Abstract

This study is a review of institutionalization, mental disorders and violence. A systematic search was performed in major databases, focusing on studies from the last twenty-two years. The results were divided into two groups: ‘studies on factors related to the risk of violence/prediction and institutionalization’ and ‘studies on the risk of violence and deinstitutionalization/inadequate mental treatment’. We found that mental illness is not directly associated with high risk of violence. Specific details of the institutionalization and assistance with deprivation of liberty are related to violent behavior. We concluded that humanized, multiprofessional approaches and trained staff, combined with the management of real risk factors of violence can contribute to a better health assistance and reduce the need for institutionalization.

Keywords:
Institutionalization; Mental Disorders; Violence; Forensic Psychiatry; Commitment of Mentally Ill

Introduction

The relation between mental health disorders and violence is a subject dating back to Antiquity, being currently more studied with some degree of systematization, although still permeated by controversial interpretations. The concept of mental health disorders, intrinsically related to what was called “madness” in the past, brings in its more contemporary conception the idea of a morbid variation of the normal, which may harm the individual’s global performance in areas such as social, occupational, family and personal, and/or the people with whom they live (Alencar; Rolim; Leite, 2013ALENCAR, A. V.; ROLIM, S. G.; LEITE, P. N. B. A história da loucura. Id Online: Revista de Psicologia, Jaboatão dos Guararapes, v. 7, n. 21, p. 15-24, 2013.).

The beginning of the development of classifications related to dangerousness, especially after the creation of the International Association of Penal Law in 1889, is another key point regarding this concept. This association established that the following would be deemed dangerous: “1) repeat offenders; 2) alcoholics and the disabled of any kind; 3) beggars and vagrants” (Garófalo 1878 apud Mecler, 1996MECLER, K. Periculosidade e inimputabilidade: um estudo dos fatores envolvidos na determinação da periculosidade do doente mental infrator. 1996. Dissertação (Mestrado em Psiquiatria e Saúde Mental) - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 1996., p. 27). From these lines, the extent of the prejudice and stigma shed on the people who presented variations from what was considered normal or were impaired in their psychic development is evident, since they would present major “anomalies” in behavior that supposedly correlated with an increased risk of violence, namely, the “degree of danger.” That is reflected in the Brazilian penal system, as well as in dozens of other countries around the world. In its article 22 (later commuted into article 26 in its 1984 revision), the 1940 Brazilian Penal Code established that criminals suffering from mental health disorders were “dangerous” (Bruno, 1991BRUNO, A. Perigosidade criminal e medidas de segurança. Rio de Janeiro: Rio, 1991.).

Before that, as known and reported in history, the way of dealing with people suffering from so-called “mental illnesses” ultimately became a kind of incarceration. Psychiatric institutions created to treat patients with mental health disorders turned into a sort of permanent shelter. Similarly, the so-called “judicial asylums,” institutions that housed people suffering from mental health disorders who had committed crimes, also became permanent shelters. Thus, regardless of having committed crimes, these individuals were perceived as a part of the asylum itself, or “belonging to the institution,” and remained so, even after most of those institutions were closed.

Thus, in this study, individuals who experience or have experienced some type of situation where they were completely bound to a psychiatric institution or equivalent are called “institutionalized,” as well as this process is referred to as “institutionalization.” The constant process of modification, not limited to physically structural issues but involving changes in mentality, in a culture that broadly relates psychic illness within the society and is more impactful on mental health disorders situations, is known as “deinstitutionalization. Improving the quality of mental health treatments (not only psychiatric) is only possible through public policies aiming, in fact, at deinstitutionalization. In a broad aspect, that means transforming and revising concepts, prejudices, stigmas, and other factors concerning the psychic illness process with the offer of other mental health care devices, such as Psychosocial Care Centers and outpatient monitoring.

Throughout history, institutionalization was the measure adopted to also deal with people suffering from mental disorders, a broader term encompassing classic mental illnesses, especially psychoses, but also referring to those “outside the norm,” as happens in behavioral disorders, cognitive deficits, and other difficulties within the psychic field. For this reason and due to the lack of individualized, multidisciplinary, and dignified treatment, such institutionalization devices started being abused and used in indiscriminate ways, giving rise to serious consequences for many patients’ health and life, as well as their families’. The lack of resources and scientific knowledge at the time served as important reinforcements for situations that were inhuman and ineffective at times.

Finally, combining this historical context and the old-fashioned treatment of the time, the legislation facilitated psychiatric hospitalizations progressing towards the institutionalization for indefinite periods for people who were mentally ill and committed an offense until there was a “cessation of dangerousness” (Brasil, 1940BRASIL. Decreto-Lei n. 2.848, de 7 de dezembro de 1940. Código Penal. Diário Oficial da União, Rio de Janeiro, 31 dez. 1940., art. 97, § 1º). The idea of presumed risk generated a serious distortion of a system intended to treat and rehabilitate the individual and, paradoxically, ended up serving as a means of imprisonment; that is, institutionalizing them for long periods (Arbex, 2013ARBEX, D. Holocausto brasileiro: genocídio: 60 mil mortos no maior hospício do Brasil. São Paulo: Geração, 2013.; Confessor Júnior, 2018CONFESSOR JÚNIOR, W. G. O iluminismo tardio no cemitério dos vivos: o manicômio judiciário no contexto da reforma psiquiátrica brasileira. 2018. Dissertação (Mestrado em Psicologia) - Universidade Federal do Rio Grande do Norte, Natal, 2018.; Correia; Passos, 2017CORREIA, L. C.; PASSOS, R. G. (Org.). Dimensão jurídico-política da reforma psiquiátrica brasileira: limites e possibilidades. Rio de Janeiro: Gramma, 2017.).

