Alcohol as a Risk Factor for Aggression and Violence: Reasons and Responses

1. A partnership of and Alcohol as a Risk Factor for Aggression and Violence: Reasons and Responses Mary McMurran

2. 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

3. 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-crime Crime Survey for England & Wales

4. Level of Violence Half no physical injury, i.e., threatening behaviour, common assault etc.

5. Victims of Violence Under-reporting? Under-recording? ONS Focus on Violent Crime & Sexual Offences 2011/12, England & Wales http://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

6. 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.

7. Perpetrators of Violence Who are victims and who are perpetrators? • 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 & Wales http://www.ons.gov.uk/ons/dcp171778_298904.pdf

8. Less overall crime by females Crime reducing over time

9. Stable and similar proportions of violence

10. Possible Reasons for Decrease in Violence

11. Alcohol as a Contributory Factor

12. Alcohol and Victims of Violence • Alcohol involved in 50% of all violent offences • 37% domestic victim • 52% acquaintance • 65% stranger Alcohol less explanatory 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

13. Heaviest Drinking Day in the Past Week, 2012 Still a substantial amount of ‘binge’ drinking, especially by young men, which is the group responsible for most violence ONS. Drinking Habits Amongst Adults, 2012. http://www.ons.gov.uk/ons/dcp171778_338863.pdf

14. Contribution of Alcohol • Identified by • Correlational studies • Longitudinal studies • Experimental studies • Case crossover studies

15. 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.

16. 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 Reducing hazardous drinking could have a major effect on population violence 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.

17. 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) ≥ 8 Hazardous; ≥ 16 Harmful; ≥ 20 Dependent

18. 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 measures Varying %ABV Different length of an ‘occasion’ Differences in individual physical attributes

19. 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.

20. 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 from A 30-year longitudinal study. Drug and Alcohol Dependence, 122, 135-141.

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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.

27. 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

28. 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?

29. Explaining Alcohol-Related Violence Public Health Risky drinking Provocation/frustration Drinking Violence Risky people Risky places Management Person Context Treatment Culture

30. 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.

31. Risky Drinking – Public Health • Violence recognised by WHO as a public health issue • Alcohol recognised as a contributing factor

32. 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.

33. 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

34. 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 hotspots • 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) Florence et al. (2011). Effectiveness of anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury. BMJ 2011;342:d3313

35. Risky Places – Management Safer Bars Kate Graham, London, ON, Canada • 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) 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.

36. 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

37. Risky Drinkers Alternative strategies for dealing with provocation, conflict, and ‘disrespect’ • 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

38. 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.

39. Mechanisms of Alcohol’s Effect • Alcohol myopia • Impaired social problem solving • Expectancy effects

40. Alcohol Myopia Explains apparently paradoxical effects, e.g., relaxation, aggression. • 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.

41. Alcohol Myopia Reduce frequency and level of intoxication; Increase self- and other-awareness • 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

42. Impairs Problem Solving Improve problem solving skills • 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.

43. Expectancy Effects • Outcome expectancies are • Cognitive representation of past learning • Instruction • Observation • Experience • ‘If …. then’ relationship • Predict future behaviour

44. Expectancy Effects • Happy • Sleepy • Dopey • Bashful • Grumpy • Doc • Sexy (not Sneezy)

45. 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.

46. Expectancy Effects Improve social confidence • 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.

47. 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

48. 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.

49. 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

50. 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