Impulsive violence may be the behavioral consequence of inefficient information processing within specific neuronal networks. Analogous to the hypothetical pathophysiology of addiction, maladaptations within reward pathways may shift goal-directed behaviors to impulsive reactions and then to compulsive habits, in order to create impulsive violence.

Many forensic psychiatric settings serve unique populations who have, in addition to traditional psychiatric symptoms, diverse legal and criminogenic needs. A lack of clear treatment standards that address all aspects of forensic care can lead to inefficient or inappropriate interventions and contribute to institutional violence.

Existing literature on aggression within psychiatric hospitals suggests that treating an aggressive patient’s symptoms could be complemented by (a) milieu environments that mitigate violence and (b) hospital-wide policies and procedures that focus on creating a safe environment. Described as an ecological approach, examples of how this broader, situational approach can reduce inpatient violence in psychiatric settings are provided throughout. The authors identify potential barriers to focusing on wards and institutional rules as well as patient treatment. Last, details of how this ecological approach has been implemented at one state hospital in California are provided.

The received wisdom is that there is no known effective treatment for psychopathic disorders. Although outcome studies have not identified an effective programmatic treatment for psychopathic disorders, such studies tend to leave the question open. If behavioral science has not established that psychopathic disorders respond to a particular programmatic approach, neither are psychopathic disorders convincingly proven to be absolutely resistant to treatment. If no treatment is known to be effective in psychopathic disorders, then any treatment seems to squander resources. What is often missing from the discussion is effective therapeutic measures to treat other behaviors that often co-occur, if they do not represent a domain of pathology of psychopathic disorders, such as impulsive aggression. After a brief summary of results of programmatic treatment of psychopathic offenders, this review focuses on the pharmacotherapy of impulsive aggression in psychopathic disorders. If the impulsive aggression that occurs with psychopathic disorders can be better controlled, treatment can have substantial benefits and would be most appropriate.

Psychosocial interventions are part of the complex understanding and treatment of violent behavior in our state mental health hospitals. A comprehensive assessment of violence and aggression includes attention to all 3 domains of prevention and assessment (primary-institutional, secondary-structural, and tertiary-direct). Trauma experiences and their consequences may include behavioral violence and aggression. The authors’ premise is that trauma is a universal component in the individual assessment of violent behavior. Therapeutic interventions must include a trauma-informed formulation to be effective. Organizational commitment to trauma-informed, person-centered, recovery-oriented (TPR) care is crucial to the efficacy of any of the interventions discussed. Thus, the dynamic nature of the individual, interpersonal, environmental, and cultural factors associated with the daily operations of the inpatient unit need to be assessed through the lens of primary and secondary violence prevention, building on the recognition that the majority of persons served and staff have significant trauma histories. Once a compassionate, respectful, empathic, and empowering approach is embraced by leadership and staff, the work with individuals can proceed more effectively. Interventions used include a variety of cognitive-behavioral, interpersonal, and somatosensory therapies. These interventions, when effectively applied, result in more self-esteem, self-mastery, self-control for the person served, and diminished behavioral violence.

Psychopathic individuals account for substantial predatory and impulsive violence. To the present, the principal intervention used to decrease the harm inflicted by psychopaths has been confinement. Nevertheless, most confined psychopathic persons return to the community. Recent advances in the understanding of the neurobiology of psychopathy hold promise for new research directions and more effective treatments. In this article, we will explore recent advances in genetics, electrophysiology, brain imaging, and psychopharmacology, as well as, in brief, their implications for new directions in research and treatment.

The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers. The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century. Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings. Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.

Responding to the California Supreme Court’s decision and its related legal obligations in Tarasoff v. Regents of Univ. of California over 30 years ago has become a standard part of mental health practice. This case influenced legal requirements governing therapists’ duty to protect third parties in nearly every state in the country. The final ruling in Tarasoff emphasized that therapists have a duty to protect individuals who are being threatened with bodily harm by their patients.

This article will provide a brief overview and update on duty to protect legal requirements. Clinical guidelines for addressing threats and the duty to protect will be discussed, along with risk management approaches. The article will conclude with a sample vignette illustrating these principles.