From this point of view, we can reflect on the infinite aspects and classifications of violence, according to the definition of the World Health Organization (OMS, 2002OMS - ORGANIZAÇÃO MUNDIAL DE SAÚDE. Relatório mundial sobre violência e saúde. Genebra, 2002., p. 5): “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” It is noted that the violence goes far beyond the physical aspect, and can arise, for example, in the form of a threat, causing deprivation and changes in the individual’s development. For this reason, in this article, the relationship between violence and mental health disorders will be addressed under the supposed risk posed by this population’s dangerousness, reflecting a great and historical stigma, and the various types of violence that they suffer, or may be subject to will also be considered and evaluated, knowing the broad definition of WHO.

Several studies have sought to associate the risk of violence with mental health disorders, but many have described small or specific samples, such as populations exclusively selected from custody hospitals or even prisons, resulting in an inadequate analysis of the mental health disorders themselves (Adshead, 1998ADSHEAD, G. Psychiatric staff as attachment figures: understanding management problems in psychiatric services in the light of attachment theory. British Journal of Psychiatry, Cambridge, v. 172, n. 1, p. 64-69, 1998.; Flannery Junior et al., 2000FLANNERY JUNIOR, R. B. et al. Assaults on staff by psychiatric patients in community residences. Psychiatry Services, Washington, DC, v. 51, n. 1, p. 111-113, 2000.; Kramp; Gabrielsen, 2009KRAMP, P.; GABRIELSEN, G. The organization of the psychiatric service and criminality committed by the mentally ill. European Psychiatry , Cambridge, v. 24, n. 6, p. 401-411, 2009.; Moscatello, 2001MOSCATELLO, R. Recidiva criminal em 100 internos do Manicômio Judiciário de Franco da Rocha. Revista Brasileira de Psiquiatria , São Paulo, v. 23, n. 1, p. 34-35, 2001.; Oliveira et al., 2017OLIVEIRA, G. C. et al. Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho. Revista Brasileira de Psiquiatria , São Paulo, v. 39, n. 1, p. 45-54, 2017.; Short et al., 2013SHORT, T. B. et al. A case-linkage study of crime victimisation in schizophrenia-spectrum disorders over a period of deinstitutionalisation. BMC Psychiatry, London, v. 13, n. 1, p. 66, 2013.). On the other hand, there are other studies demonstrating relations contrary to this (Fazel; Yu, 2011FAZEL, S.; YU, R. Psychotic disorders and repeat offending: systematic review and meta-analysis. Schizophrenia Bulletin, Oxford, v. 37, n. 4, p. 800-810, 2011.; Ghoreishi et al., 2015GHOREISHI, A. et al. Prevalence and attributes of criminality in patients with schizophrenia. Journal of Injury and Violence Research, Kermanshah, v. 7, n. 1, p. 7-12, 2015.; Mecler, 2010MECLER, K. Periculosidade: evolução e aplicação do conceito. Revista Brasileira Crescimento e Desenvolvimento Humano, Santos André, v. 20, n. 1, p. 70-82, 2010.; Oliveira et al., 2016OLIVEIRA, G. C. et al. O exame de verificação de cessação de periculosidade: a importância da avaliação ampliada em um caso com conclusão contrária ao parecer da equipe assistente. Revista Latinoamericana de Psicopatologia Fundamental, São Paulo, v. 19, n. 2, p. 322-341, 2016.). Violence in individuals with mental disorders can be certainly prevented through psychiatric treatment and clinical management regarding this aspect (Valença et al., 2011VALENÇA, A. M. et al. Retardo mental: periculosidade e responsabilidade penal. Jornal Brasileiro de Psiquiatria , Rio de Janeiro, v. 60, n. 2, p. 144-147, 2011.).

In the last 20 years, the development of standardized assessment instruments has become a priority, aiming to improve the validity and reliability of predictions regarding the risk of violence. The expectation is that these instruments will generate reliable data on the probability that patients may commit violent acts under certain circumstances.

There are also institutions that absorb mentally ill patients and shelter them for prolonged periods both in Brazil and worldwide. Sometimes, this population comes from different backgrounds, with some patients arriving from old asylums that have been closed. These patients received a “safety measure,” with protective and therapeutic goals, however, due to several distortions within the legal and aid systems, they have been kept hospitalized in these institutions for many years.

After receiving a security measure by court order, the individual must pass a new expert examination aimed to assess how dangerous they are. Such evaluation is carried out by an official state expert. The examination to verify the cessation of dangerousness must be carried out at the end of the minimum period established by the judge (between one and three years) and repeated annually until the cessation of dangerousness is determined. It is important to note that, within this context, dangerousness is a legal - instead of medical or psychological - concept, implying the ability to predict the risk of future criminal behavior by the person subjected to the security measure (Mecler, 2010MECLER, K. Periculosidade: evolução e aplicação do conceito. Revista Brasileira Crescimento e Desenvolvimento Humano, Santos André, v. 20, n. 1, p. 70-82, 2010.).

As a result, the criteria assessed for dangerousness verification extend beyond a psychiatric assessment, which is a relevant part of a broader context and deserves to be discussed transdisciplinarily.

This study aims to carry out a review of the scientific literature on the relevant and contextualized subject of violence, mental disorders (broader term), and institutionalization, taking clinical, historical, cultural, and social aspects into account.

Methodology

This is a literature review study, and, for this purpose, the main scientific databases related to the topic were used. The terms operated are the following health descriptors: “Institutionalization,” “mental disorders,” “violence,” as well as their equivalents in Portuguese and Spanish. The bases used were PubMed, Latin American and Caribbean Health Sciences Literature (Lilacs), Scientific Electronic Library (SciELO), and Virtual Health Library (Bireme). Additionally, other articles were sought in languages other than English, Spanish, and Portuguese, using the same strategies. At first, no time limit had been set, as all available data were searched in all databases. After that, we decided to restrict the analysis of the results to the last twenty-two years, seeking to provide an insight into the subject until 2020.

The selection of articles to be included in this review was done by reading the abstracts found with the goal to evaluate whether the articles were related to the subject of prolonged institutionalization/hospitalization of people with mental disorders and their possible correlation with violence. From there, the information contemplating the general and specific objectives already described has been extracted. There was no delimitation as to the type of article, as the purpose was to conduct a review on what knowledge has been produced about this topic in the last twenty-two years. Within the databases described, the research used the descriptors present in all three terms:

The total of 155 articles were found in Pubmed, 101 of which were published in the last twenty-two years. Of these, 58 contemplated the subject of this work and were studied and evaluated.

