Conflict in interaction as a result of deviation from role expectations

Whittington and Richter (2005) suggest that inpatient aggression shares many of the features of aggression occurring in other contexts, particularly when the antecedent involves interpersonal exchange. The authors articulate the concepts of ‘double

contingency’ and ‘aversive stimulation’ to offer a better understanding of the interaction dynamics which might promote aggressive behaviour. Double contingency stresses that each person can never be sure about the other person’s reaction; the only orientation each person has is the other person’s supposed direction. Thus, each person has their internal expectation of how the other person should behave. From here, a circular process of each other’s expectations begins; that is, both persons react not only to their own expectations, but also to their expectations of the other person’s expectations. A

175 typical abstract example of double contingency in inpatient settings is: nursing staff expect patients to wait patiently for their care; patients expect nursing staff to fulfil the caring tasks. It is, of course, in reality not that simplistic since patients and nursing staff generally do not behave entirely according to expectation and in a reciprocal manner. Because patients are detained and treated involuntarily, they may behave in a

challenging manner; nurses, as previously mentioned, play not only a caring role but also must maintain levels of security, which can vary from time to time as dictated by reviewed care plans for each patient. Any deviation from role expectation, it is

suggested, gives rise to distrust of one another (Whittington & Richter, 2005). Trust or distrust, in a sociological sense rather than psychological sense, only applies to the other person’s behaviour when role expectations in double contingency are not met by at least one person in the interaction exchange.

Following from double contingency and the rise of distrust is a resulting conflict of aversive stimulation, which is defined as: ‘any event that increases emotional and/or physiological arousal that is experienced as unpleasant by the person’ (Whittington & Richter, 2005). Aversive stimulation is relevant for both patient and nursing staff as there may be many potential sources in the inpatient context. It is argued that human sources of aversive stimulation are important because the aggression will often be targeted at the source. Patients have frequent close contact with nursing staff during the course of hospitalisation. The way in which nurses’ actions may potentially aversively stimulate the patient is three-fold: done deliberately (i.e., punitive); done deliberately but as part of caring (i.e., therapeutic, e.g., preventing self-harm); or done accidentally without any intent or awareness of impact (Whittington & Richter, 2005). As well as some of the actions by nurses that may be experienced as a form of aversive

stimulation for the patient, similarly, patient behaviour such as aggression, including self-harming behaviours (Whittington, Lancaster, Meehan, Lane & Riley, 2006) may be a form of aversive stimulation for nursing staff. In such instances, nursing staff may be more prepared to use coercive containment methods (Bowers et al., 2007) as guided by their emotional reactions and decision making processes.

176 8.1.3.1. Patient’s interpersonal style as a source of conflict

Interpersonal style, the characteristic way that people relate to, and view

themselves in social situations (Daffern et al., 2012) has been the subject of a growing body of research. The interest in interpersonal style is particularly important as it is suggested that how patients react to, for example, denial of requests and/or demands placed on them, is critical to the understanding of the interaction. Indeed, research has supported the view that aggressive patients can be differentiated from nonaggressive patients by their interpersonal style. Doyle and Dolan (2006) found that a measure of interpersonal style was associated with increased risk of violent behaviour by patients in a forensic mental health hospital, even whilst controlling for age, gender, length of stay and presence of major mental disorder. In another study which used the same

interpersonal measure (CIRCLE; Blackburn & Glasgow, 2006), Daffern et al., (2010) report that a coercive interpersonal style, characterised by extremity in both hostility and dominance, was associated with more frequent aggressive and self-harming behaviour. But, hostility and dominance was not independently related to aggression. It is,

therefore, suggested that aggressive patients would have elevated levels in both

dominance and hostility which is projected through their interpersonal style. This finding however cannot be asserted as conclusive, since Cookson, Daffern and Foley (2012) found that only the dominance scale of interpersonal style predicted aggression against staff. While different methods across studies have been adopted, including different measures of interpersonal style, the conclusions drawn must be considered tentative. However, the evidence thus far indicates that the study of patient’s interpersonal style is highly applicable to the understanding of inpatient aggression. Further, Doyle and Dolan (2006) found that a measure of self-reported anger correlated with an interpersonal style measure rated by a person whom has had interaction with the patient. Thus, particular interpersonal styles of persons can be validated by a measure of self-report.

There is empirical evidence to suggest that interpersonal style is independent of psychiatric symptomatology (Podubinksi, Daffern & Lee, 2012). The researchers

evaluated the relationship between a hostile-dominant interpersonal style and paranoia over a one-year period during hospitalisation. It was found that hostile-dominance was relatively stable over time even though symptoms of paranoia subsided. This finding reinforces the need to consider interpersonal style in the assessment of risk of inpatient

177 aggression, but also highlights the need to develop more targeted interventions to

manage such styles to prevent aggressive incidents. Promisingly, Daffern et al., (2013) showed that with the relevant treatment programme, and providing that treatment is completed, there is potential for the level of hostile-dominance to be reduced. They also found that a reduced hostile-dominant interpersonal style was associated with a

reduced likelihood of criminal recidivism in the community upon hospital discharge.

8.1.4. Managing patients’ interpersonal style and its impact on therapeutic