Individuals with mental illness (IMI) are significantly more likely than the general population to be involved in violence, either as victims or perpetrators. Changes in service provision have led to more caregiving responsibilities for families of IMI, placing family members both at risk for participation in violent encounters and as potential resources for averting them. Enlisting and working with families as partners in approaches to address violence involving an IMI is thus eminently logical. To date, there are no specialized programs to assist family members in this important and challenging role and little is known about what triggers such violence or how the incidents unfold. In order to develop a family-based intervention to reduce violent incidents and subsequent negative outcomes, this study examined the extant evidence regarding underlying processes that could accompany violent encounters and then presents a novel theoretical model through which to understand mechanisms that could be targeted usefully in family-level interventions to prevent violence.
A review of the extant literature on family violence and IMI was conducted and evaluated regarding the processes that might underpin violent incidents, including the causes, processes, mechanisms, and consequences of such encounters involving IMI. We then visually mapped a novel theoretical framework illustrating the factors contributing to violent incidents in order to describe the relationships and outcome.
A theoretical model that integrates the relevant constructs was developed addressing: (1) Triggering factors including (a) hostility level (anger), (b) emotional dysregulation, and (c) symptom level. These lead to (2) Filtering processes including (a) affective tone and (b) attribution. This results in the (3) outcome (violence). Triggering factors may be noticed, interpreted, and possibly acted upon by the family member, via the filtering processes. Social contextual factors (social disadvantage, access to/attitude toward MH resources, and family burden) operate outside of the process map but can affect each of the paths among the constructs. Social contextual factors can affect how behaviors or interactions are perceived, interpreted and responded to. Psychoeducation approaches can teach family members how to frame their perceptions and respond constructively, using enhanced skills to formulate interpretations (attributions of cause or purpose) and regulate expressions of emotions.
Conclusion and Implications:
While not a complete ecological model of violent interactions, our theoretical model has heuristic value for intervention development. Family psychoeducation, an evidence-based intervention highly effective in delaying relapse in IMI, is an appropriate platform for targeting and disrupting the path to aggression. An innovative restyling and expansion of the psychoeducation model, using novel content that addresses mechanisms related to the occurrence of violence, holds great promise for reducing the likelihood of violence and thus reduce the chances of negative outcomes occurring for both the family and IMIs (e.g. physical and psychological injury, involvement in the criminal justice system, marginal living arrangements or homelessness). We recommend developing this intervention by conducting family interviews to elucidate how such violence unfolds, focus groups with providers, and expert consultation to integrate data into existing psychoeducational intervention protocols to develop a model intervention.