Data-driven team case formulation for violent and challenging behaviour on acute psychiatric wards: a controlled mixed methods study

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Background: Challenging behaviour is prevalent on acute psychiatric wards, negatively affecting staff, patients, and ward environments. Restrictive practices target inpatient violence but can be traumatising and dehumanising. Team case formulation increases staff understanding of challenging behaviour and generates strategies to reduce it, but research is limited. Methodology: This two-phase study investigated feasibility, acceptability, and effectiveness of team case formulation sessions with ward staff to reduce inpatient violence and challenging behaviour. In Phase 1, highly aggressive inpatients from five acute wards were either the focus of psychologist-led case formulation sessions (cases; N = 24) or were controls (N = 24). Post-formulation sessions, ward staff (N = 21) completed a feedback survey and change in patients’ violent and challenging behaviour was measured after staff-led interventions. In Phase 2, staff experiences were explored using in-depth semi-structured interviews and surveys (N = 12). Results: In Phase 1, case formulation appeared feasible, given adherence to implementation strategy and staff feedback, and staff-rated challenging behaviour reduced in cases, compared to controls. However, there were difficulties measuring change in violent incidents using electronic health records. In Phase 2, staff reported that formulation increased empathy for patients and sessions provided a space for stress-management and collaborative reflection, but they identified implementation barriers. Conclusion: Data-driven case formulation appears feasible, acceptable, and effective to reduce challenging behaviour. Findings suggest that it is helpful for patients, staff, and ward environments; data can meaningfully inform inpatient care; and both in-person and video call are viable methods of delivery.

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