Pluralism in Psychiatry
Human Systems Therapy Techniques For Managing Aggressive Behavior In Psychiatric Services
Department of Psychiatry and Behavioral Sciences, University of Crete, & Society for System Therapy and Intervention on Individuals, Families and Larger Systems, Athens, Greece
The aim of this paper is to present certain Human Systems Therapy techniques, which have been successfully applied in managing aggressive behavior in psychiatric services. The main characteristics that differentiate Human Systems Therapy from other Systemic methods are the following: a) it is applicable on a family as well as on an individual level (multilevel); b) it includes techniques that address patient’s emotions and hence, it is applicable to psychotics and mentally retarded people; and c) it involves a third order cybernetics’ epistemology, which allows the use of knowledge steming from psychological and family studies for formulating hypotheses useful to therapy. The subjects of the current study were psychotics and mentally retarded adults. The techniques are the following: over/positive description, alchemy of behavior, changing emotional context in the ecology of mind, freedom of choice and expected consequences. The four techniques share a paradoxical element in the sense that the therapist is not confronting patient’s aggressive behavior in order to suppress it. On the contrary, the therapist acts as if the patient is not being aggressive. These techniques have been used for the last six years in psychiatric services, where they promoted complete avoidance of restraint. Besides, these techniques possibly contributed to shorten the hospitalization time of aggressive psychotics, and to improve significantly the personal abilities of profound mentally retarded adults. It is worthwhile both to further use these techniques as well as to test their effectiveness in research trials.
Research suggests a number of psychosocial methods in relation to reducing aggression in psychiatric services. These methods address primarily two types of psychiatric patients, namely psychotics and mentally retarded persons. The above patients present frequently with high aggression in psychiatric services. Factors in the psychiatric services contributing to aggression of patients include negative staff and patient relationships1,2, as well as factors related with the staff’s behavior3,4. In a study about causes of aggression in psychiatric services, when taking the patients’ perspective, the following patients’ views about staff were revealed: “There is no respect. Just because we are patients they think they can tell us to shut up”, “They don’t seem to care. I don’t think anyone trains them on how to deal with people”, “Staff seem to think once you are in here they do not need to bother”, “They treat us like prisoners and try to lock us up”. “There is a counterproductive atmosphere here”5.
The methods for reducing aggression in psychiatric services include those for reducing restraint and seclusion6-9. For a young person’s aggressive behavior there are methods such as Anger Control Training10, or Skills Training for chronically aggressive adolescents11, and for young children12,13. Most of the above methods are based on principles of behavioral and cognitive psychotherapy. According to our knowledge psychoanalytic methods in hospitalized patients or in psychiatric residential services are used only as supplementary. Family therapy has been used in relation to reducing aggression among family members. According to our current knowledge family therapy has not been applied in psychiatric services for reducing aggression. However, there is, in the Department of Psychiatry at the University of California, an Intensive Family Therapy Clinic for severe aggression among family members. In that clinic the treatment lasts up to 6 months. Within this time frame each family is seen approximately twice per week using the reflective team approach14.
Human Systems Therapy (HST)15,16 is a Systemic therapy applied to individuals, families and larger systems like groups or organizations including psychiatric units. It includes a number of paradoxical techniques that are suitable for both individual as well as family systems17.
The aim of this study is to present some techniques of Human Systems Therapy together with their basic assumptions and their potential use in Psychiatric Services settings. These techniques have the additional advantage to be applicable both to patients and their families as well as the patient’s relations with staff, the functioning of the unit as a whole, and the social milieu of the patient outside the hospital (reachingout).
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Main principles of the techniques for managing aggression.
There are a number of principles involved in Human Systems Therapy. More details the reader can find in previous publications by Paritsis15,16. For the scope of the current paper, only the principles that are relevant to managing aggression in psychiatric services are presented.
The multilevel definition of open systems
Human Systems are open living systems in the sense that they interact with their environment in order to maintain their structure and function. They are multilevel in nature consisting of cells, forming organisms, belonging to families and groups and to societies and states.
Human Systems have emergent properties, which are not pre -existent in their components. For example, the macromolecules of the cell give rise to life, the neural networks of the brain give rise to the psychological functions and intelligence, and human societies gave and continue to give rise to culture and human language.
