Treat the treatable: a comprehensive and optimistic approach to treating psychiatric violence.

The movement toward a dimensional model for psychiatric diagnoses provides a new way to conceptualize violence in mental health populations: rather than focusing on violence as a result of mental illness, we can conceptualize violence as one dimension of mental illness, thereby addressing this complex syndrome with an approach that is both humanistic and scientific. Rather than dichotomizing violent patients as either criminally minded or mentally ill, this new formulation allows us to accept the heterogeneity of violence in mental health populations, to flesh out the key contributors to violence and to “treat the treatable”. This approach is supported by a contribution from Bartholomew and Morgan, which reviews the evidence examining the relationship between mental illness and criminal behavior, and suggests that certain individuals experience both mental illness and criminal thinking. As our forensic populations rise, this Special Issue is intended to explore the gamut of topics related to that rise, from how we got here as a society to how to treat individuals once they have experienced criminalization. It is very much hoped that the reader of this Special Issue will come away with an appreciation for the population and optimism about the treatment horizon. Contributions related to the reasons for the rise in forensic populations reiterate the theme of treating the treatable, as they point to a failure to treat as a primary cause of the growing phenomenon of people with mental illness becoming involved in the criminal justice system— a process termed criminalization. Torrey reviews the impact of deinstitutionalization on the rise of violence, and offers a comprehensive argument for focusing on the treatment of psychotic behavior in the community in order to prevent criminalization, rather than deferring treatment until after the onset of psychotic behavior and associated violence to be treated in correctional or forensic settings. Warburton argues that deinstitutionalization has created a new type of psychiatric patient (namely, a patient with complex mental health, forensic, and criminogenic needs) and thus, that the standard of care for this population needs to be redefined. Schaufenbil et al 4 flesh out the first step in that new standard by proposing forensic-focused treatment planning to target issues such as violence risk. Broderick et al 5 provide more evidence for the risk of not treating mental illness in the community, as they describe inpatient violence as a consequence of the criminalization of the mentally ill in a large forensic system. Szabo et al 6 also examine the issue of aggression, but within community hospitals, and the impact of aggression on care as well as potential solutions for predicting and reducing inpatient violence in this setting. A theme emerged as the invited articles arrived: most emphasize the importance of treating the treatable. Both Felthous and Wong and Olver consider the treatment (and appropriateness of treating) psychopathic conditions—long considered to be one of the most challenging domains of forensic treatment. Both agree that treatment is appropriate, and each provides a unique approach to that end. Felthous proposes a way forward via the pharmacological treatment of impulsive behavior, after extensively educating the reader about the historical and neurobiological rationale for this approach. Stahl also expands upon this approach in his “Brainstorms” article in this issue. Complementing this approach, Wong and Olver propose alternatively to target the modifiable criminogenic risk factors, and base this notion on a review of the existing literature on psychopathy and criminal rehabilitation. Related to the need to treat criminal behavior, Pinals explores the strategies for mitigating violence risk in community outpatient settings, emphasizing the promise of folding in treatment for criminogenic thinking with standard mental * Address for correspondence: Katherine Warburton, California Department of State Hospitals, 1600 9th Street, Suite 400, Sacramento, CA 95814, USA. (Email: [email protected]) CNS Spectrums (2015), 20, 170–171. © Cambridge University Press 2015 doi:10.1017/S1092852915000309