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Vol. 28
Ottawa, Canada, November 1983
Family Violence -
Myths, Measures and Mandates*
iolence runs like a bright and discordant thread
through the fabric of society. In history, mythology
and religion, politics, media, sports and entertainment, it
is simultaneously condemned and condoned, deplored
and defended. It is a recurrent and fascinating theme in
both public and professional concerns.
While theories regarding violence abound, clear supporting evidence is strikingly inadequate. Like many
things in psychiatry and the social sciences the contributing factors derive from biology, psychology, sociology
and human organization.
Psychiatry has become involved in the diagnosis,
assessment, and prediction of violence and may have
alloweditself to be saddled with the responsibility for its
treatment. Like many of the seductive invitations that
come to psychiatry, it is important that we neither diminish what we can legitimately contribute nor arrogate to
ourselves the assumption of answers to issues outside our
competence and field of knowledge. The one option not
open to us is to stand aside, disclaiming any responsibility
to contribute to better understanding, better control and
the general mitigation of one of the most objectionable
features of human behavior.
Psychiatric expertise consists of teasing out individual,
family and group factors which may contribute to violent
behavior. Therefore, the invitation to move glibly to
explanatory social or political concepts must be declined.
Psychiatry plays a role as the moderator of macro-social
manipulation and can try to steer a middle course
between attributing violence solely to individual or family factors on the one hand and flaws in the general
organization of society on the other. This is not the most
popular course, as the answers that command most
respect are those which are clear, dogmatic and unfortunately most frequently wrong.
While ethological research has revealed that violence
occurs towards other members of the same species in
both human and animal societies, humans are unique in
Dr. Quentin Rae-Grant
President CPA, 1982-83
their development of organizations for the purpose of
violent behavior and intentional killing of others.
Humans live in an environment endowed with constructed and symbolic meaning, the patterns of which will
be more predictive of proclivity towards aggression or
peacefulness than any genetic features (1). When investigating violence then, one must recall that it is manifested
within a social context which will determine how it is
For example, while violence is generally condemned,
violence in war towards the enemy is sanctioned,
rewarded and medalled. Violence has been justified, and
still is, on the basis of defense, personal or political, in the
protection of oneself or intimates, as a means of control
for the public good and in the name of discipline or
training. The exciting car chase is celebrated on television
and replicated almost daily in high speed pursuits. Stolen
cars driven desperately by frightened adolescents are
pursued vigorously by dedicated police. The sum total
results in the wreck of the stolen car, several others in the
*Presented at the 33rd annual meeting of the Canadian Psychiatric
Association, Ottawa, Ontario, September 1983.
I Professor and Vice Chairman, Department of Psychiatry, Chairman,
Division of Child Psychiatry, University of Toronto and Psychiatristin-Chief, The Hospital for Sick Children, Toronto, Ontario.
Address reprint requests to: Dr. Quentin Rae-Grant, Psychiatrist-inChief, Hospital for Sick Children, 555 University Avenue, Toronto,
Ontario M5G IX8
Can. J. Psychiatry Vol. 28, November 1983
path of the vehicle, danger to bystanders and frequently
the demolishing of the instrument of social control, the
police cruiser. Society says that this violence is both
necessary and justified. Homicide, clearly an act of violence, is differentially evaluated according to context.
The state execution of the criminal is considered legal.
Killing in self defense is excused. Each community then is
continually engaged in drawing boundaries between legitimate and illegitimate violence. For such boundaries to
be socially and legally enforced requires a modicum of
agreement among the community members. When such
agreement is weakened, new lines of demarcation may
Theories of the origin of violence are many. Instinct
theory derived from ethology research sees aggression as
an innate drive adaptive in survival, and controlled
through the development of ritual (2). Socialpsychological approaches include the FrustrationAggression Hypothesis wherein aggression is the product
of an aversive stimulus. This argument, of course, can be
circular as anything that precedes violence can, then retrospectively be regarded as aversive or frustrating. Social
learning theory modifies this to suggest that a given stimulus may facilitate a variety oflearned responses, one of
which will be selected based on its perceived effectiveness.
