Psychiatric Disorders and Violence
The etiology of violence is multifactorial. Of course, most violent acts committed in society are not perpetrated by people with mental illness. The question of “mad or bad” has lately been replaced with “sickness or wickedness,” although this still retains a flavour of moral judgement. As psychiatrists, the most obvious moment when moral judgement may impact clinical judgement is during a criminal responsibility assessment. This influence can play a role in many other situations: when psychiatrists determine if a psychiatric patient should return to the remand centre to await trial, when an accused refuses an obvious insanity defence because he or she does not want a psychiatric labelling, or when psychiatrists make recommendations to Review Boards regarding a patient who has undoubtedly progressed clinically but does not show any insight into a violent act he or she perpetrated against a family member. This list can be adapted to different types of clinical work, whether we practise in inpatient or outpatient settings, general or forensic psychiatric services, correctional or halfway houses, or shelters for the homeless. We need to improve our ability to assess dangerous psychiatric patients and our knowledge of evidence-based treatment in such populations.
Review articles such as that by Dr Arboleda-Flórez help us identify the issues to consider in a thorough assessment of psychiatric dangerousness. The treatment of dangerous psychiatric patients must be very carefully planned, especially in rehabilitative institutions, where skilled professional resources are limited. When these patients become outpatients, this treatment requires the assistance of a multidisciplinary team that includes community halfway houses and activity centres and often members of the legal system (such as parole or probation officers) and/or members of specialized centres for the treatment of comorbid drug abuse. The extended team thus involves people who do not all belong to the same institution. We must be careful with the information we provide to others in such situations. Confidentiality is an area that must be dealt with cautiously, especially when dangerous patients may threaten the safety of others. Dr Glancy, Dr Regehr, and Dr Bryant help us resolve the difficult dilemmas regarding this issue.
The treatment of psychiatric patients who have committed violent offences is beset with ups and downs in the therapeutic alliance. Patients’ insight into their psychiatric illnesses and their dangerousness can vary widely. Some patients will be able to deal with the grief they have caused to others. In some cases, the family of homicidal patients will be able to support them, even when the victim is another family member. In many cases, these patients have great difficulties in overcoming their grief over their victim. This is a major challenge in treatment, especially in psychotherapy. These situations teach us many lessons about coping, which are very helpful in assisting other similar patients.
When treating dangerous psychiatric patients, one of the most difficult tasks we undertake is the assessment of prognosis. Prognosis goes beyond the evaluation of psychiatric symptoms: it must consider the possibility of further violence. We cannot predict dangerous behaviour, but we must provide risk management; it is the most important aspect of treatment with these patients. The more insightful and autonomous they become, the more they can participate as key players in their own care.
Renée Roy, MD, CRCPC
Institut Philippe Pinel de Montréal