Confronting Violence

We live in a violent society. As mental health professionals, we grapple with the potential, and at times the reality, of violence by our patients. We struggle with the question of when violence is a psychiatric issue.

Increasing evidence comes from epidemiological and neuroscientific studies that some forms of violence fall into the domain of psychiatric clinicians and researchers. Epidemiological studies find increased risks of violent behavior among people who are mentally ill, and increased mental illness among people who are violent. Substance abuse, antisocial and borderline personality disorders, conduct disorder, attention-deficit hyperactivity disorder, schizophrenia, mood disorders, anxiety disorders, mental retardation, and organic mental disorders have all have been linked with an increase in violent behavior. Biological studies have identified abnormalities in neurotransmitter systems that are associated with impulsive aggression, a pivotal aspect of some forms of violent behavior. The social and criminal aspects of violence cannot be minimized, but mental health professionals have an important role in research and treatment.

New and effective treatments are available for some forms of violent behavior. Pharmacologic interventions such as serotonin reuptake inhibitors and mood stabilizers have been demonstrated to reduce violent behavior in a variety of patient subgroups. Short-term, group cognitive-behavioral therapy focused on aggression shows promise for violence-prone adults and adolescents. Community-based programs that strengthen natural support systems are also beneficial. Information on these interventions is widely available in psychiatric journals.

Why are these treatments for violence scarcely used? Although we cannot change the many societal barriers to effective care for persons prone to violence, we can more vigorously address the barriers that impede mental health professionals from providing treatment. They include feelings of repulsion, a sense of helplessness and stigma, fear for personal safety, and concern about being held responsible for the consequences of destructive behavior. We lack familiarity with treatment options and underestimate our potential for therapeutic success. The result of these barriers is underdetection and undertreatment of violent behavior.

Familiarity with data and treatment options and greater clinical optimism will allow us to confront our patients' struggles with violence. Let us begin using the treatments now available while developing new techniques. The longer we wait, the greater the pain.