Opportunities For Prevention

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Violence and Mental Health: Opportunities for Prevention and Early Detection: Proceedings of a Workshop
Deepali Patel, Rapporteur
Forum on Global Violence Prevention
Board on Global Health
Health and Medicine Division
Copyright National Academy of Sciences. All rights reserved.

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2018. Violence and mental health: Opportunities for prevention and early interven-
tion: Proceedings of a workshop. Washington, DC: The National Academies Press.
doi: https://doi.org/10.17226/24916.

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PLANNING COMMITTEE ON MENTAL HEALTH AND VIOLENCE:

OPPORTUNITES FOR PREVENTION AND EARLY INTERVENTION1
MARGARET M. MURRAY (Co-Chair), Director, Global Alcohol

Research Program, National Institute on Alcohol Abuse and
Alcoholism, National Institutes of Health
MARK L. ROSENBERG (Co-Chair), President and Chief Executive
Officer, The Task Force for Global Health
ALBERT J. ALLEN, Senior Medical Fellow, Bioethics and Pediatric
Capabilities, Global Medical Affairs and Development Center of
Excellence, Eli Lilly and Company
MADELON BARANOSKI, Associate Professor of Psychiatry, Yale
University School of Medicine
ROBERT BERNSTEIN, President and Executive Director, Judge David L.
Bazelon Center for Mental Health and Law
JAMES BLAIR, Chief, Unit on Affective Cognitive Neuroscience,
National Institute of Mental Health
C. HENDRICKS BROWN, Professor, Departments of Psychiatry
and Behavioral Sciences and Preventive Medicine, Northwestern
University Feinberg School of Medicine
ERIC CAINE, Co-Director, Center for the Study and Prevention of
Suicide, University of Rochester
SHELDON GREENBERG, Professor, Division of Public Safety Leadership,
Johns Hopkins University School of Education
VICKIE M. MAYS, Professor, Department of Health Policy and
Management, University of California, Los Angeles
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are
solely responsible for organizing the workshop, identifying topics, and choosing s peakers. The
responsibility for this published Proceedings of a Workshop rests with the workshop rapporteur
and the institution.


FORUM ON GLOBAL VIOLENCE PREVENTION1
JACQUELYN C. CAMPBELL (Co-Chair), Anna D. Wolf Chair and

Professor, Johns Hopkins University School of Nursing (Until
December 2017)
MARK L. ROSENBERG (Co-Chair), President and Chief Executive
Officer, The Task Force for Global Health (until March 2014)
ALBERT J. ALLEN, Senior Medical Fellow, Bioethics and Pediatric
Capabilities, Global Medical Affairs and Development Center of
Excellence, Eli Lilly and Company (until June 2014)
FRANCES ASHE-GOINS, Deputy Director, Office on Women’s Health,
U.S. Department of Health and Human Services (until August 2014)
SUSAN BISSELL, Associate Director, Child Protection Section, United
Nations Children’s Fund (until February 2014)
ARTURO CERVANTES TREJO, National Institute of Educational
Evaluation, Mexico (until August 2017)
KATHY GREENLEE, Assistant Secretary for Aging, Administration
on Aging, U.S. Department of Health and Human Services (until
September 2016)
RODRIGO V. GUERRERO, Mayor, Cali, Colombia (until August 2017)
DAVID HEMENWAY, Professor of Health Policy; Director, Injury
Control Research Center and the Youth Violence Prevention Center,
Harvard University School of Public Health (until December 2014)
FRANCES HENRY, Advisor, F Felix Foundation (until June 2016)
L. ROWELL HUESMANN, Amos N. Tversky Collegiate Professor of
Psychology and Communication Studies; Director, Research Center
for Group Dynamics, Institute for Social Research, University of
Michigan (until June 2014)
CAROL M. KURZIG, President, Avon Foundation for Women (until
September 2014)
VALERIE MAHOLMES, Chief, Pediatric Trauma and Critical Illness
Branch, National Institutes of Health (until September 2015)
BRIGID McCAW, Medical Director, NCal Family Violence Prevention
Program, Kaiser Permanente (until August 2017)
JAMES A. MERCY, Special Advisor for Strategic Directions, Division
of Violence Prevention, National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention (until August
2017)
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables
do not issue, review, or approve individual documents. The responsibility for this published
Proceedings of a Workshop rests with the workshop rapporteur and the institution.
vii

MICHELE MOLONEY-KITTS, Managing Director, Together for Girls

(until December 2016)
LAURA MOSQUEDA, Associate Dean of Primary Care, University of
California, Irvine, School of Medicine (until August 2017)
MARGARET M. MURRAY, Director, Global Alcohol Research Program,
National Institute on Alcohol Abuse and Alcoholism, National
Institutes of Health (until September 2015)
JOHN T. PICARELLI, Program Manager for Transnational Issues,
National Institute of Justice
COLLEEN SCANLON, Senior Vice President, Advocacy, Catholic Health
Initiatives (until August 2017)
MAISHA SIMMONS, Program Officer, Vulnerable Populations Team,
Robert Wood Johnson Foundation (until May 2016)
EVELYN TOMASZEWSKI, Senior Policy Advisor, Human Rights and
International Affairs, National Association of Social Workers (until
August 2017)
ELIZABETH WARD, Chair, Violence Prevention Alliance, University of
the West Indies, Mona Campus (until August 2017)
Health and Medicine Division Staff

AUDREY GROCE, Senior Program Assistant (until September 2014)
RACHEL M. TAYLOR, Associate Program Officer (until August 2014)
KIMBERLY SCOTT, Senior Program Officer (until May 2015)
KATHERINE BLAKESLEE, Global Program Advisor, Board on Global
Health (until December 2014)
JULIE PAVLIN, Senior Board Director (from November 2016)
KATHERINE PEREZ, Senior Program Assistant (from August 2017)
JULIE WILTSHIRE, Financial Associate (until November 2014)
PATRICK W. KELLEY, Senior Board Director, Board on Global Health
(until July 2016)
viii

Reviewers
T
his Proceedings of a Workshop was reviewed in draft form by indi
viduals chosen for their diverse perspectives and technical expertise.
The purpose of this independent review is to provide candid and criti-
cal comments that will assist the National Academies of Sciences, Engineer-
ing, and Medicine in making each published proceedings as sound as possible
and to ensure that it meets the institutional standards for quality, objectivity,
evidence, and responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
ALBERT J. ALLEN, Eli Lilly and Company

MEDELON V. BARANOSKI, Yale School of Medicine
GREG BROWN, Nipissing University
PAOLO DEL VECCHIO, Substance Abuse and Mental Health Services
Administration
Although the reviewers listed above provided many constructive com-

ments and suggestions, they were not asked to endorse the content of the
proceedings nor did they see the final draft before its release. The review
of this proceedings was overseen by NANCY E. ADLER, University of
California, San Francisco. She was responsible for making certain that an
independent examination of this proceedings was carried out in accordance
with standards of the National Academies and that all review comments
were carefully considered. Responsibility for the final content rests entirely
with the rapporteur and the National Academies.
ix


Contents
1 OVERVIEW 1
Forum on Global Violence Prevention, 1
Workshop Objectives, 2
Organization of the Proceedings of a Workshop, 3

2 FRAMING THE PARADIGM 5
Violence and Mental Illness: What Do We Know?
What Do We Need? What Can We Do?, 5
Operational Definitions for the Workshop, 8
Ecological Framework, 10
Relationship Between Mental Illness and Violence, 15
Neurocognitive Mechanisms of Violent Behavior, 17
References, 19
3 AT THE INTERSECTION OF MENTAL HEALTH AND 21

VIOLENCE
Experiences and Perspectives Related to Mental Health and
Violence, 21
Detecting and Assessing Mental Health Dysfunction and Risk
for Violence, 26
References, 33
xi

xii CONTENTS
4 MEANS AND MODIFIERS 35

Restricting the Means of Violence, 35
Alcohol, Alcohol Use Disorders, and Violence, 41
References, 48
5 PREVENTION, INTERVENTION, AND TREATMENT 51

Mental Health Services and Violence, 51
Interface with the Justice Community and Opportunities for
Intervention, 56
References, 65
6 ASSEMBLING THE PIECES AND INTEGRATING 67

ELEMENTS
Evaluation of Programs for Violence Prevention and
Mental Health Promotion, 67
Reflections and the Way Forward, 69
References, 74
APPENDIXES
A Workshop-Related Discussion Papers 75
B Workshop Agenda 129
C Workshop Speaker Biographies 139

Boxes, Figures, and Tables
BOXES
1-1 Statement of Task, 3
5-1 Issues Across the Criminal Justice System, 58

5-2 What Police Patrol Officers Want Mental Health Practitioners to
Know, 59
FIGURES
A-1 Mental health expenditures, 101
A-2 The impact of being bullied on functioning in adulthood, 121
A-3 Adjusted mean young adult CRP levels (mg/L) based on childhood/
adolescent bullying status, 123
TABLES
A-1 Mental Health Professionals in LAC, 102
A-2 Number of Users Attending Mental Health Facilities, 103
xiii


Overview1
O
n February 26–27, 2014, the National Academies of Sciences,
Engineering, and Medicine’s Forum on Global Violence Prevention
convened a workshop titled Mental Health and Violence: Oppor
tunities for Prevention and Early Intervention. The workshop brought
together advocates and experts in public health and mental health, anthro-
pology, biomedical science, criminal justice, global health and development,
and neuroscience to examine experience, evidence, and practice at the
intersection of mental health and violence. Participants explored how vio-
lence impacts mental health and how mental health influences violence and
discussed approaches to improve research and practice in both domains.
FORUM ON GLOBAL VIOLENCE PREVENTION

This workshop was the seventh in a series of workshops held by the
Forum on Global Violence Prevention, which works to promote research
on both protective and risk factors, to encourage evidence-based prevention
efforts, and to facilitate dialogue and exchange by bringing together experts
from all areas of violence prevention. The forum is tasked as follows:
1 The planning committee’s role was limited to planning the workshop. The Proceedings
of a Workshop was prepared by the rapporteur as a factual account of what occurred at the
workshop. Statements, recommendations, and opinions expressed are those of individual
presenters and participants and are not necessarily endorsed or verified by the National Acad-
emies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any
group consensus.

2 VIOLENCE AND MENTAL HEALTH
• Provides an ongoing, regular, evidence-based, impartial setting for

the multidisciplinary exchange of information and ideas concerning
violence prevention
• Illuminates policy, research, and practice priorities worthy of fur-
ther study or investment
• Gathers information on the scientific basis and public health needs
pertinent to global violence prevention
Past workshops have explored the evidentiary basis of violence preven-

tion, the contagion of violence, the social and economic costs of violence,
and violence against women and children, among other topics.
WORKSHOP OBJECTIVES
In her introductory comments, planning committee co-chair Peggy
urray of the National Institute on Alcohol Abuse and Alcoholism ex-
M
plained that this workshop on mental health and violence prevention
emerged from discussions held during previous workshops, as well as cur-
rent events and media reports. She noted that what is known about mental
health and violence prevention is complicated, and what is not known is
vast. Law enforcement officials, in particular, are burdened by the number
of people with mental illness they encounter and are not well equipped to
deal with these numbers outside of traditional corrective means. Planning
committee co-chair Mark Rosenberg of The Task Force for Global Health
further explained that the intersection of mental health and violence is
confusing. Is the relationship unidirectional, and in which way, or is it
bidirectional? The workshop planning committee sought to shed light on
this issue to gain a clearer picture of this interaction.
Because the relationship between mental health and violence is com-
plex, complicated, and of interest to numerous stakeholders, the planning
committee acknowledged that it was not feasible to conduct an exhaustive
review in a 2-day workshop (see Box 1-1 for the Statement of Task). Thus,
the committee identified the following topics as important to address:
• A description of mental health function as a continuum, from opti-

mal to dysfunctional, with problems ranging from minor to serious
distress to antisocial behavior to severe mental illness
• Perpetration of violence, victims of violence, and exposure to
violence
• Interpersonal, self-directed, and collective violence
• Neurobiology of violent behavior
• Multiple ecological levels to be considered
• A life-course/developmental perspective

OVERVIEW 3
BOX 1-1
Statement of Task
An ad hoc committee will plan a 2-day public workshop to explore the rela-
tionship between mental health and violence. The workshop will feature invited
presentations and discussions with the goal of laying the foundation for progress
in improving outcomes with respect to mental health and violence embodied in
research, policy change, and program development.
Workshop speakers and participants will explore a continuum of approaches
to improving both mental health and violence prevention with these objectives:
• A rriving at a better understanding of the intersection of mental health and

violence, including
o the relationship between mental health dysfunction and risks of violence
perpetration and victimization, as well as the mental health conse-
quences of exposure to violence; and
o the extent to which improved mental health functioning and improved
mental health services can—or cannot—address concerns about vio-
lence in society.
• Exploring a new model for thinking about the intersection of mental health
promotion and violence prevention that is useful for improving outcomes
• Means of violence perpetration, including access to weapons

• Identification of the multiple sectors that must be involved, as well
as their intersection
ORGANIZATION OF THE PROCEEDINGS OF A WORKSHOP

This Proceedings of a Workshop provides a summary account of the
workshop presentations and the expert papers submitted by workshop
speakers. This proceedings comprises six chapters, including this introduc-
tion. Chapter 2, Framing the Paradigm, presents opening remarks from the
keynote speaker, Thomas Insel; operational definitions from Vickie Mays;
an ecological framework approach from Eric Caine and Janis Jenkins; an
exploration of the intersection of mental illness and violence from Mark
Rosenberg (speaking on behalf of Paul Applebaum); and the neurobiology
of violent behavior from Jim Blair. Chapter 3, At the Intersection of Mental
Health and Violence, details lived experiences and perspectives on mental
health and violence, as presented by Daniel Fisher, Elyn Saks, Harvey
Rosenthal, and Robert Bernstein. The chapter also outlines information
on assessing and detecting mental health dysfunction and risk of violence
from the presentations of Seena Fazel, Dustin Pardini, and Dieter Wolke.

Chapter 4, Means and Modifiers, includes presentations on restricting the

means of violence from Daniel Webster, Michael Phillips, and Mike Luo;
and on alcohol and alcohol use disorders from Klaus Miczek, Kenneth
Leonard, Toben Nelson, and Ronaldo Laranjeira. Chapter 5, Prevention,
Intervention, and Treatment, covers mental health services and violence
from Colleen Barry, Sharon Stephan, and Dévora Kestel, and the interface
with the justice community from Madelon Baronski, Sheldon Greenberg,
Ray Kotwicki, David Wexler, and Patrick Fox. The final chapter, Assem-
bling the Pieces and Integrating Elements, includes a presentation on an
evaluation of interventions by Hendricks Brown, and a synthesis of the
summary panel and subsequent discussion on the way forward.

Framing the Paradigm
T
he opening panels of the workshop set the stage for the subsequent
discussions. The keynote address provided an overview of the evi-
dence for and the policy involving mental illness and its relation-
ship to violence. Speakers presented on operational definitions, ecological
frameworks, cultural context, risk and protective factors, and neurobiology.
They noted the common misperception that mental illness plays a greater
role in the risk of violence than it actually does. Although, under certain
circumstances, persons with mental illness are indeed at a greater risk of
violence to others and, in general, are at greater risk for suicide.
VIOLENCE AND MENTAL ILLNESS:

WHAT DO WE KNOW? WHAT DO WE NEED?
WHAT CAN WE DO?1
Mental health and violence are often addressed in a manner that adds
to the confusion rather than the clarity, stated Tom Insel in his keynote
address, and it is important to disseminate accurate and evidence-based
information about the relationship between the two. Currently, he remarked,
there is tremendous focus from the public on mass violence (e.g., shootings)
and linking it to mental illness—a situation that requires untangling. Insel
evoked President Barack Obama’s suggested action plan to address gun
violence and mental health services, noting that these issues go beyond the
1 This section summarizes information presented by Tom Insel, National Institute of Mental
Health.

domain of criminal justice and point to social inequities. Public health tools
are e ssential in reducing violence, Insel asserted.
At the highest levels of the U.S. government, there is both a desire to
address the recent shootings in schools and public places and a hesitancy
to directly address gun violence. This desire has translated into transform-
ing mental health care to reduce additional violence. Furthermore, Insel
remarked that the framing of mental health and violence on the same axis—
though done with good intentions—has resulted in more misconceptions.
To highlight this point, he shared the following data:
• Untreated active psychosis, whether because of mental illness or

drug use, is associated with irrational behavior, which could in-
clude violence. Notably, 38 to 48 percent of the homicides and
suicides associated with people who are diagnosed with schizo-
phrenia or bipolar disorder occur at the beginning of illness, often
before treatment and sometimes before a diagnosis (Nielssen et al.,
2012; Short et al., 2013). That risk of violence is most likely to be
directed toward family and friends.
• People with treated mental illness are at no higher risk for commit-
ting violence than the general population and are at higher risk for
being the victims of violence. Scandinavian studies have indicated
that treatment of mental illness can reduce violence risk 15-fold
(Nielssen and Large, 2010).
• Violence associated with a diagnosed serious mental illness is more
likely to be self-directed than directed at others, even if one in-
cludes family and friends. Ninety percent of the approximately
38,000 suicides each year in the United States involve mental ill-
ness, while less than 5 percent of the approximately 14,000 homi-
cides each year involve mental illness (CDC, 2005). Insel calculated
this to be a 50-fold differential. Occasionally, as was the case in the
school shooting in Newtown, Connecticut, an event might include
homicide before suicide.
• The risk of suicide is greater in people with mental illness than
in the general population—almost half to three-quarters of the
population-wide suicide risk can be explained by mental illness
(Hawton and Heeringen, 2009). The lifetime risk of suicide for
men with mental illness is 4.3 percent, and for women, it is 2.1
percent, whereas it is 0.7 percent and 0.2 percent for men and
women without mental illness, respectively.
• Misinformation exists around a supposed increase in homicides
in the United States when in fact it has decreased from 9.8 per
100,000 people in 1990 to 4.8 per 100,000 in 2010. On the other
hand, suicide rates have remained relatively stable over the past

FRAMING THE PARADIGM 7
20 years. Other causes of mortality, including road traffic fatalities,

have also dropped in that same time frame.
• The United States is disproportionately represented in firearm
deaths among high-income countries, accounting for almost
80 percent of the total. For people 15 to 24 years old (i.e., the
peak period for developing psychotic illness), the risk of homicide
involving a firearm is 42 times higher and suicide involving a fire-
arm is 8.8 times higher, relative to other countries (Richardson and
Hemenway, 2011).
Insel referenced the popular perception that although the number of

omicides has decreased, mass shootings have increased. He questioned
h
this conclusion, as these are relatively rare events; while there is potential
for this trend, the evidence is not clear. These tragic events capture national
attention even though they are a small part of overall risk.
Because violence is a relatively rare event (even if it does not seem rare),
it is difficult to predict at the individual level which prevention efforts will
be the most effective. From a public health perspective, means restriction
can work to reduce both homicide and suicide, he asserted. The knowledge
on how to do so exists but can be a difficult sell in the policy arena. To this
end, Insel emphasized that to the extent that mental illness is a risk factor
for violence, treatment can help reduce it.
Treatment, however, is usually targeted to specific populations. Insel
described the findings of a mapping exercise used to determine the domains
in which suicides occur. Some populations, such as military personnel, do
not constitute a large proportion of the overall group of suicides. Others,
such as emergency department workers and health care providers, are a
much larger percentage. Deaths from gun violence compose the largest
portion. To reduce suicides, Insel proposed four measures for continued
exploration, refinement, and improvement:
1. Predictors of risk and resilience, though he acknowledged this

would be a difficult path
2. Surveillance, as data on suicides lag by almost 3 years
3. Tools for prevention and treatment
4. Evidenced-based policies for limiting access to means
An important measure that could be undertaken now is to better assist

adolescents who are on the pathway to psychosis. In the United States, the
duration of untreated psychosis is about 110 weeks—more than 2 years.
One program the National Institute of Mental Health (NIMH) supports to
address this issue is called RAISE (Recovery After an Initial Schizophrenia
Episode), which ensures that following a diagnosis, a person receives a

package of treatment in a family-centered approach with a goal of improv-

ing function in addition to reducing symptoms. This program is currently
being implemented in a few states, with data collection efforts under way
to determine its effectiveness.
A second measure Insel recommended is to move upstream in terms of
interventions. Early detection and early intervention have reduced mortal-
ity in other areas and have the potential to reduce violence, as well. Rather
than focusing on the “21-year-old who’s been psychotic for 2 years and now
gets a label in a treatment program, [focus should be placed on] the 15-year-
old who’s at highest risk, and figuring out what could be provided to that
15-year-old so that at 19 he or she doesn’t have a psychotic illness,” Insel
explained. He expressed that treatment is not only medication, but a whole
series of interventions that build resilience and executive function, provide
family psychoeducation and peer support, and improve other skills.
Insel closed with a few summary remarks:
• Most people with mental illness are not violent, and most acts of
violence are not committed by people with mental illness.
• Some people with mental illness are a danger to themselves and
others.
• Fear of those with mental illness confounds the assessment of risk
(i.e., people with mental illness are more likely to be victims than
perpetrators).
• Early detection and early treatment can reduce risk.
In the question-and-answer session following Insel’s presentation, addi

tional salient points were raised. In terms of means restriction, participants
discussed that the people who attempt suicide are often somewhat ambiva-
lent about their success—restricting one’s means does not often result in the
substitution of another means. Additionally, Insel emphasized that school-
based interventions should not be focused on addressing mental illness,
which often has not developed by adolescence, but rather on reframing
the issue as improving adolescents’ school performance and relationship
skills. The majority of those who demonstrate “precursors” do not develop
mental illness, he noted.
OPERATIONAL DEFINITIONS FOR THE WORKSHOP2

Several workshop participants and speakers mentioned that confusion
and miscommunication abound in the field of mental health, in no small
2 This section summarizes information presented by Vickie Mays, University of California,
Los Angeles.

part due to the ambiguity around terms. Vickie Mays noted that even the
term “mental health” is confusing; some equate it with mental illness,
while others place it on the side of well-being. To create a foundation for
workshop discussions, Mays presented a series of operational definitions
for common terminology in the field.
Mental health is defined as “a state of well-being in which the indi-
vidual realizes his or her own abilities, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution
to his or her community” (WHO, 2001).
On mental illness, Mays acknowledged there is no one encompassing
definition because perspectives, such as health care assessment and justice,
often have different aims. However, despite this difficulty, stakeholders
share a common goal of developing research that produces better predic-
tors, interventions, and treatments.
On the other hand, severe mental illness (SMI) has a greater consensus
in definition and comprises several disorders including bipolar disorder,
depression, obsessive compulsive disorder (OCD), panic disorder, post-
traumatic stress disorder (PTSD), and schizophrenia. SMI is disruptive, not
only for individuals, but also for families, communities, and sometimes in
the broader system. On the positive side, there are treatments, including
not just medication but also therapies. One important policy direction is
ensuring these treatments reach the people who need them. “In terms of
serious mental illness, we need to remember that recovery is possible when
we can get these treatments to people in an effective manner and in a timely
manner,” she stated.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi-
tion (DSM-5), defines a mental disorder as “a syndrome characterized
by clinically significant disturbance in an individual’s cognition, emotion
regulation, or behavior that reflects a dysfunction in the psychological,
biological, or developmental processes underlying mental functioning”
(APA, 2013). While Mays acknowledges some level of controversy around
the DSM-5 system, she highlighted the key elements of the definition of a
syndrome that is characterized by “clinically significant disturbance” in the
areas of cognition, emotional regulation, and behavior (APA, 2013).
Violence, as defined by the World Health Organization (WHO), is the
“intentional use of physical force or power, threatened or actual, against
oneself, another person, or against a group or community, that either results
in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation” (WHO, 1996). Mays emphasized the
broad definition in thinking about interventions.
Conduct disorder refers to a group of behavioral and emotional prob-
lems that usually begin during childhood or teenage years. Children with
the disorder have “long-term, continual patterns of behavior” that tend

to impact others or go against what is deemed typical by society for their

age group (WHO, 1996). Mays explained that this particular concept was
important because of the age of occurrence and because it is associated
with more severe behavior later in life. She cautioned that some symptoms
of conduct behavior, such as rule breaking, are also indicative of other
disorders such as attention deficit hyperactivity disorder (ADHD) or abuse
victimization, and that physical, family, school, and social factors could
also explain the behavior. Moreover, several factors could contribute to
the development of conduct disorder, including brain damage, child abuse,
genetic vulnerability, school failure, and traumatic life experiences.
Alcohol use disorder is a pattern of consumption that results in clini-
cally significant impairment or distress with a cluster of behavioral or physi-
cal symptoms, which can include withdrawal, craving, and tolerance. In the
DSM-5, alcohol use disorder can be mild, moderate, or severe (APA, 2013).
Similarly, substance use disorder is marked by a constellation of cog-
nitive, behavioral, and physiological symptoms and a continued use of a
substance despite the harm it causes.
Perpetrator refers to the person who has actually committed the violent
act or is responsible for it occurring. However, Mays stated that sometimes
perpetrators have been or are currently victims themselves. Additionally,
perpetrators are often addressed within the legal context, which only de-
fines the person by his or her action at the time and does not address
either the likelihood of reoccurrence or the measures that might prevent
reoccurrence.
Victim refers to the person who has been “directly and proximately
harmed as a result of the commission of an offense for which restitution
may be ordered” (USSC, 2011). This is a legal definition, Mays noted. In
terms of victims, stakeholders should examine the range of interventions
needed to make a person whole and functional again.
Participants further discussed these definitions, noting that the variety
of stakeholders with their different perspectives also have varying defini-
tions. As science in the field advances and the biological basis of mental
illness is further illuminated, these definitions can be refined. Depending
on the aims and the principles of a particular discipline, however, defini-
tions can be narrowed or expanded. Mays explained that these definitions
are evolving in the context of a changing health care field, in which both
services and actors are continuously being defined.
ECOLOGICAL FRAMEWORK
The ecological framework session included an overview and discussions
of risk and protective factors and intervention points related to mental health
and violence at the individual, relationship, community, and societal levels.

Models for Suicide Prevention and Treatment3

The focus of the workshop spans a range of problems that “encompass
individuals’ unique life circumstances, communities, societies, and the globe
all into one thoughtful discussion,” Eric Caine observed. This is chaotic, he
noted, but holds possibility for intervention. On a national level, it is pos-
sible to prevent suicide. Notably, homicides and road traffic fatalities have
decreased in part because of interventions when the outcomes were predict-
able at the population level, if not at the individual level. Although violence
prevention has traditionally fallen under the purview of the criminal justice
system, the responses have usually been reactionary. In the case of suicide,
Caine explained, a reactionary response is one that is too late. He also
observed that violence has a major global dimension: suicide, self-harm,
interpersonal violence, war, and conflict are all very different around the
world. However, looking at the burden of disease, suicide far outweighs
the combined international impact of war and interpersonal violence.
In the United States, suicides not only carry a larger burden than
homicides, but they are also substantially underestimated, particularly
self-poisoning. Deliberate self-poisoning is not the same as unintentional
poisoning, but occasionally “unintentional” means unable to determine
intent and not specifically accidental. When the number of suicides is com-
bined with the number of self-poisonings of uncertain intent, fatalities due
to self-injury climb to approximately 50,000 per year. Caine also stated that
firearms account for half of suicides, mostly due to their lethality (CDC,
2005). Because most people who attempt suicide and fail do not make
another attempt, restricting lethal means could potentially reduce suicides,
he argued.
The increase in suicides over the past decade has mostly been seen in
the middle years of life in both men and women—not in youth. While the
bulk of prevention resources is directed at youth, the suicide rate is highest
among middle-aged white men, who compose a relatively small part of the
population. The middle years are the most common time for women to
commit suicide, as well. Caine further noted that suicides are not equally
distributed across the United States. In ways not yet fully understood, sui-
cide is driven by community and by location. In fact, suicides by poisoning
and by firearm overlap significantly. There is also geographical variation in
the suicide rate: it is higher in rural areas than in urban areas, whereas the
opposite is true of homicides.
Across the United States, there is no uniform picture of self-
directed violence or interpersonal violence. However, there are common
3 This section summarizes information presented by Eric Caine, University of Rochester
Medical Center.

community-level factors that may lead to violent injuries. He noted that,

although people often choose to focus on one type of violence or another,
prevention should be addressed earlier in the trajectory.
Caine shared an ecological model from WHO, which explores the
overlap among different levels in determining risk and protective factors
of violence. There are risks at the individual, interpersonal, community,
and societal levels, all of which offer potential points of intervention. In
fact, some interventions occur at multiple levels or require cooperation
with other interventions, such as youth and family prevention programs.
Caine cautioned that exploring all levels and factors at one time can be
overwhelming.
Risk is a cumulative “unfolding phenomenon,” he explained. All risks
do not happen at once. This yields several points of potential intervention
along a developmental pathway. He shared a model that depicted risks
as a mountain range: the peaks are violent outcomes; the bases are larger
social, economic, and family factors; and in the middle are individual and
situational factors. In terms of interventions, the base includes those that
are universal, while clinical ones are at the top; in the middle are selected
and indicated interventions. Addressing the bottom and the middle would
be necessary to make a difference, he stated.
Insel shared a second framework developed from the Haddon Matrix,
which examines injury through the lens of multiple layers (i.e., individual,
agent, and environment) and along a continuum of the event (i.e., pre-event,
during, and post-event). This model, adapted for suicide, provides a starting
point for the integration of neurobiological research and social research, as
well as policy analysis.
He closed by sharing a third model focused on treatment, called the
health impact pyramid. The pyramid shows that selected clinical interven-
tions sit at the top and have a smaller population-level impact. Interventions
at the bottom of the pyramid, which are more universal, have a greater
population-level impact.
Culture, Mental Health, and Violence4

Cultural meaning is essential in considering the intersection of mental
health and violence, and what it means for a person to accept treatment
or medication, explained Janis Jenkins. A cultural lens highlights multiple
perspectives and subjective experiences in a global, comparative context.
From her research, which is team based and employs mixed methods in-
cluding clinical diagnostic criteria, statistical analysis, and ethnography,
4 This section summarizes information presented by Janis Jenkins, University of California,
San Diego.

she observed that culture overlaps sectors of the ecological framework and
is central to mental health and illness. She described several fundamental
aspects of mental illness that are shaped by culture:
• Risk and vulnerability factors (e.g., gender inequity)

• Symptom content, form, and constellation
• Clinical diagnostic process
• Illness experience: identification, explanatory model, and meaning
• Kin emotional response and bonds and attachment
• Community social support stigma
• Service use and preferred treatment modalities
• Resources for resilience and recovery
• Course and outcome
In terms of symptoms, Jenkins advised further attention to not only

whether the symptom is present, but how it presents, as well as how symp-
toms aggregate. Furthermore, culture influences what is considered typical
and atypical, how explanatory models are developed, how those with men-
tal illness are viewed, how the illness course proceeds, and what outcomes
develop. She further explained that whether mental illness is perceived as
a personality defect or a legitimate illness affects the experience of illness
as well as the recovery.
What is involved in culture and conceptualizing it? She noted that
perception of the self is highly variable. In some places, the self is more
individualistic or self-centered, while in others the self is more socio-centric.
This orientation of the self influences assumptions about the world and
one’s place in it, particularly in terms of labeling or self-identification. Emo-
tions are also products of cultural systems and cultural rules.
In a cross-cultural survey of four African societies, perceptions of psy-
chosis were examined (Edgerton, 1966). When queried on the behaviors
associated with psychosis, participants responded in a similar manner:
they were not tolerant of, and were concerned about, murder, assault, and
disruptive behaviors. “These data show both a kind of universality to the
conceptions of psychosis as well as some cultural specificity,” she stated.
In terms of violence, Jenkins shared ways in which culture can broaden
the understanding of violence. Many developing countries have high rates
of homicide, particularly Belize, Côte d’Ivoire, El Salvador, Guatemala,
Honduras, Jamaica, Malawi, and Zambia; and among developed countries,
the United States outstrips its peers. Violence is not uniform; rather, cul-
tural, socioeconomic, and political factors influence violence and instability
in these arenas can particularly disadvantage individuals with increased vul-
nerability to violence. Subjective dimensions and structural arrangements of
violence, she postulated, could offer greater insight. These would include

conceptualizing violence as ordinary, contextually specific, lived experience,

or an organized set of ideologies and practice. Structural violence, exerted
systematically, causes harm or violence and disadvantages groups of people
(Farmer, 2004). Examples include ethnocentrism, poverty, racism, and sex-
ism, all of which constrain individual agency.
Jenkins further described research she had undertaken, investigating
“the nexus among the role of the state in constructing a political ethos,
the personal emotions of those who dwell in that ethos, and the mental
health consequences for refugees or displaced persons” (Jenkins, 1991).
Researchers have examined the experience of refugees fleeing political vio-
lence and identified terms to describe that experience, including “calor”
or an intense feeling of heat that was presenting in the emergency room.
They found in their study population that people had symptoms of PTSD
and depression, but were also working hard to raise money to send home
to their families. This raised the concept of “engaged depression” and the
importance of resilience. She and her colleagues proposed that “calor”
was a cultural manifestation of the political ethos of fear and violence in-
flicted by the state, presenting in a physical aspect. They used this concept
to understand the connection among “symptom, emotion, culture, bodily
experience, [and] political ethos.”
In her concluding remarks, Jenkins described research into youth vio-
lence and mental health issues, showing links with structural issues such
as poverty. She also noted a lack of gender difference in both perpetration
and victimization. The ethnographic analysis also suggested that youth
who are preoccupied with issues of violence have comorbid mental health
conditions, as well.
Discussion
Following the presentations, speakers delved into the concepts and
themes they raised. They spoke of the failure of detecting mental illness
related to violence before the occurrence of such violence, particularly
suicide. Caine remarked that instead of focusing on individual risk, going
“upstream” at the population level means examining life circumstances
in the community and the family. The need to address the “bottom of the
pyramid” is felt around the world, and there is “tremendous commonality
around community engagement,” he continued. However, the focus is too
often on suicide or homicide as an individual problem, partly because of the
stigma around mental health. Caine also emphasized the importance of
assessing the continuum of the problem rather than the event itself, which
would include considering morbidity and disability when assessing the
burden of violence, and not just at mortality. Jenkins added that addressing

these societal issues would mean rethinking the concept of resource scarcity
and instead generating political will to build the needed capacity.
RELATIONSHIP BETWEEN MENTAL ILLNESS AND VIOLENCE5

Mark Rosenberg presented information prepared by Paul Appelbaum
on the evidence base for the relationship between mental illness and vio-
lence. Rosenberg began with the four conclusions of the presentation:
• The public perceives a strong relationship between mental health

and violence.
• Although the rates of violence are increased in patients with serious
mental illness, the relative risk is moderate and well below those
public popular perceptions.
• Mental illness accounts for only a small proportion of the overall
violence risk.
• Beyond substance abuse, it is the case that hostility, suspiciousness,
agitation, and psychotic experiences may further increase the risk
of violent behavior; however, violence is varied and multicausal,
which has implications for both prediction and treatment.
Rosenberg addressed definitional issues around the concept of risk, in-

cluding perceived risk, measured risk, absolute risk versus relative risk, and
population-attributable risk. The intersection of mental health and violence
is highly dependent on how these terms are defined. Additionally, he asked,
what is the mechanism for increased risk? Mental health includes not only
the biological basis of mental illness, but also the orientation of the indi-
vidual within the family, society, and greater cultural context. Violence can
be defined as physical, psychological, or emotional, Rosenberg explained,
and it can result in death or injury, both physical and psychological. Threat
could also be considered a form of violence.
The definition of mental illness is inconsistent in the literature. Some
studies look at schizophrenia only, and others look at serious mental ill-
nesses. Some look at Axis I disorders, while others look at personality disor-
ders, or a combination of the two. Substance use disorders can be included
as well. Because of this lack of agreement, comparative analyses should be
performed carefully to ensure comparisons are equal. Appelbaum’s inten-
tion was to focus on studies that examine violence toward others and their
relationship with Axis I disorders and substance abuse, because methods
and definitions are more refined in this area.
5 This section summarizes information presented by Mark Rosenberg, Task Force for Global
Health, with information prepared by Paul Appelbaum, Columbia University.

