The Use of Scientific Evidence about Schizophrenia and Violence in Clinical Services

This special section of the Canadian Journal of Psychiatry focuses on violent behaviour by persons with schizophrenia. Three brief but informative articles critically review clinically relevant, up-to-date evidence. Hodgins and Klein ¹ draw attention to new evidence about the aetiology of violence among people with schizophrenia, potent predictors of violence, and the need to restructure psychiatric services such that individuals developing schizophrenia are assessed for past and current violent behaviour and to provide them with a host of treatments targeting both their violent behaviours and the schizophrenia. Quinn and Kolla ² review the evidence on effective treatments, concluding that randomized clinical trials (RCTs) are urgently needed to bolster the evidence base. Swartz, Bhattacharya, Robertson, and Swanson ³ review the evidence about outpatient commitment, most of which comes from the United States. However, as noted by Hodgins and Klein, ¹ some people with schizophrenia have a long history of antisocial behaviour, ways of thinking, and attitudes that lead to noncompliance with psychiatric care. The review by Swartz et al. ³ shows that outpatient commitment does improve compliance.

However, most of this evidence is not being used by psychiatric services. First-episode clinics do not generally assess for past and current antisocial and aggressive behaviour, nor do they have the resources to treat these behaviours, including substance misuse, along with the schizophrenia. A subgroup of their patients will be prosecuted for a violent crime. If it is proven and they are judged not responsible due to a mental disorder, in most countries, they are sent to a forensic hospital. Patients are initially discharged on a court order under the jurisdiction of a provincial review board and, in other countries on similar court orders, with powers to quickly return the patients to the forensic hospital if the conditions of their discharge are not respected or their mental status deteriorates. Thus, orders for outpatient treatment begin within forensic services.

I have been the director of a large forensic psychiatric service with a geographic catchment area of 6,000,000 inhabitants for 30 years. Most patients are men with schizophrenia. They remain in hospital, on average, 5 years, with gradual access to the community long before final discharge. Throughout these years, I have done my utmost to try and base our clinical services on scientific evidence.

Powerful challenges, however, have and continue to block progress towards this goal. First, who among the clinical staff has the responsibility and the time to keep up with the literature and identify new effective treatments and assessment tools? Second, once a treatment program has been shown to be effective or an assessment tool has been shown to be valid, how are funders of a clinical service to be convinced to pay for staff training and implementation of the new program or instrument? How are competent trainers identified? Third, which staff should be trained to achieve the best results, and who covers their usual clinical responsibilities while they are being trained? Probably the biggest challenge is implementing the new treatment within the ongoing treatment program of the institution as it involves combatting resistance to change among staff.

After much reading and long discussions with C. D. Webster, in 1995 I implemented the use of the Historical Clinical Risk–20 ⁴ (HCR-20) for assessing risk of violent behaviour in both inpatient and outpatient services, soon followed by Version 2 in 1998. ⁵ This initiated a culture change within our service. However, even having obtained the necessary funds for staff training and implementation of the HCR-20, with a core group of senior staff who enthusiastically promoted the use of the new assessment tool, it took years before the use of the HCR-20 and the concept of structured professional judgement was fully implemented in our service.

Since the early 1990s, our clinical service has implemented several new assessment tools and treatments, including the Psychopathy Checklist–Revised ⁶ in 1996, the Psychopathy Checklist: Screening Version ⁷ in 1998, the Reasoning and Rehabilitation program ⁸ in 1999, Dialectic Behavior Therapy ⁹ in 2000, Integrated Psychological Therapy ¹⁰ in 2012, and the third version of the HCR-20 ¹¹ in 2014.

While a culture of change was solidly in place by 2014, the quality of institutional change was modified by the introduction of the Short-Term Assessment of Risk and Treatability (START). ¹² Since the mid-1990s, multidisciplinary treatment teams have been completing the clinical and risk items of the HCR-20, but this instrument had always been thought to “belong” to the psychiatrists and psychologists. In contrast, from the beginning, the START was considered to “belong” to the nurses and to replace the traditional way that they planned their treatment activities. The START is rated by the entire multidisciplinary team, with the nurses taking the lead. A few of the psychiatrists and psychologists resisted the new procedure. After only 2 years, the use of the START is now well embedded within service.

Implementing the use of new assessment instruments and treatments is a process of change that takes time and requires careful management and monitoring. Our experience demonstrates that a culture of permanent change can be implemented within a clinical service, thereby creating a general openness for new developments in assessment and treatment. Such a climate includes openness to new knowledge about patients and their needs and has the potential to change service delivery for the better.

Quinn and Kolla ² highlight the need for RCTs to identify effective treatments for patients with schizophrenia who engage in physically aggressive behaviour towards others. I agree that if new treatments are compared to treatment as usual (TAU), and if the new treatment is proven to be effective, those randomized to TAU should subsequently receive the new treatment. But, how does a forensic psychiatric service do this? Where does the money come from to pay staff to conduct such trials? After reading the evidence on the effectiveness of the Reasoning & Rehabilitation program with non–mentally ill offenders, I obtained funds (it was very expensive) to pay for many of our psychologists and nurses to learn how to use this program. And we still do. It works wonders! But, I have no evidence to prove it.