Psychiatric impairment, social contact, and violent behavior: evidence from a study of outpatient-committed persons with severe mental disorder

The need to better understand and manage risk of violent behavior among peo ple with severe mental illness in community care settings is increasingly b eing recognized, as public-sector mental health systems face mandates to pr ovide more cost-effective services in less restrictive environments. The po tential for serious violence in a small proportion of severely mentally ill (SMI) individuals has emerged as a key factor that increases cost and limi ts continuity and normalization of community-based services for populations with psychiatric disabilities. A major challenge to developing better stra tegies for risk assessment and management in community care settings involv es specifying complex interactions between psychiatric impairment and the c onditions of social life - including the quality and frequency of contact w ith others at close quarters. This is a study of the determinants of violen t behavior in a sample of 331 adults with severe mental disorders in commun ity-based treatment. An interaction between severity of functional impairme nt and frequency of social contact was found to be: significantly associate d with risk of violence. Among respondents with Global Assessment of Functi oning (GAF) scores in the lowest 20%, more frequent contact with family and friends was linked to a higher probability of violent events. However, amo ng better functioning respondents, frequent social contact was associated w ith lower risk of violence and greater satisfaction with relationships. The se findings suggest that, where violence risk is concerned, the most salien t feature of psychiatric impairment is the impairment of social relationshi ps - the ways in which disorders of thought and mood not only distort one's subjective appraisal of experience and threat, but impair the ability to r elate meaningfully to others, to resolve conflict and derive necessary supp ort from family and friends. Thus, social contact may be a mixed blessing f or SMI individuals. For some, it signals a positive quality of life, but fo r others - particularly those with extreme psychiatric impairment - frequen t contact may add to conflict, stress, and increased potential and opportun ity for physical violence. The impact of psychiatric impairment on violent behavior cannot be known in isolation, but must be considered in a social c ontext. Effective community-based strategies to anticipate and prevent viol ence in the lives of persons with severe mental illness must take into acco unt such interactions between social and clinical variables.