Violence and Leveraged Community Treatment for Persons With Mental Disorders

• Published in: The American journal of psychiatry Vol. 163; no. 8; pp. 1404 - 1411
• Main Authors: Swanson, Jeffrey W., Van Dorn, Richard A., Monahan, John, Swartz, Marvin S.
• Format: Journal Article
• Language: English
• Published: Washington, DC American Psychiatric Association 01.08.2006
• Subjects: Adaptation, Psychological; Adult and adolescent clinical studies; Age Factors; Biological and medical sciences; Civil rights; Community Mental Health Services - methods; Crime - statistics & numerical data; Disability; Female; Forensic Psychiatry - legislation & jurisprudence; Forensic Psychiatry - methods; Humans; Male; Medical sciences; Mental disorders; Mental Disorders - psychology; Mental Disorders - therapy; Mental health care; Miscellaneous; Patient Compliance; Patient Readmission - statistics & numerical data; Patients; Pensions - statistics & numerical data; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Public Housing - statistics & numerical data; Public safety; Risk factors; Sex Factors; Social Adjustment; Social Welfare - statistics & numerical data; Violence; Violence - psychology; Violence - statistics & numerical data; Mental disorder; Violence; Community treatment
• DOI: 10.1176/ajp.2006.163.8.1404
• ISSN: 0002-953X

Objective: This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment. Method: Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics. Results: Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage. Conclusions: A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.