SD = 21.45) (t(57) = -.991, p =
n.s.). There was no significant difference on the simplified RAS between those patients who
were aggressive on at least one occasion following instruction (M = 111.22, SD = 23.41)
when compared to those who were not (M = 105.68, SD = 24.67) (t(57) = -.625, p = n.s.).
There was no significant difference on the simplified RAS between those patients who were
aggressive on at least one occasion to observe suffering (M = 113.77, SD = 28.02) when
compared to those who were not (M = 105.77, SD = 24.12) (t(57) = -.701, p = n.s.). There
was no significant difference on the simplified RAS between those patients who were
aggressive on at least one occasion following when there was no purpose evident (M = 94.00,
SD = 21.213) when compared to those who were not (M = 106.96, SD = 24.52) (t(57) = .737,
p = n.s.).

266
Psychotic Symptom Rating Scales
There was no significant difference between patients who were aggressive on at least
one occasion following a demand for activity (M = 3.18, SD = 5.25) when compared to those
who were not (M = 1.96, SD = 4.55) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.950, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion following a demand for activity (M = 3.43, SD
= 4.75) when compared to those who were not (M = 2.19, SD = 4.18) for PSYRATS
Hallucinations Factor 2 (Physical Characteristics) (t(59) = -1.057, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion
following a demand for activity (M = 3.83, SD = 5.40) when compared to those who were not
(M = 2.65, SD = 5.12) for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation)
(t(59) = -.859, p = n.s.). There was no significant difference between patients who were
aggressive on at least one occasion following a demand for activity (M = 8.29, SD = 5.68)
when compared to those who were not (M = 5.80, SD = 5.09) for PSYRATS Delusions
Factor 1 (Cognitive Interpretation) (t(54) = -1.708, p = n.s.). There was no significant
difference between patients who were aggressive on at least one occasion following a demand
for activity (M = 3.45, SD = 3.24) when compared to those who were not (M = 2.23, SD =
2.93) for PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(55) = -1.478, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following the denial of a request (M = 3.03, SD = 5.08) when compared to those
who were not (M = 2.12, SD = 4.81) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.710, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion following the denial of a request (M = 3.72, SD
= 4.96) when compared to those who were not (M = 1.72, SD = 3.59) for PSYRATS
Hallucinations Factor 2 (Physical Characteristics) (t(59) = -1.728, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion
following the denial of a request (M = 4.00, SD = 5.48) when compared to those who were
not (M = 2.36, SD = 4.90) for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation)
(t(59) = -1.199, p = n.s.). There was no significant difference between patients who were
aggressive on at least one occasion following the denial of a request (M = 7.67, SD = 5.77)
when compared to those who were not (M = 6.48, SD = 5.18) for PSYRATS Delusions
Factor 1 (Cognitive Interpretation) (t(54) = -.790, p = n.s.). There was no significant
difference between patients who were aggressive on at least one occasion following the denial
of a request (M = 3.21, SD = 3.12) when compared to those who were not (M = 2.46, SD =
3.18) for PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(55) = -.894, p = n.s.).

267
 There was no significant difference between patients who were aggressive on at least
one occasion following provocation (M = 2.66, SD = 4.96) when compared to those who
were not (M = 2.40, SD = 5.37) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.112, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion following provocation (M = 2.75, SD = 4.38)
when compared to those who were not (M = 4.60, SD = 6.31) for PSYRATS Hallucinations
Factor 2 (Physical Characteristics) (t(59) = .875, p = n.s.). There was no significant difference
between patients who were aggressive on at least one occasion following provocation (M =
3.32, SD = 5.34) when compared to those who were not (M = 3.40, SD = 4.98) for
PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) = .032, p = n.s.). There
was no significant difference between patients who were aggressive on at least one occasion
following provocation (M = 6.88, SD = 5.68) when compared to those who were not (M =
10.20, SD = 1.79) for PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(54) = 1.291,
p = n.s.). There was no significant difference between patients who were aggressive on at
least one occasion following provocation (M = 2.85, SD = 3.15) when compared to those who
were not (M = 3.40, SD = 3.29) for PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(55) = .374, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion as a consequence of frustration (M = 3.00, SD = 5.42) when compared to those
who were not (M = 2.00, SD = 4.02) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.755, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion as a consequence of frustration (M = 3.15, SD =
4.73) when compared to those who were not (M = 2.45, SD = 4.21) for PSYRATS
Hallucinations Factor 2 (Physical Characteristics) (t(59) = -.577, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion as a
consequence of frustration (M = 3.49, SD = 5.33) when compared to those who were not (M
= 3.05, SD = 5.28) for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) =
-.312, p = n.s.). There was no significant difference between patients who were aggressive on
at least one occasion as a consequence of frustration (M = 7.78, SD = 5.50) when compared
to those who were not (M = 6.10, SD = 5.52) for PSYRATS Delusions Factor 1 (Cognitive
Interpretation) (t(54) = -1.092, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion as a consequence of frustration (M = 3.44, SD =
3.14) when compared to those who were not (M = 1.95, SD = 2.97) for PSYRATS Delusions
Factor 2 (Emotional Characteristics) (t(55) = -1.764, p = n.s.).

