International Journal of Law and Psychiatry. Printed in the U S.A. All rights reserved.
Vol.
14. pp. 245-254,
1991 Copyright
0160.2527/91 $3.00 + .OO 0 1991 Pergamon Press plc
Psychiatric Admission of Family Violent Versus Nonfamily Violent Patients Edward W. Gondolf”,
Edward P. Mulvey*,
and Charles W. Lidz”
Considerable research and scholarly commentary attempt to define the appropriate professional and societal response to violent, mentally ill individuals (see Hoge, Appelbaum, & Greer, 1989; Monahan, 1988; Webster & Menzies, 1987). Research on clinical decision making regarding commitment and admission has been limited, however, by the tendency of depicting patient violence as a unitary phenomenon (see Gottfredson & Gottfredson, 1988; Monahan, 1984). That is, all violence is considered the same, regardless of varying tactics, circumstances, and victims. This practice has possibly distorted the research efforts to assess clinician decision making, since it fails to account for the complexities of patient behavior and outcome (Mulvey & Lidz, 1984). It is possible that psychiatric professionals deciding about the disposition of a case (particularly in an emergency room situation) respond in markedly different ways to different types of violent cases (Faust, 1986; Webster & Menzies, 1987). They may respond in what qualitative researchers describe as a discretionary process of categorization (Turk, Salovey, & Prentice, 1988), rather than through the uniform application of standards, as Mills (1988) concludes. If so, it can be expected that different models of clinical decision making may apply, depending on some generalized characteristics of the case appearing before the clinician. One prominent distinction that may be influential in psychiatric decision making is whether the case involved violence toward a family member or a nonfamily member. The family violence research in the United States has shown that Police, General Practice Physicians, and Social Workers are more likely to consider circumstantial or extralegal factors in responding to cases involving family violence (Berk & Loseke, 1981; Gondolf & McFerron, 1989; Kurz, 1987). This practice is of particular concern to victim rights advocates who note research on the recurrence of family violence (Walker, 1988). Decisive and comprehensive intervention in family violence cases is warranted, especially because of the accessibility of the family violence victims, even after divorce or separation, and the escalation of the violence, even after victim counter threats and perpetrator promises to change (Walker, 1989). *Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213. Acknowledgment: This research was funded by a grant from the Antisocial and Criminal Behavior Branch, National Institute of Mental Health (#2 ROl MH 40030-40). 245
246
E.W. GONDOLF,
E.P. MULVEY,
and C.W. LIDZ
Based on the studies showing discrimination against family violent case, we would hypothesize that admission processes for family violent cases in psychiatric hospitals are likely to differ from the processes for nonfamily violent case. Fewer family violence cases are likely to be admitted, and the admitted family violent cases are likely to be more severely violent and to turn more on presentation variables-that is, circumstantial or extramedical factors. Method
Data Collection We analyzed an existing data base in an effort to explore our hypotheses regarding the psychiatric response to family violence cases. The data base was created for a more extensive descriptive research project on the clinical assessment and management of dangerousness (see Mulvey & Lidz, 1985). Observers were placed in the emergency room of a metropolitan hospital around-the-clock for a 5 month period during 1985-86. Using a type of speedwriting, observers produced near verbatim transcripts of the clinical interviews and discussions that occurred during this time. This information was transcribed into a computerized retrieval system, along with demographic and dispositional information from patients’ medical records. In addition, the two hospital staff clinicians (usually a nurse and a psychiatrist) who evaluated the patients, performed independent ratings of patients on 12 dimensions using 7-point Likert type scales. The final data base included clinical information on 382 persons who visited the psychiatric emergency room. The demographics of the total sample are similar to those of emergency room and clinic samples employed in related psychiatric research (e.g., Klassen & O’Connor, 1988; Segal, Watson, Goldfinger, & Averbuck, 1988).
Family Versus Nonfamily
Vio Ien t Categories
For the purposes of this study, cases considered to be “recently violent” were identified and then divided into two subsamples: one of family violent cases and another of nonfamily violent cases. In order to be considered a “violent case” (n = 92), a patient had to have reported, during their evaluation interview, an assault within three months prior to visiting the psychiatric emergency room. An “assault” was defined as having pushed, grabbed, hit, slapped, punched, physically fought, beat up, used a weapon, or sexually attacked another person. The recently violent cases (n = 92) accounted for 24% of the total sample of patients (n = 382). This focus on “recent” violence was taken to isolate cases whose assaults would most concern clinicians. The three month period, albeit somewhat arbitrary, appeared in the interviews to be the most relevant and discernable time frame for analysis. The majority of incidents beyond three months were markedly deficient in specificity and temporality. A period of less than three months appeared to exclude incidents that received clinical response and mention in clinical records. The recent violent cases were categorized as “family violent cases” (n = 48)
FAMILY AND NONFAMILY
VIOLENT
PATIENTS
247
