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Violence in Red
"Violent patients readily provoke fear, anger, and revulsion" (Introduction); "After a serious assault, the entire ward, staff and patients, is in an uproar" (Chapter 1); "Abnormal aggression in children and adolescents in a major public heath problem
and one of the most common reasons for psychiatric referral" (Chapter 2); "There is little in psychiatry that is more frightening than the threat of imminent violence" (Chapter 3); "Aggression is a very serious problem within public psychiatric facilities, but its treatment and management have long been a controversial issues (sic)
(Chapter 4); "Violence is a great concern to anyone responsible for quality care and safety in psychiatric hospital" (Chapter 6).
The majority of first sentences in this nine-chapter volume (including its helpful, concise introduction) support emblazoning in red the word violence in the dust cover title. Yet, the editor, Dr. Martha Crowner, earnestly wishes clinicians to get beyond such strong emotions emotions too often driving them to distance themselves from "violent patients" by focusing on problematic behaviors rather than the ill persons. It is not that we should cease to be vigilant against violent outbursts, but that clinicians, and by implication all of us, should try to understand the context and causes of violence better. Then, Dr. Crowner insists, the clinicians should embrace their obligation to employ effective treatments for the "violent patients", not just the "nonviolent" patients.
The goals of this volume to promote understanding and treatment are intentionally captured in the title of this mostly descriptive, very readable collection of essays. Each chapter is clearly organized, including a helpful introduction and a conclusion capturing the major points. Bold subtitles mark a chapters structure, These features, along with numerous references and an index, makes the volume easy to return to as a resource. As a grace note, within chapters one occasionally finds a reference to other volume chapters where the same topic is dealt with in greater or different detail.
What Is To Be Learned:
This book is designed for the range of psychiatric health care workers. The essays, however, are accessible to a more general audience, such as this bioethicist reviewer who has only recently turned her clinical and academic eye to the field of mental health care. The occasional, technically detailed areas may be skipped without endangering ones comprehension of the surrounding material.
Would a more general reader benefit from reading this volume? "Violence" in red and the heightened concern communicated by the "first sentences" are likely to speak to many folks outside the mental health care field. Violence is, after all, vivid in the public mind. However, much of this volume is directed to the mental health care professional who works with hospitalized patients and would therefore benefit from the practical information and recommendations. For example, there is step by step information and concrete advice on how to respond to a person who acts out violently, as well as how to manage compassionately and effectively the aftermath of a violent outburst. Just as importantly, there is much of value offered regarding strategies for preventing assaultive outbursts and, when appropriate, for safely putting patients into restraints.
There is a real importance, salted with irony, to this inclusion of non-pharmaceutical treatment options in an era of managed care ("managed cost"?). After all, managed care has reduced its treatment support, where there is support, mostly to the arguably less expensive approach to "caring" for mentally ill persons drugs. This is not to diminish the fact that appropriate, careful use of pharmaceuticals has vastly improved the lives of many persons struggling with mental disorders. However, this volume underscores what we are missing if we cannot find the political will to support financially the often labor intensive but arguably highly effective non-pharmaceutical treatment strategies.
This volume does more than present the issues of practical understanding and treatment. The editor divides the book into two sections, with the first tackling the practical issues so far considered. Section II consists of four chapters that Dr. Crowner describes as "different conceptual approaches to understanding violent behavior in widely different contexts" (p. xii).
That Dr. Crowner needs to divide the chapters into sections reflects one of her challenges as editor. This volume is one in the Progress in Psychiatry Series that "is designed to capture in print the excitement that comes from assembling a diverse group of experts from various locations to examine in detail the newest information about a developing aspect of psychiatry" (p. ix). As I understand the editor of the series, David Spiegel, M.D., this assembly was a symposium at which this volumes essays were presented. I do not know how much leeway the volume editor had in selecting which symposium papers were to be included. From the perspective of a reader, though, I find that the volume lacks an organicity that I would favor but that is not promised by the series editor.
Section II is diverse. Its first essay, Chapter 6, seems to belong instead in the first section because this essay has the same practical focus and implications as do Section I essays. In fact, a reader interested only in practical, clinically applicable material might skip Section II, thereby missing Chapter 6s very practical, intriguing insights and recommendations.
Chapter 7 is a detailed, conceptual look at the relationship between violence and dissociation. This essay is at places pretty technical but nevertheless rich, provocative, and my favorite essay in the volume. While Chapter 8 focuses less on violence than on impulsivity, it does important work showing where these are different and where they come together. Both these chapters have strong implications for how we ought to deal with mentally ill persons whose violent acts propel them into a legal system unequipped to handle them appropriately.
