A partnership of and Alcohol as a Risk Factor for Aggression and Violence: Reasons and Responses Mary McMurran
Dec 19, 2015
A partnership ofand
Alcohol as a Risk Factor for Aggression and Violence: Reasons and Responses
Mary McMurran
Aims
• The degree to which alcohol increases the risk of aggression and violence
• How alcohol increases the risk of aggression and violence
• The management and treatment of alcohol-related violence
Violent Crime Decreasing
http://www.ons.gov.uk/ons/rel/crime-stats/crime-statistics/period-ending-december-2013/stb-crime-stats-dec-2013.html#tab-Violent-crimeCrime Survey for England & Wales
Level of Violence
Half no physical injury, i.e.,
threatening behaviour,
common assault etc.
Half no physical injury, i.e.,
threatening behaviour,
common assault etc.
Victims of Violence
ONS Focus on Violent Crime & Sexual Offences 2011/12, England & Waleshttp://www.ons.gov.uk/ons/dcp171778_298904.pdf
HMIC (2014). Everyone’s business: Improving the police response to domestic abuse. http://www.hmic.gov.uk/wp-content/uploads/2014/03/improving-the-police-response-to-domestic-abuse.pdf
Under-reporting?Under-recording?Under-reporting?Under-recording?
Injury Related to Violence
• Violence-related injury presentations in 77 Emergency Departments (EDs) in England & Wales, 2005-2009
• Total 221,673 violence related attendances– 74% male– 45% in 18 – 30 age group
• 3% decrease overall over the reporting period• No change in 18 – 30 age group
Sivarajasingam et al. (2014). Trends in community violence in England and Wales 2005–2009.Injury, 45, 592-598.
Perpetrators of Violence
• Young and male• Nine out of ten male (86%) • Half aged between 16 and 24 years (52%)
• Women vs Men?
ONS Focus on Violent Crime & Sexual Offences 2011/12, England & Waleshttp://www.ons.gov.uk/ons/dcp171778_298904.pdf
Who are victims and who are
perpetrators?
Who are victims and who are
perpetrators?
Crime reducing over time
Crime reducing over time
Less overall crime by females
Less overall crime by females
Alcohol and Victims of Violence
• Alcohol involved in 50% of all violent offences
◦ 37% domestic victim◦ 52% acquaintance◦ 65% stranger
Flatley, J., Kershaw, C., Smith, K., Chaplin, R., Moon, D. (2010). Crime in England and Wales 2009/10. Home Office Statistical Bulletin 12/10. London: Home Office. http://rds.homeoffice.gov.uk/rds/pdfs10/hosb1210.pdf
Alcohol less explanatoryAlcohol less explanatory
Heaviest Drinking Day in the Past Week, 2012
ONS. Drinking Habits Amongst Adults, 2012. http://www.ons.gov.uk/ons/dcp171778_338863.pdf
Age 16-24 25-44 45-64 65+
MEN≥ 8 units
43% 38% 26% 29%
WOMEN≥ 6 units
36% 27% 19% 21%Still a substantial amount of ‘binge’
drinking, especially by young men, which is the
group responsible for most violence
Still a substantial amount of ‘binge’
drinking, especially by young men, which is the
group responsible for most violence
Contribution of Alcohol
• Identified by– Correlational studies– Longitudinal studies– Experimental studies– Case crossover studies
Correlational Studies – Population Level
• Drinking associated with violence
• Northern Europe > Mediterranean
• Patterns of drinking – Binge drinking more risky than
steady high alcohol consumption
Room, R., & Rossow, I. (2001). The share of violence attributable to drinking. Journal of Substance Use, 6, 218-228.
Bye, E., & Rossow, I. (2010). The impact of drinking pattern on alcohol-related violence among adolescents: An international comparative analysis. Drug and Alcohol review, 29, 131-137.
Correlational Studies – Population Level
• Survey in 2000 of 8,397 British 17-74 year olds • Self-reported violence over the past 5 years • Risk of violence was increased by (adj. OR)
– 2.52 for hazardous drinkers– 2.72 for alcohol dependent
• Attributable risk– 47% for hazardous drinkers– 23% for alcohol dependent
Coid et al. (2006). Violence and Psychiatric Morbidity in a National Household Population— A Report from the British Household Survey. American Journal of Epidemiology, 164, 1199-1208.
