Treatment Responsivity of Aggressive Forensic Psychiatric Outpatients

Abstract

Aggression replacement training (ART) is widely used to reduce aggression. Results regarding its effectiveness, however, are inconclusive regarding adults and specific populations displaying severe aggression. The current open uncontrolled treatment study aimed at assessing the social skills and anger control modules of the ART to reduce aggression in forensic psychiatric outpatients (FPOs). Furthermore, characteristics associated with treatment outcome and dropout were examined. The results suggested that aggression changed during the ART. In addition, higher baseline levels of trait aggression were associated with greater reductions of aggression, whereas more cognitive distortions were associated with less reduction. Treatment dropouts were characterized by higher levels of psychopathic traits, proactive aggression, and more weekly substance use. As there was a considerable amount of dropout; it is important to assess risk of dropping out of treatment and, subsequently, improve treatment motivation. This might enhance treatment adherence which may lead to a more successful reduction of aggression.

Associations Between Neurocognitive Characteristics, Treatment Outcome, and Dropout Among Aggressive Forensic Psychiatric Outpatients

“…Participants had to rate their aggressive behavior over a period of 3 months. The SDAS as self-report demonstrated acceptable test–retest stability: intraclass correlation coefficient (ICC) baseline – halfway measurement = .686, p < .01; halfway – end of treatment measurement = .763, p < .01; and baseline – end of treatment measurement = .651, p < .01, and acceptable internal consistency: Cronbach’s α baseline = .76, halfway measurement = .82, and end of treatment measurement = .82 ( Smeijers et al, 2017 ).…”

“…Subsequently, in accordance with Smeijers et al (2017) , a linear mixed model (SPSS, Version 24) was used to examine whether implicit baseline characteristics moderated the treatment response. One advantage of this analysis is that it is possible to include individuals with incomplete data ( Heck, Thomas, & Tabata, 2013 ).…”

“…In general, ART is considered to be effective in decreasing aggressive behavior among forensic psychiatric outpatients (FPOs), even though there are also inconsistent results ( Brännström et al, 2016 ). Furthermore, studies indicate that a high disposition to act aggressively before treatment is associated with more change during treatment ( Hornsveld, van, Dam-Baggen, Leenaars, & Jonkers, 2004 ; Hornsveld, Kraaimaat, Muris, Zwets, & Kanters, 2014 ; Hornsveld, Nijman, Hollin, & Kraaimaat, 2008 ; Hornsveld, 2005 ; Hornsveld, Nijman, & Kraaimaat, 2008 ; Smeijers, Bulten, Buitelaar, & Verkes, 2017 ), whereas presence of cognitive distortions is thought to be related to a less rapid reduction of aggression ( Smeijers et al, 2017 ). In addition, patients who dropped out of ART are characterized by more weekly alcohol and cannabis use, higher levels of psychopathic traits, and proactive aggression ( Hornsveld et al, 2014 ; Hornsveld, Nijman, & Kraaimaat, 2008 ; Smeijers et al, 2017 ).…”

“…Hostile attribution/interpretation biases, however, refer to attributing hostile intent to others’ actions and to interpret emotional facial expressions as hostile. Studies regarding these specific biases revealed that hostility biases are associated with higher levels of aggressive behavior in children as well as adults and in student populations as well as offenders and FPOs (e.g., Chen, Coccaro, & Jacobson, 2012 ; Dodge, 2006 ; Schonenberg & Jusyte, 2014 ; Smeijers et al, 2017 ). Both biases could be important causes as well as maintaining factors of aggressive behavior.…”

“…The current open uncontrolled treatment study was in continuation of Smeijers et al (2017) and was now aimed (a) at examining whether neurocognitive characteristics at baseline were associated with the change in aggression during ART among FPOs with severe aggressive behavior; (b) to explore whether treatment dropouts differed from treatment completers in these underlying neurocognitive characteristics; and (c) to examine which characteristics, other than aggression, changed during treatment.…”