The Concise Oxford Dictionary (1985) defines danger as "liability
or exposure to harm, risk or peril". It is of great concern to nurses
to identify danger in their workplaces and to take action to minimize it.
A hospital corridor is not innately dangerous but add a volume of water
to make the floor slippery and you have a source of danger. Add foot traffic
and you have the ingredients for an accident - the environment may be said
to be dangerous. The astute nurse cognizant of the danger will have the
water cleaned up or sign posted, thus minimizing the danger.
Labeling an object or situation dangerous involves a prediction that
given the presence or absence of certain conditions an object poses a likely
threat of harm to another. This brief discussion will examine the reliability
and implications of identifying those with mental illness as dangerous
to others and some of the conditions which may predispose someone to act
in a dangerous manner.
For some the association between mental illness and dangerousness is
automatic. Media portrayals of mental illness give rise to beliefs that
the sole conditions necessary for violence towards others by a person are
mental illness and the individuals liberty. This belief is further reinforced
by sensationalist reporting on occasions when someone with a diagnosed
mental illness does commit a violent act (Levey and Howells, 1995). On
these occasions any history of contact with mental health professionals
is taken as evidence that the person must have been "sick" at
the time of the act.
For many people violent acts themselves are seen as signs of illness,
hence such expressions as "he must have been sick" in response
to hearing of a particularly brutal physical or sexual assault on another.
Such a statement is a reflection of how entrenched medicine has become
in our daily lives. Conrad and Shneider (1980) point out that it is a relatively
recent phenomenon that such problems as violence and addiction have been
defined as medical problems. Medicine has ascended to a position of authority
in labeling and treating all manner of social problems and the authority
of medicine in the social domain has increasingly gained legal legitimacy.
Psychiatric predictions of future dangerousness represent the single
most significant factor in the commitment of the mentally ill in the United
States (Fisher, 1989) and this is increasingly becoming so in most countries
(Mulvey and Lidz, 1995). In New Zealand the Mental Health Act 1992 introduced
the concept of "dangerousness " in an explicit way, as a central
concept to consider in assessing and compulsorily treating those with mental
disorder. This was a significant shift from the focus of the old Act where
people could be detained because they needed care (Bridgeman, 1994). The
grounds for compulsory treatment are a mental disorder of such a degree
that it "Poses a serious danger to the health or safety of that person
or of others..." or "Seriously diminishes the capacity of that
person to take care of himself or herself..." (MH(CAT) Act, 1992).
Nurses have specific powers under the act to detain people whom they believe
pose a danger due to mental disorder for the purposes of a medical assessment.
Contention exists over what constitutes a danger and when danger becomes
serious.
When the court receives an application for a compulsory treatment order
the judge must consider whether the person poses a serious danger. According
to Cooper (1994) serious danger has been defined by precedent as an imminent,
demonstrable risk of no less than severe physical violence which is not
reasonably preventable or avoidable without compulsory treatment. Using
this narrow definition of dangerousness it would not be surprising if there
is an association between violence and the compulsorily detained mentally
ill. Indeed a history of violence will be a defining feature of this subgroup
as a history of violence or a recent violent act may be necessary to satisfy
the criteria of dangerousness. In some cases health professionals may be
impotent to compel someone to receive assessment (even though they might
benefit from it) until the individual has reached a stage where they pose
an imminent danger to others. Violence and mental illness may not even
be independent terms. Swanson et al (1990, p. 762) point out that "...
assaultive behavior lies at the core of what is labeled as psychiatric
disorder". Violence and mental disorder are to varying extents seen
as synonymous by the general public, the law and the psychiatric profession.
Nurses who work in inpatient psychiatric units are likely to encounter
people who are deemed a danger towards others. This is also true for other
settings. It has been estimated that at least half of all health professionals
will be assaulted during their careers (Blair & New, 1992). Many hundreds
of research studies and articles have been published on the issue of violence
from a broad range of perspectives. Monahan (1992) concludes on the basis
of an extensive review of the research on violence and mental disorder
that there is a limited connection between mental disorder and violence.
