El perfil psicológico de los conductores temerarios

El perfil psicológico de los conductores temerarios

Se trata de un caso reincidente, como sucede en el 70% de los conductores por delitos al volante, según un estudio realizado con 93 presos de la Modelo, en 2010. De las 771 personas que cumplen penas de prisión en España por un delito de la seguridad como causa principal, el 26,2% (202 personas) lo hacen por conducción bajo los efectos del alcohol y el 33,4% (258) por conducir sin carné, según la Fiscalía de Seguridad Vial. Las condenas por delitos contra la seguridad vial rondan las 100.000.El 70% de los conductores condenados por delitos al volante son reincidentes

Los expertos consultados por El Confidencial destacan que este tipo de conductores suelen ser personas temerarias y competitivas, sin escala de valores y con fuerte desarraigo. Sin respeto a las normas y con baja autoestima. Se suma a todo ello, que la conducción es una actividad estresante y que cualquier situación (atascos, semáforos en rojo…) incrementan la tensión y la agresividad. Pero, sobre todo, porque también hay conductores que buscan intencionadamente el riesgo, como un mecanismo de recompensa rápida cerebral que conduce a la excitación. Por otro lado no es menos cierto que muchos varones se identifican con el coche. Representa posesión, estatus social, fuerza, velocidad, seducción, además del sentimiento de libertad o independencia.  

A pesar de que el balance de seguridad vial de 2012 (aún no definitivo) facilitado por la Dirección General de Tráfico destaca que la mortalidad por accidentes en vías interurbanas se ha reducido en un 12%, 1.304 personas perdieron la vida y 6.161 resultaron heridas graves el año pasado. Es el noveno año consecutivo que desciende la siniestralidad. Las cifras son provisionales y se refieren sólo a los accidentes mortales ocurridos en vías interurbanas y tomadas hasta 24 horas después de producirse el siniestro. La mayoría de los grupos de edad han descendido en el número de fallecidos con excepción de los niños menores de 14 años y los mayores de 75 donde han aumentado las cifras. Sin embargo, el grupo donde más ha aumentado la mortalidad es entre los 35 a los 44 años y la mayoría de siniestros se produjo entre las siete y las ocho de la mañana.

Según la Memoria Social del Seguro Español 2012 de la Unión Española de Entidades Aseguradoras y Reaseguradoras (UNESPA) el perfil de la víctima de tráfico en España es de un varón de 38 años y medio de edad, que no tiene hijos ni cónyuge. No obstante, este varía según las zonas geográficas, ya que en Madrid la media de edad de la víctima es de un menor de 30 años, mientras que en otros lugares como Asturias, superan los 45 años de media.

El coste humano y económico de la siniestralidad en la carretera

Francisco Canes, presidente de la Asociación Estatal de Víctimas de Accidentes (DIA), cree que el nuevo perfil de víctima de siniestros tiene “en parte su lógica. Los varones de edad media son los que más desplazamientos por trabajo realizan a diario, además de ser los que trasladan a sus familiares y, por tanto, a más tiempo en la carretera, más probabilidades de sufrir accidentes. Además, sabemos que ellos tienen más conductas de riesgo al volante que las mujeres, que suelen ser más prudentes”.  Su asociación lleva diez años trabajando por y para las víctimas y familiares de los accidentes de tráfico.Este tipo de conductores suelen ser personas competitivas, sin escala de valores y con fuerte desarraigo

“En todo este tiempo hemos atendido 10.000 consultas. Nuestro trabajo es dar atención integral especializada, de manera totalmente gratuita, a víctimas, familias y profesionales en la fase aguda después del accidente tanto si hay heridos como fallecidos. El enfoque es multidisciplinar con trabajadores sociales, psicólogos, juristas, pedagogos, sanitarios… para lograr la mejor y más rápida reincorporación a la vida diaria de las víctimas. Asimismo formamos a profesionales de emergencias para la atención a víctimas en todo lo relacionado con el colectivo y en muchas cuestiones relacionadas con su labor. Somos especialistas en seguridad vial laboral para empresas, trabajadores, jóvenes y niños”, insiste el presidente de DIA.

