Physical Violence During Mandatory Psychiatric Treatment: Prevalence and Patient Characteristics

• Author: Henk Nijman,Anneloes Huitema,Robert Didden,Nienke Verstegen,Vivienne de Vogel
• Published date: 01 July 2020
• Date: 01 July 2020
• DOI: http://doi.org/10.1177/0093854820924691
• Subject Matter: Articles

CRIMINAL JUSTICE AND BEHAVIOR, 2020, Vol. 47, No. 7, July 2020, 771 –789.

DOI: https://doi.org/10.1177/0093854820924691

Article reuse guidelines: sagepub.com/journals-permissions

© 2020 International Association for Correctional and Forensic Psychology

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PHYSICAL VIOLENCE DURING MANDATORY

PSYCHIATRIC TREATMENT

Prevalence and Patient Characteristics

NIENKE VERSTEGEN

De Forensische Zorgspecialisten

VIVIENNE DE VOGEL

De Forensische Zorgspecialisten

University of Applied Sciences Utrecht

ANNELOES HUITEMA

De Forensische Zorgspecialisten

ROBERT DIDDEN

Radboud Universiteit

Trajectum

HENK NIJMAN

Radboud Universiteit

Fivoor

This study explores variables that predict physical violence in 614 (forensic) psychiatric inpatients. All violent incidents that

occurred in a Dutch forensic psychiatric hospital between 2014 and 2019 (N = 3,713) were coded with the Modified Overt

Aggression Scale+ based on daily hospital reports and patients’ medical records. Binary logistic regression analyses examined

which patient variables could differentiate between patients with and without physical violence during treatment and between

patients with single and multiple incidents of physical violence. Variables included in the analyses were gender, legal status,

borderline personality disorder, antisocial personality disorder, schizophrenia spectrum disorder, psychopathy (Psychopathy

Checklist–Revised [PCL-R] score), self-harm during treatment, impulsivity, intellectual disability, and length of stay. A clear

association was found between self-harm and inpatient physical violence on all outcome measures and in all analyses.

Adequate monitoring of self-harm is advised as a strategy to early identify patients with a high risk to threaten ward safety.

Keywords: forensic psychiatry; inpatients; physical violence; prevalence; self-injurious behavior

PHYSICAL VIOLENCE DURING MANDATORY PSYCHIATRIC TREATMENT

Inpatient aggression is common in both forensic and regular psychiatric hospitals with

potentially severe consequences for staff and patients. The majority of professionals work-

ing in psychiatric settings experience violence during their career (Bowers et al., 2011). For

AUTHORS’ NOTE: Correspondence concerning this article should be addressed to Nienke Verstegen,

Department of Research, De Forensische Zorgspecialisten, PO Box 174, 3500 AD, Utrecht, The Netherlands;

e-mail: nverstegen@dfzs.nl.

924691CJBXXX10.1177/0093854820924691Criminal Justice and BehaviorVerstegen et al. / Physical Violence in Forensic Psychiatry

research-article2020

772 CRIMINAL JUSTICE AND BEHAVIOR

example, a survey among Dutch mental health professionals from different psychiatric

ward types demonstrated that 67% of the 1,534 respondents had been victim of at least one

aggressive incident in the past 5 years (van Leeuwen & Harte, 2017). Adverse consequences

for professionals include emotional reactions, such as anger, fear and anxiety, symptoms of

posttraumatic stress disorder, and a negative impact on work functioning, for example,

absence from work due to illness or decreased job satisfaction (Lanctôt & Guay, 2014;

Needham et al., 2005).

Studies have shown that the consequences of inpatient aggression for staff are more

severe after the experience of physical violence than after other forms of aggression, such

as verbal aggression. For example, a study among 114 nurses in a forensic psychiatric hos-

pital demonstrated that physical violence was the only type of aggressive behavior that was

associated with burnout symptoms, such as verbal aggression, witnessing aggression against

property, or self-harm (de Looff et al., 2018). In terms of job functioning, a study of 154

nurses on various psychiatric wards demonstrated that the experience of severe physical

violence (defined as violence resulting in major injuries, such as broken bones or deep lac-

erations) or sexual violence was associated with the number of missed days from work due

to illness (Nijman et al., 2005).

IDENTIFYING PHYSICALLY VIOLENT INPATIENTS

There is a large body of research on risk factors for violence. However, many of these

studies focus on violent recidivism after forensic psychiatric treatment or imprisonment,

and the body of evidence on physical violence during forensic hospitalization is consider-

ably smaller. Given the severe consequences of inpatient physical violence for victims, it is

important to be able to assess, upon admittance, which patients have higher risks to threaten

ward safety. The available evidence suggests, however, that the predictive properties of one

of the most widely used violent risk assessment instruments (Ramesh et al., 2018), that is,

the Historical Clinical Risk Management–20 (Webster et al., 1997), were good during the

later phases of treatment, but less during the early treatment phases (de Vries Robbé et al.,

2016). Therefore, more research on physically violent inpatients is necessary. Moreover, it

should be noted that the results of the different studies are difficult to interpret. Studies

employed different definitions of violence, used different ways of measuring it (e.g., Bader

& Evans, 2015; Broderick et al., 2015), and patient samples were composed of different

diagnoses and clinical statuses (Tengström et al., 2006). Furthermore, they generally had

small sample sizes, limiting the power of statistical analyses and generalizability, and were

generally carried out in different settings and on different types of wards. Hence, there is a

clear need for studies with larger sample sizes and validated instruments to increase insight

in a patient group that exerts a large negative influence on ward safety. Despite the limited

number of studies on inpatient physical violence, there is some evidence available on the

prevalence of physically violent behavior during forensic psychiatric treatment and the

sociodemographic, criminal, and clinical characteristics of patients who display it. The cur-

rent state of evidence will be summarized in the next paragraphs.

PREVALENCE OF INPATIENT VIOLENCE

A meta-analysis of 50 studies on inpatient violence in forensic and general psychiatry

demonstrated that between 4% and 55% of all patients exhibited physically violent behavior,