Emotional Dysregulation: The Key to a Treatment ... - Springer Link

Clinical Social Work Journal, Vol. 30, No. 2, Summer 2002 ( 2002)

EMOTIONAL DYSREGULATION: THE KEY TO A TREATMENT APPROACH FOR VIOLENT MENTALLY ILL INDIVIDUALS Christina E. Newhill, Ph.D., L.C.S.W., and Edward P. Mulvey, Ph.D.

ABSTRACT: Prior research has suggested that psychopathy, substance abuse, and the presence of a personality disorder increase an individual’s risk for violence toward others. Substantial clinical literature has established emotional dysregulation as a risk marker for violence toward self. It is hypothesized that emotional dysregulation may be an important component in a constellation of risk markers for violence toward others and may interact with psychopathy and substance abuse in individuals with personality disorders to enhance risk for violence. If these hypothesized relationships exist, it suggests that the development of an intervention approach which directly targets these factors may hold promise. A potential intervention approach based on dialectical behavioral therapy, with case illustrations, is provided. KEY WORDS: violence; personality disorder; emotional dysregulation; substance abuse; dialectical behavior therapy.

INTRODUCTION: THE STATE OF RESEARCH REGARDING VIOLENCE AND MENTAL ILLNESS The most current and methodologically sound investigations of violence and mental disorder have concluded that mental illness appears to have a significant relationship to incidents of violent behavior (for reviews, see Eronen, Angermeyer & Schulze, 1998; Monahan, 1992; Appelbaum, 1994; Mulvey, 1994), and clinicians have some moderate ability to predict future violence (Lidz, Mulvey, & Gardner, 1993; Monahan, 1994). While these results provide some solace to clinicians regarding the validity of their clinical impressions, they do not lead directly to methods for improving the effectiveness of practice with potentially violent individuals. Given 157

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the massive changes in the treatment environment toward limited institutional care (Mechanic, 1999), clinicians increasingly need guidance about how to treat and monitor violent mentally ill people in the community (Stein & Santos, 1998; Dennis & Monahan, 1996). The next task confronting clinical researchers, therefore, is to generate knowledge about how to identify and intervene with those mentally ill individuals with the highest likelihood of committing violence toward others. To address this challenge, methods must be developed for identifying which individuals are at greatest risk for committing violence as well as creating effective strategies for reducing violence among those at greatest risk. Progress has certainly been made recently on actuarial methods for identifying individuals at higher risk for violence (e.g., Quinsey, Harris, Rice & Cormier, 1998; Webster, Douglas, Eaves, & Hart, 1997), and these efforts hold promise for routinizing and focusing the identification task. The advancement of theoretically-based intervention approaches for individuals with high likelihood of violence, however, is far less developed. Prior work has clearly shown that individuals with mental illness are far from homogenous in their proclivities for violence (Eronen et al., 1998; Steadman, et al., 1998), and there may be identifiable subgroups of violent individuals with mental disorder who evidence particular levels of risk. The most consistent findings of this sort identify patients with serious personality disorders and substance abuse histories as a subgroup that is at increased risk for violence. For example, Steadman et al. (1998) reported that recently discharged individuals with major mental illness and substance abuse symptoms have a significantly higher rate of violence than individuals with major mental illness who do not have substance abuse symptoms. Furthermore, within this high risk group, individuals with personality disorders were at greatest risk for violence. These findings converge with other studies that have shown higher rates of violence for individuals with substance abuse problems and personality disorders, particularly antisocial and borderline personality disorder (Else, Wonderlich, Beatty, Christie & Staton, 1993; Hare & McPherson, 1984). Even when psychotic patients are violent, underlying personality features, rather than psychotic symptoms, appear to be influential factors related to the violent behavior. For example, the presence of psychopathy in individuals with schizophrenia has been shown to significantly enhance risk of violence (Nolan, Volavka, Mohr & Czobor, 1999). Developing a set of theoretically driven interventions specifically targeted to patients with personality disorders and substance abuse and which can be realistically provided within the current community based treatment environment appears to be the logical next step in addressing the nexus of mental disorder and violence. To achieve this goal, we must first examine how each of these constructs connect and influence the production of violent behavior.

