Violence (homicides and suicides, assaults and parasuicide) poses a significant public health problem in the United States. Other sections and chapters of this book describe more thoroughly the complex challenge of violence and the clinical role that emergency psychiatrists have in working with people who are at risk for becoming violent either toward themselves or others. This chapter provides an overview of the unique role that emergency psychiatrists, as members of the health care community, have in preventing and controlling violence both at an individual and population level.

The World Report on Violence and Health, published by the World Health Organization (WHO), describes violence as a complex problem with multiple factors that influence whether an individual is prone to act in a violent manner (1). These factors can be biologic, social, cultural, economic, and political. This understanding of violence is similar to the biopsychosocial model put forward by Engel to describe the role of biologic, psychological, and social factors and their influence on human behavior and disease (2). With regard to violence, WHO uses an ecologic model for understanding these factors and how they overlap to influence an individual’s behavior (Fig. 40.1). At one level, the model describes how biology and personal history influence individual behavior, including demographics, impulsivity, educational attainment, and substance abuse, as well as prior history of aggression and abuse. On another level, the ecologic model describes how close relationships with family, friends, intimate partners, and peers might increase or decrease the risk of being a victim or perpetrator of violence. This risk depends on one’s exposure to violence, especially in the case of partner violence and child maltreatment, and for young people the acceptance or approval of violence by friends. A third level is the community where those relationships occur. Potential risk factors at the community level include high incidence of unemployment, transient neighborhoods, and population density, to name a few. The fourth level of this model describes the broad societal factors whereby violence is either encouraged or inhibited. Examples of the risk factors at a societal level include the availability of weapons and the social norms surrounding their use. Other social factors include the social and economic policies that result in inequities between different population groups (1).

Traditionally, the responsibility for preventing and controlling violence has fallen on the judicial, law enforcement, and correctional systems. The health care field has been largely responsible for the medical and mental health treatment and care of individuals after an event or, ideally, the mental health treatment of individuals at risk of violence prior to an event. With expanding knowledge regarding the multifaceted risk factors and prevention strategies for violence, the World Health Organization states that those in the health care community have a special role in preventing and controlling violence, and that this role would ideally be in collaboration with public health practitioners, researchers, law enforcement, those involved in the judicial system, and others. Those in the health care field have a unique perspective regarding violence because of their close proximity to the treatment and care of those who are potential and actual perpetrators and victims of violence. Health care personnel have access to data and information to assist with research and prevention strategies, as well as communicating to other stakeholders and policy makers
about the burden of violence. Additionally, health care personnel have access to personal stories from their patients to accompany statistics and data, which can be a powerful advocacy tool for resources, laws and regulations, and broader social and community change (1).

The purpose of this chapter is to describe more thoroughly the public health approach to reducing violence and the opportunities that emergency psychiatrists have in using its tools to prevent and control violence for both individuals and populations.