Kevin Howells

Readiness for anger management: clinical and theoretical issues

Anger management methods are a common and successful feature of contemporary cognitive behavioral therapy. Meta-analyses and narrative reviews of the outcome of anger management have been broadly supportive of the view that it is an effective approach. We argue in this paper that an important impediment to the future success of anger management is the failure to fully address the issue of treatment readiness. We discuss distinctive features of anger that make readiness a more important issue than it is for other problem emotions and affects. Relevant theoretical models of readiness are discussed and we review the components of a lack of readiness, including difficulties in establishing a therapeutic alliance. Progress in this area requires greater attention to the measurement and analysis of readiness, to its inclusion as an independent variable in outcome studies and to its clinical modification when readiness is low.

EssenCES, a short questionnaire for assessing the social climate of forensic psychiatric wards

BACKGROUNDnA supportive ward atmosphere is considered by many to be a precondition for successful treatment in forensic psychiatry, but there is a clear need for a valid and economic climate evaluation instrument.nnnAIMSnTo validate a short questionnaire, designed for assessing forensic psychiatric wards. Climate dimensions measured with the Essen Climate Evaluation Schema (EssenCES) are Therapeutic Hold, Patients Cohesion and Mutual Support and Safety (versus threat of aggression and violence).nnnMETHODnIn 17 forensic mental hospitals in Germany, patients and staff completed the EssenCES and other questionnaires. Problematic events were recorded over a period of 3 weeks on each ward.nnnRESULTSnThe anticipated three factor structure of the instrument was confirmed. The pattern of correlations also provided support for the validity of the subscales.nnnCONCLUSIONSnThe climate questionnaire is an economic and valid instrument for assessing the ward atmosphere in forensic psychiatry. Findings from a pilot study in England give confidence to the structural validity of the English version too.

A systematic review of measures of therapeutic engagement in psychosocial and psychological treatment.

This article reports a systematic review of engagement measures for psychosocial therapy. MEDLINE, EMBASE, and PsycINFO databases were searched to identify English-language studies (published 1980 to February 2010) that reported on an instrument/rating scale to measure engagement in psychosocial treatment for mental health difficulties. Forty-seven studies were identified, reporting information on 40 measures of treatment engagement. Although our findings suggest that therapeutic engagement appears to be considered an important construct to assess, they also reveal that there is little consensus in the definition of engagement employed. Few measures are generalizable across treatment settings and clinical populations, and limited information is reported on the indices of reliability and validity. It is concluded that further work is required to develop adequate measures of therapeutic engagement.

Affective Determinants of Treatment Engagement in Violent Offenders

Affective factors are likely to play a major role in determining the extent to which offenders are able to engage with, and benefit from, treatment. In this article, it is argued that the relationship between affect and treatment engagement may be understood in three ways: the access the client has to emotional states, the ability to express such states, and the willingness of the client to do this in the therapeutic session. It is suggested that affective determinants of treatment readiness can be understood with reference tomodels of emotional regulation and that attention to these affective factors in the early stages of treatment is likely to promote engagement, reduce attrition, and consequently improve treatment outcomes for violent offenders.

The EssenCES measure of social climate: A preliminary validation and normative data in UK high secure hospital settings

BACKGROUNDnThe social climate of forensic units is important but little investigated, in part because of the unavailability of a clinically practical and statistically sound measure.nnnAIMSnTo provide preliminary psychometric and normative data for the English version of the Essen Climate Evaluation Schema (EssenCES) in UK high-security hospital settings.nnnMETHODnA total of 324 staff and patients from three high-security hospital services completed the EssenCES, and a subgroup completed a range of other questionnaires related to therapeutic milieu and working environment (GMI, WAAM, WES-10).nnnRESULTSnThe original three-factor structure and satisfactory internal consistency were retained. The pattern of correlations between the EssenCES scales and other climate-related variables support the construct validity of the EssenCES measure, with the exception of the Patient Cohesion subscale.nnnCONCLUSIONSnAlthough preliminary, these data suggest that the English version of EssenCES may be a valid tool for assessing the social climate of high secure hospital settings in the UK, but a larger research study is required, covering a wider range of psychiatric disorders, types of service and levels of security.

Lost in Translation? Psychometric Properties and Construct Validity of the English Essen Climate Evaluation Schema (EssenCES) Social Climate Questionnaire.