The total of 35 articles were found in the Bireme database, 23 of which were published in the last twenty-two years, with 11 covering the subject of this work.

The search in Scielo’s database found only one article containing the three present descriptors, but its subject did not contemplate the objectives of this work. Thus, there was no evaluation of any Scielo publications.

Therefore, 124 abstracts of articles published in the last twenty-two years were initially read, then 69 articles related to the topic described, were selected. Four of those were listed under two databases and six articles were excluded from the analysis for being written in Danish, Polish, and Norwegian. Thus, the final number of total articles evaluated was 59.

The types of articles found and analyzed were: 1 randomized clinical trial, 1 case-control, 7 systematized reviews, 21 non-systematic reviews, 31 miscellaneous (reports, editorials, comments, etc.).

Results

The regions with the highest concentration of research were Europe and the United States, and the specialized magazines in which most of these articles were published were also from these areas.

As to the sociodemographic profile of this population, at least four studies were found which explicitly observed data on this topic (Crocker; Côté, 2009CROCKER, A. G.; CÔTÉ, G. Evolving systems of care: individuals found not criminally responsible on account of mental disorder in custody of civil and forensic psychiatric services. European Psychiatry, Cambridge, v. 24, n. 6, p. 356-364, 2009.; Flannery Junior et al., 2000FLANNERY JUNIOR, R. B. et al. Assaults on staff by psychiatric patients in community residences. Psychiatry Services, Washington, DC, v. 51, n. 1, p. 111-113, 2000.; O’Grady, 2004O’GRADY, J. Prison psychiatry. Criminal Behavior and Mental Health, London, v. 14, p. s25-30, 2004.; Short et al., 2013SHORT, T. B. et al. A case-linkage study of crime victimisation in schizophrenia-spectrum disorders over a period of deinstitutionalisation. BMC Psychiatry, London, v. 13, n. 1, p. 66, 2013.). The common aspect found was a population of young male adults, single, with low or no income, low level of education, unemployed, and with a history of mental health disorders, although many individuals have never been under treatment. That is, a very disadvantaged population, exposed to several destabilizing factors. To systematize the analysis of the results, the main studies were condensed into two groups: the first, seeking to describe factors related to the prediction/risk of violence through correlation with institutionalization, and the second, seeking to assess the risk of violence and/or the risk originated from the lack of assistance to deinstitutionalization.

Studies relating factors linked to the prediction/risk of violence and institutionalization

With regard to historical items and the possible relationship with institutionalization and/or violence, Douglas, Guy, and Hart’s (2009DOUGLAS, K. S.; GUY, L. S.; HART, S. D. Psychosis as a risk factor for violence to others: a meta-analysis. Psychology Bulletin, Washington, DC, v. 135 n. 5, p. 679-706, 2009.) meta-analysis used 204 studies, with 166 independent variables. The central (median) trend in effect sizes indicated that psychosis may be associated with a 49-68% increase in the risk of violence. However, there was a wide dispersion between effect sizes attributed to methodological factors, such as community or institutional samples, definition of psychosis (diagnosis, quantification, and type of symptoms), comparison group (psychosis compared with externalization versus internalization versus absence of disease) mental). The data show how specific, punctual, and diverse the presentation of violent behavior and psychotic conditions can be.

Steinert (2002aSTEINERT, T. Gewalttätiges Verhalten von Patienten in Institutionen. Psychiatrische Praxis, New York, v. 29, n. 2, p. 61-67, 2002a.) carried out a non-systematic review to investigate the risk of violence prediction. The “history of violence” predictor was the only isolated and robust one. Other predictors that were also prominent are positive symptoms (delusions and hallucinations) and other psychotic symptoms. Clinical variables analysis is impaired, as pharmacological and therapeutic interventions applied specifically for hospitalized patients influenced this assessment. According to the study, the predictors with greatest potential were male, young age, psychotic symptoms, and alcohol abuse.

In another literature review also dated from 2002, the same author studied the prediction of risk of violence in patients with severe mental health disorders and in individuals without mental health disorders (Steinert, 2002bSTEINERT, T. Prediction of inpatient violence. Acta Psychiatrica Scandinavica, Hoboken, v. 106, n. s412, p. 133-141, 2002b.). He determined that it would be necessary to separate the predictors of hospitalized or institutionalized patients from those of outpatients and people without mental health disorders. The results of the review were: people without mental health disorders, as well as severely ill patients who are not hospitalized or institutionalized, have the same predictors of violent behavior: criminal history, male, young age, and substance abuse. For hospitalized or institutionalized patients, violent behavior during hospitalization is closely related to the severity of psychopathological symptoms. Such variables were not highly significant in outpatients and non-institutionalized patients. In other words, the work showed that there is no increased risk of violence associated with mental health disorders for individuals living within the community, whether mentally ill or not. Factors related to the institutionalization itself or the type of assistance may be found in other works such as the one described below.

Flannery Junior et al. (2000FLANNERY JUNIOR, R. B. et al. Assaults on staff by psychiatric patients in community residences. Psychiatry Services, Washington, DC, v. 51, n. 1, p. 111-113, 2000.) a cohort study was carried out on people who had left institutions for the mentally ill with violent behavior in Massachusetts. Their sociodemographic profile was initially characterized as: 554 men and 472 women, 87% Caucasian, 20-80 years old (average 41), and primary schizophrenia diagnosis (71%). Next, the occurrence of several types of aggression, whether physical, sexual, verbal, and non-verbal intimidation in two periods, was evaluated: 1991-94 (first period) and 1994-98 (second period). Eighty assaults on the assistance team were reported in the first period, and 39 in the subsequent period. The type of aggression in the first period had the following profile: 30 physical assaults (37.5%), 7 sexual assaults (9.7%), and 42 verbal assaults (52.5%). In the second period, there were 22 physical assaults (57%), 4 sexual assaults (10.2%), and 9 verbal assaults (23.1%); that is, there was a significant decrease in incidents. The profile of the aggressors studied in the two periods was quite similar: male, young, and suffering from psychotic symptoms.

