¶ … Social-Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness

Concept Introduction

Society as a whole understands that two major demographic predictors of violent behavior are being male and being young. Two major clinical predictors of violent behavior are a past experiential history of violence (e.g., in the home, the community, personal delivery or receipt of violent acts or behaviors) and substance abuse (i.e., alcohol and/or drugs). Recently, it has been established that a third factor may well partner with these clinical predictors to violent behavior - being 'severely' mentally ill and refusing or refraining from taking disease management medications.

Premise

Severely mentally ill people who take their disease management medications are not more dangerous than the general population. The MacArthur Foundation Study on violence and mental illness found that psychiatric patients without substance abuse influences were no more likely to demonstrate violent behavior than any other individual in the same environment.

Premise 2

Severely mentally ill people who do not take their disease management medications are more dangerous than the general population. Several studies conducted during the 1970's - admittedly not well controlled - seem to demonstrate that those with 'severe mental illness' who were following a routine of non-compliance had an arrest rate 10 times higher than the general population.

Later studies continued to support this premise, citing " much higher rates of violent behavior among individuals with severe mental illness living in the community compared to other community residents." Individuals with schizophrenia were 21 times more likely to have used a weapon in a fight, develop an inverse correlation between their propensity toward violence and blood levels of antipsychotic medications, and be "driven" to offend by their delusions.

Article Content

In a four state study of 802 adults with severe mental illnesses (largely schizophrenic or schizoaffective disorders at 64%), this research team reports that 13.6% had been violent within the preceding 12 months. The team further defined "violent" as "any physical fighting or assaultive actions causing bodily injury to another person, any use of lethal weapon to harm or threaten someone, or any sexual assault during that period."

The report further states that those who had been violent were more likely to have been homeless, to be substance abusers, and to be already living in a violent environment. Those who had been violent were also 1.7 times more likely to have been noncompliant with antipsychotic medications.

As other such studies seem to support, the women with severe psychiatric disorders were almost as likely to have been violent (measured at 11%) as were the men (measured at 15%).

Because the data on violent behavior were collected by self-reporting methods, the authors suggested "that our findings are probably conservative estimates of the true prevalence of violent behavior for persons with SMI."

They concluded "that risk of violence among persons with SMI is a significant problem" and "is substantially higher than estimates of the violence rate for the general population."

Article Strengths

An impressive array of mechanisms were used to conduct this research; Statistical Significance tests; the Exposure to Community Violence Scale, an instrument adapted from a questionnaire used in the NIMH Community Violence Project; the Sexual Abuse Exposure Questionnaire; cross-sectional surveys; Epidemiologic Catchment Area surveys; Diagnostic Interview Schedule's assessment of antisocial personality disorder; the Conflict Tactics Scale; Sexual Abuse Exposure Questionnaire; PTSD Checklist - Civilian version; and others.

Another inherent strength in this study was the forthright willingness of the researchers to admit to the inherent limitations and potential flaws in the research. This admission paved the way for more detailed, specific demographic and experiential studies, which have led sociologists, criminal forensic scientists, medical professionals, and judiciary groups to a better understanding of the correlation between individual variables and violent enactment of these variables.

Article Weaknesses

Several publicly admitted weaknesses exist within this study; following are the author's perceptions of problematic limitations.

The ethnic sampling was skewed toward two racial groups: White/Anglo-Saxon and Black/African-American. With Hispanic ethnic groups a large and ever-growing sub-culture in the United States and the inherent cultural mores and values on violence in family defense, this group should have been a third ethnic sampling block.

The demographic sampling was limited to eastern states only. Various states - with their ethnic groupings, cultural alignments, and social mores - would add a more balanced sampling group that merely four from eastern states.

At least one of the sampling instruments - the Exposure to Community Violence Scale - produced a measurement designed...

If this were to be included in the summary of findings, the research team would also have to prove that only impoverished inner-city neighborhoods produce violent, mentally ill young people, which, of course, it cannot.
A fourth weakness in the study's structure is that there were no strict measurements or measurement accountability methods used to determine whether a subject was actually taking the prescribed antipsychotic medications or not. According to the report: "medication noncompliance was measured by asking respondents whether they had been prescribed psychiatric medications, and whether they were taking these medications only sometimes or at all." In order to make the correlation between violence and compliance (or noncompliance) therefore, a much more reliable method of measurement would need to be employed. This study made the connection based on "word of honor"; while this may well work in other studies and samplings, the erratic behavior, inability to rationalize clearly, and nature of schizophrenic/schizoaffective disorders is such that verbal reporting may not be considered reliable.

Next, an obvious lack of family interaction and viability in the development between violence and mental illness was not touched upon in the study. In order to produce reliable data, there must be a holistic view of elements associated with the final findings. From as far back as history records, the family influence on childhood and adolescent behaviors has been documented and studied. The Victorian era saw a rise in recognition of the family's impact and influence on childhood development and Leonore Davidoff develops the thesis that during childhood, the growth of the personality is based upon an emergent identity and every aspect of the familial experience is relevant to this child's sense of existence.

Finally, the lack of emphasis placed on the critical nature of the medication dosages for schizophrenic/schizoaffective disorder was notable. Despite the fact that the study of proper antipsychotic medicament is one of ongoing debate and experimentation for each individual, the pervasive medical belief that neuroleptic medications are harmless, effective, and mandatory may negatively affect the mental disorder and violence link.

Conclusion recent study pattern demonstrates that evidence continues to mount that schizophrenia and psychotic symptoms are negatively, if at all, related to the risk of future violence among offenders and individuals who receive psychiatric services. There is as yet no convincing evidence that dynamic variables (especially treatment) play a role in determining who is likely to engage in future violence."

Other research suggests that the amount of low-level violence is very high among people with mental illness, at least in the U.S. Whether it is greater among people who are similarly situated but not mentally ill is still uncertain, but it is clear that this is a serious problem, both for people with mental illness living in the community and for those with whom they live. If we are to find ways of reducing this sort of violence, we must learn how it comes about. The paper describes a study of violent incidents based on intensive interviews with both parties of the incident. Gathering reliable data on the events involved, and the integration of the two different accounts present substantial methodological problems, which, however, are manageable if adequate resources are committed to the task. The paper describes some solutions to these problems and discusses future work that needs to be done.

Recent studies suggest that the causal determinants of violent behavior in persons with mental disorder are varied and complex. The large majority of persons with severe mental illness (SMI) do not commit violent acts.

Effective community-based interventions to manage risk in such individuals must be comprehensive and broadly focused, addressing multiple problems including underlying psychopathology, addiction, trauma sequelae, and need for community support.

Violence among individuals with severe mental illness is related to multiple variables with compounded effects over the life span. Interventions to reduce the risk of violence need to be targeted to specific subgroups with different clusters of problems related to violent behavior.

Closely controlled study groups - perhaps mandatory commitment legally restrained clients - need to be evaluated over an extended period of time in order to determine which of these positions, or none of these positions, is accurate.

Until this is done, reason dictates that uncontrolled psychoaffective disorders can be instrumental in delusional behavior, and when all other factors are in place, causal to violence.