Aunque los vehículos son ahora cuatro veces más seguros que en 1970 y se han reducido en un 50% el número de muertes en la UE, los siniestros provocan 40.000 muertes al año y tienen unos costes directos e indirectos estimados de 180.000 millones de euros. Es decir, el 2% del PIB de la UE.

En España, un estudio encargado por la DGT a la Universidad de Murcia constata que el coste de que una persona fallezca en la carretera es de 1,4 millones de euros. “El valor monetario de una vida estadística”, ha sido realizado por un equipo de profesionales estadísticos de dicha universidad, y servirá para hacer estudios de cálculo viales. Según Jorge Martínez, uno de los implicados en el proyecto, este valor se obtiene de sumar el valor de una vida estadística en España (1,3 millones de euros) y las pérdidas de producción neta y los costes médicos y de ambulancia.

Pero por encima de las cifras está el sufrimiento de las víctimas. Luis Cendrero, psicólogo en DIA, explica el drama al que se enfrentan las víctimas de accidentes de tráfico. “Los accidentes son una realidad diaria pero todo el mundo piensa que a ellos no les va a tocar. Las víctimas de siniestros son todas, las que la sufren y los que la rodean. La familia también es la víctima. El impacto es tremendo, la muerte de un familiar en un accidente es como una muerte súbita. Lo importante es estar con ellos desde el primer momento, en la fase aguda. Ayudarlos a elaborar el duelo, y acompañarlos para que aprendan a vivir sin la persona querida que les falta”.

Cómo acompañar a las víctimas y familiares

No es un camino fácil. Muchos de ellos, requerirán ayuda psicológica durante más tiempo y otros se enfrentarán al síndrome de estrés postraumático. “Un sentimiento común en todas las víctimas de accidentes de tráfico es el de culpa. El padre que te comenta ‘si no le hubiera comprado la moto; ‘si le hubiera ido yo a buscar’… Tratamos de que comprendan que los acontecimientos se han producido al margen de estas situaciones, buscamos librarlos de esa culpa que agudiza el dolor y entorpece la recuperación”, insiste Cendrero.1.304 personas perdieron la vida y 6.161 resultaron heridas graves el año pasado

Tanto Cendrero como su colega psicóloga Irene De Ancosreconocen que la primera acción en cualquier accidente y las más complicada es la comunicación de malas noticias. Irene lo explica: “Todavía hoy muchos familiares reciben la trágica noticia por teléfono. Nosotros hemos estado acompañando a la Guardia Civil a las casas de los afectados para hacer una buena comunicación de malas noticias. No es fácil, pero los afectados lo agradecen. Hay que procurar que tengan apoyo familiar o de vecinos, que no estén solos en ese momento, sentarles y explicarle lo sucedido. Toda la información que rodee al acontecimiento es necesaria. También se les explica los momentos por los que van a pasar, lo que van a sentir, se trata de que sepan qué es el duelo, qué fases tiene y orientarles para que pidan ayuda porque solos no van a poder salvar la situación”.

Miguel Martín no tuvo la fortuna de saber de su hija de la mano de gente preparada. “Lo que más grabado tengo es cómo me lo contaron. Fue muy frío y distante. Me sentí muy solo en esos momentos y eché en falta más cercanía y sensibilidad. Sin embargo, gracias a DIA y a la Fiscalía de Seguridad Vial tengo que reconocer que me he sentido apoyado en todo momento. Es cierto que al principio todo el mundo se vuelca contigo, y luego con el tiempo te quedas solo, tu caso se olvida, pasa a un segundo plano. Yo he estado hundido, pero no quería darme cuenta porque tenía que mantener a la familia en pie. Mi mujer lo ha pasado realmente mal, ha tenido que acudir a varios psicólogos. No es imaginable vivir una tragedia como esta. Y ahora nos queda la otra parte: el juicio. Por un lado estamos deseando que salga y, por otro, nos produce una sensación de vértigo horrible. Volver a revivir todo, pensar si la sentencia será justa…”, explica.

La familia Martín lleva dos años esperando el juicio del accidente de su hija. “Creo que estos casos deberían dictarse con más rapidez. Es la prolongación del sufrimiento. Sabemos por nuestro abogado que el conductor tiene retirado también el carné en Reino Unido, pero no tenemos sentencia. También nos damos cuenta de que la Justicia prioriza la resolución de otro tipo de casos, algo que me resulta incomprensible”, insiste Miguel Martín.