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CHRISTINA E. NEWHILL AND EDWARD P. MULVEY

PERSONALITY DISORDERS AND VIOLENCE There is little doubt that personality disorders are relatively common, and the clinical management of such individuals is particularly difficult (Adler, 1990). A recent comprehensive summary of epidemiological studies concluded that about 10–13 percent of the population meets the criteria for a personality disorder at some point in their lifetime and that these individuals represent a disproportionate number of patients in both inpatient and outpatient clinical settings (Widiger & Trull, 1993). While considerable debate exists about the best approach for diagnosing these disorders, it is generally recognized that erratic, emotional, unpredictable behavior is most characteristic of the four personality disorders subsumed within the Cluster B grouping of the DSM-IV (APA, 1994), i.e. histrionic, narcissistic, borderline, and antisocial personality disorders. Violent behavior is seen as particularly characteristic of the antisocial (Eronen, Tiihonen & Hakola, 1997) and the borderline personality disorder subtypes (Grosz, Lipschitz, Eldar & Finkelstein et al., 1994). However, the ways that the specific features of these two personality disorders might contribute to the violence remain unclear. Although violence is presented as a criterion for the diagnosis of certain personality disorders, e.g., antisocial personality disorder, it is rarely examined as a behavioral outcome of the life course of these disorders or addressed as a target of treatment. However, two constructs identified as central to Cluster B personality disorders, i.e., emotional dysregulation and psychopathy, appear to be features that are especially good candidates to examine as factors that might be responsible for the observed increased risk for violence. Emotional Dysregulation as a Relevant Feature of Personality Disorder Emotional dysregulation is a central feature of both borderline and antisocial personality disorders although it may be expressed in different ways. Emotional dysregulation is theorized to have three dimensions: (1) a low threshold, or high sensitivity/vulnerability to emotional stimuli; (2) a high amplitude of emotional response; and (3) a slow return to baseline emotionally (Linehan, 1993). Emotional dysregulation is generally thought to result from a combination of biological predisposition and learned responses to affectively laden early experiences. Over time, such individuals may develop maladaptive mechanisms to deal with their intense affective experiences. For example, substantial clinical literature supports the notion that violence or self-mutilation can serve an emotionally self-regulating function in individuals with personality disorders (Linehan, 1993). Self-injurious behavior is often associated with relief from overwhelming feelings, e.g., dysphoria, and may even be associated

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with analgesia, i.e., absence of the experience of pain in the presence of a theoretically painful stimulus (Russ, Roth, Kakuma, Harrison & Hull, 1994; Russ, Roth, Lerman, Kakuma et al., 1992). What happens is that the emotions “fire” under certain provocation, and the self destructive behavior that follows, while not planned and intentional, serves a clear function in the pattern of the disorder (Linehan, 1997). Cutting or burning onself, though destructive, can be an effective strategy for focusing attention and decreasing overwhelming psychic pain. As a patient once commented to one of the authors: “When I feel overwhelmed with emotions, I cut myself. It helps pull me together, helps me to focus and get control. When I see the blood, it makes me feel real.” Following this logic, it is certainly reasonable to postulate that violent behavior toward others may serve a similar function, i.e., as a mechanism to regulate emotion by bringing the feeling of being emotionally overwhelmed to closure.

Psychopathy as a Relevant Feature of Personality Disorder Psychopathy is the second feature of personality disorder most logically connected to increased risk for violence. There is a long debate in the literature about the exact relationship between the construct of psychopathy and the presence of antisocial personality disorder (e.g., Hare, Hart & Harpur, 1991; Rice & Harris, 1995; Widiger et al., 1996), and it is important to note the general distinction between the two. While psychopathy is characterized by superficial charm, egocentricity, incapacity for love, guiltlessness, lack of remorse and shame, a sense that social rules do not necessarily apply to oneself, lack of insight, and failure to learn from experience (Cleckley, 1941; Millon, Simonsen, Birket-Smith & Davis, 1998; Simonsen & Birket-Smith, 1998), antisocial personality disorder (APD) is a DSM-IV diagnosis and describes criteria skewed toward an emphasis on criminal behavior (APA, 1994). Although people can be both antisocial and psychopathic, many individuals who are or could be diagnosed with APD are not psychopathic and many individuals with psychopathy “do not become criminals in the strict sense” (Simonsen & Birket-Smith, 1998; p. vii). There is also a sense that psychopathy may be more indicative of a trait-like quality of an individual. The association between violence and psychopathy may, for instance, have some origins in physiological and neuropsychological mechanisms related to autonomic sensitivity and psychological processing governing social interactions (Scarpa & Raine, 1997; Raine, 1996), and different forms of violence used by psychopathic individuals may have different psychophysiological underpinnings. For example, whereas emotional/reactive violence may be related to overarousal or hypersensitivity to emotional stimuli, i.e. emotional dysregulation, instrumen-

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tal/proactive aggression may be related to physiological underarousal (Scarpa & Raine, 1997). Whatever the exact set of interrelationships, we know that psychopathy represents a central feature of many individuals with certain personality disorders, has a clear demonstrated relationship to violence (Harris, Rice & Cormier, 1991; Millon et al., 1998; Hare, 1983; Hart, Hare & Forth, 1994), and can be measured independently of APD (e.g., Hare, 1980, 1998; Millon & Davis, 1998; Widiger & Lynam, 1998). Consequently, it certainly seems worth the effort to analyze psychopathy as a construct related to personality disorder and examine its relationship to violence more closely. A richer understanding of the mechanisms behind the relationship of psychopathy and violence is a necessary step to guide the design of effective interventions with those individuals at the greatest risk for violence (Rice, 1997).

