Treatment Responsivity of Aggressive Forensic Psychiatric Outpatients

• DOI: 10.1177/0306624X17747052
• Author: Jan Buitelaar,Danique Smeijers,Erik Bulten,Robbert-Jan Verkes
• Published date: 01 September 2018
• Date: 01 September 2018
• Subject Matter: Articles

https://doi.org/10.1177/0306624X17747052

International Journal of

Offender Therapy and

Comparative Criminology

2018, Vol. 62(12) 3834 –3852

© The Author(s) 2017

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DOI: 10.1177/0306624X17747052

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Article

Treatment Responsivity

of Aggressive Forensic

Psychiatric Outpatients

Danique Smeijers1,2,3, Erik Bulten3, Jan Buitelaar2,4,5,

and Robbert-Jan Verkes1,2,3

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.

Keywords

aggressive behavior, treatment, responsivity, forensic psychiatric patients

Disproportionate aggressive behavior, defined as aggression disproportionate to the

provocation (Siever, 2008), can have detrimental effects on victims, perpetrator, and

society (Gentile & Gellig, 2012; Patel & Taylor, 2012; World Health Organization

1Department of Psychiatry, Radboud University Medical Centre Nijmegen, The Netherlands

2Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands

3Forensic Psychiatric Centre Pompestichting, Nijmegen, The Netherlands

4Karakter Child and Adolescent Psychiatry University Center, Nijmegen, The Netherlands

5Department of Cognitive Neuroscience, Radboud University Medical Centre Nijmegen, The Netherlands

Corresponding Author:

Danique Smeijers, Centre for Forensic Psychiatry, Pompestichting, DO&O, tav Dr. Danique Smeijers,

Postbus 31435, 6503 CK Nijmegen, The Netherlands.

Email: daniquesmeijers@gmail.com

747052IJOXXX10.1177/0306624X17747052International Journal of Offender Therapy and Comparative CriminologySmeijers et al.

research-article2017

Smeijers et al. 3835

[WHO], 2007). Victims of violence, for instance, are at high risk of serious and lasting

physical damage and psychological problems, ranging from posttraumatic stress disor-

der to depression, anxiety disorders, substance abuse, and suicidal behavior (Krug,

Mercy, Dahlberg, & Zwi, 2002). Individuals who show aggressive and violent behav-

ior, however, are also characterized by multiple (social) problems, such as isolation,

greater legal costs, and absenteeism from work (Gentile & Gellig, 2012; Patel & Taylor,

2012; WHO, 2007). In addition, aggression is one of the most important reasons for

referral to forensic psychiatric institutions (Smith & Humphreys, 1997). Considering

the significant health, social, and economic consequences of aggression, there is a criti-

cal need for effective treatments of maladaptive aggressive behavior.

Generally, interventions based on principles of cognitive behavioral therapy (CBT)

are the interventions of first choice. A frequently used CBT-based intervention for

aggressive behavior is the aggression replacement training (ART; Brännström,

Kaunitz, Andershed, South, & Smedslund, 2016). The ART was originally developed

for use in children and adolescents and consists of three modules: (a) social skills

training, which focuses on responding in a prosocial way to difficult situations instead

of using aggression; (b) anger control training, which teaches techniques to exert

more control over aggressive thoughts and aggressive impulses; and (c) moral reason-

ing training, where one learns to recognize certain cognitive distortions relating to

aggression by themselves and think in a less egocentric way, by means of group dis-

cussions (Glick & Goldstein, 1987; Goldstein, Glick, & Gibbs, 1998). Originally, the

modules are given in three weekly sessions during 10 weeks. Over the years, the origi-

nal ART had been modified and applied for other settings, outcomes, and populations

(Brännström et al., 2016).

Commonly, among either juvenile or adult criminal offenders, as well as young

forensic psychiatric patients, positive results of the ART have been reported on recidi-

vism, cognitive distortions, and antisocial and aggressive behavior (Brännström et al.,

2016; Hornsveld, 2005; Hornsveld, Kraaimaat, Muris, Zwets, & Kanters, 2015;

Hornsveld, Nijman, Hollin, & Kraaimaat, 2008; Hornsveld, Nijman, & Kraaimaat,

2008; Hornsveld, van Dam-Baggen, Leenaars, & Jonkers, 2004; Landenberger &

Lipsey, 2005; Lipsey, Chapman, & Landenberger, 2001; Lipsey, Landenberger, &

Wilson, 2007). Still, results regarding the effectiveness of the ART might be consid-

ered as inconclusive. A recent systematic review documented that, at an individual

study level, ART indeed had positive effects on recidivism and anger control, social

skills, and moral reasoning in adolescents as well as in adults (Brännström et al.,

2016). However, overall the quality of the reviewed studies was found to be insuffi-

cient to conclusively claim that the ART is effective with risk rations ranging from .25

to .75. One of the major concerns is that the target groups have not been described

sufficiently. For instance, the behavior targeted by the ART is often described as anti-

social, which is rather broad, which makes it unclear for which type of (specific)

behavior the ART is most suitable as treatment. Furthermore, studies conducted among

adult populations consisted of heterogeneous samples (Brännström et al., 2016),

including violent offenders, individuals convicted for crimes such as robbery, and

even offenders with a history of psychosis. Such heterogeneous samples make it