Las asociaciones de víctimas de accidentes de tráfico reclaman también mayor celeridad de los juicios por siniestros con víctimas. Pero, sobre todo, insisten en que “en España se han adoptado múltiples medidas para frenar la siniestralidad pero no se están realizando estudios que evalúen la eficacia de las mismas o su impacto.Antes de plantearnos nuevas estrategias se hace necesario evaluar las que ya están en marcha”, recalca Francisco Canes.

Hoy cuando usted haya terminado de leer esta esta noticia se solidarizará con las víctimas. Pero, aunque todos los días, los medios de comunicación le recuerden el número de víctimas de accidentes de tráfico, probablemente, seguirá pensando que a usted no le va a ‘tocar’. Puede ‘tocar’ a todos, por eso todos debemos interiorizar el concepto de conducción responsable.

El Lado Oscuro de Ariel Castro

Ariel Castro, the former school bus driver who is a suspect in the kidnapping of three women who escaped years of incarceration, was a friendly man who befriended area children and gave no hint of what was happening behind the locked doors of his Seymour Avenue house, his neighbors say.

“If a kid didn’t have a father, they would look up to him. There was no flaw,” said Juan Perez, 27, who lives two doors down from the house from where the three abducted women escaped on Monday. “I guess he had a great mask to cover a monster.”

Castro was known for giving children rides in his four-wheeler. He attended neighborhood parties and would have a beer.

• Photos: Three missing women found in Cleveland
• Map: Cleveland kidnappings
• Police: Girl, 6, is daughter of 10-year Ohio captive Amanda Berry
• Audio: Amanda Berry's 911 call
• Photos: Long-term abductions

A day after the three women – Amanda Berry, Gina DeJesus and Michelle Knight – escaped and called police, officials and neighbors were trying to make sense of the kidnappings that go back to when the women were in their teens or early 20s. The three women had been held captive for about a decade and Berry gave birth to a daughter, now 6 years old, police said Tuesday morning.

PHOTOS: Kidnapping victims found

Because he was the owner of the house, much of the attention has focused on Castro, 52. He and his brothers Pedro, 54, and Onil, 50, have been arrested in connection with the abductions, but have not yet been formally charged, officials said at a nationally televised news conference.

According to Martin Flask, Cleveland director of public safety, police had twice responded and neither time found anything amiss at Castro’s house. 

In March 2000, police responded to a call from Ariel Castro who reported a fight in the street. There is no record of any arrest, Flask told reporters.

In January 2004, Cleveland police went to the Seymour Avenue address in response to an investigation by Children and Family Services. Castro had left a child on the school bus when he returned to the depot, Flask said. Police visited the house, knocked on the door but there was no answer. Police eventually determined there was no criminal intent in leaving the child on the bus.

Photos: Long-term abductions

Castro’s house, a white two-story home with an American flag hanging out front, is slightly dilapidated, like many on the block about two miles from downtown. Many of the other homes are abandoned, including one next door, which has boards on the windows. The area is littered with glass and weeds push up out of vacant lots. Neighbors complain that the police rarely patrol the area.

Every Saturday, Castro would take his four-wheeler out in the neighborhood and give kids rides. He’d teach them to ride a bike and show up at neighborhood barbecues to say hello.

Hector Lugo, 31, who lives on the same street, said he still can’t believe the friendly guy who would give his nieces rides was allegedly the perpetrator behind kidnappings that have baffled this city for a decade.

“He used to drive my nieces on his four-wheeler. That’s what threw me off,” Lugo said. “They always thought of him as a cool person -- a cool person to kick it with. He was an outgoing person, he never messed with anyone. He was always cool.”

MAP: Cleveland kidnappings

Castro always talked about a girlfriend, but Lugo said he never saw her. About a month ago, Lugo said, Castro brought a little girl to a nearby park, describing her as his girlfriend’s child. The girl looked exactly like Castro, Lugo says.

Like other neighbors, Lugo wondered if Castro changed somehow when his wife left him a decade ago.

