Responding to serious antisocial behaviour: The psychological assessment and treatment of aggression and violence

What constitutes ‘antisocial behaviour’ varies across time, context and culture. Nonetheless, when we think about behaviour that is antisocial we usually think about people who have acted in ways that are aggressive, intimidating or destructive and which negatively impacts on the quality of life of others (Squires, 2008). Antisocial behaviour can include the misuse of public space, a disregard for community safety or personal wellbeing, or behaviour that has the potential to harm others or damage the environment. It can range from that which is socially unacceptable through to that which is illegal.

Many of the examples of antisocial behaviour listed in the boxed information below are, to some extent, most common in adolescence and early adulthood. Indeed, it is the behaviour of children and young adults that often attracts the highest levels of public scrutiny and media attention. However, it is important to remember that antisocial behaviour during adolescence is statistically normal, and only a small proportion of young people continue to behave in ways that are considered to be antisocial into adulthood. For example, only some young people with diagnosed childhood conduct disorders will go on to meet the criteria for antisocial personality disorder in adulthood (National Institute for Clinical Excellence, 2010), and decades of criminological research have shown that the prevalence of criminal involvement peaks during middle to late adolescence, then declines rapidly and tapers off for most by their early twenties (Farrington, 1995; Moffitt, 1993).

In this article we focus on one particular type of antisocial behaviour in more detail, that which is considered aggressive or violent. Violence represents the most harmful of all antisocial behaviours, with more than 1.5 million people killed by violence around the world each year and many more suffering non-fatal injuries and chronic health problems as a consequence of exposure to violence (see Krug et al., 2002). In addition, aggression is associated with a number of the less serious antisocial behaviours listed below, and people who are violent also often engage in a range of other antisocial behaviours. In Australia, particular concern has been expressed about domestic violence, violence in Indigenous communities, and violence that occurs in childhood and adolescence.

There are more than 200 different definitions of aggression and violence in the psychological literature (Parrott & Giancola, 2006) with the distinction between the two terms largely based on the extent of physical harm that is inflicted. For most researchers violence is considered to be the physical infliction of harm, whereas aggression is the intention to inflict harm, including both psychological discomfort and physical injury (Blackburn, 1993). Thus whilst all acts of violence can be considered to be aggressive, not all acts of aggression will be violent (Howells et al., 2008).

Adapted from McAtamney and Morgan (2009)

Why do some people behave antisocially?

Numerous theories have been put forward to explain why people act in ways that are antisocial, particularly when the behaviour in question is illegal. These theories range from large-scale sociological theories that consider the influence of social structure and local communities on behaviour, through to those which emphasise the influence of different sub-groups and cultures (McGuire, 2000). For most psychologists, however, the focus is on understanding individual differences. We are interested in answering questions such as why some people from particular backgrounds act antisocially whereas others do not, why some people never behave antisocially, and why some people desist from an early age whilst others continue their antisocial and criminal behaviour across the lifespan.

Social learning theory (Bandura, 1977) has proven to be particularly influential in helping to explain antisocial behaviour, and how aggressive and violent individuals might be treated. It suggests that antisocial behaviour is learned in much the same way as any other behaviour, through imitation, modelling and vicarious reinforcement, drawing attention to how we develop expectations and beliefs about what is considered to be normal and appropriate behaviour. There are also clear links between social learning theory and what are sometimes referred to as ‘developmental and life-course criminology’ theories (e.g., Catalano & Hawkins, 1996; Farrington, 2005; Moffitt, 1993; Sampson & Laub, 2005) which highlight how different life experiences can send an individual along a particular trajectory or pathway.

Although aggression can be understood as a response to broader social, economic, political and cultural conditions, it is psychological theories of aggression that have the most direct implications for the assessment and treatment of individuals who act aggressively. For example, the General Aggression Model (Anderson & Bushman, 2002; Gilbert & Daffern, 2010) recognises the role of both personal and situational factors in interpersonal violence, identifying social learning and social information processing deficits as important causes of aggression. Imitation (observing acts of aggression) and vicarious reinforcement (perceiving aggression to be rewarded) are considered to be important, as are broader mechanisms involved in the learning of aggressive scripts during childhood and adolescence. Theories such as the General Aggression Model can help to explain why, for example, aggressive youth tend to focus on more aggression-relevant environmental stimuli, exhibit a tendency towards hostile attributions about the causes of other people’s behaviour, and have a reduced range of skills for engaging in non-aggressive social interactions.

Other theories of aggression place greater emphasis on the differences in self-regulation that exist between aggressive and non-aggressive individuals. They consider, for example, how the trait of impulsivity as well as certain states (such as intoxication or stress) can override a broad general disposition to act aggressively. There has also been interest in understanding (and changing) the aversiveness of provoking events, given that it is this which typically elicits angry emotion and changes how the individual perceives and responds to the provocation.