Aggression, it is argued, is a learned response likely to be
reproduced if reinforced (3). The psychiatric approach to
violence has concentrated on characteristics within the
violent individual and the victim, and has looked for
mental disturbance, substance abuse, previous life experience and fixed personality traits as explanatory factors
in aggressive behavior. At the other end ofthe scale, the
sociocultural approach emphasizes the cultural learning
of aggression, and the role of social structures in inhibiting or condoning and perpetuating violence.
From these and other theories one may select an
explanation, but explanations are easy and cheap and
have no value in our understanding unless they have
considered and excluded all other possible alternative
Violence like many other behaviors is probably multidetermined and only a broad approach is likely to do
justice to the complexity of the many factors involved.
Our knowledge base is bedevilled by the problem of
divergent definitions and changing social attitudes which
affect assessment of the frequency of violence. Studies of
perpetrators and victims have recently thrown the spotlight on areas such as child abuse, sexual abuse and
spousal abuse. As professional interest has increased,
numbers of reported cases have escalated exponentially.
Clearly the new statistics reflect increased concern rather
than, as some would have it, rising frequency of violence
in society.
An overall principle that psychiatry can enunciate is
that while feelings, either innate or evoked, are under
only limited control, actions stemming from them are
selected by the individual from a number of options. The
individual can, and must be, held responsible for any
Vol. 28, No.7
violent acts and their consequences.
What I would like to discuss in this presentation are
various manifestations of violence, particularly within
the family. Such an approach has been chosen because of
the relatively recent awareness of the phenomenon and its
implications for today's children who will be tomorrow's
Domestic Violence: Introduction
This area has come to attention and recognition only
recently in history and provides interesting examples of
how "social problems" evolve. For example, the Society
for the Prevention of Cruelty to Animals was created
several years before the Society for the Prevention of
Cruelty to Children was established in 1875. The latter's
creation was in response to the Mary Ellen case in which
an abused child had been forced to claim the status of an
animal in order to receive protection (4). This differentiation in the hierarchy of importance seems remarkable
today yet echoes of it prevail in 1983. For instance, there
is little outcry about the injuries in our gladiatorial
sports. Men are beaten unconscious, suffer permanent
paralysis or are hit by the baseball. This is not news nor
does it lead to any actions but woe betide the baseball
player who beans and kills a seagull. The "baseball"
diamond may not be the gull's best friend.
The identification of spousal abuse as a social problem
came about as recently as 1971 (5) and another issue,
abuse of the elderly parent, is only now beginning to
emerge (6,7).
The myth of the home as a safe place has been shattered
with the first attempts to collect statistics. In 1977, 31.5
per cent of homicides in Canada were classified as domestic. Of the homicides involving children under the age of
11, a full 79 per cent were domestic (8). Figures from 1980
show that the location of 40 per cent of homicides was the
victim's home and 17 per cent of the perpetrators were
immediate family members (9).
Homicides rarely go unreported. Lesser forms of
domestic violence however have been hidden crimes.
Recent attempts to identify family abuse, bolstered by
strong political and legal support, has created the
impression of vast increases in numbers yet these may
simply reflect the reporting of what has always occurred
and perhaps more frequently in the past than today.
Child Abuse
This was identified by Kempe, et al in 1962(10). Their
paper was primarily concerned with physical damage to
the child and directed the medical profession's attention
to detect and identify this. It is a tribute to society's
response that within five years all States within North
America and most provinces in Canada had passed mandatory laws for the reporting of abuse cases. Despite the
legal action, however, incidence figures have continued
to be misleading. The U.S. National Centre on Child
Abuse and Neglect reported in 1976 that 72 per cent of
November, 1983
physically abused children require no medical treatment
(4). They have no visible evidence of maltreatment and,
therefore, non-family members may remain unaware of
the abuse. While it is clear that child abuse occurs in all
segments of society, reported cases are skewed towards
those with lower incomes. Such families may be subject
to greater scrutiny by professionals or it may be that the
identifiers are less willing to give the abusing label to a
family more like themselves and prefer to diagnose "accidents" (11). Such differences, however, may be an accurate finding which suggests a correlation between abuse
and the stresses (physical, housing, social and economic)
under which low income families live, their relative isolation and their difficulty or fear of using a supportive
network before the.circumstance reaches the flash point
Studies of child abuse have concentrated on characteristics of abusers, the abused and abusing family. Abusers
are seen as isolated individuals with low self-esteem (13),
but with high expectations of perfection from other
human beings (14).