“I guess after the divorce, he flipped after that,” he said.

Julio Castro, the uncle of the three men arrested Tuesday, has owned a corner store down the street from the house where the women were found for 44 years. He even had photos of the missing girls up in his store for years. He said he was “stunned” to hear the allegations about one of his favorite nephews, Ariel.

On Monday, “someone told me there was a commotion – that they had found Gina DeJesus,” said Julion Castro on Tuesday in his small store where Spanish is frequently spoken. “I ran over there, happy, only to find they were taking the people out of my nephew’s house.”

Castro had lost touch with Ariel over the last few years, but remembers him as a “happy-go-lucky” man who played bass in the local band. Pedro Castro, who was also arrested, drove by the store a few weeks ago but didn’t stop, Julio Castro said.

Cuando existe un trastorno psicológico se requiere, a fin de superarlo, que la persona que lo padece quiera mejorarlo o eliminarlo para siempre

Cuando existe un trastorno psicológico se requiere, a fin de superarlo, que la persona que lo padece quiera mejorarlo o eliminarlo para siempre. Esta afirmación puede parecer un contrasentido ya que nadie desea sufrir gratuitamente; sin embargo, no es así de sencillo ya que la superación requiere un esfuerzo, a veces muy intenso, de quién lo sufre. Y ahí viene el dilema. “¿Merecerá la pena todo el esfuerzo y la lucha que se ha de realizar para desterrar ese mal que está afectando de continuo a la persona?” La respuesta dependerá de la motivación que tenga.

¿Qué es lo que motiva a una persona a hacer algo?

Existen motivaciones internas no conocidas por las personas que las poseen. Estas son las motivaciones llamadas inconscientes. La motivación se puede entender como un conjunto de factores que determinan un comportamiento. En definitiva, es el ensayo mental preparatorio de una acción.

Los motivos no son siempre objetivos y por tanto no son comunes a todos; no tienen el mismo origen, ni la misma intensidad, no todos tenemos el mismo sistema de valores. Lo que uno valora en una escala numérica del cero al diez, con un nueve, hay otro que ese valor lo cuantifica con un uno o ni siquiera lo valora. Es por ello, por lo que cada persona tiene que encontrar su razón realmente motivadora que le conduzca a ponerse en marcha.

Caso clínico a modo de ejemplo.

Se trataba de un hombre extranjero de alrededor de cuarenta años, que empezó un tratamiento psicológico por un problema de alcoholismo. Tenía problemas en el trabajo; con su mujer e hijos a los que veía sufrir constantemente; con su salud, ya muy deteriorada hasta el punto de padecer una hepatitis crónica; estados de depresión continuos y en definitiva, la carencia de una mínima calidad de vida. Él era consciente de que la solución era solamente una: dejar de beber. ¿Pero como conseguirlo? Manifestaba: -“quiero a mi mujer, adoro a mis hijos, valoro mi salud, me gusta mi profesión… y aún sumando todos ellos, no tengo fuerza para plantearme definitivamente ese BASTA YA, que es lo único que debo hacer”

Cuando estos casos se presentan en un tratamiento psicológico, no sólo en el alcoholismo sino en cualquier otro trastorno psicológico del tipo que sea, como puede ser un trastorno obsesivo, dismorfofobia, ludopatía, trastornos alimentarios etc. se debe ayudar al paciente a encontrar la motivación, “su motivación” a fin de que se disponga a luchar para superar su problema.

Volviendo al caso anterior, era evidente que ni la salud, ni el trabajo, ni la familia, ni la suma de esos componentes eran suficiente motivo para comenzar la lucha contra el alcohol. Bastó con encontrar la motivación que este paciente necesitaba para impulsarle a la acción. En su caso fue el ayudar a compatriotas suyos. Había un grupo desasistido en aquel entonces que por falta de unión, medios y problemas con el idioma, presentaba muchísimas carencias. Este paciente sintió el ímpetu, la llamada y el coraje para plantearse ese “BASTA YA” y con ayuda del tratamiento, erradicar el alcohol de su vida, uniéndose a sus paisanos y prestándoles toda su ayuda.

