Treat the treatable: a comprehensive and optimistic approach to treating psychiatric violence

The movement toward a dimensional model for psychiatric diagnoses provides a new way to conceptualize violence in mental health populations: rather than focusing on violence as a result of mental illness, we can conceptualize violence as one dimension of mental illness, thereby addressing this complex syndrome with an approach that is both humanistic and scientific. Rather than dichotomizing violent patients as either criminally minded or mentally ill, this new formulation allows us to accept the heterogeneity of violence in mental health populations, to flesh out the key contributors to violence and to “treat the treatable”. This approach is supported by a contribution from Bartholomew and Morgan, ¹ which reviews the evidence examining the relationship between mental illness and criminal behavior, and suggests that certain individuals experience both mental illness and criminal thinking. As our forensic populations rise, this Special Issue is intended to explore the gamut of topics related to that rise, from how we got here as a society to how to treat individuals once they have experienced criminalization. It is very much hoped that the reader of this Special Issue will come away with an appreciation for the population and optimism about the treatment horizon.

Contributions related to the reasons for the rise in forensic populations reiterate the theme of treating the treatable, as they point to a failure to treat as a primary cause of the growing phenomenon of people with mental illness becoming involved in the criminal justice system—a process termed criminalization. Torrey ² reviews the impact of deinstitutionalization on the rise of violence, and offers a comprehensive argument for focusing on the treatment of psychotic behavior in the community in order to prevent criminalization, rather than deferring treatment until after the onset of psychotic behavior and associated violence to be treated in correctional or forensic settings. Warburton ³ argues that deinstitutionalization has created a new type of psychiatric patient (namely, a patient with complex mental health, forensic, and criminogenic needs) and thus, that the standard of care for this population needs to be redefined. Schaufenbil et al ⁴ flesh out the first step in that new standard by proposing forensic-focused treatment planning to target issues such as violence risk. Broderick et al ⁵ provide more evidence for the risk of not treating mental illness in the community, as they describe inpatient violence as a consequence of the criminalization of the mentally ill in a large forensic system. Szabo et al ⁶ also examine the issue of aggression, but within community hospitals, and the impact of aggression on care as well as potential solutions for predicting and reducing inpatient violence in this setting.

A theme emerged as the invited articles arrived: most emphasize the importance of treating the treatable. Both Felthous ⁷ and Wong and Olver ⁸ consider the treatment (and appropriateness of treating) psychopathic conditions—long considered to be one of the most challenging domains of forensic treatment. Both agree that treatment is appropriate, and each provides a unique approach to that end. Felthous ⁷ proposes a way forward via the pharmacological treatment of impulsive behavior, after extensively educating the reader about the historical and neurobiological rationale for this approach. Stahl ⁹ also expands upon this approach in his “Brainstorms” article in this issue. Complementing this approach, Wong and Olver ⁸ propose alternatively to target the modifiable criminogenic risk factors, and base this notion on a review of the existing literature on psychopathy and criminal rehabilitation. Related to the need to treat criminal behavior, Pinals ¹⁰ explores the strategies for mitigating violence risk in community outpatient settings, emphasizing the promise of folding in treatment for criminogenic thinking with standard mental health treatments for certain at-risk populations. Dardashti et al ¹¹ provide cases to support the recently published Cal-VAT Guidelines, ¹² which were designed to approach violence based on its etiology: impulsive, predatory, and/or psychotic. Knoll ¹³ explains the history and implications the Tarasoff decision and the psychiatrist’s duty to protect when a serious risk of violent behavior is detected. Bartholomew and Morgan ¹ offer suggestions for specialized housing needs in this population. Horowitz et al ¹⁴ describe psychosocial interventions for violent behavior, and focus attention on the need for trauma-informed, person-centered, recovery-oriented approaches. Tully et al ¹⁵ describe a role for new technologies in the management of psychiatric violence in forensic populations. Bader and Evans ¹⁶ describe an ecological approach to reducing inpatient aggression.

Background for the proposed treatment articles is provided by several notable and foundational contributions related to the neurobiology of violence. Cummings ¹⁷ touches on the neurobiological aspects of psychopathy that lead to both predatory and impulsive violence, confirming the need for the multiplicity of approaches. Coccaro et al ¹⁸ have reviewed the often-hypothesized role of serotonin in impulsive aggression. Hoptman ¹⁹ reviews the neurocircuitry of impulsive aggression in schizophrenia, and provides treatment suggestions based on those findings. His findings overlap well with those of Felthous ⁷ and of Stahl ⁹ on the treatment of impulsive aggression in psychopathy. Rosell and Siever ²⁰ provide a readable, comprehensive, and compelling overview of the neurobiology, neuroanatomy, and neurochemistry of violence.

We are very pleased with this collection of articles on psychiatric violence, which complement our earlier special issue on this topic (see the October 2014 issue of CNS Spectrums) with a collection of additional related articles. All articles from both special issues will be republished together with additional contributions as a book edited by us and to be published by Cambridge University Press. We hope that these articles will stimulate creative solutions to the modern management and effective treatment of violence in the psychiatric settings of the 21st century.

Disclosures

Katherine Warburton does not have anything to disclose. Stephen Stahl is an adjunct professor of psychiatry at the University of California, San Diego School of Medicine; an honorary visiting senior fellow at the University of Cambridge in the UK, and Director of Psychopharmacology for the California Department of State Hospitals. Dr. Stahl receives research support from Avanir, CeNeRx, Forest, Genomind, Lilly, Janssen, Mylan, Mylan Specialty, Otsuka, Pamlab, Servier, Shire, Sunovion, and Takeda; is a consultant/advisor to Avanir, BioMarin, Depomed, Forest, Genentech, Genomind, GlaxoSmithKline, Jazz, Merck, Navigant, Novartis, Noveida, Neuronetics, Orexigen, Otsuka, Pamlab, Reviva, Roche, Shire, Sunovion, Taisho, Teva, and Trius; is on the speakers bureaus of Arbor Scientia, Genomind, Janssen, Lilly, Pamlab, Pfizer, Sunovion, and Takeda; and is a board member at Genomind and RCT Logic.