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Abstract
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VioLit summary
OBJECTIVE:
The aim of this study by Gondolf was to investigate the extent to which the issue of violence was discussed between psychiatrists and patients presenting to a psychiatric emergency room. The theoretical basis for the study was found in the specification of patient dangerousness as a criteria for hospital admission, and the subsequent need to address issues of patient victimization and perpetration of violence.
METHODOLOGY:
A quasi-experimental cross-sectional design was employed in this study, using a non-probability sample of 392 psychiatric patients who presented to the emergency room of a metropolitan hospital during the 6-month period of the study in 1985 and 1986. Observers were present during each patient's psychiatric evaluation, which consisted of three separate sections - a clinician to patient interview, a psychiatrist to clinician discussion, and a psychiatrist to patient interview. Notes of the interviews and of the discussion were taken verbatim by the observers, and were later transcribed for coding of the major transactions regarding violence. Of the original sample, a sub-sample of 92 recently violent patients was identified, involving those people who had physically assaulted someone within the previous three months. This group was considered to be of high clinical concern, as the issue of recent violence is a primary factor in the prediction of future dangerousness. A number of specific transactions between patient and staff were recorded: the patient's first reference to violence and the clinician's subsequent questions during the clinician- patient interview; the clinician's reference to violence and the psychiatrist's response in the psychiatrist-clinician discussion; and the psychiatrist's questions regarding violence and his or her consideration of violence in the disposition during the final psychiatrist-patient interview. The severity of the violence initially introduced by the patient was coded according to the Conflict Tactics Scale, and the level of assaultiveness was also recorded - pushing, shoving or grabbing, hitting, slapping or punching, as well as physical fights were defined as assaults; hitting with an object, beating, threatening with a weapon or forced sexual relations were defined as severe assaults. Total number of assaultive incidents reported by the patient during the first stage of the evaluation was recorded. Observers also took note of the way in which the discussion of violence was initially introduced, as well as clinician questions about the report. The assaultive behavior was rated with regard to its relationship to the patient's primary problem, and the psychiatrist's response to the presentation of the case by the clinician was also recorded. For the last section of the evaluation, observers recorded psychiatrist follow-up questions to the patient, as well as the mention of any treatment options relevant to the assaultive behavior. Analyses included examination of frequencies and cross-tabulations with Chi Square.
FINDINGS/DISSCUSSION:
The author found that 29% of the recently violent patients had committed a severe assault, with 27% of the patients mentioning a violent incident as part of their primary problem when presenting to the emergency room. Clinicians asked further questions about the violent incident in 70% of the cases, and were most likely to do so if the incident was first mentioned as part of the presenting problem. Only 15% of the clinician questioning asked for detailed information about the circumstances, nature, temporality and duration of the violence, and 75% of the psychiatrists asked only one or two of these questions. During the clinician-psychiatrist discussion, clinicians mentioned the patient's violent behavior 80% of the time, and psychiatrist questioning involved questions about general violence in only 16% of the cases. In the psychiatrist-patient interview, 39% of the psychiatrists asked questions about the violent incident, with fewer than 3% asking at least four questions about circumstances, nature, temporality and duration of violence. Only 20% of psychiatrists mentioned any treatment options, and although 55% of the cases involved assault of a family member, family violence programs were offered as a possibility in only one case. From this the author concluded that family violence was more likely to be neglected than was violence that did not occur within the family. The author also concluded that the level of discussion about violence decreased throughout the course of the patient evaluation, as did the importance attached to the issue of violence. However, the author offered alternative explanations for his findings. He suggested that the issue of gender might have influenced levels of discussion of violence - female hospital workers have been found to ask more questions about social matters, which may have led the predominantly female clinicians to seek further details about the nature of the violence more than the predominantly male psychiatrists. It was also suggested that the function of the psychiatrists was to determine who was to be admitted to hospital, and that the details of the violent incident would be irrelevant once that decision had been made. The decision for admission might have been based upon unspoken observations and contemplations on the part of the staff, precluding the need for further discussion of behavior.
AUTHOR'S RECOMMENDATIONS:
The author recommended the need for a more substantial and systematic investigation of the reported violence when making decisions about patient dangerousness. Clinicians could be required to use violence inventories, in order to determine specific details about the nature of the patient's behavior. When presenting case details to psychiatrists, they could include a more specific report of violent behavior as well as their impressions about the patient's dangerousness. Psychiatrists could also seek more detailed information from the patient, and provide referrals to health service agencies. For these types of programs to be successful, institutional support or external monitoring would be required.
EVALUATION:
This study provides an interesting examination of psychiatric discussion of violence, as well as some valuable alternative explanations of the findings and implications for policy planning. However, the small sample size precludes the widespread generalizability of findings, and the subjective nature of the coding process calls into question the internal validity of the study. The findings of the author must also be approached with some caution, as alternative explanations of the findings, as delineated by the author himself, might be more accurate. Despite these limitations, the study addresses an important issue in the evaluation and treatment of the violent patient. (CSPV Abstract - Copyright © 1992-2007 by the Center for the Study and Prevention of Violence, Institute of Behavioral Science, Regents of the University of Colorado)
KW - Psychological Evaluation
KW - Dangerousness Prediction
KW - Adult Violence
KW - Adult Patient
KW - Adult Offender
KW - Patient Violence
KW - Violence Treatment
KW - Mental Health Institution
KW - Mental Health Personnel
KW - Mental Health Patient
KW - Diagnosis
KW - Mental Health Evaluation
KW - Mental Illness
KW - Mentally Ill Patient
KW - Mentally Ill Offender
KW - Mentally Ill Adult
KW - Patient Assessment
KW - Violence Assessment
KW - Violence Prediction
Language: en |