Reducing hazardous drinking could have a
major effect on population violence
Reducing hazardous drinking could have a
major effect on population violence
The following questions are about the past year. 1.How often do you have a drink containing alcohol?□ Never □ Monthly □ 2 to 4 times a month □ 2 to 3 times
a week □ 4 or more times a week 2. How many drinks containing alcohol do you have on a
typical day when you are drinking? □ 1 or 2 □ 3 or 4 □ 5or 6 □ 7 to 9 □ 10 or more 3. How often do you have six or more drinks on one
occasion?□ Never □ Less than monthly □ Monthly □ Weekly □ Daily, or almost daily 4. How often during the last year have you found that you
were not able to stop drinking once you started? □ Never □ Less than monthly □ Monthly □ Weekly□ Daily, or almost daily 5. How often during the last year have you failed to do what
was normally expected from you because of drinking? □ Never □ Less than monthly □ Monthly □ Weekly□ Daily, or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
□ Never □ Less than monthly □ Monthly □ Weekly□ Daily, or almost daily 7.How often during the last year have you had a feeling of guilt or
remorse after drinking? □ Never □ Less than monthly □ Monthly □ Weekly□ Daily, or almost daily 8. How often during the last year have you been unable to
remember what happened the night before because you had been drinking?
□ Never □ Less than monthly □ Monthly□ Weekly □ Daily, or almost daily 9. Have you or someone else been injured as the result of your
drinking? □ No □ Yes, but not in the last year □ Yes, during the last
year 10. Has a relative, friend, or a doctor or other health worker been
concerned about your drinking or suggested you cut down? □ No □ Yes, but not in the last year □ Yes, during the last
year
Alcohol Use Disorders Identification Test (AUDIT)
Alcohol Use Disorders Identification Test (AUDIT) ≥ 8 Hazardous; ≥ 16 Harmful; ≥ 20 Dependent≥ 8 Hazardous; ≥ 16 Harmful; ≥ 20 Dependent
What is Binge Drinking?
• Drinking to get drunk• US
– MEN - 5 or more ‘standard drinks’ on one occasion– WOMEN - 5 or more ‘standard drinks’ on one
occasion
• UK– MEN - 8 or more ‘standard drinks’ on one occasion– WOMEN - 6 or more ‘standard drinks’ on one
occasion
Different measuresVarying %ABV
Different length of an ‘occasion’Differences in individual
physical attributes
Different measuresVarying %ABV
Different length of an ‘occasion’Differences in individual
physical attributes
Correlational Studies -Group Level
• Prisoners are heavy drinkers– Men - 63% hazardous drinkers
• more likely than non-hazardous drinkers to be • Young (16 -24), White, Single, Held for a violent offence
– Women - 39% hazardous drinkers• more likely than non-hazardous drinkers to be • Young (16 -24), White, Single
Singleton, N., Farrell, M., & Meltzer, H. (1999). Substance misuse among prisoners in England & Wales. London: Office for National Statistics.
Longitudinal Studies
• Boden et al. (2011)• New Zealand birth cohort (N=1265)• Interviewed at age 18, 21, 25, & 30
– Alcohol abuse/dependence (AAD) • Composite International Diagnostic Interview (DSM) (0-11
symptoms)
– Self-reported violence offences
Boden, J.M., Fergusson, D.M. & Horwood, L.J. (2011). Alcohol misuse and violent behavior: Findings fromA 30-year longitudinal study. Drug and Alcohol Dependence, 122, 135-141.
Longitudinal Studies• ≥ 5 AAD symptoms compared with no AAD
symptoms• 12 x rate of violence perpetration
– Same for men and women– Higher for younger people
• 7 x rate of victim of violence– No differences by gender or age
• 4 x rate of intimate partner violence – No differences by gender or age
Longitudinal Studies
• Controlling for shared risk factors (e.g., drug use, unemployment, family drug use and offending),
• ≥ 5 AAD symptoms are 4 x more likely to be violent than those with no symptoms
• Alcohol explains – 10% of the risk of violence perpetration– 5% of intimate partner violence
Experimental Studies
• Alcohol increases aggression particularly in those who – Get higher doses– Are aggressive by nature
Giancola, P.R. (2006). Influence of subjective intoxication, breath alcohol concentration, and expectancies on the alcohol-aggression relationship. Alcoholism: Clinical and Experimental Research, 30, 844-850.
Case Crossover Studies
• If there are precipitating events, these events should occur much more frequently during a period immediately prior to the event than at a similar period which is more distant from the event
Case Crossover Studies
• Violent offenders (N=118)• Hazard period = 24 hours prior to the violent
offence• Usual frequency = drinking during the whole of
the previous year• Control for usual frequency by calculating
exposed person time = usual frequency x length of hazard time relative risk
Case Crossover Studies
• Drinking in the previous 24 hour period increases risk by x 13 of committing a violent offence
Hǻggard-Grann, U., Hallqvist, J., Lǻngström, N., & Möller, J. (2006). The role of alcohol and drugs in triggering criminal violence: A case cross-over study. Addiction, 101, 100-108.
