Crimes against People with Mental Illness: Types, Perpetrators, and Influencing Factors.
Key words: mental illness; perpetrators; person-in-environment; victimization; violence
The discussion of violence and mental illness generally has focused on only one aspect, whether people with mental illness are likely to be violent toward themselves or others. Lost within this singular focus is the experience of violence directed at people with mental illness. Research by Chaung, Williams, and Dalby (1987) identified this concern when their study found that individuals with schizophrenia were at greater risk of being victims of a violent offense. Campbell, Stefan, and Loder (1994) raised this concern again when they indicated that individuals with mental illness were more likely to be the victim than the perpetrator of a violent crime.
There are two reasons for this singular focus in the clinical and research literature. First, as a marginalized group, individuals with mental illness often have little voice or power to speak out about their experiences of victimization. As is often the case in research focused on violence, the people who do not complain often get lost in the process. Second, if people with mental illness do complain about their victim experiences, to what degree does the criminal justice system or the mental health system believe them? Despite studies to the contrary (see Strauss, 1989), there is still a prevalent misconception that people with mental illness are unreliable informants about their life experiences. This misconception may obscure legitimate concerns about their victimization experiences.
These reasons may not completely explain the mental health community's lack of focus on victimization against people with mental illness. However, much remains unknown about criminal victimization, its cause and effect, and how people with mental illness contend with its consequences.
Violence and Mental Illness
The research on people with mental illness as perpetrators of violence sheds some light on the victimization experiences of this vulnerable group. A study conducted by Edwards, Jones, Reid, and Chu (1988) found that on a psychiatric ward a significantly higher proportion of assaultive patients were diagnosed with schizophrenia compared with the control group. The assaultive group also contained more patients from lower socioeconomic levels, involuntarily committed patients, and patients who had a previous history of assaultive behavior. Studies by Torrey (1994) and Mulvey (1994) echoed some of the themes of the earlier research. After reviewing previous studies, Torrey concluded that there is a subgroup in the mentally ill population who are more dangerous than members of the general population. The more dangerous individuals with mental illness are more likely to have a history of violence, be noncompliant with medication, and have a substance abuse problem. Mulvey reached a similar conclusion that the dual diagnosis of mental illness and substance abuse significantly increases the likelihood of violence. The role of substance abuse as a predictor of future violence was supported further by the research of Fulwiler, Grossman, Forbes, and Ruthazer (1997). Although these studies indicated an association between mental illness and risk of being violent, Torrey found this association to be strong and significant, whereas Mulvey found it to be tenuous and in need of more rigorous research. Estroff, Zimmer, Lachicotte, and Benoit (1994) identified additional interpersonal and contextual variables that influence the risk of violence by individuals with mental illness. Their study found that individuals with a diagnosis of schizophrenia were more likely to commit violent acts, that individuals with mental illness who were financially dependent on family members were more likely to threaten and commit violent acts, and that individuals with mental illness who perceived others as threatening were more likely to threaten a nd commit violent acts. Most of the targets of the violence were relatives, particularly mothers living with a family member with mental illness. The cause of such violence may be neurological (Krakowski & Czobor, 1994), social interactional (Estroff et al., 1994), or some interaction between the two (Harris & Rice, 1997). It is interesting to note that some of the risk factors associated with committing violence, such as substance abuse and a diagnosis of schizophrenia, are the same as those for becoming the victim of violence.
Victimization and Mental Illness
Few studies have examined the victimization of people who have mental illness. The first detailed report on crimes against former mental hospital patients (Lehman & Linn, 1984) found that patients who were young and single were more likely to be victims of a crime. These victims reported more psychopathology and were more likely to use emergency mental health services. Another early study by Jenkins, Bell, Taylor, and Walker (1989) examined the circumstances of victimization in African American psychiatric outpatients. The authors suggested that individuals with mental illness are more vulnerable to victimization because of their illness. This finding was supported by Jacobson (1989) who found that physical assault histories were more common among psychiatric patients than in the general population. A more recent study by Darves-Bornoz, Lemperiere, Degiovanni, and Gaillard (1995) found that women with schizophrenia or bipolar disorder were at higher risk of rape. These disorders lead to increased social vulne rability because of the chronicity of the disorder and the social drift that results from mental illness. The authors suggested that flattened or inappropriate emotional expression creates risk situations and that a lack of coping skills prevents self-protection. The authors also found that substance abuse in women with schizophrenia was associated with increased risk of rape.