The authors of the same study also described the profile of the victims of the attacks, getting to important conclusions: they were professionals in direct contact with the inmates, lacking specialized education and adequate training, under acute stress (69%) and other mental illnesses, such as sleep disorders, hypervigilance, as well as the presence of intrusive memories (48%). Based on these results, the institution chose to train the hospital staff after the first period of the study using the ASAP - “Assaulted staff action program” - a program aimed at employees who are victim of aggression. A good part of the significant reduction in the number of aggressions that occurred in the post-training period may be attributed to the training. This study proved the relevance of training health care professionals, calling for a look also to the professional and to those who assist the patient, moving past the observation of violence from the patient’s point of view, as a sick professional can also instigate violent demonstrations.

In turn, Warburton (2014WARBURTON, K. The new mission of forensic mental health systems: managing violence as a medical syndrome in an environment that balances treatment and safety. CNS Spectruns, Cambridge, v. 19, n. 5, p. 368-373, 2014.) carried out a cross-sectional study on psychiatric patients in the state of California. According to him, physical aggression was the main reason for hospitalization and the main impediment to discharge in various services. There would be three main motivations for aggression: poor impulse control, planned predatory behavior (“signs” - “I don’t like,” “I want to assault,” “I want to kill”), and positive psychotic symptoms. Proposals were made to improve this issue, including the assessment of the risk of violence; customized treatments based on the type of aggression: dialectical behavior therapy for impulsivity, safety interventions in predatory aggression, and antipsychotic medication for psychotic symptoms; monitoring of substance abuse; independent forensic assessment of the clinic, and care for the environment and hospital layout.

Studies relating risk of violence and lack of assistance/deinstitutionalization

Short et al. (2013SHORT, T. B. et al. A case-linkage study of crime victimisation in schizophrenia-spectrum disorders over a period of deinstitutionalisation. BMC Psychiatry, London, v. 13, n. 1, p. 66, 2013.), in a case-control study, the criminal records of 4,168 schizophrenics (1975-2005) who were not institutionalized were compared to a random sample of 4,641 individuals from the Australian community. Compared to the community controls, patients with schizophrenia spectrum disorder were significantly more likely to have a record of violence (10.1% vs. 6.6%) as well as suffer violent sexual assaults (1.7% vs. 0.3%). Another finding observed was that the recorded victimization rate more than doubled in patients with a spectrum of schizophrenia but remained constant within the community.

People with schizophrenic spectrum disorders are particularly vulnerable to victimization for violent crimes. Although the comorbidity with substance abuse and crime increases the chances of victimization, they may not fully explain the increase in the rates concerning these individuals. According to this work, deinstitutionalization may have contributed, in part, to the unintended consequence of the increase in victimization rates among mentally ill patients.

Kramp and Gabrielsen (2009KRAMP, P.; GABRIELSEN, G. The organization of the psychiatric service and criminality committed by the mentally ill. European Psychiatry , Cambridge, v. 24, n. 6, p. 401-411, 2009.) also sought to analyze the relationship between the reorganization of the psychiatric treatment system and the growing number of patients involved in crimes such as manslaughter, arson, and other violent actions perpetrated by individuals with mental health disorders. Using Danish records, the positive or negative annual growth rate was estimated in social and community psychiatry (explanatory variables), as well as the prevalence and incidence of forensic patients involved in crimes (response variables) from 1980 to 1997 in each of the Danish municipalities. There was an indication that the closure of vacancies in hospitals did not have an immediate effect on the number of forensic patients or serious crimes. However, according to the authors, the comparative analysis showed that, over time, the decrease in the number of psychiatric beds was significantly related to the growth in rates of crimes such as manslaughter and arson committed by forensic patients, hence the importance of the availability of hospitalization devices for psychotic patients whose behavior involve some risk of violence.

Videbech et al. (2010VIDEBECH, P. et al. Patients at a psychiatric residential institution in Djursland. Ugeskr for Laeger, Copenhagen, v. 172, n. 5, p. 351-355, 2010.) assessed the health situation in therapeutic residences in Denmark. The authors found a group of people suffering from serious mental health disorders, in addition to poorly treated physical illnesses. A high rate of violent episodes and psychotic behavior was observed in these patients, besides a great number of frequent short hospitalizations. When establishing a comparison of this group with a population control not suffering from mental health disorders, the authors found a two-fold higher prevalence of metabolic syndrome in institutionalized individuals in relation to the control population. The hypothesis brought to light by the study was that an unhealthy lifestyle associated with psychopharmacological treatments would result in a higher risk of cardiovascular events. Thus, the authors propose a mandatory regular screening for physical diseases as a means to guarantee the patients’ health. They also believe that those patients should ideally be kept in a long-term psychiatric ward, besides getting more incisive actions from the justice system regarding serious cases.

Wahlbeck et al. (2011WAHLBECK, K. et al. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. British Journal of Psychiatry , London, v. 199, n. 6, p. 453-458, 2011.) studied a cohort of patients admitted to psychiatric hospitals in Finland, Sweden, and Denmark between 1987 and 2006, and sought to assess their life expectancy, among other observations on the health of these patients, with the main outcome being up to fifteen years after hospital discharge and the control group comprised by non-sick population. Patients with mental disorders had a mortality rate three times higher than the non-sick population. Women lived 15, and men 20 years less than their respective controls. During the deinstitutionalization era, life expectancy among people suffering from mental disorders decreased in all three countries. The determinants of mortality found included an unhealthy lifestyle, neglect of body care, and a “culture” of not taking physical diseases into account when approaching psychiatric patients. People with mental disorders are also more often unemployed, single, and marginalized. Stigma raises great barriers to the access to health care. The results point to a greater need for actions aimed at promoting health, improving the system, and preventing suicide and violence within the Nordic health system.

