Reports reveal an increase in the number of individuals with serious mental illness in jails, prisons and forensic hospitals. Despite the wide-ranging and devastating consequences of this 'criminalization' of mental illness, there remains a lack of information on the subject as well as on the provision of care for these patients. This important new book fills a gap in the literature by examining topics such as: the history and policy factors related to criminalization; original research on forensic populations; pharmacological and psychological treatment strategies; and principles and guidelines for diversion out of the criminal justice system.
Neurocognition and Social Cognition Training as Treatments for Violence and Aggression in People with Severe Mental Illness
Mackenzie T. Jones and Philip D. Harvey
There is a wide-ranging belief that people with severe mental illnesses (SMI) are violent or dangerous. Most patients with schizophrenia are not chronically aggressive or violent; among patients with schizophrenia, there is a small increase in violence and violent offending on average compared with general population standards in the USA and Europe.1,2 However, violence on the part of people with SMI has several features that differentiate it from violence in the general population. First, it is less likely to be motivated by financial reasons. Second, it can be unpredictable and directed toward strangers. Not being financially motivated, it is more challenging for the general public to avoid. While few people would walk alone in a dark and deserted part of a large city, most people in general would not feel like they need to avoid standing on a subway platform. However, most people who push strangers off subway platforms, leading to fatal injuries, have mental illness and generally have no connection with the people that they attack.3 In fact, in 20 of 20 cases with available background information reviewed by Martell and Dietz, the offenders and the victims did not know each other, and the offenders were psychotic.3
Despite the fact that random violence can occur with people with SMI, during the period that was surveyed in the study, 1977–1991, there were at least 1,600 and up to 2,605 murders per year in New York when this survey was conducted.4 Thus, 20 out of approximately 30,000 murders were attributable to random subway platform pushing. As a result, although the offenses were striking, random, and terrifying, these are extremely uncommon. This still does not reduce the sensationalism of violence in the media and resulting stigmatization.5
Most victims of aggressive behavior on the part of people with SMI are family members, fellow patients, and mental health professionals who are injured while attempting to treat members of the SMI group. So, much like violence in general, most violence in people with SMI stays within the patient’s social network and needs to be viewed accordingly. The most common cases of violence in SMI are violent acts directed at people with whom the patient is very familiar. This may not be different from the general population, wherein physical abuse of family members is very common, and the majority of homicides are still committed by people who know the people that they kill. For example, among male homicide victims, only 29% were killed by someone they did not know, and assaults were committed by someone known to the victim in 64% of cases as well.6
Aggressive and violent behavior, including both verbal and physical aggression, have considerable adverse consequences for people with SMI. For example, most state hospital beds in America are occupied by forensically committed people with SMI. In California, for example, there are five state hospitals where no more than 10% of the residents are nonforensic cases.7 Even for state hospital patients who are not committed, aggression and violence are the primary reason for long hospital stays. For example, White et al.8 reported on the reasons that prevented discharge from a state hospital during a period of aggressive downsizing. Out of a total of 894 patients considered for discharge, only 27% could be discharged, with the primary reasons preventing discharge, in order of importance, being impulsivity, hostility, excitement, and uncooperativeness. Cognitive performance, hallucinations, and negative symptoms did not predict the likelihood of discharge, although delusions did. As a result, several of the features of individuals with specific treatment-resistant symptoms, despite pharmacological therapies, prevent discharges even when the hospital management is highly motivated to empty the hospital. Considering that verbal aggression is also a barrier to successful discharge from long-term care, actual physical violence is not required to prevent discharge to less restrictive settings.9
There are several potential causes of violent behavior on the part of people with SMI, based on correlational studies. These include intellectual, cognitive, and social-cognitive deficits, psychopathic/antisocial traits, skills deficits, substance abuse, and specific psychotic features. Each of these potential causes will be briefly addressed before we discuss potential treatments that target these symptoms.
Although cognitive impairments are common in SMI and are clearly correlated with many elements of disability, the research on cognitive impairment as a determinant of violence has yielded some highly specific findings. Although people with SMI do not commonly manifest co-morbid intellectual disability (ID), the research on violence in SMI, particularly among state hospital patients, suggests that this is more common in violent patients.10 Global cognitive performance deficits are commonly found to be associated with risk for violence, although the patterns of specific cognitive impairments, however, are somewhat inconsistently associated. For example, Ahmed et al.11 found an overall difference between violent and nonviolent state hospital inpatients on the MATRICS Consensus Cognitive Battery, but only working memory and verbal learning were subscales significantly worse in aggressive patients. In contrast, Serper et al.12 found that impairments in executive functioning predicted increased violence during acute admissions, and Krakowski and Czobor13 found more executive functioning impairments in lower aggression cases.
There are several different domains of social cognition, including understanding the mental states of others, recognizing emotions, and making attributions for the reasons that others act the way that they do.14 These elements of social cognition diverge in their functional importance. Understanding mental states and recognizing emotions appear to be related to impairments in everyday social functioning, while attributions fail to predict these types of disability.15 However, attribution style predicts the presence of paranoid ideation, which, particularly when delusional in severity, is associated with unprovoked attacks on others.16 Thus, attributional style may contribute to a belief that others are mistreating you, leading to attempts to contravene and reduce threats. In fact, a recent study suggested a direct impact of social-cognitive deficits on violent behavior, while neurocognition’s effects were mediated through social-cognitive functioning and deficits in everyday functioning.17
Scores on the Psychopathy Checklist (PCL) have been compared across aggressive and nonaggressive patients with SMI. The results are quite consistent, in that PCL scores were the best predictor of community violence on the part of people with SMI in the MacArthur risk assessment study.18 A series of studies of hospitalized inpatients have generated similar findings. For example, Krakowski and Czobor13 found that PCL scores were the best predictor of high levels of aggression, and Volavka19 reviewed the research literature and suggested that psychopathic traits were responsible for more violent assaults in patient units compared with psychotic symptoms.
Skills deficits in schizophrenia include reduced ability to perform everyday social and functionally skilled acts.20 These deficits can lead to considerable frustration because tasks that are easily completed by others are challenging, time-consuming, and poorly performed. Further, social skill deficits can also lead to problems in interacting with others, which can interact with negative attributions and lead to negative interactions. As noted above, deficits in real-world functioning were found to be associated with violent acts.17 Further evidence for this argument is provided by Martinez Martin et al.,21 who found that impairments in the ability to perform everyday activities and social competencies were associated with increased aggressive behavior.
Both paranoid delusions and command hallucinations have been found to be associated with violent acts.22,23 The relationship between these symptoms and violence is face-valid, in that it is easy to understand why an individual could become violent upon hearing voices directing him/her to engage in violent acts. However, in addition to paranoia and hallucinations, lack of insight is clearly required. If the individual were aware that the voices or ideas constituted a psychotic symptom, they would be considerably less likely to act on them.24
Violence in nonhospitalized people with SMI is more common in individuals with concurrent substance abuse.25 Abuse of several different drugs is common in schizophrenia and is estimated to have a prevalence as high as 50%.26 The most commonly abused substances are alcohol, cannabis, and cocaine. Individuals with co-morbid schizophrenia and substance abuse are found to have the highest rates of violent behavior;27 so reducing substance abuse might have a beneficial effect.28