SUBSTANCE ABUSE AND VIOLENCE The link between substance use (particularly alcohol) and risk for violence is well established (Teplin, 1994), with a substantial proportion of violent incidents suggesting a direct contribution of intoxication to violence (Collins & Schlenger, 1988; Collins, 1989; Pernanen, 1991). Theoretical explanations for the violence-alcohol link range across impulsedriven, external-stimulus-driven, cognition-driven, and social dynamics hypotheses (Pernanen, 1993). There are, however, few descriptive studies of how alcohol affects social interactions to promote violence outside of the laboratory setting (Bushman & Cooper, 1990). Indeed, the role of context on the relationship between alcohol or drug consumption and violence appears to be substantial and complex, but poorly understood (Moss & Tarter, 1993). Some drug use, for example, may promote violence as part of the activities involved in obtaining money to buy drugs or to control the drug market (Fagan & Chin, 1990; Goldstein, 1985). In other cases, an individual’s alcohol consumption may only lead to violence when certain people with whom the person has conflict are present. For example, one patient stated to one of the authors: “Yeah I drink. I drink every day. But I don’t get violent unless my old man is around. Then we get into it. If I’m not wasted, though, I can walk away from it.” What this patient’s statement illustrates, is that it is often the combination of the use alcohol or drugs within a provocative context that leads to violence. The strong association between drinking and drug use and violence is found in samples of individuals with mental illness, but information about the mechanisms of this effect in this group of individuals is also sparse. Both drinking and drug use have been shown, in epidemiological

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research, to be associated with risk status among people with mental illness across the range of mental disorders (Swanson, 1994), and substance use and symptomatology may have a synergistic effect on violence (Mulvey, Gardner, Lidz, Graus, & Shaw, unpublished manuscript). Unfortunately, there are simply no detailed longitudinal studies of the effects of alcohol and drug use among people with personality disorders or other mental illness that would allow for a clear picture of the role of this factor in setting the stage for violent incidents.

TYPES OF VIOLENCE Exploration of the connections between personality disorders, substance abuse, and violence must also take into account that all violence is not the same. Violent encounters may result from a variety of circumstances and motivations (Dodge, 1991), and it is simplistic to think that a singular mechanism applies to all situations. One of the most useful broad distinctions is between reactive and proactive violence (Dodge & Coie, 1987). Reactive violence consists of those incidents precipitated by emotional reactions to perceived threat, loss, or other danger, e.g., a threat of harm in the context of a negatively affectively-charged, high conflict relationship. For example, a husband and wife may argue over the husband’s harsh physical discipline of the children. The wife threatens to take the children and leave. The husband then grabs a gun and threatens to shoot the family and then kill himself. In contrast, proactive violence is undertaken to achieve an identifiable social or material purpose, e.g., coercive aggressive behavior in the context of one individual trying to dominate or control another individual. For example, a robber may go into a jewelry store and calmly tell the clerk he will kill the clerk unless the clerk gives him all the jewelry the robber wants. When the clerk hesitates, the robber shoots and kills him. Obviously, the distinction between these two types of violence is often blurry in practice (Dodge, 1991), but the theoretical distinction is useful to guide description and theoretical development. At the extremes, the distinctions are clear but in the middle, there is often a very mixed picture. Even in the above examples, the husband might be seen as treating his family members as objects to be controlled and the robber may have been overcome with insult and anger when the clerk refused his request. As a result, one may best view different types of violence along a continuum rather than as dichotomous absolutes (Cornell et al., 1996). Despite the seeming apparent utility of this distinction, there has been little prior research aimed at finding different predictors of violence in reactive versus proactive violent individuals. What research there is

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has almost exclusively examined the behavior of two specific subgroups: male elementary school children (Price & Dodge, 1989) and violent offenders in forensic settings (Cornell et al., 1996). In Cornell et al.’s work (1996), raters coded each offender’s most recent offense according to six offense characteristics to explore what variables distinguish reactive from instrumental (or proactive) violence, with findings suggesting there was a pattern of characteristics, e.g., an individual’s level of psychopathy, differentially associated with instrumental and reactive violence. Developing a reliable and valid measure of reactive versus proactive violence for use with non-offender adults is an additional logical step for both enriching knowledge regarding the context and dynamics of violence in this area and, potentially, for measuring treatment effectiveness with this population.