Assessing aggressive and violent behaviour

In assessing aggressive and violent behaviour it is useful to remember that the behaviour is not random, even in highly antisocial individuals. Rather it is a result of individual sensitivities and tendencies and how these interact with environmental events. If we take the example of aggression towards others that occurs when the perpetrator is angry, we know that this typically occurs when the perpetrator perceives frustration from achieving important goals, where expected rewards fail to eventuate, or when events occur that are in some way experienced as aversive. The angry individual typically perceives the provoking agent to have acted deliberately and maliciously and feels justified in using aggression or violence.

We should not, however, assume that aggression will always serve the same function. Aggression that occurs in the context of the workplace, in the commission of other crimes, in an intimate personal relationship, or in response to specific mental health symptoms may have very different causes and functions. Culture will also influence how (and when) anger is expressed. Thus, whilst there may be common elements to aggression across different situations and between different individuals, it is particularly important to carefully assess the antecedents and consequences of each specific incident (see Howells, 1998) before deciding whether or how to intervene.

Assessing risk

Every assessment of an aggressive or violent individual should consider the extent to which other people are at risk and, when necessary, ensure that steps are taken to warn others when the risk is considered to be either serious or imminent (see ‘Psychologists’ duty to warn’ over page). A number of different risk assessment tools are now available that can help psychologists identify the presence of risk factors – which can be defined as any variables that increase the likelihood that an individual will be violent – and to make predictions about the likelihood of future violence. It is generally recommended that these tools are used whenever available (Australian Psychological Society, 2005) given that it is now well established that actuarial or structured assessments of risk are more accurate than unaided clinical assessments. However, it is important to remember that many of these tools have not been validated in Australia, and caution is warranted before using them with individuals from minority cultural groups or with those who identify as being from Aboriginal or Torres Strait Islander backgrounds.

Some risk assessment tools have been designed to predict violence generally, whereas others predict specific types of violence such as intimate partner violence, violence in psychiatric units, or sexual violence. It is important to choose the tool that produces the highest rate of predictive validity for the local population and setting in which it is to be used (Singh, Grann, & Fazel, 2011). It is also important that the risk assessment provides guidance on management and treatment and is sensitive to change, so that re-assessment is useful.

Most of the risk assessment tools that are available have been designed to identify individuals who are at increased risk for violence over medium to long time frames (e.g., 2-3 years). These measures typically incorporate a range of historical and dispositional factors that are either unchanging or which are likely to be relatively stable over time. There is some evidence to suggest that clinical risk factors have most value in the prediction of imminent risk. Clinical items included in one of the most widely used measures of violence risk, the HCR-20 (Webster, Douglas, Eaves, & Hart, 1997), include a lack of insight into mental health problems, negative or antisocial attitudes, active symptoms of major mental illness, impulsivity, and non-compliance with treatment attempts. Additionally, risk for violence is also thought to increase as the severity of substance use problems increases, particularly in relation to the use of alcohol, cocaine and amphetamines.

Treating aggression and violence

Criminological research, such as that conducted by McGee, Wickes, Corcoran, Bor and Najman (2011) in their prospective longitudinal study of mothers and their children in Brisbane, has shown that antisocial behaviour can be predicted by factors such as deficits in family processes and structure, poor school performance and early childhood aggression. These are all areas in which the psychologist can intervene, whether this be in terms of prevention, early intervention or treatment. Indeed, there is growing evidence that violence can be prevented though a range of strategies, including those that help to develop safe, stable and nurturing relationships between children and their parents and caregivers, that reduce the availability and harmful use of alcohol, that reduce access to guns, knives and pesticides, and which promote gender equality to prevent violence against women (World Health Organization, 2010).

Interventions for children with conduct disorder and related antisocial problems have a strong focus on working with parents and families, as well as on limiting the escalation of existing problems. The National Institute of Clinical Excellence (2013) recommends parenting training programs for children aged between 3 and 11 years, as well as child-focused social and cognitive problem-solving programs using a cognitive behavioural model. The recommendations for older children aged between 11 and 17 are for multimodal interventions, for example, multisystemic therapy.

