What to do?
The links that arise between schizophrenia and violence are shown schematically in fig.2. How can these bonds be broken?
It is tempting to draw up some ideal scheme for easing or eliminating violence as a complication of schizophrenia. Of course, ideally, it would be advisable to early identify inadequate education and take measures to eliminate the causes of this in all children, and not only in 0.5–0.8% who may develop schizophrenia. Similarly, problems in interpersonal relationships, behavioral disorders and inadequate performance by parents of their duties would be desirable to consider in childhood in order to eliminate these causes or at least weaken their influence. Some researchers call for the detection of pre-psychotic states and early intervention ( McGorry et al , 2005). But the impact on these complex phenomena goes far beyond our capabilities as doctors, and probably also – until more compelling data is obtained in favor of the effectiveness of early interventions – beyond our ability as scientists to effectively support them. Then what are the clinical implications for everyday practice?
It is time for the psychiatric community to agree that aggressive and antisocial behavior is a possible complication of the current schizophrenic syndrome.With the recognition that the problem of violence is our sphere, it will be possible to take measures to eliminate its causes.As long as the problem of violence is minimized or ignored as “non-disease related,” it is impossible to make any progress in reducing the risk.It is necessary to recognize individuals at high risk, although they make up less than 10% of the population of schizophrenic patients, and give a correspondingly high priority to organizing the treatment of their disease.But how can they be recognized?
Early detection of high-risk patients
Individuals who are at high risk of violence in the future should be identified, avoiding abusive stigma: it is necessary to ensure that the identification process as the primary clinical task is consistent with the mitigation of their risk factors.Risk assessment is not some kind of mysterious technology that requires expensive specialized training.This is a practical work that should be simple, clinical, multidisciplinary and should be systematically carried out.
SimpleThe high-risk group includes a huge number of young men who have a history of childhood behavior disorder, antisocial and aggressive behavior during adolescence, substance abuse , unemployment, and a disorganized lifestyle.
Clinical.The risk increases dramatically with individuals who show anger and suspicion, are unable to understand the essence of what is happening, reject the therapy, threatening and thoughtless.Specific delusional syndromes, especially jealous rage, dramatically increase the risks – just as much as personality traits such as heartlessness and the conviction of the right to impunity.
Multidisciplinary.No professional group has a monopoly on the knowledge necessary for risk assessment, so everyone must make an appropriate contribution.The current behavior in the hospital, social conditions, mental state, assessments of personality traits and level of intelligence, as well as, most of all, a carefully collected history have a certain meaning.
Systematic. The need for risk assessment in psychiatric practice has led to the development of a variety of tools with widely varying accuracy. This is not the place to discuss the quality of the various checklists. It is best to use dynamic as well as static variables, which will allow you to recognize which factors may be targets for their elimination. Their primary appointment for the doctor is to direct attention to the known correlates of aggressive behavior. Evaluation tools allow you to identify risk groups. However, they do not help with an acceptable probability of error to indicate the chances that a particular individual at high risk will be violent. Therefore, they can be considered good tools for assessing needs and bad ones for justifying checks for the purpose of applying punishment. Evaluation tools, such as HCR – 20 ( Webster et al , 1997), which includes a checklist of questions for evaluating psychopathy, allows us to structure the specialist’s approach to risk assessment, while at the same time not going beyond common sense and leaving room for the application of clinical knowledge.
General principles of patient management
Many high-risk patients are young, substance abusers , treatment-rejecting and disorganized.The organization of treatment for these individuals with schizophrenia depends on whether they have managed to achieve complete abstinence over a sufficiently long period from the use of cannabis and other psychoactive substances that patients have abused.There is little point in hospitalizing for several days or even a couple of weeks, since in most cases the patient will still be under the influence of psychoactive substances that he abuses.
Similarly, hospitalization is unlikely to succeed if the patient has the opportunity to regularly leave for a local dealer or receive visitors bringing him drugs.The effectiveness of treatment depends on prolonged hospitalization (4–8 weeks), which may initially involve the patient in a closed ward.After discharge, few individuals in this group will comply with the regimen of medication, they are also unlikely to voluntarily remain in the housing in which they are supervised.Court guidelines for community treatment may help to adhere to the regimen of medication, but where it is possible, preference is given to the depot preparation.