or “nonfamily violent cases” (n = 44) using the following criteria. Thirty-seven patients whose recent assault, or assaults, had been committed exclusively against a family member were categorized as “family violent cases,” along with 11 additional cases whose presenting or primary incident was against a family member and who also recently assaulted a nonfamily person. The “nonfamily violent cases” consisted of 42 patients whose recent assault, or assaults, were exclusively of nonfamily members, and two additional cases in which the patient’s primary or presenting assault was against a nonfamily member while secondarily reporting a recent family assault as well. The family and nonfamily categories do provide what appears to be two categories with distinguishing case characteristics, as well as categories based on criteria available directly to clinicians during the interview (see Gondolf, Mulvey, & Lidz, 1990). Variables Two dependent or outcome measures were used in this study: (a) whether the patient was admitted to the hospital and (b) whether the patient was involuntarily committed when he or she did enter the hospital. The “outcome,” or case disposition, was determined by reviewing the medical records for each recently violent case and checking it against the available textual material from the evaluation interviews. The group committed were naturally a subset of the group admitted. Two types of variables were used as independent variables. The first set of variables was comprised of “case characteristics,” or information that seemed most likely to be considered by clinicians in deciding about admission or commitment (Marson, McGovern, & Pomp, 1988). This set of variables consisted of demographic variables (i.e., age, sex, race, employment status, and educational level) and aspects of case history and diagnostic status. These case history variables consisted of whether the patient had previously been hospitalized, arrested, attempted suicide, or diagnosed as having a major psychiatric disorder (i.e., the primary DSM-III-R diagnosis was schizophrenia or a mood disorder, as opposed to a personality disorder or alcohol dependence, cf., Segal et al., 1988). The total number of reported assaults (past and recent) was also considered a case history variable. The “case characteristics” included another set of variables: factors related to the presentation of the case in the emergency room. Thepatientpresentation variables included whether the patient was accompanied by others at presentation- that is, whether the patient appeared in the emergency room with family, friends, social service staff, ambulance drivers, or police. An additional variable was the involvement of hospital security staff. The case characteristic variables, except for the continuous age, educational level, and number of total assaults variables, were treated as dichotomous measures, coded “1” if the condition was present and “0” if it was absent. The logarithm of age was used in the analysis to compensate for its skewed distribution. The second major set of variables represented the clinicians’perceptions of the patients. For the purposes of this study, clinician ratings of chronically dangerous, currently suicidal, hostile, lacking in self-care, and psychotic seemed to be of most interest in light of what clinicians are supposed to con-
248
E.W. GONDOLF,
E.P. MULVEY,
and C.W. LIDZ
sider in their evaluation of the patient for admission and commitment and were relatively independent from one another (r < .50). Currently dangerous, for instance, was not used because of its colinearity with hostility, chronic dangerousness, and commitment. The clinician and physician ratings were summed for each case resulting in a 2 to 14 scale for analysis.
Analysis The variables were first cross tabulated by category of violent patient (family violent versus nonfamily violent) to describe the sample. Chi square statistics were used at the .l significance level to accommodate the effect of the small sample size. We might otherwise have used a significance level that corrects for experiment-wise effect. A more elaborate comparison of the two categories of violent patients appears elsewhere (Gondolf et al., 1990). It substantiates the tendencies derived in this study with a larger sample that includes patients identified as violent in hospital records as well as through self-reports in the evaluation interviews. Discriminant functions are the principal mode of analysis used to assess the admission and commitment decision making for both family and nonfamily violent cases.’ Stepwise discriminant functions (Wilks method; Tolerance = .OOl) for family violent cases and for the nonfamily violent cases were computed for the outcome measure of admission and then for commitment. The stepwise procedure was used over a direct entry of all the variables, because its exclusion of variables is preferred with a small sample size and in an exploratory investigation. The stepwise discriminant procedure was conducted for each set of predictive variablesfirst, the “case characteristics” and, second, the “clinician perceptions.” The functions using the more subjective clinician perceptions offered a means to confirm the case characteristic functions based on a different and more objective data source. Results
Descriptive Analysis of Sample Variables As Table 1 indicates, the nonfamily violent cases were more likely to be male, living alone, and suicidal than the family violent cases. With regard to presentation, the nonfamily cases were significantly more likely to involve security (30% vs. 14%). The family and nonfamily violent cases appear, however, similar in terms of amount and tactic of their violence. The mean of total assaults is 3.3 (SD = 1.9) versus 3.3 (SD = 1.7); and the mean clinician rating for dangerousness is 7.6 (SD = 2.8) versus 7.7 (SD = 3.1). ‘The discriminant analysis was appropriate and sufficient for examining the interval-level clinician perception ratings. The first set of case characteristic variables were largely dichotomous, however, and thus compromised the linear assumptions of discriminant analysis. To address this issue, a logistic regression was computed to confirm the findings. The logistic regression would have been sufficient and preferable; however, the small sample of cases (produced by the generally low base rate of violence patients), and the use of two subsamples of these violent cases, reduced the likelihood of obtaining significant logistic coefficients.
FAMILY AND NONFAMILY VIOLENT PATIENTS
249
TABLE 1 Variable Frequencies for Recent Family and Nonfamily Violent Cases
Case Characteristics
Family Violent (n = 48) # o/o
Nonfamily Violent (n = 44) # o/o
Total Violent (n = 92) # %
Demographics Maleb Black College education Living with familya Unemployed
32 18 13 36 25
36 21 10 17 27
67 39 23 53 52
Age
M SD 31 11
Case History/Diagnosis Past hospitalization Past arrest Suicide attemptb Major disorder
20 20 7 22
Total assaults (8 max.)
M 3.6
Presentation With others Security involvedb Outcome Admittedb Committed
67% 38% 28% 75% 54%
42% 42% 14% 47%
84% 48% 23% 40% 64%
M SD 29 10
73% 42% 26% 58% 58%
t(df) prob. 2.13 n.s.