TREATMENT OF PERSONALITY DISORDERS AND SUBSTANCE ABUSE AND ITS RELATIONSHIP TO VIOLENCE The nature and effectiveness of treatment approaches for personality disorders (in particular, for emotional dysregulation and psychopathy) and substance abuse vary widely, and there is no accepted treatment technology that addresses each of these areas simultaneously. Developing effective treatment approaches for individuals with personality disorders is certainly challenging given the diverse nature of these disorders and the difficulty of engaging many of these patients in constructive therapeutic relationships. Many people with problems related to their personality disorder do not seek treatment on their own and are only seen clinically at the insistence of someone else, e.g., a spouse, the court, or the police, or as part of another person’s treatment, e.g., as the spouse of the “identified patient” (Perry & Valliant, 1989). Cognitive-behavioral approaches specifically tailored for the treatment of personality disorders have been developed (e.g., Beck & Freeman, 1990), and anecdotal evidence regarding these approaches shows them to be promising. For borderline personality disorder, a number of models have been introduced, including Kernberg’s (1985) directive psychodynamic treatment and Linehan’s (1993) dialectical behavior therapy (DBT). Since its inception, DBT has been modified for use in a variety of settings, including inpatient (Silk, Eisner, Allport et al., 1994) and partial hospitalization programs (Simpson, Pistorello, Begin et al., 1998), and with other populations, e.g., clients with substance abuse problems (Linehan & Schmidt, 1995) and comorbid conditions (Reich, 1997). DBT is an approach that, at its core, attempts to balance acceptance and change strategies both within each treatment session and over time. The treatment modus is a combination of group skills training and individ-

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ual psychotherapy. Skills training addresses four types of skills: mindfulness (attention to one’s experience), interpersonal effectiveness, distress tolerance, and emotion regulation. One controlled study of Linehan’s approach has been conducted (Linehan et al., 1991; Linehan, Heard, & Armstrong, 1993), showing clear indicators of the treatment’s effectiveness in certain problem areas. As compared to controls, those patients receiving DBT showed greater reduction in self-destructive behavior, were more likely to stay in treatment, and required fewer days of hospitalization. None of the tests of these interventions, however, has examined violence to others as an outcome variable. As yet, there is no body of controlled empirical research addressing the treatment of individuals with antisocial personality disorder or severe psychopathy and the relationship of that treatment to subsequent dangerousness (Quinsey et al., 1998). Treatment seems to be most useful, albeit with limited effectiveness, with young offenders of low or moderate risk, however, no studies on serious adult offenders have shown that treatment significantly lowers recidivism (Quinsey et al., 1998). In fact, one study (Rice, 1997) reported that milieu and group treatments had a paradoxical effect, resulting in an exacerbation, rather than a reduction of subsequent antisocial behaviors. This suggests that differential effects might be expected, depending on how treatment is structured. Currently, however, this has not been tested and our knowledge of how to reduce violence in psychopathic individuals remains rudimentary (Quinsey et al., 1998: p. 207). Interventions for substance abuse, meanwhile, have a long history of equivocal results. A multidisciplinary approach using a combination of detoxification, medication to ease withdrawal and/or prevent relapse, achievement and maintenance of sobriety, relapse prevention, and selfhelp has shown good results for many individuals who abuse or are addicted to alcohol or other drugs (Carson, Butcher & Mineka, 1996; Sarason & Sarason, 1996). Treatment dropout, however, remains an ongoing challenge (Booth, Cook & Blow, 1992). None of the interventions have focused on the relationship of substance abuse to violence by using violence as a treatment outcome measure, or demonstrated an effective method for reducing violence and substance abuse. In summary, efforts at treating personality disorders and substance abuse show variable results. DBT appears to show the most promise as an effective treatment for emotional dysregulation related to parasuicidal behavior; other cognitive behavioral approaches have been tried with mixed effectiveness with personality disorders; no effective treatment has been established for psychopathy; and a variety of treatment interventions are available for substance abuse with the goal of achieving sobriety. Combining these problem areas with violence reduction as an outcome has not been addressed in the treatment literature, yet there is substantial clinical evidence that these constructs commonly overlap in patients. Fur-

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thermore, the literature clearly suggests that having a Cluster B personality disorder, especially if psychopathy is present, in combination with a substance abuse problem places one at heightened risk for violence. We hypothesize that the underlying risk enhancing factor behind these observed relationships may be a problem with emotion regulation. It is well known that drugs and alcohol have various disinhibiting effects on emotions secondary to the pharmacological effect of the substance(s) on the brain (Cox & Klinger, 1988). Also, as noted above, both borderline and antisocial or psychopathic individuals have problems with emotion regulation. This leads to the hypothesis that it may be the component of emotional dysregulation that serves as the link between these other risk enhancing variables and violent behavior. If so, that would point to a specific target for therapeutic intervention. If a treatment strategy could be devised that would directly target problems related to emotional dysregulation and serve to enable patients to learn strategies for constructively regulating emotions, it could result in a reduction of violent behavior among those most at risk for this behavior.