Chapter 9 is for me disappointing. It is the final chapter in the volume, yet ends with a section that introduces briefly (lists) five ethically and professionally contested recommendations regarding (pre and post) commitment and treatment issues. The author is among those who believe that these admittedly controversial recommendations follow from research supporting his chapters thesis: "persons with acute mental disorder have a modestly elevated risk of violence and
clinicians have modest abilities to predict this violence" (p. 174). As a bioethicist, I was disheartened to see the recommendations merely briefly stated. There is no discussion of their merits and dismerits, particularly of the ethical values at stakes. There are no footnoted references to those who argue against any of these recommendations. It is not that I necessarily disagree with all the recommendations for one, mandatory out-patient treatment has much to recommend it but without any discussion, the reader is left hanging as the chapter and the volume abruptly come to a close.
What Is Missing:
My final comments concern what is not found in this volume. The first missing piece is an introductory, conceptual discussion of possible clinical and moral meanings of violence. This would have provided a critical and fundamental context for the volume. For all the diversity of the symposium presenters represented in this volume, this crucial perspective is missing.
Just why a framing discussion of violence would have been helpful can be illustrated by two discomforts that remain with me. The first discomfort arises from Dr. Crowner emphasis on the importance of understanding and treating the violent patient, not the violent behavior. She argues convincingly that the clinician should focus on the ill person in her complex individuality. It concerns me, though, that thinking about "the violent patient" requires a troubling act labeling. Labels can be stigmatizing and are sticky. Moreover, in at least one place in this volume it is suggested, and supporting evidence presented, that among hospitalized patients a violent act is rare. So, by virtue of a rare act, a person is labeled violent and distinguished from "nonviolent" patients. This raises an additional curiosity. If mentally ill persons only get hospitalized because they pose a danger to themselves or others (and that danger stems from their mental illness), then by necessity all hospitalized mentally ill person are categorized as violent if dangerous means violent, as it seems to in this volume.
This leads to my second discomfort, which stems from the use of various terms, such as assault, (abnormal) aggression, and danger, as if they are unproblematically interchangeable with violence . Different possible understandings and implications of these terms are overlooked. Violence ("in red", you will remember) is arguably an alarming, morally condemning word. Yet, as one author points out with respect to her study of in-hospital violence, the term violence captures actions that vary in their harmfulness and intent. Among these we find acts that turn out to be done in self-defense, whether mistakenly or not. Where not mistaken, perhaps the real violence is psychological, aimed at and provoking the targeted person, who then physically responds in self-defense. Then, too, some acts turn out to be fairly harmless, intended to be more playful. Perhaps "violence" is too strong a term, laden with too much emotional and moral baggage, to cover all the actions examined in this book? It would at least be good to have this kind of discussion up front.
There is a second missing piece in this volume: the clinically rich data presented could be rendered even more useful by being drawn together in a final chapter one identifying both common themes and conflicting findings. An especially important theme running quietly through the book is the fact that childhood abuse, neglect, and uninformed/unskilled parenting seem to be implicated for a number of young people in their eventual development of mental disorders. It seems plausible that many of the psychosocial treatments discussed in the book could be effectively modified for educational and training programs for children at risk in the general population. A summary chapter could emphasize the implications of these themes and findings for research and for public education concerning the critical need to improve the funding of mental health care and prevention programs.
All in All:
Given the insights within this volume and the fact that its implications go beyond the walls of the mental health institution, this volume is well worth reading. This is true not just for mental health professionals, but for all with a mind to finding ways to reduce aggression, assault, and violence in our society.
Linda A. Rankin, Ph.D., is a Clinical Ethicist and an Assistant Professor of Medicine in the Department of Medicine, University of Tennessee Medical Center at Knoxville, Knoxville, TN. She is also faculty in the Inter-Campus Graduate Program in Medical Ethics, based in the Department of Philosophy at the University of Tennessee. This past year she turned her attention to bioethical issues in mental health. Her responsibilities included redesigning and teaching the (Fall) academic course intended to prepare M.A. level Philosophy students for their (Spring) Masters Clinical Practicum at Lakeshore Mental Health Institute (state hospital) and Helen Ross McNabb Center (private community mental health center). She redesigned, expanded, and supervised this Masters Clinical Practicum.