"If ever the children fail to meet their excessive
demands, or behave in a way that is annoying or
frustrating, the parents' past feelings of inadequacy,
worthlessness, and frustration are stirred up and may
result in violent outbursts of uncontrolled rage" (15).
Others have extended this concept to emphasize the
importance of the circumstances of family life, particularly the experience of rejection during childhood, as a
precursor of abusive behavior as a parent. There seems to
be suggestive evidence of inter-generational transmission
of abuse, perhaps resulting from the modelling of physical aggression and violence as a way to resolve uncomfortable situations (16,17). Kinard (18) has noted some
correlation between having a depressed mother and being
an abusive parent.
Finally, from the adult point of view aggression
towards children frequently occurs in the context of
aggression towards the spouse and self-destructive
behavior (19). Yet the assumption that higher rates of
clear psychiatric disturbance would be found among
adult abusers has been challenged by recent work which
suggests no such correlation in these cases (20).
Looking at the child's role, there have been several
postulations. The fact that in a number of studies a high
percentage of abused children were found to be premature led to investigations as to whether disruption of early
bonding or aversive characteristics of the premature baby
played a factor. The work of Minde (21), however, concluded that the interval between birth and initial contact
of mother and premature infant is not related to later care
taking and child development. Prematurity may in fact
result in compensatory care and greater parental
The work of Stella Chess and Thomas (22) on temperamental factors emphasizes the importance of the "goodness of fit" between child and parent and that the child's
temperament is in early evidence and in some broad ways
remarkably stable. Olweus (23) has also noted the stability of the "bully" personality in Swedish classrooms. The
concept of temperament is an important one in the
explanation of differential treatment of children by their
parents. Abusive mothers have suggested that their
abused children are more difficult to care for than their
siblings (4). A substantial proportion of child abuse
occurs in the name of discipline and confrontations in
which the child is forced to do something he does not
want to do or may be unable to perform (24). Indeed,
certain actions or behavior of children may evoke disproportionate and very primitive violence and angry
"Encopresis often produces disproportionate disgust
in parents. While normally parents react less intensely
to their own child's feces, the mothers of many encopretics experience such anger and depression that they
may reject or punish to the point of abuse, particularly
in response to what they see as deliberate, hostile,
aggressive soiling" (25).
Mothers more frequently abuse children; however,
they are also more exposed to their children. If time spent
with children is controlled for, fathers are in fact found to
be more abusive (26). Both parents or partners are usually involved either in promoting, sanctioning or permitting the abuse which occurs.
Children are themselves among the most violent
members of the household and this violence is very much
related to what they receive from their parents. Children
physically punished are three times as likely to assault
their siblings as children alternatively disciplined (27).
Violent interactions with siblings are very influential in
terms of later behavior and the particular role experienced, that is observer, perpetrator or victim, may be
more significant in the long run than the overall level of
violence in the family (28).
Two major research questions lie in this area. Aggressive adults have a history of aggression in childhood but
there are many more aggressive children than aggressive
adults. What are the factors that mitigate those who find
alternative constructive emphasis and what perpetuates
this continuing pattern?
The second question is around sibling violence. There
are few studies of this, particularly because it is accepted
as normal. Yet a U.S. national sample of 733 families
found that 53 out of each 100 children had attacked a
sibling so severely that had it been a non-family member
it would have clearly been labelled as actionable assault
(29). Steinmetz (30) found that in 57 randomly selected
families, 70 per cent of children under 8 engaged in intersibling violence. From 9-13, 68 per cent still used it as did
63 per cent ofthose 14or older. Astonishing was a sample
of college students who had used violence on siblings in
the past year in 62 per cent of cases (31). Sibling violence
is more frequent than parent-child or husband-wife violence. Boys in every age group are more violent than girls.
