Purpose. This paper describes the treatment and effects of an integrated behavioural therapy programme for each of four male, psychotic in-patients considered to be intractably violent and dangerous.

Method. Each patient, after years of various combinations of treatments and extended periods in restraints, was administratively referred to psychology services. Extensive pre-treatment observation and evaluation revealed that, for each patient, anger was a significant link in the behavioural chains leading up to violent behaviour. Target behaviours were identified and tailored for each patient.

A strong therapeutic alliance was developed and maintained between each patient and the primary clinician. Integrated systems theory provided a framework for the synthesis of classical and operant conditioning approaches including (but not limited to) pre-treatment skill building, behaviour shaping, desensitization, and affect modulation with other psychological approaches. No aversive techniques were used. Extensive groundwork and ongoing staff development were devoted to building the trust, ability, confidence and effectiveness of the nursing staff who took part in implementing the interventions.

Results. All participants were able to increase and sustain prosocial behaviours and interactions including improved anger management skills. Violent behaviour and hours in seclusion and restraint were reduced and finally eliminated in each case. All participants were transferred to a less restrictive setting. These dramatic treatment successes rekindled a sense of hopefulness and empowerment in treatment staff.

Conclusions. Intractability is a relative term. Violent behaviour can be successfully eliminated even while psychotic phenomena persist. Integrated, relationship-based behavioural therapy—while labour intensive—is a valuable adjunct to other psychotherapeutic modalities for persistently violent, severely disordered individuals.