Understanding and Treating Violent Psychiatric Patients

Underpinning the appearance of this timely collection of nine essays on different aspects of violence and psychiatric disorders is the belief that, for the most part, violent patients are poorly understood and haphazardly managed with an emphasis too often on containment and control rather than on painstaking analysis and humane and effective treatment. As the title makes plain, understanding the mainsprings, context, and precipitating and perpetuating factors at the core of psychiatric violence is an essential starting point if the treatment of psychiatric patients who behave violently is to match in sophistication and quality the care provided to their nonviolent counterparts.

In general, the collection lives up to its declared objectives. There are useful and balanced contributions on the pharmacological treatment of violent adult inpatients, on the assessment and treatment of seriously aggressive children and adolescents, on violence and dissociation, and on current understandings of impulse control. There is much that is compassionate, sensible, and practical, not least the repeated emphasis on the need for clinicians to learn the point and purpose of any particular assault if repeated episodes of violent behavior by disturbed individuals are to be prevented.

The ambiguity and uncertainty of modern psychiatry’s engagement with the issue of violence surfaces, however, when the rather different issues of physical restraint and seclusion are considered together. There is the somewhat ritualistic insistence that seclusion should not be used as a substitute for treatment, as a punishment, or as a response to obnoxious behavior. The distinction between seclusion as punishment and seclusion as “a contingency in the behavior therapy of dangerous behaviors” (one of the indications for the use of seclusion advocated by APA’s 1985 Task Force on Seclusion and Restraint [1]), however, is often more apparent to the therapist than to the patient. It is interesting to note that New York State does not permit the seclusion of mentally retarded patients. One wonders what would happen to modern psychiatry if the use of seclusion was ruled impermissible in the treatment of the mentally ill.

The collection concludes with a characteristically sober and economic review by John Monahan of the evidence linking psychiatric disorder and violence. That mental illness is a risk factor for violence in the community now seems established, but the degree of the risk remains arguable. Most studies suggest it is small, certainly when compared with factors such as socioeconomic status and a history of violence. Monahan wonders whether earlier hospitalization, looser criteria for involuntary commitment, and the removal of the right of committed patients to refuse medication might prove useful contributions to the reduction of psychiatric violence in the community. Whatever the outcome of such debates, the fact remains that just as efforts to destigmatize psychiatry become more robust and energetic, growing public and professional concern about violence threatens to turn us back to an era of straitjackets, cells, manacles, and incarceration. This volume provides a useful and sober corrective to extreme positions and is a most useful guide to practitioners in daily clinical contact with highly distressed and disturbed patients.