Does Alcohol Cause Violence?• There is a broad, reliable, positive, main effect
of alcohol on violence• There is enough evidence to say that alcohol is a
causal factor for violence • This means that reducing alcohol consumption
will reduce violence• However, alcohol is neither necessary nor
sufficient in explaining violence
Variation Between and Within People
• Not everyone who drinks is violent• Even people who are violent after drinking are
not violent on every drinking occasion• How do we explain this?
Explaining Alcohol-Related Violence
Person Context
Violence
Culture
Drinking
Provocation/frustration
Risky drinking
Risky drinking
Risky placesRisky
placesRisky
peopleRisky
people
Public HealthPublic Health
ManagementManagementTreatmentTreatment
Risky Drinking – Public Health
• Public health – organized measures to prevent disease, promote
health, and prolong life among the population as a whole.
– focus on entire populations, not on individual patients or diseases.
Risky Drinking – Public Health
• Violence recognised by WHO as a public health issue
• Alcohol recognised as a contributing factor
Risky Drinking – Public Health
• Effective public health measures to reduce alcohol-related violence – Reduce overall consumption
• Price increases through taxation• Fewer outlets• Limitations on days and hours of sales
– Restrict sales hours for on-premises licences (i.e., earlier closing)
• BUT, unpopular with drinkers and the alcohol industry• Preference for INEFFECTIVE strategies – school
education programmes and information strategies
Rossow, I., & Bye, E. (2013). The problem of alcohol-related violence: An epidemiological and public health perspective. In M. McMurran (Ed.). Alcohol-related violence: Prevention and Treatment. Chichester: Wiley.
Risky Places - Management
• Trouble ‘hot-spots’, e.g., specific pubs and clubs• Especially at weekends• Aggressive people frequent the same places -
not interested in ‘cold-spots’• When provocations are likely
– Closing time– Fast food shops– Taxi queues
Risky Places – Management
• City centre planning– More and closer taxi ranks– Fewer fast food outlets next to pubs and clubs
• Policing– Zero-tolerance policing
• but adversely impacts on police-public relations– Problem-oriented policing
• Anonymised information from emergency departments (locations, time, days, weapons etc)
• Map hotspotsFlorence et al. (2011). Effectiveness of anonymised information sharing and use in health service, police, and local governmentpartnership for preventing violence related injury. BMJ 2011;342:d3313
• Comparison of Cardiff and 14 similar cities for 21
months • Health service and police
service records of violence• Incidence rate ratio 0.58
(95%CI 0.49 to 0.69)
• Comparison of Cardiff and 14 similar cities for 21
months • Health service and police
service records of violence• Incidence rate ratio 0.58
(95%CI 0.49 to 0.69)
Risky Places – Management Safer Bars• Risk assessment workbook
– Alerts the owner to potential environmental risks (e.g., bottlenecks, floor plan, security staff etc)
• Staff training– Recognising aggression early,
intervening early, de-escalation etc.• Experiment
– Bars randomised to Safer Bars (18) or not (12)
– Aggression observed weekend nights– Less aggression in Safer Bars (RR=0.83)
Kate Graham, London, ON, Canada
Graham, K. et al. (2004). The effect of the Safer Bars programme on physical aggression in bars: results of a randomized controlled trial. Drug and Alcohol Review, 23, 31 – 41.
Risky Drinkers - Treatment
• Need to understand– Who we should treat– Why they are aggressive when intoxicated– How alcohol increases the risk of violence– What works in offender/drinker treatment
Risky Drinkers
• Male• High trait aggression• Aggression established in behavioural repertoire• Hypermasculine values
– Aggression is the right way to maintain respect
• Excited by fighting– Even if they didn’t set out for excitement
Alternative strategies for dealing with provocation, conflict, and ‘disrespect’
Alternative strategies for dealing with provocation, conflict, and ‘disrespect’
Risky Drinkers
• Interviews with 149 offenders who were violent when intoxicated – main motives for alcohol-related aggression– Being offended by someone
• an insult, an inappropriate comment, or a grudge
– Seeing others in need of help • a male friend in a fight
– Seeing an opportunity for material gain • a vulnerable victim
McMurran, M., Hoyte, H., & Jinks, M. (2012). Triggers for alcohol-related violence in young male offenders. Legal and Criminological Psychology, 17, 307-321.