One concern raised by this research is the potential risk of ongoing victimization. Some studies suggest that a victimization history increases the risk of further victimization. For example, childhood sexual abuse was associated with adult sexual or physical assault for all psychiatric outpatients (Lipschitz et al., 1996), and sexual victimization was associated with risk-taking behavior and repetition of traumas (Darves-Bornoz et al., 1995). One outcome of such repeated victimization is the increased alienation a person with mental illness may experience (DeNiro, 1995). Such alienation may lead to increased isolation and loneliness and a consequent decline in overall functioning.
Information was sent to the National Alliance for the Mentally Ill (NAMI) and the National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD) requesting volunteers for a study on victimization experiences among people with schizophrenia, schizoaffective disorder, and bipolar disorders. Letters requesting volunteers were sent to all NAMI state affiliates and community mental health centers throughout the state of Illinois. The notice asked that interested volunteers contact the principal investigator (the first author) and request a survey. A total of 318 surveys were distributed. A total of 265 surveys were returned, for a response rate of 83.3 percent. Of those returned, 234 were usable, for a final response rate of 73.3 percent. The 31 unusable surveys were filled out incorrectly or contained writing and other marks that obscured the survey information. (Characteristics of the sample are summarized in Table 1).
The survey consisted of three sections: (1) demographic and clinical information about the respondent, (2) information about whether the respondent had ever experienced certain types of crimes during his or her lifetime, and (3) specific contextual information about the crime the respondent selected as the most traumatic ever experienced.
Types of Crimes Experienced. The categories for types of crimes experienced came from the U.S. Department of Justice (1994) categories used for their crime and victimization statistics. The categories cover both crimes against people and crimes against property. This report presents data only for crimes against people.
Specific Contextual Information. Each respondent was asked to identify the crime experienced that had been the most traumatic. The respondent was then asked to indicate how often this crime had occurred, where it usually occurred, if the respondent knew the perpetrator of the crime, and, if so, what their relationship to the perpetrator was.
Study Limitations. Several limitations affected this study. First, individuals had to contact the principal investigator to request a survey. Although this process increased the response rate, it did self-select participants who were motivated and may have had a personal interest in the topic. Second, the reliance on contacts with NAMI and NARSAD for many of the participants in the study limits the diversity of participants. Third, response bias may have led some respondents to overinclude or underinclude victim experiences. In particular, men may have been less likely to report sexual victimization experiences.
Types of Crimes Experienced
Total Types of Crimes Experienced. Women reported experiencing an average of 10.33 (SD = 4.74) types of crimes during their lifetime. Men reported experiencing an average of 8.80 (SD = 3.50) types of crimes during their lifetime. With an alpha level of .05, the effect of gender was statistically significant (F(1, 234) = 7.54, p = .007). The sample as a whole reported an average of 9.64 (SD = 4.29) types of crimes experienced during their lifetimes.
Crimes against People. Women were significantly more likely to report the experience of childhood and adulthood sexual abuse by known and unknown perpetrators and to have been raped or threatened with rape by known or unknown perpetrators (Table 2). Men were significantly more likely to report the experience of being robbed and hurt or robbed and not hurt and of attempted robbery in which they were hurt. These rates of victimization are substantially higher than that found in the general population. The U.S. Department of Justice (1994) found the rate for violent crime in the general population was about 50 per 1,000 people ages 12 and older. Other rates were 1.5 for rape, 6.0 for robbery, 11.0 for aggravated assault, and 30.0 for simple assault (all rates are per 1,000 people ages 12 and older).
