CANADIAN JOURNAL OF PSYCHIATRY Vol. 28 Ottawa, Canada, November 1983 No.7 PRESIDENTIAL ADDRESS Family Violence - Myths, Measures and Mandates* QUENTIN RAE-GRANT, M.B., Ch.BI V 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 perceived. 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 505 506 CANADIAN JOURNAL OF PSYCHIATRY 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 emerge. 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 "reasons." 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 adults. 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 FAMILY VIOLENCE 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 (12). 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 involvement. 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 507 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 reactions. "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 508 CANADIAN JOURNAL OF PSYCHIATRY 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 marketed. 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 development." 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" (34). 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 FAMILY VIOLENCE 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 'abuse'." 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, 509 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 510 CANADIAN JOURNAL OF PSYCHIATRY 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 family." 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 (48). 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 sciences. 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 definition. 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 FAMILY VIOLENCE 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- 511 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. Acknowledgement The invaluable help of Jane Helleiner in the research and preparation for this paper is gratefully acknowledged. References I. Neal A, ed. Violence in animal and human societies. Chicago: Nelson Hall, 1976. 2. Lorenz K. On aggression. New York: Harcourt Brace Jovanovich, 1966. 3. Bandura A. Learning and behavioral theories of aggression. In: Kutash SB, Kutash LB, Schlesinger LB, and Associates. Violence: perspectives on murder and aggression. San Francisco: Jossey Bass, 1978. 4. Kadushin A, Martin JA. Child abuse: an interactional event. New York: Colombia University Press, 1981. 5. Tierney KJ. The battered women movement and the creation of the wife beating problem. Social Problems 1982; 29(3): 207-20. 6. Rathbone-McCuan E, Voyles B. Case detection of abused elderly parents. 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