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Violence by Persons with Serious Mental Illness Toward Family Caregivers and Other Relatives: A Review

Labrum, Travis PhD, LCSW; Zingman, Michael A. MPH; Nossel, Ilana MD; Dixon, Lisa MD, MPH

Author Information
Harvard Review of Psychiatry: 1/2 2021 - Volume 29 - Issue 1 - p 10-19
doi: 10.1097/HRP.0000000000000263

Abstract

Persons living with serious mental illness (SMI)—defined as schizophrenia, bipolar disorder, or other mental disorders resulting in substantial functional impairment—are at a modestly increased risk of committing violence1,2 and at an even greater risk of being victims of violence.3 While only 21% of violence by the general population is committed against family members,4 approximately half of all violent acts by persons with SMI occur toward such persons.5–7 This discrepancy, in combination with the elevated risk of violence by persons with SMI, results in violence occurring in a sizable minority of families with a member with SMI. Such violence has many detrimental consequences for family members—including possible injury8 and increased levels of burden, psychological distress, and trauma symptoms9—and also for persons with SMI, such as impaired relationships10 and disconnection from family members.11,12

This article opens with a review of available evidence regarding (1) rates of violence by persons with SMI toward family members, (2) factors positively associated with such violence, and (3) how family members perceive and understand violence by persons with SMI, as described in qualitative studies. Following that review, we offer recommendations for the prevention of violence by persons with SMI toward family members and suggestions for future research.

We acknowledge that violence between family members and persons with SMI may be directed toward persons with SMI13 or be bidirectional.14 We have chosen to focus on violence committed by persons with SMI toward family members—primarily caregivers and non-intimate-partner relatives—as the majority of research investigating violence in families with a member with SMI has been conducted in that area. This article was informed by our own previous scholarly work and research, and also by searching PubMed for sources published between 2015 and 2019 using the search terms violence OR aggression AND (schizophrenia OR psychosis OR serious mental illness OR severe mental illness) AND (family OR caregiving OR parent). While the studies in this article have not employed a uniform definition of violence, most have generally defined violence as any assaultive acts (regardless of whether they resulted in physical injury or involved the use of a weapon) or threats of assaultive acts involving a weapon; this definition of violence is the one we use in the present article. We acknowledge that conflict and violence between family members are often dynamic and interactive. We use the terms commit and victim in an effort to be congruent with extant scholarship in this area.

RATES OF VIOLENCE TOWARD FAMILY MEMBERS

Unfortunately, no studies using representative samples have estimated the prevalence of perpetration/victimization of family violence by persons with SMI. As such, research in this area has relied on the use of convenience samples, primarily recruited through family support organizations (e.g., National Alliance on Mental Illness) and inpatient or outpatient mental health treatment agencies. Labrum and Solomon15 reviewed known studies describing rates of victimization among family members by persons with mental illness from across developed nations. In these studies, the overwhelming majority of persons with mental illness had SMI, and most family members were caregivers. The authors concluded that “the best available estimate is that 20% to 35% of persons with high levels of contact with a relative with psychiatric disorders have been the victim of violence committed by their relative with psychiatric disorders in the past 6 to 12 months, and that at least 40% have been the victim of said violence since the onset of their relative’s illness.”15(p 2955)

Since that review,15 only a handful of additional studies have examined this phenomenon. Among 208 primary caregivers of persons with SMI admitted to a psychiatric hospital in Beijing, 45% reported having experienced physical attacks by their relatives with SMI in the past year.16 Similarly, in a sample of 113 adult siblings in Osaka, recruited from a family group association, the reported lifetime rate of victimization of violence by siblings with schizophrenia was 46%.17 In a study examining victimization based on participants’ responses to a single prompt regarding violent behavior by care recipients in early psychosis, Smith and colleagues18 found that 14% of London caregivers had experienced physical violence by their relatives with schizophrenia.