In looking at the perceived risk of violence by people with mental

illness, Rosenberg noted that the public sees a strong relationship. The
General Social Survey (GSS) provides some illustrative data. For the GSS,
people were queried about the risk of violence in a specific situation. The
situation involved a hypothetical person named John whose mental health
is described as deteriorating over a period of a few months, until he became
housebound, neglected his hygiene, and began to hear voices. Participants
in the survey responded that if John had schizophrenia, it was 61 percent
likely that he would commit violence; if major depression, then 34 percent;
and if drug dependence, then 87 percent. Rosenberg also cited a public
opinion survey in which 46 percent of participants thought people with a
serious mental illness are “by far more dangerous” than the general popula-
tion; and one-third thought locating a group home for people with mental
illness in a residential neighborhood endangered local residents (Smith et
al., 2013).
Though these data indicate that perceived risk is vastly exaggerated,
evidence does suggest that there is an incremental risk associated with
mental illness. The Epidemiologic Catchment Area Surveys looked at vio-
lence in the year prior in a sample representative of the general population.
Researchers defined violence as hitting or throwing things at a partner or
spouse, hitting a child and causing injury, using a weapon in a fight, and
fighting while drinking. They looked at the distribution of violent risk
and found that the percentage of violent people in the group with no diag-
nosed disorder was 2 percent. By specific diagnostic groups, there was an
increasingly elevated risk of violent behavior: 2.37 percent in those with
anxiety disorders, 8.36 percent in those with schizophrenia, and up to
21.3 percent in those with substance use disorder (NIMH, 1991).
Rosenberg stated that Appelbaum examined a second dataset, the
National Epidemiologic Survey on Alcohol and Related Conditions, which
assessed violence in the past year and mental illness. For those with men-
tal illness, the relative risk of violence was 2.0, serious mental illness was
3.5, and substance use disorder was 3.3; for serious mental illness plus
substance use disorder, it was 11.5 (NIAAA, 2005). Notably, the highest
risk was found with the combination of mental illness and substance use
disorder. At the same time, Appelbaum cautions that relative risk is depen-
dent on the comparison group, and the general population might not be
the best control.
In another study, the MacArthur Violence Risk Assessment Study,
1,000 people were followed for 1 year after discharge and interviewed
every 10 weeks. They were compared with people in their own neighbor-
hoods. In the first 10 weeks after discharge, people with mental illness did
have an elevated risk compared with the community, which was higher
when substance use disorders were included. Additionally, when using the

appropriate control groups, the relative risk of violence for discharged

individuals within the study community decreased slightly compared with
results of relative risk in the general population. When controlling for sub-
stance abuse, this relative risk almost disappeared. It is the combination of
substance abuse and mental illness that saw the highest increase.
Rosenberg also raised the issue of population-attributable risk. What
proportion of violence in the population as a whole is due to mental ill-
ness? In other words, if mental illness were reduced, how much reduction
would be seen in violence? A study in the United Kingdom found that the
population-attributable risk for any personality disorder was 37 percent,
for hazardous drinking it was 50 percent, and for antisocial personality
disorder, 24 percent. Similar studies have found lower relative risk; mental
illness is less important of a risk factor. Some studies suggest that substance
use accounts for an increased risk, and others have found several risk fac-
tors related to violence, few of which are also related to mental illness.
Rosenberg closed by reiterating the four conclusions: the public per-
ceives a strong association between mental illness and violence; rates of
violence are increased but only moderately; only a small proportion of vio-
lence is attributable to mental health; and violence is variable with multiple
causes and implications for treatment.
During the ensuing discussion, speakers raised additional issues around
definitions. One issue is that there are no diagnostic categories for someone
who is hostile all the time—there is a marked difference in the way angry
affect is treated versus other types of affect. Another issue raised was mea-
suring the adverse impact of exposure to violence on the mental health of
children; violence prevention could be framed as mental health promotion
in this respect.
NEUROCOGNITIVE MECHANISMS OF VIOLENT BEHAVIOR6

James Blair spoke about the neurocognitive systems that mediate or
increase risk of interpersonal violence. He distinguished between two forms
of interpersonal violence: reactive violence is frustration based or threat
based, while instrumental violence is used to achieve a goal. Several mental
health conditions increase the risk of reactive aggression, such as anxiety,
borderline personality disorder, childhood bipolar disorder, depression,
intermittent explosive disorder, and psychopathy. Whereas only one men-
tal illness increases the risk of instrumental aggression—psychopathy (i.e.,
callous and unemotional [CU] traits). However, both types of aggression
are normative behaviors; reactive aggression is the ultimate response to a
6 This section summarizes information presented by James Blair, National Institute of
Mental Health.

threat, and in some circumstances, instrumental aggression might be the

appropriate decision to make.
Blair explained the brain mechanism responsible for reactive aggres-
sion, a threat-response circuitry that includes the amygdala hypothalamus
and extends into the periaqueductal gray. This neurocognitive system gen-
erates the response to a threat: in the distance, it might cause a person to
freeze; closer, it might cause flight; and in very close proximity, it might
result in fighting. This process is somewhat regulated by various frontal
systems, as well. It is also highly responsive to the amount of stimulation—
from low, freeze, to high, fight. He suggested that this should mean that
individuals who are at heightened risk for reactive aggression should also
have a heightened responsiveness of this circuitry. In fact, this is the case
in brain scans of people with PTSD and other disorders known to increase
risk of reactive aggression. Trauma and neglect also increase the responsive-
ness of this threat circuitry, and problems of emotional regulation block the
ability to reduce the responsiveness.
In terms of instrumental aggression, Blair pointed to a dysfunction in
empathic responsiveness that increases risk. This dysfunction manifests
clinically in CU traits, such as low pro-social emotions, including a lack
of remorse or guilt, lack of empathy, or lack of attachment to other indi
viduals. This brain circuitry includes the amygdala and the ventral medial
prefrontal cortex, as well. The amygdala is responsible for basic socializa-
tion, such as learning how others react to one’s actions. Depending on those
reactions, one might choose to repeat or avoid that particular action in the
future. However, if there is dysfunction in this circuitry, then there is an
increase in CU traits and an inability to respond to the distress or pain of
other individuals. Blair indicated that this inability to respond is not gen-
eral, as there is no problem with recognizing anger or disgust.
A third brain mechanism described by Blair is a set of systems re-
sponsible for reward- and punishment-based decision making, which are
not specifically related to CU traits. Problems in this circuitry tend to be
prevalent across conduct disorders and to some extent in substance abuse
populations. It also involves the amygdala, the ventral prefrontal cortex,
and the caudate. Researchers have hypothesized, based on data from rat
studies, that in the face of stimulus, a person might expect a positive out-
come (i.e., reward) or a negative outcome (i.e., punishment). Normally,
once a person determines which response will generate which outcome,
he or she will continue the behavior that earns the reward. They learn to
anticipate, or predict, which stimulus generates the reward and adapt their
behavior accordingly when that feedback changes. However, in people with
disruptive behavior or conduct disorder, this process does not occur. Addi
tionally, those with conduct disorder show problems in the representation

of value in the ventral medial prefrontal cortex. These issues are also seen
in people with substance use disorders, ADHD, and externalizing disorders.
In summary, Blair noted that the three neurocognitive systems he dis-
cussed might have a relationship with certain disorders, but are not disorder
specific. The acute threat response, if overly responsive, is more likely
to have an episode of reactive aggression. If an individual has empathic
problems, then he or she will not be as responsive to the distress or pain
of others and is less likely to be inhibited in causing harm. And those with
problems in the reward-and-punishment circuitry have issues with external-
izing disorders.
He speculated that there are additional factors that affect brain pro-
cesses, such as poverty, which modulates decision making, and impover-
ished diet, which affects the development of brain structures such as the
amygdala. Genetics, too, might play a role in increased responsiveness in
the acute threat circuitry, and possibly other systems. And finally, he men-
tioned the role of alcohol, which in healthy individuals reduces response to
distress of others and affects reward–punishment decision making.
In the discussion following the presentation, Blair addressed a question
regarding how suicide plays out in these neurocognitive systems by noting
that it is difficult to determine because the brain architecture explored does
not generate self-harm behavior in mammalian species. Impulsivity plays
a role, but the process is not necessarily within one of the three systems
he described. While reactive and instrumental aggression are different pro-
cesses, what is reactive is subjective and lies within the perception of the
perpetrator and his or her social milieu. He also discussed the implication
of this research on treatment; presumably, treatments that teach pro-social
behavior should recalibrate these systems in individuals with mental health
conditions. This seems to be true in several cases, but he noted that conduct
disorders, for example, might also require pharmacology.
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disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
CDC (Centers for Disease Control and Prevention) National Center for Injury Prevention and
Control. 2005. Web-based Injury Statistics Query and Reporting System (WISQARS™).
https://www.cdc.gov/injury/wisqars/index.html (accessed November 11, 2017).
Edgerton, R. 1966. Conceptions of psychosis in four East African societies. American Anthro-
pologist 68(2):408–425.
Farmer, P. 2004. An anthropology of structural violence. Current Anthropology 5(3):307.
Hawton, K., and K. van Heeringen. 2009. Suicide. The Lancet 373(9672):1372–1381.
Jenkins, J. H. 1991. The state construction of affect: Political ethos and mental health among
Salvadoran refugees. Culture, Medicine, and Psychiatry 15(2):139–165.

NIAAA (National Institute on Alcohol Abuse and Alcoholism). 2005. National epidemiologic
survey on alcohol and related conditions. Rockville, MD: U.S. Department of Health and
Human Services, National Institute on Alcohol Abuse and Alcoholism.
Nielssen, O. B., and M. M. Large. 2010. Rates of homicide during the first episode of psycho-
sis and after treatment: A systematic review and meta-analysis. Schizophrenia Bulletin
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to self and others during the first episode of psychosis. Journal of Clinical Psychiatry
73(5):e580–e587.
NIMH (National Institute of Mental Health). 1991. Epidemiologic catchment area survey
of mental disorders, wave I (household), 1980–1985. Rockville, MD: U.S. Department of
Health and Human Services, National Institute of Mental Health.
Richardson, E. G., and D. Hemenway. 2011. Homicide, suicide, and unintentional firearm
fatality: Comparing the United States with other high-income countries. Journal of

Trauma and Acute Care Surgery 70(1):238–243.
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patients with and without comorbid substance-use disorders to community controls. Acta
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IL: National Opinion Research Center.
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Sentencing Commission.
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World Health Organization.

At the Intersection of
Mental Health and Violence
T
he relationship between mental health and violence is complex and
often misunderstood, with a number of misperceptions around risk
of violence and victimization. Speakers discussed the stigma and
discrimination that people with mental illness experience, particularly in
the media. They also discussed the need for additional research on the
intersection of mental health and violence, noting that the detection and
the assessment of risk of violence are imprecise. Speakers also examined
how a better understanding of the pathways for and the risk factors of
violence could yield more effective interventions.
EXPERIENCES AND PERSPECTIVES RELATED

TO MENTAL HEALTH AND VIOLENCE
Daniel Fisher of the Riverside Community Mental Health Center opened
the panel titled “Experiences and Perspectives Related to Mental Health and
Violence” by describing the importance of language. He noted that “pa-
tient” and “consumer” are not preferred terms within the community, and
“survivor” is imprecise, and he suggested “people with lived experience” as
a more inclusive and less discriminatory term. These issues, he stated, are
not laboratory or clinical issues, but rather community and cultural issues.
He emphasized that a more nuanced and accurate perspective of these lived
experiences would help reduce stigma and provide better treatment op-
tions. For example, a peer-support recovery movement, similar to Alcohol-
ics Anonymous, exists to provide nonmedical options for those with lived
experience to connect and empower each other on the path to recovery.
21

Panelists further explored these issues within the context of the use of
mechanical restraints, misperceptions around violence and its association
with mental illness, as well as the history of deinstitutionalization and the
failure to transition to community-based care.
Use of Restraints1
Because there is a misperception that people with mental illness are
more prone to violence, it is a common practice to use mechanical restraints
in institutional settings. But Elyn Saks asserted that the use of restraints,
though well intentioned, is itself a violent act. Restraints when used over
a length of time are extremely painful and degrading and cause feelings of
helplessness. They can also be retraumatizing for those with posttraumatic
stress disorder (PTSD) or for other survivors of trauma. She noted that,
in her personal experience, the use of restraints was not necessarily due
to her own behavior. In fact, the literature supports the idea that the use
of r estraints has more to do with the institutional ethos than other factors,
such as p atient characteristics or patient–staff ratio.
In exploring why restraints are used, Saks noted that there are studies
that indicate that restraints help those being restrained feel safer. However,
she observed that in her experience, she had never heard anyone express
that sentiment, and that emergency fatalities do not lessen with the use of
restraints. A second, more legitimate reason is that restraints can be pro-
tective for health care and service providers. For those patients who might
become imminently violent, there is legitimate justification for restraints.
However, she noted four reasons why the use of restraints as protection
might be problematic:
• Restraints are often abused, despite statutes intended to prevent such

abuse. She gave the example of one client she knew whose chart
suggested restraints were used more for discipline than imminent
violence.
• Imminent danger is difficult to predict, and patient and physician
perspectives on a patient’s own dangerousness vary widely on this.
• While well meaning, the use of restraints is an act of violence and
can be more dangerous than not using them. Most staff injuries
occur in the restraint process, which could indicate that the use of
restraints itself causes people to be violent.
• There are often less restrictive alternatives available, such as the use
of a padded cell.
1 This section summarizes information presented by Elyn Saks, University of Southern
California.

AT THE INTERSECTION OF MENTAL HEALTH AND VIOLENCE 23
Saks suggested that restraints might cause more deaths than lives they
save. In a series of articles in the Hartford Courant, a Harvard University
statistician estimated that one to three people die each week in restraints—
aspirating in their own vomit, strangling, or having heart attacks. She stated
that since there are other means of protecting people, it is not clear whether
restraints cost or save lives. Restraint-reduction efforts have resulted in
lowered use of restraints without increased violence in Philadelphia and
Massachusetts. The United Kingdom by and large does not use extreme
restraints, and has not done so for 20 years.
In cases where the use of restraints might be justified (e.g., transport-
ing a violent person or when a medical professional needs to be in close
quarters), Saks recommended several enhanced procedural steps:
• Requiring 15-minute checks or an attempt to remove the restraints

every hour
• Changing the liability scheme to make harm caused by restraints
more liable (and harm caused by lack of restraint less liable)
• Providing guidelines to patients on behavior that will result in the
removal of restraints
• Videotaping all restraint episodes
• Forbidding “spread eagle” restraint
In the discussion following Saks’s presentation, workshop participants

raised questions around the use of chemical restraints, particularly in the
older population, and alternatives to restraints. Saks spoke of additional
considerations around elderly populations, such as dementia and risk of
falling. However, she stated that restraints are not always the answer—a
person sitting with the patient could also provide assistance. Another audi-
ence member mentioned the use of a hospital bed programmed to alert staff
if the patient tried to get up.
Impact of Violence on People with Mental Illness2

Harvey Rosenthal spoke about the impact of violence on the com-
munity of people with mental illness, particularly the fallout after horrific
episodes of “active shooter” violence. The stigma and the misinforma-
tion around the role mental illness plays in violence is often heightened
after incidents of mass violence, with resounding repercussions. Rosenthal
mentioned that policies are often promoted in government that seek to
respond to these incidents, but instead result in depersonalization and
2 This section summarizes information presented by Harvey Rosenthal, New York Associa-
tion of Psychiatric Rehabilitation Services, Inc.

criminalization of people with mental illness, and threaten to undo progress

in promoting recovery, dignity, and integration.
One challenge that Rosenthal raised is that mental illness is loosely de-
fined, particularly in the general population. Some people consider autism a
mental illness (it falls instead under the rubric of developmental disability).
A recent Kansas ruling in the Supreme Court places sex offenses under
mental illness. And others consider sociopathy and substance abuse to be
mental illnesses. At the same time, the common perception that one must
be “crazy” to commit horrific acts confuses matters further and feeds into
the misperception that mental illness is a risk factor for violence.
Rosenthal reiterated the fact that people with mental illness are at most
marginally more violent than the general public. He noted that only 4 per-
cent of violent crimes are affiliated with mental illness, and that 1 in 70,000
people with mental illness are committing murder of strangers (Swanson,
2015). To put it another way, of the 140,000 people in New York who are
deemed “seriously and persistently mentally ill,” two of them are at risk
of committing murder. Additional research has concluded that there is no
clear relationship between psychiatric diagnosis and mass murder, and that
most mass murderers are young men with no diagnosis of psychosis (Fox,
2015). Despite these facts, the perception of the link between mental illness
and violence has policy consequences, such as campaigns to force medica-
tion and other treatment on people. In New York, Rosenthal stated, the
law now mandates that mental health professionals report if a patient who
owns a gun expresses anger.
On the other hand, people with mental illnesses are 11 times more
likely to be victims of violence and 5 times more likely to be murder vic-
tims. And, yet, Rosenthal asserted, the public discourse still revolves around
the harm potentially committed by people with mental illness, and not the
potential harm faced by the vulnerable. In particular, there are efforts to
promote forced-treatment laws, despite the previously cited lack of evidence
on a link between mental illness and violence.
Rosenthal did share some positive items that have come about recently
regarding mental illness and violence. In particular, the Associated Press
(AP) created guidelines for its reporters on writing about incidents in which
people with mental illness might be involved:
• Do not describe an individual as mentally ill unless pertinent to the

story and the diagnosis is properly sourced.
• Do not use derogatory terms such as “insane,” “crazy,” “nuts,” or
“deranged.”
• Do not assume that mental illness is a factor in violent crime.
• Do not use descriptions that denote pity, such as “afflicted with.”

He closed by discussing the implications of a “broken system,” a com-

monly used term with different meanings for different stakeholders. For
consumers, it is disempowering, dependency fostering, and overly focused
on medication. For families, it is a lack of assistance with their loved ones.
For others, it means more forced treatment. And for the media and much
of the general public, it means unchecked violence. To fix this, he suggested
that a new narrative needs to be created—one that is focused on both the
facts and the nuance around mental health and violence, and one that gives
voice to people with mental illness.
Reflecting on Mental Health and Violence3

Robert Bernstein observed that people with mental illness have endured
a long history of segregation and discrimination. In 1990, the Americans
with Disabilities Act (ADA) was passed with the intention of “mainstream-
ing” people with disabilities, including mental illness. The ADA was a sea
change in the treatment of people with mental illness, away from the previ-
ous approach of mandatory institutionalization and custodial care toward a
focus on community inclusion and multimodal treatment. In 1999, the U.S.
Supreme Court ruled that, per the ADA, unwarranted institutional confine-
ment was a form of segregation and that public systems have an obligation
to provide integrated services where feasible.
This is of course an ongoing discourse, Bernstein stated, but there
are profound reforms occurring to improve situations for people with
mental illness. In particular, deinstitutionalization was the cornerstone for
a mental health civil rights movement that preceded the ADA, and one that
is still an important element today. In the 1960s and the 1970s, deinstitu-
tionalization was the first wave of reform and was based on the terrible
conditions in state hospitals, where patients were not only incarcerated
but also routinely put in restraints. Given that most people with mental
illness are not a danger to themselves or others, and that the institutions
themselves raised other problematic issues, Bernstein asserted that deinsti-
tutionalization was a positive goal.
However, he was careful to point out that integration of patients with
communities was intended to be accompanied by a comprehensive com-
munity mental health movement, in which services are community based
rather than hospital based. Yet, this movement never materialized, and as
a result of poor funding, the mental health domain today exists as a crisis
system. People with serious mental illness have suffered, and perceptions
of mental illness have suffered as well.
3 This section summarizes information presented by Robert Bernstein, Judge David L.
Bazelon Center for Mental Health Law.

The community mental health movement was intended to provide ser-

vices to anyone with mental illness, but today it operates solely for those
who pose a danger. Because of a lack of funding, Bernstein stated, there is
little investment in prevention and early intervention with a primary focus
on emergency response. The current mental health system, he noted, is an
upstream system failure—the development of a mental health crisis being evi-
dence of a lack of early intervention. He closed by noting that because of this
systematic lack of funding where it is most needed for long-term solutions,
there is a perverse incentive now to capitalize on public perceptions of mental
health and violence if it means greater resource allocation for mental health.
Discussion
Following the presentations, panelists and workshop participants dis-
cussed additional issues raised, including challenges outside the United
States. In Latin America and the Caribbean, the movement toward recovery
and integration is not nearly as robust. Fisher and Rosenthal both noted
that the recovery movement has its roots in the United States, and it is im-
portant that, even while expanding it outside the United States, continued
work and sustained commitment is maintained at its origin.
Additionally, Eric Caine of the University of Rochester Medical Center
expanded on the issue of community mental health, observing that one of
the reasons for its lack of prioritization and funding was a change in the
way mental health was structured and treated. Caine went on to note that,
previously, community mental health fell under the purview of the National
Institute of Mental Health, but currently the Substance Abuse and Mental
Health Services Administration (SAMHSA) provides block grants to states,
with individual counties developing systems and allocating funds. At this
level of granularity, he postulated, grassroots and peer-led organizations
have an important role in shaping community mental health.
DETECTING AND ASSESSING MENTAL HEALTH

DYSFUNCTION AND RISK FOR VIOLENCE
Detection of risk of violence is currently an imprecise science, speakers
observed, that could benefit from greater study and refinement. One of the
major challenges faced is that violence is not a high-probability event, and
statistically the percentage of violent people is low. Risk factors for violence
are also varied, and it is unclear which factors and in which combination
might result in a violent act. With current instruments, this results in inac-
curate assessment of risk, which carries implications for those with mental
illness and those with a propensity for violence. Speakers discussed these
challenges and approaches to develop more refined instruments.

Violence Risk Assessment4

Seena Fazel spoke about risk assessment for interpersonal violence by
providing an overview, synthesizing evidence, and reflecting on implications
and next steps. Violence assessments, he stated, range from unstructured
clinical opinion to validated instruments that use tools as proxies for
clinical judgment. There are some 200 of these instruments in existence,
and they are widely used in forensic psychiatric services and criminal
justice settings. Often, they are used to make decisions about sentencing,
parole, and probation. Assessments that combine elements of structured
and unstructured approaches, such as actuarial instruments to calculate a
probability score, or categorizing risk as high, medium, or low based on a
predetermined checklist of risk factors, are commonly used.
Fazel and his colleagues examined the literature and located 40 system-
atic reviews and meta-analyses on commonly used tools to determine their
evidence base. They found a number of problems with these studies, includ-
ing a failure to exclude duplicates (resulting in overestimation of effects) or
to explore heterogeneity (resulting in wide variance). They found six studies
that actually examined predictive validity; five of those explored only the
PCL-R (Psychopathy Checklist), and one looked at another instrument.
Because of this lack of comprehensive evidence, they ran their own
meta-analysis, which also included previously unpublished data. This re-
sulted in a large study of 73 samples with about 24,000 individuals who
underwent risk assessment by 1 of the 9 most commonly used tools. The
outcomes were presented in a few different ways, but Fazel singled out
the positive predictive value (PPV) in particular, because of its clinical
usefulness. PPV is an assessment of how well the instrument identifies true
positives—that is, “if an instrument determines high risk, how many of
those people go on to violently offend or sexually offend?” he explained.
Per the meta-analysis, the PPV for “violent offending” was 0.41, meaning
the majority of those determined to be high risk did not, in fact, go on to
commit violence. At the same time, the analysis showed a PPV of 0.91 for
the low-risk group determination, suggesting the tools were better at assess
ing those who would not go on to commit violence5 (Fazel et al., 2012).
Fazel noted that how well the instruments perform is highly dependent
on their use. The PPV for determining violent offense suggested that they
were not great at predicting violence and therefore were not suitable for
decisions such as sentencing or release from hospital. Looking at other
4 This section summarizes information presented by Seena Fazel, University of Oxford,
United Kingdom.
5 A PPV of 0.41 indicated that of those in the high-risk group, only 41 percent went on to
commit violence. However, a PPV of 0.91 indicated that 91 percent of the time, the test was
correct in determining an individual was in the low-risk group (Fazel et al., 2012).

outcomes from the meta-analysis, Fazel noted there was some evidence that
the instruments could inform treatment and management plans and could
be used to screen out low-risk individuals. In comparing them to other
tools, Fazel observed that they fared poorly compared with diagnostic tools
but were more similar to existing prognostic tools from other medical dis-
ciplines. However, the consequences of moderately useful tools in violence
prevention are different: There are costs in terms of extended detention, as
well as costs of staff training and time.
In a second review, Fazel and his colleagues looked more closely at
different tools specifically designed for populations with mental illness. He
noted that they were disappointing due to wide variation in their predictive
ability. Additionally, only two studies looked at schizophrenia, which would
normally be considered a risk factor for violence. In looking at the content
of the tools, he and his team determined there is a wide variation in what
is included; for example, the instruments included a wide variety of factors
related to criminal history, failing to converge on what that entailed. And in
another recent study by Jeremy Coid and his colleagues, these instruments
were found to fare even more poorly with psychopathy than they do with
mental illness (Coid et al., 2013).
Fazel concluded his remarks with a summary of his findings. The
risk assessment tools he examined had limited value in predicting risk of
reoffending but could be useful in identifying different risk groups for man-
agement. More importantly, he argued that the tools should be used dif-
ferently: to screen out low-risk people as a means of focusing resources on
the remainder. He also felt that the research could be better improved—by
independent funding, validation by impartial experts, and higher standards
of evidence—toward the development of better assessment tools.
Strategies for Preventing Youth Violence6

Serious violence, Dustin Pardini observed, peaks in adolescence. Most
youth who engage in violence cease over time, and only a small percent-
age persist into adulthood. In his presentation, he focused on programs
implemented during elementary school, before children display seriously
violent behavior. Universal interventions are delivered to an entire popula-
tion of youth, while selected programs target youth with population-level
or demographic risk factors, such as living in a high-crime neighborhood.
Indicated interventions, which represent a large percentage of interven-
tions, focus on children who exhibit early forms of violent behavior, such
as physical fighting, or characteristics of oppositional defiant disorder and
conduct disorder.
6 This section summarizes information presented by Dustin Pardini, University of Pittsburgh.

In a recent meta-analysis, effect sizes demonstrated that indicated inter-

ventions produced the greatest reduction in aggressive behavior, most likely
because these youth are already showing high levels of aggression (Wilson
et al., 2003). The effects get smaller as the intervention becomes more gen-
eral, though they still remain significant. So which approach is better? On
the one hand, the identification of high-risk individuals who will commit
violence is difficult. Instead, the focus should be on reducing the risk in
the population as a whole. The benefit per individual would be small, but
everyone would be included in the intervention. On the other hand, some
research indicates that a small number of juvenile offenders actually com-
mit a large amount of youth violence. Focusing on those adolescents would
have optimal impact on the overall amount of crime.
Pardini noted that both approaches have their advantages and dis
advantages, but he suggested that further exploration of how best to imple-
ment targeted interventions was important, particularly the process of
screening youth for the programs. An effective screening instrument needs
to be brief, psychometrically reliable, precise, and administered across
multiple settings. Most importantly, it should significantly predict future
violence and have evidence to show such. Because violence is a relatively
low-probability event, a risk-screening instrument will generate a higher
number of false positives.
There are several practical implications of making errors with the in-
strument, Pardini emphasized. Where the line is drawn between high and
low risk, or when there is a false positive, makes the difference between a
child being placed in the intervention or not. This could have negative rami-
fications for the child because of the labeling, as well. Also, there is some
evidence to suggest that grouping children into such interventions could
result in deviancy training, in which there is take-up of adverse outcomes
instead of prevention. False positives are also a poor use of funds, and false
negatives reduce the impact of the program.
Currently, there are no standardized empirically based risk-assessment
tools for screening youth to refer them to targeted programs. There are a
few ad hoc tools, but none that are available for the general population.
These ad hoc tools are based on the idea that early conduct problems are
strong predictors for future violent behavior, an association seen in longi-
tudinal studies. In an analysis of these risk-assessment tools, Pardini and
his colleagues determined that they were mediocre at accurately identifying
high-risk youth, with a large number of false positives, especially among
girls. This is not surprising, because as Pardini previously explained, vio-
lence peaks in adolescence and ceases over time. Only a small number of
violent youth persist in their violence.
The Pittsburgh Youth Survey, which began in 1986, was an attempt
to develop a more accurate risk-assessment tool (van Wijk et al., 2005).

Researchers followed a sample of children from public schools in Pittsburgh

over time. The children were questioned at specific points about their vio-
lent behavior, and official criminal records were also collected. Among the
sample, the rates of violence were high, echoing concerns about a dispro-
portionate impact of violence on minority youth. Pardini and his colleagues
looked at all of the risk factors at the first assessment point—not just behav-
ioral issues, but also family conditions, peer influence, and neighborhood
characteristics, among others. They identified 51 risk factors, and using sta-
tistical regression, found the 11 strongest, ranging from academic issues to
physical aggression to family poverty. These risk factors demonstrate b etter
sensitivity and specificity than many adult assessment tools, but P ardini felt
there was room for improvement. He proposed examining multiple datasets
across the country and conducting comparable analyses to replicate fac-
tors measured by parents, teachers, and the children themselves. Once they
have identified those factors that consistently predict violence, they plan to
develop standardized item content to assess each risk domain. The final step
would be the development of a psychometric tool with as brief a measure
as possible that can be administered across multiple settings.
Impact of Bullying and Mental Health7

Dieter Wolke opened his presentation by remarking that bullying has
a definition in common language, but also a scientific construction that
goes beyond conduct problems. He emphasized that while conflict among
children teaches them how to resolve conflicts, bullying is not about con-
flict resolution but about power and intentional harmdoing. There are
different types of bullying, such as overt bullying, relational bullying, and
cyberbullying.
Wolke identified four groups associated with bullying:
• Pure bully, who perpetrates the aggression but never becomes a

victim
• Pure victim, who gets bullied but never bullies others
• Bully-victim, who bullies at times and is bullied at other times
• Neutral child, who can be a bystander or a defender
From where does bullying stem? In evolutionary biology, bullying could

be a means of accessing resources and gaining dominance in a hierarchy. In
fact, bullying could be protective against having to fight all the time. If this
is true, Wolke posited, then it should be seen in all socioeconomic status
7 This section summarizes the information presented by Dieter Wolke, University of W

arwick,
United Kingdom.

groups, but would be more frequent the scarcer the resources. In a recent
meta-analysis, Wolke and his colleague concluded that, indeed, bullying is
found in all classes and segments in society (Tippett and Wolke, 2014). In
another meta-analysis, researchers discovered that bullying is more preva-
lent in more unequal societies, so that inequality as a proxy for scarcity is
in fact correlated with bullying occurrence (Elgar et al., 2009).
Adverse consequences of bullying have been explored in the litera-
ture, and Wolke shared some examples. In one study in primary school,
Wolke and his colleagues looked at physical and emotional health prob-
lems in the four previously mentioned bully groups. He noted that the
most strongly affected group is the bully-victims, who are somewhat
socially defeated. Those with the lowest problems are the pure bullies,
who are not victims of bullying themselves (Wolke et al., 2001). In a
longitudinal study on bullying history, researchers found that incidence
of bullying is not the only factor—chronic bullying has add-on effects.
Those who are currently being bullied fare worse than those who were
bullied in the past, but those bullied currently and in the past do worst
of all (Bogart et al., 2014).
In another study with far-reaching implications, researchers in B ritain
discovered that bullying in elementary school was associated with self-harm
with intent to commit suicide at age 17, with a population-attributable frac-
tion of 20 percent (Lereya et al., 2013). This means that if bullying were
eliminated, Wolke explained, 20 percent of adolescent self-harm cases could
be prevented. He emphasized the importance of this by noting that, by
comparison, obesity, which commands significant resources for its preven-
tion, only accounts for 3 percent of heart attacks. Other research supports
similar findings; another study found that chronic bullying before age 11
increases risk of psychotic experiences threefold (Wolke et al., 2014).
In studies done in adults who experienced bullying as children, re-
searchers again found health problems, particularly psychological condi-
tions, in those who were pure victims, but also bully-victims. They had
poorer psychosocial outcomes, as well, including difficulty maintaining
employment and relationships (Copeland et al., 2013; Wolke et al., 2014).
In another study looking at inflammatory responses to C-reactive protein,
the stronger or more chronic the bullying, the higher the response. The
largest change was for victims, followed by bully-victims, but the lowest
was in pure bullies (Copeland et al., 2014).
Wolke closed his remarks by summarizing the findings from the lit-
erature: being bullied has wide-ranging effects on mental health, from
increasing risk for psychopathology to adverse psychosocial and social out-
comes. The chronically bullied and bully-victims have the worst long-term
outcomes. Bullies do not experience these adverse outcomes but do tend to
show lower empathy and higher rates of manipulation as adults.

Bullying is highly prevalent, affecting 15 to 20 percent of the popula-

tion, and affects all social strata. In the United Kingdom, the majority of
children who have not attended school for a whole year have not done so
because of bullying. Bullying’s impacts extend beyond the individual and
his or her long-term outcomes, but also has an impact on society through
workplace productivity. Policies that address bullying, Wolke asserted, will
have a universal impact.
Discussion
In response to questions regarding mental illness risk factors for youth
violence, Pardini noted that the main driving predictors are conduct dis-
orders and oppositional defiant disorder; others, such as depression and
anxiety, do not have a strong relationship. Additionally, when he and his
colleagues analyzed other potential factors, such as trauma and physical
abuse and neglect at home, they were also not as significant in predicting
future violent behavior.
A related topic raised in discussion between panelists and the audience
was the role of the family in bullying. In response to one such question,
Wolke noted that over time, children spend more time with their peers than
their family members, emphasizing the importance of peer acceptance. He
went on to explain that while violence by parents is detrimental to a child’s
well-being, most violence experienced is by peers and siblings. However,
violence among siblings is rarely considered abuse or bullying. But Wolke
noted that sibling violence has adverse effects, particularly in regard to
bullying—those who are victimized in their own home by a sibling are 4 to
12 times more likely to be a victim at school, as well. And those who bully
their siblings are three times more likely to bully others.
Participants at the workshop also further explored challenges raised by
screening, including the important distinction between a diagnosis and a
positive screen, the latter of which has been shown to decrease productivity.
Additionally, screening in schools raises issues around data protection. The
combination of a false-positive screen and potential privacy concerns has
profound negative implications for individuals.
Finally, in a discussion around criminalization of sibling abuse, bully-
ing, and other violent youth behavior, panelists and several audience par-
ticipants raised skepticism around the effectiveness of criminalizing people.
While some bullying and family violence would under other circumstances
be considered crimes, families and schools are often reluctant to report
such incidents. In addition, several participants noted that rehabilitation
and treatment have a greater positive impact than criminalization in both
other-directed and self-directed violence.