Other Types of Crimes. Two types of crimes, not covered by the U.S. Department of Justice statistics, were identified out of our clinical experience working with individuals with severe psychiatric disorders. Unwanted sexual activity was defined as "engaging in any kind of sexual activity even though you did not want to because the person promised to give you something you needed, such as money, clothing, food, cigarettes, and so forth." In the sample, 36 (27.9 percent) women reported experiencing this crime, compared with five (4.8 percent) men. The difference between genders was statistically significant [[[chi].sup.2](1, N = 234) = 21.5, p [less than] .001]. Convinced to give property away was defined as "being convinced by someone to give your money or possessions to him or her even though you still needed the money or possessions." In the sample, 57 (44.2 percent) women reported experiencing this crime, compared with 31 (29.5 percent) men. The difference between genders was statistically significant [[[chi].sup.2](1, N = 234) = 5.3,p = .02].
Context of Specific Crimes Experienced
Types. Data were collected on the type of crime each respondent selected as the most traumatic. For women, the five crimes most identified as traumatic were (1) rape by a known perpetrator (n = 22 or 17.1 percent), (2) adulthood sexual abuse by a known perpetrator (n = 16 or 12.4 percent), (3) rape by an unknown perpetrator (n = 13 or 10.1 percent), (4) childhood sexual abuse by a known perpetrator (n = 9 or 7.0 percent), and (5) unwanted sexual activity (n = 8 or 6.2 percent). For men, the five crimes most identified as traumatic were (1) aggravated assault with injury (n = 16 or 15.2 percent), (2) completed robbery with injury (n = 14 or 13.3 percent), (3) completed robbery without injury (n = 11 or 10.5 percent), (4) simple assault with minor injury (n = 9 or 8.6 percent), and (5) childhood physical abuse by a known perpetrator (n = 9 or 8.6 percent).
Know Perpetrator. Of the 234 respondents, 124 (53 percent) indicated they knew the perpetrator of the crime they selected as the most traumatic. Between genders, women (n = 80 or 64.5 percent) were significantly more likely than men (n = 44 or 35.5 percent) to indicate they knew the perpetrator of this traumatic crime [[[chi].sup.2](1, N = 234) = 9.40, p = .002] (Table 3).
A separate analysis compared the type of perpetrator with the five most often selected types of crimes for both the 80 female and the 44 male respondents. For the 22 women who selected "raped by a known perpetrator" as the most traumatic crime, the most common identified perpetrator was a friend (31.8 percent), followed by a family member (22.7 percent), someone just met (22.7 percent), a relative (18.2 percent), and a service provider (4.5 percent). For the 16 women who selected "adulthood sexual abuse by a known perpetrator," the most common identified perpetrator was a relative (31.2 percent), followed by a family member (25.0 percent) or friend (25.0 percent), other (12.5 percent), and a police officer (6.2 percent). For the nine women who selected "childhood sexual abuse by a known perpetrator," the most common identified perpetrator was a family member (88.9 percent) or a relative (11.1 percent). For the eight women who selected "unwanted sexual activity," the most common identified perpetrator was a s ervice provider (62.5 percent), followed by either a friend (12.5 percent), a police officer (12.5 percent), or someone just met (12.5 percent).
For the 16 men who selected "aggravated assault with injury," only seven could identify the perpetrator of the crime. In all seven cases the perpetrator was identified as someone the man just met. Of the 14 men who selected "completed robbery with injury," only one could identify the perpetrator as someone he had just met. Of the 11 men who selected "completed robbery without injury," none could identify the perpetrator of the crime. Of the nine men who selected "simple assault with minor injury," only two could identify the perpetrator of the crime as someone he had just met. Of the nine men who selected "childhood physical abuse by a known perpetrator," all nine identified the perpetrator as a family member.
How Often Selected Crime Occurred. Women were significantly more likely than men to report that the crime they selected as most traumatic occurred more than once during their lifetime [[[chi].sup.2](3, N = 234) = 18.04, p [less than] .001]. In fact, of the 105 men in the survey, 76 (72.4 percent) indicated the crime that was most traumatic occurred only once in their life. Of the 80 women who could identify the perpetrator of the selected crime, 14 (17.5 percent) indicated the crime occurred six or more times during their lives. The most often identified perpetrator of these crimes was a family member (13.7 percent). Of the 44 men who could identify the perpetrator of the selected crime, five (11.4 percent) indicated that the crime occurred six or more times during their lives. In all five cases the perpetrator was identified as a family member.