Given the need to minimize side effects, especially akathisia and dysfunction of the frontal lobe, which may accompany the neuroleptic deficiency syndrome, the second generation of atypical antipsychotic drugs should first be prescribed ( Swanson et al , 2004). At present, choice is limited to deporisperidone , at least until the deposited forms of other atypical preparations become available.
Coercion is unlikely to achieve the desired goal in the long run.If you try to deprive these adolescents of the psychoactive substances they use, alcohol, and the only peer group they have known for a long time and impose drugs on them that they do not believe in and consider them unnecessary, then you must provide them with some substantial compensation. .In the short term, in order to provide different types of activities and to structure their lives, they will need improved housing, regular support from specialists, with whom they have developed good relations, and investments that they value.In the medium term, their cooperation can be supported by programs to improve social interaction, improve production skills, provide recreational activities and play sports.The debt o- term plan for these individuals if they are unable to establish a structured and bring joy to the life of (this applies to employment, leisure or group itself (inter) aid) to remain constant risk of relapse of substance abuse, lower social level and the risk of crime .
A minority of high-risk patients will experience systematic paranoid delusions.At first glance, it seems that they are less of a problem, or at least more familiar, since the main mediator of risk are the symptoms of the disease.However, in fact, they are at least equally suspicious and often do not openly follow the healing recommendations.Perhaps because of the sense of superiority divorced from reality, it is more difficult to interest them and they are more undermining the strength of specialists.In addition, these patients need inpatient medical care with rehabilitation, the use of depot preparations and the subsequent persistent observation of a physician, especially when the coverage of delusions is rather slowly losing its strength, if at all.They, like any other disorganized group, should be assisted in the formation of social skills, the development of responsiveness in interpersonal relationships, in developing an ability to manage anger and, most of all, in effective social reintegration .
Organization of events for the provision of social assistance and labor rehabilitation
Patients at high risk who leave the hospital need permanent housing in areas with low crime rates. This elementary and obvious recommendation seems hopelessly idealistic because of resistance to dormitories, “halfway houses” (institution for the rehabilitation of prisoners who have served their sentences, cured drug addicts, alcoholics, the mentally ill – ed .) diseases, not to mention “perpetrators with mental disorders,” in more privileged areas.The community should not continue to push an undesirable individual to the places where the commission of a repeated offense is in fact predetermined.
Individuals with schizophrenia and a high risk of violence upon returning to the community need both a structural and an active supportive lesson.Repeated offenses are committed less frequently due to employment, stable relationships and mixing with non-criminal peers.The formation of work skills in unmotivated, poorly educated individuals with schizophrenia, who have not had experience in the past, is of great importance.And after the closure of hospitals in the 1960s – 1970s, psychiatric services responded adequately to the problem of rehabilitating patients who were long-term in closed psychiatric institutions.Perhaps the time has come to treat the problem of young people with disabilities who belong to a high-risk group with the same seriousness.
Disorders in development, hereditary predisposition and the schizophrenic process itself form in some individuals characteristic features and attitudes that can be called criminogenic.Restricting the ability to exercise violence largely depends on the modification of these factors and the forms of behavior that these factors engender.
Under any circumstances, deep skepticism about the effectiveness of treatment of severe personality disorders persists, especially if they are part of the schizophrenic syndrome. This is partly due to the fact that the favorite methods used recently, for example, dynamic psychotherapy techniques, psychotherapeutic communities, individual work with patients and simplified behavioral psychotherapy techniques, were either ineffective or complex statistical methods were required to prove any of their effectiveness. with special justification. Personality disorders as nosological units are usually incurable, but many components of these disorders are open to modification and improvement. In patients with dangerous manifestations of schizophrenia, it is often possible to improve interpersonal skills, control anger, develop a constructive sense of self-confidence, strengthen sympathy for the victim, and eliminate or mitigate cognitive distortions that support destructive behaviors ( Novaco , 1997; Renwick et al , 1997). You cannot form a harmonious strong pro-social personality, but you can reduce the chances of antisocial behavior in the future ( Hollin , 2003; McGuire , 2003).