REFERENCES
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M. Schuster. 2014. Peer victimization in fifth grade and health in tenth grade. Pediatrics
133(3):440–447.
Coid, J., S. Ullrich, and C. Kallis. 2013. Predicting future violence among individuals with
psychopathy. British Journal of Psychiatry 203(5):387–388.
Copeland, W. E., S. Wolke, and A. Angold. 2013. Adult psychiatric and suicide outcomes
of bullying and being bullied by peers in childhood adolescence. JAMA Psychiatry
70(4):419–426.
Copeland, W. E., D. Wolke, S. T. Lereya, L. Shanahan, C. Worthman, and E. J. Costello.
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adulthood. Proceedings of the National Academy of Sciences of the United States of
America 111(21):7570–7575.
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dict violence and antisocial behavior in 73 samples involving 24,827 people: Systematic
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Means and Modifiers
D
espite advances in the science of violence prevention, several gaps
and challenges remain. The impact of violence is mediated through
several means, such as firearms and pesticides, and modifiers, such
as alcohol. Specifically, the lethality of firearms and commonly used pesti-
cides result in higher fatalities, while alcohol reduces inhibitions that might
otherwise be a barrier to violence. Speakers presented on how these means
and modifiers affect violence and violence prevention, and how reducing
access to these means can reduce violence.
RESTRICTING THE MEANS OF VIOLENCE

Speakers discussed issues around the access to lethal means of violence
and successful methods to reduce such access, particularly among those
with mental illness. Speakers also noted, however, that such violence tends
to be self-directed rather than other-directed. As noted by other speakers
in the workshop, people with mental illness are not at higher risk of inter-
personal violence compared with the general population, but their risk of
self-directed violence is much higher. Thus, speakers discussed how restrict-
ing access to lethal means could be a method of reducing the incidence of
suicide and self-directed harm.
35

Firearms Means Restriction and Mental Health1

Daniel Webster considered the research on firearms prohibitions
on people with mental illness. A study conducted by Jeff Swanson in
Connecticut analyzed data from public mental health and criminal justice
agencies, providing a sample of 23,000 individuals with severe mental illness
(Swanson et al., 2013). Criteria for severe mental illness included diagnosis
and hospitalization for schizophrenia, bipolar disorder, and major depres-
sive disorder. The study focused on two general cohorts: one had at least
one of four p otential mental illness disqualifications for firearms possession,
the other had no disqualifications. Of the overall sample, only 5 percent
were disqualified because of severe mental illness. In 2007, the state began
recording these disqualifications. The study compared the rates of violence
in both groups before and after the onset of reporting. Swanson and his
colleagues found an odds ratio of 0.69; essentially, there was a 31 percent
reduction in risk for arrest of violent crime because of the reporting, while
those who were not affected by reporting had no change in offending
(Swanson et al., 2013). Webster pointed out that while crime in this study
involved more than just gun-related incidents, it still showed a significant
impact on gun-related crime. Other studies looking at interpersonal violence
and other mental health issues, including substance abuse, also show that
mental-illness-related prohibitions reduce violence in those two groups. In
particular, one study looked at perpetrators of intimate partner violence and
found reductions in homicide associated with firearm restrictions for those
with restraining orders (Vigdor and Mercy, 2006).
However, most of the risk related to mental health and violence is
around self-harm and access to lethal means. Webster noted that there is a
common perception that someone with intent of suicide will find a way
to do so regardless of available methods. In contrast, several historical
examples of restriction of lethal means and subsequent reduction of sui-
cide. For example, the removal of coal ovens in British homes reduced
suicides by one-third, and raising the barrier on the Duke Ellington Bridge
in W
ashington, DC, reduced suicides by one-half. The success of a suicide
attempt is also related to the lethality of the method. Despite the high avail-
ability of means such as rope, knives, and poison, these make up a lower
percentage of the case fatality rate compared with firearms.
Bringing these two factors together suggests that suicide risk associated
with access to lethal means is higher. In a national study, Doug Weibe found
that, controlling for other factors, risk is elevated threefold when there is a
gun in the home (Wiebe, 2003), a finding shown in other research as well.
1 This section summarizes information presented by Daniel Webster, Johns Hopkins
Bloomberg School of Public Health.

MEANS AND MODIFIERS 37
Other studies, both cross-sectional and longitudinal, that look at the popu-
lation level have found a positive association with prevalence of firearms
ownership and risk of suicide, with higher risks at younger ages2 (Miller
et al., 2007; Stevens et al., 2006). On a similar note, an analysis of gun
ownership rates in the 1990s and youth suicide rates showed that suicides
decreased dramatically as household gun rates dropped.
Regarding restricting firearms access to youth, the laws that require
owners to lock guns away reduced suicide risk among 14- to 17-year-olds
by 8 percent overall. Additional laws related to restricting firearms did not
have an effect, though, nor did they have an effect on older youth aged 22
to 24 years3 (Webster et al., 2004). Other studies support these findings,
showing protective effects for older individuals with the Brady Handgun
Violence Prevention Act and some state laws that require permits for pur-
chasing (Andrés and Hempstead, 2011).
Means Restriction and Suicide4

Suicide accounts for 60 percent of all violent deaths in men, and 75 per-
cent in women, globally. In high-income countries, more than 80 percent of
violent deaths are suicide. In sub-Saharan Africa and Latin America, suicide
accounts for a lower proportion of violent deaths, but in Asia and Eastern
Europe, suicide accounts for more than half of violent deaths. Of all sui-
cides globally, 84 percent occur in low- and middle-income countries. China
and India account for 56 percent of all male suicides and 61 percent of all
female suicides. However, most of the research and intervention models on
suicide prevention come from high-income countries.
In both China and India, 50 percent of suicides are due to poison, usu-
ally pesticides or rodent poisons, both of which are lethal. In a study that
looked at suicides globally, researchers found that one-third used poison,
usually found in the home (Gunnell et al., 2007). Phillips described a few
characteristics of pesticide poisoning and suicide in China:
• Relative to other methods, it is lethal—6 percent of those who end

up in the emergency department die, versus 1 percent of those who
use other methods.
• 43 percent of those who use pesticides thought about the attempt
for less than 5 minutes, compared with 16 percent of those who
2 Difference in suicide rates for 1 percentage point higher in household firearm ownership
in state, 2000–2002 (Miller et al., 2007; Stevens et al., 2006).

3 Estimates for youth-focused firearm laws on suicide rates among ages 14 to 17 years
(Webster et al., 2004).

4 This section summarizes information presented by Michael Phillips, Shanghai Jiao Tong
University School of Medicine.

used other methods of suicide; this is partly because of the ready

availability of such pesticides.
• Those who use pesticides tend to have low intent to die, which
contradicts the popular opinion that those who are more intent on
dying use more lethal methods.
• Only 33 percent of those who ingest a pesticide had a diagnosis of
mental illness at the time, compared with 54 percent of those who
use other methods.
Michael Phillips emphasized that last point by addressing “common knowl-

edge” in the West that suicide is an outcome of mental illness. From their
research, Phillips and his colleagues observed that more than 60 percent
of those who attempt suicide do not in fact have mental illness, and using
psychological autopsy, they found that 30 percent of those who died of
suicide did not have a mental illness.
Regions in China where pesticides are stored in homes have higher
rates of suicide than regions where pesticides are less likely to be stored at
home. At the same time, as China’s population has increasingly urbanized,
with fewer people working in agriculture, access to pesticides has dropped,
and suicides have reduced. Phillips remarked that there are 100,000 fewer
suicides in China per year than 20 years ago. He hypothesized that in low-
and middle-income countries with a large agricultural sector, patterns of
pesticide access and use might be a more useful approach to suicide reduc-
tion than prevalence and treatment rates of mental disorders. As such, he
proposed a set of strategies to address suicide by pesticide poisoning:
• Banning the most toxic compounds

• Decreasing access to pesticides in the home
• Community education about the lethality of these chemicals and
about appropriate storage
• Improved training and increased access to necessary drugs and
equipment for rural primary care health providers
While improving medical knowledge and treatment and raising com-

munity awareness are important, Phillips asserted that means restriction
should be the main focus of efforts to reduce suicide. The effectiveness of
means restriction, however, is dependent on how feasible the restriction is,
and what the proportion of deaths that particular method comprises. It
also depends on whether a substitution method is available. As an example,
Phillips described a study in Sri Lanka in which a more lethal chemical
was substituted for one that was banned; yet, when the importation of
highly toxic pesticides was completely banned, the suicide rate dropped

dramatically. He cautioned that a means-restriction approach should be

constantly monitored for these and other types of mediating factors.
Phillips also suggested additional large-scale interventions for restrict-
ing means:
• Promote secure storage in homes, fields, or a centralized commu-

nity location
• Establish a minimum pesticide list, so individuals may only own
certain pesticides
• Promote integrated pest management programs
• Apply a tax to pesticides that increases with pesticide lethality
• Limit usage of pesticides in each village or community to a small
number of licensed individuals who would apply pesticides for all
community members
• Train pesticide retailers to recognize potentially suicidal individuals
• Limit sale of pesticides to single-use amounts
Phillips closed with a description of a project he and his colleagues

implemented in Shaanxi province in China. The objective of the project was
to promote the installation of 10,000 lockboxes for the storage of pesti-
cides. An educational campaign was also rolled out and suicide rates before
and after the intervention were monitored and compared with other town-
ships without the intervention. The lockboxes had two keys, with the idea
that two people (usually husband and wife) were required to open the box.
Researchers followed the families over 3 years to assess compliance. They
found that there was limited uptake of the intervention—about 20 to
30 percent. People were using the box, but few were using the locks. When
the educational component stopped, use of the locks dropped: 88 percent
were using the box, but almost none of them were locking it after the 3-year
period. Ultimately, they did see a drop in suicide rates in the intervention
areas—about 23 percent—while the rates in the control sites increased by
2 percent. Phillips observed that 100 percent compliance is unreasonable
to expect, and means restriction needs to be part of a larger overall suicide
prevention strategy. Yet, he noted that in low- and middle-income countries,
focusing on individual-level mental health approaches might not be the best
use of resources.
Regulation and Means Restriction5

Mike Luo described issues raised by several news stories he wrote re-
garding gun violence and mental illness. In particular, in examining mass
5 This section summarizes information presented by Mike Luo, The New York Times.

violence events, such as one in which a disturbed young man opened fire on
a crowd, killing several people, he questioned what it meant for people with
mental illness to have access to firearms. He noted that the current federal
standard stipulates that one cannot purchase or possess firearms if one has
been involuntarily committed or adjudicated as “mentally defective.” The
vast majority of those with mental illness, even severe mental illness, will
never get to this point. Luo and his colleagues wanted to explore this area
further to learn the stories of people with diagnosed mental illness who
possessed firearms. However, he noted, there was a big privacy challenge in
this area, dealing with both mental health and gun ownership.
In most states, he observed, records of purchases of concealed handgun
permits are not publicly available. Because he was unable to obtain such
records via public inquiries, he instead inquired at police departments and
courts for records of people from whom firearms were confiscated for
mental health reasons. Such calls are not enough to disqualify someone
from possessing firearms but are usually grounds for temporary confiscation
because a person is a danger to himself or herself or to others. However,
the circumstances under which it is legal to confiscate a firearm are not
straightforward. Luo noted that while taking away a firearm on someone’s
person is usually allowable, the situation is less clear when the firearm is
in another location. Most police departments would require a warrant to
confiscate the weapon in these circumstances; for example, Connecticut and
Indiana passed laws giving police more leeway on this.
In the past year in Connecticut, there were 180 instances when police
removed firearms from people they deemed to pose a risk of imminent
danger, 40 percent of which involved serious mental illness. In 2012, Luo
and his colleagues found that in Marion County, Indiana, there were 30
instances of confiscation, with about 40 percent of those involving mental
illness. Most people were placed under observation, but not involuntarily
committed, and in most instances, the firearms were returned shortly.
Luo cited a few examples of these policies at work. In Indianapolis,
before the law giving police greater jurisdiction was passed, an individual
with a diagnosis of schizophrenia retook possession of his firearm and
was later involved in a police shooting. In Hillsborough County, Florida,
there was another instance in which a veteran with a history of treatment
for depression, anxiety, and paranoia made violence-related comments
to his psychiatrist and subsequently had his firearms confiscated. He was
involuntarily hospitalized but not committed, and a few months later had
his firearms returned. In a third situation in Colorado, an individual with
prior suicide attempts, who also had not been committed, had successfully
requested his firearms be returned.
In the context of these cases, Luo raised a series of questions about the
intersection of privacy, regulation, public health, science, and rights. Given

that involuntary commitment is a difficult process, where is the standard

set for disqualification of possession of firearms? Should there be a protocol
for restoring rights, and what should it look like? What is the best way to
predict future violence by a person with mental illness and in possession
of a gun? Where is the line between Second Amendment rights and public
health and safety?
Discussion
In the subsequent discussion, workshop participants shared their per-
spectives on issues raised during the presentations, particularly around
predicting future violence and restricting lethal means. Webster noted
that, rather than focusing on diagnosis or involuntary commitment to dis
qualify an individual from owning a lethal weapon, the focus should be on
potential danger. For example, indicators of substance abuse, such as mul-
tiple violations for driving under the influence of alcohol (DUIs), magnify
risk associated with severe mental illness. Mark Rosenberg of The Task
Force for Global Health agreed, and he suggested that stress and distress
are triggers for suicide and could be assessed.
Phillips echoed comments made earlier, stating that predicting indi
vidual behavior is very difficult, and current instruments to do so are impre-
cise. Luo concurred, mentioning that most assessments of risk are conducted
by psychiatrists using unstructured criteria.
Eric Caine of the University of Rochester Medical Center considered
whether community-based approaches, in which all members of the com-
munity feel invested, might be a more effective means of reducing violence.
He spoke about a program in King County, Washington, in which a coali-
tion was built among public health officials, injury prevention stakeholders,
and firearms retailers. The program involves incentivizing firearms buyers
to purchase gun locks by offering discounts. It does not ask anyone to
serve as a gatekeeper, but instead builds a community of safety. Caine sug-
gested that such an approach might help bridge differences among different
stakeholders.
ALCOHOL, ALCOHOL USE DISORDERS, AND VIOLENCE

Alcohol’s impact on violence is observable but not fully understood.
Speakers discussed insights from experimental and observational studies
that explore the neurobiological and sociological pathways of alcohol-
mediated violence. They also discussed gaps in policies, both in the United
States and around the world, including those related to lack of funding and
political and social will.

Escalated Aggression in Rodent Models:

Novel Brain Mechanisms for Alcohol6
Evidence suggests that alcohol plays a significant role in violence, but
the relationship is complicated, Klaus Miczek explained. For example, two-
thirds of all violence involves alcohol: 86 percent of homicides, 60 percent
of sexual offenses, 75 percent of spousal abuse, and 30 percent of assault
offenders report using alcohol.
In the 1980s, a watershed discovery illuminated the mechanism by
which alcohol affects the brain, which caused a shift toward focusing
on specific proteins, such as glutamate, GABA, and serotonin. He noted
that alcohol has a biphasic dose-effect: at low and acute doses it has
pro-aggressive effects, and at high doses it is anti-aggressive. Alcohol
withdrawal also causes aggression; the greater the exposure to alcohol,
the more intense the withdrawal and the more intense the aggressive epi-
sodes. However, the impact of alcohol on individuals is highly variable. In
a certain subset of individuals, alcohol causes a large change in aggressive
behavior. Miczek asked, “Who are these individuals, how can they be
identified, and can they be corrected?”
In mouse studies, researchers have observed that some mice display
large increases in aggressive behavior, as well as a change in the pattern
of that behavior. In an animal that consumes water, the typical pattern for
biting is in the rump. For those who ingest alcohol, the shift in target is
dramatic: not only are they biting more frequently, but the bites themselves
cause greater injury.
Miczek expounded further on the mechanisms by which these behavior
shifts occur:
• Dopamine. Aggression produces dangers, but it also produces satis-

faction and pleasure associated with rewards. In animal studies, it is
possible to measure neurochemical events before, during, and after
an aggressive act, as well as during recovery. In anticipation of an
aggressive episode, dopamine rises in the nucleus accumbens while
serotonin drops in the cortex. Researchers provoke an aggressive
episode at a specific time of day for 10 days, and then do nothing on
the 11th day. What they observe is the same neurochemical change
in the rodent’s brain on the last day, despite the event not occurring.
In effect, the rodent has been conditioned.
• Hypothalamus stimulation. Researchers discovered a locus of
aggression in the hypothalamus by injecting a virus carrying a
light-sensitive protein into the brain and then stimulating the
6 This section summarizes information presented by Klaus Miczek, Tufts University.

protein. Afterward, the rodents can be triggered, by flashing a

light, to attack both animate and inanimate objects. Miczek sug-
gested that these findings could be explored further in the alcohol
animal research.
• Serotonin. Numerous studies over the years have focused on sero-
tonin and its effects on aggression and violence. Findings have been
inconsistent because serotonin is a complex molecule. Serotonin
neurons in the brainstem project to other parts of the brain in a
segregated manner, so they can be individually turned off by insert-
ing toxins in specific places. Additionally, only serotonin neurons
that originate in subregions that also express dopamine receptions
are important in aggressive behavior, indicating the system consists
of parallel processes. Focusing on the relevant serotonin process
has implications for research on the impact of alcohol.
• GABA. The GABA (γ-aminobutyric acid) receptor is the target of
action for alcohol. Alcohol acts as a positive allosteric modulator
to facilitate the action of GABA, an inhibitory neurotransmitter.
Because of the biphasic effect of alcohol (i.e., pro-aggressive at low
doses, sedative at high doses), it was originally thought that differ-
ent mechanisms were involved. In the 1990s, researchers discov-
ered that different genes encode subunits of the GABAA receptor,
with the α-2 subunits related to pro-aggressive effects.
• Glutamate. The N-methyl-D-aspartate (NMDA) receptor is one
of several glutamate receptors in the brain. It has a number of
subunits, which can be targeted to alter psychotic episodes. In par-
ticular, the use of a specific Alzheimer drug, memantine, enhances
aggression in individuals who do not show heightened aggression,
but produces no effect on those who do. Glutamate and GABA
act as a go-and-stop mechanism for serotonin, including serotonin
subsystems responsible for heightened aggression.
• Neuroendocrine factors. There is some promising evidence that
corticotropin-releasing factor receptor 1 (CRF1) has a calming ef-
fect on mice with heightened aggression, possibly by mediating an
aggression-related serotonin pathway.
Miczek closed by emphasizing the important role that the mouse model
played in teasing apart the various pathways in the brain that result in
aggressive behavior, particularly in relation to alcohol consumption, in a
manner not possible in human research.

Alcohol Use and Intimate Partner Violence7

Kenneth Leonard remarked that the association between alcohol use
and interpersonal violence has been observed in several cultures and contexts
around the world, regardless of strictness of alcohol norms, level of violence,
or other cultural overlays. This relationship has also been seen in multiple
samples, including a nationally representative sample and criminal and
clinical populations. It is an association of moderate strength and observed
longitudinally, even when other factors related to aggression and conflict
within relationships are controlled (Leonard and Senchak, 1996).
While there are effects of chronic use of alcohol, much of the aggression-
related effects stem from the acute use of alcohol. Leonard noted that this can
be studied in two ways: event-based research and experimental studies (largely
in college students administered alcohol). Event-based research would include
the examination of an event of partner violence, and a comparable event,
such as a severe argument that did not result in violence. In a study Leonard
conducted with his colleagues, couples were queried on alcohol consumption
during conflicts involving verbal aggression, moderate physical aggression,
and severe aggression. The husband’s drinking was strongly associated with
severe violence, while the wife’s drinking was less clear (Leonard and Quigley,
1999). In another study, men and women d escribed conflict episodes that did
or did not involve violence in the months before alcohol abuse treatment. In
the events that had physical conflict or violence, the husband’s use of alcohol
was higher (Murphy et al., 2005).
In experimental studies of alcohol and aggression, the aggression that is
provoked is usually mild and not necessarily similar to violence seen in the
community. Many of them include competitions that involve the “reward”
of inflicting mild harm (e.g., a mild shock) on their opponent. Alcohol
consumption tends to result in a more intense shock, an effect that is dose-
dependent, while the placebo (i.e., no alcohol) has no effect (Bushman,
1997; Ito et al., 1996).
Other types of experimental studies look at alcohol use and aggres-
sive verbal behavior. In the context of intimate partner violence, Leonard
remarked, this makes sense as violence often emerges out of an ongoing
verbal conflict. In one study, couples were invited to discuss a previously
agreed upon topic of conflict, to establish a baseline. They were then sepa-
rated for a period of time, and the husband was given alcohol. When they
returned to discuss another conflict, the interaction was marked by very
high levels of negativity on the part of both the husband and the wife, an
effect not seen when a placebo was administered (Leonard and Roberts,
7 This section summarizes information presented by Kenneth Leonard, Research Institute
on Addictions.

1998). In a similar study, researchers also found that the association be-
tween alcohol and negativity was highest among those who also showed
antisocial tendencies (Jacob et al., 2001).
Leonard proposed a cognitive disruption model to explain alcohol’s
impact on aggression. Intoxication leads to some level of cognitive impair-
ment, to which people adapt by focusing on salient cues and missing subtle
context. This theory suggests that alcohol should exacerbate overt emo-
tions in certain settings—that is, a setting that evokes aggression would be
heightened with alcohol, whereas a situation that evokes sadness would
have low risk of aggression. Alcohol exacerbates a person’s reaction to
the most dominant cues and hides those that are peripheral and could be
inhibiting (Parrott and Giancola, 2004). To the extent that mental illness
is associated with negative affect and impaired self-control, Leonard pos-
tulated, alcohol might interact with psychopathology to create a high risk
of violence. He showed one study that suggested a synergistic effect for
substance use disorders and mental illness (Van Dorn et al., 2012).
Finally, successful treatment of alcohol use disorders results in a reduc-
tion of aggression. If sobriety levels are maintained, then both verbal and
physical violence is reduced. If there is relapse, then the rate of violence
increases again.
Evidence-Based Policies to Reduce Alcohol-Related Violence8

Alcohol creates a wide range of negative consequences that have impli-
cations in the public health policy realm. Toben Nelson observed that while
several behaviors are risky, not all of them are public health issues because
they do not result in population-level harm. Alcohol consumption, on the
other hand, is a common social activity that is associated with several risks
to the public as a whole. The risks associated with alcohol consumption
increase as exposure increases. However, consumption of alcohol lies on a
curve, with a larger number of the population at the lower consumption
end, and a smaller number at the higher end. Thus, even though high con-
sumption carries a greater risk to individuals, lower levels of consumption,
which occur at greater frequency, pose a greater risk to the population as a
whole. As epidemiologist Geoffrey Rose noted, “a large number of people
exposed to a small risk may generate many more cases than a small number
exposed to a high risk.” The vast majority of health harms in a community
arises from a moderate or lower level of risk.
This yields two approaches to harm reduction, Nelson noted: the high-
risk approach that provides individual-level treatment, and a population-level
8 This section summarizes information presented by Toben Nelson, University of Minnesota
School of Public Health.

approach that aims to change behavior and the conditions that shape that
behavior. Often, these two approaches are seen as oppositional, when they
should be complementary. Nelson spoke of a theory developed by Alex
Wagenaar and Cheryl Perry that looked at the relationship of high-risk in-
dividuals embedded within a community. While much research has focused
on drinking and alcohol-related problems or individual risk factors that
increase drinking behavior, Wagenaar and Perry considered that, within
the community, there is a wide range of availability of alcohol. Problems
of alcohol at the individual level are a function of the economic, legal, or
physical availability of alcohol in those communities. This availability, in
turn, is shaped by policies and norms around how alcohol is provided or
restricted. Nelson and his colleagues examined the efficacy of some of these
policies around the United States and created a list of the top 10:
1. Alcohol excise taxes (state)

2. State alcohol control systems (monopoly)
3. Bans on alcohol sales
4. Outlet density restrictions
5. Wholesale price restrictions
6. Retail price restrictions
7. Alcohol beverage control agencies that are present, functional, and
adequately staffed
8. Dram shop liability laws
9. Hours of sale restrictions
10. Restrictions on alcohol consumption in public places and events
Regarding taxes, Nelson noted the evidence that price strategies are
inversely related to violence: the higher the price of alcohol, the lower the
rates of alcohol-related violence (Wagenaar et al., 2010). On alcohol retail
density, studies show more violence and violent crime where there is greater
density, and time-series data show increases in violence when alcohol out-
lets privatize and proliferate. Despite evidence for these types of programs
being effective in reducing harm related to alcohol consumption, there has
not been increased uptake of them, Nelson noted. Instead, policies judged
to be less effective are on the rise in the United States.
Alcohol Policy: Challenges and Successes in Latin America9

In terms of the global burden of disease, alcohol has higher impacts in
countries in Latin America than in the United States or Europe. In Brazil, an
9 This section summarizes information presented by Ronaldo Laranjeira, Universidade Fed-
eral de São Paulo and National Institute on Alcohol and Drug Policy, Brazil.

unregulated alcohol market and close ties between the alcohol industry and
politicians are challenges for the alcohol control policy landscape. There
is little awareness among policymakers and little community involvement
in alcohol policy, and there are few good examples of successful alcohol
policies and programs within Brazil.
Ronaldo Laranjeira further described the unregulated market in Brazil:
There is no licensing requirement to sell alcohol, resulting in nearly 1 alco-
hol outlet per 200 people. In addition, an estimated 30 percent of drivers
on weekends are intoxicated, and there is little restriction on adolescent
purchase of alcohol. The price of alcohol is inexpensive as well. Laranjeira
noted that one can of beer costs 30 cents (by comparison, a liter of orange
juice costs $3.50). Alcohol is also marketed heavily in Brazil. Laranjeira
stated that normally, sale of alcohol in sports stadiums is forbidden by law.
However, for the World Cup in 2014, lobbying from both the International
Federation of Associated Football (FIFA) and the alcohol industry suc-
ceeded in changing that law.
Despite these and other challenges, Laranjeira shared an example of a
successful program in the city of Diadema, in São Paolo state. Diadema has
around 350,000 inhabitants, most of whom are low to middle class. In the
1990s, there was a high rate of homicides—102 per 100,000 people—with
50 percent occurring between 9 p.m. and 6 a.m. There was also a high rate
of violence against women during that time, as well as a high incidence
of gang activity and car crashes. In 2002, a municipal law was passed
prohibiting the sale of alcohol between 11 p.m. and 6 a.m. The law was
enforced, with local police verifying compliance every night. The first viola-
tion resulted in a warning, the second in a fine, and the third in a fine and
the working permit license suspended. Despite the previously mentioned
lack of licensing, enforcement on this law was active, and there was high
approval among the community.
Ten years of homicide data were examined, from 1995 to 2005, includ-
ing homicide data both before and after the law was enacted. The results
showed that 528 lives were saved, with a 46 percent reduction in homicides.
Additional years of data have reinforced this reduction in violence, with a
homicide rate of less than 20 per 100,000 people in the past few years and a
decrease in violence against women, as well (Duailibi et al., 2007). Laranjeira
closed by noting that one important factor in the success of this program was
the continued enforcement; success of program replications in other cities has
decreased because of a failure to sustain the nightly police checks.
Discussion
In the ensuing discussion, speakers and workshop participants fur-
ther explored some of the main themes raised, notably the importance

of enforcement in setting policy and the role of the unregulated alcohol

markets and the alcohol industry. Participants also discussed additional
policy approaches, such as those that restrict alcohol use and firearms
possession, and interventions that merge population-based and individual-
focused perspectives.
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Prevention, Intervention, and Treatment
S
everal systems, particularly mental health services and the justice
system, play crucial roles in addressing mental illness and violence.
If not established as supportive structures, they can cause harm and
trauma and possibly increase the risk of violence. Speakers explored how
these systems can protect and heal, by building positive environments and
providing treatment and redress.
MENTAL HEALTH SERVICES AND VIOLENCE

Speakers discussed ways in which the provision of mental health services
can both prevent and reduce violence. Access to care means appropriate
treatment for people with mental illness, particularly for those who might
seem disruptive to society and whose actions could result in the involve-
ment of the justice system. Furthermore, early and universal m ental health
services, including those in schools, have implications for reduced v iolence
prevalence across society by addressing risk factors directly. S peakers also
discussed the role of policy and programs in expanding services and increas-
ing access in the United States and Latin America.
Mental Health and Access to Services1

Stigma around mental health is often exacerbated by a perception of a
higher risk of violence among those with mental illness. Colleen Barry cited
1 This section summarizes information presented by Colleen Barry, Johns Hopkins
Bloomberg School of Public Health.
51

a study that found 46 percent of those surveyed believe that people with
serious mental illness are much more dangerous than those without; 29 per-
cent were willing to work closely with someone with a mental illness, and
33 percent were willing to have a neighbor with a mental illness. These per-
ceptions are also affected by whether the respondents had experience, either
directly or through a family member or close friend, with mental illness.
This context, Barry argued, is important for considering the connection
between public attitudes and broader support for mental health services.
Many people experience mental illness, and seeking care is common;
one in five seeks care yearly, and one in three over the lifetime. Broadly
speaking, she asserted, treatment history or diagnosis is not a specific or
useful predictor of violence. Most people with mental illness do not com-
mit acts of violence, and most violent acts are not committed by people
with a diagnosis of mental disorder. Less than 2 percent of the population
meets the diagnostic criteria for severe and persistent mental illness, and it
is a subgroup of those—adults with conduct disorders in childhood—that
has the strongest association with violence. But even among that sub-
group, the majority is not violent but instead is more likely to be victims
of violence.
Given this background, Barry asked, can access to services impact
violence? She described two types of services most often discussed: broad
institutionalized care and universal screening. On the first, she observed
that there is no clear association between institutionalized care and patterns
of violence among people with severe and persistent mental illness. Addi
tionally, there are several civil rights challenges with institutionalization
and its history of practice. On universal screening, she pointed out there is
both low specificity for screening instruments and a lack of capacity in the
system for the additional individuals who might be identified in screening.
She concluded that broad approaches are not likely to be effective in reduc-
ing violence related to severe mental health disorders.
There is a role, she noted, for targeted interventions that improve access
and treatment for adolescents with conduct disorders, particularly interven-
tions that address co-occurring mental health and substance use disorders
or that are oriented toward suicide prevention. Yet, many of them have not
been well implemented. She emphasized, however, that there are reasons
beyond violence to improve behavioral health systems in the United States,
such as dealing with undertreatment and inappropriate treatment, quality
of care, and even measuring and tracking quality. This has implications for
payment and insurance, particularly in the context of performance-based
metrics. In contrast to the overall health care system, Medicaid plays a
much larger role in covering the costs of care and treatment, while private
insurance is limited. Even within insurance schemes, historically, mental
health services have been underprovisioned and underfunded. However,

PREVENTION, INTERVENTION, AND TREATMENT 53
people with severe mental illnesses are uninsured at a much higher rate than
people with no mental diagnosis.
The Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act, enacted in 2008, was intended to equalize coverage
for mental health and substance use services, as comparable to other health
services within an insurance program, including not only coinsurance, but
deductibles and copayments, as well. It also required that insurance pro-
gram designs, including elements such as prior authorization and provider
networks, had to be equal. Its impact is significant, especially in providing
out-of-pocket financial protection.
The Patient Protection and Affordable Care Act of 2010, designed
to expand access to and affordability of all health care services, has also
resulted in increased coverage of mental health services. Barry explained
that this increase is due to an expansion of public programs, reform and
redesign of insurance markets, and delivery system and payment reform.
While the state health insurance exchanges account for some of the expan-
sion, the bulk of it is a result of Medicaid expansion, particularly the new
Medicaid Health Home option, which allows for different types of services
that have not been traditionally financed but are important for coordinat-
ing care.
The new health care provisions also have implications for criminal jus-
tice. People in prisons have the option to enroll in or maintain M edicaid,
which provides continuity of coverage. For those on antipsychotics, for
example, this means continued medication access and could result in low-
ered recidivism. Barry closed with a reflection about stigma and mental
health, citing a recent study of her own in which, when presented with
information about the recovery and treatment of people with mental illness,
survey respondents responded more favorably when asked if they would
be willing to work closely with or live next to a person with mental illness.
Such v ignettes, she observed, could dramatically alter public perception on
mental illness and improve mental health services and access.
Role of School Mental Health in

Mental Health Promotion and Violence Prevention2
School mental health was defined by Sharon Stephan as a partnership
between schools and community health and behavioral health organiza-
tions, guided by youth and families. While it includes students in special
education, its scope is all students and a full array of services from uni-
versal prevention to tertiary care. Of the roughly 96,000 public schools in
the United States, approximately 40 percent of them indicated that mental
2 This section summarizes information presented by Sharon Stephan, University of Maryland.

health services were provided by a combination of school employees and

community employees. An additional 32 percent indicated services were
only provided by school staff, and another 28 percent by outside partners.
The community partnership offers schools the ability to provide a
broad continuum of care beyond what school staff provides. Community
partners also reduce necessary and expensive services, such as emergency
room visits, by facilitating pathways, providing preventive care, and as-
sisting with transition from inpatient psychiatric care back to schools. It is
important to note, however, that community partners are building on the
school’s existing platform and supplanting staff.
Mental health service provision in schools is based on a few principles:
• Healthy students make better learners, and students who succeed

in school are more likely to be healthy.
• Adult mental health has its roots in childhood experiences and
mental health, and early treatment yields better prognosis in

adulthood.
• About one in five children will experience mild mental health im-
pairment, and one in 10 will experience severe impairment. Many
of them do not receive the care they need outside of school (McKay
et al., 2005), so schools serve as a de facto mental health system
for children.
• Addressing mental health in school versus in the community means
less time lost from school or work for students and their parents,
respectively.
Stephan stated that promising evidence suggests that there are benefits
to in-school mental health services. Around social and emotional learning
and universal mental health promotion, there are improvements in student
social competency and behavioral and emotional functioning. Additionally,
improvements are seen in academic indicators, such as grades, test scores,
attendance, and teacher retention. There is also evidence of cost savings to
schools and communities.
In looking at violence, Stephan remarked that youth are exposed to
violence in a variety of settings, including school and home, and more
than 60 percent of them report lifetime exposure to traumatic events
(McLaughlin et al., 2013). One in five youth report being physically as-
saulted by peers; a similar proportion report emotional violence by peers,
as well. The school is a common setting for physical intimidation, assault,
and emotional violence, with more than half of all incidents occurring in
school (Turner et al., 2011). During the 2009 school year, 1 in 10 schools
reported a serious violent incident that required the presence of criminal
law enforcement (Robers et al., 2012). Moreover, 16 percent of students

report carrying a firearm to school, and 6 percent of students report missing

school because of safety concerns (CDC, 2008). This violence has reper-
cussions for educational attainment. For example, in a study in Baltimore,
Maryland, increasing violence was associated with reduced reading achieve-
ment in elementary school students, while increasing perception of safety
was associated with higher achievement (Milam et al., 2010).
A public health approach to violence prevention in schools would
have multiple intervention points, including the student, the classroom,
the school, and the community. In addition, evidence-based health inter-
ventions focus more broadly on safety, rather than on just security, as the
research suggests that measures such as security cameras and guards are
not effective. The interventions with evidence of success include environ
mental design, teaching students to be peer mediators, and multifamily
group intervention.
Stephan presented further information on one particular intervention,
Positive Behavioral Intervention and Supports (PBIS), which is a schoolwide
framework targeting school climate. PBIS is currently in about 20,000
schools. Some evidence suggests that PBIS improves perception of safety
and reduces aggressive behavior. Elements of the intervention include adapt-
ing the environment through natural surveillance, access management (e.g.,
better signage), physical maintenance, visibility maximization, and order
maintenance.
Mental Health in Latin America and the Caribbean3

The Global Burden of Disease shows depression as the second largest
cause of disability globally. In Latin America and the Caribbean (LAC), 14
percent of disability-adjusted life years (DALYs) and 35 percent of years
lost to disability (YLDs) are related to mental health and neurological dis-
orders. Treatment gaps for mental disorders, such as anxiety, schizophrenia,
depression, and alcohol use disorder, in LAC are also higher than global
rates (Kohn et al., 2004).
Globally, there is also an insufficiency of mental health resources: the
world median percentage of the public health budget dedicated to mental
health is less than 3 percent. In LAC, the majority of countries allocate be-
tween 1 and 5 percent of the public budget to mental health, with a small
number of countries having no allocation whatsoever. Of the monies dedi-
cated to mental health, 88 percent goes to mental hospitals, which leaves
only 12 percent (of the less than 5 percent) for community-based services.
Dévora Kestel remarked that in LAC, there are on average 2 psychiatrists,
3 This section summarizes information presented by Dévora Kestel, Pan American Health
Organization.

