JustResearch Edition no. 9

Reviews

MENTAL DISORDER AND VIOLENCE

Swanson, J. W., Swartz, M. S., Essock, S. M., Osher, F. C., Wagner, H. R., Goodman, L. A., Rosenberg, S. D., and Meador, K. G. (2002). The social-environmental context of violent behaviour in persons treated for severe mental illness. American Journal of Public Health, 92, 1523-1531.

Reviewer: Dan Antonowicz, A/Senior Research Officer

The authors of the present study indicate that while the risk of violence is somewhat elevated in individuals with severe mental illness (SMI), most of these individuals do not engage in violent behaviour. However, it is also suggested in the article that there may be a significant increase in the likelihood of violent behaviour if psychopathology converges with other risk factors.

There is some evidence that a large proportion of individuals in treatment for mental health problems have at some time been a victim of violent physical or sexual abuse. According to the authors, the long-term effects of victimization may be compounded by risk factors such as substance abuse, homelessness, adverse social environments, and treatment non-compliance. Taken together, the risk of violence may be noticeably increased in specific subgroups of persons with SMI. However, it is unclear to what extent each of these risk factors contributes to violent behaviour by individuals with mental illness either independently or together.

In order to examine this question, a multivariate analysis of pooled samples of treated individuals with SMI in four US states (N=802) was conducted. Participants were male and female adults with psychotic or major mood disorders receiving inpatient or outpatient services in the public mental health systems of Connecticut, Maryland, New Hampshire, or North Carolina. Each of the five samples was weighted to match distributions of age and the prevalence of substance abuse derived from the National Institute on Mental Health (NIMH) National Comorbidity Study.[1] Data for the present study was collected on violent behaviour, victimization, demographic and social-environmental variables, and clinical/institutional variables.

Violent behaviour in the previous year was defined as "any physical fighting or assaultive actions causing bodily injury to another person, any use of a lethal weapon to harm or threaten someone, or any sexual assault during that time period." In terms of victimization, participants were asked questions about experiences of physical or sexual abuse occurring before and after age 16. Demographic and social-environmental variables included age, sex, race, marital status, income, and homelessness in the past year. Clinical/institutional variables included psychiatric diagnosis, substance abuse, and psychiatric admissions.

Logistic regression was conducted to examine the effects of victimization, demographic/social environmental variables, and clinical/institutional variables on risk of violent behaviour. The interaction effect of sexual abuse with physical abuse history on later violence was examined using the odds ratio (i.e., the average change in the odds of a predicted event) for sexual abuse alone, physical abuse alone, and the combination of the two. The same approach was used to test the interaction of early-life (before age 16) and later-life (after age 16) victimization on violent behaviour.

This study found that the one-year prevalence of violence was 13%. Furthermore, violence was found independently associated with history of violent victimization, homelessness, cohabitation, exposure to community violence, substance abuse, and history of psychiatric admission. However, no single factor emerged as the primary predictor of violence. The effects of victimization on violence were found to be highly significant if subjects had experienced repeated physical abuse throughout their lives. Individuals who had been victimized only during early life, but not after age 16, were no more likely to commit violent acts than were persons who had never been victimized. However, the risk of violence was several times higher in those who were victimized both before and after age 16, compared with individuals victimized during only one of these time periods. Thus, in the current study repeated abuse has a cumulative association with violence.

Substance abuse and exposure to community violence were also each found to be strongly associated with violent behaviour. Subjects with none or only one of these factors had predicted probabilities of violence of 2% or below. However, adding a second risk factor doubled the probability of violence, and respondents with all three risk factors combined were by far the most likely to commit violent acts (predicted probability of 30%). These analyses support the view that violence by individuals with SMI may be the result of multiple variables with compounded effects over the lifespan. No association was found in the current study between gender and violence.

The results of the present study must be considered in light of a number of limitations. The overall effect of mental disorder cannot be examined since treatment for SMI was a requirement for study participation, and no comparison group without treatment for mental illness was included. Given that the data were gathered in a cross-sectional survey, causal ordering cannot be established. Furthermore, the survey relied solely on self-reporting to obtain information about engaging in violent behaviour which may have served to underestimate the rates of violence. A final limitation is that variations in mental health treatment receipt, type or intensity were not examined. Thus, it is difficult to conclude whether mental health interventions might lower the risk of violence in these participants.

In conclusion, individuals with SMI and with combined risk factors in several domains–past traumatic experiences, current clinical problems including substance abuse and continuing exposure to adverse social environments characterized by persistent violence–represent an increased risk for violence. Given the wide range of contributing risk factors found in the present study, the authors suggest that interventions designed to reduce the risk of violence among

individuals with SMI will need to target specific subgroups with different clusters of risk factors related to violence. In order to help further inform intervention efforts, more research will need to be undertaken to determine why violent behaviour occurs in individuals with mental illness who have certain characteristics and experiences.

In terms of the Department of Justice of Canada, there was a parliamentary review of the mental disorder provisions of the Criminal Code in 2002. In order to help inform the review, a report was prepared that included data on the number of individuals found "unfit to stand trial" and "not criminally responsible" across Canada. One of the concerns that have been raised by the public is the belief that the majority of mentally disordered accused commit violent offences. The issue should be examined in Canada in order to determine the prevalence of violence among mentally disordered accused.