Where Selected Crime Most Often Occurred. Women were significantly more likely than men to report that their selected crime occurred in the home rather than in a hospital or mental health institution, some other type of building, or a public space [[[chi].sup.2](3, N = 234) = 18.28, p [less than] .001]. Men were more likely to report that their selected crime occurred in a public space (on the street, in a park, and so forth).
Influence of Demographic and Clinical Characteristics
A separate analysis looked at the role of demographic and clinical characteristics of the experience of crime and victimization. First, using total number of crime categories experienced as the dependent variable, a series of analyses of variance were performed to determine whether any specific characteristic showed a significant difference. For the demographic characteristics, there were significant differences between gender [F(l, 234) = 7.54, MS = 134.72, p = .007], marital status [F(6, 234) = 5.01, MS = 83.41, p [less than].001], and living situation [F(3, 234) = 16.3, MS = 250.07, p [less than].001]. Women who were never married or who lived in a residential facility or group home experienced significantly more types of crimes. For the clinical characteristics, significant differences were found between psychiatric diagnosis [F(3, 234) = 29.1, MS = 392.44, p [less than] .001] and substance abuse problem [F(l, 234) = 46.96, MS = 720.48, p [less than] .001]. Individuals diagnosed with schizophrenia or who had a substance abuse problem experienced significantly more types of crimes. Using the Generalized Linear Model tests of between-subjects effects, an analysis was conducted looking at the significance of one-, two-, and three-way interactions between the independent variables and the dependent variable (Table 4).
In general, women experienced more types of crimes, and the crimes tended to happen more than once and be committed by someone close to the woman. The types of crimes these women reported as being the most traumatic primarily consisted of some type of sexual exploitation. The men tended to experience different types of crimes, mostly involving assault and robbery, which most often occurred only once in their lives and was committed by someone unknown to the man or by a more casual acquaintance. Although both men and women who knew the perpetrator of the most traumatic crime were likely to identify a family member as the perpetrator, women overall tended to experience more crime at the hands of people they were close to, such as family members, friends, and relatives.
The study indicates that women and individuals that have a more serious psychiatric diagnosis (such as schizophrenia) are more likely to have experienced more types of victimization. Other groups of respondents who appear to have experienced more types of victimization include never-married people who are substance abusers, women who live in a residential or group home facility, individuals (especially women) who have a diagnosis of schizophrenia and a substance abuse problem.
The identification of the perpetrator is an important aspect in understanding the effect of victimization among people with mental illness. Some studies indicate the concern of families over being the target of violence by relatives with mental illness (Torrey, 1994). The findings from this study indicate that family members and relatives often are identified as the perpetrators of acts of violence against their relatives who have mental illness. This finding does not negate the importance of violence against family members, but it does raise the question of whether there is a circular nature to violence in some families coping with mental illness.
Social workers continue to provide the majority of direct services to people with severe mental illnesses. Also, social workers have a commitment to advocating for and ensuring the health and safety of vulnerable populations. Violence against people with mental illness brings both of these professional attributes together. The findings from this study support the recommendations from other studies (Jacobson, Koehler, & Jones-Brown, 1987; Jacobson & Richardson, 1987) that social workers need to be aware of and better assess for victimization experiences among people with mental illness. Asking questions about victimization during assessment may shed light on the overall prevalence of victimization among this vulnerable population. Identifying victimization history and subsequent effect on client functioning and response to treatment better equips social workers for effective treatment. Social workers should be aware of specific groups that may be at higher risk of victimization and how such experiences may aff ect assessment, treatment, and daily functioning. Failure to assess victimization history may result in continued victimization, repetition of trauma, or the potential for ongoing domestic violence.
Social workers who develop and provide crime prevention programs for people with a mental illness should incorporate the findings on perpetrators into their training material. Programs that focus on crimes committed by strangers may not address the needs of those who are being victimized, or at risk of victimization, by relatives and friends. Programs already in existence for "acquaintance rape" or "family violence" should be made accessible to individuals with a mental illness. In addition to crime prevention programs, social workers should explore the development of postcrime intervention and services. The effect of violence on the longitudinal course of serious mental illness is not well understood. The influence of victimization on day-to-day symptom fluctuations, and relapse may be an important component for social workers to consider.