268
 There was no significant difference between patients who were aggressive on at least
one occasion for instrumental purposes (M = 2.56, SD = 4.58) when compared to those who
were not (M = 2.67, SD = 5.13) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = .072, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion for instrumental purposes 2 (M = 3.00, SD =
4.36) when compared to those who were not (M = 2.86, SD = 4.63) for PSYRATS
Hallucinations Factor 2 (Physical Characteristics) (t(59) = -.105, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion for
instrumental purposes (M = 3.82, SD = 5.83) when compared to those who were not (M =
3.14, SD = 5.10) for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) = -
.453, p = n.s.). There was no significant difference between patients who were aggressive on
at least one occasion for instrumental purposes (M = 8.63, SD = 5.62) when compared to
those who were not (M = 6.60, SD = 5.44) for PSYRATS Delusions Factor 1 (Cognitive
Interpretation) (t(54) = -1.247, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion for instrumental purposes (M = 3.00, SD =
2.81) when compared to those who were not (M = 2.85, SD = 3.29) for PSYRATS Delusions
Factor 2 (Emotional Characteristics) (t(55) = -.157, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion to reduce social distance (M = 3.40, SD = 5.19) when compared to those who
were not (M = 2.49, SD = 4.94) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.528, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion to reduce social distance (M = 3.40, SD = 4.50)
when compared to those who were not (M = 2.80, SD = 4.57) for PSYRATS Hallucinations
Factor 2 (Physical Characteristics) (t(59) = -.378, p = n.s.). There was no significant
difference between patients who were aggressive on at least one occasion to reduce social
distance (M = 4.00, SD = 5.23) when compared to those who were not (M = 3.20, SD = 5.32)
for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) = -.438, p = n.s.).
There was no significant difference between patients who were aggressive on at least one
occasion to reduce social distance (M = 9.20, SD = 5.27) when compared to those who were
not (M = 6.74, SD = 5.23) for PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(54)
= -1.286, p = n.s.). There was no significant difference between patients who were aggressive
on at least one occasion to reduce social distance (M = 3.40, SD = 3.27) when compared to
those who were not (M = 2.79, SD = 3.13) for PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(55) = -.557, p = n.s.).

