Dynamics of Violent Incidents Involving Individuals with Serious Mental Illness

Background and Purpose: While most individuals with serious mental illness (SMI) do not commit violence, this population is at a modestly increased risk. In addition to deleterious impacts on victims, acts of violence by individuals with SMI contribute to stigma and are often used as justification for coercive public policies (e.g., involuntary outpatient treatment). For these reasons, it is critical that violence by persons with SMI be prevented. Research utilizing a situational/event perspective focuses on the precipitants, processes, and immediate contexts of specific events of aggression, which are often malleable. Consequently, such research is well suited to guide the development of interventions for preventing violence. Unfortunately, scant research to date on the topic of violence by individuals with SMI has utilized an event perspective, and we are unaware of any study that has done so by examining perceptions of both persons with SMI and support persons. The objective of the present study is to examine how persons with SMI and their support persons perceive and experience the same specific act of violence involving both parties to better understand how such incidents unfold to inform preventive interventions.

Methods: In-depth, semi-structured qualitative interviews were conducted with dyads of individuals with serious mental illness (ISMIs) who had engaged in violence in the past six months (n = 34) and a family member or friend who witnessed or participated in the violent incident (n = 34). Participants (approximately 50% African American and 50% Caucasian) were recruited via a university-wide research website, clinician referral, research registry, and family advocacy groups. Interviews with ISMIs and support persons were conducted separately regarding the same recent violent incident examining how each participant perceived and experienced the event. The coding scheme for the detailed narratives addressed several domains including stressors/triggers/escalators, feelings, attributions, de-escalation strategies, type of incident, substance use, and involvement of social services/legal system. Interviews were transcribed verbatim, with thematic analysis performed by two trained qualitative coders with discrepancies reconciled by the research team.

Findings: Several themes emerged: (1) Nearly all acts of violence occurred in the context of verbal arguments; (2) Violence is frequently triggered by the perception of disrespect or the need to defend oneself or others; (3) Violence is seen as more justified if someone “crosses a line” understood by both parties; (4) Violence involving family members frequently involves longstanding feelings, patterns and conflicts as if the violence follows an understood “script”; (5) Scarcity of resources (cigarettes, food, housing, time) is a frequent source of conflict; (6) Mental illness is often invoked as an explanatory or exculpatory factor in the occurrence of violence.

Conclusion and Implications: Most violent acts by ISMIs targeted support persons and occurred in the context of ongoing conflict and immediate disagreements. Family Psychoeducation is an evidence-based intervention shown to delay illness relapses and reduce family stress and burden. An innovative refinement of Family Psychoeducation addressing the themes identified in this study (e.g., educating parties on conflict resolution strategies) is a promising intervention to prevent acts of violence by persons with SMI.