Mechanisms of Alcohol’s Effect
• Alcohol myopia• Impaired social problem solving• Expectancy effects
Alcohol Myopia• Alcohol decreases the
number of cues to which a person can attend
• Attend to dominant cues, e.g., threat;
• Inhibitory cues are less salient, e.g., bouncers
Giancola, P.R. et al. (2010). Alcohol myopia revisited: Clarifying aggression and other acts of disinhibition through a distorted lens.Perspectives on Psychological Science, 5, 265-278.
Explains apparently paradoxical effects, e.g., relaxation, aggression.
Explains apparently paradoxical effects, e.g., relaxation, aggression.
Alcohol Myopia
• Focus on salient cues– Threat fear
• Flight or fight– Insult/Injury anger
• Alcohol makes violence more likely– Reduces self-awareness– Reduces other awareness– Reduces access to non-violent strategies– Increases access to well-established violent responses
Reduce frequency and level of intoxication;
Increase self- and other-awareness
Reduce frequency and level of intoxication;
Increase self- and other-awareness
Impairs Problem Solving
• In threatening situations, alcohol impairs access to complex problem-solving strategies
• Intoxicated people are– Unable to cope with the number of response
options– Fail to access socially appropriate responses, and – Make default aggressive responses when provoked
Hoaken, P.N.S., Shaughnessy, V.K., & Pihl, R.O. (2003). Executive cognitive function and aggression: Is it an issue of impulsivity?Aggressive Behavior, 29, 15-30.
Improve problem solving skills
Improve problem solving skills
Expectancy Effects
• Outcome expectancies are – Cognitive representation of past learning
• Instruction• Observation• Experience
• ‘If …. then’ relationship• Predict future behaviour
Expectancy Effects
• Alcohol-aggression outcome expectancy• “If I drink, then I become aggressive”• Predicts aggression • Potency has been called into question• Effect disappears when control for dispositional
aggressiveness
Giancola, P.R. (2006). Influence of subjective intoxication, breath alcohol concentration, and expectancies on the alcohol-aggression relationship. Alcoholism: Clinical and Experimental Research, 30, 844-850.
Expectancy Effects
• More relevant appears to be drinking to give social confidence
• “If I drink, I will be more confident socially”• May be a risk if lots of over-confident lads are in
the same place• May be a particular problem for anxious
offenders – vigilance for threat exacerbated by alcohol myopia
McMurran, M. (2007). The relationships between alcohol-aggression proneness, general alcohol expectancies, drinking, and alcohol-related violence in adult male prisoners. Psychology, Crime and Law, 13, 275-284.
Improve social confidence
Improve social confidence
What Works?
• Very little evidence of what works for alcohol and violence
• Treatments for ‘substance misuse’– May or may not include people with alcohol problems
• Treatments for violence– May or may not address drinking
• Argument that there should be alcohol-related violence treatments rather than only alcohol and/or only violence
Systematic Review of Alcohol-Related Violence Treatments
• 4 studies of 2 treatments– SafERteens– COVAID
• One other alcohol-related violence programme not yet been evaluated – the ‘Alcohol Free Good Lives’ programme
McMurran, M. (2012). Individual-level interventions for alcohol-related violence: A Rapid Evidence Assessment (REA). Criminal Behaviour and Mental Health, 22, 14-28.
SafERteens
• Adolescents admitted to ER for violence related to alcohol (n=726)
• Experiment – Therapist intervention - goal setting and personal
feedback for alcohol use and violence, normative resetting, decision balance for staying away from drinking and fighting, and role plays for alcohol refusal, anger management and conflict resolution
– Computer delivery of above– Brochure listing community services
SafERteens
• Follow-up at 3 months by self-report• Therapist vs Brochure
– Peer aggression • RR = 0.74, 95%CI 0.61 to 0.90
– Peer violence• RR = 0.70, 95%CI 0.52 to 0.95
– Adverse consequences of violence• RR = 0.76, 95%CI 0.64 to 0.90
SafERteens
• Follow-up at 6 months by self-report• Therapist vs Brochure
– Adverse consequences of violence• RR = 0.56, 95%CI 0.34 to 0.91
• Computer vs Brochure – Adverse consequences of violence
• RR = 0.57, 95%CI 0.34 to 0.95
No differences on any alcohol consumption
variables
No differences on any alcohol consumption
variables
Walton, M.A. et al. (2010) Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: A randomized controlled trial. Journal of the American Medical Association, 304, 527–535.
What Works?