Policymakers involved in mental health issues may need to address two key concerns. First, should people with mental illness be seen as a vulnerable population similar to elderly people and children? Most states have programs and legislation that focus on the monitoring of and intervention in abuse against elderly people and children. Should people with mental illness he included in such programs and legislation, or will new policies be needed that provide a mechanism for oversight of abuse against this population? Second, should crimes against people with mental illness be viewed as "hate crimes" in much the same way that crimes targeted against gay and lesbian people or ethnic minority groups are viewed? If a perpetrator selects a person as the victim of a crime because the person has a mental illness, does this constitute a hate crime? In a sense, the person has been singled out for victimization because of a specific characteristic.
Future research should use larger and more diverse samples to better determine the true prevalence rates of crimes against people with mental illness. With such samples it would be possible to compare the rates of victimization for people with mental illness and people who have no mental illness. Diverse samples may shed light on the role of ethnicity, culture, and other contextual variables on the experience of victimization. Additional research could focus on specific characteristics that contribute to an increased vulnerability to victimization. Such findings could help social workers develop specialized programs incorporating social skills training and self-defense education. Longitudinal studies that could follow a cohort of adults who have mental illness to determine factors that better predict future victimization experiences would be helpful. Such studies could benefit from qualitative interviewing to develop a better sense of the effect of victimization on an individual's sense of self, his or her il lness, symptoms, and recovery process. Understanding the lived context in which victimization occurs could help shape the development of crime prevention and postcrime services for people with mental illness.
James A. Marley, PhD, ACSW, is assistant professor, School of Social Work, Loyola University of Chicago.
Sarah Buila, ACSW, is a doctoral student, School of Social Work, University of Illinois at Urbana-Champaign.
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Selected Sample Demographic and Clinical Characteristics, by Gender (N = 234) Women (n = 129) Demographic and Clinical Characteristics n % Age (years) Education (years) Ethnicity African American 27 20.9 Hispanic 9 7.0 Asian 3 2.3 White 89 69.0 Native American 1 0.8 Living situation My own house/apartment by myself 35 27.1 My own house/apartment with someone 42 32.6 Family member/relative house/apartment 26 20.2 Residential facility/group home 26 20.2 Age at first psychiatric diagnosis Current primary psychiatric diagnosis Schizophrenia (any type) 20 15.5 Schizoaffective 36 27.9 Bipolar (any type) 69 53.5 Other 4 3.1 Positive substance abuse problem or history 47 36.4 Men (n = 105) Demographic and Clinical Characteristics M SD n Age (years) 42.6 14.4 Education (years) 12.8 2.2 Ethnicity African American 25 Hispanic 9 Asian 7 White 63 Native American 1 Living situation My own house/apartment by myself 19 My own house/apartment with someone 48 Family member/relative house/apartment 17 Residential facility/group home 21 Age at first psychiatric diagnosis 18.5 6.0 Current primary psychiatric diagnosis Schizophrenia (any type) 20 Schizoaffective 22 Bipolar (any type) 58 Other 5 Positive substance abuse problem or history 29 Demographic and Clinical Characteristics % M SD Age (years) 41.2 13.1 Education (years) 13.3 2.3 Ethnicity African American 23.8 Hispanic 8.6 Asian 6.7 White 60.0 Native American 1.0 Living situation My own house/apartment by myself 18.1 My own house/apartment with someone 45.7 Family