The Effects of an Aggression Management Program on Risk of Violence in Male Schizophrenia Patients

Abstract

Introduction Schizophrenia is a psychiatric disorder characterized by abnormalities in brain neurotransmitters, resulting in disturbances in emotional regulation, cognitive processes, perception, and general behaviors. Patients diagnosed with schizophrenia demonstrate a higher propensity for violent behavior compared to the general population, particularly in male patients, who exhibit a higher incidence of aggressive behaviors than females. Aggressive behaviors exhibited by patients with schizophrenia have profound effects on the patients themselves, disrupt familial relationships, and evoke apprehension within society. Such behaviors pose threats to both life and property, affecting the patients and those in their vicinity, leading to substantial social and economic ramifications. Due to these severe implications, patients exhibiting violent behaviors are considered psychiatric emergencies that necessitate immediate and comprehensive intervention.

Objectives 1) To compare the risk scores for violent behavior among male patients with schizophrenia within the experimental group at pre-intervention, post-intervention, and two-week follow-up phases, and 2) To compare the risk scores for violent behavior between the experimental and control groups of male patients with schizophrenia at pre-intervention, post-intervention, and two-week follow-up phases.

Design A quasi-experimental design with two-group repeated measures was employed, utilizing Ajzen’s Theory of Planned Behavior, which posits that an individual’s behavior is driven by their intentions and rational considerations. Individuals can effectively control their behaviors if they are committed to doing so, leading to the desired behaviors being sustained and enduring. This theory comprises three belief components: 1) Behavioral beliefs, 2) Normative beliefs, and 3) Control beliefs. Additionally, Rosenbaum’s concept of self-control was integrated, which asserts that individuals can refrain from certain actions through rational behavior control and patience to achieve desired outcomes. Individuals also have the ability to manage emotional stress and appropriately regulate their emotions according to the situation. The researchers incorporated these concepts to design therapeutic activities within a behavioral management program aimed at adjusting beliefs, attitudes, and perspectives toward aggressive behavior to be more appropriate and socially acceptable. The program consists of six activities: 1) Building positive relationships, 2) Enhancing understanding of illness and aggressive behavior, 3) Creating a safe environment, 4) Developing behavioral attitudes and beliefs, 5) Strengthening self-control confidence, and 6) Planning for relapse prevention. 

Methodology The sample consisted of 60 male patients with schizophrenia receiving treatment at a psychiatric hospital in a northeastern province. The participants were purposively selected based on the following inclusion criteria: 1) aged 20-59 years, 2) diagnosed with schizophrenia according to ICD-10 criteria (F20.0 - F20.9), 3) assessed with a high risk of violence using the Prasri Violence Severity Scale (PVSS) with pre-experiment scores ranging from 14 to 32, 4) stable psychiatric symptoms, 5) proficient in Thai communication, 6) no prior participation in an aggressive behavior therapy program, and 7) willingness to participate in the program. The sample was divided into two groups: 30 patients in the experimental group from the first male psychiatric ward and 30 patients in the control group from the second male psychiatric ward. The research instruments included: 1) a personal information questionnaire, 2) the PVSS, a 9-item scale with a content validity index (CVI) of .89, and 3) a 6-activity aggressive behavior management program. The content validity of the program was verified by three experts, yielding a CVI of .86. Data collection was conducted from July to October 2024. Due to the varying lengths of hospital stays and the average hospitalization period of 6-8 weeks, the experimental group was divided into three subgroups of 10 patients each, with staggered activity start times. Activities and data collection for the experimental group were conducted in the group activity room of the male psychiatric ward. Post-program and 2-week follow-up assessments of the risk of violence were conducted using the PVSS. The control group received regular nursing care, including individualized mental health education based on their needs, followed by immediate and 2-week follow-up PVSS assessments before discharge. Data were analyzed using descriptive statistics and two-way repeated measures ANOVA to compare the mean risk of violence scores between the experimental and control groups.

Results The sample was aged between 21 and 51 years, with a mean age of 36.62 years (SD = 8.98). The majority were single (75.00%) and had been diagnosed with schizophrenia for 1 to 5 years (56.67%). On average, they had been hospitalized with a median of 3 times. An analysis of the differences in personal characteristics between the experimental and control groups revealed no statistically significant differences. Prior to the experiment, the control group had a high mean score for risk of violence (M = 21.37, SD = 3.59), which decreased to a moderate level immediately post-experiment (M = 12.87, SD = 2.30) and increased to a high level at the 2-week follow-up (M = 15.87, SD = 3.31). In contrast, the experimental group had a high mean violence risk score before the experiment (M = 21.77, SD = 2.79), which decreased to a low level immediately post-experiment (M = 3.73, SD = 0.64) and increased to a moderate level at the 2-week follow-up (M = 6.53, SD = 2.81). The results of the two-way repeated measures ANOVA indicated that the violence risk in male patients with schizophrenia in the experimental group differed significantly across the pre-experiment, immediate post-experiment, and 2-week follow-up periods (F = 802.246, p < .001). The interaction between time and the program had a statistically significant effect on the violence risk in male patients with schizophrenia (F = 127.574, p < .001). Furthermore, an analysis of the violence risk between the experimental and control groups revealed a statistically significant difference (F = 106.529, p < .001).

Recommendation The findings of this study indicate that the aggressive behavior management program for male patients with schizophrenia effectively reduces the risk of violence in these patients. Psychiatric nurses can apply this program in the care of male patients with schizophrenia who share similar contexts with the study sample. Additionally, long-term studies may be beneficial in enhancing the safety of both patients and staff in psychiatric wards.