A historical review carried out by Manning (2009MANNING, C. Imprisoned in state care? Life inside Kew Cottages 1925-2008. Health and History, Sydney, v. 11, n. 1, p. 149-171, 2009.) assessed the situation of psychiatric patients tutored by the Australian State in the Kew Cottages home between 1925 and 2008. Founded in 1887, Kew Cottages was Australia’s oldest, and also their largest specialized institution for people with intellectual disabilities. Kew Cottages was originally conceived as a place of benevolent care and education for children. However, its isolated location, resembling that of a “Lunatic Asylum,” together with the use of physical security measures, granted it a reputation as a place of incarceration. Despite the introduction of reforms in the mid-twentieth century to provide residents with greater freedom, the precarious living conditions, very strict regulations, violence, and abuse contributed to the development of a prison environment within the institution.

Lamb and Weinberger (2013LAMB, H. R.; WEINBERGER, L. E. Some perspectives on criminalization. Journal of the American Academy of Psychiatry and the Law, Bloomfield, v. 41, n. 2, p. 287-293, 2013.) conducted a review of recent publications, evaluating whether patients with severe mental health disorders had criminal bounds. Their work found that patients who presented these behaviors often received inadequate or unstructured treatment, with no social control or comprehensive monitoring within the mental health system, if needed. The public health systems demand greater funding and accountability to care for these patients. These situations can be treated and are certainly avoidable.

Silver (2006SILVER, E. Understanding the relationship between mental disorder and violence: the need for a criminological perspective. Law and Human Behavior, Southport, v. 30, n. 6, p. 685-706, 2006.) carried out a non-systematic review on violence and mental disorders and their theoretical bases. According to the author, the theories of “criminal careers” and “local life circumstances” need to be studied and revised to consider the adoption of a new organized and systematized structure that takes into account the patient’s changes over time. This would greatly contribute to a better understanding of the determinants of violent behaviors among people suffering from mental health disorders who live in the community. The author concluded that the proposition of an organized treatment system based on research and evidence, managed by standardized instruments with rigorous documentation of patients’ clinical and criminological contexts, the assessment of family members and other people involved in their social context and which, combined to a structure establishing rewards in the face of progressive individual improvements, for example, would provide a good model for the effective reduction of the risk of violence among people with mental disorders.

As further discussed, the latest studies show us that strategies that take into account the dynamics of the individual, as well as the environment and other determinants of violence, and the deinstitutionalization process can lead to a greater chance to understanding the violence process without being limited to the institutionalization/deinstitutionalization dichotomy.

Discussion

The articles found showed a concern/discussion regarding the issue of violent behavior and mental health disorders; the presence or absence of those factors, while associated; and the issue concerning the institutionalization/deinstitutionalization and its consequences. Systematic reviews, including a meta-analysis (Douglas; Guy; Hart, 2009DOUGLAS, K. S.; GUY, L. S.; HART, S. D. Psychosis as a risk factor for violence to others: a meta-analysis. Psychology Bulletin, Washington, DC, v. 135 n. 5, p. 679-706, 2009.), found very large heterogeneity in the samples, the criteria used, and the great biases inherent from assessments to determine the risk of violence, with the topic demanding a multidisciplinary approach.

In the studies included in this review, the “history of violence” factor appears as a significantly isolated item, and this information is corroborated by several other authors (Mecler, 2010MECLER, K. Periculosidade: evolução e aplicação do conceito. Revista Brasileira Crescimento e Desenvolvimento Humano, Santos André, v. 20, n. 1, p. 70-82, 2010.; Oliveira et al., 2017OLIVEIRA, G. C. et al. Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho. Revista Brasileira de Psiquiatria , São Paulo, v. 39, n. 1, p. 45-54, 2017.; Teixeira et al., 2007TEIXEIRA, E. H. et al. Esquizofrenia, psicopatologia e crime violento: uma revisão das evidências empíricas. Jornal Brasileiro de Psiquiatria , Rio de Janeiro, v. 56, n. 2, p. 127-133, 2007.). However, such information in no way helps to prevent the first violent episodes and does not provide any information about which factors might actually give rise to the risk of violent behavior, so that it can be modified and dealt with.

In fact, when considering exclusively the historical aspect of previous violent behaviors, there is a contribution to the increase of the stigma against the mentally ill, who will then be perceived as dangerous and lacking the ability to socialize or recover.

Goffman (1988GOFFMAN, E. Estigma: notas sobre a manipulação da identidade deteriorada. 4. ed. Rio de Janeiro: LTC, 1988.) brings significant data directly related to the establishment of signs (cut, marks, or even burns) in individuals with “bad moral status,” physical disorders, or anything strange or less desirable than the “normal.” As shown by the author, fulfilling a norm, or simply supporting them is a way of exercising prejudice. The feeling of inferiority will only generate more insecurity and stigma on both sides.

Personal experiences, especially narratives of self-reports, are capable of triggering some kind of change and motivation within those people who are segregated/stigmatized. This allows for the “discredited,” or even the “discreditable,” to show that something different than what is expected by society may take place (Goffman, 1988GOFFMAN, E. Estigma: notas sobre a manipulação da identidade deteriorada. 4. ed. Rio de Janeiro: LTC, 1988.) since the differences or difficulties faced by the mentally ill are usually stigmatized.

Thornicroft (2006THORNICROFT, G. Shunned: discrimination against people with mental illness. New York: Oxford University Press, 2006.) describes real situations experienced by people with mental disorders, such as significant restrictions on basic civil rights in the United States, difficulty in applying for rent or even buying their own home, restrictions on the use of swimming pools in certain clubs, driving a vehicle, or obtaining a visa. Historically, in several states of the U.S., the right to vote was also restricted and inaccessible to individuals suffering from mental health disorders. In the same text, there are examples of mentally ill victims of violence, both physical and sexual.