CLINICAL ILLUSTRATIONS Observing how emotional dysregulation interacts with psychopathy, substance abuse, and violence in patients with a personality disorder is a useful starting point on the development of an intervention to reduce violence through enhancing emotional control. Several examples illustrating the interaction of these constructs came to the attention of the authors while conducting an ongoing direct interview study to develop a measure of emotional dysregulation. This study has two major objectives: to develop a reliable and valid measure of emotional dysregulation, for which no established measure appears to exist, and to gather rich information about the dynamics and context of emotional dysregulation. To achieve the second objective, we asked our subjects, all of whom have been diagnosed with a Cluster B personality disorder, how they experience emotions, which emotions are most difficult to tolerate, and what kinds of contextual situations elicit dysregulation of their emotions. The 35 subjects interviewed so far have produced a wealth of clinical information about the potential relationships of these constructs. The two examples provided below illustrate the types of first hand accounts that patients give about the central role of emotional dysregulation in their violent incidents. They are drawn from the sections of the interviews where the patient is asked to comment on violent incidents they were involved in and their emotional state at the time of the incident. Questions in italics were asked by the interviewer.

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Case #1 I don’t know how it happened, man, I mean I was there for help but when I saw this guy I know from the neighborhood, I just snapped. He bumped me, gave me no respect. I told him to apologize and he wouldn’t. So I just lost it. (What do you mean “you lost it”?) I just lost it, I pulled out a gun. I wouldn’t have shot him, no. I just wanted to show him he couldn’t mess with me. (How did you feel when this was happening?) Nothing . . . everything . . . I couldn’t handle it. I was really mad and I couldn’t see straight. I’m sorry now but at the time . . . no . . . I couldn’t of done anything else. I couldn’t get past the feelings.

Case #2 (When you feel very negative toward someone or something, how do you usually behave in response to the emotions?) Nobody really cares about me. Nobody. (What do you mean?) Like I broke up with my boyfriend. I didn’t want to break up but I knew he’d be breaking up with me so, like, I did it first, you know, so I’d hurt less. But, anyway, I got really angry, I threw things, I wanted to hit him. I wanted him to hurt like I was hurting. I felt worthless and then like I was spiraling down this hole. I couldn’t stand it. I wanted to cut myself or cut him. I couldn’t stand the pain, I just wanted the pain to stop. So I hit him, kept hitting him. Then I cut myself . . . I wanted him to hurt, to know it was his fault. (How did you feel then?) I felt better then, I don’t know why. (Were either of you drinking at the time?) Well, yeah, I had a couple of beers. Sometimes that helps. (Helps?) Helps to deal with my feelings. I wasn’t drunk though . . .

These are two examples of reactive violence which illustrate how dysregulated emotions appear to lead to violent behavior toward self or others. In both cases, the patients reacted to the perception of a threatening provocation with intense overwhelming emotions. Being in such an emotional state was experienced as intolerable and not in the patient’s control (e.g., “I couldn’t get past the feelings”; “I couldn’t stand the pain”) and the patients used violence as a mechanism to achieve emotion regulation and regain control. In the first case, the patient threatened the other person with a weapon and, in the second case, the patient admitted feeling better after physically hurting herself and emotionally hurting her boyfriend. The consequences of the actions were destructive but effective. The suggested therapeutic challenge is to help patients develop coping strategies that are equally effective but not destructive to self or others.

IMPLICATIONS FOR TREATMENT In this paper, we argue that emotional dysregulation appears to be the critical theoretical link between the characteristics inherent in Cluster B personality disorders, substance abuse and violent behavior and thus

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constitutes a potentially very fruitful focus for therapeutic intervention. However, the exact approach for addressing the link between emotional dysregulation and violent behavior has yet to be developed. Certainly, other established approaches for addressing emotional dysregulation in people with personality disorders provide valuable starting points. Dialectical Behavioral Therapy (DBT) is one approach that could serve as a platform upon which to construct an intervention for addressing the relationship between emotional dysregulation and violence. The following case illustrates the potential for such an approach: Case #3 (When you are feeling strong emotions, and you want or have to focus your attention to something else, what specifically helps you to do that?) Well, I used to lose it, you know . . . (What would happen?) I’d get real emotional and, like, I’d get violent . . . I’d throw things . . . dishes, whatever. Sometimes I hit other people and hurt them. I’d feel really bad afterward but I couldn’t help it. But now, I use my DBT skills and it helps. (Can you tell me more about that?) Well, it helps me step back . . . I’ll say to myself “a feeling is just a feeling” over and over and it helps. I can get back in control. It’s scary when I think about what I used to do . . . I don’t want to think about it, how it was. But I’m better now.