269
 There was no significant difference between patients who were aggressive on at least
one occasion to enhance status or social approval (M = 2.57, SD = 4.70) when compared to
those who were not (M = 2.79, SD = 5.60) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = .158, p = n.s.). There was no significant difference between patients
who were aggressive on at least one occasion to enhance status or social approval (M = 3.26,
SD = 4.64) when compared to those who were not (M = 2.11, SD = 4.25) for PSYRATS
Hallucinations Factor 2 (Physical Characteristics) (t(59) = -.924, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion to
enhance status or social approval (M = 3.67, SD = 5.35) when compared to those who were
not (M = 2.58, SD = 5.17) for PSYRATS Hallucinations Factor 3 (Cognitive Interpretation)
(t(59) = -.743, p = n.s.). There was no significant difference between patients who were
aggressive on at least one occasion to enhance status or social approval (M = 7.33, SD = 5.78)
when compared to those who were not (M = 6.81, SD = 4.97) for PSYRATS Delusions
Factor 1 (Cognitive Interpretation) (t(54) = -.311, p = n.s.). There was no significant
difference between patients who were aggressive on at least one occasion to enhance status or
social approval (M = 2.98, SD = 3.23) when compared to those who were not (M = 2.69, SD
= 2.98) for PSYRATS Delusions Factor 2(Emotional Characteristics) (t(55) = -.309, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following instruction (M = 3.22, SD = 4.76) when compared to those who were
not (M = 2.54, SD = 5.02) for PSYRATS Hallucinations Factor 1 (Emotional Characteristics)
(t(59) = -.380, p = n.s.). There was no significant difference between patients who were
aggressive on at least one occasion following instruction (M = 4.44, SD = 4.45) when
compared to those who were not (M = 2.63, SD = 4.53) for PSYRATS Hallucinations Factor
2 (Physical Characteristics) (t(59) = -1.111, p = n.s.). There was no significant difference
between patients who were aggressive on at least one occasion following instruction (M =
5.78, SD = 6.36) when compared to those who were not (M = 2.90, SD = 5.01) for
PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) = -1.527, p = n.s.). There
was no significant difference between patients who were aggressive on at least one occasion
following instruction (M = 10.22, SD = 4.52) when compared to those who were not (M =
6.60, SD = 5.54) for PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(54) = -1.846,
p = n.s.). There was no significant difference between patients who were aggressive on at
least one occasion following instruction (M = 3.78, SD = 2.77) when compared to those who
were not (M = 2.73, SD = 3.20) for PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(55) = -.919, p = n.s.).

270
 There was no significant difference between patients who were aggressive on at least
one occasion to observe suffering (M = 3.33, SD = 4.18) when compared to those who were
not (M = 2.56, SD = 5.05) for PSYRATS Hallucinations Factor 1 (Emotional Characteristics)
(t(59) = -.359, p = n.s.). There was no significant difference between patients who were
aggressive on at least one occasion to observe suffering (M = 5.33, SD = 4.56) when
compared to those who were not (M = 2.64, SD = 4.49) for PSYRATS Hallucinations Factor
2 (Physical Characteristics) (t(59) = -1.398, p = n.s.). There was no significant difference
between patients who were aggressive on at least one occasion to observe suffering (M =
6.83, SD = 6.49) when compared to those who were not (M = 2.95, SD = 5.05) for
PSYRATS Hallucinations Factor 3 (Cognitive Interpretation) (t(59) = -1.744, p = n.s.). There
was no significant difference between patients who were aggressive on at least one occasion
to observe suffering (M = 10.50, SD = 5.68) when compared to those who were not (M =
6.78, SD = 5.42) for PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(54) = -1.582,
p = n.s.). There was no significant difference between patients who were aggressive on at
least one occasion to observe suffering (M = 4.17, SD = 2.93) when compared to those who
were not (M = 2.75, SD = 3.16) for PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(55) = -1.051, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident (M = 6.00, SD = 4.24) when compared to
those who were not (M = 2.53, SD = 4.96) for PSYRATS Hallucinations Factor 1 (Emotional
Characteristics) (t(59) = -.976, p = n.s.). Patients who were aggressive on at least one
occasion when there was no purpose evident had a higher PSYRATS Hallucinations Factor 2
(Physical Characteristics) (M = 9.50, SD = .707) when compared to those who were not (M =
2.68, SD = 4.43) (t(59) = -2.161, p = .035). Patients who were aggressive on at least one
occasion when there was no purpose evident had a higher PSYRATS Hallucinations Factor 3
(Cognitive Interpretation) (M = 13.00, SD = 0.00) when compared to those who were not (M
= 3.00, SD = 5.04) (t(59) = -2.783, p = .007). There was no significant difference between
patients who were aggressive on at least one occasion when there was no purpose evident (M
= 13.50, SD = 3.54) when compared to those who were not (M = 6.94, SD = 5.46) for
PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(54) = -1.677, p = n.s.). There was
no significant difference between patients who were aggressive on at least one occasion when
there was no purpose evident (M = 5.50, SD = 2.12) when compared to those who were not
(M = 2.80, SD = 3.14) for PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(55) =
-1.200, p = n.s.).