Como decíamos anteriormente, no sólo en los casos de adicciones se ha de encontrar la motivación adecuada para emprender la lucha. En las obsesiones se necesita para vencer las compulsiones. En la agorafobia para eliminar las conductas de evitación. En la fobia social para enfrentarse a aquellas situaciones que la persona considera imposibles de superar. En definitiva, para la superación de cualquier tipo de trastorno psicológico o situación trágica y penosa que en la vida se presente, siempre se requiere un esfuerzo de la persona que lo padece.

¡Que bien lo entendió Victor Frankl!, cuando a través de su motivación y de buscar su sentido de vida, pudo superar las atrocidades del campo de concentración donde estuvo prisionero. Allí escribió “El hombre en busca de sentido”, que le sirvió de motivación para sobrevivir. Su motivo, su sentido de vida, fue la ayuda a los demás.

La motivación es lo que nos mueve desde dentro. Cada persona debe encontrar sus propios motivos, su propio trampolín que le ayude a tomar impulso y a luchar contra sus adversidades.

La Enfermedad Mental no esta Ligada a la Violencia cada caso es un caso

Facts About Mental Illness and Violence

Fact 1: The vast majority of people with mental illness are not violent.

Here is what researchers say about the link between mental illness and violence:

- "Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small, and further, the magnitude of the relationship is greatly exaggerated in the minds of the general population (Institute of Medicine, 2006)."

- "…the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994)."

- "The absolute risk of violence among the mentally ill as a group is very small. . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994)."

-"People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). People with severe mental illnesses, schizophrenia, bipolar disorder or psychosis, are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al.,1999)."

Fact 2: The public is misinformed about the link between mental illness and violence.

A longitudinal study of American’s attitudes on mental health between 1950 and 1996 found, “the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.” Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).

Fact 3: Inaccurate beliefs about mental illness and violence lead to widespread stigma and discrimination:

The discrimination and stigma associated with mental illnesses stem in part, from the link between mental illness and violence in the minds of the general public (DHHS, 1999, Corrigan, et al., 2002).

The effects of stigma and discrimination are profound. The President’s New Freedom Commission onMental Health found that, “Stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).”

Fact 4: The link between mental illness and violence is promoted by the entertainment and news media.

"Characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence" (Mental Health American, 1999).

"Most news accounts portray people with mental illness as dangerous" (Wahl, 1995).

"The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses" (Wahl, et al., 2002).

Citations
American Psychiatric Association. (1994). Fact Sheet: Violence and Mental Illness. Washington, DC: American Psychiatric Association.

Appleby, L., Mortensen, P. B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. The Lancet, 358, 2110-2112.

Corrigan, P.W., Rowan, D., Green, A., et al. (2002) .Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, 28, 293-309.

DHHS. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.http://www.surgeongeneral.gov/library/mentalhealth/toc.html

Hiday, V. A. (2006). Putting Community Risk in Perspective: a Look at Correlations, Causes and Controls. International Journal of Law and Psychiatry, 29, 316-331.
Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: Institute of Medicine, 2006.

Mental Health America. American Opinions on Mental Health Issues. Alexandria: NMHA, 1999.

Mulvey, E. P. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663-668.

Pescosolido, B.A., Martin, J.K., Link, B.G., et al. Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996General Social Survey. Bloomington: Indiana Consortium for Mental Health Services Research and
Joseph P. Mailman School of Public Health, Columbia University, 2000. Available: http://www.
indiana.edu/~icmhsr/amerview1.pdf

Pescosolido, B.A., Monahan, J. Link, B.G. Stueve, A., & Kikuzawa, S. (1999). The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems.American Journal of Public Health, 89, 1339-1345.

New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.

Wahl, O. (1995). Media Madness: Public Images of Mental Illness. New Brunswick, NJ: Rutgers University Press.

Wahl, O.F., et al. (2002). Newspaper coverage of mental illness: is it changing? Psychiatric Rehabilitation Skills, 6, 9-31.

Solo algunos Enfermos Mentales son Violentos

Violence and mental illness: an overview

HEATHER STUART¹

Author information ► Copyright and License information ►

This article has been cited by other articles in PMC.