The greatest vulnerability of the mentally ill to the violence addressed by Thornicroft (2006THORNICROFT, G. Shunned: discrimination against people with mental illness. New York: Oxford University Press, 2006.) is in line with some of the articles in this review, as well as others on the subject, such as Short et al. (2013SHORT, T. B. et al. A case-linkage study of crime victimisation in schizophrenia-spectrum disorders over a period of deinstitutionalisation. BMC Psychiatry, London, v. 13, n. 1, p. 66, 2013.), Wahlbeck et al. (2011WAHLBECK, K. et al. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. British Journal of Psychiatry , London, v. 199, n. 6, p. 453-458, 2011.), Abdalla-Filho & Souza (2009Abdalla-Filho, E.; Souza, P. A. Bioética, psiquiatria forense e a aplicação da medida de segurança no Brasil. Revista Bioética, Brasília, DF, v. 17, n. 2, p. 181-190, 2009.), Teixeira et al. (2007TEIXEIRA, E. H. et al. Esquizofrenia, psicopatologia e crime violento: uma revisão das evidências empíricas. Jornal Brasileiro de Psiquiatria , Rio de Janeiro, v. 56, n. 2, p. 127-133, 2007.), and Gattaz (1999GATTAZ, W. F. Violência e doença mental: fato ou ficção? Revista Brasileira de Psiquiatria , São Paulo, v. 21, n. 4, p. 196, 1999.).

Scheirs et al. (2012SCHEIRS, J. G. et al. Client factors as predictors of restraint and seclusion in people with intellectual disability. Journal of Intellectual and Developmental Disability, Abingdon, v. 37, n. 2, p. 112-120, 2012.) carried out a cross-sectional study at a Dutch institution to research variables that were most related to the need for physical or chemical restraint in patients with intellectual disabilities. The authors concluded that no sociodemographic variable was statistically significant and that there are greater predictors of more relevant violent behavior, such as low adaptive functioning, challenging non-violent behavior, and a higher intellectual level (within their sample of patients with intellectual disabilities). Institutionalization seems to have caused the harmful phenomenon of frustrating individuals with better intellectual capacity, given the limitations and barriers of the institutionalized and enclosed environment.

The characterization of the results of this review, in which the works are almost exclusively focused on the assessment of the violence perpetrated by the patient, with a rare in-depth evaluation of the factors which gave rise to this violence and that are not dependent on the individual, reinforces the old-fashioned character of this thought. Few studies dealt with the violence suffered by institutionalized people and, whenever they are carried out, they end up comprising historical reviews, especially from the asylum period. The awareness that this violence persists nowadays, not only in its physical form, but also through coercion, prejudice, and disdain, characterizing typically institutional violence, is extremely important.

In ²⁰⁰⁶VALENÇA, A. M.; MORAES, T. M. Relação entre homicídio e transtornos mentais. Revista Brasileira de Psiquiatria , São Paulo, v. 28, p. s62-s68, 2006. Suplemento 2., ²⁰¹³VALENÇA, A. M.; NASCIMENTO, I.; NARDI, A. E. Relationship between sexual offences and mental and developmental disorders: a review. Archives of Clinical Psychiatry, São Paulo, v. 40, n. 3, p. 97-104, 2013., and ²⁰¹⁵VALENÇA, A. M. et al. Retardo mental: periculosidade e responsabilidade penal. Jornal Brasileiro de Psiquiatria , Rio de Janeiro, v. 60, n. 2, p. 144-147, 2011., Valença et al. sought to relate factors to the presence of violent behavior with regard to risk prediction and prevention of the manifestation of this behavior (Valença; Moraes, 2006VALENÇA, A. M.; MORAES, T. M. Relação entre homicídio e transtornos mentais. Revista Brasileira de Psiquiatria , São Paulo, v. 28, p. s62-s68, 2006. Suplemento 2.; Valença; Nascimento; Nardi, 2013VALENÇA, A. M.; NASCIMENTO, I.; NARDI, A. E. Relationship between sexual offences and mental and developmental disorders: a review. Archives of Clinical Psychiatry, São Paulo, v. 40, n. 3, p. 97-104, 2013.; Valença et al., 2015VALENÇA, A. M. et al. Retardo mental: periculosidade e responsabilidade penal. Jornal Brasileiro de Psiquiatria , Rio de Janeiro, v. 60, n. 2, p. 144-147, 2011.). Clinical criteria were decisive in these studies, mainly the presence of productive symptomatology, relapse, lack of insight, and cognitive distortions. This proves that adequate clinical control is fundamental to avoid recurrence within the mental patients’ population.

Regarding the prediction of violent behavior, Oliveira et al. (2017OLIVEIRA, G. C. et al. Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho. Revista Brasileira de Psiquiatria , São Paulo, v. 39, n. 1, p. 45-54, 2017.) concluded that the use of validated instruments and the development of a semi-structured interview with the purpose of assessing the risk of violence in psychiatric patients in custody would be ways of circumventing or, at least, reducing possible distortions. Also according to the authors, research that provides data to help the identification of individuals suffering from mental disorders who are at risk of violent behavior, as well as their proper treatment, can contribute to the prevention of this conduct, as well as its expression within the social environment. As a consequence, they could allow for a better characterization of groups and risk situations, clarifying the specific motivations related to the manifestation of violent behavior in individuals with mental disorders.