Probably the most extensive research examining the relationship between
violence and mental disorder was undertaken in the 1980s in what is known
as the National Institute of Mental Health's Epidemiological Catchment
Area Surveys involving close to 10,000 interviews in various parts of the
United States. Swanson et al (1990) found that 2.1 % of those who did not
meet DSM-III criteria for mental disorder reported committing a violent
act in the previous year. This compares with 12.7% for those who met criteria
for schizophrenia, 11.7% for major depression, 11% for mania or bipolar
disorder, 24.6% for alcohol abuse/dependence and 34.7% for drug abuse/dependence.
"Violence was most likely to occur among young, lower class men, among
those with a substance abuse diagnosis, and among those with a diagnosis
of major mental disorder" (Monahan, 1992). Monahan (1992, p.517) identifies
further analysis based on this data which suggests that when "...
patients were not experiencing psychotic symptoms, their risk of violence
was not appreciably higher than a demographically similar members of their
home communities...".
Epidemiological research serves to confirm the assumption that alcohol
or drug abuse may be one of the conditions that may predispose one towards
violence and tentative links may be drawn between the symptoms of mental
illness and violence. However further research is necessary to provide
precision in the clinical decision making process. For example most people
with a diagnosis of schizophrenia are not violent in fact they may be more
likely to be victims of violence than perpetrators (Bridgeman, 1994).
A frequent method of inquiry used to illuminate the nature of violence
within the mentally ill as a subgroup has been to examine the characteristics
of those psychiatric patients who have been violent and compare them with
groups who have not. Blomhoff, Seim and Friis (1990) found that the best
single predictor of violence was a history of previous violence. Other
significant findings were a high degree of violence in the family of origin
and a high level of aggression on admission accompanied by an absence of
anxiety.
An assumption of a great deal of research is that if a greater number
of symptoms and demographic characteristics are explored a more precise
model might evolve to inform predictions of dangerousness. Paranoid schizophrenia
is one diagnostic subgroup which has long been associated with violence
(Blair and New, 1991). Junginger (1995) explored compliance with command
hallucinations, a relatively common phenomena which may accompany this
disorder. Based on self reporting by psychiatric patients he found that
people were at risk of violence if they experienced command hallucinations.
People who could give an identity to the hallucinated voice were more likely
to comply with the commands and most significantly, the dangerousness of
the commands appeared to be a function of the environment, that is people
tended to experience less violent commands in hospital than those experienced
elsewhere.
Yet another approach to understanding aggression and violence is the
quest for neurobiological correlates. If structural and functional changes
in the brain are found to be associated with violent behavior then the
labeling and treatment of dangerousness could truly be claimed as the legitimate
domain of medicine.
Damage to certain centres of the brain such as the limbic structures,
temporal, and frontal lobes have been found to be associated with aggressiveness
and rage (Garza-Trevino, 1994). Certain medical conditions such as temporal
lobe epilepsy have also been linked with violent behavior in humans and
other species (Garza-Trevino, 1994).
It is doubtful whether abnormalities in genetic structure, endocrine
function or neurotransmitter balance can fully account for most violent
behavior. Kalat (1992, p. 433) for example points out that the highest
incidence of violence, as measured by crime statistics, is in men 15 to
25 years old, who also have the highest level of testosterone in the blood.
However not every young man with elevated testosterone is violent. While
biological factors may account for violent behavior in a small number of
individuals, and a predisposition in others it is more likely that the
physical and social environment plays at least a modifying role.
The research by Junginger (1995) is particularly interesting because
it suggests that the environment has a modifying effect on symptoms of
illness, in this case the "dangerousness" of command hallucinations.
Other research has focused on environmental or temporal factors such as
overcrowding, staffing levels, noise and time of day with mixed and sometimes
contradictory results (Blair and New, 1991). More consistent and reliable
results may be found in the research on violence and the social environment.
Violence towards other does not occur in an interactional vacuum. At
least one other person must be involved and a pattern of interaction usually
precedes violence. Sheridan et al (1990) examined perceived events leading
up to the use of restraints in a psychiatric unit from the patients' perspective.