4 psychologists, and 1 social worker per 100,000 people. Additionally, she

noted that the majority of these personnel work in psychiatric hospitals or
psychiatric units in hospitals; across LAC, less than 40 percent of them work
in ambulatory care. Nonpersonnel resources, in particular beds, are also
concentrated in the hospitals, with very little community housing. K estel also
commented on the variation and quality of mental health policy; most poli-
cies are outdated and would not meet internationally agreed upon standards.
The Pan American Health Organization’s work in the region is focused
on two aspects: leadership and governance, and mental health and social
care services. Greater investment in both aspects is needed, Kestel felt,
because the mental health burden in LAC cannot be addressed solely by
mental health professionals, but should be integrated with primary care
and community care. And importantly, without a more comprehensive and
better funded approach to mental health, there cannot be a system to ad-
dress violence and care for victims and perpetrators.
Discussion
Several themes raised by the speakers were further explored by audience
participants following the presentations. In the absence of a robust com-
munity mental health system, and with limited capacity of mental health
professionals, prisons in the United States have served the role of mental
health care providers—a situation that participants felt was not necessarily
one to emulate in other parts of the world. In particular, as children leave
school for various mental health or violence issues, many of them end up in
prison. Michael Phillips of the Shanghai Mental Health Center noted that
in China the transition of mental health care from involuntary commitment
to voluntary has resulted in more people with mental illness ending up in
prison. He commented that training community health w orkers in mental
health could be one way to address the personnel shortage, while others
noted that integrating mental health and general health could address issues
in both domains.
INTERFACE WITH THE JUSTICE COMMUNITY

AND OPPORTUNITIES FOR INTERVENTION
Gaps in community mental health care have resulted in an increased
role for the criminal justice system in addressing mental health needs. At
the same time, a disproportionate number of people with mental illness are
incarcerated, and the correctional system has an obligation to meet their
psychiatric needs. Speakers discussed the ways in which the justice system
can serve those needs, as well as how it can be a supportive environment
rather than a punitive one.

Encounters with the Justice Community and

Opportunities for Intervention4
Madelon Baranoski described early mental health linkages to the justice
system, noting that, historically, those who could not afford private care
often ended up in prisons. In a time when there were no effective treat-
ments for severe mental illness, reformers worked to move people to other
facilities where, though they were still isolated from the general public, they
would be treated more fairly. These facilities became modern-day asylums,
and care deteriorated. With the advent of treatment options for severe
mental illness, it was no longer considered humane to isolate people with-
out due process. The U.S. Supreme Court in 1966 declared that dangerous
ness was a prerequisite for involuntary commitment, and the process of
deinstitutionalization began.
However, with the transition of people with severe mental illness from
institutions to the community, there was no additional provision for care
or treatment. And while Baranoski cautioned that not everyone with a
mental illness is violent, a number of them end up in prison for what she
termed “nuisance crimes,” such as breach of peace. Baronski went on to
note that while the number of people with mental illness in prison is in-
creasing, the increase is not because of violence, but rather because life is
becoming more destabilized. Poverty, low education, limited housing and
resources, and discrimination contribute to the increased number of people
with mental illness in prison. In addition, the public misperception that
people with mental illness are more dangerous results in the justice system
taking control where it seems the mental health system has failed. Jails and
prisons, Baranoski asserted, should be the last step. The interface begins
with policing, moves to the courts, and if all else fails, ends up in prison.
Box 5-1 describes a few of the issues that arise in this process.
Public Safety and Mental Health5

Police play an important and complex role in community mental health
services, but, as Sheldon Greenberg noted, there are many areas in need
of improvement. Some areas are easier and simpler to address, such as
terminology. For example, the Association of Public-Safety Communica-
tions Officials International (APCO) uses the code “10-96,” which trans-
lates to “mental subject,” rather than “person with mental illness.” This
change, he asserted, is a simple one to make, but is still an important one.
4 Thissection summarizes information presented by Madelon Baranoski, Yale University.

5 This section summarizes information presented by Sheldon Greenberg, Johns Hopkins
University School of Education.

BOX 5-1
Issues Across the Criminal Justice System
Law Enforcement: Excessive force, involuntary treatment, symptom manage-

ment without arrest, interviewing, reliability of victims’ reports, protection of public,
risk of injury to police, civil rights, local customs, cost, and training.
The Courts: Civil rights, societal values, equal protection, competency to pro-
ceed, competency to be a witness, competency to accept a plea, appropriate
punishment, protection of public, risk of recidivism, capacity to serve probation,
access to alternatives, cost, and training.
Department of Correction: Constitutional right to treatment, constitutional right

to refuse treatment, forced medication, overcrowding, definition of mental illness,
lack of resources, safety, access to parole, community reintegration, cost, and
training.
He further observed that police officers think that their work is mis-
understood by researchers and other social service providers. For example,
about 70 percent of police work does not involve law enforcement, and
much of a police officer’s interaction with the public is not recorded. Many
police officers would like to do more to serve people with mental illness,
but barriers of time and resources stand in the way (Cooper et al., 2004).
The justice system in the United States is one of the most fragmented
professional systems in the country, Greenberg remarked. There are about
18,000 state and local law enforcement agencies in the United States; how-
ever, if a department has fewer than 10 officers, it is not required to report
within the federal system. Across the world, police agencies are sometimes
military or quasi-military operations or they fall under the purview of
a national police system. Similarly, the court system is fragmented, and
sound data do not exist on numbers because many courts are temporary.
Incarceration is not well integrated either: prisons, jails, and lockups are
distinct places and fall under different jurisdictions, police departments,
sheriff departments, departments of corrections, county jails, and state and
federal penitentiaries.
In addition to the fragmentation, Greenberg observed that the conversa-
tion around deinstitutionalization and community-based services occurred
before the majority of today’s police departments were in service, and
there is still miscommunication around mental health issues. Additionally,
policing is primarily a reactive profession—that is, police officers respond
to calls and attempt to resolve them on the spot. Greenberg stated that, on

average, an officer has approximately 2.5 seconds to react appropriately

when deciding if the situation calls for the use of lethal or nonlethal force.
However, police officers receive minimal training on mental health—only an
average of 2.5 hours, most of which is focused on process and not purpose
or ideology. This is within the context of 16 to 24 weeks of academy train-
ing, with an additional 8 to 12 weeks of field training. Between minimal
training and limited personnel, police face several challenges in providing
appropriate services to people with mental illness, several of which are
outlined in Box 5-2.
Greenberg raised several additional concerns at the intersection of
law enforcement and mental health. There are an estimated 1.2 million
people with mental illness currently incarcerated, but it is not clear how
many have already been sentenced and how many are in jail awaiting trial.
Many of these individuals face a significant amount of bias. Furthermore,
there is miscommunication and distrust between the police and the com-
munity, which could be improved with some bidirectional learning. He
gave the example of working with the National Association for the Deaf
to reduce killings of deaf people that occurred at traffic stops because of
BOX 5-2
What Police Patrol Officers Want
Mental Health Practitioners to Know
Sample of comments:
• I function alone.
• I am the only officer on duty this shift.
• My immediate focus is on safety. I need to know about the crisis at hand,
who is hurt or in danger, the environment, and access to weapons. Talk
about mental illness, what happened in the past, and everything else will
occur later.
• The closest hospital to my beat is 25 miles away.
• People with mental illness and their families don’t know what to expect
when I arrive.
• At 3:30 a.m. on a Sunday, I don’t have access to mental health workers or
county attorneys . . . if I get hold of them they don’t want to come out.
• The family calls and wants help . . . then when I explain what I can or have
to do, they turn on me. It’s tough. I understand. They want intervention
without consequence. They want help I’m not able to give.
• You need to know how we approach potentially life-threatening situations.
• We’re criticized for using force. We follow a use-of-force continuum. We
can’t take chances. It is better to be judged by 12 than carried by 6.

misunderstanding. Police were better trained, but it was not until there was
outreach in the deaf community that the shootings were reduced.
Greenberg closed by noting that rather than focusing on top-level goals,
such as policy, procedure, or funding, interventions primarily should focus
on point of entry. He noted two specific groups that could benefit from
interventions focused on the point of entry: emergency dispatchers, who
gather and disseminate information and thereby create the foundation for
potential encounters, and the police, who interact with the affected family
or the environment in a direct way. Better training and support for emer-
gency dispatchers and police is particularly crucial.
Education and Treatment as Alternatives for Incarceration6

Ray Kotwicki spoke about an intervention used successfully at Emory
University. It is a 4-year program for medical students to help people iden-
tify patients who have symptoms of mental illness, such as impulsivity and
para-suicidality, in primary care clinics and other places. The intervention
is designed to divert such people away from the penal justice system and
toward treatment. Kotwicki noted that once people agree to treatment,
there need to be good treatment options. Skyland Trail, his community
treatment facility in Atlanta, Georgia, is one such innovative center.
Health professionals tend to view the mental health field with negativ-
ity, argued Kotwicki, and medical students typically are not attracted to
psychiatry. This is partially because of misperceptions around mental illness
and treatment, as well as a lack of understanding of the biological basis of
mental illness. In addition, people who do psychiatry clerkships in facilities
where containment, not recovery, is the goal tend to have a less positive
experience in working with people with mental illness. Thus, part of the
work at Skyland Trail is also educational, to engage health professionals in
a more positive way when addressing mental health.
Skyland Trail also incorporates educational programs for law enforce-
ment. Kotwicki and his colleagues studied the impact of a 2-day training
for police officers involving mental health professionals, including doctors
and nurses. They saw a robust, statistically significant improvement in
attitudes and knowledge about how to manage situations involving people
with symptoms of mental illness. This finding tracks with other research, in
which exposure to an individual with mental illness is one of the best ways
to reduce personal stigma.
The same paradigm shift for engaging professionals also applies to
treatment for patients’ recovery. Periodic measurement of indicators associ-
ated with violence, such as psychosis and impulsivity, and indicators related
6 This section summarizes information presented by Ray Kotwicki, Skyland Trail.

to social relationships and immediate environment, can shed light on how

engagement of professionals can positively impact recovery. Using pre- and
post-test outcome assessments of these indicators, Skyland Trail has shown
statistically significant improvement in people who underwent the program,
not just in symptomology but in managing relationships and quality of life
to reduce violent behavior. Kotwicki concluded his presentation by empha-
sizing the importance of access: proper treatment can yield great benefits,
but only if people can be directed toward and reach such programs.
Therapeutic Jurisprudence7
Therapeutic jurisprudence is a healing approach to the law, with the
intention of “rehabilitation, compliance with the law, and helping victims
to cope with the impact of crime on their lives,” David Wexler stated. He
explained that therapeutic jurisprudence is best known in special problem-
solving or solution-focused courts, such as drug treatment court, mental
health court, and domestic violence court. The law has an effect on well-
being. This effect has been largely ignored in administration of the law, but
Wexler argued that it should be studied and factored into law reform. The
Hague Institute for Innovation of Law is exploring options to maintain
therapeutic jurisprudence, particularly in criminal law and juvenile justice.
It is an interdisciplinary approach that involves psychology, criminology,
and social work, as well as working with offenders and victims.
While it has mostly been used in specialized courts, the therapeutic
jurisprudence approach has broader implications for those who fail to meet
the qualifications of those special courts. Attempts to expand the special
courts often encounter budget obstacles, so a second option is to apply the
skills and insights elsewhere in the criminal justice system, in which people
with mental illness or drug or alcohol problems might find themselves.
Wexler suggested that there are several elements that could be incorpo-
rated with the wider system, such as early diversion, bail hearings, plea
negotiations, judicial settlement conferences, non-incarcerative sentences,
and conditional release. Wexler noted that his project also examines police
interrogation and newer, more humanistic methods of investigative inter-
viewing, even before a person’s entry into the court system. In this way, he
remarked, the project looks at both the law in action and the roles of legal
actors, including judges, lawyers, and therapists.
In exploring how such elements might be included in criminal justice,
Wexler noted that he and his colleagues examined which practices are in
place already, which are not, why they are not, and how they could be
7 This section summarizes information presented by David Wexler, International Network
of Therapeutic Jurisprudence.

maximized. They also examined what kind of training would be required

for legal actors to incorporate therapeutic jurisprudence insights. It is
also important, he explained, to note which existing structures allow for
adaptability to new processes, and which legal structures might need to be
reformed. He gave the example of probation, which is traditionally handed
down unilaterally by a judge. Instead, the literature indicates that soliciting
offender input, such as asking him or her to personally justify a probation-
ary sentence and conditions, enhances offender compliance and a sense of
fair treatment.
At its heart, Wexler remarked, therapeutic jurisprudence is multi
disciplinary and draws from insights of different realms. He concluded
by citing important research areas: relapse prevention planning, reasoning
and rehabilitation, desistance from crime, treatment adherence, behavioral
contracting, active listening, and restorative justice.
Behavioral Health Care in Correctional Facilities8

Patrick Fox described the shift of population, cost, and burden from
community-based and state-hospital-based mental health systems to the cor-
rectional system as trans-institutionalization. Since the mid-1970s, the
prison population has steadily increased. Currently, there are approximately
2.5 million individuals incarcerated, with another 4.2 million on parole or
probation—representing 2.9 percent of the population. The vast majority
of those entering the criminal justice system, particularly those with behav-
ioral health disorders, are not being arrested for violent crimes. Yet, among
people with behavioral health disorders, there is a 40 percent lifetime preva-
lence of incarceration. Additionally, there are huge racial disparities, with
African American and Hispanic individuals being grossly overrepresented.
Fox emphasized that these racial disparities pervade the entire criminal jus-
tice system, from death penalty cases to insanity pleas, and even probation
and parole decisions (though there is no correlation between the race of the
arresting officer and these disproportionate incarceration rates of people of
color). The increase in prison populations also trends with a commensurate
increase in substance use arrests.
People with behavioral health disorders are also overrepresented in the
criminal justice system, especially as mental institutions close. Currently,
about half of those within the correctional system experience some form of
mental illness. This is a problem because the focus of psychiatric hospitals
is on the restoration of health and treatment, whereas correctional facilities
are intended to contain and punish. Fox further discussed the differences
between mental health facilities and prisons:
8 This section summarizes information presented by Patrick Fox, University of Colorado.

• Treatment versus security. 90 percent of staff at a state psychiatric

hospital are mental health professionals or support staff, and secu
rity is an ancillary service. In a prison or jail, 90 percent of staff
are correctional officers, with security equipment, while therapy is
a secondary consideration.
• Crisis intervention. When there is a behavioral health emergency,
correctional officers are usually first responders in a correctional
facility. However, mental health staff who manage such events
in psychiatric hospitals have a greater understanding of trauma-
informed care and recovery.
• Standards. The Joint Commission and the Centers for M edicare &
Medicaid Services serve as crediting bodies for hospitals, whereas
the American Correctional Association and the National Commis-
sion on Correctional Health Care work on the correctional side.
• Discharge. Release from a mental health facility is based on recovery,
whereas release from prison is conditioned on resolving the criminal
offense.
Fox stated that within correctional facilities, prisoners have a right to

treatment, as mandated by several court rulings. Ruiz v. Estelle in 1980 laid
down six criteria for mental health services:
1. Systematic screening and evaluation

2. Treatment that is not just close observation or seclusion
3. Trained mental health professionals
4. Confidential and complete medical records (separate from the cus-
tody record)
5. Safeguards governing the use of psychotropic medications
6. A suicide prevention program
Additional laws, such as the Americans with Disabilities Act (ADA),

have also served to improve quality of care. Entities such as the National
Commission on Correctional Health Care and the much older American
Correctional Association provide standards for 90 percent of jails and
prisons in the United States. Because of these laws and standards, mental
health treatment has improved. A 2000 report indicated that 95 percent of
adult correctional facilities comply with screening requirements, but other
quality measures are lower (Beck and Maruschak, 2001).
Mental health treatment varies greatly between jails and prisons be-
cause of differences in funding and standards at the local, state, and federal
levels. How a community chooses to allocate funds (that could go toward
other systems) can constrain or expand treatment services. In particular,

because incarceration is still seen as a punishment, there is resistance to

funding and provision of mental health services in jails.
When treatment is available, Fox said, the goal is shifting from prevent-
ing poor outcomes to a more proactive approach of developing indepen-
dent living and social skills. Therapy is now focused on improving mood
and functioning, modifying behavior, and developing vocational skills for
future employment. Different treatment modalities exist, including group
therapy, though their implementation is not always of the highest standard.
Standards around the use of medication have also been altered: there is a
much narrower mandate for the use of medications, and in all cases except
emergencies, informed consent must be obtained. When consent cannot be
obtained, there must be a clear rationale for the use of medication, as well
as documentation of any side effects.
Another crucial mental health measure is suicide prevention. Thus,
current standards require screening and assessment for suicide risk in cor-
rectional facilities. Fox noted that suicide is the second leading cause of
death in jails and the third leading cause of death in prisons. Half of com-
pleted suicides occur within the first week of incarceration. Among the
interventions to reduce suicide are reducing means (e.g., no fixtures in cells,
cameras, and monitoring for substance withdrawal), reducing distress by
allowing contact with family members, and monitoring changes in mood
around any court dates.
Administrative segregation, or solitary confinement, is another issue
in correctional facilities. Fox referred to it as a dehumanizing environment
with pronounced psychological effects. Persons with mental illness are
overrepresented in administrative segregation, and there is evidence that it
exacerbates pre-existing mental conditions (Metzner, 2002). Fox suggested
that the externalizing behaviors of someone with mental illness could be
seen as disruptive behavior within a correctional facility and might result
in the use of administrative segregation. The increased decompensation
and limited access to mental health professionals could result in prolonged
confinement, as well.
Despite the challenges and limitations of addressing mental health
in the current incarceration system, there are shifts occurring. Fox shared
the restorative justice model, an approach that focuses on the needs of the
victim and the offender, the prevention of recidivism, and the duty of
the community to maintain peace and restore order. Restorative justice
programs help individuals take inventory and accountability of actions
and understand where the origins of their criminogenic behavior reside.
Correctional facilities with these programs would have special management
units and treatment facilities for those with mental illness. And perhaps
most important are offender re-entry programs, particularly programs that

include outreach by community mental health professionals, that prepare

individuals with mental illness to successfully reintegrate into communities.
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Assembling the Pieces and

Integrating Elements
T
hroughout the workshop, participants shared a myriad of experi-
ences, evidence, and practice in multiple domains related to mental
health and violence prevention. In the last panel of the workshop,
speakers and participants communicated knowledge and best practices on
inexpensive and more nimble program evaluation. They also discussed
final thoughts and raised additional questions on advancing the science
and practice.
EVALUATION OF PROGRAMS FOR VIOLENCE PREVENTION

AND MENTAL HEALTH PROMOTION1
A number of traditional and alternative evaluation designs can be used
to assess the efficacy of violence prevention programs, by addressing im-
portant questions such as could a program work under optimal conditions?
Does a program work under realistic conditions? And how does a program
work, and can it be improved? Hendricks Brown described a 2009 National
Research Council and Institute of Medicine report that laid out these three
stages of evaluation, starting with efficacy and effectiveness studies and
leading to implementation and dissemination studies (NRC and IOM,
2009). The former two address whether a program achieves the desired
outcomes, and the latter deal with adoption, sustainability, and scaling up,
and require different evaluation models.
1 This section summarizes information presented by Hendricks Brown, Northwestern
University.
67

Issues of evaluation are value-laden, he remarked, not just from a

scientific perspective, but also a community perspective. Of note, there is
a history of abuse in research, particularly in communities of color. There
are also issues of cost, some of which disproportionately burden non
governmental organizations that work with people of color. He further
explained that these issues need to be confronted upfront because they
are relevant to whether an evaluation can be carried out. He cautioned,
though, that if a program is to be considered evidence based or evidence
informed, it should have information to that end, at least under some set of
circumstances. At a minimum, certain indicators could be measured, such
as program fidelity and participation. Furthermore, Brown said the gold
standard for evaluation is the randomized controlled trial (RCT) because
it is designed to eliminate as many biases as possible. He noted that while
sound evaluation evidence can be obtained from an RCT, sometimes it is
unethical or impractical to conduct one.
Because violence is a relatively low-frequency event, large studies
are needed to observe the effect sizes that indicate program success. He
described the example of looking at completed suicide in youth. Because
the youth suicide rate is small, it is estimated that a study would require at
least 1 million person-years of risk, which would mean following 1 million
youth for 1 year or 100,000 youth for 10 years; it would require intense
labor input to follow up with so many individuals. Such large studies are
expensive. Thus, he considered other options to enrolling large numbers
of people in trials. The first is to look at an intermediary outcome; for
example, assessing suicide attempts versus completed suicide, because at-
tempts occur at a higher frequency than completed suicides. The second is
to combine data across trials and synthesize findings. A third approach is to
use a less expensive evaluation design, such as using administrative records
to screen and identify individuals over a long period of time. The Positive
Parenting Program, or Triple P, a family support program to prevent be-
havioral and emotional problems in children, used such an approach. In the
United States, the National Death Index and the National Violent Death
Reporting System are other sources of data.
Additionally, he described a method he called “roll-out design,” some-
times referred to as “dynamic wait list design” and “stepped wedge trial
design,” in which groups are randomized to treatment and control groups
as the program is rolled out. It has the added benefit of allowing an
examination of the implementation strategy. He gave an example of one
such program, which used a suicide gatekeeper program called Question,
Persuade, and Refer (QPR) in a school district. The program was rolled
out to randomly assigned schools, with new schools added each quarter.
The outcome, school referrals for suicide, was measured before and after
the schools were enrolled. By using a rolling method of enrollment, the

ASSEMBLING THE PIECES AND INTEGRATING ELEMENTS 69
first year and the first three quarters of the second year always maintained
a control group (i.e., un-enrolled) for comparison. One of the advantages
of this methodology is that, when the whole community has agreed to the
intervention, there is still a process for incorporating everyone. Because
all the schools received the intervention, there was no delay or associated
costs. At the same time, there was a benefit to the schools that received
the intervention first because often school districts are eager to imple-
ment a program sooner rather than later. However, those who receive the
intervention later have the advantage of more efficient implementation.
Finally, an important benefit of roll-out design is that evaluation is built
into implementation—meaning that cost issues around evaluation may be
averted and that accountability is naturally integrated with the process.
Once a program has been deemed effective, the final step in evalua-
tion is making a program work. Brown noted that there are two areas for
this step. On the research side, implementation science gathers generalized
knowledge of program design; while on the practice side, quality improve-
ment is an ongoing local evaluation. He shared the RE-AIM perspective for
ensuring program success:
• Reach: the percentage of the community that receives the program

• Effectiveness: does the program have benefit?
• Adoption: bring into host organizations and service-delivery
systems
• Implementation with fidelity
• Maintenance
Brown further noted that these measurable elements determine whether the
implementation will be successful.
In the discussion following the presentation, participants queried
Brown regarding issues of sustainability, such as funding evaluations and
ensuring continuity and consistency as personnel change at program sites.
Participants discussed requiring a measure of evaluation in grant proposals
and the importance of building partnerships with the entire community.
They also considered alternate methods of gathering data for evaluation,
such as practice-based evidence and ongoing data collection in mobile
health (mHealth) programs, that could integrate with traditional methods.
REFLECTIONS AND THE WAY FORWARD

The workshop closed by synthesizing the discussions over the 2 days,
with participants offering reactions and thoughts on the topics presented.
They spoke from multiple perspectives, reflecting the diversity of opinions
and practices present at the workshop.

Mental Health Services2

Colleen Barry recalled Thomas Insel’s remarks that untreated mental
illness and alcohol and substance use disorders are associated with violence,
and there is a role for mental health services and policies. She noted that
there is also a role for understanding evidence; from a program perspec-
tive, dissemination is a critical piece in seeing translation of evidence into
practice. Despite several rigorous studies demonstrating evidence of certain
practices, there has been very little uptake of these programs. She also said
that, in regard to evaluation, there is a role for examining unintended con-
sequences of policies.
One way to implement and disseminate services and policies would be
to create a financial incentive, such as an appropriately applied pay-for-
performance model. She gave the example of an accountable care organi-
zation in Massachusetts with 64 different performance measures. Because
only one measure was related to the population of individuals with mental
health and substance use disorders, there was little change in regard to
that system of care. She closed by noting that sustainability is critical, and
financing and insurance changes can be instrumental as well.
Mental Health and Justice3

Sheldon Greenberg reflected on the knowledge gap between the mental
health field and the justice system. He noted that while mental illness plays
a significant role in justice, it is not on the radar of the politically driven
system. Within all disciplines of the mental health field, the end goal is the
same: better quality of service and support for people with mental illness.
So what, he queried, is the formula for achieving this goal, and how can
practitioners, researchers, and advocates develop it? He envisioned this
formula to be cross-cutting, with different stakeholders having the ability
to refine it for their own practices.
He echoed Barry’s comments about disseminating research, also not-
ing that along the translation pathway, barriers exist that inhibit frontline
professionals from accessing research around what works. Other types of
research are of interest as well. When a patient first comes in contact with
the system, what happens to the information that is initially provided? How
does that impact interventions? Research on fear was also of interest to
Greenberg, particularly people’s fear of what will occur after the initial con-
tact that might inhibit them from being honest. Knowing more about this
2 This section summarizes information presented by Colleen Barry, Johns Hopkins B

loomberg
School of Public Health.
3 This section summarizes information presented Sheldon Greenberg, Johns Hopkins University
School of Education.

fear could assist in developing more trust with professionals and countering
misinformation in the media and the general public.
He closed by asserting that cross-disciplinary collaboration for policy,
coupled with mandates for providing better education and training in all
fields, could build an institutional culture of understanding across all dis-
ciplines. In parallel to this work in professional fields, people with mental
illness and their families, he argued, should be better equipped to engage
the system at any point of contact.
Culture and Construction of Mental Health4

Janis Jenkins reiterated her earlier comment that empirical research
demonstrates the central place of culture in nearly every aspect of mental
illness. Thus, the ecological model of risk and protective factors could be
enhanced by integrating culture across different domains, such as the indi-
vidual and his or her relationship to community and society. Understanding
the role of culture will require a deeper, broader understanding and could
include research, such as ethnography of people and their encounters with
violence as both victims and perpetrators. In particular, more information
is needed about adolescents and their view of the cultural legitimacy of
their frustration, anger, and violence, as well as ethnographic research on
the culture of law enforcement and cultural assumptions, toward the goal
of more reciprocal engagement.
For effective community intervention programs, Jenkins emphasized a
need to account for the cultural aspects of the relationship between mental
illness and violence, particularly in incorporating the perspective and ex-
pertise of people with mental illness, and to acknowledge the limitations of
psychopharmacology as treatment. She also considered the importance
of the school setting in teaching what constitutes a culture of violence.
Finally, she closed by challenging the culture of scarcity as an excuse for
failing to adequately support mental health programs.
Global Perspectives of Mental Health5

Dévora Kestel challenged the notion that further research on mental
illness is needed, stating that she wished it were possible to implement
even one-third of what is known. Instead, research on services that are
intervention- and action-oriented is more important for those who want
4 This section summarizes information presented by Janis Jenkins, University of California,
San Diego.
5 This section summarizes information presented by Dévora Kestel, Pan American Health
Organization.

to change current practice. She remarked that, on the implementation side,

she would like to see more linkage of evidence-based practices and practice-
based evidence, as well as increased dissemination of those practices that
have “worked enough.”
She questioned whether deinstitutionalization had worked, as the idea
of “putting people away” has not changed in the United States or else-
where. People with mental illness are not receiving the community-based
care they need, but instead still end up in institutions, whether psychiatric
hospitals or prisons or others. She argued that this is a priority policy direc-
tion that needs greater uptake in all mental health disciplines. A compre-
hensive network of community-based mental health services, she opined, is
the best way to prevent violence.
Influence of Violence on Mental Health6

James Mercy emphasized the importance of addressing the intersec-
tion of suicide and interpersonal violence, noting that one is not more
important than the other, because several factors related to each overlap.
He also pointed out that while suicide might result in greater mortality,
the morbidity related to interpersonal violence should not be overlooked.
Evidence is emerging that indicates the long-term effects of interpersonal
violence, including chronic disease. It also has a strong impact on mental
health: Exposure to violence in childhood is responsible for 30 percent of
adult psychopathology (Kessler et al., 2010). Thus, he noted, it is important
to look not only at the influence of mental health on violence but also at
the influence of violence on mental health.
Mercy remarked that there are effective treatments to mitigate the
effects of exposure to violence, but it is an area that needs more research
into implementation and dissemination, particularly for scaling up in low-
and middle-income countries. He also raised the question of whether these
treatments could be considered primary prevention, since they might in the
long run reduce interpersonal and self-directed violence.
Further research is needed, he concluded, in gathering better data link-
ing mental health and the means of perpetrating violence and in what works
in preventing violence related to mental illness, such as physician counseling
or background checks.
6 This section summarizes information presented by James Mercy, Centers for Disease
Control and Prevention.

Brain, Behavior, and Targeted Interventions7

James Blair remarked that while another speaker had mentioned that
population-based interventions achieve greater “bang for the buck,” he
believed there was an important role for individual-based interventions, as
well. He cited an example of a school-based anti-bullying program in the
United Kingdom that saw a reduction in rates of bullying, except in one
group. The individuals in this group, he noted, are better suited for specific
interventions to change underlying behavior; although screening tools are
imperfect, they are somewhat useful for identifying these individuals.
Importantly, do current interventions actually work for these indi
viduals? he queried. While some individuals do see a reduction in aggression
with certain interventions, such as cognitive behavioral therapy (CBT), the
neurobiological mechanisms are not clear. Blair commented that research to
illuminate this mechanism more clearly, coupled with the overt behavioral
change, would be important support in calling for additional resource allo
cation for these interventions. At the same time, there are individuals who
do not respond as well to these interventions, so developing new interven-
tions for them is an important priority.
Discussion
To close the workshop, participants shared their perspectives on the
discussions over the 2 days and presented their thoughts on research,
program implementation, and policy. Important questions were raised on:
• How to create constructive and ongoing collaboration, particularly

among those with opposing political aims, that works toward a
shared goal.
• How to mainstream some of the nontraditional approaches raised,
such as therapeutic jurisprudence.
• How to end programs that do not work, expand those that do, and
allocate resources for them.
• How to operationalize cross-cultural situational analysis, such as
the role of science in policy, attitudes of policymakers, and incen-
tivization of native providers, in developing countries.
• How to better adapt program evaluation designs that are truly fit
for the purpose.
• How to create public buy-in to invest in dissemination of successful
programs and program evaluation.
7 This section summarizes information presented by James Blair, National Institute of
Mental Health.

• How to harmonize data and data systems so that researchers who

work from different angles can be more aware of evidence-based
practices and instruments and access common data elements.
Participants shared additional lessons or approaches learned from their

own experiences:
• Individuals at the highest risk of violence are also at the highest

risk of re-offending. One participant remarked that the best inter
vention for this group might be to reach them at a young age; in
particular, addressing the earliest stages of behavior through a
better understanding of the precursors of both mental health and
violence.
• Similarly, another participant noted that trauma early in life leads
to sequela through the life span. Preventing that trauma could lead
to a different developmental arc for those individuals.
• At the same time, treatments for posttraumatic stress disorder
(PTSD) and other illnesses, such as attention deficit hyperactivity
disorder (ADHD), do have measurable effects in the brain, so even
those in the highest-risk groups for violence can be treated,
even later in life. In particular, if treatment prevents reoccurrence
of violence, it could be considered a form of prevention.
• A few participants discussed the potential for addressing the fear
response and reactivity. There are several treatments, such as CBT,
that reduce threat sensitivity and responsiveness in people with
PTSD. These have implications for similar interventions in people
with high levels of aggression.
REFERENCES
Kessler, R. C., K. A. McLaughlin, J. G. Green, M. J. Gruber, N. A. Sampson, A. M. Zaslavsky,
S. Aguilar-Gaxiola, A. O. Alhamzawi, J. Alonso, M. Angermeyer, C. Benjet, E. Bromet,
S. Chatterji, G. de Girolamo, K. Demyttenaere, J. Fayyad, S. Florescu, G. Gal, O. Gureje,
J. M. Haro, C. Hu, E. B. Üstün, S. Vassilev, M. C. Viana, and D. R. Williams. 2010.
Childhood adversities and adult psychopathology in the WHO World Mental Health
Surveys. British Journal of Psychiatry 197(5):378–385.
NRC and IOM (National Research Council and Institute of Medicine). 2009. Preventing men-
tal, emotional, and behavioral disorders among young people: Progress and possibilities.
Washington, DC: The National Academies Press.

Appendix A
Workshop-Related Discussion Papers
CONTENTS
A.1 Neurocognitive Mechanisms Implicated in Increasing the Risk for

Violence, R. James R. Blair 77
A.2 Violence and Mental Health: Opportunities for Prevention and

Early Intervention, A Workshop of the National Academies of
Sciences, Engineering, and Medicine’s Forum on Global Violence
Prevention, February 26, 2014, Daniel Fisher 84
A.3 Interface with the Justice Community: The Police,

Sheldon Greenberg 90
A.4 Mental Health in Latin America and the Caribbean,

Dévora Kestel 98
A.5 Heavy Episodic Alcohol Use and Intimate Partner Violence:

A Cross-Cultural Public Health Issue, Cory A. Crane and
Kenneth E. Leonard 106
A.6 Peer Bullying and Mental Health, Dieter Wolke 119
75

FIGURES AND TABLES
Figures
A-1 Mental health expenditures, 101
A-2 The impact of being bullied on functioning in adulthood, 121
A-3 Adjusted mean young adult CRP levels (mg/L) based on childhood/
adolescent bullying status, 123
Tables
A-1 Mental Health Professionals in LAC, 102
A-2 Number of Users Attending Mental Health Facilities, 103

APPENDIX A 77
A.1
NEUROCOGNITIVE MECHANISMS IMPLICATED

IN INCREASING THE RISK FOR VIOLENCE
R. James R. Blair1
1 National Institute of Mental Health, Bethesda, MD
Correspondence to:
R. James R. Blair, PhD
9000 Rockville Pike
Bldg. 15k, Room 205, MSC 2670
Bethesda, MD 20892
[email protected]
This work was supported by the Intramural Research Program of the

National Institute of Mental Health, National Institutes of Health, under
grant number 1-ZIA-MH002860 to James Blair.
The authors report no conflicts of interest.
Introduction:
Distinguishing Forms of Violence
The goal of this brief review is to consider neurocognitive mechanisms
that, when dysfunctional, have been suggested to increase the risk for
violence. However, before this can be considered it is worth noting that,
from a neuroscience perspective, there appears to be more than one form
of violence (Blair, 2001). Specifically, a distinction should be drawn be-
tween reactive (affective/defensive/impulsive) and instrumental (proactive/
planned) aggression (Crick and Dodge, 1996).
Reactive aggression is unplanned and can be characterized as impul-
sive. It is explosive, involves the active confrontation of the victim and
is typically accompanied by negative affect (anger, sadness, frustration,
and irritation). One notable feature distinguishing reactive aggression in
humans from that studied in animals is that in humans, it is often associated
with frustration (Berkowitz, 1993). Frustration occurs when an individual
continues to do an action in the expectation of a reward but does not actu-
ally receive that reward (Berkowitz, 1993).
Instrumental aggression in contrast is planned. It involves the selection
of a behavior (a covert or overt aggressive response) in anticipation of a
positive outcome (e.g., acquisition of territory or goods, improvement of

social status, or gratification of a perceived need). Typically, there is an

absence of accompanying intense emotion.
Different psychiatric conditions are associated with risks for different
forms of aggression. Thus, patients with mood and anxiety conditions (e.g.,
posttraumatic stress disorder [PTSD]), as well as patients with intermittent
explosive disorder (IED) and borderline personality disorder (BPD), are at
increased risk for reactive aggression. In contrast, individuals with the per-
sonality disorder psychopathy, who show reduced guilt and empathy, show
an increased risk for instrumental aggression coupled with an increased
risk for reactive aggression (Frick et al., 2005). Importantly, a common
pathophysiology likely underpins the increased risk for reactive aggression
in PTSD, IED, and BPD (even if there are other aspects of pathophysiology
that are idiosyncratic to the individual disorders). In contrast, a rather dif-
ferent pathophysiology likely underpins the increased risk for instrumental
aggression in individuals with psychopathic traits.
A System Mediating Reactive Aggression:

Acute Threat Response
The acute threat response involves freezing to a distal threat, fleeing if
the threat approaches, and fighting if the threat is very proximal (Blanchard
et al., 1977). As such, reactive aggression can be considered the ultimate
response to extreme threat. Considerable work with animals has determined
that the acute threat response is mediated by a neural circuit that runs from
the medial amygdala downward, largely via the stria terminalis to the medial
hypothalamus, and then the dorsal half of the periaqueductal gray (Panksepp,
1998; Gregg and Siegel, 2001). This circuitry is assumed to mediate reactive
aggression in humans as well (Blair, 2001). In a healthy individual, a very
high level of threat might initiate reactive aggression. However, it is suggested
that certain clinical conditions lead to lower levels of threat having the same
consequence. This is because prior priming of the circuitry, as a consequence
of the clinical condition, means that a less intense threat is necessary to initi-
ate reactive aggression (Blair, 2001).
Several psychiatric conditions show a significantly increased risk for
reactive aggression. These include PTSD, IED, and BPD (Coccaro et al.,
2007; New et al., 2009). In line with the suggestions above of a lowered
threshold, patients with these clinical conditions all show heightened re-
sponsiveness of regions implicated in reactive aggression, particularly the
amygdala, to emotional provocation (Coccaro et al., 2007; Lee et al., 2008;
New et al., 2009). In addition, patients with BPD have also been found to
show an increased amygdala response to interpersonal provocation (New
et al., 2009).