Evaluation of the abuse of alcohol and other psychoactive substances in individuals with schizophrenia willy-nilly becomes the top priority. Currently, in individuals with a high risk of violence, substance abuse is almost a universal phenomenon, therefore, effective control of it will be a necessary (preliminary) condition for any other treatment. This is not the place to analyze or recommend specific approaches to substance abuse , except that it can be repeated that it should be given the same clinical priority both at the place of residence and in hospital conditions, as well as eliminating or alleviating active psychopathological symptoms. In our service at Thomas Hospital Embling we use numerous approaches aimed at obtaining optimal results, considering the patient’s willingness to change and working within the framework of the concept of harm minimization ( Stanton & Shadish , 1997; Sheils & Rolfe , 2000; Mueser et al , 2003). Substance abuse may not be the main driver of violence in individuals with schizophrenia, but as long as it doesn’t decrease or, I dare to hope, it will not stop, no other preventive method will give a chance for success.
Restructuring of therapeutic goals and help systems
Whatever the theory claims, psychiatric services, especially under pressure, focus primarily on controlling the symptoms of the disease.The fact that this is always enough is doubtful, but in high-risk groups this is absolutely not enough.Substance abuse, personality weaknesses, and social conditions necessary to give equal, if not control psychopathology priority, then at least they should be an essential part of the treatment process.In part, this will depend on new resources, but equally it will require a change in the priorities of mental health services and the expectations of doctors.In order for such therapeutic goals to be completely transformed into a sustainable system of medical care, it will need restructuring and retraining of the specialists working in it.
In order to address the issues of criminality and substance abuse in schizophrenia to have a chance of success, not only the introduction of several special programs should be envisaged – the patient must be fully embraced by the desire for change. The main thing for such a system is the active participation of nursing staff working in the department and at the place of residence of the patient. Top nurses should be aware of and participate in their patient programs. All staff in the department and outpatient services who will interact with the patient should be aware of the current goals and methods of patient management in order to reinforce the work performed during individual and group psychotherapy. Psychotherapy sessions should not be a “black box”, a mysterious act. They should be transparent, correspond to the descriptions in the manual, and the questions “why”, “what” and goals should be known not only to the psychotherapist and the patient, but also to all relevant personnel on a daily basis. This approach provides for significant changes in the established order and power. Nursing staff is central to the therapeutic process; psychologists play a much larger role in evaluating and developing programs for specific patients; social workers and occupational therapists (by Standard Occupational Classification System – SOC: they plan, organize and implement programs aimed at restoring the abilities to work, manage the household and everyday life, and also contribute to the overall independence of people who are unable to work for any reason; included in the section “diagnosticians and medical practitioners” – approx. ed .) occupy a more important place, especially in the management of patients by place of residence. Such changes are a challenge for psychiatrists who, succumbing to temptation, will focus only on the symptoms, thinking only about the problems of the disease. However, if the system should work, psychiatrists should play the leading role, and only by making the biopsychosocial ideology of modern psychiatry a reality , such an approach will achieve the goal.
The effectiveness of introducing such a system into our court hospital and community services has been evaluated in the state of Victoria over the past 18 months. This system is already associated with a reduction in cases of violence in wards and a sharp increase in the duration of work of nurses. However, not in forensic psychiatric, but in general psychiatric services, such restructuring should give the greatest dividends for patients and the wider community of people.
Schizophrenic syndromes are associated with a high incidence of aggressive behavior. Psychiatric services should work to prevent such incidents for the sake of their patients, as well as for the wider public. In most cases, violence among individuals with schizophrenia occurs in relatively small subgroups, which probably constitute no more than 10–15% of the patient population. These high risk subgroups can be recognized well in advance. However, it is important that even in these subgroups only a few ever commit serious acts of violence. This is the basis for applying risk management techniques that complement medical care and treatment of the entire group, rather than justifying the use of coercive methods and disability to individuals. Violence on the part of representatives of high-risk groups is caused not only by active psychopathological symptoms, but also by such factors as personality weaknesses, a change in social status, and concomitant substance abuse .
In order to prevent future violence, approaches aimed at characterizing the criminogenic personality, meeting the need for employment and / or structured activities, at eliminating substance abuse , as well as promoting a network of adequate and supportive social connections and relationships are necessary . It is problematic to continue tolerating the situation when marginalization occurs individuals at highest risk of aggressive behavior or openly rejected by various services. To suggest that they necessarily receive better help only because the likelihood of patient aggressive behavior is higher is problematic to the same extent. However, as soon as we, as mental health professionals, are prepared for the fact that coping with violence is part of the real goals of our work, the problem will become an issue of an adequate level of medical care and treatment for specific violations, and not the best or worst services for any particular individual .