Finally, in the child abuse area one has to remember
the different power roles within the family and the fact
that power may not always be used with malevolent
intent. For example, the adolescent severely beaten for
adopting the mores of the North American adolescent
may have incurred this by contravening an immigrant
family's different cultural values and engendering
extreme concern about the consequences for the future.
The parental right to physically discipline the child is
seemingly both upheld and denied in our society. In
particularly stressed families the "right" to utilize physical discipline may take on added importance:
"N ot having control over much of their lives, expecting to have control over the limited but significant
segment of their lives concerned with parent-child
relationships, they feel more than ordinarily frustrated
when they sense a loss of control even here" (4).
Finally one has to recognize that there exists still in the
Criminal Code of Canada Section 43 the following passage: "Every school teacher, parent or person standing in
the place of a parent is justified in using force by way of
correction towards a pupil or a child as the case may be,
who is under his care, if the force does not exceed what is
reasonable under the circumstances." Society, outraged
by child abuse, condemns the parents, crucifies the agencies responsible, but still in its formal code of behavior
retains a clause which can be used to continue practices
now forbidden to parents or immediate family. This is in
contrast to Sweden which has had the honesty to take the
step of prohibiting any physical assault on a child by any
individual whatsoever.
Sexual Abuse of Children
This has become a focus of concern even more recently
than physical child abuse itself. Despite very careful and
pioneering work such as that of Cormier et al. (32),
Cooper and Cormier (33) and what this suggests for
intervention, the area has flourished with theories of
causation and even more remarkably, has blossomed
with various types of answers. There are several treatment packages involving various combinations of legal,
personal and family interaction that have become highly
popular and propagandized. Although it is difficult, if
not impossible, to evaluate the differential effectiveness
of any of these, nevertheless they are being well and truly
The myths are many and the facts are few. A federal
commission including physicians, social workers, lawyers and judges has been appointed by the Department of
Health and Welfare and the Department of Justice to
review this whole area from a legal, medical and social
point of view. The Commission, headed by Dr. Robin
Badgley, is presently in the final stages of completing the
report, tapping into multiple sources of data. These
include a national population survey of2,300 Canadians,
information from police forces across Canada on 6,200
cases of known incidents of sexual abuse; a national
hospital survey using data from 12 major tertiary hospi-
Vol. 28, No.7
tals and a review of 1,438 sexual abuse cases obtained
from the child protection agencies in all the provinces and
the Yukon. In each situation, where possible, extensive
data on the nature of the sexual assault has been
requested and both victim's and professional's views as to
later physical and emotional harms sought. What this
report will contain is the best collection of presently
available information for Canada which has up to now
not been obtainable in a detailed fashion, or from such
multiple sources. Until the Commission report appears,
no reference can be made to its findings but one can
reasonably expect that it will provide a picture of the
occurrences, nature and consequences of these incidents
in a way that will make a major contribution to our
knowledge base and to the formulation of legitimate
conclusions and recommendations for change.
Among the myths that prevail in this area is that incest
is infrequent, sub-cultural and occurs in isolated areas.
The facts are that sexual abuse of various forms is much
more frequently a part of children's experience than one
has up to now been led to believe. Finklehor (34), using a
non-clinical and retrospective approach with New England college students, found that 19.2 per cent of the
women and 8.6 per cent ofthe men reported some instances of childhood sexual victimization. The perpetrators
were overwhelmingly male and 94 per cent of the
women's experiences were heterosexual and 84 per cent
of the men's homosexual. The most frequent type of
abuse was genital fondling of either child or the adult.
For half the women and 17 per cent of the men their
partners were immediate family members. Finklehor
found that pre-adolescence was a period of greater abuse
than adolescence despite physiological immaturity:
"... vulnerability to sexual abuse is more related to
(the child's) vocabulary of sexual knowledge and skills
than to physiological factors such as breast
Finklehor found that sexual abuse and violence were
clearly linked. One of the most disturbing findings was
that half of the students who had experienced abuse felt
that they had been victims of coercion.
"The primary recollection of the child is of the coercion. That there was sex involved is perhaps less
important than the fact that there was aggression"
Equally clear is that many children subjected to this
were aware of a secretiveness, sense of shame and sense of
doing wrong, long before they were able to enunciate the
particular concepts attached to this. Unfortunately, as
some victims report, when they tried to tell their story to
people in authority they often were not believed.