24 23 18 22
55% 52% 43% 51%
44 43 24 44
48% 47% 26% 49%
SD 1.9
M 3.3
SD 1.7
t(of) .79(90)
35 14
73% 30%
28 6
65% 14%
63 20
69% 22%
30 20
62% 42%
35 14
80% 33%
65 34
71% 37%
prob. n.s
“p < .Ol; bp < .l
Nevertheless, a smaller percentage of family violent cases (62%) were admitted, in comparison to nonfamily violent cases (80%) (X2 = 3.22[1]; p < .l). This means that family cases were nearly twice as likely to be released to outpatient care. In terms of commitment, the difference between the two categories was not statistically significant (42% vs. 33%). This amounts to two thirds of the admitted family violent cases being committed, and only 40% of the admitted nonfamily violent cases being committed. A discriminant function was computed to confirm the relative explanatory power of the family/ nonfamily categorization.2 A cross-tabulation of three major subcategories of *The standardized coefficients of the stepwise function for admission were: past arrest = .38; suicide attempt = .24; presentation with others = .89; security involved = .48; and family violent = - .40 (Wilks Lambda = .71; p < ,001; Correct Classification = 74%). The category of violence (family violent case versus nonfamily violent case) was at least as influential as the two other case history variables that produced significant results, but apparently not as influential as the presentation variables. The discriminant function for commitment produced a vary similar result, except that education (.38) was also included in the final function and the “family violent” variable was not (Wilks Lambda = .71; p < .05; Correct Classification = 72%).
250
E.W. GONDOLF, E.P. MULVEY. and C.W. LIDZ
Discriminant
TABLE 2 Functions for Case Characteristics
Admitted Case Characteristics
Family
Committed
Nonfamily
Family
Nonfamily
Demographics Male Black Unemployed Education Age Case History Past hospitalization Past arrest Total assaults Suicide attempt Major disorder Presentation With others Security involved
.38 .27
.48
.83 .38
.72 .60
.62 .82
.80 .37
Significance Wilk’s lambda Correct classification
,001 .60 81%
.l .86 78%
,001 .53 77%
,001 .50 80%
.30 - .38 .75 -.28 .40
.45 ~ .60
.26 .75
n = 92.
family violence shows that cases involving spouse assault were the least likely to be admitted (36070)~ as compared to those who assaulted parents or guardians (70%) or who assaulted siblings or adolescent children (79%) (X2 = 6.31[2];p < .05).
Discriminant Functions with Case Characteristics As shown in Table 2, the admission functions both for family and nonfamily cases were similar in several fundamental ways, but suggest some instructive differences. In both functions, being accompanied to the emergency room “with others” is the most influential variable in distinguishing the admission and commitment outcomes (discriminant coefficients = .83 and .72).3 The security staff being involved and previous suicide attempts also substantially raise the chances of being admitted or committed. The demographic variables did not significantly contribute to the admission outcome for either family or nonfamily violent cases. ‘The variable “with others” was recorded to include “by self,” “with family or friends,” and “with police or ambulance staff.” Forty-three percent of the admitted family cases were brought in by police or ambulance staff, and none of the family violent cases assigned to outpatient treatment were accompanied by these professionals (X2 = 15.87[2]; p < ,001). Sixty percent (12) of the committed nonfamily cases were brought in by police or ambulance staff, and 75% (11) of the committed nonfamily violent cases were brought in by police or ambulance staff (X2 = 20.48[2]; p < ,001). In sum, accompaniment by professionals is most likely to lead to admission or commitment.
FAMILY AND NONFAMILY
Discriminant
VIOLENT PATIENTS
251
TABLE 3 Functions for Clinician Perceptions
Committed
Admitted Clinician
Perceptions
Ratings Lacks self-care Hostile Psychotic Dangerous Suicidal Significance Wilk’s lambda Correct classification
Family
Nonfamily
Family
Nonfamily
.60
.28 .82 .29
.96
.96
.52
.51 .66
,001 .65 81%
.Ol .71 76%
.27
,001 .49 79%
,001 59 74%
n = 92.
The principal difference between the two admission discriminant functions is that past arrests and a major disorder significantly contribute to the admission of family violent cases, but not of the nonfamily violent cases. The function with nonfamily violent cases was the weaker of the two accounting for only 24% of the variance (Wilks Lambda = -86) as compared to 40% for nonfamily cases (Wilks Lambda = .60). The classification rates are, nevertheless, comparable and substantially better than chance. The discriminant functions computed for commitment suggest some underlying differences (see Table 2). While the presentation variables of being with others and involving security are again strongly influential, there is a greater range of variables that contribute to the commitment of family violent cases. Family violent patients who are older, black, have repeated assaults, and have not been previously hospitalized, besides being with others and involving security at presentation, are the most likely to be committed. Whereas, suicidal, not arrested, previously hospitalized, and poorly educated patients are the most likely nonfamily violent patients to be committed. In essence, the chronically “antisocial” family violent person and the very “sick” nonfamily violent person are most likely to be committed. Discriminant functions using clinician perceptions to determine admission and commitment reflected the same commonalties evidenced in the discriminations using case characteristics (see Table 3). In all but the admission function for nonfamily cases, the variance was largely explained by the hostility attributed to the patient, much as the “with others” and “security involvement” variables accounted for the variance in the previous set of functions. Discussion
The Evidence for Different Decision Making Our hypothesis that the admission and commitment process would differ for family violent cases and nonfamily violent cases was partially substantiated. The differences were most pronounced for the admission process. The
252
E.W. GONDOLF,
E.P. MULVEY,
and C.W. LIDZ
first major difference is in admissions rates. The family violent cases appeared to be equivalently violent in terms of reported severity and frequency of assaults and the clinicians’ perceptions of their dangerousness. Nevertheless, the family violent cases were less likely to be admitted than the nonfamily cases (62% vs. 80%). Patients who abused their siblings or adolescent children were three times as likely to be admitted than those who abused their wives or girlfriends. That family violence perpetrators were more likely to be released is of particular concern, since their victims are more readily accessible than those of the nonfamily violent perpetrators (Walker, 1989). The hospital admissions appear to differ in terms of the factors involved in the decision-making process. The family violent cases who were admitted displayed a greater constellation of problems; they were more likely to have past arrests, suicide attempts, and major disorders. In other words, the family violent cases may need to be more serious in order to be admitted. For both the family and nonfamily violent patients, the patient’s being accompanied by others was the most influential variable in predicting admission, as previous research might suggest (Marson et al., 1988). Our examination of the commitment process showed less discrepancy in the actual percentages of committed family versus nonfamily violent cases (42% vs. 33%). As might be expected, the commitment process appeared to involve a greater constellation of factors than the admission process, since it is a more select subset of those admitted. Those family violent cases who were committed were more likely to be young, highly assaultive, parent and/or sibling abusers accompanied to the emergency room and also requiring security staff to restrain them. In sum, the family violent cases, who are admitted and committed, appear more seriously violent and the nonfamily cases as more sickly (e.g., they are more likely to have been previously hospitalized).