ABSTRACT

This paper evaluates the relationship of mental illness and violence by asking three questions: Are the mentally ill violent? Are the mentally ill at increased risk of violence? Are the public at risk? Mental disorders are neither necessary nor sufficient causes of violence. Major determinants of violence continue to be socio-demographic and economic factors. Substance abuse is a major determinant of violence and this is true whether it occurs in the context of a concurrent mental illness or not. Therefore, early identification and treatment of substance abuse problems, and greater attention to the diagnosis and management of concurrent substance abuse disorders among seriously mentally ill, may be potential violence prevention strategies. Members of the public exaggerate both the strength of the association between mental illness and violence and their own personal risk. Finally, too little is known about the social contextual determinants of violence, but research supports the view the mentally ill are more often victims than perpetrators of violence.

Keywords: Mental illness and violence, stigma, violence prevention, victimization

Are the mentally ill violent? Are they more violent than people without a mental illness? Are they a risk to public safety? These questions have framed both the scientific and the public debate surrounding the relationship of violence to mental illness.

Unless otherwise stated, 'violence' will refer to acts of physical violence against others, since these are the most fear-inducing for the public and the greatest determinants of social stigma and discrimination. The term 'mental illness' will be reserved for non-substance related disorders, usually major mental illnesses such as schizophrenia or depression. Substance related disorders and concurrent substance abuse will be identified and discussed as separate risk factors.

ARE THE MENTALLY ILL VIOLENT?

Over time, there seems to have been a progressive convergence of mental illness and violence in day-to-day clinical practice. From early declarations disavowing the competence of mental health professionals to predict violence, there has been a growing willingness on the part of many mental health professionals to predict and manage violent behaviour. With the advent of actuarial risk assessment tools, violence risk assessments are increasingly promoted as core mental health skills: expected of mental health practitioners, prized in courts of law and correctional settings, and key aspects of socially responsible clinical management (1,2).

Many psychiatrists, particularly those working in emergency or acute care settings, report direct experiences with violent behaviour among the mentally ill. In Canada, for example, where violence in the population is low relative to most other countries, the majority of psychiatrists are involved in the management and treatment of violent behaviour, and 50% report having been assaulted by a patient at least once (3). However, clinical experiences with violence are not representative of the behaviours of the majority of mentally ill. Social changes in the practice of psychiatry, particularly the widespread adoption of the dangerousness standard for civil commitment legislation, means that only those with the highest risk of violence receive treatment in acute care settings.

In fact, a serious limitation of clinical explanations of violent and disruptive behaviour is their focus on the attributes of the mental illness and the mentally ill to the exclusion of social and contextual factors that interact to produce violence in clinical settings. Even in treatment units with a similar clinical mix and acuity, rates of aggressive behaviours are known to differ dramatically, indicating that mental illness is not a sufficient cause for the occurrence of violence (4). Studies that have examined the antecedents of aggressive incidents in inpatient treatment units reveal that the majority of incidents have important social/structural antecedents such as ward atmosphere, lack of clinical leadership, overcrowding, ward restrictions, lack of activities, or poorly structured activity transitions (4-6).

The public are no less accustomed to 'experiencing' violence among the mentally ill, although these experiences are mostly vicarious, through movie depictions of crazed killers or real life dramas played out with disturbing frequency on the nightly news. Indeed, the global reach of news ensures that the viewing public will have a steady diet of real-life violence linked to mental illness. The public most fear violence that is random, senseless, and unpredictable and they associate this with mental illness. Indeed, they are more reassured to know that someone was stabbed to death in a robbery, than stabbed to death by a psychotic man (7). In a series of surveys spanning several real-life events in Germany, Angermeyer and Matschinger (8) showed that the public's desire to maintain social distance from the mentally ill increased markedly after each publicized attack, never returning to initial values. Further, these incidents corresponded with increases in public perceptions of the mentally ill as unpredictable and dangerous.

In some countries, such as the United States, public opinion has become quite sophisticated. The public judge the risk of violence differently, depending on the diagnostic group, with rankings that broadly correspond to existing research findings. For example, Pescosolido et al (9) surveyed the American public (N=1,444) using standardized vignettes to assess their views of mental illness and treatment approaches. Respondents rated the following groups as very or somewhat likely of doing something violent to others: drug dependence (87.3%), alcohol dependence (70.9%), schizophrenia (60.9%), major depression (33.3%), and troubled (16.8%). While the probability of violence was universally overestimated, respondents correctly ranked substance abusers among the highest risk groups. Similarly, they significantly overestimated the risk of violence among schizophrenia and depression, but correctly identified these among the lower ranked groups.