With these population figures and they are probably an
underestimate, theories of the "typical" incestuous father
or family must be looked on with scepticism.
Having investigated 58 cases of incest encountered in
the clinical setting, Meiselman (35) concludes:
"The typical incestuous father is not mentally
retarded, psychotic or pedophilic, but is characterized
November, 1983
by some sort of personal disturbance that interferes
with his ability to control his impulses in a situation
where the temptation to commit incest exists."
However, in other clinical reports correlations between
certain parental characteristics and sexual abuse are
often defined:
"... psychopathy, alcoholism, drug abuse in parents,
divesting of maternal responsibility onto the child,
-extreme closeness, overprotection and indulgence of
child by the father, jealousy and cutting-off of peer
contacts and dating by father, serious disorganizing
mental illness in mother" (IS).
Browning and Boatman (36) have found that depression is frequent in the wives of incestuous men and conclude that this may explain the characteristics which have
been interpreted as collusive, including sexual withdrawal from the husband, passivity and emotional distance
from the children and knowledge of, but unwillingness to
interfere with, the "secret" family activities. The role of
the mother has also been investigated in studies claiming
that role reversal is frequent in incestuous families resulting from the fact that the mother is absent or incapacitated and the daughter has taken on several aspects of the
maternal role, including sexual activity with father. The
child has also been implicated in sexual abuse. While
Meiselman (35) has rejected the notion of daughter
seductiveness, this concept is still perpetuated by some
clinicians. Meiselman suggests that the term implies both
willful behaviour and awareness of the consequences of
such behavior on the part of the child -neither of which
exist. Nonetheless, the role of the child continues to be
emphasized. Brant and Tisza (37) argue that one must
look beyond the characteristics of the perpetrator.
"... children are not always the passive victims of
adults. Rather sexual abuse is usually a manifestation
of family pathology, and several family members as
well as the child are usually active in perpetuating the
While most condemn sexual abuse, some extremists
have suggested that sexual activity between adults and
minors is part of the changing ethos of greater freedom,
intensifying attachment and security in an increasingly
alienated world. Organizations have been formed to
promote this particular philosophy, such as the Guyon
society in the U.S.
One common form of incest or sexual abuse is between
siblings (34) but is this to be defined as violent abuse?
What is normal and healthy exploration and discovery?
What is coercive and exploitative? The law in Canada
presently defines a three year age difference as falling
within this non-noxious boundary.
There are many claims for long term adverse effects of
sexual abuse, including suppression of sexual desire, (38)
predisposition to psychological disturbance (18) and a
tendency as an adult to repeat the behaviour (39) but the
picture is sufficiently complicated to leave such dogmatic
assertions in real question. How often can these consequences be assigned to the other events in the child's life,
for example, growing up in a dysfunctional family or to
the effects of ill-judged intervention (40,41). The paradigm of intervention as frequent as it was unfortunate,
was that the child, on reporting incest and being believed,
was removed to a foster home, feeling shamed, guilty,
extruded and totally unable to explain or answer why she
was being punished. Father, the bread winner, was sometimes injail and the family on welfare, a rather inglorious
result of the expression of genuine concern. Today's
approaches that emphasize removing the offender and
working with the family towards the restoration of more
usual functions, particularly between the adult partners,
promise at least more humane responses to these situations of legitimate therapeutic and societal concern.
Spousal Abuse
Of recent and very legitimate concern is inter-spousal
violence which may exist alongside child abuse, yet is
treated as a separate phenomenon in the literature. In the
majority of cases this means abuse of the woman or wife.
While, statistically, women are as likely to kill their
spouse as men, wives kill seven times more frequently in
self-defense (42). The outcome of any violent episode is
markedly more detrimental to women. Berk, et al. (43)
have challenged both the notions of mutual combat and
battered husbands by noting that in abusive incidents
spouses exchange injuries only 4 per cent of the time; men
only are injured 3 per cent of the time while women have
injuries on almost 40 per cent of these occasions. From
the physical point of view at least the direction is clear.
