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

Stable and similar proportions of

violence

Stable and similar proportions of

violence

Possible Reasons for Decrease in Violence

Alcohol as a Contributory Factor

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• Happy • Sleepy • Dopey • Bashful • Grumpy • Doc • Sexy (not Sneezy)

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.

COVAID

Control Of Violence for Angry Impulsive Drinkers

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

Personal Scientist

• SEE Study their behaviour

Experiment with change

Evaluate the outcome

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

Mary.McMurran@nottingham.ac.uk