VIOLENCE IN INSTITUTIONS is written by four authors, all of whom are involved with the Mental Health Centre in Penetanguishene, Ontario, Canada. Three of the authors are psychologists, the fourth is a staff instructor. As the authors themselves put it "the book is the culmination of over 15 years of effort on the part of the authors to understand the problem of violence in psychiatric institutions, and to develop a staff training course designed to control it."
The book is divided into three parts:
1. Literature review & background research
2. Description of a staff training course, including background and rationale
3. Information for those developing their own course and/ or preparing to act as trainers
In their introduction the authors clearly state their starting-point in suggesting that violence in institutions is in large part a product of the ways staff customarily deal with patients. Staff members may unwittingly provoke escalation and assaults. Therefore meaningful changes in the behaviour of patients might best be accomplished by modifying staff behaviour.
The book therefore mainly deals with changing behaviour, more so than with understanding behaviour.
The first part of the book which aims at understanding institutional violence is itself divided into three: a review of the literature, results of two (previously published) background studies and a selection of violent incidents which are described and commented on.
The review of the literature leads to the conclusion that institutions with a high level of violence have the following characteristics:
- rapid turnover of large numbers of young individuals with histories of institutional aggression
- many individuals with backgrounds of poor community adjustment
- staff who are generally inexperienced and approach residents in an authoritarian manner while attempting to maintain control through the exclusive use of aversive or punitive consequences
- an environment in which residents have fairly unrestricted and unsupervised access to each other in a crowded area with little structured activity, and in which assaultive behavior is excused and staff impose no cost for its occurrence.
Many large correctional and psychiatric facilities or institutions for the mentally retarded have many or all of these characteristics.
Most literature is realting to violence in institutions is atheoretical in nature: violence is seen as a problem to be eliminated. Research on the effectiveness of strategies used to eliminate violence is therefore relevant as well. The authors provide a useful overview concerning the effectiveness of strategies used to prevent or stop violence. The conclusion must be that little is known about the effects of most of the strategies.
The attempts to reduce institutional aggression include:
- drug treatment, which meets with many difficulties while there is a lack of insight on what causes the effectiveness of certain drugs;
- seclusion and mechanical restraint
- behavioral treatments consisting of either suppressing aggressive behaviour immediately or teaching prosocial skills
The authors synthesis points to a mixed strategy consisting of careful management of contingencies, cautious application of drug treatment, practices that reduce crowding and increase the stability of the social environment and increase of structured activities for residents. In line with their starting point, the authors find support for their idea that significant reductions in institutional violence could be achieved by a staff training programme aimed at teaching:
- nonrestrictive, nonauthoritarian and nonprovocatiove ways of interacting with residents;
- behavioural cues and situational characteristics associated with assaultiveness;
- effective verbal strategies for use with highly upset individuals.
The first of the two long-term studies discussed by the authors seems to indicate that frustration and anger arousal are important instigating components to the aggression of psychiatric patients. The second study on staff injuries indicates that restraint situations where staff physically control patients are more dangerous than assault situations.
So the authors see more than enough reason to present their staff training course as a useful means to prevent and control violence. Not surprisingly the course builds in many ways upon courses used by the police. The police is faced by similar problems in dealing with violence and has long ago found out that violence is the result of an interaction and rarely erupts without warning. In this light it is also enlightening to have knowledge of studies - also referred to in the book - where "normal" people are secretly admitted to psychiatric hospitals or are assigned a role of "guard" or "inmate" in a prison.
In general, VIOLENCE IN INSTITUTIONS is a highly readable book with an approach that for many professionals will be a fresh one. To professionals involved in instutions it can be useful. From a scientific point of view, possibilities for future research become visible. More systematic data are needed and more attention for a theoretical inbedding of different strategies used. In this respect sex-differences are interesting as well: in institutions (as in the real world), males (both male patients and male staff) are more likely to use violence. Almost completely lacking is attention for possible functions of violence. Although there is some space in the book devoted to the follow-up of violent incidents, in the form of negotiations and conflict resolution, more attention for processes of social repair and reconciliation seems in order.
© Otto M.J. Adang, 1993
This review was published earlier in Aggressive Behavior