What is less clear is whether there exists a different
mechanism by which women abuse their men folk,
through a constant verbal degrading, belittling, comparison and general character annihilation that may be less
physically destructive but is no less violent. As with child
abuse or sexual abuse, it is difficult to obtain incidence
figures for abuse to spouses. Most police will not lay
charges unless there is a complainant. Where they are
willing to act without this, as recently in Winnipeg, there
has been a 1000 per cent increase in charges in the first
five months of this policy (44).
Unlike the area of child abuse, the impetus to improve
the situation has been almost entirely the result of political awareness and activism on the part of the women's
movement rather than third party advocates. The literature is more characterized by sociocultural frameworks.
Some such as Dobash and Dobash (45) have argued:
"We do not seek the explanations offamily violence in
deviant or pathological individuals or family structures. Seeking the causes and sources of violence and
crime through an emphasis on pathological individuals or deviant relationships has been an important
activity of those who would ignore the simple fact that
violence is endemic to modern Western societies."
Similar criticism of professionals is made by Borkowski, Murch and Walker (46):
"There is a sense in which practitioners who believe
that marital violence deviates from the imagined
norm of happy marriage may be seen as perpetuating an ideology or social myth that serves to buttress faith in the institutions of marriage and the
Nevertheless, one has to consider the fact that some
women marry or live with men who abused them before
they entered into the relationship, frequently return after
being severely abused and are reluctant or refuse to lay
charges. The failure to leave such a relationship however
cannot be glibly interpreted as either the acceptance of
violence as legitimate or evidence for theories of sadomasochism on the part of the women. For many women
the option of moving out of the home, particularly if
there are children involved, is a tenuous, unattractive and
more theoretical than practical solution. To add to that,
simply leaving the situation does not guarantee a termination of the violence. It is suggested that abused wives
are characterized by passivity, internalization of blame,
social isolation, compliance and loyalty (47). However
whether such personality traits lead to a greater vulnerability to abuse or are the manifestations of a "battered
woman's syndrome" resulting from the abuse is not clear
Hofeller (49) has indicated certain unique aspects of
aggression within the spousal relationship.
1. The victim is involved in an ongoing relationship
with the assailant.
2. The action of leaving to avoid the abuse is often
accompanied by increased violence, as well as other
negative consequences, financial and social.
3. The victim receives intermittent positive reinforcement for staying through the loving and contrite
behavior of the assailant between violent episodes ..
Hofeller (49) and Walker (48) both suggest that
"learned helplessness" on the part of the wife results from
the realization that she is unable to control her partner's
behavior and that this leads to a feeling of lost control
over all aspects of her life.
Separation and Divorce
Still within the family one has to look at the consequences of violence in the separation and divorce situation. The incidence of divorce is increasing rapidly from 1
in 100 in 1921 to 5 in 100 in 1951, one in four in 1971 and
presently reaching 40 per cent of marriages. While these
figures have been interpreted as a rejection of the institution of marriage, more reasonably it seems they reflect a
rejection of the life time commitment to a single spouse.
This interpretation is supported by high remarriage rates.
Most divorces in Canada are legally "conflict free."
Only 5 per cent are legally contested. Nevertheless, these
5 per cent represent only a proportion of bitter fights
conducted between the divorcing adults with child custody being a dominant issue. The disputes which require
court intervention in order to reach any resolutions seem
to arise out of the frustration of a sense of entitlement;
entitlement to property, finances, right to parent, right to
Vol. 28, No.7
access, right to direct. The child may be the pawn in the
parental conflict. Unfortunately feelings of frustration
may be escalated by the legal "battle" the outcome of
which is frequently injurious to all sides. While the children are better off with a single parent than in a conflictridden "complete" family the experience of divorce usually entails short term penalties, the manifestations of
which will vary with the ages of the children involved. For
all ages however the constant feature is an increase in
aggressivity for males and females and the increase likelihood that their own marriages may have a similar end
(50). The parent and child may gang up against the
remaining parent, or both the custodial and the visiting
parent may feel they have outstanding legitimate grievances (51). The extent of the child's trauma will depend
on the effectiveness of the divorce in reducing stress and
conflict between the parents and the nature of the continuing relationship between the child and each parent. It
remains a legal fiction that divorce signals the end of the
relationship between the spouses or the satisfactory resolution of all issues under dispute. The child's sense of
turbulence may be kept inflamed by continued parental
conflict. A violent, if still infrequent corollary, is the
kidnapping of the children by one parent and removal to
a distant area and jurisdiction.