Public perceptions of the link between mental illness and violence are central to stigma and discrimination as people are more likely to condone forced legal action and coerced treatment when violence is at issue (9). Further, the presumption of violence may also provide a justification for bullying and otherwise victimizing the mentally ill (10). High rates of victimization among the mentally ill have been noted, although this often goes unnoticed by clinicians and undocumented in the clinical record. In a study of current victimization among inpatients, for example, 63% of those with a dating partner reported physical victimization in the previous year. For a quarter, the violence was serious, involving hitting, punching, choking, being beaten up, or being threatened with a knife or gun. Forty-six percent of those who lived with family members reported being physically victimized in the previous year and 39% seriously so. Three quarters of those reporting violence from a dating partner retaliated, as did 59% of those reporting violence from a family member (11). In addition, many people with serious mental illnesses are poor and live in dangerous and impoverished neighbourhoods where they are at higher risk of being victimized. A recent study of criminal victimization of persons with severe mental illness showed that 8.2% were criminally victimized over a four month period, much higher than the annual rate of violent victimization of 3.1 for the general population (12). A history of victimization and bullying may predispose the mentally ill to react violently when provoked (13).

ARE THE MENTALLY ILL AT INCREASED RISK OF VIOLENCE?

Scientists are less interested in the occurrence of isolated acts of violence among those with a mental illness, and more interested in whether the mentally ill commit acts of violence with greater frequency or severity than do their non-mentally ill counterparts. Therefore, the question of whether the mentally ill are at a higher-than-average risk of violence is central to the scientific debate.

Definitive statements are difficult to make and it is equally possible to find recent literature supporting the conclusions that the mentally ill are no more violent, they are as violent, or they are more violent than their nonmentally ill counterparts (14). Prior to 1980, the dominant view was that the mentally ill were no more, and often less likely to be violent. Crime and violence in the mentally ill were associated with the same criminogenic factors thought to determine crime and violence in anyone else: factors such as gender, age, poverty, or substance abuse. Any elevation in rates of crime or violence among mentally ill samples was attributed to the excess of these factors. When they were statistically controlled, the rates often equalized. However, although the main risk factors for violence still remain being young, male, single, or of lower socio-economic status, several more recent studies have reported a modest association between mental illness and violence, even when these elements have been controlled (1-2,7,13-16).

Because of the significant methodological challenges faced by researchers in this field, the nature of this association remains unclear. For example, violence has been difficult to measure directly, so that researchers have often relied on official documentation or uncorroborated selfreports. The prevalence of violence has been demonstrated to differ dramatically depending on the source (17). Most samples have not been representative of all mentally ill individuals, but only of those with the highest risk of becoming dangerous, such as those who are hospitalized or arrested. Study designs have not always eliminated individuals with a prior history of violence (a major predictor of future violence), controlled for co-morbid substance abuse, or clearly determined the sequencing of events, thereby weakening any causal arguments that might be made (14).

The MacArthur Violence Risk Assessment Study recently completed in the United States (1,18,19) has made a concerted effort to address these problems, so it stands out as the most sophisticated attempt to date to disentangle these complex interrelationships. Because they collected extensive follow-up data on a large cohort of subjects (N=1,136), the temporal sequencing of important events is clear. Because they used multiple measures of violence, including patient self-report, they have minimized the information bias characterizing past work. The innovative use of same-neighbour comparison subjects eliminates confounding from broad environmental influences such as socio-demographic or economic factors that may have exaggerated differences in past research.

In this study, the prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from their non-substance abusing neighbourhood controls. A concurrent substance abuse disorder doubled the risk of violence. Those with schizophrenia had the lowest occurrence of violence over the course of the year (14.8%), compared to those with a bipolar disorder (22.0%) or major depression (28.5%). Delusions were not associated with violence, even 'threatcontrol override' delusions that cause an individual to think that someone is out to harm them or that someone can control their thoughts. Previous cross-sectional studies conducted in the United States (20,21) and Israel (22,23) had linked threat-control override delusions to an increased risk of violence.