Few studies have used reports by persons with SMI to examine the occurrence of violence by this population toward family members. In a small sample of women with SMI recruited from outpatient treatment organizations, 17% reported committing physical intimate partner violence in the past two years, and 23% reported having committed such violence in their lifetimes.19 With a sample primarily recruited from mental health support organizations, 13% of participants with bipolar disorder or schizophrenia reported having committed violence against the relative with whom they spend the most time in the past six months, and 36% reported committing such violence since first diagnosed with a mental illness.14

Due to the use of convenience sampling, the results of these studies should be interpreted with caution; nonetheless, these findings suggest victimization of family violence may be substantially more common among persons with relatives with SMI than among the general population. Among the general population, rates of victimization by non-intimate-partner relatives are considerably lower than rates of victimization by intimate partners.20 The National Intimate Partner and Sexual Violence Survey21 employs a definition of violence that is roughly similar to those of the studies reviewed above (i.e., physical violence not requiring physical injury or use of a weapon). In contrast to the rates of victimization by relatives with SMI, the National Intimate Partner and Sexual Violence Survey estimates that only 2.9% of women and 3.8% of men have been victims of violence by intimate partners in the past year.21

RISK FACTORS FOR VIOLENCE TOWARD FAMILY MEMBERS

Research examining risk factors for violence by persons with SMI toward family members has examined factors in the following domains: (1) persons with SMI, (2) family members, (3) reliance of persons with SMI on family members for tangible and instrumental support, and (4) interactions/relationships between persons with SMI and family members. As a visual aid, factors found to be positively associated with the likelihood of family violence by this population are listed in Text Box 1. As the results summarized below are from correlational studies, it should be noted that claims of cause and effect cannot be made. After risk factors for family violence by persons with SMI are presented, we briefly describe what is known regarding whether similar factors are related to intimate partner violence—the most common form of family violence20—by the general population.

Text Box 1

Factors Positively Associated with the Risk of Violence by Persons with SMI Toward Family Members

Persons with SMI

Among adults with SMI, younger adults are more likely than those who are older to commit violence toward family members.8,22–26 While men are more likely to commit violence,27,28 violence by women is more likely to occur in the home and to target family members.29 Presumably as a consequence, the evidence that men are more likely to engage in family violence is inconsistent.5,23,24,26,30–33 Lower educational attainment26 and income33 have been found to increase the risk of family violence. The association of race/ethnicity and family violence has infrequently been examined.

Drug and alcohol use has consistently been found to increase the risk of violence by persons with SMI toward family members.8,26,30,33 Significant differences in the risk of family violence have not been found in relation to the specific mental health diagnosis of persons with SMI,33 although analyses examining subgroups of persons with SMI who have committed violence suggest that psychotic symptoms may be more predictive of violence toward family members than non-relatives.34 The number of psychiatric hospitalizations has been found to be associated with increased risk of family violence,26,32,33 as have medication nonadherence and not attending mental health treatment.33,35 Histories of violence, crime, or arrest are positively associated with family violence by persons with SMI,22,30,33 with tentative evidence suggesting an association with a history of physical victimization.36

Younger age, lower educational attainment and income, drug and alcohol use, antisocial behaviors, and victimization are also associated with intimate partner violence by the general population.37

Family Members

Some evidence suggests that among family members of persons with SMI, younger relatives are more likely to be victims.22,33 Earlier studies found mothers to disproportionately be victims of violence.6,31,38 More recent studies have not found parents33 or female relatives18,32,33 to more often be victims. Mothers may be at an increased risk, however, of being a victim of homicide, in particular.39,40 Family members with lower incomes26,32,33 and who are not employed full time33 are more likely to report experiencing violence by their relatives with SMI.

Among the general population, younger persons and those with lower incomes or who are unemployed are more likely to be victims of intimate partner violence.37 Similarly, while no consistent evidence indicates that women are more likely to be victims of intimate partner violence overall,37 women are considerably more likely than men to incur injuries41 or murder42 by intimate partners.

