Rehab Rounds: Behavioral Management of Aggression Through Teaching Interpersonal Skills

Introduction by the column editors: Aggressive behavior is a major problem among mentally ill people—in the community as well as in institutions. Epidemiologic data indicate that aggressive behavior occurs more often among individuals with psychotic disorders, especially when they have persecutory delusions and hallucinations or a comorbid substance use disorder (1). Aggressive individuals, with their high frequency of unpredictable verbal threats, throwing of objects, breaking of furniture and windows, and physical assaults, tend to populate long-term units in psychiatric hospitals disproportionately (2). Psychotropic medications rarely ameliorate these behaviors, and even when they are able to suppress aggression, they often result in unacceptable side effects, including "chemical restraint." Physical seclusion and restraint are often used but have never been shown to yield benefits beyond temporary control.The treatment of choice for aggressive and destructive behavior is applied behavior analysis and therapy (3), including interventions that can teach patients alternatives to aggression and reduce the likelihood of future aggression (4). Social skills training has been shown to be effective in building behavioral repertoires that enable individuals to have their social and material needs met in appropriate ways (5), rather than through creating disturbances. A spectrum of positively reinforcing methods, including differential reinforcement of other behavior, differential reinforcement of incompatible behavior, use of environmental antecedents to change the patient's affect, and use of the token economy, have been empirically validated as treatment interventions to reduce or eliminate aggression (6,7,8).To contain and manage aggressive and destructive behavior, special inpatient units have been established where behavior therapy procedures can be implemented effectively and competently by interdisciplinary staff, usually supervised by a behaviorally trained psychologist. This month's Rehab Rounds column describes a unit at Arizona State Hospital that employs a multimodal array of interventions—especially social skills training—to modify aggression and build adaptive repertoires.