The above emergent properties together with the environment act in a reciprocal way. For example, culture specifies the behavior of man, stimulation and information influences the functioning of the brain and the living conditions of the cell can alter its functioning. Thus, each level influences others in a reciprocal way. Consequently, the more levels we intervene at the more multiplicative outcome will be achieved. The practical consequence of HST is that the therapist can intervene at many different levels at the same time through using the same techniques. For example the therapist intervenes at an individual level, through individual therapy, at the level of family relations through family therapy, at the level of personal relations (therapy with other patients and the staff), and at the level of psychiatric unit as a whole.
Cognition and affect interact and are integrated
Traditional psychology and cognitive behavior therapy take the view that external information is received by the cognitive system and evaluated on the basis of past experiences, and the above evaluations are used to shape emotions and behavior.
Systemic views on the relation between cognition and affect highlight that they influence each other and are integrated at higher psychological processes’ level18,19. In recent years the interaction between cognition and affect has been empirically proved20-25. As a result, structures similar to that of schemas and scripts can be developed to include affective components as well, in order to directly influence emotions for altering behavior and cognition. These enriched structures are named zeugmas in HST.
Third order cybernetics and epistemology
Third order Cybernetics is discussed here only in relation to systemic epistemology. In first order cybernetics the study of the observed is sufficient for achieving knowledge. In second order cybernetics, besides the observed, the observer is also taken into account26. According to some theorists the observer is considered to be even more important, in relation to his/her properties of autopoesis, self-reference and autonomy27,28. It needs to be acknowledged at this point that, when applying second order cybernetics in systems and family therapy, scientific knowledge concerning bio-psychosocial causes is not much utilized.
The need for a third order cybernetic movement is suggested29. From an epistemological point of view third order cybernetics acknowledges that the relationships between the observer and the observed need to be taken into account. The consideration of these relationships (present-past) enables the observer to perceive the observed in a way that contributes to the survival, satisfaction and development of the observer. This is done through the process of evolution, learning and the progress of science as a result of the interactions in the past. While in second order cybernetics the observer is considered to be mostly independent from the observed (reality is constructed), in third order cybernetics the observer is considered as partly dependent on the observed.
The epistemology of third order cybernetics has three practical implications for therapy. The first is that a therapeutic change in relationships alters consequently perception and behavior. In the case of aggression a change in the context can facilitate the change in emotions, perceptions and behavior. The second practical implication is that scientific knowledge is useful concerning the bio-psycho- social causes of aggression, which have to be utilized in treatment. The third implication is that the above can be applied equally to all levels of human systems organization (individual, interpersonal, family, of the unit and of the social environment and network) enhancing therapeutic effectiveness.
Taking into account scientific knowledge regarding causes of aggression, Human Systems Therapy has developed a series of techniques. External causes of aggression include frustration, dissatisfaction, threat, danger, attack, physical pain, punishment, and other forms of aggression from third parties. HST techniques offer the opposite inputs than these of the external causes of aggression. As a result, these techniques facilitate the reduction of aggression and promote collaborative as well as friendly behavior.
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Main HST techniques for reducing aggression
In this section four techniques of HST will be presented in some detail. These techniques were carefully selected as they have proven to be the most useful in reducing aggressive behavior occurring in psychiatric services. In total, 15 HST techniques regarding aggressive behavior have been developed.
These techniques share three main characteristics. The first is that they address the emotional sphere of the patient. The second is that they are paradoxical in nature in the sense that the therapist does not react in the usual way of either confronting or defending patient’s aggressive behavior. The third is that they offer inputs opposite to those leading to aggression.
According to the overpositive description technique16 the therapist describes in an as positive as possible way both the properties as well as the behaviors of the client system. This needs to be done in a genuine way. For example the bad is presented as less bad, the good as very good etc.
As a result, the patient feels happier, more secure, calmer and friendlier. Consequently, the patient’s aggression is reduced. Furthermore, this technique enables the improvement of the therapeutic relationships between the patient and the therapist, the staff and his/her social environment in general.
It needs to be highlighted, at this point, that there are a number of family therapy techniques that seem to overlap with overpositive description. Namely, positive connotation30, compliments31, kerkroporta32, and emphasizing the positive33. A crucial difference between the above-mentioned techniques and overpositivedescription is that the later is a more intense and general technique, which is expected to be more effective.
Alchemy of behavior
The therapist demonstrates positive aspects of patient’s thoughts, feelings and/or actions towards the attacked person. In this line patient’s aggressive behavior against someone is described as being in favor of the latter. In case the recipient of the aggressive behavior is present then he/she is encouraged to respond positively.