A more careful analysis of the publications by Videbech et al. (2010VIDEBECH, P. et al. Patients at a psychiatric residential institution in Djursland. Ugeskr for Laeger, Copenhagen, v. 172, n. 5, p. 351-355, 2010.), Kramp and Gabrielsen (2009KRAMP, P.; GABRIELSEN, G. The organization of the psychiatric service and criminality committed by the mentally ill. European Psychiatry , Cambridge, v. 24, n. 6, p. 401-411, 2009.) or, still, Fuller Torrey (2015FULLER TORREY, E. Deinstitutionalization and the rise of violence. CNS Spectrums, New York, v. 20, p. 207-214, 2015. Número especial 3.), intended to correlate the deinstitutionalization with a process of increasing violent crimes committed by mental patients. As demonstrated by the articles in this review (Glied; Frank, 2014Glied, S.; Frank, R. G. Mental illness and violence: lessons from the evidence. American Journal of Public Health, Washington, DC, v. 104, n. 2, p. 5-6, 2014. ; Lamb; Weinberger, 2013LAMB, H. R.; WEINBERGER, L. E. Some perspectives on criminalization. Journal of the American Academy of Psychiatry and the Law, Bloomfield, v. 41, n. 2, p. 287-293, 2013.; Manning, 2009MANNING, C. Imprisoned in state care? Life inside Kew Cottages 1925-2008. Health and History, Sydney, v. 11, n. 1, p. 149-171, 2009.; Silver, 2006SILVER, E. Understanding the relationship between mental disorder and violence: the need for a criminological perspective. Law and Human Behavior, Southport, v. 30, n. 6, p. 685-706, 2006.), situations of violence and risk are punctual and involve the minority of patients. Historically, the situation of institutions founded on an approach focused on punishment, incarceration, and physical restrictions can influence behaviors that involve violent responses. Considering the idea of re-institutionalizing patients, even though (and obviously) using a model with better infrastructure, might look like a backward solution. The historical analysis of these institutions is clear in the aspect in which they came up with a model quite different from what they have ultimately become. Initially, they were called nursing homes, convalescence homes, spas, etc.

Foucault (2001FOUCAULT, M. Os anormais: curso no Collège de France (1974-1975). São Paulo: Martins Fontes, 2001.), Correia and Passos (2017CORREIA, L. C.; PASSOS, R. G. (Org.). Dimensão jurídico-política da reforma psiquiátrica brasileira: limites e possibilidades. Rio de Janeiro: Gramma, 2017.), and Arbex (2013ARBEX, D. Holocausto brasileiro: genocídio: 60 mil mortos no maior hospício do Brasil. São Paulo: Geração, 2013.) deal with the subject of restrictions, institutionalization, and difficulties and distortions of asylum models for psychiatric treatment. There are several reports of mistreatment, unnecessary prolongations of hospitalizations, and inadequate and distorted therapeutic proposals. A nefarious consequence was the increase in institutional violence and a huge number of deaths which could have been prevented.

The stigma resulting from inadequate therapeutic approaches is portrayed very clearly by the patients themselves. Nascimento & Leão (2019NASCIMENTO, L. A.; LEÃO, A. Estigma social e estigma internalizado: a voz das pessoas com transtorno mental e os enfrentamentos necessários. História Ciências Saúde - Manguinhos, Rio de Janeiro, v. 26, n. 1, p. 103-121, 2019.) published an important qualitative work in which it is clear how much the mentally ill perceive themselves as stigmatized and victims of prejudice. Recovery strategies, which can be understood as a recovery process experienced differently by each individual, seeking their recovery in the most active and participatory way possible, is undoubtedly an important factor for overcoming the effects of stigma and other negative effects of the presence of mental health disorders (Nascimento; Leão, 2019NASCIMENTO, L. A.; LEÃO, A. Estigma social e estigma internalizado: a voz das pessoas com transtorno mental e os enfrentamentos necessários. História Ciências Saúde - Manguinhos, Rio de Janeiro, v. 26, n. 1, p. 103-121, 2019.; Serpa Junior et al., 2017SERPA JUNIOR, O. D. et al. Relatos de experiências em recovery: usuários como tutores, familiares como cuidadores/pesquisadores e efeitos destas práticas em docentes e pesquisadores em saúde mental. Cadernos Brasileiros de Saúde Mental, Florianópolis, v. 9, n. 21, p. 250-270, 2017.).

It is important to highlight how Flannery Junior et al. (2000FLANNERY JUNIOR, R. B. et al. Assaults on staff by psychiatric patients in community residences. Psychiatry Services, Washington, DC, v. 51, n. 1, p. 111-113, 2000.) investigated the profile of aggressions carried out by people who had left a psychiatric institution. The innovation of this work was to think from the perspective of the professional and not to merely associate violence and the patient. In fact, the authors identified a profile of the professionals who were victims of violence: those with inadequate education or training backgrounds, and who suffered from mental illnesses, such as acute stress, sleep disorders, hypervigilance, and other psychic disorders. According to this study, an intervention focused on the professional team contributed to a steep decrease in the aggressions, which dropped to under half the previous number over the observation timespan (four years), despite the increase in the number of hospitalizations in the same period. That is, there are measures to be taken to prevent violent behavior and they are not limited to the patient itself but associated with several other factors.

Thus, it can be considered that the most plausible alternatives, the ones with a greater chance of preventing violence among the mental patients population and with a higher incidence of re-socialization and good clinical control, are the adequate training of staff and creation of systematic, standardized models that take the evolution and dynamics of the process related to violence into consideration, as addressed in different studies, including Silver’s (2006SILVER, E. Understanding the relationship between mental disorder and violence: the need for a criminological perspective. Law and Human Behavior, Southport, v. 30, n. 6, p. 685-706, 2006.), Mecler’s (2010MECLER, K. Periculosidade: evolução e aplicação do conceito. Revista Brasileira Crescimento e Desenvolvimento Humano, Santos André, v. 20, n. 1, p. 70-82, 2010.), Valença, Nascimento and Nardi’s (2013VALENÇA, A. M.; NASCIMENTO, I.; NARDI, A. E. Relationship between sexual offences and mental and developmental disorders: a review. Archives of Clinical Psychiatry, São Paulo, v. 40, n. 3, p. 97-104, 2013.), and Oliveira et al’s. (2017OLIVEIRA, G. C. et al. Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho. Revista Brasileira de Psiquiatria , São Paulo, v. 39, n. 1, p. 45-54, 2017.).

There are robust scientific studies in place, including systematic reviews and meta-analysis, proving that mental health disorders are not the most important factor in assessing the risk of violence, or even an isolated factor leading to it (Abdalla-Filho; Engelhardtb, 2003ABDALLA-FILHO, E.; ENGELHARDTB, W. A prática da psiquiatria forense na Inglaterra e no Brasil: uma breve comparação. Revista Brasileira de Psiquiatria, São Paulo, v. 25, n. 4, p. 245-248, 2003.; Achá et al., 2011ACHÁ, M. F. F. et al. Prevalence of mental disorders among sexual offenders and non-sexual offenders. Jornal Brasileiro de Psiquiatria, Rio de Janeiro, v. 60, n. 1, p. 11-15, 2011.; Bonta; Law; Hanson, 1998BONTA, J.; LAW, M.; HANSON, K. The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychological Bulletin, Washington, DC, v. 123, n. 2, p. 123-142, 1998.; Ghoreishi et al., 2015GHOREISHI, A. et al. Prevalence and attributes of criminality in patients with schizophrenia. Journal of Injury and Violence Research, Kermanshah, v. 7, n. 1, p. 7-12, 2015.; Mecler, 1996MECLER, K. Periculosidade e inimputabilidade: um estudo dos fatores envolvidos na determinação da periculosidade do doente mental infrator. 1996. Dissertação (Mestrado em Psiquiatria e Saúde Mental) - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 1996.; Menezes, 2001MENEZES, R. S. Homicídio e esquizofrenia: estudo de fatores associados. 2001. Dissertação (Mestrado em Medicina e Ciências Médicas) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2001.; Oliveira et al., 2017OLIVEIRA, G. C. et al. Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho. Revista Brasileira de Psiquiatria , São Paulo, v. 39, n. 1, p. 45-54, 2017.; Valença; Moraes, 2006VALENÇA, A. M.; MORAES, T. M. Relação entre homicídio e transtornos mentais. Revista Brasileira de Psiquiatria , São Paulo, v. 28, p. s62-s68, 2006. Suplemento 2.; Valença; Nascimento; Nardi, 2013VALENÇA, A. M.; NASCIMENTO, I.; NARDI, A. E. Relationship between sexual offences and mental and developmental disorders: a review. Archives of Clinical Psychiatry, São Paulo, v. 40, n. 3, p. 97-104, 2013.; Whittington et al.. 2013WHITTINGTON, R. et al. A systematic review of risk assessment strategies for populations at high risk of engaging in violent behaviour: update 2002-8. Health Technology Assess, London, v. 17, n. 60, p. i-xiv, 2013.).

Several studies have investigated the relationship between mental health disorders and violent behavior. Menezes (2001MENEZES, R. S. Homicídio e esquizofrenia: estudo de fatores associados. 2001. Dissertação (Mestrado em Medicina e Ciências Médicas) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2001.) found that the absence of psychiatric treatment prior to the crime was the main variable related to violent behavior, highlighting, then, the possibility of it being preventable.

In Brazil, one of the situations in which we are confronted with violence and institutionalization is when a mentally ill person commits a crime and is deemed unimputable, according to Article 26 of the Brazilian Penal Code. In this case, the person will be held in custody by the Brazilian State and may remain institutionalized for decades, even if as a result of a not so serious crime, due to being considered a potentially dangerous individual. The presumed dangerousness only ends with the Examination to Attest the Cessation of Dangerousness, which must be carried out by an official expert psychiatrist. Mecler (2010MECLER, K. Periculosidade: evolução e aplicação do conceito. Revista Brasileira Crescimento e Desenvolvimento Humano, Santos André, v. 20, n. 1, p. 70-82, 2010.) and Oliveira et al. (2016OLIVEIRA, G. C. et al. O exame de verificação de cessação de periculosidade: a importância da avaliação ampliada em um caso com conclusão contrária ao parecer da equipe assistente. Revista Latinoamericana de Psicopatologia Fundamental, São Paulo, v. 19, n. 2, p. 322-341, 2016.) researched hundreds of Brazilian psychiatric reports and identified that, in most of these exams, the psychiatric expert does not seem to subject his report to a standardization and systematization that takes the most relevant points in the risk of violence into consideration, in disagreement with what is presented in the scientific literature comprised in this review.

This situation calls for great reflection concerning the Examination to Attest the Cessation of Dangerousness, as its lack of systematization and standardization regarding the data collection hinders not only the analysis of the data but also the quality of the exam, which many times fails to address some relevant factors for an efficient analysis of the risk of violence. It was based on this, and after discussions on the subject together with managers and clinical staff, that the Instituto de Perícias Heitor Carrilho, the place where all the evaluations for the cessation of dangerousness in the state of Rio de Janeiro are carried out, implemented the Multiprofessional and Psychosocial Care Expert Examination (Empap) in October 2017.

This exam provides a new model in accordance with scientific, historical, and cultural assessments, as well as all the advancement in health and legal knowledge, taking into consideration the principles of dignity and international human rights regulations. Empap was conceived from a multidisciplinary perspective, treating some central points in an objective and explicit way, considering historical items, criminology, social and clinical factors, and the perspective for the future from the expert’s point of view and the psychosocial support which the patient should receive upon release of the security measure (Costa et al., 2018COSTA, C. A. R. et al. Perigo real ou imaginário: uma reflexão crítica e uma proposta de modelo alternativo ao exame de verificação de cessação da periculosidade vigente no código penal brasileiro. Revista Brasileira de Ciências Criminais, São Paulo, n. 144, p. 323-355, 2018.).

It is prejudiced, stigmatizing, and contrary to scientific evidence to consider the mentally ill as individuals at greater risk of violent behavior compared to the general population. Of course, there are situations in which, especially if left untreated, they may become violent, but those characterize specific contexts, with treatable and changeable factors. Quality and humanized care, in which prolonged hospitalization and institutionalization are avoided, are certainly excellent means to reduce the risk of violent behavior by these individuals.

The identification of risk factors associated with violent behavior is essential to achieve an adequate assessment in relation to mental health disorders, without referring strictly to the prolonged, archaic, and stigmatizing hospitalization/institutionalization model, when perceived as the only possible alternative.

The application of standardized instruments and a systematic assessment based on technical and scientific knowledge can provide more reliable data to predict and avoid the risk of violence within this population or even avoid the abusive enforcement of the security measure. The combination of the organization of a standardized, holistic, and dynamic health treatment system, will allow for the offer of adequate monitoring and actual re-socialization, without the reinforcement of the stigma and archaic thinking leading to the conclusion that institutionalization is the only possible solution.

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