Differing Categorizations Theoretically, our findings lend support to the notion that psychiatric decision making is, at least in part, a discretionary process of categorization (Turk et al., 1988), rather than the uniform application of standards (Mills, 1988). Several explanations for the family violence versus nonfamily violence categorization have been suggested in studies of police arrests (Berk & Loseke, 1981) and medical care (Kurz, 1987). Psychiatric staff may minimize the family violence as a private matter or merely a “marital difficulty,” as the myths of family violence suggest (Walker, 1989). Or the family violence may be viewed more as a systemic interaction between victim and perpetrator, rather than one with a definitive perpetrator (Shupe, Stacey, & Hazelwood, 1987). In other words, psychiatric staff may be more likely to consider the family violence as provoked and therefore less impulsive than the nonfamily violence. This is particularly relevant given Segal et al.% (1988) finding that “impulsivity” was the most influential factor in determining clinician decisions in their study. Our study must be considered exploratory in nature because of a few fundamental qualifications. Probably the most difficult issue facing research in this field is the relatively low base rate of violent patients. This problem is compounded by dividing the violent patients into two subsamples. The small sam-
FAMILY AND NONFAMILY
VIOLENT
PATIENTS
253
ples analyzed with several variables may mean that the computed functions are unstable. Also, our subsamples of family and nonfamily violent cases remain somewhat arbitrary and convenient; preliminary research suggests that more complex distinctions for family violence cases are warranted (McNiel & Binder, 1987). Furthermore, our presentation and outcome measures remain relatively simplistic. The dichotomous variable for commitment does not, for instance, reflect the negotiation process that occurs between psychiatric staff and patient (Reed & Lewis, in press). These issues are addressed in a qualitative study of the sample that allows for more distinctions in the sample and a description of the decision making processes (Gondolf, 1990). In any case, our quantative study substantiates the notion that admissions to a psychiatric hospital is a discretionary process. This process appears to discriminate against family violence cases, as the family violence literature would predict. More needs to be done, therefore, to address the distinction of family violence and nonfamily violence in psychiatric research and clinical practice.
References Berk, S., & Loseke, D. (1981). Handling family violence: Situational determinants of police arrest in domestic disturbances. Law and Society Review, IS, 3 17-344. Faust, D. (1986). Research on human judgement and its application to clinical practice. Professional Psychology, 17, 420-430. Gondolf, E. W. (1990). Psychiatric response to family violence: Identifying and confronting neglected danger. Lexington, MA: Lexington Books. Gondolf, E. W., & McFerron, R. (1989). Handling battering men: Police action in wife abuse cases. Criminal Justice and Behavior, 16, 429-439. Gondolf, E. W., Mulvey, E. P., & Lidz, C. W. (1990). Characteristics of perpetrators of family and nonfamily assaults. Hospital and Community Psychiatry, 41, 191-193. Gottfredson, D. M., Gottfredson, S. D. (1988). Stakes and risks in the prediction of violent behavior. Violence and Victims, 3, 247-262. Hoge, S. K., Appelbaum, P. S., & Greer, A. (1989). An empirical comparison of the Stone and dangerousness criteria for civil commitment. American Journal of Psychiatry, 146, 170-175. Klassen, D., & O’Connor, W. (1988). Prospective study of predictors of violence in adult male mental patients. Law and Human Behavior, 12, 143-158. Kurz, D. (1987). Emergency department responses to battered women: Resistance to medicalization. Social Problems, 34, 69-8 I. Marson, D. C., McGovern, M. P., & H. C. Pomp. (1988). Psychiatric decision making in the emergency room: A research overview. American Journal of Psychiatry, 145,918-925. McNiel, D. E., & Binder, R. L. (1987, August). Patterns of family violence associated with acute mental illness. Paper presented at the Third National Family Violence Research Conference, Durham, NH. Mills, M. J. (1988). Civil commitment: The relationship between perceived dangerousness and mental illness. Archives of General Psychiatry, 45, 770-773. Monahan, J. (1984). The prediction of violent behavior: Toward a second generation of theory and policy. American Journal of Psychiatry, 141, 10-15. Monahan, .I. (1988). Risk assessment of violence among mentally disordered: Generating useful knowledge. International Journal of Law and Psychiatry, I I, 249-257. Mulvey, E. P., & Lidz, C. W. (1984). Clinical considerations in the prediction of dangerousness in mental patients. Clinical Psychology Review, 4, 379-401. Mulvey, E. P., & Lidz, C. W. (1985). Back to basics: A critical analysis of dangerousness research in a new legal environment. Law and Human Behavior, 9, 187-197. Reed, S. C., & Lewis, D. A. (in press). The declining significance of involuntary commitment: Negotiating patient status in a deinstitutionalized mental health system. Qualitative Sociology.