member/relative house/apartment 16.2 Residential facility/group home 20.0 Age at first psychiatric diagnosis 18.7 6.2 Current primary psychiatric diagnosis Schizophrenia (any type) 19.0 Schizoaffective 21.0 Bipolar (any type) 55.2 Other 4.8 Positive substance abuse problem or history 27.6 Self-Reported Crimes Experienced by Respondents, by Gender (N = 234) Women (n = 129) Type of Crime Experienced n % Childhood physical abuse Unknown perpetrator 40 31.0 Known perpetrator 49 38.0 Childhood sexual abuse Unknown perpetrator [***] 40 31.0 Known perpetrator [***] 58 45.0 Adulthood physical abuse Unknown perpetrator 17 13.2 Known perpetrator 27 20.9 Adulthood sexual abuse Unknown perpetrator [***] 23 17.8 Known perpetrator [***] 35 27.1 Rape Unknown perpetrator [***] 34 26.4 Known perpetrator [***] 42 32.6 Attempted rape Unknown perpetrator [***] 39 30.2 Known perpetrator [***] 46 35.7 Robbery Completed with injury [**] 23 17.8 Completed without injury [*] 37 28.7 Attempted with injury [*] 24 18.6 Attempted without injury 30 23.3 Assault Aggravated with injury 29 22.5 Aggravated, threatened with weapon 41 31.8 Simple, with minor injury 51 39.5 Simple, without injury 38 29.5 Purse snatching/pocket picking 48 37.2 Men (n = 105) Type of Crime Experienced n % Childhood physical abuse Unknown perpetrator 37 35.2 Known perpetrator 48 45.7 Childhood sexual abuse Unknown perpetrator [***] 11 10.5 Known perpetrator [***] 7 6.7 Adulthood physical abuse Unknown perpetrator 11 10.5 Known perpetrator 17 16.2 Adulthood sexual abuse Unknown perpetrator [***] 1 1.0 Known perpetrator [***] 2 1.9 Rape Unknown perpetrator [***] 1 1.0 Known perpetrator [***] 1 1.0 Attempted rape Unknown perpetrator [***] 11 10.5 Known perpetrator [***] 7 6.7 Robbery Completed with injury [**] 34 32.4 Completed without injury [*] 46 43.8 Attempted with injury [*] 32 30.5 Attempted without injury 27 25.7 Assault Aggravated with injury 21 20.0 Aggravated, threatened with weapon 41 39.0 Simple, with minor injury 42 40.0 Simple, without injury 27 25.7 Purse snatching/pocket picking 36 34.3 (*.)p[less than].05. (**.)p[less than].01. (***.)p[less than].001. (df = 1 for all comparisons). Respondent-Identified Perpetrator of Selected Traumatic Crime, by Gender (N = 124) Women (n = 80) Identified Perpetrator n % Family member 26 32.5 Relative 12 15.0 Friend 17 21.3 Service provider (counselor, doctor, nurse) 8 10.0 Police officer 3 3.8 Someone just met 11 13.8 Other 3 3.8 Men (n = 44) Identified Perpetrator n % Family member 15 34.1 Relative 1 2.3 Friend 6 13.6 Service provider (counselor, doctor, nurse) 3 6.8 Police officer 2 4.5 Someone just met 16 36.4 Other 1 2.3 [[chi].sup.2](6, N = 124) = 12.52, p = .05. Generalized Linear Model Tests of Between-Subjects Effects: Significant One-, Two-, and Three-Way Interactions Source SS df MS F Sig. Correct model 3111.35 [b] 87 35.76 4.47 .000 Diagnosis 211.40 3 70.47 8.80 .000 Gender 126.03 1 126.03 15.75 .000 Substance 58.03 1 58.03 7.25 .008 Gender x diagnosis 89.46 3 29.82 3.73 .013 Marital x substance 160.72 3 53.57 6.70 .000 Gender x living 104.92 3 34.57 4.37 .006 Diagnosis x substance 103.71 3 34.57 4.32 .006 Gender x diagnosis x substance 90.04 2 45.02 5.62 .004 Gender x living x substance 42.65 1 42.65 5.33 .022 Gender x marital x substance 33.81 1 33.81 4.22 .042 Eta Observed Source Squared Power [a] Correct model .727 1.00 Diagnosis .153 .994 Gender .097 .976 Substance .047 .763 Gender x diagnosis .071 .799 Marital x substance .121 .972 Gender x living .082 .864 Diagnosis x substance .082 .860 Gender x diagnosis x substance .072 .853 Gender x living x substance .035 .631 Gender x marital x substance .028 .533 NOTE: Dependent variable = total crime categories experienced. (a.)Computed using alpha = .05. (b.)[R.sup.2] = .727 (adjusted [R.sup.2] = .564).
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|Author:||Marley, James A.; Buila, Sarah|
|Date:||Apr 1, 2001|
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