COSTS AND BENEFITS TO SERVICES FOR JUVENILE OFFENDERS

Robertson, A. A., Grimes, P. W., and Rogers, K. E. (2001).A short-run cost-benefit analysis of community-based interventions for juvenile offenders. Crime and Delinquency, 47, 2, 265-284.

Reviewer: Kelly Morton, Research Officer

The purpose of this study was to determine if two alternatives to regular probation (RP) were cost-beneficial in the short-run when compared to regular probation, specifically with regard to youth who use drugs and alcohol. The two alternatives were Intensive Supervision and Monitoring (ISM) and a Cognitive Behavioural Treatment (CB) program. The ISM program was similar to regular probation; however, the youth service counsellors had more frequent contact with the youth and their families, schools, or employers. In the CB program, the youth were also subject to the regular requirements of probation, with the added com- ponent of 60 hours of cognitive skills training, 24 hours of group therapy for the youth, and 24 hours of group therapy for the parents or guardians. All conditions lasted approximately 6 months, and all youth were subject to random drug testing. Additionally, the youth completed a variety of questionnaires concerning behaviour and substance use prior to and following service delivery (immediately, 6 and 12 months post-treatment). A total of 153 youth completed the program to which they were assigned. The design of the study was quasi-experimental in that assignment to a program was based on where the youth resided. Essentially, they were assigned to programs within their own communities. Program referrals were made by the courts for criminal or status offences.

For the purposes of this study, benefits were defined as the expected reduction in expenses to the criminal justice system (i.e., subsequent referrals and court-ordered days of detention) due to the specific service. Costs were defined as the additional spending required to support and maintain the programs. Using multiple regression models, the authors evaluated characteristics that increased a young offender's likelihood of completing a program, as well as those characteristics that influenced the expenses to the criminal justice system during an 18-month time period (including the 6 months in the program). Those characteristics that were found to make a young offender more likely to complete the program were being female, being in a stable home with a strong degree of parental oversight, and being in school. Additionally, having prior criminal justice system referrals and displaying behavioural responses to psychological distress made a youth more likely to drop out of the program. It is interesting to note that when the offender characteristics were held constant, the more time the youth spent with a counsellor the more likely the youth was to complete the program. However, when contact time was also held constant and the interventions were examined, those who participated in the CB condition (the condition with the most contact) were more likely to drop out.

The factors that increased the likelihood of spending by the criminal justice system (in terms of further referrals or days in detention) were being young, being male, being a minority, being impulsive, not enrolled in school, having committed a criminal rather than status offence, having prior criminal justice referrals, regular use of hard drugs, and being involved in gang activity. Additionally, when compared to RP the CB condition was found to be more effective at reducing short-term costs to the criminal justice system, whereas there was no difference found between the RP and ISM condition. After controlling for offender characteristics, the CB condition was found to reduce criminal justice expenditures by approximately $2,928 per participant over 18 months. After taking into account outside funding, the cost of running the CB program over 18 months was approximately $1,493 per participant. Therefore, there was an approximate saving of $1,435 per participant.

There are several limitations to this study. Most importantly, the risk levels of the youth were not evaluated or taken into account. Research has shown that high-risk youth should receive intensive levels of treatment/supervision, whereas low risk youth should receive minimal levels of treatment/supervision (Andrews and Bonta, 1998). This study evaluated young offenders who had committed both status and criminal offences. Since the type of program the youth was referred to was dependent on where the youth resided, high risk youth may have been referred to low levels of supervision and low risk youth may have been referred to intensive treatment. This fact may account for the high drop-out rate evidenced in the CB condition. Other limitations include the fact that the evaluation was conducted in three different counties, and thus there may be extraneous variables at work that are accounting for the variability. Additionally, although the results suggest that the CB condition is cost beneficial in the short term, there is no evidence that these benefits continue in the long term. It is possible that with a longer follow-up time period, the cost beneficial effects of the CB program may diminish or disappear.

Given these limitations, however, in the short term, the CB condition demonstrates effectiveness in reducing the number of youth who are subsequently referred to or detained by the criminal justice system. When one evaluates this in monetary terms, there are considerable savings for taxpayers and the government in referring youth to cognitive behavioural treatment programs. Previous research into treatment effectiveness has also demonstrated that cognitive-behavioural approaches are the most effective form of treatment for reducing recidivism (Andrews et al, 1990).

The Research and Statistics Division is currently conducting a meta-analytic examination of the young offender treatment literature to deter-mine best practices in reducing recidivism. Data from approximately 200 individual studies have been aggregated in order to determine best practices in the rehabilitation of youth in conflict with the law. Preliminary results indicate that treatment programs which include cognitive skills training, involve both group and family counselling, and limit exposure to six months, which is consistent with the Cognitive Behaviour Program in this study, provide encouraging results.

References

[1] The National Institute on Mental Health National Comorbidity Study provides a nationally representative probability sample of subjects with psychotic or major mood disorders who reported being hospitalized, using speciality mental health services within the past six months, or both.