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E.P. MULVEY,
and C.W. LIDZ
Segal, S. P., Watson, M. A., Goldfinger, S. M., & Averbuck, D. S. (1988). Civil commitment in the Psychiatric emergency room. Archives of General Psychiatry, 45, 748-763. Shupe, A., Stacey, W., & Hazelwood, L. (1987). Violent men, violent couples: The dynamics of domestic violence. Lexington, MA: Lexington Books. Turk, D. C., Salovey, P., & Prentice, D. A. (1988). Psychotherapy: An information-processing perspective. In E. C. Turk & P. Salovey (Eds.), Reasoning inference, and judgement in clinical psychology. New York: Free Press. Walker, L. E. A. (1988). Intervention with victim/survivors. In I. B. Weiner&A. K. Hess (Eds.), Handbook offorensicpsychology. New York: John Wiley & Sons. Walker, L. E. A. (1989). Psychology and violence against women. American Psychologist, 44, 695-702. Webster, C. D., & Menzies, R. J. (1987). The clinical prediction of dangerousness. In D. N. Weisstub (Ed.), Law and mental health, vol. 3. Elmsford, NY: Pergamon Press.
Vol.
14. pp. 245-254,
1991 Copyright
0160.2527/91 $3.00 + .OO 0 1991 Pergamon Press plc
Psychiatric Admission of Family Violent Versus Nonfamily Violent Patients Edward W. Gondolf”,
Edward P. Mulvey*,
and Charles W. Lidz”
Considerable research and scholarly commentary attempt to define the appropriate professional and societal response to violent, mentally ill individuals (see Hoge, Appelbaum, & Greer, 1989; Monahan, 1988; Webster & Menzies, 1987). Research on clinical decision making regarding commitment and admission has been limited, however, by the tendency of depicting patient violence as a unitary phenomenon (see Gottfredson & Gottfredson, 1988; Monahan, 1984). That is, all violence is considered the same, regardless of varying tactics, circumstances, and victims. This practice has possibly distorted the research efforts to assess clinician decision making, since it fails to account for the complexities of patient behavior and outcome (Mulvey & Lidz, 1984). It is possible that psychiatric professionals deciding about the disposition of a case (particularly in an emergency room situation) respond in markedly different ways to different types of violent cases (Faust, 1986; Webster & Menzies, 1987). They may respond in what qualitative researchers describe as a discretionary process of categorization (Turk, Salovey, & Prentice, 1988), rather than through the uniform application of standards, as Mills (1988) concludes. If so, it can be expected that different models of clinical decision making may apply, depending on some generalized characteristics of the case appearing before the clinician. One prominent distinction that may be influential in psychiatric decision making is whether the case involved violence toward a family member or a nonfamily member. The family violence research in the United States has shown that Police, General Practice Physicians, and Social Workers are more likely to consider circumstantial or extralegal factors in responding to cases involving family violence (Berk & Loseke, 1981; Gondolf & McFerron, 1989; Kurz, 1987). This practice is of particular concern to victim rights advocates who note research on the recurrence of family violence (Walker, 1988). Decisive and comprehensive intervention in family violence cases is warranted, especially because of the accessibility of the family violence victims, even after divorce or separation, and the escalation of the violence, even after victim counter threats and perpetrator promises to change (Walker, 1989). *Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213. Acknowledgment: This research was funded by a grant from the Antisocial and Criminal Behavior Branch, National Institute of Mental Health (#2 ROl MH 40030-40). 245
246
E.W. GONDOLF,
E.P. MULVEY,
and C.W. LIDZ
Based on the studies showing discrimination against family violent case, we would hypothesize that admission processes for family violent cases in psychiatric hospitals are likely to differ from the processes for nonfamily violent case. Fewer family violence cases are likely to be admitted, and the admitted family violent cases are likely to be more severely violent and to turn more on presentation variables-that is, circumstantial or extramedical factors. Method
Data Collection We analyzed an existing data base in an effort to explore our hypotheses regarding the psychiatric response to family violence cases. The data base was created for a more extensive descriptive research project on the clinical assessment and management of dangerousness (see Mulvey & Lidz, 1985). Observers were placed in the emergency room of a metropolitan hospital around-the-clock for a 5 month period during 1985-86. Using a type of speedwriting, observers produced near verbatim transcripts of the clinical interviews and discussions that occurred during this time. This information was transcribed into a computerized retrieval system, along with demographic and dispositional information from patients’ medical records. In addition, the two hospital staff clinicians (usually a nurse and a psychiatrist) who evaluated the patients, performed independent ratings of patients on 12 dimensions using 7-point Likert type scales. The final data base included clinical information on 382 persons who visited the psychiatric emergency room. The demographics of the total sample are similar to those of emergency room and clinic samples employed in related psychiatric research (e.g., Klassen & O’Connor, 1988; Segal, Watson, Goldfinger, & Averbuck, 1988).