APPENDIX A 79
Several psychosocial stressors, such as exposure to trauma and neglect,

are known to selectively increase the risk for reactive aggression in humans
(Crick and Dodge, 1996). Notably, these stressors have also been shown to
increase the amygdala response to threat (McCrory et al., 2011; Tottenham
et al., 2011). In short, it can be argued that these stressors increase the risk
for reactive aggression because they increase the responsiveness of systems
mediating the acute threat response. Because of this, the individual is more
likely to display reactive aggression in response to future provocation.
Neurocognitive Mechanism That, When Dysfunctional,

Increases the Risk for Instrumental Aggression:
Empathic Responsiveness
An association between reduced empathic responsiveness to the distress
of others and an increased risk for aggression has long been made (Miller
and Eisenberg, 1988). Work has shown that empathic responses to the
distress of others diminish aggressive responding (Perry and Perry, 1974).
Moreover, empathic responding is critical for socialization. Caregivers most
typically respond to transgressions that harm others by focusing on the
distress of the victim (Nucci and Nucci, 1982). When this socialization
is successful, the individual is less likely to choose actions that will harm
others because of the aversive feelings he or she experiences in relation to
the anticipated victim’s distress.
Different definitions of empathy have been provided. But the functional
processes, with respect to modulating the risk for aggression, concern the
impact of distress cues (fearful, sad, and pained facial and vocal expres-
sions) on (1) current behavior by interrupting it; and (2) future behavior
by guiding, through social learning, the individual away from behavioral
choices associated with harm to others. The amygdala is considered to be
critical for both these processes. Considerable data show that the amygdala
is responsive to fearful expressions (Adolphs, 2010) and, to a lesser extent,
sad and pained expressions. Activation of the amygdala initiates f reezing—
interrupting current behavior. In addition, the amygdala is important for
social learning. The amygdala enables the association of stimuli with the
aversive reinforcement engendered by the fear of others (Jeon and Shin,
2011). This social learning means that the healthy individual comes to value
actions that harm other individuals as aversive (Blair, 2013).
Deficient empathy is associated with conduct disorder (CD), particu-
larly that associated with psychopathic traits, including reduced guilt (Blair,
2013). Such patients show reduced physiological responsiveness to expres-
sions of distress in peers (Blair, 1999; de Wied et al., 2012). In addition,
they show reduced amygdala responses to fearful and sad expressions, as
well as the pain of others (Marsh et al., 2008; Viding et al., 2012; White

et al., 2012). The presence of psychopathic traits, particularly reduced guilt

and empathy, are associated with an increased risk for instrumental aggres-
sion (Cornell et al., 1996). The suggestion is that the individual with psy-
chopathic traits is less likely to stop aggressing in response to the victim’s
distress because there is less amygdala activity and consequent freezing. In
addition, such an individual is less guided away from actions that harm
others because he or she has less learned the aversive value of actions that
harm others. In line with this, individuals with psychopathic traits have
been found to show greater indifference to transgressions that harm others
(Aharoni, Antonenko, and Kiehl, 2011; Blair, 1995) and reduced amygdala
responses to such transgressions (Glenn, Raine, and Schug, 2008). Such
indifference means that the individual is more likely to commit an action
that will harm others to achieve his or her goals.
Neurocognitive Mechanism That, When Dysfunctional,

Increases the Risk for Reactive and Instrumental Aggression:
Reward–Punishment-Based Decision Making
Problems in reward–punishment-based decision making are likely to
increase the risk for reactive and instrumental aggression in several ways.
First, individuals who fail to learn how to obtain rewards and avoid punish-
ments through their decisions face high risk for impulsivity and frustration.
Both impulsivity and frustration, in turn, predict risk for reactive aggression
(Berkowitz, 1974). Second, it is suggested that systems involved in decision
making are also involved in the regulation of the acute threat response.
Specifically, ventromedial frontal cortex is involved in the selection of
appropriate action as a function of the value outcomes associated with
different behavioral choices (a critical component of reward–punishment-
based decision making). An angry reactive response to provocation may
not be selected if the negative value of the detrimental consequences of this
action is appropriately represented (e.g., costs of imprisonment). Third, and
relatedly, instrumental aggressive responses will be less likely to be selected
if the negative values of their detrimental consequences are represented
(e.g., victim’s distress, and costs of imprisonment).
Systems neuroscience research links specific forms of decision m aking,
involving reinforcement-based learning, to a circuit that connects the
striatum, amygdala, and ventromedial frontal cortex as well as other struc-
tures (O’Doherty, 2012). Patients with conduct disorder exhibit a form of
impaired decision making associated with dysfunction in this neural circuit.
For example, they are more likely to respond to stimuli that e ngender pun-
ishment or continue to respond to stimuli that, while once rewarding, now
engender punishment (Crowley et al., 2010; Finger et al., 2008; White et al.,

APPENDIX A 81
2013). Notably, such forms of impaired decision making occur in conduct

disorder either with or without high levels of callous and unemotional traits
(White et al., 2013), as well as in patients with ADHD without conduct
disorder (Plichta et al., 2009; Scheres, Milham, Knutson, and C astellanos,
2007; Strohle et al., 2008). Moreover, they may occur in unaffected but
at-risk children, born to parents with their own histories of conduct prob-
lems or drug addiction (Yau et al., 2012). Thus, impaired decision making
arising from fronto-striatal dysfunction may represent a shared substrate
for frequently comorbid disorders, such as conduct d isorder, ADHD, and
substance use disorders.
Conclusions
In conclusion, this review outlines three neurocognitive systems
that, when dysfunctional, increase the risk for aggression. These are (1)
the acute threat response implicating the amygdala, hypothalamus, and
periaqueductal gray; (2) empathic responding (instrumental) implicating
the amygdala and, in the context of decision making influenced by em-
pathy for potential victims, ventromedial frontal cortex; and (3) reward–
punishment-based decision making implicating striatum and ventromedial
frontal cortex. Importantly, identifying these systems provides treatment
targets. Interventions can be designed to address the functioning of these
systems and their efficacy, indexed by their impact on the systems them-
selves, as well as downstream consequences of reduced aggression.
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A.2
VIOLENCE AND MENTAL HEALTH:

OPPORTUNITIES FOR PREVENTION AND EARLY INTERVENTION,
A WORKSHOP OF THE NATIONAL ACADEMIES OF SCIENCES,
ENGINEERING, AND MEDICINE’S FORUM ON
GLOBAL VIOLENCE PREVENTION,
FEBRUARY 26, 2014
Daniel Fisher
Presentation by Daniel Fisher, M.D.,

Executive Director, National Empowerment Center,
25 Bigelow St., Cambridge, MA 02139
The very title of this conference saddens me, and makes me angry.
Clearly the gun lobby has been effective in changing the narrative from con-
trolling guns to controlling those of us who have been labeled mentally ill.
This narrative is based on false information equating persons with mental
health disorders with increased violence.
Introduction
In my 20s I was diagnosed with schizophrenia and was involuntarily
hospitalized on three occasions. Ironically, I was studying the possible bio-
chemical bases of mental illnesses at the National Institute of Mental Health
(NIMH) at the time. (That was in the late ’60s. In May of last year, 45 years
later, Dr. Thomas Insel of NIMH stated that NIMH will not use the Diag-
nostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]
because its diagnostic categories are not based on biological m arkers.) I
was researching the factors controlling the biosynthesis of dopamine and
serotonin. I so reduced human experiences to chemistry that I became
convinced that we all were merely chemical machines, and that we lacked
meaning or agency. I lost the meaning of human relationships and emo-
tional expression. Being unable to understand communication left me out
of touch. I believe this empty view of life and the loneliness it produced left
me in despair and caused me to depart from everyday reality. I indeed did
fit the DSM definition of schizophrenia. I recovered from schizophrenia by
finding meaning through emotionally connecting with others and myself. I
concluded that we have a self that supersedes all we can write in a formula.
This understanding brought me back to everyday life with people. I decided
I could learn more about this human dimension by becoming a psychiatrist,

APPENDIX A 85
and have practiced in clinical settings for the last 35 years. I also founded
and run the National Empowerment Center, a Substance Abuse and Mental
Health Services Administration (SAMHSA)-funded, technical assistance
center dedicated to bringing hope and recovery to the mental health system
and society.
Recovery depends on people with mental illness finding meaningful
relationships and working in the community. The misinformation perpetu-
ated by our media is interfering with recovery. This incorrect coupling of
mental health issues with violence increases prejudice and discrimination
among all members of society. (Advocates are rejecting the use of the term
“stigma” because the term itself has produced increased prejudice.)
I will summarize the evidence that people diagnosed with mental health
conditions are no more violent than matched community members without
such a label. Although there is a lack of association of violence and mental
health conditions, the increased attention on mental health can be an op-
portunity to improve that system. Therefore, I will point out problems in
our mental health system and society that are barriers to recovery. Finally,
I will recommend ways that our mental health system needs to continue
its transformation from a maintenance-based to a recovery-based system.
The Evidence Does Not Link Persons with

Mental Health Disorders to Violence
A recently published report by the Consortium for Risk-Based Firearm
Policy (2013) concluded: “Research evidence shows that the large majority
of people with mental illness do not engage in violence against others and
most violence is caused by factors other than mental illness.” The report
also found that “research evidence suggests that . . . mental illness alone
rarely causes violence.” These conclusions were based on three studies
(Elbogen and Johnson, 2009; Swanson et al., 2013; Van Dorn et al., 2012).
This evidence fits closely with the findings of the MacArthur Violence
Risk Assessment Study, considered one of the most definitive published stud-
ies of mental health issues and violence. Dr. Heather Stuart (summarized
the MacArthur Study as follows: The MacArthur Violence Risk Assessment
Study (Applebaum et al., 2000; Monahan et al., 2001; Steadman et al.,
1998, 2000) “has made a concerted effort to address . . . [methodologi-
cal] problems, so it stands out as the most sophisticated attempt to date to
disentangle these complex interrelationships” (Stuart, 2003).
Because they collected extensive follow-up data on a large cohort of subject
(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-neighbor comparison subjects eliminates confound-

ing 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 neighborhood controls. Delusions were not associ-
ated with violence, even ‘threat control override’ delusions that cause an
individual to think that someone is out to harm them or that someone can
control their thoughts. (Stuart, 2003)
Fazel and colleagues (Fazel et al., 2009a), carried out a meta-analysis

of 20 studies that examined a possible relationship of violence to mental
health conditions. They concluded that “psychosis comorbid with substance
abuse confers no additional risk over and above the risk associated with
substance abuse.” This finding was consistent with their own finding that
schizophrenia, in the absence of substance abuse, did not increase the risk
of violence when compared to the general population (Fazel et al., 2009b).
Therefore, every significant research study carried out starting with the
MacArthur Study in the late 1990s has concluded that:
1. Persons with mental illness are no more likely than the matched
controls in the community [to perform violent acts].
2. Persons with a substance abuse disorder carry a substantial risk of
increased violence.
Therefore, “Strategies that aim to reduce gun violence by focusing . . .

on restricting access to guns by those diagnosed with a mental illness are
unlikely to reduce the overall rate of gun violence in the United States”
(Consortium for Risk-Based Firearm Policy, 2013).
The National Instant Background Check System, NICS, should be

focused on dangerousness and a history of violence rather than a mental
health diagnosis per se (Consortium for Risk-Based Firearm Policy, 2013).
After all, those of us diagnosed with a mental health disorder account for
only 4 percent of the gun-related homicides (Swanson et al., 2013).
Our Mental Health System Is Not a Welcoming Place

It is dehumanizing, and hope-robbing approaches are major reasons
why it is broken. It could practice hospitality, like hotels, through the prac-
tice of dialogue. Instead it practices varying degrees of coercion, persuasion,
and suggestion. These all are forms of trauma. To be trauma-informed, we
need to adhere to principles of dialogue emphasizing connecting, especially
at the emotional level, mutual respect for the full humanity of the person

APPENDIX A 87
in distress and listening to his or her voice, believing in them, and giving
them hope and humility. Peers can greatly enhance these qualities when
their roles as recovery coaches are valued and understood.
Our Deeper Malaise

Rather than focus on our mental health system alone, I want to point
out that dehumanizing labels and coercion are a reflection of a deeper woe,
that is, the breakdown of cohesion in our communities. The fear in our
society of people who are different or odd is the basis for such reactions.
We desperately need to rebuild positive connections to each other in our
communities. Cross-cultural studies have shown that contact with people of
differing race and culture, as well as mental health issues, is a critical factor
in becoming more comfortable with them. Contact also decreases prejudice,
stigma, and discrimination.
Recommendations
1. Broaden the community dialogue on mental health, and ensure
that persons with lived experience of mental health conditions are
included in the planning and participation of these dialogues.
2. NIMH and SAMHSA should promote the training and evaluation
of Open Dialogue (Seikkula, 2006) in the United States, to reach
people where they live, and while they are still connected to their
natural supports. This approach, developed in Finland, is the most
successful approach in the world for helping young people who
have experienced their first psychotic experience to recover a full
life in the community.
3. Hiring peers in valued roles as crisis workers and in peer-run
respites; peers are capable of reaching persons whom non-peers
cannot reach. This is true because when you have experienced delu-
sions and voices, you know how to reach and connect with other
persons going through a similar experience. Peer-run respites are a
good example of the application of this capacity of peers in divert-
ing persons from hospitalization (see the section on crisis respites
at www.power2u.org).
4. Training first responders, peers, and families in Emotional CPR.
This is a preventative public health program, enabling anyone to
help another person through an emotional crisis. eCPR, therefore,
represents the type of primary prevention that would reach a much
greater proportion of persons than present programs that focus on
persons labeled with mental health disorders (see www.emotional-
cpr.org).

5. Speakers sharing recovery stories in person with media officials,

police, parents, and other important community groups. Research
has shown that the most effective way to reduce prejudice and
discrimination is through people sharing their stories (Corrigan,
2005).
6. Educating the media to not continue the misinformation of links
between mental health issues and violence (the “See Me” campaign
in Scotland is a good example of this media education).
7. Continue the transformation from a medical narrative to a recovery
narrative that was started in the Surgeon General’s Mental Health
Report (1999) and the New Freedom Commission (Fisher, 2008;
New Freedom Commission on Mental Health, 2003).
Comments on Other Talks Given at the

National Academies of Sciences, Engineering, and Medicine’s
Workshop on Violence and Mental Health
Dr. Paul Appelbaum pointed out that Wayne LaPierre, vice president
of the National Rifle Association (NRA), quickly shifted the blame for the
Sandy Hook shootings in December 2012 from guns to persons labeled
with mental illness. He said that the problem of gun violence is not guns
but people with mental illness, whom he described as “deranged mongrels.”
The NRA called for ensuring that persons labeled with mental illness be
placed on the National Instant Criminal Background Check System (NICS).
This represented a change in policy of the NRA, which as recently as 2007,
had loosened the NICS: “The price for bringing the NRA on board [for
the NICS bill of 2007] was to take the ‘mentally ill’ tag away from anyone
‘rehabilitated through any procedure available under law’ and to enact a
‘Relief from Disabilities’ reform. The latter reform a llowed people classified
as mentally ill, and unable to buy guns, to get their rights back with more
ease” (Weigel, 2013).
References
Appelbaum, P.S., Robbins, P.C., Monahan, J. 2000.Violence and delusions: Data from the
MacArthur Violence Risk Assessment Study. Am. J. Psychiatry 157:566-572.
Consortium for Risk-Based Firearm Policy. 2013. Guns, public health and mental illness:
An evidence-based approach for state policy. John Hopkins University: Baltimore, MD.
Corrigan, P. 2005. On the stigma of mental illness: Implications for research and social
change, fifth edition. American Psychological Association: Washington, DC.
Elbogen, E., and Johnson, S. 2009. Intricate link between violence and mental disorder results
from national epidemiological survey on alcohol and related conditions. Archives Gen-
eral Psychiatry 66:152-161.

APPENDIX A 89
Fazel, S., Gulati, G., Linsell, L., Geddes, J.R., and Grann, M. 2009. Schizophrenia and vio-
lence: Systematic review and meta-analysis. PLoS Med 6(8): e1000120. doi:10.1371/
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Fazel, S., Låndström, N., Hjern, A., Grann, M., and Lichtenstein, P. 2009b. Schizophrenia,
substance abuse, and violent crime. JAMA 301(19):2016-2023.
Fisher, D.B. 2008. Promoting recovery. Learning about mental health practice. Eds. T. Stickley
and T. Basset. John Wiley and Sons: Chichester, U.K. pp. 119-139.
McGinty, E., et al. 2013. Gun policy and serious mental illness: Priorities for future research
and policy. Psychiatric Services, epub ahead of print, doi:10.1176/appi. Ps.201300141.
Monahan, J., Steadman, H.J., Silver, E., et al. 2001. Risk assessment: the MacArthur Study of
Mental Disorder and Violence. Oxford University Press: Oxford, U.K.
New Freedom Commission on Mental Health. 2003. Achieving the promise: Transforming
mental health care in America final report. DHHS Pub. No. SMA-03-3832. U.S. Depart-
ment of Health and Human Services: Rockville, MD.
Seikkula, J., and Trimble, D. 2005. Healing elements of therapeutic conversation: Dialogue as
an embodiment of love. Family Process 44(4):461-475.
Seikkula, J., Aaltonen, K., Alakare, B., Haarakanga, K., Keranen, J., and Lehtinen, K. 2006.
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Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research
16(2):214-228.
Steadman, H.J., Silver, E., Monahan, J., Appelbaum, P.S., et al. 2000. A classification tree
approach to the development of actuarial violence risk-assessment tools. Law Humanity
Behavior 24:83-100.
Steadman, H.J., Mulvy, E.P., Monahan, J., et al. 1998. Violence by people discharged from
acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen
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March 15.

A.3
INTERFACE WITH THE JUSTICE COMMUNITY: THE POLICE

Sheldon Greenberg, Ph.D.
Johns Hopkins University
Despite the long-term call by criminal justice and mental health profes-
sionals, advocates, and political officials to work together more effectively
in providing services to people with mental illness, progress in many juris-
dictions (cities, counties, towns, states, tribal land) and nations has been
slow. This paper presents and expands on a portion of the information
presented during the workshop titled Mental Health and Violence: Oppor
tunities for Prevention and Early Intervention. It offers information on
the interface between the criminal justice and mental health communities,
addresses some of the reasons for measured progress, and suggests ways in
which the two professions might advance success. While this paper briefly
addresses public safety, including corrections, it focuses primarily on inter
action among the police, mental health providers, and people who have
mental illness and their families, friends, and other advocates.
For decades, mental health professionals, advocacy organizations, fam-
ily members, political leaders, and others have sought to have the criminal
justice system or criminal justice community (generally perceived as consist-
ing of the police, courts, and corrections) end the unnecessary “criminaliza-
tion” of mental illness. This continues to be a priority.
Generally, an arrest is defined as the taking of a person into custody by
a legal authority, usually in response to a criminal charge. The criminaliza-
tion hypothesis is based on the assumption that police inappropriately use
arrest to resolve encounters with people who have mental illness (Engel and
Silver, 2001). Criminalization that can affect the future of a person with
mental illness goes beyond traditional arrest and may include criminal cita-
tions (usually issued for minor offenses that do not require taking a person
into custody) and inclusion of names in criminal incident reports.
Terms such as “criminal justice system” and “criminal justice com-
munity” suggest that there is a common foundation of standards, policies,
practices, and other linkages across the profession. In fact, criminal justice
in the United States and in many other nations is a highly fragmented,
parochial, and compartmentalized and, at times, is a competitive collection
of local, state, tribal, and federal agencies. There is no central organiza-
tion, professional association, or other body with the authority to mandate
policy, practice, or change. As of 2011, there were approximately 15,000
local police departments in the United States. The majority of these agencies

APPENDIX A 91
have fewer than 25 personnel. Fewer than 70 agencies serve jurisdictions

with large populations (500,000 or more) (Baltic, 2011). Fragmentation
exists in other nations as well, although some nations have a single national
police force (France, Italy, Japan, New Zealand, Nicaragua) or a small
number of agencies (Sweden, United Kingdom), and other nations’ law
enforcement services are provided by their defense agency/military (Chilean
Carabineros).
For a brief perspective on the larger justice system in the United States,
there are 3,365 local jails, not including state, federal, military, or juvenile
correctional institutions. Data on the number of courts—federal, state,
local, military, and specialized—are weak, although it is estimated that
there are more than 3,000 trial court judges serving the nation. The global
criminal justice system is diverse, and the concept of justice (fair processes,
just outcomes, respect for human rights and dignity, upholding law) is too
varied and complex in some nations and ill-defined in others to describe
adequately in this paper (Nagel, 2005).
Since the period of deinstitutionalization (intended to close large, often
antiquated public mental health hospitals and ensure the transfer of patients
to community-based mental health services) that began in the mid-1950s
and increased continually through the 1980s, criminal justice agencies
have altered policies, procedures, training, and relationships with mental
health providers and advocates to overcome difficulties stemming from
critical and routine interaction with people who have severe mental illness
(Lurigio and Swartz, 2000). When deinstitutionalization began in 1955,
there were approximately 560,000 severely mentally ill patients in the
nation’s public psychiatric hospitals. By 1994, this number was reduced by
more than 485,000 patients to approximately 72,000 (Frontline, 2005).
Several failed federal acts and the weak community response to supporting
those who returned to the community placed new and immediate burdens
on the p olice, courts, and corrections. Similar experiences occurred in other
nations and continents, including Australia, New Zealand, and Western
Europe (Fakhoury and Priebe, 2002). Two significant consequences of
deinstitutionalization have been the “criminalization of mental illness”
(Peternelj-Taylor, 2008) and victimization of people who have mental illness
(Teplin et al., 2005).
In considering the interface with the criminal justice system by mental
health providers, public health, social services, the faith community, and
other organizations, it is essential to focus on the role of the frontline police
officer as the “point of entry” and “point of diversion” toward or away
from arrest, prosecution, and incarceration. Generally, a police officer’s
decision to connect with a mental health service provider or other support
service, arrest (criminalize), pursue hospitalization or other placement, or
handle the call informally is based primarily on the characteristics and

constraints of each situation rather than the symptomatology or awareness

of mental illness (Lamb et al., 2002; Teplin, 2000). Action and decisions by
prosecutors and the courts will be determined, in great part, by the actions
and reports of the responding police officers.
Police agencies have sought to improve response to calls for service and
other incidents involving people with mental illness, especially those con-
sidered crisis or emergency situations. These new developments (training,
advances in policy, scrutiny of arrests, crisis intervention teams), however,
have been targeted almost exclusively at improved handling of individual
incidents. Less attention has been devoted to developing or implementing
comprehensive, multiagency, and preventive approaches (Cordner, 2006).
Generally, police become involved in situations and interact with people
who have mental illness when problems surface (Cordner, 2006). One
three-city study found that 92 percent of uniformed patrol officers had at
least one interaction with a person experiencing a mental health crisis in
the previous month. Police officers report that they are involved in an aver-
age of six calls per month specifically related to people with mental illness
(Borum, 2000; Vermette et al., 2005). An estimated 7 percent of police
contacts in jurisdictions with 100,000 or more involve people with mental
illness (Deane et al., 1999). The above data are based on reported incidents.
A significant percentage of a police officer’s interaction, intervention, and
problem-solving activity never makes its way into police reports and is
never captured in the data. Such activity is not found in the reported data
for several reasons: the situation requiring police intervention may have
been resolved quickly or informally; the officer did not want the involved
individuals to be named in a report; and/or the information may have been
recorded according to the initial call (assault, domestic situation, suspicious
activity, injured person), with no identifiers related to mental illness. In
some cases, the officer simply may have chosen not to file a formal report.
Research shows consistently that police officers do not want to criminal-
ize events involving people with mental illness unless significant violation of
the law has occurred (assault, theft, arson, weapons violation) and cannot
be ignored or handled less formally. Officers express frustration in handling
calls involving people with mental illness because of the lack of needed
information, the lack of immediately available resources, and the lack of
coordination in effort between police and mental health professionals (Engel
and Silver, 2001; Novak and Engel, 2005; Wells and Schafer, 2006).
There is minimal research on the face-to-face interaction among the
first-responding patrol officer, the person who has mental illness, family
members, and others. Little is known about what occurs in the first moments
of a situation that drives the involved players toward pursuing informal de-
escalation, or more formal interventions, such as criminalization, a call for
response by mental health professionals, commitment/hospitalization, or

APPENDIX A 93
other interventions or diversions from the criminal justice system (Tucker,

Hasselt, and Russell, 2008).
Notable progress was made with the establishment of Crisis Interven-
tion Teams (CITs) in the late 1980s, which brought together well-trained
police officers and mental health professionals to respond immediately
to calls for service involving people who have mental illness. Although
recognized primarily for intervention in serious or critical situations, CITs
responded to any call (crisis and non-critical) in which the caller or re-
sponding police officer identified the need for support. These teams primar-
ily appeared in urban and metropolitan environments—Baltimore County,
Charlotte-Mecklenburg, Los Angeles, Memphis, and Milwaukee—which
had the demand and resources to support them. In some of these jurisdic-
tions, police officers received 40 hours of instruction or more on interven-
tion strategies and often participated in joint training with mental health
workers.
Officers who received the training and were assigned to CITs reported
improved ability to recognize and respond to calls involving people with
mental illness, reduced stereotyping, greater empathy, improved ability to
resolve the situation, better communication skills, and increased patience.
They further reported that they were less likely to arrest and more prone to
redirect the individual toward other forms of support (Hanafi et al., 2008).
Importantly, research shows that officers trained to participate in CITs or
who received comparable training regarding mental health intervention
were less likely than their peers, in some situations, to use force or perceive
escalating force as effective in dealing with a person who has mental illness
(Compton et al., 2009).
Access to CITs in the United States began declining in recent years,
along with other support services, due to local budget crises and federal
cost containment strategies (Cunningham et al., 2006). Expansion of CITs
is questionable for the foreseeable future.
Training for police personnel remains a void in improving criminal
justice service to people who have mental illness. Data on the number of
police officers trained are unreliable since some agencies train more than
those needed to serve on CITs, and others, especially smaller agencies, rely
on other organizations to train their employees. Some agencies do not keep
comprehensive data on training provided to their employees. Some states
and larger agencies have sought to provide mental health intervention train-
ing to a minimum of 20 percent of their officers (Compton et al., 2008).
To date, there has been minimal research assessing the quality of CIT and
other mental health training provided to police officers, its endurance over
time, or the impact it has on outcomes for people who have mental illness
and their families (Lord et al., 2011).

Officers assigned to CITs receive training that surpasses the norm for
their peers. A survey of 33 state law enforcement certification agencies
(Police Officer Standards and Training Commissions [POSTs]), which exist
in almost every state in the United States, showed that the average train-
ing for police officers on “mental illness” was 9.1 hours. The majority of
training courses ranged from 2 to 4 hours, with the shortest course being
50 minutes. These courses included content on awareness and process
(policies and procedures for arrest, safety, and commitment to a hospital,
shelter, or other care facility). Some of the courses described by the states
incorporated mental illness with training on all “special populations,” with
no information on time allotted specifically to mental illness. Two states
reported that they have no requirement for training on mental illness. Little
research is available on training provided to specialized police agencies,
such as school police, campus police and security personnel, transporta-
tion police, and tribal police. The inconsistency in and minimal amount of
training provided to police on service to people who have mental illness is
a global issue (Psarra et al., 2008).
Calls are made to the police by people with mental illness who have
been victimized, as well as by spouses, other family members, neighbors,
mental health professionals, and people who simply observe behavior or
an incident but have no relationship to the person with mental illness. The
importance of the initial point of contact—often a police or other govern-
ment call taker/dispatcher—in obtaining critical information and relaying
it to the responding police patrol officer cannot be overstated. Despite
improved police call-taking protocols, information provided to the police
call taker by the victim or observer (witness) is too often brief, panicked,
incomplete, and inaccurate. They may only report the immediate need,
threat, or danger and fail to mention that a person who has mental illness
is involved. As such, the initial information a police officer receives may
make no reference to mental illness or contain any details about risk, ex-
isting injury or illness, medication use, illicit substance abuse, presence of
weapons, or precise location. Officers need, but often lack, information on
the individual’s medical or criminal history, cause of the crisis or hostility,
prior suicide or self-injury attempts, and attending physicians, among other
information (James, 1990). Information provided to a responding police
officer may be described as and limited to the following:
• Man injured
• Woman acting out
• Doctor has trouble with patient
• Unknown trouble
• Suspicious circumstance
• Assault

APPENDIX A 95
• Threat of assault
• Threat of suicide
• Parent cannot control child
• Disorderly conduct
• Assist with a commitment
Officer safety and the safety of others are paramount when police
officers receive a call for service or personally observe an unusual behav-
ior. When information about mental illness is conveyed, no matter how
detailed, police officers make assumptions about the potential for danger
(Watson et al., 2004).
Lack of Information and Need for Research on Initial Points of Contact

Much of what occurs—including police officers’ discretionary decision
making to criminalize or divert from criminalization—is based on the ob-
served behavior, early formulation of perceptions, and communication that
occurs in the early moments of the situation. Yet, little is known about the
nature and quality of the initial face-to-face interaction of police officers
called into situations involving people who have mental illness. Conclusions
and assumptions about the early one-on-one interaction that occur are
drawn from police incident report narratives, interviews, anecdotal infor-
mation, and, to a lesser degree, statistical reports, policies and procedures,
and training curricula.
There is minimal research on the initial face-to-face interaction (point
of contact) between police officers and people who have mental illness.
There is little research on the initial interaction between responding p olice
officers and spouses, family members, neighbors, and other involved p arties.
There is little research on how information conveyed early in a situation
might influence, positively or negatively, the re-criminalization of a person
with mental illness who had prior contact with the criminal justice system.
Research is needed to answer key questions that can possibly lead to more
positive courses of action for people with mental illness who are victimized,
accused, or perceived as being dangerous to themselves or others:
• What is the level of understanding about the situation by the

responding officer before he or she arrives?
• What facts were conveyed to the police department by the caller,
and how was this information relayed to the responding officer?
• At what point in the situation does awareness of mental illness
become known?
• What co-occurring factors (injury, illicit substance abuse) were
apparent at the immediate point of contact?

• What was the real or perceived level of risk of harm (presence of

weapons, threats), and how did it evolve?
• How emotional or tense was the situation upon the officer’s arrival?
• What words or actions by the dispatcher, family members, wit-
nesses, and people who have mental illness set the course for po-
lice action, particularly the criminalizing or decriminalizing of the
situation?
• To what degree did the immediate situation allow for alternatives
to criminalization?
• Was information shared about prior history, including incarcera-
tion or hospitalization, and what influence did this have on the
initial thinking and action by the responding police officer(s)?
• Was the availability (readiness at the time of need) of mental health
service providers known to the initial responding officer(s)?
• At what point did police officers connect with a mental health ser-
vice provider, and what was the nature of their initial information
sharing and action planning?
Other Needs to Improve Police Interaction

Other needs and recommendations to improve interaction between the
police and people who have mental illness were discussed during a round-
table discussion with public safety practitioners held at The Johns Hopkins
University (Division of Public Safety Leadership, 2013). The following re-
flects some of these needs and recommendations. Due to space limitation,
the following recommendations are noted in brief:
• Improved methods for conveying research to frontline practitioners

• Research on point-of-contact communication and other character-
istics of initial interaction that influence outcomes
• Orientation/training for mental health professionals on public
safety and, particularly, the police (culture, fragmentation, train-
ing, policy, safety mandates, discretion, liability)
• Research on the curricula being used to teach the police, with atten-
tion to awareness, interaction, use of community-based resources,
and law
• Model curricula for police, designed to accommodate the various
time limitations imposed by police academy schedules
• Model curricula for police on how to manage concurrent issues
(mental illness, mobility or communication disability, criminal be-
havior, homelessness, substance abuse, injury)
• Model curricula on interacting with people with mental illness who
are victimized

APPENDIX A 97
• Research on successes, beyond crisis intervention teams, particu-

larly those related to informal diffusion of situations and those in
which criminalization did not occur
• Model training and awareness programs, supported by marketing
strategies, to educate people who have mental illness and their
support network (spouse, family, friends) on interacting with the
police, particularly during initial contact
• Advancing call-taker protocols to obtain more and better informa-
tion from callers to relay to responding police officers and, where
joint response occurs, mental health workers or CITs
References
Baltic, S. E. (Ed.). (2011). Crime in the United States 2011. Bernan Press.
Borum, R. (2000). Improving high-risk encounters between people with mental illness and the
police. The Journal of the American Academy of Psychiatry and the Law, 28(3), 332-337.
Compton, M. T., Bahora, M., Watson, A. C., and Oliva, J. R. (2008). A comprehensive review
of extant research on Crisis Intervention Team (CIT) programs. Journal of the American
Academy of Psychiatry and the Law Online, 36(1), 47-55.
Compton, M. T., Neubert, B. N. D., Broussard, B., McGriff, J. A., Morgan, R., and Oliva, J.
R. (2009). Use of force preferences and perceived effectiveness of actions among Crisis
Intervention Team (CIT) police officers and non-CIT officers in an escalating psychiatric
crisis involving a subject with schizophrenia. Schizophrenia Bulletin, sbp146.
Cordner, G. (2006). People with mental illness. Problem-oriented guides for police, Problem-
Specific Guides Series (40).
Cunningham, P., McKenzie, K., and Taylor, E. F. (2006). The struggle to provide community-
based care to low-income people with serious mental illnesses. Health Affairs, 25(3),
694-705.
Deane, M. W., Steadman, H. J., Borum, R., Veysey, B. M., and Morrissey. J. P. (1999). Emerg-
ing partnerships between mental health and law enforcement. Psychiatric Services, 50(1),
99-101.
Division of Public Safety Leadership. (2013). Roundtable on Police response to People with
Mental Illness. Johns Hopkins University, School of Education, Division of Public Safety
Leadership, March 19, 2013, Columbia, Maryland.
Engel, R. S., and Silver, E. (2001). Policing mentally disordered suspects: A reexamination of
the criminalization hypothesis. Criminology, 39(2), 225-252.
Fakhoury, W., and Priebe, S. (2002). The process of deinstitutionalization: An international
overview. Current Opinion in Psychiatry, 15(2), 187-192.
Frontline. (2005). Deinstitutionalization: A Psychiatric “Titanic.” Retrieved from http://www.
pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html.
Hanafi, S., Bahora, M., Demir, B. N., and Compton, M. T. (2008). Incorporating crisis inter-
vention team (CIT) knowledge and skills into the daily work of police officers: A focus
group study. Community Mental Health Journal, 44(6), 427-432.
James, R. (1990). What do police officers really want from the mental health system? Hospital
and Community Psychiatry, 41(6), 663.
Lamb, H. R., Weinberger, L. E., and DeCuir, W. J. (2002). The police and mental health.
Psychiatric Services, 53(10), 1266-1271.