It is the treatment of aggressive and violent adolescents and adults that provides the focus for many psychologists in their everyday practice. Anger management is one of the most widely used treatments for aggressive and violent clients, although intensive group treatment programs for serious violent offenders are also commonly delivered by correctional and forensic mental health services across Australia. These approaches are based on cognitive behavioural models which explain antisocial or aggressive behaviour in terms of socio-cognitive deficits that significantly impair the capacity to reason. In other words, the aggressive or violent client is seen as lacking the social problem-solving skills necessary to identify and deal with problems that are typically associated with everyday living. Accordingly the focus of intervention is often on changing maladaptive cognitions or cognitive distortions. In violence prevention programs for perpetrators of domestic violence the emphasis is often on changing those beliefs and attitudes towards women that facilitate aggressive and violent behaviour. Treatment is typically delivered in small group settings, and the group is encouraged to use the Socratic method to confront and challenge each other when comments are made that suggest the presence of cognitive distortions. Progress in the development of evidence-based intervention programs for known perpetrators who identify as being from Aboriginal and Torres Strait Islander backgrounds has been slow, although frameworks for culturally specific and culturally safe violence prevention programs have been developed (Day, Jones, Nakata, & McDermott, 2012).

Anger management

Anger management is an effective treatment that produces reliable clinical change. Beck and Fernandez (1998), in their meta-analysis of 50 outcome studies, concluded that individuals receiving cognitive behavioural anger management were 75 per cent better off, in terms of anger reduction, than untreated controls. However, there is less evidence that anger management works with those who have lengthy histories of serious violence (Heseltine, Howells, & Day, 2010).

Four core components of anger management appear to be important. First, exposure to provocation (either overt or covert) that leads to some level of emotional arousal. Second, cognitive change is required given that anger arousal is commonly understood to be mediated by the presence of automatic thoughts and beliefs. Third, self-management skills are needed to encourage the development of appropriate coping skills, and finally, relaxation to help to reduce physiological arousal and to manage stress. Acceptance-based approaches that teach clients to feel emotions and bodily sensations more fully are also increasingly being incorporated into anger management programs.

Violent offender treatment programs

Treating seriously violent offenders is both time consuming and difficult, particularly with individuals who have comorbid conditions that complicate engagement and are the focus of significant treatment in and of themselves (e.g., schizophrenia, personality disorder). Treatment typically occurs in small groups over a period of several months (equating to hundreds of hours of treatment time). These programs aim to increase motivation and commitment to change, to develop problem awareness through an investigation of personal risk factors for violent offending, and to help participants acquire the skills (such as cognitive restructuring, problem solving, and empathy and arousal management) to manage situations without resorting to violence (Serin, Gobeil, & Preston, 2009). Addressing beliefs that support violence, reducing the rehearsal of violent imagery and managing anger are also key components of contemporary interventions. In Australia most state correctional services offer this type of multi-module intensive treatment programs for seriously violent prisoners.

Reviews of the effectiveness of psychological treatments to reduce violent behaviour in offenders suggest that treatment can be successful (McGuire, 2008). Jolliffe and Farrington (2007), in a systematic review of violent offender treatment conducted for the Ministry of Justice (UK), cautiously concluded that “interventions with violent offenders were effective both at reducing general and violent re-offending, with a difference in percentage reconvicted of about eight to eleven per cent for general re-offending measures and seven to eight per cent for violent re-offending measures” (p. iv). They did note, however, that effectiveness varied considerably according to factors such as the content of the intervention, the delivery of the intervention, and the methodology of the study. Clearly, much can be done to improve the ways in which violent offender treatment is conceptualised and delivered, as well as evaluated.

For youth violent offenders, interventions are most effective when they are supported by evidence-based theories and utilise active learning methods (Andrews, Zinger, et al., 1990). Adolescents with established repertoires of violent behaviour are likely to require multi-modal interventions that include family and individual therapy addressing key criminogenic needs and problematic psychosocial adjustment, particularly in the areas of education, employment, family and friendships (Brown et al., 1997).

Challenges

One of the biggest challenges in working with aggressive and violent clients is engaging them in a process of behaviour change. Often the client’s goal in attending treatment will be to change the source of frustration, irritation or annoyance, rather than to take responsibility for his or her own feelings and behaviour. Some clients steadfastly maintain that they are justified in their behaviour and that it is appropriate for them to have acted aggressively or violently; many do not believe that any other reaction would have been appropriate. Habitually aggressive individuals may also be hostile towards treatment providers. Supervision and expert knowledge are required to engage these clients in a process of behaviour change.

Conclusion

It is clear that psychologists have an important role to play in the assessment, treatment, management and prevention of antisocial behaviour, especially when it causes serious harm. This is particularly the case for aggression and violence, and psychologists have come to play a leading role in the assessment and treatment of those who engage in this type of behaviour. Those who work in this area can make a significant difference to the wellbeing of individuals who are considered antisocial and the communities in which they live. This is most effectively done by carefully assessing risk, developing detailed case formulations that are based on considered assessments of the antecedents to aggressive behaviour and the functions it serves, and delivering treatments that engage violent individuals in a process of behaviour change that equips them with the skills that they need to meet their needs in more socially appropriate ways.

The principal author can be contacted at [email protected]