Physical violence is a frequent occurrence in acute community psychiatry units worldwide. Violent acts by patients cause many direct injuries and significantly degrade quality of care. The most accurate tools for predicting near-term violence on acute units rely on current clinical features rather than demographic risk factors. The efficacy of risk assessment strategies to lower incidence of violence on acute units is unknown. A range of behavioral and psychopharmacologic treatments have been shown to reduce violence among psychiatric inpatients.

The relationship between mental illness, violence, and criminal behavior is complex, and involves a multifaceted interaction of biological, psychological, and social processes. In this article, we review the emerging research that examines the neurobiological and psychological factors that distinguish between persons with mental illness who do and who do not engage in crime and violence. Additionally, a novel model for understanding the interaction between mental illness and criminalness is proposed. (As defined by Morgan and colleagues, criminalness is defined as behavior that breaks laws and social conventions and/or violates the rights and wellbeing of others.) Stemming from this model and outlined research, we argue that management and treatment approaches should target the co-occurring domains of mental illness and criminalness to improve criminal and psychiatric outcomes. Specifically, we discuss and propose effective housing (management) and biopsychosocial intervention strategies for improving outcomes.

Criminal conduct is not always violent, and violence does not always lead to criminal charges. Moreover, crime and violence have multifaceted etiologies. Most violence in society is not attributable to mental illness. Where there is a small relationship between violence and mental illness, the risk of violence increases for individuals with substance use histories. Underlying trauma can also play a role. Antisocial attitudes, behaviors, and peer groups further increase the risk that individuals, including those with mental illness, will find themselves at risk of criminal recidivism. Criminal histories among public mental health populations, and mental health and substance use disorders among criminal populations are each higher than general population comparisons. Care within behavioral health settings should therefore target decreased criminal recidivism and decreased violence as part of recovery for those individuals at risk, using trauma-informed approaches and peer supports. Interventions that show promise bring criminal justice and behavioral health systems together, and include police-based diversion, specialty courts, court-based alternatives to incarceration, and coordinated re-entry programs. This article reviews these options along with specific risk management strategies, such as using risk, needs, and responsivity factors as a means of improving overall outcomes for persons with mental illness, while minimizing their risk of further criminalization and victimization.

Almost no literature addresses treatment planning for the forensic psychiatric patient. In the absence of such guidance, recovery-oriented multifocal treatment planning has been imported into forensic mental health systems from community psychiatric settings, despite the fact that conditions of admission and discharge are vastly different for forensic psychiatry inpatients. We propose that instead of focusing on recovery, forensic treatment planning should prioritize forensic outcomes, such as restoration of trial competence or mitigation of violence risk, as the first steps in a continuum of care that eventually leads to the patient’s ability to resolve forensic issues and return to the community for recovery-oriented care. Here we offer a model for treatment planning in the forensic setting.

Aggression and violence represent a significant public health concern and a clinical challenge for the mental healthcare provider. A great deal has been revealed regarding the neurobiology of violence and aggression, and an integration of this body of knowledge will ultimately serve to advance clinical diagnostics and therapeutic interventions. We will review here the latest findings regarding the neurobiology of aggression and violence. First, we will introduce the construct of aggression, with a focus on issues related to its heterogeneity, as well as the importance of refining the aggression phenotype in order to reduce pathophysiologic variability. Next we will examine the neuroanatomy of aggression and violence, focusing on regional volumes, functional studies, and interregional connectivity. Significant emphasis will be on the amygdala, as well as amygdala–frontal circuitry. Then we will turn our attention to the neurochemistry and molecular genetics of aggression and violence, examining the extensive findings on the serotonergic system, as well as the growing literature on the dopaminergic and vasopressinergic systems. We will also address the contribution of steroid hormones, namely, cortisol and testosterone. Finally, we will summarize these findings with a focus on reconciling inconsistencies and potential clinical implications; and, then we will suggest areas of focus for future directions in the field.