The social climate of correctional (forensic) settings is likely to have a significant impact on the outcome of treatment and the overall functioning of these units. The Essen Climate Evaluation Schema (EssenCES) provides an objective way of measuring social climate that overcomes the content, length, and psychometric limitations of other measures. But the English translation of the EssenCES has yet to be sufficiently validated for use in forensic settings in the United Kingdom. The current study presents psychometric properties (factor structure and internal consistency) and an examination of construct validity with the English EssenCES. Satisfactory internal consistency was found for all EssenCES scales, and the expected three-factor structure was confirmed with both staff and residents and in prison and secure hospital settings using confirmatory factor analysis. Evidence to support construct validity was established using multilevel models, which showed statistically significant associations between scores on the EssenCES and scores on the Working Environment Scale, institutional aggression, and site security. Future validation work and potential practical applications of the EssenCES are discussed.

Brief anger interventions with offenders may be ineffective: a replication and extension

Anger-management interventions are widely delivered in the criminal justice and forensic mental health systems. Whilst previous research has generally supported the thesis that anger management is an effective intervention for anger problems in general there remains a need to determine its effectiveness with offender populations. This paper reports the results of a controlled outcome study of a 20 h anger-management program offered to offenders. Those receiving treatment showed improvements in their knowledge about anger, but showed little change on measures of anger and anger expression when compared to waiting-list controls. Scores on measures of treatment readiness and level of need for treatment were however, correlated with post-treatment improvement. These findings are discussed in terms of their implications for the assessment and selection of appropriate participants for offender anger-management programs.

The Function of Aggression in Personality Disordered Patients

It has been suggested that psychological interventions for personality disorders should focus on improving adaptive expression of the functional needs expressed through problematic behaviors such as aggression. The measurement of function is a necessary condition for devising a function-based treatment approach. Two studies that employ a method for assessing the functions of aggressive behavior in personality disordered patients are described by: (a) a retrospective analysis, through file review of inpatient aggressive behaviors and of the index offenses of patients admitted for treatment, and (b) an analysis of inpatient aggressive incidents where staff and patients were interviewed to elicit functions. Results showed that most aggression had the function of expressing anger, although other functions were also evident. The profile of functions observed in the inpatient studies was somewhat dissimilar to that observed in the studies of predominantly psychotic patients. Therapeutic implications of these findings are discussed.

Evaluating innovative treatments in forensic mental health: A role for single case methodology?

Abstract The rapid development of new forensic mental health services and treatments has created a demand for research and evidence relating to the effectiveness of interventions. Unfortunately, the literature on outcomes of treatments for mentally disordered offenders is sparse, compared with the substantial ‘what works’ literature regarding non-disordered offenders in the criminal justice system. In this paper we propose that single case research methodologies have a part to play in remedying this unsatisfactory state of affairs. The strengths and limitations of single case methods are discussed and comparisons made with RCTs, particularly in the context of dangerous and severe personality disorder (DSPD) services in England and Wales. Important strategic decisions that need to be made in relation to the implementation of single case experimental methods are outlined.

Alcohol-related violence defined by ultimate goals: a qualitative analysis of the features of three different types of violence by intoxicated young male offenders.

Based upon a functional approach to understanding aggression, we aimed to identify the occurrence of and to describe the features of three types of alcohol-related violence defined a priori by ultimate goals: (1) violence in pursuit of nonsocial profit-based goals, (2) violence in pursuit of social dominance goals, and (3) violence as defence in response to threat. A sample of 149 young men with offences of violence that were alcohol related was interviewed. Cases were classified and detailed information from the first ten cases in each class (N=30) was subjected to thematic analysis. Intoxicated violence in pursuit of nonsocial profit-based goals was opportunistic and motivated by the desire for more alcohol or drugs. Violence, in these cases, although serious, appeared to be brief. Intoxicated violence in pursuit of social dominance goals was typically precipitated by past or current insult or injury, and was accompanied by strong anger and an adrenaline rush. Attacks were ferocious, and robbing the victim was not uncommon, perhaps to inflict additional humiliation. Feelings of pride and satisfaction were typical and expressions of remorse were uncommon. Regarding intoxicated violence as defence in response to threat, attacks were often expected, and in some cases the respondent made a pre-emptive strike. Weapon use was common in this group. Fear was experienced, but so too was anger. Feelings of excitement were not reported and remorse was common. Further validation of these types is warranted, and the potential implications of these findings for prevention and treatment are discussed.