Reliance of Persons with SMI on Family Members for Tangible and Instrumental Support

Financial dependence of persons with SMI on family members is positively associated with the risk of family violence;6,33 the demand for money has been identified as an impetus for such violence and aggression.10,39 Many persons with SMI rely on their families for housing, and cohabitation of persons with SMI and family members has repeatedly been found to increase the risk of family violence by this population,23,26,33,43 with cohabitation nearly always being present in the rare cases of parricide that occur by persons with schizophrenia.39 Family members who provide greater levels of caregiving to relatives with SMI have been found more likely to be victims33 or to fear that their relatives with SMI will harm them or others.44 Similarly, violence is more likely to occur when family members act as representative payees for persons with SMI30,33 or otherwise manage their money.32,33

Relying on intimate partners for tangible and instrumental support has not commonly been examined as a risk factor for committing intimate partner violence among the general population.37 To the contrary, being financially dependent has been hypothesized to increase the risk of victimization—not perpetration—of intimate partner violence,45 with occasional evidence supporting this hypothesis.46

Interactions/Relationships of Persons with SMI and Family Members

Termed limit-setting practices, family members often attempt to modify the behavior of relatives with SMI through encouragement, verbal pressure, and contingency contracts.47 Regardless of the intent of family members, limit-setting practices may be interpreted as coercive or ill intended by persons with SMI. Medication use is often an area in which limit-setting practices are employed.38 In one study, nearly one-third of caregivers perceived aggression by persons with SMI to be the result of them insisting that their relatives with SMI take medications.10 Examining limit-setting practices broadly, Labrum and Solomon33 found the use of such practices to be the variable most strongly associated with acts of family violence. Additionally, use of limit-setting practices mediated the relationship between providing caregiving and the risk of family violence. In other studies, limit-setting practices were found to have been used by family members in at least half of events preceding acts of violence.39,43

The level of contact between persons with SMI and family members is positively associated with the risk of family violence30,33 and aggression.48,49 A premorbid poor-quality relationship between persons with SMI and family members is also related to family violence.8,22 Other factors positively associated with family violence by persons with SMI include criticism,18,32 hostility,6,18,25,31 verbal aggression,50 and physical violence14,24 by family members toward persons with SMI, and verbal aggression by persons with SMI toward family members.51

Intimate partner violence by the general population has similarly been found to be positively associated with poor relationship quality and verbal/psychological aggression (which likely encompasses criticism and hostility),37 with much intimate partner violence being bidirectional.52 Research has not specifically examined limit-setting practices in relation to the risk of intimate partner violence by persons without SMI, although loosely similar constructs (e.g., relationship discord and disagreements regarding preferences) are known to be predictive of intimate partner violence.37

HOW FAMILY MEMBERS PERCEIVE AND UNDERSTAND VIOLENCE

We identified 18 qualitative studies that report on the perspectives and experiences of family members regarding violence by persons with SMI. The primary focus of some of these studies was violence by persons with SMI toward caregivers/family members, with the remaining studies primarily being focused on different topics (e.g., caregiving burden and housing dilemmas) but also reporting on violence in relation to these topics. Supplemental Table 1, http://links.lww.com/HRP/A132 presents the 18 studies identified, along with salient characteristics of each. Below, we summarize the results of these studies in four areas: (1) experiences of violence and contemplating the reasons for violence, (2) impacts of, and responses to, violence, (3) family management of violence, and (4) perceptions of mental health treatment in relation to violence.

Experiences of Violence and Contemplating the Reasons for Violence

Family members often experienced violence in their own homes and when alone with their relatives with SMI.10 Some family members reported that violence came suddenly—often around the onset of mental illness—and was associated with an acute exacerbation of psychiatric symptoms, particularly symptoms of psychosis or mania.11,57,61,64,66,67 Different family members reported that violence followed a gradual increase in symptoms or other stressors.11,57,64,66,67 The warning signs for violence that were identified included persons with SMI experiencing fatigue, confusion, fear, delusions, or increased substance use.61 Relatives with SMI were occasionally described to be unlike themselves during acts of violence.53,64

