Mental Health Nursing

156 Acute Mental Health Nursing
Table 7.3 Psychosocial interventions for violent behaviour
• Coping strategy enhancement – coping with distress resulting from hallucinations and
delusions
• Belief modification – modifying delusions and beliefs about voices
• Case management – assertive outreach, contingency planning, early intervention,
relapse prevention, therapeutic alliance
• Family interventions – increasing patient activity and decreasing contact with family,
stress management, problem solving
• Anger management – self-monitoring, relaxation, cognitive restructuring
• Medication management – assessment and management of side-effects, selfmedication
strategies
• Motivational interviewing – encouraging hope and motivation
• Problem-solving approaches – systematic approach to solving problems and dilemmas
working with service users with challenging and aggressive behaviours.
The vast majority of service users who are in secure settings have serious
mental illness and residual distressing positive symptoms (Ewers and
Doyle, 2001). As there is often a link between violent disturbed behaviour
and symptoms, any interventions which could increase the service
users’ self-management should play an integral part of risk assessment
and management. New training programmes have been developed for
mental health nurses working with forensic populations applying the
principles of psychosocial interventions (Gournay, 2000). Psychosocial
interventions, and in particular formulation-based cognitive behavioural
interventions (Table 7.3), are seen by many as the psychological
treatment of choice when working with violent and forensic populations
(McGuire, 1995; Novaco et al., 1997; Thomson, 2000; Wong and
Gordon, 2000) although further rigorous treatment trials are required in
this area.
Although people suffering from mental illnesses contribute little to
overall violence in society there is still a significant minority of mental
health service users who pose a risk to others, usually to those who work
or live with them. Therefore, there is a need for mental health nurses to
assess violence risk to try and distinguish between which service users
will be violent in in-patient and community settings, and to identify what
interventions are required to prevent violence and to minimise the risk to
the service user and others. A minimum basic framework for assessing
the risk of violence and aggression should include attempts to obtain a
history, the use of an objective measure integrated with the assessment
of their current presentation, a consideration of the context and identification
of protective factors. This approach should assist the mental health
nurse in reaching an informed judgement that will result in defensible
decision-making.