On the positive
side, this book packs a huge amount into its 180 pages, and there is no obvious
alternative text. It is essentially an academic literature review, written in a
style that balances factuality with readability, it has ‘text boxes’ which list
key points, includes a glossary of terms, and is so copiously referenced that
the list amounts to 43 pages!

That said, the
weaknesses of the text are obvious. It shows little sign of the critical
intention embodied in the book’s title, and there is a tendency to catalogue
series of empirical studies without drawing any conclusions. Readers are mostly
left to judge for themselves the limitations and rigour of the myriad empirical
studies cited, on the basis of the information provided. The differences
between groups of research subjects, and the definitional boundaries within
which they were formed, are largely ignored, and so studies from Scandinavian
countries, England, Scotland, Canada and the United States are juxtaposed
without concern for the radically different jurisdictional, administrative,
professional and clinical systems in which they were conducted.

The book’s
structure makes it difficult to find answers to the kinds of questions that
arise for clinicians, such as whether a person with schizophrenia becomes less
likely to engage in violent acts as they get older. The answer may be somewhere
in this text, but it is difficult to know where. The brevity of the index is
also unhelpful: the terms ‘gender’ and ‘women’, for example, do not appear in
the index, and yet there is a paragraph on that topic as a predictive factor on
p.43.

A short text on
such complex problems is bound to make many omissions, and so there is no
discussion of violence perpetrated by mentally disordered children and
adolescents, of specific acts of violence such as homicide or parricide, of
specific mental disorders such as schizophrenia, about violence among mentally
disordered women, or about violence within institutions. In the context of
acute, secure and forensic psychiatry these are the kind of topics that are
likely to have clinicians reaching for this text.

Despite claims
that the review is ‘wide-ranging’, the authors have drawn almost exclusively
from the clinical psychiatry and psychology literature, and have overlooked
some important resources emanating from other disciplines. This is unfortunate
because those from nursing in particular are concerned with the practicalities
of assessing and working with violent individuals. Following on from this, a
mere seven pages are devoted to describing violence prediction tools, and these
are the already familiar HCR-20, VRAG and MacArthur Risk Assessment Study.
Furthermore, the coverage is introductory, and I easily found more detailed
information free of charge on the Internet. Indeed, the authors have entirely
ignored the Internet as a resource, both for their text, and for clinicians.
This is unfortunate because the Internet is increasingly likely to be the first
port of call for practitioners and academics alike, and some advice on
accessing and utilizing relevant sites would have been helpful.

The concluding
discussion of the clinician-patient relationship and the management of violence
in a health care or correctional setting is disappointingly brief. It relies
heavily on John Gunn’s chapter on dangerousness from the Gunn & Taylor text
of 1993 and has little to say about managing violence in an institutional
setting. In terms of drawing out practice implications from the evidence they
have reviewed, Blumenthal and Lavender stay at a safe distance from the sharp
end, restricting their comments to social, attitudinal and policy issues. The
authors assert several times in the course of the text that “The mentally ill
make a small contribution to the overall levels of violence in society”
(p.127). While such comments reflect political sensitivity, they are of little
help to clinicians who work day-after-day with mentally disordered clients and
face the challenge of assessing and managing violence as a matter of routine.

For a practical
guide to assessing and managing violence, readers will need to look elsewhere,
perhaps beginning with Assessment and
Clinical Management of Risk of Harm to Other People. (London: Royal College
of Psychiatrists, 1996), which is not mentioned by Blumenthal and Lavender.
Mostly, they will need to go to the journal literature and the materials
available on the Internet (via the Canadian Corrections pages, or Phil Wood’s
Forensic Nursing page, for example). Alternative texts are few indeed, and
Blumenthal and Lavender have brought together a mass of hitherto disparate
evidence, which provides a useful starting point for mental health
professionals, and students of psychology and psychiatry, trying to understand
the links between violence and mental disorder. Despite my criticisms, I will
be ordering a copy for the university library!

© Colin A. Holmes

Dr Colin A Holmes, Professor of
Nursing (Mental Health), James Cook University, Townsville, Queensland,
Australia

Categories: MentalHealth, Ethics