Family Versus Nonfamily
Vio Ien t Categories
For the purposes of this study, cases considered to be “recently violent” were identified and then divided into two subsamples: one of family violent cases and another of nonfamily violent cases. In order to be considered a “violent case” (n = 92), a patient had to have reported, during their evaluation interview, an assault within three months prior to visiting the psychiatric emergency room. An “assault” was defined as having pushed, grabbed, hit, slapped, punched, physically fought, beat up, used a weapon, or sexually attacked another person. The recently violent cases (n = 92) accounted for 24% of the total sample of patients (n = 382). This focus on “recent” violence was taken to isolate cases whose assaults would most concern clinicians. The three month period, albeit somewhat arbitrary, appeared in the interviews to be the most relevant and discernable time frame for analysis. The majority of incidents beyond three months were markedly deficient in specificity and temporality. A period of less than three months appeared to exclude incidents that received clinical response and mention in clinical records. The recent violent cases were categorized as “family violent cases” (n = 48)
FAMILY AND NONFAMILY
VIOLENT
PATIENTS
247
or “nonfamily violent cases” (n = 44) using the following criteria. Thirty-seven patients whose recent assault, or assaults, had been committed exclusively against a family member were categorized as “family violent cases,” along with 11 additional cases whose presenting or primary incident was against a family member and who also recently assaulted a nonfamily person. The “nonfamily violent cases” consisted of 42 patients whose recent assault, or assaults, were exclusively of nonfamily members, and two additional cases in which the patient’s primary or presenting assault was against a nonfamily member while secondarily reporting a recent family assault as well. The family and nonfamily categories do provide what appears to be two categories with distinguishing case characteristics, as well as categories based on criteria available directly to clinicians during the interview (see Gondolf, Mulvey, & Lidz, 1990). Variables Two dependent or outcome measures were used in this study: (a) whether the patient was admitted to the hospital and (b) whether the patient was involuntarily committed when he or she did enter the hospital. The “outcome,” or case disposition, was determined by reviewing the medical records for each recently violent case and checking it against the available textual material from the evaluation interviews. The group committed were naturally a subset of the group admitted. Two types of variables were used as independent variables. The first set of variables was comprised of “case characteristics,” or information that seemed most likely to be considered by clinicians in deciding about admission or commitment (Marson, McGovern, & Pomp, 1988). This set of variables consisted of demographic variables (i.e., age, sex, race, employment status, and educational level) and aspects of case history and diagnostic status. These case history variables consisted of whether the patient had previously been hospitalized, arrested, attempted suicide, or diagnosed as having a major psychiatric disorder (i.e., the primary DSM-III-R diagnosis was schizophrenia or a mood disorder, as opposed to a personality disorder or alcohol dependence, cf., Segal et al., 1988). The total number of reported assaults (past and recent) was also considered a case history variable. The “case characteristics” included another set of variables: factors related to the presentation of the case in the emergency room. Thepatientpresentation variables included whether the patient was accompanied by others at presentation- that is, whether the patient appeared in the emergency room with family, friends, social service staff, ambulance drivers, or police. An additional variable was the involvement of hospital security staff. The case characteristic variables, except for the continuous age, educational level, and number of total assaults variables, were treated as dichotomous measures, coded “1” if the condition was present and “0” if it was absent. The logarithm of age was used in the analysis to compensate for its skewed distribution. The second major set of variables represented the clinicians’perceptions of the patients. For the purposes of this study, clinician ratings of chronically dangerous, currently suicidal, hostile, lacking in self-care, and psychotic seemed to be of most interest in light of what clinicians are supposed to con-
248
E.W. GONDOLF,
E.P. MULVEY,
and C.W. LIDZ
sider in their evaluation of the patient for admission and commitment and were relatively independent from one another (r < .50). Currently dangerous, for instance, was not used because of its colinearity with hostility, chronic dangerousness, and commitment. The clinician and physician ratings were summed for each case resulting in a 2 to 14 scale for analysis.
Analysis The variables were first cross tabulated by category of violent patient (family violent versus nonfamily violent) to describe the sample. Chi square statistics were used at the .l significance level to accommodate the effect of the small sample size. We might otherwise have used a significance level that corrects for experiment-wise effect. A more elaborate comparison of the two categories of violent patients appears elsewhere (Gondolf et al., 1990). It substantiates the tendencies derived in this study with a larger sample that includes patients identified as violent in hospital records as well as through self-reports in the evaluation interviews. Discriminant functions are the principal mode of analysis used to assess the admission and commitment decision making for both family and nonfamily violent cases.’ Stepwise discriminant functions (Wilks method; Tolerance = .OOl) for family violent cases and for the nonfamily violent cases were computed for the outcome measure of admission and then for commitment. The stepwise procedure was used over a direct entry of all the variables, because its exclusion of variables is preferred with a small sample size and in an exploratory investigation. The stepwise discriminant procedure was conducted for each set of predictive variablesfirst, the “case characteristics” and, second, the “clinician perceptions.” The functions using the more subjective clinician perceptions offered a means to confirm the case characteristic functions based on a different and more objective data source. Results
Descriptive Analysis of Sample Variables As Table 1 indicates, the nonfamily violent cases were more likely to be male, living alone, and suicidal than the family violent cases. With regard to presentation, the nonfamily cases were significantly more likely to involve security (30% vs. 14%). The family and nonfamily violent cases appear, however, similar in terms of amount and tactic of their violence. The mean of total assaults is 3.3 (SD = 1.9) versus 3.3 (SD = 1.7); and the mean clinician rating for dangerousness is 7.6 (SD = 2.8) versus 7.7 (SD = 3.1). ‘The discriminant analysis was appropriate and sufficient for examining the interval-level clinician perception ratings. The first set of case characteristic variables were largely dichotomous, however, and thus compromised the linear assumptions of discriminant analysis. To address this issue, a logistic regression was computed to confirm the findings. The logistic regression would have been sufficient and preferable; however, the small sample of cases (produced by the generally low base rate of violence patients), and the use of two subsamples of these violent cases, reduced the likelihood of obtaining significant logistic coefficients.