Lord, V. B., Bjerregaard, B., Blevins, K. R., and Whisman, H. (2011). Factors influencing the
responses of crisis intervention team–certified law enforcement officers. Police Quarterly,
14(4), 388-406.
Lurigio, A. J., and Swartz, J. A. (2000). Changing the contours of the criminal justice system
to meet the needs of persons with serious mental illness. Criminal Justice, 3, 45-108.
Nagel, T. (2005). The problem of global justice. Philosophy and Public Affairs, 33(2), 113-147.
Novak, K. J., and Engel, R. S. (2005). Disentangling the influence of suspects’ demeanor and
mental disorder on arrest. Policing: An International Journal of Police Strategies and
Management, 28(3), 493-512.
Peternelj-Taylor, C. (2008). Criminalization of the mentally ill. Journal of Forensic Nursing,
4(4), 185-187.
Psarra, V., Sestrini, M., Santa, Z., Petsas, D., Gerontas, A., Garnetas, C., and Kontis, K.
(2008). Greek police officers’ attitudes towards the mentally ill. International Journal of
Law and Psychiatry, 31(1), 77-85.
Teplin, L. A. (2000). Keeping the peace: Police discretion and mentally ill persons. National
Institute of Justice Journal, 244, 8-15.
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in adults with severe mental illness: Comparison with the National Crime Victimization
Survey. Archives of General Psychiatry, 62(8), 911-921.
Tucker, A. S., Van Hasselt, V. B., and Russell, S. A. (2008). Law enforcement response to the
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Watson, A. C., Corrigan, P. W., and Ottati, V. (2004). Police officers’ attitudes toward and
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Wells, W., and Schafer, J. A. (2006). Officer perceptions of police responses to persons with a
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29(4), 578-601.
A.4
MENTAL HEALTH IN LATIN AMERICA AND THE CARIBBEAN

Dévora Kestel, M.Sc.
Pan American Health Organization
“There is no health without mental health.” Despite this powerful

statement, the mental health situation in Latin America and Caribbean
countries (LAC) still lags behind where it should and could be. To analyze
this situation from a public health perspective, we have selected a few
indicators that facilitate the comparison among countries and sub-regions,
and that at the same time provide sufficient information to adequately
understand the current situation and appreciate potential opportunities
from a regional perspective.

APPENDIX A 99
Although the general data available from LAC present a situation that
could be viewed as dismal, it is important to highlight that there are many
good examples in the region worth replicating. There are countries that
have been reforming—a continuously ongoing process—their mental health
system for decades; there are also regions or towns within countries that
use their autonomy to move the mental health agenda forward, even when
the national situation is not as advanced.
This brief article intends to highlight some of the most salient features
of mental health systems in LAC.
Burden, Prevalence, and Treatment Gap

Recent studies of the global burden of disease show once again the
importance of considering mental health as a public health issue (1). Depres-
sion is the eleventh cause of disability globally (before TB, diabetes, and lung
cancer), and it ranks from third to seventh in the Americas region, depending
on the different subregions being considered (2).
Noncommunicable diseases (NCDs) account for 54 percent of the total
global health burden, and mental health and substance use disorders and
are the biggest contributors to the NCD burden. In LAC, the Disability
Adjusted Life Years due to neuropsychiatric disorders amount to 14 percent
of the total amount (11 percent mental and behavioral disorders, 3 percent
intentional injuries) (1).
Comparing the prevalence of these disorders with the available records
of attendance to mental health services allows for the identification of a
treatment gap. A treatment gap represents the percentage of people with
severe mental disorders that do not receive treatment (3). At the global
level, data from 2004 showed the extent of the treatment gap: 35.5 to
50.3 percent of serious cases did not receive any treatment within the prior
year in developed countries, but the proportion of cases not receiving any
treatment in developing countries was much higher: 76 to 85 percent. These
figures clearly indicate how the problem of mental health services availabil-
ity is not just of concern in developing countries (4).
A recent study of the treatment gap in LAC highlights that 73.5 percent
of adults with severe and moderate affective disorders, anxiety disorders,
and substance use disorders in the Americas do not receive treatment (47.2
percent in North America, and 77.9 percent in LAC). In the United States,
the treatment gap for schizophrenia is 42.0 percent, and in LAC, 56.2
percent (5).

Resources Availability
One partial explanation for this significant gap is the inadequacy of
funds available to develop appropriate services for those suffering from
mental and neurological disorders. The world median of the health budget
allocated to mental health is 2.82 percent (6).
Mental health expenditures at the regional level are not that different
from global levels; the median health budget allocated to mental health is
2.3 percent, with differences linked to sub-regional characteristics.
In the context of the existing limited budget environment, it is very
important to understand how those resources are used. The principal part
of that budget goes to outdated, custodial style, psychiatric hospitals, with
very limited funds made available for the development of community-
based mental health services. Specifically, in the English-speaking Caribbean
countries, the mental health budget is 3.5 percent of the health budget, and
84 percent of that budget goes to mental hospitals. In Central America, the
mental health budget is even lower, at 1.5 percent of the health budget, with
75 percent of it spent in mental hospitals. In South America, the budget
represents 2 percent of the health budget, with 66 percent going to mental
hospitals (7).
Figure A-1 illustrates the median percentage of the government health
budget allocated to mental health and to psychiatric hospitals, by subregion
and total.
Policies, Plans, and Laws in Mental Health

Having a mental health policy and or a plan (whether it is independent
or integrated as part of a general health document is not relevant) is very
important to concentrate efforts and available resources into common
objectives that will lead to a positive impact on the mental health of the
population.
Most of the countries and territories in the region have developed
mental health policies and plans; only six of them still do not have such
a policy tool. However, having a document written and approved does
not necessarily mean that it is being implemented. Several countries have
a newly developed mental health policy or plan that advocates for the de-
velopment of community-based mental health services, while, for example,
their services remain concentrated in mental hospitals (7).
Regarding mental health legislation, only eight countries have legisla-
tion specific for mental health issued after the year 2000. The implications
in this context are related to the lack of appropriate instruments to protect
and promote the human rights of the mentally ill and their families.

FIGURE A-1 Mental health expenditures (7).

SOURCE: Figure developed by Dévora Kestel for the WHO-AIMS: Report on Mental Health Systems in Latin America and the
Caribbean, by Dévora Kestel, copyright 2013 PAHO. Reprinted with the permission of the Pan American Health Organization.
101
Mental Health Professionals

Broadly speaking about human resources, there is limited availability
of personnel working in mental health. At the global level, there is less than
one psychiatrist per 200,000 people or more.
In the LAC region, there are 2.1 psychiatrists per 100,000 people.
Although the national average in some countries may not necessarily be
small, most of them are frequently concentrated in the capital or main cities
of the country, leaving large territories uncovered. Other mental health pro-
fessionals are generally less present in the region. The presence of nurses,
psychologists (with the exception of some countries in South America),
social workers, and occupational therapists is quite limited, ranging from
around two to less than one professional of each category per 100,000
inhabitants.
Table A-1 below offers a summary of mental health workers available
in the LAC region (7).
Organization of Mental Health Services

The analysis of existing services in LAC highlights the inefficiency in the
location of beds. Globally, 62 percent of psychiatric beds are located in
mental hospitals, with 21 percent in general hospitals, and just 16 percent
in residential facilities (6, 7).
TABLE A-1 Mental Health Professionals in LAC

Social Occupational
Subregion Psychiatrists Nurses Psychologists Workers Therapists Others
Central 1.5 2.3 2 0.7 0.2 2.3
America,
Mexico
and Latin
Caribbean
Non-Latin 1.9 14.3* 0.3 1.1 0.1 20.8

Caribbean
South 2.9 1.6 10.2 1.1 0.2 3.8

America
Total 2.1 6 4.2 1 0.2 9

average
* A few islands with a small population and a relatively high number of general nurses (all
involved with mental health patients) create this high number.
SOURCE: Presented by Dévora Kestel on October 30, 2015.

APPENDIX A 103
In LAC, 86.6 percent of the total number of available psychiatric beds

are located in psychiatric hospitals, meaning that in many countries, the only
answer for people suffering from mental disorders is a bed in a psychiatric
hospital, which, in the majority of cases, are outdated custodial institutions
that promote a systematic violation of human rights (7).
If a person is in need of hospitalization for an acute episode, he or
she would have to access one of the 10.6 percent of the total number of
available beds located in general hospitals that are dedicated to psychiatric
care (7).
For those persons who may need a longer time to recover without nec-
essarily needing hospital care, they should be considered lucky to access the
limited number of beds available in residential facilities (2.7 percent of the
total number of available beds) (7).
Paradoxically, when looking at the flow of patients in different mental
health facilities, results indicate that those same hospitals that concentrate
most of the limited available resources deal with between 5 and 13 percent
of the total number of patients who visit any mental health facility in the
year assessed. (7) The rest of the patients are seen by ambulatory services, in
general hospitals, or in any other service available at the community level,
developed with only 12 percent of the budget available for mental health
(as mentioned above, 88 percent of the budget dedicated to mental health
goes to traditional mental hospitals).
Table A-2 illustrates the number of mental health services’ users, by
100,000 people, visiting available facilities in the year of World Health Or-
ganization Assessment Instrument for Mental Health Systems (WHO-AIMS)
TABLE A-2 Number of Users Attending Mental Health Facilities

Psychiatric
Outpatient Units in
Facilities Day General Residential Psychiatric
Subregion (median) Hospitals Hospitals Facilities Hospitals
South 1.232 22.3 83.3 4.7 70.72
America
Central 588 5.1 50 0.6 68

America,
Mexico
and Latin
Caribbean
Non-Latin 936 7.5 119 2.5 171.4

Caribbean
SOURCE: Presented by Dévora Kestel on October 30, 2015.

implementation in their respective country. Although the data collection is

not precise (sometimes miscounting a patient with a contact), it nevertheless
offers an idea of the patient flow. For instance, looking at South America,
70.72 patients were treated in psychiatric hospitals, while over a thousand
were treated in all other services available and developed with very limited
resources (7).
Good Experiences in the Region

In 1990, a regional Conference for Restructuring of Psychiatric Care
was held in Caracas, Venezuela. That conference is considered to be an
important milestone in the region because of its recognition of the need
to move the attention, until then primarily focused on the psychiatric hos-
pital, to the development of decentralized, community-based services that
are participatory, comprehensive, and that ensure continuity of care. The
conference also introduced the need to ensure the protection of patients’
human rights.
Since then, several regional declarations paired with Pan American
Health Organization (PAHO) and WHO resolutions have been expanded
and approved by member states, all of which aim at the development of a
mental health system that will eventually provide an appropriate answer to
the mental health needs of the population.
In parallel, several countries in the region are at different stages of seri-
ous reforms to their mental health systems, in some cases at the national
level, and in others at the regional or even local level.
In October 2013, the World Health Assembly approved a Comprehen-
sive Mental Health Plan of Action that emphasized the need to move ahead
in this path that was initiated several years or decades ago (8).
In 2014, PAHO prepared an update to its Regional Mental Health Plan
of Action to align it with the global plan. The regional plan is expected to
be approved by the Ministers of Health of the Americas by October 2014.
The priorities identified in these plans are concentrated around four
main areas:
• Leadership and governance

• Community-based mental health and social care services
• Promotion and prevention
• Information systems, evidence, and research
The adaptation of these plans to national realities should help countries

move ahead with needed reforms to their existing mental health services.

APPENDIX A 105
Final Considerations
Although countries are moving toward the development of community-
based mental health services that are decentralized and closer to people’s
realities, there is still much to do to have the region ready to answer to
situations related to violence or other specific needs, such as the appropriate
response to populations affected by disasters (natural or man-made) and
the needs of vulnerable groups.
Countries in the region will be ready to answer to these situations
when an appropriate range of mental health services, from promotion and
prevention to rehabilitation and recovery, based in the community will
be available and when mental health will fully be integrated with general
health services.
When discussing violence and mental health, mental health profes-
sionals should be aware that most LACs’ mental health systems create and
direct violence toward individuals with mental disorders and their families.
Until changes occur to their mental health systems, this violence will con-
tinue to neglect to provide patients with the attention and services they need
and will maintain the idea that the mentally ill are violent.
Integrating mental health with general health services is a good strategy
to ensure that the health system as a whole will offer adequate care to the
people who need it.
References
1. Murray, C. J. L. et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries
in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study.
2010. Lancet, 2012; 380: 2197–2223.
2. Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman G., et al. 2013.
Burden of depressive disorders by country, sex, age and year: Findings from the Global
Burden of Disease Study 2010. PLoS Med 10(11): e1001547. doi: 10.1371/journal.
pmed.1001547.
3. Kohn, R., Saxena, S., Levav, I., and Saraceno, B. 2004. The treatment gap in mental
health care. Bull World Health Organ 82: 858-66 pmid: 15640922.
4. World Health Organization. World Mental Health Survey Consortium. 2004. Preva-
lence, severity, and unmet need for treatment of mental disorders in the World Health
Organization World Mental Health Surveys. JAVA, http://www.ncbi.nlm.nih.gov/
pubmed/15173149.
5. Kohn, R. 2013. Treatment gap in the Americas, http://www.paho.org/hq/index.
php?option=com_contentandview=articleandid=9408andItemid=99999.
6. World Health Organization. 2011. Mental Health ATLAS 2011, http://www.who.int/
mental_health/publications/mental_health_atlas_2011/en.
7. Pan American Health Organization. 2013. WHO-AIMS: Report on mental health
systems in Latin America and the Caribbean, http://www.paho.org/hq/index.
php?option=com_contentandview=articleandid=935andItemid=1106andlang=enandlimi
tstart=7.
8. World Health Organization. Comprehensive mental health action plan 2013–2020,
http://www.who.int/mental_health/publications/action_plan/en.

A.5
HEAVY EPISODIC ALCOHOL USE AND INTIMATE PARTNER

VIOLENCE: A CROSS-CULTURAL PUBLIC HEALTH ISSUE
Cory A. Crane, Ph.D.
Kenneth E. Leonard, Ph.D.
Research Institute on Addictions

University at Buffalo
Intimate partner violence (IPV) involves the perpetration of physically

aggressive acts against a spouse or dating partner and has been identified
as a serious social concern with considerable health and financial costs at
the individual, family, and societal levels (Lawrence et al., 2012). A review
of 249 peer-reviewed articles detected a high prevalence of past year and
lifetime (19.2 percent and 33.6 percent, respectively) physical IPV victim-
ization among heterosexual individuals, with slightly higher rates of vic-
timization among females (23.1 percent) than males (19.1 percent) across
all studies (Desmarais et al., 2012). In a separate review of 111 articles,
Desmarais and colleagues (2012) reported comparable rates of physical
IPV perpetration across all participants (24.8 percent) with slightly higher
rates of female-to-male (28.3 percent) than male-to-female (21.6 percent)
perpetration.
Traditional conceptual models of IPV focused on constructs such as
gender roles, power and control, and cultural sanctions for male-to-female
aggression, and were advanced through a societal mandate to help explain
and prevent IPV (Pence and Paymar, 1993). These early models spawned
intervention approaches and public policies that focused on accountability
as well as psychoeducation and remain predominant today (Babcock et
al., 2004). Those who adhered to this early conceptual framework argued
that alcohol use should be considered an u nacceptable excuse for violent
behavior and unequivocally rejected the notion that intoxication may play
a causal role in episodes of IPV. The past 20 years of research, however, has
largely failed to support both the traditional models (Dutton and Corvo,
2007) and associated interventions (Babcock et al., 2004), and has offered
largely consistent empirical support for an alternative conceptualization
of heavy alcohol use as a contributing causal factor in episodes of IPV
(Leonard, 2005).
This research has been guided by and has contributed to the current
prevailing theories describing the proximal effects of heavy alcohol con-
sumption on violent behavior, which focus on attention allocation and the

APPENDIX A 107
disinhibiting characteristics of alcohol. These theories are based on the di-

rect psychopharmacological effects of alcohol, which include a wide range
of transitory impairments in higher-order executive cognitive functioning
(Giancola et al., 2010). Among other effects, alcohol intoxication is thought
to impair decision making through the exacerbation or amplification of
attention to dominant environmental cues that may instigate violence while
limiting attention to less salient cues that may inhibit violent responding,
such as the long-term consequences of violent actions (Steele and Josephs,
1990; Taylor and Leonard, 1983). Alcohol expectancies serve as the basis
for an alternative set of theories by which alcohol facilitates IPV through
the perpetrator’s own beliefs about the mitigating effects of intoxication
on one’s own culpability for socially unacceptable partner violent behavior.
Although alcohol expectancy theories have received some scientific support,
the majority of research has found little evidence for moderating effects
on the relationship between alcohol intoxication and the perpetration of
partner violence (e.g., Quigley and Leonard, 2006).
Human research contributing to our current understanding of the rela-
tionship between heavy alcohol use and IPV has utilized survey, longitudi-
nal, event-based, experimental, and treatment-evaluation methodologies to
support an assertion of causality based on the preponderance of evidence
drawn from the multi-method approach (Leonard, 2005). Prior reviews
have detected a significant effect of alcohol on general physical aggression
(e.g., d = .22; Lipsey et al., 1997) and provided further empirical impetus
to extend this work into the field of partner violence, resulting in multiple
meta-analytic investigations examining the relationship between indices of
heavy alcohol use and IPV within cross-sectional and case control studies,
inclusive of considerable diversity in sample characteristics. These reviews
find high heterogeneity across studies and significant overall effect sizes in
the small to medium range. Ferrer and colleagues (2004) examined 9 studies
and reported that male IPV perpetrators were more likely to abuse or be
dependent upon alcohol than non-violent male participants (d = .57). Stith
and colleagues (2004) reached similar conclusions regarding the effect size
of alcohol on IPV perpetration after aggregating data from 22 studies of
male participants (d = .48).
In an effort to update prior reviews and examine moderators that may
account for the heterogeneity in effect sizes across studies reported in previ-
ous meta-analyses, Foran and O’Leary (2008) conducted the most recent
and comprehensive review of this literature. In addition to corroborating
the small-to-medium relationship between alcohol and IPV among males
(d = .47), a small but tentatively homogeneous relationship was detected
among eight studies involving female participants (d = .28). Moderation
analyses examined the robustness of effects across various male sample
characteristics. Effects did not differ across married and dating samples.

The relationship between alcohol and IPV was comparable across clinical
and community samples as well. Not included in moderation a nalyses, the
small-to-medium relationship between heavy alcohol use and IPV has been
reported within incarcerated (e.g., Logan et al., 2001; White et al., 2001),
emergency department ( Lipsky et al., 2005), and military (Pan et al., 1994)
samples, and nascent literature indicates an association among gay and
lesbian samples, as well (Klostermann et al., 2011). Furthermore, research
indicates that the link between heavy alcohol use and IPV is a cross-cultural
phenomenon extending across ethnic groups (Caetano et al., 2001) and
beyond Western nations with varying alcohol use and violence norms,
including countries in South America (Kishor and Johnson, 2004), Asia
(Rao, 1997), and Africa (Yigzaw et al., 2005). Most recently, problematic
male alcohol use was determined to increase the odds of male-to-female
IPV perpetration in 12 of 14 regions (N = 24,097 across 10 countries) that
participated in the World Health Organization Multi-Country Study on
Women’s Health and Domestic Violence population-based survey study
between the years of 2000 and 2003 (Abramsky et al., 2011). Thus, the
existing literature provides consistent evidence for an association between
heavy alcohol use and IPV that can be observed widely.
There have been fewer longitudinal investigations addressing the asso
ciation between heavy alcohol use and IPV. However, the available evi-
dence suggests that heavy alcohol use is longitudinally predictive of IPV
perpetration over short follow-up periods, but the evidence is less sup-
portive over long follow-up periods. Although not a longitudinal study,
Leonard et al. (1985) found that alcohol disorders within the past 3 years
were predictive of husband IPV, while alcohol disorders that occurred
before the last 3 years were not. This observation is consistent with longi-
tudinal research involving premarital (Heyman et al., 1995) and newlywed
(Quigley and L eonard, 1999) couples in which alcohol problems were
predictive of IPV at the earliest, but not subsequent, follow-ups. L eonard
and Senchack (1996) reported that prospective reports of premarital
problematic alcohol use were predictive of physical IPV perpetration
among husbands during the subsequent first year of marriage, even after
controlling for premarital IPV. Similarly, Keller and colleagues (2009) re-
ported that husband, but not wife, alcohol problems predicted increased
physical IPV at a 2-year follow-up. The composite longitudinal evidence
indicates that problematic alcohol use may be longitudinally associated
with subsequent IPV and that this relationship may attenuate over time,
possibly in response to shifting patterns of alcohol use as well as dynamic
dyadic coping and adjustment strategies.
These studies demonstrate a general association between alcohol and
IPV, but lack the temporal element necessary to establish causation. This
proximal relationship can be best established through event-based as well as

APPENDIX A 109
laboratory analogue or experimental methodologies. Event-based research

reveals that alcohol is often involved in IPV events and that perpetrator
intoxication is predictive of both the occurrence and severity of violence.
On the international scale, a cross-sectional study of the most severe epi-
sodes of physical IPV experienced by male and female respondents in 13
nations revealed relative uniformity in greater violence severity among
alcohol-involved events compared to sober events (Graham et al., 2011).
In the United States, an examination of epidemiological data provided by
a subset of male (n = 501) and female (n = 1,756) participants who re-
ported IPV victimization on the National Violence Against Women Survey
(NVAWS; Tjaden and Thoennes, 2000) demonstrated that 33.6 percent of
IPV events involved perpetrators under the influence of a lcohol and that,
after controlling for victim alcohol use, females were more likely to sustain
injuries if their male partner had been drinking heavily (Thompson and
Kingree, 2006).
Past year conflict interviews of 366 newlywed couples were conducted
at their first wedding anniversary and similarly revealed that husbands
were more likely to be drinking during physically, rather than verbally,
violent conflicts (Leonard and Quigley, 1999). Participants from 61 of
these couples completed conflict interviews after the third anniversary and
described both an alcohol-involved and a non-alcohol-involved IPV episode
(Testa et al., 2003). Episodes of IPV in which the husband reported alcohol
use evidenced more violent acts, more severe violence, and greater mutual
violence than episodes that did not involve husband alcohol use. High rates
of perpetrator alcohol use during IPV events have also been reported by
victims in emergency departments (Lipsky et al., 2005) and higher blood
alcohol levels have been reported during violent conflicts in comparison
to nonviolent conflicts by treatment-seeking alcoholics (Murphy et al.,
2005). At the greatest extreme, proxy and victim reports reveal that rates
of problematic drinking may be even higher among intimate partner homi-
cide perpetrators (52.0 percent) than nonfatal partner violence perpetrators
(30.9 percent) and that the majority of intimate partner homicides (59.5
percent) may o ccur while the perpetrator is under the influence of alcohol
(Campbell et al., 2003; Sharps et al., 2001).
Prospective research techniques (e.g., daily diary and ecological
momentary assessment) represent an amalgam of longitudinal and event-
based methodologies and allow for a daily process analysis of the relation-
ship between heavy alcohol use and IPV through frequent reporting. A
single, recent investigation collected 56 independent, daily reports from
both members of 118 community couples (Testa and Derrick, 2014).
Despite detecting expectedly few acts of IPV during the study period, per-
petrator alcohol use significantly predicted subsequent physical IPV perpe-
tration both later in the same day and within 4 hours.

These types of observational designs provide strong evidence for cor-

relations between heavy alcohol use and IPV but retrospective, self-reported
accounts of alcohol-involved IPV are subject to recall errors and other
reporting biases. Although previous meta-analyses have intentionally ex-
cluded the experimental literature (e.g., Foran and O’Leary, 2008), a num-
ber of carefully controlled experimental studies have examined the direct
effects of alcohol administration on proxy measures of IPV and remain
integral to establishing the case for causality under the most rigorous crite-
ria. The sexual (for a review, see Abbey, 2011; Rehm et al., 2012) and gen-
eral (for a review, see Exum, 2006) aggression literatures are replete with
examples of experimental evidence supporting the effects of heavy alcohol
consumption on aggressive and violent responding, such as setting more
frequent or intense shocks for an opponent after having received alcohol in
a competitive reaction time task (Bushman, 1997). The ecological validity
of traditional aggression paradigms to IPV perpetration has been called into
question, necessitating the generation of contemporary assessment meth-
odologies that more closely approximate relationship-specific stressors,
instigators, and aggressive response options (Tedeschi and Quigley, 1996).
Conflict resolution studies recruit couples to identify and discuss
sources of relationship conflict with active alcohol manipulations. Coding
of these recorded conversations has revealed effects of alcohol on IPV-re-
lated verbal behaviors. In a sample of 145 newlywed couples, Leonard and
Roberts (1998) reported that husbands who had received alcohol, as well as
their sober wives, displayed greater verbal negativity than those couples in
which the husband had received either a placebo or nonalcoholic beverage.
Similar effects of acute alcohol consumption on negativity during couple
interactions have been detected among alcohol-abusing participants (Haber
and Jacob, 1997; Jacob and Krahn, 1988; Jacob and Leonard, 1988). Other
research has demonstrated that the effects of alcohol on negativity among
alcohol abusing husbands may be confined to those with high antisocial
tendencies (Jacob et al., 2001). A recent study (Testa et al., 2014) offered
discrepant findings, detecting no negative effects of a couple’s alcohol
manipulation on relationship interactions. The couples in this study were
unique, however, in that they reported relatively high relationship satisfac-
tion, were involved in stable long-term relationships, and were both heavy
social drinkers, suggesting that they had likely developed satisfactory skills
to cope with alcohol-involved conflict.
An alternative experimental paradigm involves recoding verbal re-
sponses to audio situations involving a simulated intimate partner. Exami-
nation of response content for aggressive intent consistently reveals that
participants react with greater aggression following alcohol administration
and anger induction. Eckhardt (2007) randomly assigned a sample of 102
husbands to an alcohol, placebo, or nonalcoholic beverage condition and

APPENDIX A 111
reported the greatest aggressive verbalizations among the participants who

received alcohol, particularly if they had reported previously perpetrating
marital violence. Using the same paradigm, Eckhardt and Crane (2008)
detected a comparable effect of alcohol on aggressive verbalizations among
a sample of 37 male and 33 female participants, particularly among those
who reported high dispositional aggressive responding.
The research detailed above strongly supports alcohol as a contributing
cause to IPV. Heavy or problematic alcohol use at the time of IPV perpe-
tration does not function as a unilateral determinant of IPV, however, as
evidenced by small-to-medium effect sizes and high heterogeneity across
meta-analyses, IPV episodes that involve no alcohol in event-based studies,
as well as variability across individuals in experimental data. Emerging
from the aforementioned disinhibition and attention allocation models,
individual and situational factors may increase the likelihood of alcohol-
involved IPV. Indeed, individuals with low relationship satisfaction (e.g.,
Leonard and Senchak, 1996), high dispositional anger (e.g., Norlander
and Eckhardt, 2005), aggressive tendencies (e.g., Eckhardt and Crane,
2008), and antisociality (e.g., Leonard and Senchak, 1996) seem to be at
high risk of IPV perpetration following heavy alcohol consumption. Simi-
larly, longitudinal data suggest that alcohol problems are associated with
increased IPV perpetration the following year only among husbands high
in both hostility and avoidance coping strategies (Schumacher et al., 2008).
However, as noted by Leonard (2005), there is evidence to suggest that this
synergistic effect breaks down among the most highly aggressive, and that
for these individuals, alcohol may increase the severity of aggression, but
not the occurrence. This notion, which came to be referred to as the “Mul-
tiple Thresholds” theory, has been explicated by Fals-Stewart, Leonard,
and Birchler (2005).
Treatment
It is important to recognize that alcohol is neither a necessary nor a
sufficient cause of intimate partner violence but instead, it contributes, in
concert with other factors, to an increase in the occurrence and severity of
such violence. Hence, in some groups, alcohol may have a minimal impact
on IPV, while in other groups, its impact may be quite substantial. This is
most apparent when we examine treatment populations. These popula-
tions offer a unique opportunity to observe both the association between
problematic alcohol use and IPV as well as mutual changes in these condi-
tions over time. We see strikingly high rates of comorbidity regardless of
the identified treatment sample. Alcohol problems are detected in upwards
of 50 percent of mandated and voluntary male IPV treatment seekers (e.g.,
Brown et al., 1999; Dalton, 2001; Gondolf, 1999; Stuart, et al., 2003).

High rates of hazardous drinking are also detected among female IPV of-
fenders (Stuart et al., 2003). Rates of IPV among substance abuse treatment
seeking samples also routinely exceed 50 percent in both male and female
samples (e.g., Chase et al., 2003; Gondolf and Foster, 1991; Murphy and
O’Farrell, 1994; Murphy et al., 2001).
Despite the high co-occurrence of problematic alcohol use and IPV, the
behaviors are not routinely assessed unless included among the initial refer-
ral questions (Easton et al., 2007). Little evidence supports the effectiveness
of IPV treatment programs at preventing subsequent acts of violence. Meta-
analytic reviews have revealed small or non-significant effects, suggesting
that treatment may reduce the risk of IPV by as little as 5 percent beyond
legal intervention alone (e.g., Babcock et al., 2004; Feder and Wilson, 2005).
Eckhardt and colleagues (2013) recently collected all case controlled studies
of IPV treatment programs to report that the existing research, though meth-
odologically flawed, contained roughly equivocal support for and against the
effectiveness of IPV interventions. The failure of IPV treatment programs
has been attributed, in part, to poor rates of attendance and high attrition
(Babcock and Steiner, 1999; Gondolf, 2000). Heavy alcohol use may also
impact the poor outcomes of IPV treatment inasmuch as IPV perpetrators
with alcohol problems attend fewer sessions and drop out of treatment at a
greater rate than perpetrators without drinking problems (for a review, see
Daly and Pelowski, 2000; Olver et al., 2011).
Indeed, substance abuse treatment success has been associated with
reductions in IPV. One investigation found that intensive treatment for
alcohol dependence, in the absence of IPV-specific content, resulted in
significant reductions not only in alcohol use but also physical and psy-
chological IPV perpetration at 6- and 12-month follow-ups, according to
male clients and their wives (Stuart et al., 2003). Similar results were found
among a sample of females seeking treatment for alcohol dependence; treat-
ment resulted in reductions in alcohol, physical violence, and psychological
IPV perpetration at 6- and 12-month follow ups (Stuart et al., 2002). In a
larger treatment evaluation study, alcohol treatment resulted in reductions
in the prevalence of IPV from baseline assessment to 1-year follow-up and
a greater increase in IPV among relapsed clients relative to remitted clients
at 2 year follow-up (O’Farrell et al., 2003).
When detected, however, dual alcohol problems and IPV most often
result in assignment to separate treatment programs that fail to coordinate
efforts to minimize client burden, reducing the likelihood of completing
either program (Bennett and Lawson, 1994; Schumacher et al., 2003).
Initial evidence suggests that integrated alcohol and IPV treatments may be
more effective than treatment as usual. Evaluations of behavioral couples
therapy for alcohol and IPV problems have evidenced reductions in alcohol
use as well as the prevalence of IPV among both male and female partners

APPENDIX A 113
at a 1-year follow-up, again with less violence among remitted compared

to relapsed clients (O’Farrell et al., 2000; O’Farrell et al., 2004). A sepa-
rate investigation reported significant reductions in IPV from baseline to
post-treatment among clients randomly assigned to an integrated cognitive-
behavioral therapy for substance abuse and IPV but not clients assigned to
an alternative, standard treatment protocol (Easton et al., 2007).
Thus, research among treatment-seeking samples offers further con-
firmation of the general interrelationship between alcohol and IPV while
highlighting the need to address both conditions among relevant clinical
samples. Problematic alcohol use is associated with IPV treatment dropout,
and successful substance abuse treatment reduces the risk of future IPV
perpetration beyond violence interventions alone. Even still, integrated
programs for clients with special treatment needs are routinely met with
resistance and remain more the exception than the norm.
Future Directions
Although we have briefly reviewed the literature that has contributed
to our considerable understanding of the effects of acute heavy alcohol
consumption on IPV, there is a dearth of research into the effects of chronic
heavy alcohol use on the risk of perpetrating IPV. The processes by which
chronic heavy alcohol consumption may affect the ability to interpret and se-
lect prosocial responses to incoming social stimuli remain unclear. One model
describes indirect effects, positing that chronic alcohol use increases the risk
of IPV through gradual changes to interpersonal dynamics that r educe rela-
tionship satisfaction, increase relationship stress, and decrease reliance upon
non-violent conflict resolution tactics designed to accommodate a partner or
improve the partnership (Quigley and Leonard, 1999). Alternatively, neuro-
biological evidence reveals that chronic alcohol use is associated with neu-
ronal death and widespread deficits in executive cognitive functioning (e.g.,
Sullivan et al., 2002). Easton and colleagues (2008) extended this research
to report greater cognitive impairment (e.g., attention, concentration, flex-
ibility) among alcohol-dependent men who reported IPV perpetration when
compared to alcohol-dependent men who reported no IPV perpetration. As
previously stated, much of the existing research provides evidence for the
proximal effects of heavy alcohol consumption on IPV, even among individu-
als with chronic alcohol abuse problems. Additional long-term longitudinal
and neuropsychological research beginning in adolescence and extending
through early adulthood is required to further develop our understanding of
the biopsychosocial effects of chronic alcohol use on IPV.
The role of psychopathology, as well as its interaction with alcohol, in
IPV perpetration represents another underdeveloped area of research. Simi-
lar to alcohol, early IPV models conceptualized mental illness as an excuse

for unacceptable violence (Pence and Paymar, 1993). Although emerging

research now suggests that certain mental health conditions associated with
impulse control problems or affective dysregulation, such as mood and
anxiety disorders, may increase the risk of IPV perpetration (Crane et al.,
2014; Hatters-Friedman and Loue, 2007), existing IPV treatment protocols
fail to take mental illness into consideration. Given initial evidence that
suggests a synergistic effect of substance use and mental illness on violent
behavior (e.g., Van Dorn et al., 2012), the effects of mental illness on com-
pliance and recidivism may need to be evaluated within the context of IPV
treatment and existing interventions adapted to improve outcomes for this
select group as well as their partners.
Our review of IPV treatment research suggests that current options are
insufficient to accomplish the goal of violence prevention and that there is
a great need for the development and evaluation of more effective inter-
ventions that focus on individual needs rather than a uniform protocol.
Heavy alcohol consumption, as a contributing cause of IPV, and interac-
tions between alcohol use and partner influences are emerging as important
treatment considerations. As such, nascent research into integrated treat-
ment programs for both problematic alcohol use and IPV show promise,
as do relationship-systems interventions that focus on dynamic, interactive
processes at the couple level. The available treatment portfolio and public
policies that govern their implementation must be expanded to accommo-
date individual substance use, psychiatric, and dyadic needs.
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APPENDIX A 119
A.6
PEER BULLYING AND MENTAL HEALTH