271
Brief Psychiatric Rating Scale – Short Version
There was no significant difference between patients who were aggressive on at least
one occasion following a demand for activity (M = 3.47, SD = 1.54) when compared to those
who were not (M = 3.40, SD = 1.58) for BPRS Conceptual Disorganisation (t(95) = -.230, p
= n.s.). There was no significant difference between patients who were aggressive on at least
one occasion following a demand for activity (M = 2.96, SD = 1.90) when compared to those
who were not (M = 2.93, SD = 1.93) for BPRS Hallucinatory Behaviour (t(95) = -.101, p =
n.s.). There was also no significant difference between patients who were aggressive on at
least one occasion following a demand for activity (M = 3.81, SD = 1.68) when compared to
those who were not (M = 4.10, SD = 1.68) for BPRS Unusual Thought Content (t(95) = .845,
p = n.s.), and no significant difference between patients who were aggressive on at least one
occasion following a demand for activity (M = 10.28, SD = 4.20) when compared to those
who were not (M = 10.40, SD = 4.24) for BPRS Total (t(95) = .137, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following the denial of a request (M = 3.47, SD = 1.62) when compared to those
who were not (M = 3.40, SD = 1.47) for BPRS Conceptual Disorganisation (t(95) = -.213, p
= n.s.), and no significant difference between patients who were aggressive on at least one
occasion following the denial of a request (M = 2.98, SD = 2.02) when compared to those
who were not (M = 2.90, SD = 1.75) for BPRS Hallucinatory Behaviour (t(95) = -.197, p =
n.s.). There was also no significant difference between patients who were aggressive on at
least one occasion following the denial of a request (M = 4.13, SD = 1.78) when compared to
those who were not (M = 3.67, SD = 1.53) for BPRS Unusual Thought Content (t(95) = -
1.345, p = n.s.), and no significant difference between patients who were aggressive on at
least one occasion following the denial of a request (M = 10.62, SD = 4.47) when compared
to those who were not (M = 9.95, SD = 3.81) for BPRS Total (t(95) = -.774, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following provocation (M = 3.47, SD = 1.54) when compared to those who
were not (M = 3.20, SD = 1.75) for BPRS Conceptual Disorganisation (t(94) = -.508, p =
n.s.), and no significant difference between patients who were aggressive on at least one
occasion following provocation (M = 2.93, SD = 1.95) when compared to those who were not
(M = 3.00, SD = 1.56) for BPRS Hallucinatory Behaviour (t(94) = .109, p = n.s.). There was
also no significant difference between patients who were aggressive on at least one occasion
following provocation (M = 3.94, SD = 1.71) when compared to those who were not (M =
3.60, SD = 1.35) for BPRS Unusual Thought Content (t(94) = -.609, p = n.s.), and no
significant difference between patients who were aggressive on at least one occasion