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TABLE 1 Variable Frequencies for Recent Family and Nonfamily Violent Cases
Case Characteristics
Family Violent (n = 48) # o/o
Nonfamily Violent (n = 44) # o/o
Total Violent (n = 92) # %
Demographics Maleb Black College education Living with familya Unemployed
32 18 13 36 25
36 21 10 17 27
67 39 23 53 52
Age
M SD 31 11
Case History/Diagnosis Past hospitalization Past arrest Suicide attemptb Major disorder
20 20 7 22
Total assaults (8 max.)
M 3.6
Presentation With others Security involvedb Outcome Admittedb Committed
67% 38% 28% 75% 54%
42% 42% 14% 47%
84% 48% 23% 40% 64%
M SD 29 10
73% 42% 26% 58% 58%
t(df) prob. 2.13 n.s.
24 23 18 22
55% 52% 43% 51%
44 43 24 44
48% 47% 26% 49%
SD 1.9
M 3.3
SD 1.7
t(of) .79(90)
35 14
73% 30%
28 6
65% 14%
63 20
69% 22%
30 20
62% 42%
35 14
80% 33%
65 34
71% 37%
prob. n.s
“p < .Ol; bp < .l
Nevertheless, a smaller percentage of family violent cases (62%) were admitted, in comparison to nonfamily violent cases (80%) (X2 = 3.22[1]; p < .l). This means that family cases were nearly twice as likely to be released to outpatient care. In terms of commitment, the difference between the two categories was not statistically significant (42% vs. 33%). This amounts to two thirds of the admitted family violent cases being committed, and only 40% of the admitted nonfamily violent cases being committed. A discriminant function was computed to confirm the relative explanatory power of the family/ nonfamily categorization.2 A cross-tabulation of three major subcategories of *The standardized coefficients of the stepwise function for admission were: past arrest = .38; suicide attempt = .24; presentation with others = .89; security involved = .48; and family violent = - .40 (Wilks Lambda = .71; p < ,001; Correct Classification = 74%). The category of violence (family violent case versus nonfamily violent case) was at least as influential as the two other case history variables that produced significant results, but apparently not as influential as the presentation variables. The discriminant function for commitment produced a vary similar result, except that education (.38) was also included in the final function and the “family violent” variable was not (Wilks Lambda = .71; p < .05; Correct Classification = 72%).
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E.W. GONDOLF, E.P. MULVEY. and C.W. LIDZ
Discriminant
TABLE 2 Functions for Case Characteristics
Admitted Case Characteristics
Family
Committed
Nonfamily
Family
Nonfamily
Demographics Male Black Unemployed Education Age Case History Past hospitalization Past arrest Total assaults Suicide attempt Major disorder Presentation With others Security involved
.38 .27
.48
.83 .38
.72 .60
.62 .82
.80 .37
Significance Wilk’s lambda Correct classification
,001 .60 81%
.l .86 78%
,001 .53 77%
,001 .50 80%
.30 - .38 .75 -.28 .40
.45 ~ .60
.26 .75
n = 92.
family violence shows that cases involving spouse assault were the least likely to be admitted (36070)~ as compared to those who assaulted parents or guardians (70%) or who assaulted siblings or adolescent children (79%) (X2 = 6.31[2];p < .05).
Discriminant Functions with Case Characteristics As shown in Table 2, the admission functions both for family and nonfamily cases were similar in several fundamental ways, but suggest some instructive differences. In both functions, being accompanied to the emergency room “with others” is the most influential variable in distinguishing the admission and commitment outcomes (discriminant coefficients = .83 and .72).3 The security staff being involved and previous suicide attempts also substantially raise the chances of being admitted or committed. The demographic variables did not significantly contribute to the admission outcome for either family or nonfamily violent cases. ‘The variable “with others” was recorded to include “by self,” “with family or friends,” and “with police or ambulance staff.” Forty-three percent of the admitted family cases were brought in by police or ambulance staff, and none of the family violent cases assigned to outpatient treatment were accompanied by these professionals (X2 = 15.87[2]; p < ,001). Sixty percent (12) of the committed nonfamily cases were brought in by police or ambulance staff, and 75% (11) of the committed nonfamily violent cases were brought in by police or ambulance staff (X2 = 20.48[2]; p < ,001). In sum, accompaniment by professionals is most likely to lead to admission or commitment.
FAMILY AND NONFAMILY
Discriminant
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TABLE 3 Functions for Clinician Perceptions
Committed
Admitted Clinician
Perceptions
Ratings Lacks self-care Hostile Psychotic Dangerous Suicidal Significance Wilk’s lambda Correct classification
Family
Nonfamily
Family
Nonfamily
.60
.28 .82 .29
.96
.96
.52
.51 .66
,001 .65 81%
.Ol .71 76%
.27
,001 .49 79%
,001 59 74%
n = 92.
