A programme for aggression management in secure psychiatric settings trials the latest international research, reports Louise Hunt

Habitual aggressive behaviour is often a major barrier to people in secure psychiatric settings being able to make progress. But a new type of treatment programme being trialled in the North West aims to give people with complex histories of aggression the chance to move forward with their lives.

The Life Minus Violence programme is an intensive group and individual cognitive behavioural treatment package that its creators believe is the first to be based on the latest international research in aggression theory.

The programme is also a valiant example of joint-sector working. A pressing need for focused aggression treatment for patients in secure mental health settings based on up-to-date research was identified by forensic psychologists working separately at Mersey Care trust's psychological services and at sites run by Partnerships in Care, an independent provider of secure mental health facilities.

They felt traditional anger management programmes were too broad, looking at aggression as part of anti-social behaviour, such as alcohol or drugs misuse. By focusing purely on how aggression manifests itself, the programme aims to help participants understand and manage their aggression and, ultimately, lead an aggression-free life.

When they realised how closely their ideas matched, the four lead authors decided to work together on developing the programme. They are: Jane Ireland, a leader in violence treatment and her twin sister Carol Ireland, both at Ashworth Hospital high secure unit, along with Partnerships in Care chartered psychologist Emma Shillabeer and regional head of psychology Katie Bailey.

Developing the programme

The programme took a year and a half to develop, has involved a large team of contributors, and received start-up funding from the (late) Modernisation Agency's Enhancing Patient Care fund. The£250,000-a-year rolling fund is paying for a team of therapists at the Mersey Care trust. Partnerships in Care has also pooled its resources.

The programme has been running at Ashworth high secure unit since March and was later introduced at medium and low secure sites The Spinney, Kemple View and Arbury Court. Central Lancashire University is also working with Ashworth Hospital, as part of a research project.

Last month the programme won a Medical Futures innovation award for best public-private partnership in mental health and neuroscience.

While anger management programmes have been offered for many years, Dr Jane Ireland explains why she thinks the programme is the first of its kind: 'I feel strongly that other anger management programmes are general delinquency programmes and don't take into account core aggression theory and its developments in the last 15 years.'

Ms Bailey agrees: 'There was no other programme that met the needs of this complex client group, drawing on such a range of aggression theory and validated by international consultants.'

Psychologists from across the globe were invited to help develop the individual modules.

'The involvement of international consultants was fantastic. We e-mailed the consultants whose research has been most cited in these areas and everyone agreed to do it,' says Ms Bailey.

The resulting programme is based on a positive psychology approach rooted in emotional intelligence and social learning theories. It focuses on clients' strengths in managing their aggression, and what they learn when they are not being aggressive, rather than when they make mistakes.

'People tend to treat people with aggression as if they've got no skill in managing it,' says Dr Ireland.

The programme consists of nine treatment modules covering motivation, coping, the development of aggression, emotional regulation, empathy and emotional intelligence, information processing, consequences, interpersonal skills and relapse prevention. These are taken over around 125 treatment sessions or 300 clinical hours.

Ms Bailey adds: 'We hope to give them a care pathway, where theoretically they could start in a high secure unit and move through to medium and low secure units with refresher courses. It is about inclusion for a very difficult-to-include group.'

An important facet is that people with similar risks are put together for the group therapy. Dr Ireland says: 'We spend a lot of time selecting people for group sessions because there is evidence people with low-risk behaviour can be influenced by those with high risk.'

Study for men

A study has been set up at Ashworth Hospital with mentally disordered men who have been aggressive more than once. There are 14 participants undertaking the programme, alongside a control group with people who were suitable for it.

Dr Ireland says that already changes in clients' behaviour have been noted. 'The patients we are working with at Ashworth have been in seclusion for years so the fact they are managing to maintain treatment after five months is in itself pretty significant.

'We have seen changes in their appearance or they are getting better at reporting when they have disturbing thoughts.'

Of the medium and low secure units, Ms Bailey says: 'Clients have certainly identified that they need to undertake the programme and that their aggression is a major barrier. But it's too early to say what the impact is.'

Partnerships in Care is evaluating the programme across the different sites and NHS Ethics will evaluate the effectiveness of the programme run by Mersey Care trust after one year, as part of a four-year study.

If it proves effective the programme could produce multiple benefits to clients. Along with improving quality of life and safety in society, high secure units are very expensive, so if people can move through the system to lower secure facilities, then there are potential cost savings to be made.

Life Minus Violence's authors believe the programme has scope for nationwide uptake in a range of psychiatric and prison settings. Ms Bailey adds: 'I would say two-thirds of the population in medium and low secure units would benefit from the programme.'

'We believe it is as theoretically good as we can make it so there is no reason why it couldn't be rolled out nationally,' concludes Ms Bailey.