Family members frequently contemplated the reasons that persons with SMI acted violently, but often found it challenging to understand such reasons,64,66,67 with one participant reporting, “I felt the violence happened suddenly. I was confused. I want to know why he did it.”66(p 158) Many family members believe that violent behavior is the result of symptoms of mental illness, with some even perceiving violence to be intrinsic to mental illness.60 Similarly, it is often perceived that violence by persons with SMI is related to treatment-service issues such as a lack of services, resources, or education to navigate the mental health system.56,68 In particular, family members perceived violence to be related to persons with SMI not being adherent to medications10,64,66 or being discharged from inpatient treatment prematurely.61 Unfortunately, however, a few participants noted that violence did not cease with engagement in psychiatric treatment.64

Family members often thought poor communication, lack of mutual understanding, or stressful interactions with persons with SMI promoted aggressive behavior.57 They also believed that violent behavior resulted from discussion of the relative’s mental illness or directives that they made regarding medication use and household rules (e.g., chores, waking up).10,66 For example, one parent reported, “It is too difficult to get him to take his medicines. He becomes very angry by shouting at me and throwing objects at me while I go near him with the medicines.”10(p 65)

Some family members believed that violent behavior, rather than being a symptom of mental illness, was a normal result of life stressors, family relationships, or traumatic events.60 Others believed it to be the result of their relatives being perpetrators of violence—as opposed to being disabled and “harmed” persons60(p 2610)—who were unable to obtain what they wanted, desired revenge for how they were treated as children, or hated their victims.66

Other perceived reasons for violence include victimization, inadequate self-control, and episodes of excitement, stress, pain, anger, impulsivity, lack of sleep, or substance use experienced by persons with SMI.57,61,64,66,67 Reflecting the role of stress in violent incidents, one parent remarked, “My son felt stress due to relationships with others. To release the stress, he used to commit violence against me.”66(p 159)

Impacts of and Responses to Violence

Family members often perceived violent episodes and other challenges related to providing care as causing them and other family members significant stress and burden. They also felt, however, a strong sense of responsibility to care for their relatives with SMI and guarantee their safety.54,56,57,61,68 Across multiple studies, family members reported feeling guilt, grief, and fear that their relatives with SMI would be harmed.11,58,59,63,64,66,67 Many conveyed having sympathy for their children with SMI, as a result of their impaired daily functioning and delay in achieving life goals (regarding, e.g., relationships, employment, independent living). One parent reported, “It hurts, a child like that can’t do things like everyone else . . . I keep thinking about how miserable he is: never married, no kids, sitting with his mother, fighting . . . He is tired of it and I am tired of it.”60(p 2611)

Emotional responses to violent behavior varied, depending on the perceived reasons for violent behavior.60 Parents who believed violence was the result of their relatives’ mental illness tended to respond to their relatives’ violence with care and concern.60 Alternatively, certain parents felt a tension between having negative feelings toward their children with SMI and the belief that parents should love their children. Some family members described emotionally distancing themselves from their relatives with SMI, whereas other family members described themselves as becoming overprotective and trying to control the behaviors of their relatives with SMI.60

While some family members had difficulty admitting that they feared their child,59 others described the substantial fear that they experienced as a result of the unpredictable and recurrent nature of violence by their relatives with SMI.57,58 One parent described feeling in danger of being killed by her son as a result of repetitive violence.58 Different family members, however, presented as desensitized to violent behavior; regarding violent behavior by an adult child with SMI, one participant noted, “We’ve being dealing with this for 8 years . . . getting used to it.”54(p 555) Parents often described violent episodes as traumatic, confusing, and causing significant disruption to their lives,57 with many having symptoms of anxiety or depression.54,57,61,64 One qualitative study reported, “All family members had damage to their mental health.”649(p 552)

Many parents reported a strong sense of self-blame67 and fatalistic beliefs regarding violent behavior, with some feeling helpless, voiceless, trapped, and overwhelmed by the situation.53,54,56,57,59,60,68 Likely reflecting these feelings, one caregiver reported, “I hoped for my son’s death. I was exhausted.”64(p 552) Family members reported that their willingness to continue being the primary caregiver for their relatives with SMI changed daily, depending on their relatives’ level of symptoms and violent behavior.56 Most caregivers felt that violence resulted in an overall deterioration of their relationships with persons with SMI,11,64,66,67 and families often became more distanced and fragmented after continuations of violence.64