This patient was making the explicit connection between the skills learned from DBT and control of violent outbursts, and this is not an isolated example. Many of our interviews suggest that the skills taught in DBT help not only with reducing violence toward self but are also useful in reducing violence toward others. Typically, patients tell us that they entered treatment following a suicide attempt or parasuicidal behavior but that treatment also helped with their problems with violence toward other people. A more systematic linking of the concepts of emotional dysregulation and a refinement of the DBT treatment approach to address violence to others directly could produce a programmatic approach that mirrors what many of our interviewed patients have found for themselves. This is not to imply that such an approach would be a panacea for treating violent patients with personality disorders. Like most treatments, it might be effective in different ways and to different degrees for different types of outcomes, and would require refinement for individuals with different types and frequencies of violent behavior. We would hypothesize, for instance, that different factors may be more or less relevant to consider when addressing proactive or reactive violence. In proactive violence, which involves anticipatory planned choice, antisocial personality disorder and psychopathy may be more influential factors related to risk of violence, and treatment might then focus more on how to make rational choices that lead to positive rather than harmful consequences,

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i.e., a kind of therapeutic risk-benefit analysis. In reactive violence, borderline personality disorder and emotional dysregulation may play larger roles, thus making it more prudent to focus treatment on emotion regulation skills to restore emotional balance. If emotional dysregulation and substance abuse together produce more serious and more frequent violence than either condition alone, then teaching emotion regulation skills must be coupled with teaching relapse prevention. Such targeted assessment and intervention could be particularly effective if it also considered the environmental and situational aspects of violent incidents with this population. Situations that are particularly provocative could be used as targeted contexts for skill exercises, role plays, and scenarios for problem solving in treatment. In conclusion, a critical step in the advancement of strategies to manage violent mentally ill individuals in the community is the development of specialized treatment approaches that can be easily delivered by the average community mental health clinic. Based on our reading of the literature, individuals with personality disorders, substance abuse, and psychopathy are at the greatest risk for continued serious, frequent violence. All of these disorders feature problems of emotional dysregulation as a key component, and this issue may be the common thread that could guide clinical interventions for individuals at high risk for violence. We believe that DBT is an excellent platform from which to develop such a treatment. Focusing our thinking on developing a sound, specialized treatment like this could help us meet one of the most challenging tasks that clinicians face. Moreover, if we, as a society, demand that individuals with mental illness must live in and be accepted by communities, we have an obligation to provide the supports and tools needed to ensure success. A focused, theoretically based approach to treating violent patients would go a long way in this effort.

REFERENCES Adler DA (1990) Treating personality disorders. New Directions for Mental Health Services, Volume 47. San Francisco: Jossey-Bass. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Washington, D.C.: Author. Appelbaum, P. (1994). New directions in the assessment of dangerousness of the mentally ill. The Japanese Journal of Psychiatry and Neurology, 48, 77–83. Beck, A.T. & Freeman, A. (1990). Cognitive Therapy of Personality Disorders. New York: Guilford. Booth BM, Cook CL & Blow FC (1992). Cormorbid mental disorders in patients with AMA discharges from alcoholism treatment. Hospital and Community Psychiatry, 43: 730– 731. Bushman, B.J. & Cooper, H.M. (1990). Effects of alcohol on human aggression: An integrative research review. Psychological Bulletin, 107, 341–354.