272
following provocation (M = 10.35, SD = 4.27) when compared to those who were not (M =
9.80, SD = 3.62) for BPRS Total (t(94) = -.390, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion as a consequence of frustration (M = 3.54, SD = 1.55) when compared to those
who were not (M = 3.25, SD = 1.55) for BPRS Conceptual Disorganisation (t(95) = -.862, p
= n.s.), and no significant difference between patients who were aggressive on at least one
occasion as a consequence of frustration (M = 2.94, SD = 1.96) when compared to those who
were not (M = 2.97, SD = 1.81) for BPRS Hallucinatory Behaviour (t(95) = .073, p = n.s.).
There was also no significant difference between patients who were aggressive on at least one
occasion as a consequence of frustration (M = 3.91, SD = 1.74) when compared to those who
were not (M = 3.97, SD = 1.58) for BPRS Unusual Thought Content (t(95) = .168, p = n.s.),
and no significant difference between patients who were aggressive on at least one occasion
as a consequence of frustration (M = 10.40, SD = 4.41) when compared to those who were
not (M = 10.19, SD = 3.76) for BPRS Total (t(95) = -.234, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion for instrumental purposes (M = 2.96, SD = 1.56) when compared to those who
were not (M = 3.63, SD = 1.52) for BPRS Conceptual Disorganisation (t(95) = 1.925, p =
n.s.), and no significant difference between patients who were aggressive on at least one
occasion for instrumental purposes (M = 2.63, SD = 1.82) when compared to those who were
not (M = 3.07, SD = 1.93) for BPRS Hallucinatory Behaviour (t(95) = 1.026, p = n.s.). There
was also no significant difference between patients who were aggressive on at least one
occasion for instrumental purposes (M = 3.63, SD = 1.78) when compared to those who were
not (M = 4.04, SD = 1.64) for BPRS Unusual Thought Content (t(95) = 1.088, p = n.s.), and
no significant difference between patients who were aggressive on at least one occasion for
instrumental purposes (M = 9.33, SD = 4.22) when compared to those who were not (M =
10.71, SD = 4.14) for BPRS Total (t(95) = 1.463, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion to reduce social distance (M = 3.25, SD = 1.77) when compared to those who
were not (M = 3.48, SD = 1.51) for BPRS Conceptual Disorganisation (t(95) = .545, p = n.s.),
and no significant difference between patients who were aggressive on at least one occasion
to reduce social distance (M = 2.81, SD = 1.94) when compared to those who were not (M =
2.98, SD = 1.90) for BPRS Hallucinatory Behaviour (t(95) = .312, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion to reduce
social distance (M = 3.25, SD = 1.57) when compared to those who were not (M = 4.06, SD
= 1.68) for BPRS Unusual Thought Content (t(95) = 1.788, p = n.s.), and no significant

273
difference between patients who were aggressive on at least one occasion to reduce social
distance (M = 9.50, SD = 4.52) when compared to those who were not (M = 10.49, SD =
4.13) for BPRS Total (t(95) = .866, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion to enhance status or social approval (M = 3.38, SD = 1.55) when compared to
those who were not (M = 3.54, SD = 1.56) for BPRS Conceptual Disorganisation (t(95) =
.484, p = n.s.), and no significant difference between patients who were aggressive on at least
one occasion to enhance status or social approval (M = 2.82, SD = 1.94) when compared to
those who were not (M = 3.16, SD = 1.85) for BPRS Hallucinatory Behaviour (t(95) = .869, p
= n.s.). There was no significant difference between patients who were aggressive on at least
one occasion to enhance status or social approval (M = 3.82, SD = 1.68) when compared to
those who were not (M = 4.11, SD = 1.68) for BPRS Unusual Thought Content (t(95) = .829,
p = n.s.), and no significant difference between patients who were aggressive on at least one
occasion to enhance status or social approval (M = 10.03, SD = 4.03) when compared to
those who were not (M = 10.81, SD = 4.45) for BPRS Total (t(95) = .887, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion following instruction (M = 3.33, SD = 1.44) when compared to those who were
not (M = 3.46, SD = 1.57) for BPRS Conceptual Disorganisation (t(95) = .262, p = n.s.), and
no significant difference between patients who were aggressive on at least one occasion
following instruction (M = 4.50, SD = 1.51) when compared to those who were not (M =
3.85, SD = 1.69) for BPRS Unusual Thought Content (t(95) = -1.265, p = n.s.). There was no
significant difference between patients who were aggressive on at least one occasion
following instruction (M = 12.00, SD = 3.86) when compared to those who were not (M =
10.09, SD = 4.20) for BPRS Total (t(95) = -1.484, p = n.s.). Patients who were aggressive on
at least one occasion following instruction had a higher BPRS Hallucinatory Behaviour scale
score (M = 4.17, SD = 1.90) when compared to those who did not (M = 2.78, SD = 1.85)
(t(95) = -2.432, p = .017).
There was no significant difference between patients who were aggressive on at least
one occasion to observe suffering (M = 3.00, SD = 1.27) when compared to those who were
not (M = 3.50, SD = 1.58) for BPRS Conceptual Disorganisation (t(95) = 1.009, p = n.s.), and
no significant difference between patients who were aggressive on at least one occasion to
observe suffering (M = 2.45, SD = 2.07) when compared to those who were not (M = 3.01,
SD = 1.88) for BPRS Hallucinatory Behaviour (t(95) = .915, p = n.s.). There was also no
significant difference between patients who were aggressive on at least one occasion to
observe suffering (M = 3.55, SD = 1.97) when compared to those who were not (M = 3.98,

