Introduction

Severely disturbed behaviour posing a risk to the patient, the treating team or other patients can co-exist with or arise out of acute and chronic forms of psychosis, although a direct relationship is often obscure. These behaviours may settle as soon as the florid aspects of a psychosis dissipate; at other times they may come more sharply into focus as the psychosis improves. On many occasions the intensive care aspect is, de facto, more about the management of challenging behaviours than any psychotic condition. A wide range of behaviours may be construed as challenging. Effectively any behaviour sufficiently persistently disruptive or dangerous to the treatment setting might be defined as challenging. Common examples in psychiatric settings are:

• non-compliance with medication

• extreme withdrawal on the ward

• physical violence to staff, other patients or property

• sexual aggression

• self-harm and suicide attempts

• firesetting

• persistent verbal abuse

Before considering psychological interventions it is important to note that the task of treating patients with a combination of psychotic and behavioural disorder is very frequently made more difficult by the fact that other dimensions of the patient's life may equally show impairment. Shepherd (1999) defines the ‘challenging behaviour group’ as having a combination of severe and intractable clinical symptoms, a range of behavioural problems and profound social dislocation. One might add problems of family conflict, degradation of living skills and perhaps disorders of personality.

Challenging behaviour within this conception is not a new phenomenon.