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Carson RC, Butcher, JN & Mineka S (1998). Abnormal Psychology and Modern Life, Tenth Edition: 1998 Update. New York: Longman. Cleckley H (1941). The Mask of Sanity. St. Louis, MO: Mosby. Collins JJ & Schlenger W. (1988). Acute and chronic effects of alcohol use on violence. Journal of Studies on Alcohol, 49, 516–521. Collins JJ (1989). Alcohol and violent behavior: Less than meets the eye. In: NA Weiner, ME Wolfgang (eds.), Pathways to Criminal Violence. Newberry Park, CA: Sage. Cornell DG, Warren J, Hawk G, Stafford E, Oram G & Pine D(1996). Psychopathy in instrumental and reactive violent offenders. Journal of Consulting and Clinical Psychology, 64(4): 783–790. Cox WM & Klinger E (1988). A motivational model of alcohol use. Journal of Abnormal Psychology, 97: 168–180. Dennis DL & Monahan J (1996). Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law. New York: Plenum. Dodge KA (1991). The structure and function of reactive and proactive aggression. In: DJ Pepler & KH Rubin (Eds.), The Development and Treatment of Childhood Aggression, pp. 201–218. Hillsdale, NJ: Erlbaum. Dodge KA & Coie JD (1987). Social information processing factors in reactive and proactive aggression in children’s peer groups. Journal of Personality and Social Psychology. 53(6): 1146–1158. Else, L., Wonderlich, S., Beatty, W., Christie, D. & Staton, R. (1993). Personality characteristics of men who physically abuse women. Hospital and Community Psychiatry, 44(1), 54–58. Eronen M, Angermeyer MC & Schulze B (1998). The psychiatric epidemiology of violent behaviour. Social Psychiatry and Psychiatric Epidemiology, 33 (Suppl 1): S13–S23. Eronen M, Tiihonen J & Hakola P (1997). Psychiatric disorders and violent behavior. International Journal of Psychiatry in Clinical Practice, 1(3): 179–188. Fagan J & Chin K (1990). Violence as regulation and social control of distribution of crack. In: M de la Rosa, E Lambert, B Gropper (eds.), Drugs and Violence. Rockville, MD: National Institute of Drug Abuse. Goldstein PJ (1985). The drugs-violence nexus: A tri-partite conceptual framework. Journal of Drug Issues, 15: 493–506. Hare RD (1998). Psychopaths and their nature: Implications for mental health and criminal justice systems. In: Millon T, Simonsen E, Birket-Smith M & Davis RD (eds.), Psychopathy: Antisocial, Criminal, and Violent Behavior (pp. 188–212). New York: Guilford. Hare, R.D. (1980). A research scale for the assessment of psychopathy in criminal populations. Personality and Individual Differences. 1: 111–119. Hare, R.D. (1983). Diagnosis of antisocial personality disorder in two prison populations. American Journal of Psychiatry, 140, 887–890. Hare, R.D., Hart, S.D. & Harpur, T.J. (1991). Psychopathy and the DSM-IV criteria for antisocial personality disorder. Journal of Abnormal Psychology, 100, 391–398. Harris, G.T., Rice, M.E. & Cormier, C. (1991). Psychopathy and violent recidivism. Law and Human Behavior, 15, 625–637. Hart SD, Hare RD & Forth AE (1994). Psychopathy as a risk marker for violence: Development and validation of a screening version of the Revised Psychopathy Checklist. In: Monahan J & Steadman HJ (Eds.), Violence and Mental Disorder: Developments in Risk Assessment. Chicago: University of Chicago. (pp. 81–98). Kernberg, O.F. (1985) Borderline Conditions and Pathological Narcissism. Northvale, NJ: Jason Aronson. Lidz, C.W., Mulvey, E.P. & Gardner, W.P. (1993). The accuracy of predictions of violence to others. Journal of the American Medical Association, 269: 1007–1011. Linehan MM (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford. Linehan, M. (1997). Personal communication. Linehan, M., Armstrong, H., Suarez, A., Allmon, D. & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060–64. Linehan M., Heard H. & Armstrong H. (1993). Naturalistic followup of a behavioral treat-

170


ment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50: 971–4. Linehan M & Schmidt H (1995). The dialectics of effective treatment of borderline personality disorder. In: O’Donohue WT & L Krasner. Theories of Behavior Therapy: Exploring Behavior Change (pp. 553–584). Washington, D.C.: American Psychological Association. Mechanic D (1999). Mental Health and Social Policy: The Emergence of Managed Care. Boston: Allyn & Bacon. Millon T & Davis RD (1998). Ten subtypes of psychopathy. In: Millon T, Simonsen E, BirketSmith M & Davis RD (1998). Psychopathy: Antisocial, Criminal and Violent Behavior (pp. 161–170). New York: Guilford. Millon T, Simonsen E, Birket-Smith M & Davis RD (1998). Psychopathy: Antisocial, Criminal, and Violent Behavior. New York: Guilford. Monahan, J. (1992). Mental disorder and violence behavior: Perceptions and evidence. American Psychologist, 47, 511–521. Moss HB, Tarter RE (1993). Substance abuse, aggression and violence: What are the connections? The American Journal of Addictions, 2:149–160. Mulvey, E. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663–668. Mulvey EP, Gardner WP, Lidz CW, Graus J & Shaw EC (unpublished manuscript). Symptomatology and violence among mental patients. Law and Psychiatry Program, University of Pittsburgh School of Medicine, Pittsburgh, PA. Nolan KA, Volavka J, Mohr P & Czobor P (1999). Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder. Psychiatric Services, 50: 787– 792. Pernanen, K. (1993). Research approaches in the study of alcohol-related violence. Alcohol Health and Research World, 17(2): 101–107. Perry, J.C. & Valliant, G.E. (1989) Personality Disorders. In: Kaplan, H.I. & B.J. Sadock (Eds.) Comprehensive Textbook of Psychiatry/V: Volume Two. Baltimore: Williams & Wilkins. Price JM & Dodge KA (1989). Reactive and proactive aggression in childhood: Relations to peer status and social context dimensions. Journal of Abnormal Child Psychology, 17: 455–71. Quinsey VL, Harris GT, Rice ME & Cormier CA (1998). Violent Offenders: Appraising and Managing Risk. Washington, D.C.: American Psychological Association. Raine A (1996). Autonomic nervous system factors underlying disinhibited, antisocial, and violent behavior: Biosocial perspectives and treatment implications. In: Ferris CF, Grisso T, (Eds), et al. Understanding aggressive behavior in children. Annals of the New York Academy of Sciences, Vol. 794 (pp. 46–59). New York: New York Academy of Sciences. Reich JH (1997). Modification of treatment approaches for Axis I disorders in patients who also have a concurrent Axis II disorder. Journal of Contemporary Psychotherapy, 27(4): 369–383. Rice ME (1997). Violent offender research and implications for the criminal justice system. American Psychologist, 52: 414–23. Rice, M.E. and Harris, G.T. (1995). Psychopathy, schizophrenia, alcohol abuse and violent recidivism. International Journal of Law and Psychiatry, 18, 333–342. Russ, M.J., Roth, S.D., Kakuma, T., Harrison, K. & Hull, J. (1994). Pain perception in selfinjurious borderline patients: Naloxone effects. Biological Psychiatry, 35, 207–209. Russ, M.J., Roth, S.D., Lerman, A., Kakuma, T., et al. (1992). Pain perception in selfinjurious patients with borderline personality disorder. Biological Psychiatry, 32, 501– 511. Sarason IG & Sarason BR (1996). Abnormal Psychology: The Problem of Maladaptive Behavior. Upper Saddle River, NJ: Prentice-Hall. Scarpa A & Raine A (1997). Psychophysiology of anger and violent behavior. Psychiatric Clinics of North America, 20(2): 375–394. Silk KR, Eisner S, Allport C, DeMars C, et al. (1994). Focused time-limited inpatient treatment of borderline personality disorder. Journal of Personality Disorders, 8(4): 268– 278. Simonsen E & Birket-Smith M (1998). Preface. In: Millon T, Simonsen E, Birket-Smith