274
SD = 1.65) for BPRS Unusual Thought Content (t(95) = .801, p = n.s.), and no significant
difference between patients who were aggressive on at least one occasion to observe suffering
(M = 9.27, SD = 4.20) when compared to those who were not (M = 10.47, SD = 4.19) for
BPRS Total (t(95) = .888, p = n.s.).
There was no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident (M = 3.63, SD = 1.69) when compared to
those who were not (M = 3.43, SD = 1.54) for BPRS Conceptual Disorganisation (t(95) = -
.345, p = n.s.), and no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident (M = 3.00, SD = 1.51) when compared to
those who were not (M = 2.94, SD = 1.94) for BPRS Hallucinatory Behaviour (t(95) = -.080,
p = n.s.). There was no significant difference between patients who were aggressive on at
least one occasion when there was no purpose evident (M = 3.75, SD = 1.67) when compared
to those who were not (M = 3.94, SD = 1.69) for BPRS Unusual Thought Content (t(95) =
.311, p = n.s.), and no significant difference between patients who were aggressive on at least
one occasion when there was no purpose evident (M = 10.38, SD = 4.27) when compared to
those who were not (M = 10.33, SD = 4.21) for BPRS Total (t(95) = -.032, p = n.s.).
The Relationship Between Purpose with Severity, and Psychotic Symptoms at the Time of
Aggression
Patients who were aggressive in response to a demand for activity had a higher
PSYRATS Delusions Factor 1 (Cognitive Interpretation) (M = 1.73, SD = 3.81) when
compared with those that did not (M = 4.38, SD = 4.88) (t(68) = 2.249, p = .028). There was
no significant difference between those aggressive behaviours that occurred in response to a
demand for activity (M = 1.09, SD = 2.43) when compared with those that did not (M = 2.43,
SD = 2.80) for PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(69) = 1.941, p =
n.s.).
There was no significant difference between those aggressive behaviours that occurred
following the denial of a request (M = 4.62, SD = 5.19) when compared with those that did
not (M = 2.91, SD = 4.33) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68)
= -1.479, p = n.s.). There was no significant difference between those aggressive behaviours
that occurred following the denial of a request (M = 2.56, SD = 3.02) when compared with
those that did not (M = 1.68, SD = 2.53) on PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(69) = -1.312, p = n.s.).
There was no significant difference between those aggressive behaviours that occurred
following provocation (M = 3.45, SD = 4.74) when compared with those that did not (M =
3.93, SD = 4.71) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = .341, p

275
= n.s.). There was no significant difference between those aggressive behaviours that
occurred following provocation (M = 2.00, SD = 2.82) when compared with those that did not
(M = 2.07, SD = 2.50) on PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(68) =
.087, p = n.s.).
There was no significant difference between those aggressive behaviours that occurred
as a consequence of frustration (M = 4.00, SD = 4.85) when compared with those that did not
(M = 2.55, SD = 4.31) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = -
1.061, p = n.s.). There was no significant difference between those aggressive behaviours that
occurred as a consequence of frustration (M = 2.24, SD = 2.82) when compared with those
that did not (M = 1.50, SD = 2.54) on PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(69) = -1.205, p = n.s.).
There was no significant difference between those aggressive behaviours that occurred
for instrumental purposes (M = 5.63, SD = 4.66) when compared with those that did not (M =
3.27, SD = 4.68) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = -1.222,
p = n.s.). There was no significant difference between those aggressive behaviours that
occurred occurring for instrumental purposes (M = 3.13, SD = 2.59) when compared with
those that did not (M = 1.87, SD = 2.74) on PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(69) = -1.338, p = n.s.).
There was no significant difference between those aggressive behaviours that occurred
to reduce social distance (M = 0, SD = 0) when compared with those that did not (M = 3.76,
SD = 4.76) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = 1.567, p =
n.s.). There was no significant difference between those aggressive behaviours that occurred
to reduce social distance (M = 0, SD = 0) when compared with those that did not (M = 2.13,
SD = 2.77) on PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(69) = 1.529, p =
n.s.).
Patients who were aggressive to enhance status or social approval had a significantly
higher PSYRATS Delusions Factor 1 (Cognitive Interpretation) (M = 2.04, SD = 4.33) when
compared with those that did not (M = 4.43, SD = 4.74) (t(68) = 2.107, p = .039). There was
no significant difference between those aggressive behaviours that occurred to enhance status
or social approval (M = 1.27, SD = 2.69) when compared with those that did not (M = 2.44,
SD = 2.7) on PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(69) = 1.768, p =
n.s.).
There was no significant difference between those aggressive behaviours that occurred
following instruction (M = 9.00, SD = 0) when compared with those that did not (M = 3.46,
SD = 4.69) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = -1.171, p =

276
n.s.). There was no significant difference between those aggressive behaviours that occurred
following instruction (M = 5.00, SD = 0) when compared with those that did not (M = 1.97,
SD = 2.73) on PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(69) = -1.100, p =
n.s.).
There was no significant difference between those aggressive behaviours that occurred
to observe suffering (M = 4.50, SD = 6.36) when compared with those that did not (M = 3.51,
SD = 4.71) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68) = -.290, p =
n.s.). There was no significant difference between those aggressive behaviours that occurred
to observe suffering (M = 2.50, SD = 3.54) when compared with those that did not (M = 2.00,
SD = 2.74) on PSYRATS Delusions Factor 2 (Emotional Characteristics) (t(69) = -.253, p =
n.s.).
There was no significant difference between those aggressive behaviours that occurred
when there was no purpose evident (M = 9.00, SD = 0) when compared with those that did
not (M = 3.46, SD = 4.69) on PSYRATS Delusions Factor 1 (Cognitive Interpretation) (t(68)
= -1.171, p = n.s.). There was no significant difference between those aggressive behaviours
that occurred when there was no purpose evident (M = 5.00, SD = 0) when compared with
those that did not (M = 1.97, SD = 2.73) on PSYRATS Delusions Factor 2 (Emotional
Characteristics) (t(69) = -1.100, p = n.s.).
Severity of Aggression
There was no significant difference in severity when aggression followed a demand
for activity (M = 7.93, SD = 1.73) when compared to when it did not (M = 7.92, SD = 2.10)
(t(474) = -.070, p = n.s.). Aggressive behaviour following the denial of a request had a lower
mean severity (M = 7.48, SD = 1.983) than when it did not (M = 8.17, SD = 1.952) (t(474) =
3.711, p = .0001). Aggression following provocation had a higher mean severity (M = 8.07,
SD = 1.854) than those when it did not (M = 7.50, SD = 2.294) (t(473) = -2.724, p = .007).
Aggression occurring as a consequence of frustration had a lower mean severity (M = 7.55,
SD = 2.183) than when it did not (M = 8.45, SD = 1.533) (t(473) = -2.724, p = .0001).
There was no significant difference in severity when aggression occurred for
instrumental purposes (M = 7.55, SD = 2.26) when compared to when it did not (M = 7.98,
SD = 1.94) (t(474) = 1.619, p = n.s.). There was no significant difference in the severity of
aggression perpetrated to reduce social distance (M = 8.24, SD = 1.67) when compared to
when it did not (M = 7.89, SD = 2.02) (t(474) = -1.076, p = n.s.). Aggression to enhance
status or social approval had a higher mean severity (M = 8.28, SD = 1.764) than when it did
not (M = 7.75, SD = 2.070) (t(474) = -2.709, p = .007). Aggression following instruction had
a higher mean severity (M = 9.24, SD = 1.954) than when it did not (M = 7.88, SD = 1.976)

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(t(474) = -2.787, p = .006). Aggression perpetrated to observe suffering had a lower mean
severity (M = 9.33, SD = 1.940) than when it did not (M = 7.87, SD = 1.973) (t(474) = -
3.091, p = .002). There was no significant difference in severity of aggression when there was
no purpose evident (M = 8.75, SD = 1.92) when compared to when there was (M = 7.90, SD
= 1.99) (t(474) = -1.692, p = n.s.).

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