• COVAID is designed according to findings from meta-analyses of the characteristics of interventions that reduce offending:– Theory-based– Structured– Cognitive-behavioural– Target criminogenic need– Designed to suit offenders abilities and learning
styles
COVAID
• A 10 x 2 hour structured cognitive-behavioural treatment programme
• Selection criteria ~ – aggressive or violent after drinking (2-3 incidents in
past 2 years)
• Group community and secure setting versions• CSAP accredited
Intervention Components
• Integrated into a coherent whole ~– Based around Novaco’s system of angry aggression,
with – Attention to how alcohol use exacerbates angry
aggression
Angry Aggression System
Trigger-provocation, insult, frustration,injustice
Thoughts-hostile, inflammatory
Feelings- arousal, anger
Behaviour- aggression, violence
Exacerbated by Drink
Trigger Thoughts
FeelingsBehaviour
Provocative placesProvocative people
Salience of threat
Anger/fearReduced anxiety
Use overlearned behavioursAlternative strategies notaccessible
Modify All Parts of the System
Trigger Thoughts
FeelingsBehaviour
Change drinking venues and buddies
Non-hostile interpretations
Anger managementStress management
Problem solvingConflict management
Moderation/abstinence
Alternative activities
COVAID SessionsPre-COVAID– 1. Introduction and assessment– 2. Explaining drunken aggression– 3. Harm reduction– 4. Managing stress and tension– 5. Altering triggers– 6. Weakening beliefs about the effects of alcohol– 7. High risk situations– 8. Problem solving– 9. Problem solving 2– 10. Synthesis and evaluationBooster session
My Methods of Self-Control
• Identify methods that they already use successfully– Highlight self-efficacy
• Add new methods throughout COVAID
Randomised Controlled Trial
• Feasibility study for a randomised controlled trial- NOMS Cymru- HMP Parc & HMP Cardiff
• Nic Bowes • Recruitment
– COVAID = 56– Treatment as usual = 59
Measures• Alcohol-Related Aggression Questionnaire
(ARAQ)• McMurran et al. (2006). The alcohol-related aggression questionnaire. Addiction Research
and Theory, 14, 323-343.
• Controlled Drinking Self-Efficacy Scale (CDSES)• Sitharthan et al. (2003). Development of a controlled drinking self-efficacy scale and
appraising its relation to alcohol dependence. Journal of Clinical Psychology, 59, 351-362.
• Official reconvictions (PNC)
Interim OutcomesCOVAID TAU F P eta2
Mean (SD)Time 1
Mean (SD) Time 2
Mean (SD)Time 1
Mean (SD)Time 2
ARAQ (AA)
N=41 31.98 (9.77)
27.93 (10.64)
N=48 30.01 (11.97)
29.88 (13.71)
4.73 <.05 0.05
CDSES N=40 295.75 (111.21)
415.96 (119.47)
N=48 353.29 (113.96)
373.90 (133.72)
13.53 <.001 0.14
Bowes, N., et al. (2012). Treating alcohol-related violence: Intermediate outcomes in a feasibility study for a randomised controlled trial in prisons. Criminal Justice and Behavior, 39, 333-344. DOI:10.1177/0093854811433759
eta2 = effect size; .01 is small, .06 is medium, .14 is large
Recidivism Outcomesat 6 months
Bowes, N., et al. (2013). Treating alcohol-related violence: A feasibility study of a randomized controlled trial in prisons. Under review.
Violence – RR=1.00; 95% CI=0.88, 1.13, z=0.06, P=0.95
Any - RR=0.99; 95% CI=0.81, 1.21, z=0.10, P=0.92
No differenceNo difference
Recidivism Outcomesat mean 17 months
Bowes, N., et al. (2014). Treating alcohol-related violence: A feasibility study of a randomized controlled trial in prisons. Journal of Forensic Psychiatry and Psychology, 25, 152-163.
Violence – RR=1.23; 95% CI=0.93, 1.63, z=1.44, P=0.15
Any - RR=1.71; 95% CI=1.04, 2.83, z=2.10, P=0.04
13.26% fewer
13.26% fewer
20.01% fewer
20.01% fewer
13% fewer crimes over 17 months = £150K savings for
every 100 offenders treated
13% fewer crimes over 17 months = £150K savings for
every 100 offenders treated
Cost of a violent crime est. £11,617 in
2007/8
Cost of a violent crime est. £11,617 in
2007/8
Conclusion
• Recognition that alcohol-related violence is an important problem
• Most emphasis on public health approached (rightly so)
• Neglect of individual interventions