The importance of substance abuse as a risk factor for violence has been well articulated in other studies. Consequently, this may stand out as one of the robust clinical findings in the field (24-28). Substance abuse in the context of medication non-compliance is a particularly volatile combination and poor insight also may be a factor (25).

ARE THE PUBLIC AT RISK?

It is important to keep in mind that both serious violence and serious mental disorder are rare events. Therefore, it is difficult to judge the practical importance of findings that may show an elevated risk of violence among samples of mentally ill as they tell us little about public risk.

One way of approaching this issue is ask who are the most likely targets of violence by the mentally ill: members of the general public or members of their close personal networks? Most recent studies suggest that violent incidents among persons with serious mental disorders are sparked by the conditions of their social life, and by the nature and quality of their closest social interactions (29). In the MacArthur Violence Risk Assessment Study (1), for example, the most likely targets of violence were family members or friends (87%), and the violence typically occurred in the home. Discharged patients were less likely to target complete strangers (10.7%) compared to their community controls (22.2%). Similarly, in a social network study that followed 169 people with serious mental disorder over thirty months (30), violence most frequently erupted in the family when relationships were characterized by mutual threat, hostility, and financial dependence; when there was a diagnosis of schizophrenia with concurrent substance abuse; and when outpatient mental health services were used infrequently. Of the over 3,000 social network members studied, only 1.5% were ever targets of violent acts or threats.

A related question asks to what extent do mentally ill contribute to the overall prevalence of community violence. Using data from the Epidemiologic Catchment Area studies conducted in the United States, Swanson (31) reported population attributable risks for self-reported physical violence. Attributable risk refers to the overall effect a factor has on the level of violence in the population. For those with a major mental disorder, the population attributable risk was 4.3%, indicating that violence in the community could be reduced by less than five percent if major mental disorders could be eliminated. The population attributable risk for those with a substance abuse disorder was 34%, and for those with a comorbid mental illness and substance abuse disorder it was 5%. Therefore, by these estimates, violence in the community might be reduced by only 10% if both major mental disorders and comorbid disorders were eliminated. However, violence could be reduced by over a third if substance abuse disorders were eliminated.

Using a similar approach, a Canadian study asked what proportion of violent crimes involving a police arrest and detention could be attributed to people with a mental disorder. They surveyed 1,151 newly detained criminal offenders representing all individuals incarcerated in a geographically defined area. Three percent of the violent crimes accruing to this sample were attributable to people with major mental disorders, such as schizophrenia or depression. An additional seven percent were attributable to offenders with primary substance abuse disorders. Therefore, if major mental illness and substance disorder could be eliminated from this population, the proportion of violent crime would drop by about 10% (32).

CONCLUSIONS

Several general conclusions are supported by this brief overview. First, mental disorders are neither necessary, nor sufficient causes of violence. The major determinants of violence continue to be socio-demographic and socio-economic factors such as being young, male, and of lower socio-economic status.

Second, members of the public undoubtedly exaggerate both the strength of the relationship between major mental disorders and violence, as well as their own personal risk from the severely mentally ill. It is far more likely that people with a serious mental illness will be the victim of violence.

Third, substance abuse appears to be a major determinant of violence and this is true whether it occurs in the context of a concurrent mental illness or not. Those with substance disorders are major contributors to community violence, perhaps accounting for as much as a third of self-reported violent acts, and seven out of every 10 crimes of violence among mentally disordered offenders.

Finally, too much past research has focussed on the person with the mental illness, rather than the nature of the social interchange that led up to the violence. Consequently, we know much less than we should about the nature of these relationships and the contextual determinants of violence, and much less than we should about opportunities for primary prevention (30). Nevertheless, current literature supports early identification and treatment of substance abuse problems, and greater attention to the diagnosis and management of concurrent substance abuse disorders among seriously mentally ill as potential violence prevention strategies (25).

MASTER RAVENSBRÜCK 20.7.mp4

Jugendbegegnungstage Ravensbrück 2009