Dieter Wolke, Ph.D.
University of Warwick,
Department of Psychology (Lifespan Health and Wellbeing Group) and
Division of Mental Health and Well-being (Warwick Medical School),
Coventry, UK
This paper considers the importance of bullying as a major risk factor

for physical and mental health and adaptation to adult roles, including
forming lasting relationships and integrating into work and being eco-
nomically independent. Evidence is provided that bullying by peers either
at school or at home by siblings has been mostly ignored by health pro
fessionals but should be considered as a significant risk factor and safe-
guarding issue. Policy suggestions are made to more effectively recognize
and manage a ffected children.
Bullying
Bullying is the systematic abuse of power and is defined as aggres-
sive behavior or intentional harm doing among peers that is carried out
repeatedly, and involves an imbalance of power, either actual or perceived,
between the victim and the bully.1 Bullying can take the form of direct bul-
lying, which includes physical and verbal acts of aggression such as hitting,
stealing, name calling, or indirect bullying, which is characterised by social
exclusion and rumor spreading.2,3,4 Children can be involved in bullying
as victims and as bullies, but also as bully/victims, a subgroup of victims
who display bullying behavior.5,6 Recently there has been much interest
in cyberbullying, which can be broadly defined as any bullying which is
performed via electronic means, such as mobile phones or the Internet. Ap-
proximately 50 percent of children report having been bullied at some point
in their lives, and 10 to 14 percent experience chronic bullying lasting for
more than 6 months.7,8 Between 2 and 5 percent are bullies, and a similar
number are bully/victims in childhood/adolescence.9 Rates of cyberbullying
are substantially lower, around 4.5 percent for victims and 2.8 percent for
perpetrators (bullies; bully/victims), with up to 90 percent also traditionally
(face to face) bullied.10 Being bullied by peers is the most frequent form of
abuse encountered by children, much higher than abuse by parents or other
adult perpetrators.11

Bullying Is Not a Conduct Disorder

Bullying is found in all societies, including modern hunter–gatherer
societies and ancient civilizations. It is considered to be an evolutionary
adaptation and the purpose is to gain access to resources, secure sur-
vival, reduce stress, and allow for more mating opportunities.12 Indeed,
it has been shown that bullies are highly motivated to gain high status,
dominance, and the strategic behavior enables access to social success and
romantic partners.13 Indeed, many bullies of both sexes are bi-strategic,
employing both means of bullying but also acts of aggressive “prosocial”
behavior to enhance their own position by being public and making the
recipient dependent as they cannot reciprocate.14 Indeed, bullies (but not
bully/victims or victims) have been shown to be strong, to have good social
and emotional understanding, and to be highly popular.15 Thus, they are
not conduct disordered. Indeed, unlike conduct disorder, bullies are found
in all socioeconomic groups16 and ethnic groups.17 If bullying is about
power rather than an individual disorder, it should be more frequent in
contexts where there is little cohesion and less equality in terms of access
to resources. Indeed, bullying prevalence increases with inequality in na-
tions,18 classrooms,19 and even at home.20 Furthermore, it has been shown
that interventions to reduce bullying have little success if the bully is highly
popular, i.e., has social power and there is no incentive to discontinue
socially enhancing behavior.21 In contrast, victims have been described
as withdrawn, unassertive, easily emotionally upset, and as having poor
emotional or social understanding;15,22 whereas bully/victims tend to be ag-
gressive, easily angered, low on popularity, and frequently bullied by their
siblings,23 i.e., most like conduct-disordered children.
Adverse Consequences of Being Bullied

Until fairly recently, most studies on the effects of bullying were cross-
sectional or just included brief follow-up periods. Thus, pre-existing mental
health problems may explain that the children were bullied, rather than
bullying being the “cause” of the problems. Furthermore, most studies just
investigated victimization rather than also bullying perpetration and few
distinguished between victims and bully/victims. However, recent longitu-
dinal studies into adolescence,24,25,26 early adulthood8,9,27,28 and even into
late adulthood29 indicate that being the victim of bullying is associated
with often severe mental health problems, including anxiety disorders,
depression, self-harm and suicide, personality disorder,30 and psychotic
symptoms that are long lasting and persist up to 40 years later! The use of
genetically sensitive designs where mono-zygotic twins (genetically identical
living in the same households) but discordant for experiences of bullying

APPENDIX A 121
were compared, showed that internalizing problems increased over time

only in those who were bullied.31 Furthermore, longitudinal studies allow
for the control of pre-existing mental illness, family factors from parent-
ing, domestic violence to abuse, and social disadvantage.32 Thus, there is
mounting evidence that being exposed to bullying as victim or bully/victim
has unique adverse impact on mental health.33 Furthermore, most recent
evidence indicates that being bullied leads to highly increased difficulties in
economic behavior, losing or leaving jobs, and lower income and overall
poorer quality of life29,32,34 (see Figure A-2).
The carefully controlled longitudinal studies paint a converging picture
of the long-term effects of being bullied in childhood. Firstly, the effects of
being bullied are found beyond other childhood adversity and adult abuse.9
In fact, when compared to the experience of having been placed into care
in childhood, the effects of frequent bullying were as detrimental 40 years
later!29 Secondly, there is a dose–effect relationship between being victim-
ized by peers and outcomes in adolescence and adulthood. Those who
were bullied more frequently,29 more severely (i.e., direct and indirectly
bullied25) or more chronically bullied (i.e., over a longer period of time8)
show more adverse outcome. Thirdly, even those who have escaped from
Health Wealth Social

Psychiatric, Poor school Poor
suicidality, performance, relationships
serious illness, less income, with parents,
smoking, slow dismissed from few friends, no
illness jobs, poor in confidante, low
recovery managing quality of life
finances
Victimization
Baby Toddler School Teen Adult
FIGURE A-2 The impact of being bullied on functioning in adulthood.8,9,27,29,32

SOURCE: Figure developed by Dieter Wolke.

being previously bullied at school age still show an increased risk for their
health, self-worth, and quality of life years later.24 Fourthly, where victims
and bully/victims have been considered separately, bully/victims seem to
show the poorest outcome ranging from mental health, to economic adap-
tation, social relationships to early parenthood.9,27,32,35 Fifthly, studies that
did distinguish between bullies and bully/victims found no adverse effects
of being a pure bully on adverse adult outcomes. This is consistent with
a view that bullies are highly sophisticated social manipulators who show
little empathy and are callous.36
Processes
There are a variety of potential routes by which being victimized may
affect later life outcomes. Being bullied may alter physiological responses
to stress,37 interact with a genetic vulnerability such as variation in the se-
rotonin transporter (5-HTT) gene,38 or affect telomere length (aging) or the
epigenome.39 Altered HPA-axis activity and altered cortisol responses may
not only increase the risk for developing mental health problems40 but also
increase susceptibility to illness by interfering with immune responses.41
A recent study found that bullied children may experience higher than
normal chronic inflammation and associated health problems that can per-
sist into adulthood.42 Blood tests for C-reactive protein (CRP), a marker
of low-grade systemic inflammation in the body often associated with
cardiovascular disease, metabolic syndrome, and psychological disorders,
revealed that CRP levels in the blood of bullied children increased with the
number of times they were bullied. Additional blood tests carried out on
the children after they had reached 19 and 21 years old revealed that those
who were bullied as children had CRP levels more than twice as high as
bullies, whereas bullies had CRP levels lower than those who were neither
bullies nor victims (see Figure A-3). Thus, bullying others appears to have
a protective effect in reducing the general rise in chronic inflammation
from childhood to early adulthood. This is consistent with studies showing
lower inflammation for individuals with higher socioeconomic status43 and
studies with non-human primates showing health benefits for those higher
in the social hierarchy.44 The clear implication of these findings is that both
ends of the continuum of social status in peer relationships are important
for inflammation levels and health status.
Furthermore, experiences of threat by peers may alter cognitive re-
sponses to threatening situations45 or affect school performance. Both al-
tered stress responses and altered social cognition (e.g., being hypervigilant
to hostile cues46) and neuro-circuitry47 related to bullying exposure may
affect social relationships with parents, friends, and co-workers. Finally,
victimization, in particular of bully-victims, has been found to be associated

APPENDIX A 123
FIGURE A-3 Adjusted mean young adult CRP levels (mg/L) based on childhood/
adolescent bullying status.
NOTE: These values are adjusted for baseline CRP levels as well as other CRP-
related covariates. All analyses used robust standard errors to account for repeated
observations.
SOURCE: Reprinted with permission from Copeland et al., 2014.
with poor concurrent academic achievement.48 In the UK alone, more than

16,000 young people aged 11–15 are estimated to be absent from state
school with bullying as the main reason, and 78,000 are absent where bully-
ing is one of the reasons given for absence.49 The risk of failure to complete
high school or college in chronic victims or bully/victims increases the risk
of poorer income and job performance.32
Summary and Implications

Childhood bullying has serious effects on health, leading to substantial
costs for individuals, their families and society at large. In the United States,
it has been estimated that preventing high school bullying results in life-
time cost benefits of more than $1.4 million per individual.50 Many bullied
children suffer in silence, and are reluctant to tell their parents or teachers
about their experiences, for fear of reprisals or shame.51 Up to 50 percent
of children say they would rarely, or never, tell their parents, while between
35 percent and 60 percent would not tell their teacher.52

Considering this evidence of ill effects of being bullied and the fact that
children will have spent much more time with their peers than their parents
by the time they reach 18 years of age, it is more than surprising that child-
hood bullying is not at the forefront as a major public health concern.53
Children are hardly ever asked about their peer relationships by health
professionals. This is because health professionals are poorly educated
about bullying and find it difficult to raise the subject or deal with it.54 To
prevent violence against oneself (e.g., self-harm) and reduce mental health
problems, it is imperative to address bullying!
Key Messages
• Childhood bullying is a significant risk factor leading to harmful
physical, psychological, and social effects that can last a lifetime.
• It affects children from all socioeconomic backgrounds and ethnic
groups and requires universal intervention.
• There is a need for greater awareness and responsiveness in pri-
mary and secondary health care as part of a communitywide,
integrated approach to stemming the effects of childhood bullying.
• Evidence-based guidance needs to be developed on how best to
identify affected children in health care, provide support to chil-
dren and their parents, and, where necessary, make referrals to
appropriate agencies for associated physical and mental health
problems.
• Effective interventions that can be delivered in primary care to
minimize the consequences of being bullied are needed. These may
include innovative online interventions.55
• New approaches are needed to channel the considerable leadership
abilities and need for social recognition of bullies into socially ac-
ceptable and prosocial activities.
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Appendix B
Workshop Agenda
Mental Health and Violence:

Opportunities for Prevention and Early Intervention
A Workshop of the
National Academies of Sciences, Engineering, and Medicine’s
Forum on Global Violence Prevention
February 26–27, 2014
Keck Center of the National Academies of

Sciences, Engineering, and Medicine
500 Fifth Street NW, Washington, DC 20001
Rooms 100 and 101
(Room 101 is the overflow room with webcasting)
129

The goal of this workshop is to examine the evidence, research,

and perspectives about mental health and violence to facilitate
enhanced global action and policies for the prevention of violence
associated with mental illness, as well as treat its consequences that
occur around the world.
The workshop will explore a continuum of approaches for
improving both mental health and violence prevention with the
following objectives:
• To arrive at a better understanding of the intersection of

mental health and violence, including the following:
o The relationship between mental health and risk of both
violence perpetration and victimization, as well as the
mental health consequences of exposure to violence
o The extent to which improved mental health function-
ing and mental health services can address current con-
cerns about violence in society
• To explore a new model of the intersection of mental
health and violence that will be useful for improving out-
comes. The model will include the following:
o A description of mental health function as a continuum
from optimal to dysfunctional, with problems ranging
from minor to serious distress to antisocial behavior to
severe mental illness
o Perpetration of violence, victims of violence, and expo-
sure to violence
o Interpersonal, self-directed, and collective violence
o Neurobiology of violent behavior
o Multiple ecological levels to be considered
o A life-course/developmental perspective
o Means of violence perpetration, including access to
weapons
o Identification of the multiple sectors that must be in-
volved, as well as their intersection

APPENDIX B 131
Day 1: Wednesday, February 26, 2014
8:00 AM Continental Breakfast
8:10 AM Welcome from the National Academies of Sciences, Engineer-

ing, and Medicine
• Patrick Kelley, National Academies of Sciences,

Engineering, and Medicine’s Board on Global Health and
African Science Academy Development Initiative
8:15 AM Welcome and Workshop Goals
• Peggy Murray, National Institute on Alcohol Abuse and

Alcoholism, Workshop Planning Committee Co-Chair
• Mark Rosenberg, The Task Force for Global Health,
Workshop Planning Committee Co-Chair
8:45 AM Opening Keynote
The intersection of mental health and violence is a critical and

complex public health problem. Considering the importance
and complexity of the issue, this keynote address will focus on:
What do we know? What do we need to know? And, what can
we do now to improve outcomes in this area?
• Thomas Insel, National Institute of Mental Health
Part I: Understanding the Problem

9:15 AM–2:00 PM
The objectives of this session include highlighting the inter-

section of mental health and violence through a common under-
standing of terms, a description of the risk and protective factors
that come into play on various ecological levels, and identification
of the significant neurocognitive mechanisms related to violence.
Additionally, a panel of individuals will share their lived experi-
ences and perspectives of mental health and violence.

9:15 AM Operational Definitions for the Workshop

This presentation will provide operational definitions of key
terms for the new model being explored during the workshop,
including mental health, mental illness, violence, conduct dis-
order, alcohol and substance use disorders, perpetrators, and
victims.
• Vickie Mays, University of California, Los Angeles
9:45 AM Ecological Framework

This session will present an overview and discussions of risk
and protective factors and intervention points related to mental
health and violence at the individual, relationship, community,
and societal levels.
• Eric Caine, University of Rochester Medical Center

• Janis Jenkins, University of California, San Diego
10:30 AM BREAK
10:45 AM What Is the Relationship Between Various Mental Illnesses and

Violence?
This presentation will include what is known about the relation
ship between various mental illnesses and violence and why it is
important for what is known to be represented accurately. The
presentation will be followed by discussion with the workshop
participants.
• Mark Rosenberg
11:30 AM Understanding the Neurocognitive Mechanisms of Violent

Behavior
This presentation will include a sketch of some of the neu-
rocognitive mechanisms related to violence and how such
mechanisms are affected by various factors, including stress
and alcohol, and how they can be used for prediction. The
presentation will be followed by discussion with the workshop
participants.
• James Blair, National Institute of Mental Health
12:00 PM LUNCH

APPENDIX B 133
1:00 PM Experiences and Perspectives Related to Mental Health and

Violence
This session includes experiences and perspectives of men-
tal health and violence, including stigma, victimization, and
vulnerability, as well as media depictions of the relationship
between mental illness and violence. The presentations will be
followed by discussion with the workshop participants.
Moderator/Panelist: Daniel Fisher, Riverside Community

Mental Health Center
• Elyn Saks, University of Southern California (by video-
conference)
• Harvey Rosenthal, New York Association of Psychiatric
Rehabilitation Services, Inc.
Discussant: Robert Bernstein, Judge David L. Bazelon
Center for Mental Health Law
Part II: Exploring a New Model of the Intersection of Mental

Health and Violence
Day 1: 2:00–5:15 PM and Day 2: 8:20 AM–2:15 PM
The objectives for this session are to explore a multifactorial

model of the intersection of mental health and violence and to illu
minate the current evidence of the effectiveness of key interventions
for preventing violence and promoting mental health. Topics to
be covered include detecting and assessing risk for mental health
dysfunction and violence; the values and limitations of current
assessments; the role of varying means of violence; the relationship
of alcohol and alcohol use disorders in occurrences of violence;
the opportunities in mental health service delivery for preventing
violence and providing care to victims, perpetrators, and observers;
and the critical significance of the interface between the criminal
justice community and individuals with mental illness in preventing
violence victimization and perpetration.

2:00 PM Detecting and Assessing Mental Health Dysfunction and Risk

for Violence
This panel will explore current capabilities to identify and
assess mental health dysfunction and the risk for violence
and how this affects treatment. Panelists will discuss both the

values and limitations of the current state of risk assessment

and how assessment can be improved. The presentations will
be followed by discussion with the workshop participants.
Moderator: Vickie Mays

• Seena Fazel, University of Oxford, United Kingdom
• Dustin Pardini, University of Pittsburgh
• Dieter Wolke, University of Warwick, United Kingdom
3:30 PM BREAK
3:45 PM Mental Health and Means of Violence

The means of violence vary by nation, culture, and often by
circumstances of convenience. This panel will explore issues of
access to means that include the legal and constitutional rights
of individuals and the public at large. Panelists will examine
practices and tools that show promise in the prevention of
violence while balancing the needs and rights for individual
and information privacy. The panel will also discuss the need
for improvements in early and correct identification of people
who are at risk for committing violence that do not create or
compound barriers to seek needed care. Lastly, the panel will
discuss what is needed to improve research and intervention
design to contribute to better outcomes in violence preven-
tion and early intervention. Panelists will present on firearms,
homicide, and nonfatal injuries and pesticides, other means,
and suicide. The presentations will be followed by discussion
with the workshop participants.
Moderator: Mark Rosenberg

• Daniel Webster, Johns Hopkins Bloomberg School of
Public Health
• Michael Phillips, Shanghai Jiao Tong University School
of Medicine
Discussant: Mike Luo, The New York Times (by telephone)

5:15 PM Summary of Day 1 and Wrap Up
• Peggy Murray
5:30 PM Adjourn Day 1

APPENDIX B 135
Day 2: Thursday, February 27, 2014
8:00 AM Continental Breakfast
8:15 AM Opening and Summary of Day 1
• Peggy Murray
• Mark Rosenberg
8:20 AM Alcohol, Alcohol Use Disorders, and Violence

Alcohol is one of the most significant risk factors for violence.
At the same time, alcohol addiction and the harmful use of
alcohol are among the identified alcohol use disorders in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. This panel will focus on the unique role of alcohol
consumption and alcohol use disorders in the occurrence of vio
lence and current developments in interventions to address it.
Presentations will cover a range of scientific and policy-focused
activities ranging from basic research to h uman laboratory
studies of behavior, and finally, evidence-based interventions
and effective alcohol control policies. The presentations will
Moderator: Peggy Murray

• Klaus Miczek, Tufts University
• Kenneth Leonard, University at Buffalo
• Toben Nelson, University of Minnesota
• Ronaldo Laranjeira, Universidade Federal de São Paulo,
Brazil
9:45 AM Violence Prevention and Mental Health Services

This panel will describe how mental health services present the
opportunity to prevent violence while providing care to those
in need including victims and perpetrators of violence. Panel-
ists will explore service and care access, current capabilities for
risk identification and risk reduction, opportunities for early
intervention and response, and strategies for improvement of
mental health services for prevention and early intervention.
The presentations will be followed by discussion with the
workshop participants.

Moderator: A.J. Allen, Eli Lilly and Company

• Colleen Barry, Johns Hopkins Bloomberg School of
Public Health
• Sharon Stephan, University of Maryland
• Dévora Kestel, Pan American Health Organization
11:00 AM BREAK
11:15 AM Interface with the Justice Community and Opportunities for

Intervention
In the United States in the 1960s, deinstitutionalization of per-
sons with mental illness shifted psychiatric care from long-term
inpatient hospitals to community mental health and other out-
patient facilities. Unintended consequences, including lack of
adequate funding to mental health centers, lack of employment
opportunities, and a dearth of low-income housing resulted in
many people not receiving either adequate treatment or housing.
Many mentally ill people were on the streets and had significant
interface with the criminal justice system. This panel will exam-
ine that interface across the three components of criminal jus-
tice: law enforcement, criminal courts, and incarcerations. With
a focus on each of the components and with a global perspec-
tive, panelists will present the challenges to balancing civil rights
and public interest, the opportunities for creative interventions,
and the obstacles and risks that remain. The presentations will
Moderator: Madelon Baranoski, Yale University

• Sheldon Greenberg, Johns Hopkins University School
of Education
• Ray Kotwicki, Skyland Trail
• David Wexler, International Network of Therapeutic
Jurisprudence
• Patrick Fox, University of Colorado
12:45 PM LUNCH
1:45 PM How Are Interventions Being Evaluated? How Can Evaluation

Be Improved?
The principal goals of prevention science are to improve public
health by identifying alterable risk and protective factors and
to assess the effectiveness of prevention interventions includ-
ing optimal modes for diffusion and dissemination. Theories

APPENDIX B 137
of human development and social ecology are often used to

design interventions that aim to elicit behavior change, espe-
cially those that examine violence or mental health from a life-
course perspective. This session will examine the successful use
and limitations of randomized controlled trials for determining
efficacy of interventions for violence prevention; the alternative
rigorous evaluation designs to evaluate their effectiveness and
impact; and how well the programs are being implemented.
Evaluation findings can lead to program or intervention adap-
tation, quality improvement for existing programs, improved
design for future interventions, and sustainability for effective
interventions. Partners to engage in evaluations and program
impact improvement efforts will also be discussed.
• Hendricks Brown, Northwestern University
Moderator for question-and-answer session only:
• Kimberly Scott, Health and Medicine Division
Part III: The Way Forward

2:15–4:00 PM
The objective for this session is to examine how to improve

outcomes with respect to mental health and violence. The focus
will be on three areas: research, policy change, and program devel
opment. Questions to be addressed include the following: How
do we reframe the issue in a manner that will promote under-
standing and improve both mental health promotion and violence
prevention? What are the most important research questions that
need to be addressed? How do we communicate more effectively
with the various constituencies that need to be involved? How do
we mobilize the various sectors and actors who have important
roles in research, program and policy development, financing, and
implementation? What are the significant barriers and how can
they be overcome? How should we move forward? What are the
priority items for the agenda going forward? Panelists have been
drawn from the perspectives of mental health services, criminal jus-
tice, culture and anthropology, mental health services in low- and
middle-income countries, and violence prevention.

2:15 PM Reflections from the Workshop and the Way Forward
Moderator: Mark Rosenberg

• Colleen Barry, Johns Hopkins Bloomberg School of
Public Health
• Sheldon Greenberg, Johns Hopkins University School
of Education
• Janis Jenkins, University of California, San Diego
• Dévora Kestel, Pan American Health Organization
• James Mercy, Centers for Disease Control and Prevention
3:30 PM Open Discussion
4:00 PM Workshop Adjournment

Appendix C
Workshop Speaker Biographies

As of February 2014
Albert J. Allen, M.D., Ph.D., is the senior medical fellow with responsibility
for bioethics and pediatric capabilities at Lilly Research Labs, Eli Lilly and
Company, Indianapolis, Indiana. Dr. Allen received a B.S. in chemistry and
an M.S. in biochemistry from The University of Chicago and an M.D. and
a Ph.D. from the University of Iowa. In 1995, Dr. Allen and his mentors,
Dr. Susan Swedo and Dr. Henrietta Leonard, shared the American Academy
of Child and Adolescent Psychiatry’s Norbert and Charlotte Rieger Award
for Scientific Achievement for their research on possible infection-triggered
cases of obsessive compulsive disorder (OCD) and tics. In the same year,
he joined the Institute for Juvenile Research at the University of Illinois
at Chicago, where he was an assistant professor in child and adolescent
psychiatry. In Chicago, he established and ran a pediatric OCD and tic
disorders clinic. He joined Eli Lilly in April 2000 and, in late 2003, he
became global medical director of the Strattera Product Team. In October
2004, he was made global medical director of the Neuroscience Platform
Team. In the past few years, he was the senior medical director globally
for attention deficit hyperactivity disorder (ADHD) and related disorders.
He was also extensively involved with several activities related to pediatric
studies and global regulatory activities across Lilly’s neuroscience products,
and has participated in pharmaceutical industry activities in pediatric drug
development and the assessment of drugs in development for human abuse
liability. He chairs Lilly’s Bioethics Advisory Committee and co-chairs
Lilly’s Pediatric Steering Committee, and he is the past chair of Lilly’s Drug
Abuse Liability and Dependence Advisory Committee. Dr. Allen is a mem-
ber of the American Psychiatric Association and the American Academy
139

of Child and Adolescent Psychiatry. He is also a specialty fellow of the

American Academy of Pediatrics. In July 2012, he was appointed to the
Secretary’s Advisory Committee on Human Research Protections, a federal
advisory committee in the U.S. Department of Health and Human Services
(HHS) that provides expert advice and recommendations to the Secretary
of HHS on issues and topics pertaining to the protection of human research
subjects.
Paul S. Appelbaum, M.D., is the Elizabeth K. Dollard Professor of Psychia-

try, Medicine, and Law, and director of the Division of Psychiatry, Law,
and Ethics, Department of Psychiatry, College of Physicians and Surgeons
of Columbia University; a research psychiatrist at the New York State Psy-
chiatric Institute; and an affiliated faculty member, Columbia Law School.
He directs Columbia’s Center for Research on Ethical, Legal, & Social
Implications of Psychiatric, Neurologic, & Behavioral Genetics, and heads
the Clinical Research Ethics Core for Columbia’s Clinical and Translational
Science Award program. His research interests include the prediction and
management of violent behavior by people with mental illness. He is the
author of many articles and books on law and ethics in clinical practice
and research. Dr. Appelbaum is a graduate of Columbia College, received
his M.D. from Harvard Medical School, and completed his residency in
psychiatry at the Massachusetts Mental Health Center of the Harvard
Medical School in Boston. He is past president of the American Psychiatric
Association and a member of the National Academy of Medicine.
Madelon Baranoski, Ph.D., M.S.N., is an associate professor in the Depart

ment of Psychiatry, Law and Psychiatry Division, of Yale University School
of Medicine, and faculty in the Immigration and Veterans Clinics in the
Yale Law School. She is also vice chair of the Yale University Human
Investigation Committees and the director of the New Haven Jail Diversion
Program of the Connecticut Department of Mental Health and Addiction
Services and the Connecticut Mental Health Center. Her research interests
include violence risk assessment and management, cultural manifestations
of trauma and depression, assessment of competency in court-ordered eval-
uations, and state-of-mind evaluations. Dr. Baranoski received her B.S.N.
from the University of Maryland Walter Reed Army Institute in 1969, her
M.S.N. from Yale University School of Nursing in 1974, and her Ph.D. in
clinical and developmental psychology from the University of Pennsylvania
in 1982. She has published and presented on risk assessment and manage-
ment in psychiatric populations.
Colleen L. Barry, Ph.D., M.P.P., is an associate professor and an associate

chair for research and practice in the Department of Health Policy and

APPENDIX C 141
Management at the Johns Hopkins Bloomberg School of Public Health.

Professor Barry conducts policy analysis and political communication re-
search with a focus on vulnerable populations and often stigmatized health
conditions, including mental illness, substance use, and obesity. Much of
her current research involves examining the implications of various aspects
of the Patient Protection and Affordable Care Act on persons with mental
illness and/or substance use disorders. She has also led studies examining
public opinion and political persuasion in the context of childhood obesity,
mental illness, and gun policy.
Robert Bernstein, Ph.D., is a psychologist with a strong interest in ensuring

meaningful community participation and promoting the consumer voice
within mental health systems, particularly for individuals who are marginal-
ized or neglected by public systems. For 19 years before his appointment to
this post, Dr. Bernstein was the architect and director of one of the nation’s
oldest and largest mental health and aging programs. NSO-Older Adult Ser-
vices in Detroit, Michigan, featured an innovative system that blended in-
home services and advocacy to support older adults with persistent mental
illnesses in integrated community settings. In addition to his work with that
trailblazing program, he ran a private practice where he specialized in treat-
ing children and adolescents. Dr. Bernstein is a leader in the field of mental
health policy and advocacy. He has published several important papers
and served as an expert in litigation concerning such areas as conditions
in psychiatric institutions, the use of seclusion and restraint, community
mental health, older adult needs, and fair housing. He also contributed to
the preparation of the 1999 Surgeon General’s Report on Mental Health
and the President’s New Freedom Commission on Mental Health.
James Blair, M.D., is the chief of the Unit on Affective Cognitive Neuro
science at the National Institute of Mental Health (NIMH). Dr. Blair
received a doctoral degree in psychology from University College L ondon
in 1993 under the supervision of Professor John Morton. Following
graduation, he was awarded a Wellcome Trust Mental Health Research
Fellowship, which he held at the Medical Research Council Cognitive
Development Unit for 3 years. Subsequently, he moved to the Institute
of Cognitive Neuroscience, University College London. There, with Uta
Frith, he helped form and co-lead the Developmental Disorders group,
and was ultimately appointed senior lecturer. He joined the NIMH Intra
mural Research Program in 2002. Dr. Blair’s primary research interest
involves understanding the neurocognitive systems mediating affect in
humans and how these become dysfunctional in mood and anxiety dis-
orders. His primary clinical focus is on understanding the dysfunction of
affect-related systems in youth with specific forms of conduct disorder.

His research approach includes techniques employed in cognitive neuro-

science (both neuropsychology and functional imaging), psychopharma-
cology, and molecular genetics.
C. Hendricks Brown, Ph.D., is a professor in the Departments of Psychia-

try and Behavioral Sciences and Preventive Medicine in the Northwestern
University Feinberg School of Medicine. He also holds adjunct appoint-
ments in the Departments of Biostatistics and Mental Health at the Johns
Hopkins Bloomberg School of Public Health, as well as in the Department
of Public Health Sciences at the Miller School of Medicine at the University
of Miami. He directs the National Institute on Drug Abuse–funded Center
for Prevention Implementation Methodology (Ce-PIM) for Drug Abuse and
Sexual Risk Behavior and an NIMH-funded study to synthesize findings
from individual-level data across multiple randomized trials for adolescent
depression. Recently, his work has focused on the prevention of drug abuse,
conduct disorder, depression, and particularly the prevention of suicide. Dr.
Brown has been a member of the National Academies of Sciences, Engi
neering, and Medicine’s Committee on Prevention Science, and serves on
numerous federal panels, advisory boards, and editorial boards.
Eric Caine, M.D., has investigated factors that contribute to suicide, with
a focus on links to unemployment, choice of specific methods, burdens of
suicide, and attempts during young and middle adulthood. Past research
has focused on military personnel and their families in the areas of inti
mate partner and family violence and suicide. Currently, his work has
addressed public health approaches to prevention that complement indi
vidually oriented treatments. He has been the principal investigator of
multiple N ational Institutes of Health (NIH) research and training grants
related to suicide research and prevention. Since 2001, he has led a series
of collaborative initiatives in China that deal with suicide prevention, the
delivery of mental health services in developing countries, and the potential
for public health approaches to reduce injuries and deaths.
Seena Fazel, M.D., F.R.C.Psych., is a Wellcome Trust senior research fellow

in clinical science at the University of Oxford, and a consultant forensic
psychiatrist at Oxford Health National Health Service (NHS) Foundation
Trust. His research work focuses on relationship between severe mental ill-
ness and violent crime, violence risk assessment, and the mental health and
the suicide risk of prisoners. He has served on advisory boards for NHS
research funding committees and the crime reduction charity Nacro, and
has given evidence to the U.K. Government Justice Select Committee and
the United Nations–backed Khmer Rouge war crimes tribunal.

APPENDIX C 143
Daniel Fisher, M.D., Ph.D., obtained a Ph.D. in biochemistry to discover the

possible chemical basis of mental health issues. While carrying out neuro
chemical research at the National Institute of Mental Health, Dr. Fisher was
diagnosed with schizophrenia. He recovered through building meaningful
relationships. He found a biochemical explanation of behavior too alienat-
ing; to humanize the mental health system, he obtained an M.D. at The
George Washington University Medical School and completed psychiatric
training at Harvard University. Dr. Fisher worked for 25 years as a commu-
nity psychiatrist at a mental health center, founded the National Empower
ment Center, has been a member of the New Freedom Commission on
Mental Health, and helped organize the National Coalition for Mental
Health Recovery. He has given more than 1,000 speeches and workshops
on recovery and peer support across the United States and in 12 countries.
He is on the faculty of the University of Massachusetts Department of Psy-
chiatry, where he is helping to adapt Open Dialogue to the United States.
Dr. Fisher helped peers in Louisiana respond to the emotional crises follow-
ing Hurricanes Katrina and Rita. Based on his post-Katrina experiences, he
helped develop Emotional CPR.
Patrick Fox, M.D., completed his residency training in general adult and
forensic psychiatry at the Yale School of Medicine in 1999. He is board
certified in Adult General and Forensic Psychiatry. Additionally, he currently
serves on the Forensic Examination Committee for the American Board of
Psychiatry and Neurology. He has presented nationally and internationally
on seclusion and restraint reform, physician-assisted suicide, mental health
reform, sex offender management, violence risk management, outpatient civil
commitment, and jail diversion programs. He has also served on state panels
addressing access to care for and management of youth with psychiatric dis-
abilities, sex offender registration, sexually violent predator statutes, and civil
commitment. Following his completion of residency and fellowship training,
Dr. Fox remained on the faculty at Yale as an assistant professor, working
initially as a consulting forensic psychiatrist for the Connecticut Department
of Mental Health and Addiction Services, and later serving as director for
the Whiting Forensic Division, Connecticut’s maximum security forensic
hospital. Additionally, he was deputy director for Yale’s Forensic Psychiatry
Training Program from 2007 to 2012. In 2012, he took a position as at-
tending psychiatrist for the Denver County Sheriffs’ Department, managing
the city jail’s most acutely ill inmates. In April 2013, Dr. Fox was appointed
deputy director of clinical services for the Colorado Department of Human
Services’ Office of Behavioral Health. He has been serving as acting director
for the Office of Behavioral Health since October 2013. In this capacity, he
is responsible for overseeing all administrative and clinical services related to
the provision of mental health and substance abuse treatment for the office.