The principal difference between the two admission discriminant functions is that past arrests and a major disorder significantly contribute to the admission of family violent cases, but not of the nonfamily violent cases. The function with nonfamily violent cases was the weaker of the two accounting for only 24% of the variance (Wilks Lambda = -86) as compared to 40% for nonfamily cases (Wilks Lambda = .60). The classification rates are, nevertheless, comparable and substantially better than chance. The discriminant functions computed for commitment suggest some underlying differences (see Table 2). While the presentation variables of being with others and involving security are again strongly influential, there is a greater range of variables that contribute to the commitment of family violent cases. Family violent patients who are older, black, have repeated assaults, and have not been previously hospitalized, besides being with others and involving security at presentation, are the most likely to be committed. Whereas, suicidal, not arrested, previously hospitalized, and poorly educated patients are the most likely nonfamily violent patients to be committed. In essence, the chronically “antisocial” family violent person and the very “sick” nonfamily violent person are most likely to be committed. Discriminant functions using clinician perceptions to determine admission and commitment reflected the same commonalties evidenced in the discriminations using case characteristics (see Table 3). In all but the admission function for nonfamily cases, the variance was largely explained by the hostility attributed to the patient, much as the “with others” and “security involvement” variables accounted for the variance in the previous set of functions. Discussion
The Evidence for Different Decision Making Our hypothesis that the admission and commitment process would differ for family violent cases and nonfamily violent cases was partially substantiated. The differences were most pronounced for the admission process. The
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first major difference is in admissions rates. The family violent cases appeared to be equivalently violent in terms of reported severity and frequency of assaults and the clinicians’ perceptions of their dangerousness. Nevertheless, the family violent cases were less likely to be admitted than the nonfamily cases (62% vs. 80%). Patients who abused their siblings or adolescent children were three times as likely to be admitted than those who abused their wives or girlfriends. That family violence perpetrators were more likely to be released is of particular concern, since their victims are more readily accessible than those of the nonfamily violent perpetrators (Walker, 1989). The hospital admissions appear to differ in terms of the factors involved in the decision-making process. The family violent cases who were admitted displayed a greater constellation of problems; they were more likely to have past arrests, suicide attempts, and major disorders. In other words, the family violent cases may need to be more serious in order to be admitted. For both the family and nonfamily violent patients, the patient’s being accompanied by others was the most influential variable in predicting admission, as previous research might suggest (Marson et al., 1988). Our examination of the commitment process showed less discrepancy in the actual percentages of committed family versus nonfamily violent cases (42% vs. 33%). As might be expected, the commitment process appeared to involve a greater constellation of factors than the admission process, since it is a more select subset of those admitted. Those family violent cases who were committed were more likely to be young, highly assaultive, parent and/or sibling abusers accompanied to the emergency room and also requiring security staff to restrain them. In sum, the family violent cases, who are admitted and committed, appear more seriously violent and the nonfamily cases as more sickly (e.g., they are more likely to have been previously hospitalized).
Differing Categorizations Theoretically, our findings lend support to the notion that psychiatric decision making is, at least in part, a discretionary process of categorization (Turk et al., 1988), rather than the uniform application of standards (Mills, 1988). Several explanations for the family violence versus nonfamily violence categorization have been suggested in studies of police arrests (Berk & Loseke, 1981) and medical care (Kurz, 1987). Psychiatric staff may minimize the family violence as a private matter or merely a “marital difficulty,” as the myths of family violence suggest (Walker, 1989). Or the family violence may be viewed more as a systemic interaction between victim and perpetrator, rather than one with a definitive perpetrator (Shupe, Stacey, & Hazelwood, 1987). In other words, psychiatric staff may be more likely to consider the family violence as provoked and therefore less impulsive than the nonfamily violence. This is particularly relevant given Segal et al.% (1988) finding that “impulsivity” was the most influential factor in determining clinician decisions in their study. Our study must be considered exploratory in nature because of a few fundamental qualifications. Probably the most difficult issue facing research in this field is the relatively low base rate of violent patients. This problem is compounded by dividing the violent patients into two subsamples. The small sam-
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VIOLENT
PATIENTS
253
ples analyzed with several variables may mean that the computed functions are unstable. Also, our subsamples of family and nonfamily violent cases remain somewhat arbitrary and convenient; preliminary research suggests that more complex distinctions for family violence cases are warranted (McNiel & Binder, 1987). Furthermore, our presentation and outcome measures remain relatively simplistic. The dichotomous variable for commitment does not, for instance, reflect the negotiation process that occurs between psychiatric staff and patient (Reed & Lewis, in press). These issues are addressed in a qualitative study of the sample that allows for more distinctions in the sample and a description of the decision making processes (Gondolf, 1990). In any case, our quantative study substantiates the notion that admissions to a psychiatric hospital is a discretionary process. This process appears to discriminate against family violence cases, as the family violence literature would predict. More needs to be done, therefore, to address the distinction of family violence and nonfamily violence in psychiatric research and clinical practice.
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Segal, S. P., Watson, M. A., Goldfinger, S. M., & Averbuck, D. S. (1988). Civil commitment in the Psychiatric emergency room. Archives of General Psychiatry, 45, 748-763. Shupe, A., Stacey, W., & Hazelwood, L. (1987). Violent men, violent couples: The dynamics of domestic violence. Lexington, MA: Lexington Books. Turk, D. C., Salovey, P., & Prentice, D. A. (1988). Psychotherapy: An information-processing perspective. In E. C. Turk & P. Salovey (Eds.), Reasoning inference, and judgement in clinical psychology. New York: Free Press. Walker, L. E. A. (1988). Intervention with victim/survivors. In I. B. Weiner&A. K. Hess (Eds.), Handbook offorensicpsychology. New York: John Wiley & Sons. Walker, L. E. A. (1989). Psychology and violence against women. American Psychologist, 44, 695-702. Webster, C. D., & Menzies, R. J. (1987). The clinical prediction of dangerousness. In D. N. Weisstub (Ed.), Law and mental health, vol. 3. Elmsford, NY: Pergamon Press.
