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Department of Military Psychiatry, Walter Reed Army Institute of Research, Washington, DC 20307-5100.
Significant differences in the incidence and distribution of violent behavior in mental hospital wards exist even when the diagnoses and other characteristics of patients are essentially the same. In an effort to compare the structure and predictability provided by organizational and interpersonal processes in violent and peaceful wards, the senior author spent 38 months in participant-observation and interviewing on six wards in three state mental hospitals. Patterns emerged in ward social organization and staff behavior that were associated with varying levels of violence. These patterns reinforced previous observation that violence is a symptom of disorder not only in the biological and psychological field but also in the sociocultural field. Violence was more frequent and more extreme in wards in which staff functions were unclear, and in which events such as activities, meetings or staff-patient encounters were unpredictable. Violence was less frequent and less extreme in wards characterized by strong psychiatric leadership, clearly structured staff roles, and events that were standardized and predictable. Ward social organization characterized by standardized, repeated, predictable behavioral and procedural rituals provided stability and autonomy that supported efforts to develop a therapeutic milieu.
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