Sheldon Greenberg, Ph.D., is a professor of management in the School

of Education, Division of Public Safety Leadership at the Johns H opkins
School of Education. He served as associate dean for more than a decade,
during which time he led the Police Executive Leadership Program and
established university partnerships with the U.S. Secret Service and the U.S.
Immigration and Customs Enforcement. For almost 2 years, Dr. Greenberg
served as associate dean and interim director of the Johns Hopkins Univer-
sity Division of Business and Management (currently the Carey Business
School). His primary research interests are police patrol, the relationship
between police and public health, police organizational structure, highway
safety, campus and school safety, the role of the police in community de-
velopment, and community organizing. Before joining Johns Hopkins Uni-
versity, Dr. Greenberg served as associate director of the Police Executive
Research Forum, the nation’s largest law enforcement think tank and center
for research. He began his career with the Howard County, Maryland,
Police Department, where he served as a patrol officer, supervisor, director
of the police academy, director of research and planning, and commander
of the Administrative Services Bureau. He worked with the U.S. Marshals
Service, U.S. Border Patrol, U.S. Department of Justice, and U.S. Depart-
ment of State, as well as with police agencies in C
yprus, the Czech Republic,
Hungary, Jordan, Kenya, Pakistan, and Panama. Dr. Greenberg has served
on national commissions and task forces on violence in schools, race-based
profiling, police response to people who have mental illness, police recruit-
ing, highway safety, military deployment, and homeland defense. He serves
also as a member of the Federal Law Enforcement Training Accreditation
Board. Dr. Greenberg is the author of numerous articles and several books,
including Stress and the Helping Professions, Stress and the Teaching Pro-
fession, and On the Dotted Line, a guide to hiring and retaining police
executives. He has completed his fourth book, Mastery of Police Patrol,
which will be published by Pearson Prentice Hall, and is working on his
fifth book on managing community fear.
Thomas R. Insel, M.D., is the director of the National Institute of Mental

Health (NIMH), the component of the National Institutes of Health
(NIH) committed to research on mental disorders. Dr. Insel has served
as director of this $1.5 billion agency since 2002. During his tenure,
he has focused on the genetics and neurobiology of mental disorders,
as well as transforming approaches to diagnosis and treatment. Before
serving as NIMH director, Dr. Insel was professor of psychiatry at Emory
University, where he was founding director of the Center for Behavioral
Neuroscience and director of the Yerkes Regional Primate Center in
Atlanta. Dr. Insel’s research has examined the neural basis of complex
social behaviors, including maternal care and attachment. A member of

APPENDIX C 145
the National Academy of Medicine, he has received numerous national and

international awards and served in several leadership roles at NIH.
Janis Jenkins, Ph.D., received her Ph.D. from the University of California,
Los Angeles, and completed her postdoctoral training in clinically relevant
medical anthropology at Harvard Medical School. She is internationally
recognized for her expertise on cultural and mental health. Her principal
interests include the course and outcome of major mental illness, psy-
chopharmacology, ethnicity, violence, adolescence, resilience, and quali-
tative methods. Her research has been conducted with Latino and Latin
American immigrants and refugees, along with Euro-American, African
American, and Native American populations. As co-principal investigator
for the National Institute of Mental Health (NIMH)-funded study “South-
west Youth and the Experience of Psychiatric Treatment,” Dr. Jenkins
and her team have investigated psychiatric disorders, cultural meaning,
and violence among adolescents who have received inpatient treatment
in New Mexico. Dr. Jenkins has been on faculty at Harvard University,
Case Western Reserve University, and University of California, San Diego,
where she is professor of anthropology and adjunct professor of psychiatry.
She has been principal investigator for a series of NIMH-funded studies
on culture and mental health. She has also been awarded funding by the
School for Advanced Research and the National Alliance for Research on
Schizophrenia and Depression. Dr. Jenkins has served as a member of three
Scientific Review Groups at NIMH. She is a member of the Institute for
Advanced Studies in Princeton, New Jersey (in residence during academic
year 2011–2012). She has been visiting scholar-in-residence at the Russell
Sage Foundation in New York City, the Institute of Social Medicine in Rio
de Janeiro, and Distinguished Visiting Faculty at Monash University in
Melbourne, Australia. She has published widely in scientific journals, in-
cluding American Journal of Psychiatry, British Journal of Psychiatry, and
Medical Anthropology Quarterly. She has published two edited volumes:
Schizophrenia, Culture, and Subjectivity: The Edge of Experience (with
R. J. Barrett) by Cambridge University Press (2004) and Pharmaceutical
Self: The Global Shaping of Experience in an Age of Psychopharmacology
(School for Advanced Research, 2011).
Patrick W. Kelley, M.D., Dr.P.H., joined the National Academies of Sci-

ences, Engineering, and Medicine in July 2003 as the director of the Board
on Global Health. He was subsequently appointed as the director of the
Board on African Science Academy Development. Dr. Kelley has overseen
a portfolio of National Academies expert consensus studies and convening
activities on subjects as wide ranging as the evaluation of the President’s
Emergency Plan for AIDS Relief (PEPFAR); the U.S. commitment to global

health; sustainable surveillance for zoonotic infections; substandard, falsi-

fied, and counterfeit drugs; innovations in health professional education;
cardiovascular disease prevention in low- and middle-income countries;
interpersonal violence prevention in low- and middle-income countries; and
microbial threats to health. He also directs a unique capacity-building
effort, the African Science Academy Development Initiative, which over
11 years aims to strengthen the capacity of eight African academies to pro-
vide independent, evidence-based advice to their governments on scientific
matters.
Before joining the National Academies, Dr. Kelley served in the U.S.
Army for more than 23 years as a physician, residency director, epide-
miologist, and program manager. In his last U.S. Department of Defense
(DoD) position, Dr. Kelley founded and directed the DoD Global Emerging
Infections Surveillance and Response System. This responsibility entailed
managing surveillance and capacity-building partnerships with numerous
elements of the federal government and with health ministries in more
than 45 developing countries. He also founded the DoD Accession Medical
Standards Analysis and Research Activity and served as the specialty editor
for a landmark two-volume textbook, titled Military Preventive Medicine:
Mobilization and Deployment. Dr. Kelley is an experienced communicator
having lectured in English or Spanish in over 20 countries. He has authored
or co-authored more than 70 scholarly papers, book chapters, and mono-
graphs and has supervised the completion of more than 25 National Acad-
emies consensus reports and workshop summaries. While at the National
Academies, he has obtained grants and contracts for work conducted by his
unit from more than 60 governmental and nongovernmental sources. Dr.
Kelley obtained his M.D. from the University of V irginia and his Dr.P.H. in
epidemiology from the Johns Hopkins Bloomberg School of Public Health.
He has also been awarded two honorary doctoral degrees and is board
certified in Preventive Medicine and Public Health.
Dévora Kestel, M.Sc., M.P.H., is a mental health regional adviser at the Pan
American Health Organization (PAHO). She is Argentinean and obtained
her M.Sc. in psychology (Universidad Nacional de La Plata). She later
earned an M.Sc. in public health at the London School of Hygiene and
Tropical Medicine. After completing her university studies in Argentina,
she moved to Italy, where she worked for 10 years in the development
and supervision of community-based mental health services in Trieste and
other cities of the region. In 2000, she joined the World Health Organiza-
tion (WHO) in Kosovo as a mental health officer. In 2001, she moved to
Albania, holding the same position until 2006, when she was appointed
WHO Representative to Albania. In both countries, she worked closely with
the Ministries of Health to help establish comprehensive community-based

APPENDIX C 147
mental health systems. In 2007, Mrs. Kestel joined PAHO as a subregional

mental health adviser for the English-speaking Caribbean countries, based
in Barbados. Since November 2011, Mrs. Kestel has served as the regional
mental health adviser, based in Washington, DC, providing technical co-
operation in the mental health field to the region, with special attention to
the Caribbean subregion.
Ray Kotwicki, M.D., M.P.H., is passionate about linking excellent clinical

care with medical student education. As the director of medical student
education for the Department of Psychiatry and Behavioral Sciences at
Emory University’s School of Medicine, he focuses on helping trainees
cultivate not only proficiency in delivery of mental health and primary care
medical services, but also medical professionalism. In partnership with
Dr. Lisa B
ernstein from the Department of Internal Medicine, Dr. Kotwicki
co-directs the Emory School of Medicine’s “Becoming A Doctor” curricu-
lum, a 4-year longitudinal program designed to train medical students in
the highest standards of clinical skills, professionalism, ethics, and medi-
cal professionals’ roles and responsibilities within society. He received the
prestigious Dean’s Golden Apple Teaching Award in 2010. In addition to
his responsibilities in education, Dr. Kotwicki serves as chief medical officer
of Skyland Trail, a private nonprofit community treatment facility recently
awarded the American Psychiatric Association’s Gold Award. Skyland
Trail’s mission is to inspire people with mental illness to thrive through a
holistic program of evidence-based psychiatric treatment, integrated medi-
cal care, research, and education. Services offered at Skyland Trail include
residential treatment, partial hospitalization, intensive outpatient care, and
community-based health navigation support, based on patients’ individu-
alized recovery plan and needs. Emory’s medical students beginning their
psychiatry clerkships orient at Skyland Trail, and several remain at the
program for the duration of their mental health training. Dr. Kotwicki is
past president of the Board of Positive Impact, Inc., a prevention and service
delivery program for people infected with or affected by HIV/AIDS, and
currently sits on the Board of Directors for Georgia Psychiatric Physicians
Association and Mental Health America of Georgia. He contributes to the
Emory community in other ways as well, including roles within the Medical
School’s Admission Committee, Progress and Promotions Committee, and
Executive Curriculum Committee. The National Alliance on Mental Illness
honored Dr. Kotwicki’s many contributions to training law enforcement
officers on crisis intervention techniques by naming him an “Exemplary
Psychiatrist in Georgia” in 2007.
Ronaldo Laranjeira, Ph.D., is a professor of psychiatry and addictive behav-

iors at the Federal University of São Paulo, and the director of the National

Institute of Alcohol and Drugs Policies, Brazil. He finished his Ph.D. at the
London University, National Addiction Center, with Professor Griffith Ed-
wards in 1995. He returned to São Paulo, Brazil, and set up an Addiction
Research Unit. His work at the National Addiction center has focused on
several areas: organizing for the first time in Brazil two national household
surveys on alcohol and drugs, in collaboration with Dr. Raul Caetano from
Texas University; working on the study and implementation of alcohol and
drug policies in the community, such as the closing of bars in the city of
Diadema, zero blood alcohol concentration for drivers, partner violence
related to alcohol, and violence and mortality related to “crack/cocaine”
use; implementing an alcohol and drug treatment system in the State of São
Paulo. Dr. Laranjeira is also a member of the Department of Addiction of
the Brazilian Psychiatric Association.
Kenneth Leonard, Ph.D., is the director of the Research Institute on

Addictions and a research professor of psychiatry at the University at
Buffalo Medical School. He received his Ph.D. in clinical psychology from
Kent State University in 1981, and postdoctoral training in psychiatric and
alcohol epidemiology at the Western Psychiatric Institute and the Clinic at
the University of Pittsburgh. He is a Fellow in Divisions 50 (Addictions) and
28 (Psychopharmacology and Substance Abuse) in the American Psycholog-
ical Association, and is a former president of Division 50. He is a member
of the International Society for Research on Aggression, and is currently a
council member for this organization. He is also a member of the Research
Society on Alcoholism. He has been a member of the editorial board of the
Journal of Studies on Alcohol since 1992, a member of the Board of Direc-
tors of Alcoholism: Clinical and Experimental Research, and a member of
the Editorial Advisory Board, Review of Aggression and Violent Behavior.
He served as associate editor for the Journal of Abnormal Psychology and
has been consulting editor for the Journal of Abnormal Psychology and for
Psychological Bulletin. Dr. Leonard’s research interests have centered on
the interpersonal and familial influences on substance abuse, as well as the
influence of substance abuse on interpersonal and family processes. He is
internationally recognized for his research on substance abuse and intimate
partner violence, but has been concerned with the impact of alcoholism on
child development and the role of marital and family processes in the pre-
vention and treatment of substance abuse. He has also conducted research
focused on the prevalence of violence in the lives of young men and women,
and factors associated with “bar room” violence.
Michael Luo has worked at The New York Times since 2003. He became
deputy metropolitan editor in 2014, helping to oversee coverage of New
York City and the surrounding region and directing a team of reporters

APPENDIX C 149
focusing on investigations and long-form feature projects. Before becoming

an editor, he was a reporter for 3 years in The New York Times’s inves-
tigations cluster. Much of his work explored gaps in gun laws and their
impact on public safety, as well as the influence of the gun lobby. He spent
2012 working on investigative stories related to the presidential campaign.
Mr. Luo has written about economics and the recession as a national cor-
respondent; covered the 2008 presidential campaign and the 2010 midterm
elections; and done stints in the Washington, DC, and Baghdad bureaus. He
started at the paper on the metropolitan desk. Before joining The New York
Times, he was a national writer at The Associated Press, where he wrote
narrative feature stories from around the country. He has also worked
at Newsday and the Los Angeles Times. In 2002, he won a George Polk
Award for criminal justice reporting and a Livingston Award for Young
Journalists for a series of articles on three poor, mentally retarded African
Americans in Alabama who were in prison for killing a baby who probably
never existed. As a result of the series, two of the prisoners were freed; the
third remained in prison on a separate charge. Mr. Luo graduated in 1998
from Harvard University, where he majored in government.
Vickie M. Mays, Ph.D., M.S.P.H., is a professor in the Department of Psy-

chology in the College of Letters and Sciences, as well as a professor in the
Department of Health Policy and Management. Professor Mays is also the
director of the University of California, Los Angeles, Center on Research,
Education, Training, and Strategic Communication on Minority Health
Disparities. She teaches courses on health status and health b ehaviors of
racial and ethnic minority groups, research ethics in biomedical and be-
havioral research in racial/ethnic minority populations, research methods
in minority research, as well as courses on social determinants of mental
disorders and psychopathology. She holds a Ph.D. in clinical psychology
and an M.S.P.H. in health services, with postdoctoral training in psychiatric
epidemiology, survey research as it applies to ethnic minorities (University
of Michigan) and health policy (RAND). Professor Mays’ research primar-
ily focuses on the mental and physical health disparities affecting racial and
ethnic minority populations. She has a long history of research and policy
development in the area of contextual factors that surround HIV/AIDS in
racial and ethnic minorities. This work ranges from looking at barriers to
education and services to understanding racial-based immunological dif-
ferences that may contribute to health outcome disparities. Other areas of
research include looking at the role of perceived and actual discrimination
on mental and physical health outcomes, particularly as these factors im-
pact downstream disease outcomes. Her mental health research examines
availability, access, and quality of mental health services for racial, ethnic,
and sexual minorities. She is the co-principal investigator of the California

Quality of Life Survey, a population-based study of more than 2,200 Cali-

fornians on the prevalence of mental health disorders and the contextual
factors associated with those disorders.
James A. Mercy, Ph.D., is a special adviser for strategic directions at the

Division of Violence Prevention in the National Center for Injury Preven-
tion and Control of the Centers for Disease Control and Prevention (CDC).
He began working at CDC in a newly formed activity to examine violence
as a public health problem and, over the past two decades, has helped to
develop the public health approach to violence and has conducted and
overseen numerous studies of the epidemiology of youth suicide, family
violence, homicide, and firearm injuries. Dr. Mercy also served as a co-
editor of the World Report on Violence and Health prepared by the World
Health Organization (WHO) and served on the editorial board of the
United N ation’s Secretary General’s Study of Violence Against Children.
Most recently he has been working on a global partnership with UNICEF,
the President’s Emergency Plan for AIDS Relief, WHO, and others to end
sexual violence against girls. His recent publications include “Attention-
Deficit/Hyperactivity Disorder, Conduct Disorder, and Young Adult Inti-
mate Partner Violence” (Archives of General Psychiatry, 2010) and “Sexual
Violence and Its Health Consequences for Female Children in Swaziland: A
Cluster Survey Study” (Lancet, 2009).
Klaus A. Miczek, Ph.D., is the Moses Hunt Professor of Psychology, Psy-

chiatry, Pharmacology, and Neuroscience at Tufts University. He has served
on research review committees for the National Institute on Drug Abuse,
National Institute of Mental Health, National Institute on Alcoholism and
Alcohol Abuse (NIAAA), and National Center for Research Resources.
He was a member of the National Academy of Sciences panel on “Under
standing and Preventing Violence” (1989–1992), as well as its ILAR/NRC
panel on the “Psychological Well-Being of Primates.” He has been the
coordinating and principal editor of Psychopharmacology since 1992, and
he serves on the editorial board of half a dozen other journals in this
area. He was the president of the Division of Psychopharmacology, and
of the Behavioral Pharmacology Society, and chaired the Committee on
Animals in Research and Ethics of the American Psychology Association.
He has received numerous prizes including the Solvay Duphar Award of
the Division of Psychopharmacology and Substance Abuse of the American
Psychological Association, a MERIT award from NIAAA, and Silver Medals
of the Charles University (Czech Republic). In 1997, the president of the
Federal Republic of Germany bestowed the Knight’s Cross of the Order of
Merit on him. Dr. Miczek was named the Boerhaave professor at the medi-
cal faculty of Leiden University (Netherlands) and was a two-time Japan

APPENDIX C 151
International Science and Technology Fellow at the University of Tokyo.

He was visiting professor at La Sapienza University in Rome, the Charles
University in Prague, and at the University of Tuebingen in Germany.
In 2006, Tufts University recognized Dr. Miczek with the Distinguished
Scholar Award, and he was elected fellow in the American Association
for the Advancement of Science. He published some 200 research journal
articles and 40 reviews, and edited 20 volumes on psychopharmacological
research concerning brain mechanisms of aggression, anxiety, social stress,
and abuse of alcohol and other drugs. He was originally educated in Berlin
(Germany) and received his Ph.D. in biopsychology from the University
of Chicago. Currently, the work in Dr. Miczek’s laboratory investigates
two problems in the areas of (1) stress and drug abuse, and (2) behavioral
neurobiology of a ggression. First, members of the laboratory aim to learn
about neuroadaptive mechanisms via which specific social stressors can
intensify compulsive drug use or alternatively engender depressive-like
anhedonia. Second, they are seeking to characterize the neurobiological
features of those individuals who engage in escalated aggression after al-
cohol consumption.
Margaret M. Murray, Ph.D., M.S.W., is the director of the Global Alcohol

Research Program, National Institute on Alcohol Abuse and Alcoholism
(NIAAA), National Institutes of Health. Dr. Murray directs NIAAA’s efforts
in international research collaboration spanning each of the Institute’s pri-
orities in biomedical, epidemiological, prevention, and treatment research.
This includes serving on U.S. Science and Technology Committees, NIH,
and government-wide initiatives in global health, and representing NIAAA
to multilateral organizations such as WHO. She is primarily responsible
for facilitating collaborative relationships at the individual institute and
scientist level. Dr. Murray is also a lecturer at the National Catholic School
of Social Service at Catholic University, where she teaches the foundation
courses in social welfare policy in the master of social work program.
Toben Nelson, Sc.D., is a primary faculty member of the Alcohol Epide-

miology Program at the University of Minnesota School of Public Health.
He has research interests in health policy, organizational change, health
behavior during developmental transitions, social determinants of health,
program evaluation, prevention of alcohol-attributable harm, violence pre-
vention, and motor vehicle safety.
Dustin Pardini, Ph.D., conducts research that involves elucidating the

precursors and outcomes associated with the development of antisocial
behavior (e.g., violence, theft) from childhood to adulthood, as well as
evaluating the impact that early psychosocial interventions can have on

these problems. Much of this work has focused on the development and
treatment of conduct problems among youth exhibiting callous and un-
emotional (CU) traits. Over the past 8 years, this has involved analyzing
data from two of the most extensive longitudinal studies ever conducted
within the United States: the Pittsburgh Youth Study (co-director) and the
Pittsburgh Girls Study. Dr. Pardini’s innovative research directly influences
the adoption of the new conduct disorder specifier based on the presence
of CU traits (called limited prosocial emotions) in the Diagnostic and Sta-
tistical Manual, Fifth Edition (DSM-5), and earned him the Early Career
Contribution Award from the Society of the Scientific Study of Psychopathy
(2013). He is currently serving as a consultant to members of the Conduct
Disorders Research Committee for the eleventh revision of the International
Classification of Diseases (ICD-11). He has also been involved in research
designed to evaluate the effectiveness of interventions for children exhibit-
ing early aggression, including the Stop Now and Plan (SNAP) and the
Resources to Enhance the Adjustment of Children (REACH) programs.
Michael Phillips, M.D., M.P.H., is currently the director of the Suicide

Research and Prevention Center of the Shanghai Mental Health Center,
executive director of the WHO Collaborating Center for Research and
Training in Suicide Prevention at Beijing Hui Long Guan Hospital, pro-
fessor of psychiatry and global health at Emory University, professor of
clinical psychiatry and clinical epidemiology at Columbia University, vice
chairperson of the Chinese Society for Injury Prevention and Control, and
treasurer of the International Association for Suicide Prevention. He is
currently the principal investigator on a number of multicenter collabora-
tive projects on suicide, depression, and schizophrenia. His recent publica-
tions include “Repetition of Suicide Attempts: Data from Emergency Care
Settings in Five Culturally Different Low- and Middle-Income Countries
Participating in the WHO SUPRE-MISS Study” (Crisis, 2010) and “Non-
fatal Suicidal Behavior Among Chinese Women Who Have Been Physically
Abused by Their Male Intimate Partners” (Suicide and Life-Threatening Be-
havior, 2009). Dr. Phillips is a Canadian citizen who has been a permanent
resident of China for more than 25 years. He runs a number of research
training courses each year; supervises Chinese and foreign graduate stu-
dents; helps coordinate WHO mental health activities in China; promotes
increased awareness of the importance of addressing China’s huge suicide
problem; and advocates improving the quality, comprehensiveness, and ac-
cess to mental health services around the country.
Mark L. Rosenberg, M.D., M.P.P., is the executive director of the Task

Force for Global Health. Previously, for 20 years, Dr. Rosenberg was at the
Centers for Disease Control and Prevention (CDC), where he led its work

APPENDIX C 153
in violence prevention and later became the first permanent director of the
National Center for Injury Prevention and Control. He also held the posi-
tion of special assistant for behavioral science in the Office of the Deputy
Director (HIV/AIDS). Dr. Rosenberg is board certified in both psychiatry
and internal medicine with training in public policy. He is on the faculty
at Morehouse Medical School, Emory Medical School, and the R ollins
School of Public Health at Emory University. Dr. Rosenberg’s research and
programmatic interests are concentrated on injury control and violence
prevention, HIV/AIDS, and child well-being, with special attention to be-
havioral sciences, evaluation, and health communications. He has a uthored
more than 120 publications and recently co-authored the book Real Col-
laboration: What It Takes for Global Health to Succeed (University of
California Press, 2010). Dr. Rosenberg has received numerous awards
including the Surgeon General’s Exemplary Service Medal. He is a member
of the N ational Academy of Medicine. Dr. Rosenberg’s organization, the
Task Force for Global Health, participated in the National Academies of
Sciences, Engineering, and Medicine–sponsored workshop Violence Preven-
tion in Low- and Middle-Income Countries: Finding a Place on the Global
Agenda, and the Task Force remains interested in helping to continue the
momentum of the workshop through the Forum on Global Violence Pre-
vention. The Task Force is heavily involved in the delivery of a number of
global health programs and sees many ways in which interpersonal violence
and conflict exacerbate serious health problems and inequities.
Harvey Rosenthal has more than 38 years of experience working to pro-

mote public mental health services and policies that advance the recovery,
rehabilitation, rights, and community inclusion of people with psychiatric
disabilities. Since 1993, Mr. Rosenthal has served as the executive direc-
tor of the New York Association of Psychiatric Rehabilitation Services
(NYAPRS), a peer-led consumer-provider partnership that has worked
to improve services, social conditions, and public policies in New York
and nationally that touch the lives of people with psychiatric disabilities.
Under his leadership, NYAPRS has supported a strong grassroots advo-
cacy community, developed recovery training programs for community
providers, and has created nationally replicated peer-service and economic
development innovations. Mr. Rosenthal is currently providing a broad
array of training and technical assistance nationally to promote peer-run
and recovery services. He regularly works to fight stigma, discrimination,
and coercion and to expand informed choice protections. Mr. Rosenthal
currently serves on the board of the Bazelon Center for Mental Health
Law, acts as co-chair of the Peer Leaders Interest Group for ACMHA:
the College for Behavioral Health Leadership, and is a member of the
consumer-survivor subcommittee to the Center Mental Health Services

Advisory Group. He is a member of New York’s Medicaid Redesign

Team and its Most Integrated Settings Coordinating Council. His interest
in promoting mental health recovery is also personal, dating back to his
own hospitalization at age 19.
Elyn R. Saks, Ph.D., J.D., specializes in mental health law, criminal law, and
children and the law. Her recent research focused on ethical dimensions of
psychiatric research and forced treatment of the mentally ill. She teaches
Mental Health Law, Mental Health Law and the Criminal Justice System,
and Advanced Family Law: The Rights and Interests of Children. She served
as the University of Southern California (USC) Law’s associate dean for
research from 2005 to 2010 and also teaches at the Institute of Psychiatry
and the Law at the Keck School of Medicine at USC and is an adjunct pro-
fessor of psychiatry at the University of California, San Diego. Professor
Saks was a 2009 recipient of a MacArthur Foundation fellowship and in
fall 2010 announced she is using funds from the “Genius Grant” to create
the Saks Institute for Mental Health Law, Policy, and Ethics. The Institute
spotlights one important mental health issue per academic year and is a
collaborative effort that includes faculty from seven USC departments: law,
psychiatry, psychology, social work, gerontology, philosophy, and engi
neering. Professor Saks recently published The Center Cannot Hold: My
Journey Through Madness (Hyperion, 2007), a memoir about her struggles
and successes with schizophrenia and acute psychosis. Other publications
include Refusing Care: Forced Treatment and the Rights of the Mentally Ill
(University of Chicago Press, 2002), Interpreting Interpretation: The Limits
of Hermeneutic Psychoanalysis (Yale University Press, 1999), and Jekyll on
Trial: Multiple Personality Disorder and Criminal Law (with Stephen H.
Behnke, New York University Press, 1997). Before joining the USC Law
faculty in 1989, Professor Saks was an attorney in Connecticut and an
instructor at the University of Bridgeport School of Law. She graduated
summa cum laude from Vanderbilt University before earning her master of
letters from Oxford University and her J.D. from Yale Law School, where
she also edited the Yale Law Journal. She holds a Ph.D. in psychoanalytic
science from the New Center for Psychoanalysis. Professor Saks is a mem-
ber of Phi Beta Kappa; an affiliate member of the American Psychoanalytic
Association; a board member of Mental Health Advocacy Services; and a
member of the Los Angeles Psychoanalytic Foundation, Robert J. Stoller
Foundation, and American Law Institute. Professor Saks won both the
Associate’s Award for Creativity in Research and Scholarship and the Phi
Kappa Phi Faculty Recognition Award in 2004.
Kimberly A. Scott, M.S.P.H., has been a senior program officer on the

Health and Medicine Division’s Board on Global Health since September

APPENDIX C 155
2005. She currently directs two forums: one on Global Violence Prevention
and the other on Public–Private Partnerships for Global Health and Safety.
She is also co-directing a workshop on Evaluation Methods for Large-Scale,
Complex, Multinational Global Health Initiatives. From 2009 to 2013, she
was the study co-director for the outcome and impact evaluation of the U.S.
global HIV/AIDS initiative (i.e., the President’s Emergency Plan for AIDS
Relief, or PEPFAR). Her portfolio of work for the National Academies also
includes a mix of consensus studies, workshops, and other activities, includ-
ing the Evaluation of the Implementation of PEPFAR; Preventing Violence
in Low- and Middle-Income Countries; the Assessment of the Role of Inter-
mittent Preventive Treatment for Malaria in Infants; Depression, Parenting
Practices, and the Health Development of Children; and Achieving Global
Sustainable Surveillance for Zoonotic Diseases. Before joining the National
Academies, she was an analyst on the health care team at the U.S. Gov-
ernment Accountability Office. Before returning to graduate school, she
coordinated a foundation-funded program at Duke University’s Center
for Health Policy, Law, and Management to integrate public and private
mental health services with the continuum of care for people living with and
affected by HIV/AIDS in 54 counties in North Carolina. For 6 years, she
served as the executive director of a Ryan White–funded HIV/AIDS con-
sortium, developing a comprehensive ambulatory care system for 21 mostly
rural counties in North Carolina. Previous North Carolina health-related
committee service includes several advisory committees to the governor of
North Carolina and to the secretary of the North Carolina Department
of Health and Human Services for programmatic and policy issues related
to HIV care, prevention, and treatment, as well as substance abuse preven-
tion and treatment. She received an M.S.P.H. in health policy analysis from
the University of North Carolina, Chapel Hill. As an Echols Scholar, she
completed her undergraduate studies at the University of Virginia.
Sharon Stephan, Ph.D., is a leading figure in advancing school mental

health (SMH) research, training, policy, and practice at national, state, and
local levels. Dr. Stephan is a licensed clinical psychologist and a tenured
associate professor at the University of Maryland School of Medicine,
Division of Child and Adolescent Psychiatry. After providing direct mental
health promotion and treatment service for several years in the Baltimore
City Public Schools, Dr. Stephan was appointed as director of research
for the national Center for School Mental Health (CSMH) in 2002. From
2005 to 2010, she guided the advancement of research and policy in her
role as the CSMH director of research and analysis, and in 2010 became
the CSMH principal investigator and co-director with Dr. Nancy Lever.
Dr. Stephan has extensive expertise and leadership related to implementa-
tion science, quality assessment and improvement, evaluation and outcome

measurement, and SMH service delivery, workforce development, and state

and local capacity building. Her evaluation and project direction experi-
ence is extensive, having served as the principal investigator, site principal
investigator, or lead evaluator for several projects including two SAMHSA
Systems of Care evaluations; the SAMHSA Healthy Transitions Initiative
evaluation; two R01s from NIMH on Enhancing SMH Quality; Maryland’s
Early Childhood Mental Health Consultation Evaluation; the National
Assembly on School-Based Health Care (NASBHC) Mental Health Edu-
cation and Training Initiative; Youth Moving Others Through Voices of
Experience; M aryland’s Governor’s Office for Children Evidence-Based
Practices Fidelity and Outcomes Evaluation; and the Baltimore SMH Ini-
tiative. Dr. Stephan has published extensively, with many peer-reviewed
articles and editorial service, and is a highly regarded and sought after
speaker and trainer. She has held leadership roles on several national com-
mittees, including the SAMHSA Federal-National partnership, the National
Evidence-Based Practice Consortium, the National Coordinating Com-
mittee on School Health and Safety (NCCSHS), the CDC SMH Capacity
Building Project, the National Assembly on School-Based Health Care
(Evaluation and Quality Panel, Training and Technical Assistance Panel),
and the SAMHSA National Child Traumatic Stress Network Trauma Ser-
vices Adaptation Center for Schools (School Treatment Workgroup and
Military Families Workgroup).
Daniel W. Webster, Sc.D., M.P.H., is a professor of health policy and man-

agement and directs the Ph.D. program in Health and Public Policy at the
Johns Hopkins Bloomberg School of Public Health. Dr. Webster is director
of the Johns Hopkins Center for Gun Policy and Research, deputy direc-
tor for research for the Johns Hopkins Center for the Prevention of Youth
Violence, and core faculty of the Johns Hopkins Center for Injury Research
and Policy. Dr. Webster holds a joint appointment as professor in the School
of Education’s Division of Public Safety Leadership at Johns Hopkins,
and is a senior research fellow with the Police Executive Research Forum.
Dr. Webster is one of the nation’s leading experts on firearm policy and
the prevention of gun violence. He is co-editor of Reducing Gun Violence
in America: Informing Policy with Evidence and Analysis (Johns Hopkins
University Press, 2013). He has published numerous articles on firearm
policy, youth gun acquisition and carrying, the prevention of gun violence,
intimate partner violence, and adolescent violence prevention. He has stud-
ied the effects of several violence prevention interventions, including state
firearm and alcohol policies, policing strategies, street outreach and con-
flict mediation, public education campaigns, and school-based curricula.
Dr. Webster teaches Understanding and Preventing Violence, Research and

APPENDIX C 157
Evaluation Methods for Health Policy, and graduate seminar in health

and public policy.
David B. Wexler, Ph.D., is a professor of law and director of the Interna-

tional Network on Therapeutic Jurisprudence at the University of Puerto
Rico in San Juan, Puerto Rico, and Distinguished Research Professor of
Law, Rogers College of Law, Tucson, Arizona. He received the Ameri-
can Psychiatric Association’s Manfred S. Guttmacher Forensic Psychiatry
Award; chaired the American Bar Association’s Commission on Mental
Disability and the Law; chaired the Association of American Law Schools’
Section on Law and Mental Disability; chaired the Advisory Board of the
National Center for State Courts’ Institute on Mental Disability and Law;
was a member of the Panel on Legal Issues of the President’s Commission
on Mental Health; was a member of the National Commission on the
Insanity Defense; served as vice president of the International Academy of
Law and Mental Health; received the New York University School of Law
Distinguished Alumnus Legal Scholarship/Teaching Award; received the
Distinguished Service Award from the National Center for State Courts;
and served as a member of the MacArthur Foundation Research Network
on Mental Health and the Law. Dr. Wexler has been named an Honorary
Distinguished Member of the American Psychology-Law Society. In Oc-
tober 2012, at its Congress in Pontevedra, Galicia, Spain, Dr. Wexler was
named Honorary President of the Iberoamerican Association of Therapeu-
tic Jurisprudence, an organization headquartered at the University of Vigo.
Therapeutic jurisprudence writing is now in 10 languages, and some of Dr.
Wexler’s own work has been translated to Hebrew, Portuguese, Spanish,
and Urdu. He is a consultant on therapeutic jurisprudence to the National
Judicial Institute of Canada and the Judicial Academy of Puerto Rico, and
has served as a Fulbright Senior Specialist, lecturing on therapeutic juris-
prudence in Australia and New Zealand. Before entering law teaching, Dr.
Wexler practiced for the Criminal Division of the U.S. Department of Jus-
tice. He first explicated the therapeutic jurisprudence perspective in a paper
written in 1987. He and Professor Bruce Winick of the University of Miami
worked together to further develop the area, which is now of interest to
practitioners and academics of many disciplines and nations.
Dieter Wolke, Ph.D., studied at the University of Kiel in Germany and ob-
tained his Ph.D. from the University of London Faculty of Science. He has
worked at different colleges of the University of London (i.e., Institute of
Education; King’s College; and the Institute of Child Health, Hospital for
Sick Children) and the Universities of Munich, Hertfordshire (chair), Bristol
(chair in lifespan psychology, and deputy director of the Avon Longitudinal
Study [ALSPAC]), and was guest professor of the University of Zurich and

scientific director of the Jacobs Foundation, Zurich (2004–2006) before

joining the University of Warwick. Dr. Wolke is currently professor of
developmental psychology and individual differences in the Department
of Psychology (Faculty of Science) and in the Division of Mental Health
and Well-being (Warwick Medical School) at the University of Warwick.
He is the lead of the Lifespan Health and Well-being Research Stream in
the Department of Psychology. Much of his research is interdisciplinary
(psychology, social, and medical sciences), longitudinal, and in the field of
developmental psychopathology. His major research topics are (1) peer or
sibling victimization (bullying): precursors, consequences, and interven-
tions; (2) early regulatory problems in infancy and their long-term conse-
quences; (3) how preterm birth affects brain development, psychological
development, and quality of life. He is involved as principal investigator/
co-principal investigator in a range of follow-up studies in the United
Kingdom and Germany, including the ALSPAC cohort, EPICure Study, the
Bavarian Longitudinal Study, and the U.K. Household Longitudinal Study
(Understanding Society), which is the largest longitudinal panel study in
the world, including more than 100,000 people with a special interest in
biomarkers. Dr. Wolke has published more than 200 articles in leading jour-
nals and is on the editorial boards of several journals and several scientific
advisory boards.

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THE NATIONAL ACADEMIES PRESS

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Violence and Mental Health: Opportunities for Prevention and

172 pages | 6 x 9 | PAPERBACK

National Academies of Sciences, Engineering, and Medicine 2018. Violence and

– Access to free PDF downloads of thousands of scientiﬁc reports

Copyright © National Academy of Sciences. All rights reserved.

Deepali Patel, Rapporteur

Forum on Global Violence Prevention

Board on Global Health

Health and Medicine Division

Copyright National Academy of Sciences. All rights reserved.

This project was supported by AB InBev; Administration for Community Living;

International Standard Book Number-13: 978-0-309-46662-2

Copyright 2018 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine.

Copyright National Academy of Sciences. All rights reserved.

The National Academy of Sciences was established in 1863 by an Act of

The National Academy of Medicine (formerly the Institute of Medicine) was

The three Academies work together as the National Academies of Sciences,

Learn more about the National Academies of Sciences, Engineering, and M

Copyright National Academy of Sciences. All rights reserved.

Consensus Study Reports published by the National Academies of Sciences,

Proceedings published by the National Academies of Sciences, Engineering, and

Copyright National Academy of Sciences. All rights reserved.

PLANNING COMMITTEE ON MENTAL HEALTH AND VIOLENCE:

MARGARET M. MURRAY (Co-Chair), Director, Global Alcohol

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

FORUM ON GLOBAL VIOLENCE PREVENTION1

JACQUELYN C. CAMPBELL (Co-Chair), Anna D. Wolf Chair and

Copyright National Academy of Sciences. All rights reserved.

MICHELE MOLONEY-KITTS, Managing Director, Together for Girls

Health and Medicine Division Staff

Copyright National Academy of Sciences. All rights reserved.

ALBERT J. ALLEN, Eli Lilly and Company

Although the reviewers listed above provided many constructive com-

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

3 AT THE INTERSECTION OF MENTAL HEALTH AND 21

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4 MEANS AND MODIFIERS 35

5 PREVENTION, INTERVENTION, AND TREATMENT 51

6 ASSEMBLING THE PIECES AND INTEGRATING 67

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Boxes, Figures, and Tables

5-1 Issues Across the Criminal Justice System, 58

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

FORUM ON GLOBAL VIOLENCE PREVENTION

Copyright National Academy of Sciences. All rights reserved.

2 VIOLENCE AND MENTAL HEALTH

• Provides an ongoing, regular, evidence-based, impartial setting for

Past workshops have explored the evidentiary basis of violence preven-

• A description of mental health function as a continuum, from opti-

Copyright National Academy of Sciences. All rights reserved.

• A rriving at a better understanding of the intersection of mental health and

• Means of violence perpetration, including access to weapons

• A rriving at a better understanding of the intersection of mental health and

In the question-and-answer session following Insel’s presentation, addi