Elevations of impulsive behavior have been observed in a number of serious mental illnesses. These phenomena can lead to harmful behaviors, including violence, and thus represent a serious public health concern. Such violence is often a reason for psychiatric hospitalization, and it often leads to prolonged hospital stays, suffering by patients and their victims, and increased stigmatization. Despite the attention paid to violence, little is understood about its neural basis in schizophrenia. On a psychological level, aggression in schizophrenia has been primarily attributed to psychotic symptoms, desires for instrumental gain, or impulsive responses to perceived personal slights. Often, multiple attributions can coexist during a single aggressive incident. In this review, I discuss the neural circuitry associated with impulsivity and aggression in schizophrenia, with an emphasis on implications for treatment. Impulsivity appears to account for a great deal of aggression in schizophrenia, especially in inpatient settings. Urgency, defined as impulsivity in the context of strong emotion, is the primary focus of this article. It is elevated in several psychiatric disorders, and in schizophrenia, it has been related to aggression. Many studies have implicated dysfunctional frontotemporal circuitry in impulsivity and aggression in schizophrenia, and pharmacological treatments may act via that circuitry to reduce urgency and aggressive behaviors; however, more mechanistic studies are critically needed. Recent studies point toward manipulable neurobehavioral targets and suggest that cognitive, pharmacological, neuromodulatory, and neurofeedback treatment approaches can be developed to ameliorate urgency and aggression in schizophrenia. It is hoped that these approaches will improve treatment efficacy.

Novel technological interventions are increasingly used in mental health settings. In this article, we describe 3 novel technological strategies in use for management of risk and violence in 2 forensic psychiatry settings in the United Kingdom: electronic monitoring by GPS-based tracking devices of patients on leave from a medium secure service in London, and closed circuit television (CCTV) monitoring and motion sensor technology at Broadmoor high secure hospital. A common theme is the use of these technologies to improve the completeness and accuracy of data used by clinicians to make clinical decisions. Another common thread is that each of these strategies supports and improves current clinical approaches rather than drastically changing them. The technologies offer a broad range of benefits. These include less restrictive options for patients, improved accountability of both staff and patients, less invasive testing, improved automated record-keeping, and better assurance reporting. Services utilizing technologies need also be aware of limitations. Technologies may be seen as unduly restrictive by patients and advocates, and technical issues may reduce effectiveness. It is vital that the types of technological innovations described in this article should be subject to thorough evaluation that addresses cost effectiveness, qualitative analysis of patients’ attitudes, safety, and ethical considerations.

Aggression is a behavior with evolutionary origins, but is often both destructive and maladaptive in today’s society. Research over the past several decades has confirmed the involvement of neurotransmitter function in aggressive behavior. This research has centered around the “serotonin hypothesis.” As this literature continues to grow, guided by pre-clinical research and aided by the application of increasingly sophisticated neuroimaging methodology, a more complex picture has emerged. As current pharmacological and therapeutic interventions are effective but imperfect, it is hoped that new insights into the neurobiology of aggression will reveal novel avenues for treatment of this destructive and costly behavior.

Therapeutic nihilism on treating psychopathy is widespread and is largely based on many outdated and poorly designed studies. Important recent advances have been made in assessing psychopathy and recidivism risks, as well as in offender rehabilitation to reduce reoffending, all of which are now well supported by a considerable literature based on credible empirical research. A 2-component model to guide risk reduction treatment of psychopathy has been proposed based on the integration of key points from the 3 bodies of literature. Treatment programs in line with the model have been in operation, and the results of early outcome evaluations are encouraging. Important advances also have been made in understanding the possible etiology of mentally disordered offenders with schizophrenia and history of criminality and violence, some with significant features of psychopathy. This article presents a review of recent research on risk reduction treatment of psychopathy with the additional aim to extend the research to the treatment of mentally disordered offenders with schizophrenia, violence, and psychopathy.

There is increasing interest in developing more nuanced methods for managing aggression and violence in long-term psychiatric inpatient settings. However, the dearth of controlled studies has, at times, hampered presentation of viable options. Following the publication of guidelines developed in the California State Hospital forensic system, the authors present a group of 7 cases illustrating different approaches to violence management, including pharmacological, psychotherapeutic, and environmental interventions.