Family members reported feeling challenged by their inability to break the cycle of repeated violence.57 They were often fearful about discussing their experiences with others because of the stigma of mental illness and a desire to be perceived as strong; one participant reported, “I felt shame. I felt embarrassed. I didn’t want to tell others.”57(p 345) Family members often decided to not report violent behavior to the authorities unless it resulted in a physical injury, with one parent reporting, “You don’t report your own son to the police. You just don’t.”11(p 64)

Family Management of Violence

Many family members reported that a useful method for dealing with acts of aggression was to avoid further stimulating or provoking their ill relatives.64,66 Varghese and colleagues10 described four types of problem-focused coping used by family members during violent episodes: (1) verbal (e.g., talking to persons with SMI in a calm and tender manner), (2) avoidant (e.g., leaving persons with SMI alone), (3) mechanical (e.g., locking relatives with SMI in their rooms or physically restraining them with ropes), and (4) diversion (e.g., encouraging persons with SMI to engage in nonaggressive behaviors such as deep breathing and going for walks). Family members also described attempting to prevent aggressive behavior by speaking carefully to persons with SMI, reiterating their love for their relatives,52 and providing relatives with opportunities to engage in meaningful activities.59 Family members believed that affirmation, empathy, and optimism were useful in overcoming violence.55,59

Many family members considered setting limits and enforcing household rules as important steps in managing or preventing aggressive behavior;67 for example, several caregivers described having told their relatives that they would be allowed to live in their homes only if they were adherent to their psychiatric medications, did not use substances, and did not act violently.53,56 Some discussed having removed their children from home because of continued violence.68 Family members described continuing to treat their relatives with SMI with care and noted the importance of maintaining their relatives’ privacy and autonomy.53,54 Often families needed time and perspective to gain control of the home environment, make decisions, and set rules without guilt, and to attempt to help their loved ones with SMI achieve more independence.53

Perceptions of Mental Health Treatment in Relation to Violence

As previously described, family members often reported feeling that inadequacies in mental health treatment contribute to violence by persons with SMI. Similarly, family members endorsed the value of psychiatric medications to reduce violent behavior.57 Some family members described that, whereas they defined treatment success as stabilization of psychiatric symptoms and improvements in daily functioning, mental health professionals placed more emphasis in treatment on ensuring that persons with SMI were no longer violent.56 Mental health professionals were reported to often assume that family members would be willing caregivers for persons with SMI after hospital discharge, but family members often had fears regarding the repetition of violence and felt unable to adequately care for their relatives because of their aggressive behavior.56 Certain family members felt that their caregiving role was involuntary since viable care alternatives were unavailable.56 They often felt forced to make difficult decisions, balancing the needs of their relatives with their own needs for safety and emotional stability. Some parents feared for their own safety if they allowed their adult children with SMI to cohabitate with them, but also feared that if they did not allow their children to live with them, the children would be victimized while homeless.56 Family members discussed the need for better support in preventing and managing violent behavior by their relatives.54 They believed that mental health services could be useful for them to learn violence-management techniques, and many sought such services when they could not address the violent behavior by themselves. Unfortunately, family members reported that such mental health services were hard to access.57,64 They perceived that receiving updated information about their relatives’ illnesses would help them determine how they could best support their relatives and manage their violent and aggressive behavior.59 Certain family members reported that that police were superior to the mental health system in helping with the management of violent behavior.64