Contrary to expectation most patients perceived events leading up to use
of restraints as external rather than internal to themselves. Thus delusions
and hallucinations were seen as events that triggered aggression in only
a minority of cases, whereas patient-staff conflict, enforcement of rules
and conflict with other patients were more commonly perceived as precipitants
(Sheridan et al, 1990). Such research tends to confirm the idea that it
is not the symptoms of mental illness which tend to trigger violence but
rather it is the response of others to the person or a the individuals
response to others.
The views that most people who are violent are out of control and that
staff need to control patients are outdated and may in themselves precipitate
unnecessary conflict (Morrison, 1993). Watson's (1991, p.14) study of care
and control in psychiatric settings suggests that "...controlling
practices contribute to the stress of mental illness and provoke the very
behaviors they are designed to contain". Violence then, may become
a self fulfilling prophesy. Staff may create distance between themselves
and those whom they perceive as dangerous. Under the umbrella of "safety"
controlling practices may ensue creating conflict, culminating in violent
behavior. The person may then be said to have a history of violence justifying
further controls and possibly reinforcing that violent behavior.
The notion that violent behavior can be learned and reinforced is validated
by research by Morrison (1994, p.249) who found that of psychiatric patients
who had been violent most utilised what she called a "coercive"
interactional style", that is "...using others for self gain".
She found that this style of relating overshadowed even a history of violence
as a predictor of latter violence (Morrison, 1993). Morrison (1993) proposed
that most violence among those with mental illness was similar to violence
among wider society. The key to preventing violence is to eliminate the
rewards for violence and to reinforce non-coercive styles of relating.
The rewards for violence will be idiosyncratic. For some it may be seclusion
or time-out, for others merely the sense of power that one has over another,
for others it may be the focused attention of health professionals.
As nurses and clinicians we are equipped with an armory of statistics
on who might be violent towards others e.g. the young, intoxicated, male
patient with schizophrenia, We also have a responsibility to interpret
and use these findings with caution. While useful in telling us who might
be violent, the research is far from useful in telling us who is dangerous
with any specificity. The reality of skilled clinical decision making is
such that clinicians take into account the conditional nature of violence
(Mulvey and Lidz, 1995). Anyone may be dangerous under certain conditions.
For example some people tend to be violent in their home environment and
otherwise present a respectable face to the world, others are violent only
when intoxicated. The symptoms of mental illness for most people are not
necessary conditions in themselves for violence.
When in hospital nurses are the frequent targets of violence. It is
therefore important that nurses have an understanding of why people in
general are violent and most importantly the conditions under which the
individual patient may be violent. This means being involved with patients
and attempting to understand them as individuals. This will be evidenced
when we see care plans in action which takes into account the conditions
under which the individual has been and is likely to be violent rather
than the generic "potential for violence" that is so common.
Interventions are needed which set explicit boundaries for socially acceptable
behavior and consequences for unacceptable behavior, while also reinforcing
non-coercive styles of relating.
It will now be evident that comparing the dangerousness of a person
with an object such as a floor is flawed. Unlike a floor people can and
do use violence in a purposeful way to get what they want. Labeling a person
as dangerous may have far reaching effects for that individual. The label
may travel with that person affecting their relationships with other people
to such an extent that in some instances future violence becomes a function
of the effect of the label. On the other hand the effect of labeling a
floor as dangerous is likely to be the minimization of danger. One is unlikely
to hear "Be careful.. that floor was once dangerous, it may be dangerous
again" but the opposite is true for people. There is a potential that
people will relate to the individual who is labeled as dangerous in a manner
which increases that person's sense of alienation and which may reinforce
and even provoke violent behavior. When aware of this dynamic health professionals
are challenged to respond to the individual in a way which validates and
empowers.
Nurses must challenge coercive and controlling institutional practices
that may reinforce and provoke violent behavior. Opportunities for patients
to get what they want and need without recourse to violence must be provided.
At the same time the risk of violence must be acknowledged and the victims
of violence supported. These are major challenges for nurses and the institutions
in which they work. Health professionals face the dilemma of balancing
a societal mandate to control those with mental illness and a mandate to
care for them. All who work with the mentally ill, in whatever setting
must ensure that caring takes precedence.
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