171


M & Davis RD (1998). Psychopathy: Antisocial, Criminal and Violent Behavior (pp. vii–xi). New York: Guilford. Simpson EB, Pistorello J, Begin A, Costello E, et al. (1998). Use of dialectical behavior therapy in a partial hospitalization program for women with borderline personality disorder. Psychiatric Services, 49(5): 669–673. Steadman, H., Mulvey, E., Monahan, J., Robbins, P., Appelbaum, P., Grisso, T., Roth, L., & Silver, E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, 1–9. Stein LI & Santos AB (1998). Assertive Community Treatment of Persons with Severe Mental Illness. New York: W.W. Norton. Swanson JW (1994). Mental disorder, substance abuse, and community violence: An epidemiological approach. In: J Monahan, HJ Steadman, Violence and Mental Disorder: Developments in Risk Assessment, pp. 101–136. Chicago: University of Chicago Press. Swanson, J.W., Holzer, C.D., Ganju, V.K. & Jono, R.T. (1990). Violence and psychiatric disorder in the community: Evidence from the Epidemiologic Catchment Area Surveys. Hospital and Community Psychiatry, 41, 761–770. Taylor PJ (1995). Schizophrenia and crime: Distinctive patterns in association. In: Hodgins S, et al. (eds.), Mental Disorder and Crime (pp. 63–85). Newbury Park: Sage. Teplin L (1994). Psychiatric and substance abuse disorders among male urban jail detainees. American Journal of Public Health, 84: 290–293. Webster, CD, Douglas, KS, Eaves, D, & Hart, SD (1997). Assessing risk of violence to others. In CD Webster & MA Jackson (Eds.), Impulsivity: Theory, assessment, and treatment (pp. 251–277). New York: Guilford Press. Widiger, T.A., Hare, R., Rutherford, M., Alterman, A., Corbitt, E., Hart, S., Woody, G., Cadoret, R., Robins, L., Zanarini, M., Apple, M., Forth, A., Kultermann, J. and Frances, A. (1996). DSM-IV antisocial personality disorder field trial. Journal of Abnormal Psychology, 105, 3–16. Widiger TA & Lynam DR (1998). Psychopathy and the five-factor model of personality. In: Millon T, Simonsen E, Birket-Smith M & Davis RD (1998). Psychopathy: Antisocial, Criminal and Violent Behavior (pp. 171–187). New York: Guilford. Widiger TA & Trull TJ (1993). Borderline and narcissistic personality disorders. In: Sutker PB & Adams HE (eds.), Comprehensive Handbook of Psychopathology, Second Edition (pp. 371–394). New York: Plenum.

Christina E. Newhill, Ph.D., L.C.S.W. Associate Professor School of Social Work University of Pittsburgh 2117 Cathedral of Learning Pittsburgh, PA 15260 [email protected]

Edward P. Mulvey, Ph.D. Professor of Psychiatry Director, Law and Psychiatry Program Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine