Since the 1950s, there has been a substantial shift from long-term institutional mental health (MH) care to community-based services. The introduction of specialist community-based teams and a 70 per cent reduction in MH beds in the UK since the late 1980s means that people with greater acuity of illness and complexity are being treated in the community. As a consequence, MH services are more likely to need to manage violent behaviour in the community. Within MH services, successful management of violence is predicated on a range of factors/interventions. These include management of specific conditions, most notably schizophrenia, personality disorder and substance misuse. Multidisciplinary team working, effective communication and collaboration across services play important roles, arguably more so than the service model. Key clinical risk factors for violence in mental illness, how to modify these risks in community MH services, different service models that may help achieve this, domestic violence and lone working are discussed. Liaison with the police, the role of AMHPs, MHA assessments, and law and guidance on personal safety in the community are also discussed. The criminal justice system has an important role in addressing violence, and there is mention also of the Code for Crown Prosecutors and MAPPA arrangements.

This chapter provides an overview of the legislative frameworks that are relevant to the management of violence by persons with mental disorders in the United Kingdom. Three jurisdictions apply (England and Wales, Scotland and Northern Ireland). Individual frameworks and their variants are not discussed in detail; rather, substantial differences relevant to the management of violence are highlighted. Core principles guiding routine medical practice of ‘consent’ and ‘do no harm’ remain relevant in the management of violence, and legislation provides a framework when coercion may be necessary to manage an acute violent act, the immediate risk of further violence or the longer-term risk of violence. Pertinent legislation is discussed, including the Human Rights Act 1998, and mental health and mental capacity acts. Deprivation of Liberty Safeguards (DoLS), which are soon to be replaced by the Liberty Protection Safeguard Scheme (LPS), community treatment orders (CTOs) and review of the Mental Health Act are also discussed.

Many groups are more vulnerable to violence than others, with children, some ethnic minorities and the elderly more at risk than others. In this section, these aspects of vulnerability are examined closely. Children exposed to violence are perhaps the group who suffer most, as the effects of abuse and harm can scar them for the rest of their lives. Their inability to resist makes the need for safeguarding paramount, but intervention often takes place late when the damage has been done. Older people and those with intellectual disability are similarly vulnerable and the chapters in this section offer sound advice on management. Black, Asian and other minority groups (BAME) deserve a separate chapter. They are both more vulnerable to violence and perceived as more likely to express violence, a perception that is often wrong and can have racist overtones. There is controversy over the causes of violence in this group, but the authors present a balanced view containing sound advice.

The illegal killing of George Floyd led to Black Lives Matter protests around the world and energised the call for discrimination to be addressed in society. In this chapter we explore evidence of mental health inequalities in those from BAME communities and acknowledge that some groups in society, who may or may not identify as BAME, such as asylum seekers travellers and the LGBTQ+ community, also face discrimination. We mention the theory of intersectionality, racial gaslighting and the detrimental impact of austerity on health outcomes. Readers are reminded of the historical reports into the deaths of Michael Martin, Joseph Watts and David ‘Rocky’ Bennett and of the 2002 Sainsburys Centre review which identified a ‘circle of fear’. The finding of the independent review of the MHA and the recently published rapid review of ethnic health disparities by the NHS Race and Health Observatory are highlighted. NHS England and NHS Improvement’s Advancing Mental Health Equalities Strategy, the RCPsych equality action plan, and The Patient and Carers Race Equalities Framework (PCREF) are explained. Stereotyping of black males and the disproportionate use of force (including tasers), is discussed and the authors call for the implementation of mandatory training covering the nature of discrimination.

Because violence can manifest anywhere, we all need to be prepared for its impact. The following four chapters describe the main settings outside standard psychiatric inpatient wards where violence is manifest in different ways and how the different environmental circumstances influence management.

In the community, potential victims are much less protected and, as far as is possible, de-escalation (defusion) of violence becomes the primary intervention.

The problem of violence in medical settings has sadly come to the fore in recent years because of an increase in episodes, and its management and prevention need to be developed further. Emergency departments are in the front line here, and paramedics and other ambulance staff are also vulnerable to assault. It is to be expected that when common policies of management are adopted, hospital settings will gain greatly.

The new chapter on forensic psychiatry and adult inpatient secure settings () offers readers an insight into the historical context behind the existence and development of forensic psychiatric services in England and Wales. Key pieces of legislation are outlined, as is a description of how forensic services are currently configured.

This chapter provides an overview of violence and victimisation. This includes consideration of the complex relationship between mental health and violence, highlighting the increased risk of violent victimisation experienced by individuals suffering from mental illness. The developing impact of the COVID-19 pandemic and associated health measures such as lockdown orders on violence (and, in particular, domestic abuse) is explored. We describe the history and development of legal protections and statutory services for victims in the United Kingdom. This includes the 2021 Victims’ Code. The authors discuss public health strategies in the conceptualisation and prevention of violence, and there is consideration of future developments within this field. Current resources available for victims of violence are outlined, alongside a detailed list of organisations that individuals who have been victimised can contact for advice and support.

Violence and aggression remain common reasons for admission to psychiatric wards, and violence and aggression commonly occur in inpatient psychiatric units. Furthermore, exposure to violence and aggression has a deleterious impact on patient and staff safety, treatment outcomes, staff morale and performance, and on the therapeutic environment. The chapter begins with a discussion of clinical governance and of factors that contribute to violence. The importance of service user and carer involvement is emphasised, as is the need to create a safe and therapeutic ward environment. Sexual safety and comorbid substance misuse is mentioned. Principles of managing acutely disturbed behaviour and the prediction of violence in inpatient settings are summarised. Readers are also reminded of issues pertaining to observation, de-escalation, seclusion and restraint. The extra care area, therapeutic interventions, meaningful activity and the role of psychologists on acute wards to reduce the risk of violence and restricted practices are discussed. The chapter concludes with considerations regarding pursuing criminal proceedings against violent perpetrators and inpatient care in the context of COVID-19.

This section is concerned with the highly important subject of the interaction of violence with society as a whole. If we can improve the outcomes of children involved in violence, have good ways of linking programmes of treatment with societal understanding and can overcome the pain and anger of victims who have been exposed to violence, we will have moved a long way.

The evidence that those with mental illness are much more likely to be victims of violence than its perpetrators is repeated several times in this book, and we make no apology for this; it needs to be repeated over and over again until society understands.

Professionals working in health, social care and the justice system require a robust understanding of when to share confidential information; the information-sharing chapter (Chapter 18) has been expanded from the first edition and provides information on legislation and guidance to be considered when sharing information about patients and information sharing by organisations supporting victims of crimes committed by mentally disordered offenders. The chapter includes discussion of the new Victims’ Code and of liaison with victims.

This chapter considers the use of medication as an emergency response in the management of violent and disturbed behaviour. It addresses the complex factors surrounding the decision to use rapid tranquillisation, followed by reviewing the risks and benefits of specific medication options. This is discussed within the context and continuum of acute patient care, in keeping with good practice principles, and with consideration to the relevant patient-related and medication-related risks. The current evidence for using medication or ECT in the management of a medium- and longer-term risk of violence in the context of mental illness is briefly reviewed. The recommendations are applicable to all inpatient mental health units in the United Kingdom.

This section sets the tone for the rest of this book. The management of the threat of violence is a highly individual matter that cannot be decided unilaterally by any official guidance. But all management requires a framework within which practitioners have to work, only going outside it under exceptional circumstances. In Chapter 1, Eric Baskind makes a bold attempt to bring all together with the suggestion of a common set of guidelines, as violence can show itself, often Medusa-like in its sudden venom, in every possible setting. So, it is wise to have a common policy of management. But we are not there yet, and Chapter 2 tells us exactly where we are at present in terms of legislation, a subject that changes often and which depends on the locality. This is an excellent aide-memoire to those who organise management programmes and need to ensure that they are both legal and justified.

The final two chapters add a more personal touch to the book. When there are so many directives, requirements, management advice and instructions around the subject of violence we must not forget that each episode represents a common universal experience, one in which many feelings are engendered, from deep hurt to anger. The staff exposed to violence need emotional and practical support too, and the initiatives in these concluding chapters show that these can be provided by many who are conventionally ‘outside the system’. Looking at a problem with completely fresh eyes can often be an enormous help. It offers a new sense of direction, better understanding and a more specifically personal impact that can help resolution. Together, these accounts end the book on a note of quiet optimism. Oh brave new world, that has such people in it – long may they thrive.