PhD research shows impact of aggression on staff and patients in forensic care

Swearing, hitting, kicking, spitting. Just some of the incidents of aggression that occur regularly in forensic psychiatric institutions. Nevertheless, little was known about its nature and extent. Which patients in particular exhibit this behavior? What is it like for staff to be confronted with aggressive patients? Moreover, what is the impact on other patients?

Nienke Verstegen, researcher at De Forensische Zorgspecialisten, conducted research into these questions at the Van der Hoeven Clinic in Utrecht and Amersfoort. For her research, she analyzed thousands of aggression incidents and interviewed 9 tbs patients and 25 staff members.

On July 6, 2023, she will receive her PhD from Maastricht University with her dissertation 'Hurt people hurt people. Characteristics and impact of inpatient aggression in forensic mental health care' under the supervision of Prof. Dr. Didden (Radboud University) and Prof. Dr. Vogel, extraordinary  professor of Forensic Care at the Faculty of Psychology and Neuroscience.

Nature and Extent of Aggression Incidents

The results of the study show that both verbal and physical aggression are common. In this, perpetration and victimization are close to each other. One moment a patient is a perpetrator, because the person strikes a blow, but the next moment a victim, because the other person strikes back. In addition, research shows that some forms of aggression sometimes go unnoticed but do have an impact, such as the so-called “micro-aggression”. This involves, for example, a subtle but offensive remark or a joke that is not actually a joke. Furthermore, it appears that self-harm patients in particular are more likely to show physical aggression toward others, such as pulling hair, hitting and kicking. Here it is notable that self-harm is especially prevalent among female patients. Also, compared to male patients, they are more likely to treat others violently.

Impact of aggression

Employees and patients report mostly the same effects after exposure to aggression. Among other things, they experience fear and anger and feel they must always be alert. Both groups are at risk of becoming traumatized. At the same time, employees sometimes struggle with the place aggression occupies in their work. Is it just part of the job and should they "therefore" be able to handle it? Or should they raise the alarm earlier and ask for help?


The study shows that there is a risk of (re)traumatization in forensic psychiatry. This applies to both staff and patients. It is therefore important that care institutions become more aware of the risk of trauma and develop special guidelines to prevent and limit (re)traumatization as much as possible. In this regard, training in the recognition of micro-aggression would be a good contribution. Healthcare institutions should also do more research into means that can be used at personal, team and organizational level to deal with aggression in order to ensure safety within the institutions.

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