Violence and Mental Disorder

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