The solution of joint custody, a Californian invention,
now mandatory in that State unless argued otherwise,
requires such a degree of co-operation, ability to resolve
disputes, and mutual respect between the ex-spouses,
that the outsider is left with the question as to why the
divorce is occurring at all.
From this presentation I would like to underline certain principles for research and investigation leading to
intervention in these rather broad social fields and with
regard to the involvement of psychiatry and the social
1. An important question is that of definition. It must
be recognized that what is considered violence may
vary considerably. The researcher must clearly state
the criteria used for inclusion and exclusion if there
is to be meaningful comparison of different studies.
2. Once a definition is agreed to, the next step is to
delineate the extent of the problem. To do this
accurately one requires information from multiple
sources, agencies and groups, clinics, social services, police and welfare agencies. Epidemiology
should precede etiology.
3. It must be kept in mind that clinical populations
invariably skew the findings and therefore, conclusions from clinical studies cannot be readily generalized to include the broader groups included in the
4. Nevertheless, extensive and intensive studies of a
small number of cases can still provide most valuable information on which to predicate research
directions and their applicability to the population
under review.
5. Data, therefore, should be collected on a routine
November, 1983
basis rather than to confirm or to fit into any of the
existing explanations or theories. The atypical case
is more useful for extending knowledge than the
prototypic clinical history. Particularly in looking
at the influence of past events, it may be wise to heed
the warning of Yarrow et al (52) that "methodological interpretations may be more tenable than theoretical ones."
6. Economics and economic factors are frequently
more powerful explainers of differences and too
often have been ignored.
7. The law rarely changes behavior but the law and its
application do change the statistics and do influence
public concern.
8. Violence can be attributed to the abuse of power or
its opposite, a sense of powerlessness, to a frustration of basic human needs and often a sense of
frustrated entitlement.
For issues that I have discussed I have tried to make
clear that no one approach or discipline contains all the
answers or the expertise to provide solutions or the ability to make changes unilaterally. Each has a significant
contribution. Each contribution is complementary. Each
must respect the contributions of others and each must
know its own limits.
Let me leave you with just one message. What I have
described is the application of the methods of clinical
research to areas of human suffering with which we are
concerned and to whose alleviation we can contribute. It
complements the remarkable advances in the hard
science psychiatric research of the fourth psychiatric
revolution, but it is no less vital or worthwhile. We cannot induce all residents to do basic research nor should
we. But we can, and in training programmes must, induce
the spirit of inquiry, curiosity, questioning, discontent
with our present knowledge, methods and theories. To
stay complacent with these would only play into the
hands of those who would be rid of all of us and that for
which we stand.
Beleaguered at the moment, we watch in dismay as
arms expenditures escalate and welfare programmes disappear; as we are on the verge of creating a new Vietnam
in El Salvador; as areas of human concern, protection,
help and support are callously destined for cuts. Those of
us who were involved more with heart than with head in
attempts to even out disparities in living, equalize rights,
reduce the grind of poverty, have grown grey and thin on
the top and may be tired as we watch the small gains that
were made, callously eroded. In the 60's we marched to
the banner of hope and perfectability but we were poorly
equipped by knowledge and method to make these
changes. We lost our opportunity then, because we had
not defined and refined what we could do rather than
what we wanted and dreamed of doing.
As we hunker down in the trenches in this conservative,
human service-slashing era, let us at least better train
those coming into the leadership than we ourselves were
trained, to be effective in the politics of psychiatry, men-
tal health, resource deployment and constructive use,
relying in their pleadings on facts rather than faith.
We may have to wait but the time again will come for
concern, compassion and caring. Our task and challenge
is to see that we and our younger colleagues are equipped
and trained to take this opportunity and run with it to
more effective and enduring ends.
The invaluable help of Jane Helleiner in the research and
preparation for this paper is gratefully acknowledged.
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