For example, following the accusation of an angry schizophrenic patient towards his ugly wife that she was having sex with most of the men in their small town, and even with his brother, the therapist commented the following: “I understand that you love and admire your wife to the extent that you think that most of the men in this small town want to have sex with her; she seems to be irresistible even for your brother”. Then the patient smiled and replied: “I may be wrong”.
Changing the emotional context in the ecology of mind
The therapist pretends that ignores the aggressive behavior of the patient and invites him/her to activities and dialogue, which are pleasant and of interest to the patient.
Freedom of choice and expected consequences
The therapist comments on the patient’s aggressive actions as realizing or expressing the patient’s freedom of choice regarding the outcome of his action. Afterwards, the therapist invites the aggressive person to think about the results of his actions concerning his own benefit or damage on him or her. At the same time, the therapist does not comment at all (or negatively), on the result of the patient’s aggressive action or destruction on the patient’s environment (human or otherwise). Then the therapist continues that each time you want to have the result A you will do the behavior B, and if you do not want the result A then you will not do the behavior B.
For example a mother was telling her 26 years old daughter (and student of medicine) when to drink her milk in the morning. The therapist understands that the mother is upsetting her daughter and asks the mother what feelings the daughter has when her mother is instructing her. The mother says that the daughter is pleased. Then the therapist asks the daughter and the daughter says that she is becoming very upset on the situation. Then the doctor says to her mother “each time you want to upset your daughter you will tell her to drink her milk, and each time you want your daughter to be calm you will not tell her about milk”. Following this intervention the mother stopped instructing her daughter.
This technique may move the patient’s psychological functioning from a non-conscious emotional reaction to a conscious decision making.
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Some results of application in psychiatric services
The described techniques have been applied in two different settings involving psychiatric patients. The first one was a Psychiatric Intensive Care Unit and the second one was a residential home for adults with profound mental retardation.
Psychiatric Intensive Care Unit
The patients of this unit were mostly psychotic; 70% of the total sample were schizophrenics. There were 651 admissions in total within 3 years, during which these techniques were applied, and the average time of hospitalization was 23 days.
In this PICU these techniques were applied for three years and there was no restraint at all. This lack of restraint included both physical and mechanical, and it was accompanied with the occasional use of seclusion.
An indication of the degree of success of these techniques is that in 7 PICU in England the average number of restrained patients was 27% 34.
Residential home for adults with profound mental retardation
This residence opened 6 years ago. At the time, fifteen adults lived in the residential home (9 men and 6 women). The average age of the residents was 31,6 years. The subjects came from the National Child Psychiatric Hospital, which was closed due to psychiatric reformation that took place in Greece. Average time of previous hospitalization was 18 years.
In the beginning, the neighbors complained about the residents’ “aggressive” behavior, namely about their shouting and screaming. In addition, complains have stopped for more than a year and a half. Restraint and/or seclusion were avoided completely. Nowadays there is almost no severe violence. Together with the improvement in aggressive behavior significant improvement in the residents’ adaptive functioning has also taken place.
Discussion and conclusions
Violence and aggression in psychiatric services are major problems and both restraint as well as seclusion are used. By implementing HST techniques in the two above-mentioned settings, we did not need to use restraints, this being the best result regarding aggression in psychiatric services according to our knowledge. HST techniques are found to be successful both in psychotic patients, including schizophrenics, as well as in mentally retarded persons. Among the two categories the most difficult cases, according to our experience, were that of the mentally retarded, probably because psychotherapeutic methods are very difficult to be implemented in these cases. As HST techniques mainly address emotions they are expected to be more effective than any other techniques on these categories of patients. It is interesting that by applying these techniques there is an additive result over time concerning each patient.
Besides, these techniques possibly contribute to the sort time of hospitalization (23 days on average) of schizophrenics, to the better staff and patients relations, and to the considerable improvement of personal abilities of adults with profound mental retardation.
These techniques have been also applied to non hospitalized patients with good results as well.
In conclusion, HST techniques appear to be more affective so far for reducing aggression in psychiatric services and to have general applicability to all type of patients, especially those suffering psychosis or mental retardation. The most possible reason for that is that these techniques are primarly addressing emotions and not cognition, which is known to be more disturbed in psychosis and mental retardation.
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