SYNTHESIS AND IMPLICATIONS

A substantive difference in the phenomena of family violence by persons with SMI versus persons without SMI is that the psychiatric symptoms and other illness-related symptoms of persons with SMI likely play a unique role in the former. Clinical characteristics of persons with SMI known to increase the risk of family violence (e.g., medication nonadherence and history of hospitalization) are similarly associated with the risk of general violence (regardless of relation to the victim) by this population.28 Although not yet researched, other illness-related symptoms that increase the risk of general violence by persons with SMI (e.g., impairments in social cognition) likely also increase the risk of family violence. Consequently, interventions successful in reducing violence by persons with SMI generally will likely also decrease violence specifically against family members. Based on qualitative studies and occasional quantitative evidence,34 psychosis and acute psychiatric symptoms appear to play a pronounced role in violence against family members. As such, efforts to prevent violence against family members should include (1) interventions that support family members in managing acute symptoms and crises (two such interventions are described below) and (2) better access to, and engagement in, mental health treatment for persons with SMI. Specific recommendations for strengthening engagement in mental health treatment among persons with SMI include increasing the use of technology in treatment—for example, making treatment-related contacts through social media and using innovative, internet-based treatments that may be more palatable to younger clients. Another way of strengthening engagement is by making treatment more recovery-oriented—for example, offering peer services, providing culturally competent and person-centered care, and placing greater emphasis on achieving a strong therapeutic alliance.69

Given the many similarities, as noted above, in the risk factors for family violence by persons with SMI and by members of the general population, these phenomena likely have much in common. Family violence theorists view conflict among family members as universal,70 resulting from the inevitable discrepancies in parties’ goals, desires, and preferences, referred to as personal agendas.71 Verbal aggression and physical violence are considered methods of resolving discrepancies in personal agendas and are more often employed when parties have fewer alternative resources to achieve their goals.72 Discrepancies in goals or preferences unable to be resolved and also other relationship stressors compromise relationships and “build up” to acute events—where violence occurs after verbal aggression has escalated but failed to resolve the conflict at hand.73 The available evidence (described in the above sections pertaining to risk factors and findings from qualitative studies) indicates that this process of escalating conflict may play a role in family violence by persons with SMI. Indeed, families with a member with SMI may be more likely to experience such escalations because of a greater presence of discrepant personal agendas and other relationship stressors, such as the financial, emotional, and social costs related to caregiving. As an example of how conflicting personal agendas may play a role in family violence by persons with SMI, a common risk factor for this phenomenon involves family members’ efforts to set limits with persons with SMI; the immediate goals or preferences of family members versus persons with SMI are inherently divergent (acknowledging that family members may set limits on the assumption that doing so is beneficial for persons with SMI). The reliance of persons with SMI on family members for tangible and instrumental support, along with other known risk factors, is also likely connected to violence—at least partly—because of the increased presence of opposing personal agendas. An analysis of incidents responded to by police suggests that one of the mechanisms through which co-residence, substance use, medication noncompliance, and behavioral manifestations of psychiatric symptoms are connected to family violence is through arguments centered around these topics (Labrum & Solomon, manuscript in preparation).

Unfortunately, we are unaware of any research conducted in the United States or any other Western nation testing the effectiveness of interventions in preventing family violence by persons with SMI. Based on our review, as presented above, we recommend that efforts to prevent family violence by persons with SMI seek to (1) decrease the occurrence of conflicting personal agendas and other relationship stressors by expanding the range and availability of formal alternatives to the reliance of persons with SMI on family members, and (2) support the capabilities of family members to successfully prevent and resolve conflicts.

Decreasing Opportunities for Family Conflict

Support provided by family members to persons with SMI enhances the quality of life and longevity of persons with SMI74,75 and leads to greater family cohesion and gratification among family members.76 Such support may even prevent violence against non-relatives.77 Nonetheless, the reliance of persons with SMI on family members’ support (e.g., for housing, completing activities of daily living, monitoring medication compliance and safety-related behaviors) can create new opportunities for conflicting personal agendas and introduces new burdens and other stressors,78 which may lead to resentments, criticism, and hostility by both parties. This dynamic is especially likely when the existing support arrangements are not the preference of either party or when caregivers feel overextended. Expanding the availability of formal supports for persons with SMI (e.g., supportive housing, intensive case management, professionally provided representative payee services) would provide options for reducing the reliance of persons with SMI on their families, likely lessening opportunities for relationship stressors and conflicts.

