CLINICAL HANDBOOK OF SCHIZOPHRENIA

39. Aggression, Violence, and Psychosis 399to the importance of anger that, when coupled with psychotic symptoms, is associatedwith higher rates of violence and aggression. However, the link between anger and violenceis not a simple one: Whereas anger can be an activator of aggression, it is neithernecessary nor sufficient to induce violence, and an understanding of a violent event has tobe contextualized within the environment in which the incident occurred. This is veryrelevant for people with psychosis, whose experience and response to anger-provokingevents may be partly influenced by not only their delusional thinking but also their dayto-daylife within adverse, controlling, disrespectful, and unempathic environments.This evidence suggests that clinicians must account for the following key factorswhen working with people who have a psychosis and problems with aggression and violence:(1) illness factors, such as particular psychotic symptoms; (2) substance use; (3) anger;and (4) environmental factors. Any intervention is likely to require the clinician to understandthe problems of aggression and violence across all of those areas, while taking intoaccount the complex environmental, personality, and historical factors that contribute tothe problem. It is helpful not to view the aggression or violence as something that iswholly located within the individual, but as the product of a complex system of constantlychanging variables.People who are aggressive and violent often reside on inpatient or possibly secureunits and present with a range of complex needs compared to people living within thecommunity. For example, although there is some variation, this group of people is likelyto have had prior challenges to services in terms of anger and violence within the contextof a history of chronic substance use. Because they are more likely to be “resistant” totraditional treatment approaches, these individuals’ persistent psychotic symptoms or beliefsmay have interfered with traditional assessments and treatments. Typical symptomsmay include the presence of specific types of command hallucinations and/or delusionalbeliefs that interfere with engagement in services (e.g., delusionally driven catastrophicimplications of discussing psychotic experiences with the staff). Additionally, it is not uncommonfor clients within such secure units to be socially unsupported outside of theirresidential unit due to a history of gradual deterioration in interpersonal relationshipsand, in the case of people residing in some secure units, to be geographically displacedfrom their home location.These difficulties pose challenges in maintaining a cohesive multidisciplinary approach,and present problems in the process of diagnosis and identification of the mostappropriate treatment approaches. Furthermore, all therapeutic work has to occur withinthe context of a need to balance custodial and therapeutic agendas.PSYCHOTHERAPEUTIC INTERVENTIONS FOR THIS POPULATIONPsychotherapeutic treatments for this group of people have not been widely described inthe literature. However, recent work has suggested a number of approaches that may behelpful. For example, psychological interventions, such as cognitive-behavioral treatmentsin conjunction with antipsychotic medication, have been shown to reduce effectively theseverity and frequency of psychotic symptoms in people with treatment-resistant psychosis.Cognitive-behavioral methods have also been successful in treating anger- and substanceuse–related problems in clients with severe mental health problems. It is possible to integratethese treatments to provide a comprehensive intervention that attempts to meet thecomplex needs of people with psychosis and violence problems.Figure 39.1 illustrates a clinical formulation that assists in understanding, assessing,and treating people with these complex problems. As can be seen, the occurrence of vio-