Supporting Capabilities to Prevent and Resolve Conflicts

Despite the potential barriers, family members can be successfully engaged in treatment and other positive interventions,79 and doing so has been found to produce benefits for both family members and their loved ones with SMI.80–83 Open Dialogue is a recent, promising model that includes family involvement. We recommend that family members be assisted in preventing and resolving conflicts by being provided with education and support regarding conflict resolution, communication skills, strategies for de-escalating conflict, and recognition of common triggers for, and early signs of, aggression. An intervention addressing these topics with both family members and persons with SMI has been developed in Taiwan and been found to be effective in preventing aggression by this population.84 A similar intervention delivered to family members and persons with SMI is currently being developed in the United States.85 We also believe that two additional family interventions, though not addressed specifically at these problems (and not yet investigated for such, either), may be effective in decreasing family conflict and violence: McFarlane’s Multifamily Group model86 and National Alliance on Mental Illness’s Family-to-Family educational program.87 Notably, both of these interventions address how to successfully manage mental health crises.

McFarlane’s model is a professionally facilitated clinical intervention that addresses problem solving, effective communication, illness management, family coping, and development of a supportive network.86 Explicit guidance is given to professional group facilitators in intervening when there is an imminent risk of violence. Over time, group members are encouraged to support one another during crises that are less acute. Potential safety issues, behaviors that may increase the risk of relapse, and family conflicts are areas where problem-solving techniques are used in the multifamily group. While family psychoeducation may be effective in reducing violence toward family members by strengthening family members’ skills in communication, problem solving, and managing crises, this evidence-based practice has had, so far, limited implementation in real-world settings.88

National Alliance on Mental Illness’s Family-to-Family educational model is available across the United States in the English language, with some availability in Spanish. It is a relatively brief intervention (consisting of eight sessions) delivered in the community by peer family members. It similarly addresses psychoeducation, support, and problem-solving and communication skills. The model additionally teaches crisis-management skills, including de-escalation, collaborative crisis planning, and seeking outside help. De-escalation involves identifying early warning signs and addressing them to prevent or manage a developing crisis. In addition to receiving information and guidance in managing a developing crisis, family members receive training in communication skills and problem solving in an effort to support positive communication and to decrease conflict. While its effectiveness in decreasing family violence has not been examined, the Family-to-Family model has been found to improve family problem solving and acceptance, and to decrease distress.89

CONCLUSION

Although most persons with SMI do not engage in violence toward family members or others,1,2 a concerning minority of family members have experienced or feared44,90 violence by their relatives with SMI. While evidence suggests that violence toward family members by this population is associated with specific clinical characteristics such as psychotic symptoms and medication nonadherence, this violence is likely to be at least as strongly explained by the high levels of conflict that family members and persons with SMI experience. This conflict is surely experienced, to a great extent, in connection with family members providing considerable support and supervision to persons with SMI. Efforts seeking to decrease family violence should offer alternatives to persons with SMI relying on family members for material aid and instrumental support, and should support the capacities of persons with SMI and family members in successfully navigating the conflict and other relationship stressors they experience.

In contrast to the wealth of research conducted regarding community violence by persons with SMI, violence occurring in families of persons with SMI has received surprisingly scant attention. In particular, despite evidence indicating that persons with SMI are often victims of violence by family members13 and that family violence may be bidirectional,14 research has largely failed to examine these topics. Nearly all of the research findings reviewed in this article are based on the reports of family members, with research rarely examining the perspectives of persons with SMI. We recommend that future research examine family violence toward persons with SMI and the potential for bidirectional violence, include the perspectives of persons with SMI, explore strategies utilized by this population to prevent and manage conflict with family members, and test the effectiveness of peer-developed approaches in ameliorating conflict. Likewise, interventions specifically aiming to prevent conflict and violence in families with a member with SMI should be developed and tested in the United States. Such interventions could include highly accessible, brief psychoeducational models. In Japan, for example, a video-based intervention for family members—developed with the input of persons with schizophrenia— has demonstrated promising results in decreasing family violence by persons with schizophrenia.91 The intervention could be adapted for use with other disorders, and it could easily be modified to be delivered online—a potentially important direction of development.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

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      Keywords:

      aggression; bipolar; family; schizophrenia

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