“Research supports the view the mentally ill are more often victims than perpetrators of violence.” Even so Senators seek to keep guns away from mentally ill
This paper evaluates the relationship of mental illness and violence by asking three questions: Are the mentally ill violent? Are the mentally ill at increased risk of violence? Are the public at risk? Mental disorders are neither necessary nor sufficient causes of violence. Major determinants of violence continue to be socio-demographic and economic factors. Substance abuse is a major determinant of violence and this is true whether it occurs in the context of a concurrent mental illness or not. Therefore, early identification and treatment of substance abuse problems, and greater attention to the diagnosis and management of concurrent substance abuse disorders among seriously mentally ill, may be potential violence prevention strategies. Members of the public exaggerate both the strength of the association between mental illness and violence and their own personal risk. Finally, too little is known about the social contextual determinants of violence, but research supports the view the mentally ill are more often victims than perpetrators of violence.
- Are the mentally ill violent?
- Are they more violent than people without a mental illness?
- Are they a risk to public safety?
Unless otherwise stated, ‘violence’ will refer to acts of physical violence against others, since these are the most fear-inducing for the public and the greatest determinants of social stigma and discrimination. The term ‘mental illness’ will be reserved for non-substance related disorders, usually major mental illnesses such as schizophrenia or depression. Substance related disorders and concurrent substance abuse will be identified and discussed as separate risk factors.
ARE THE MENTALLY ILL VIOLENT?
Over time, there seems to have been a progressive convergence of mental illness and violence in day-to-day clinical practice. From early declarations disavowing the competence of mental health professionals to predict violence, there has been a growing willingness on the part of many mental health professionals to predict and manage violent behaviour. With the advent of actuarial risk assessment tools, violence risk assessments are increasingly promoted as core mental health skills: expected of mental health practitioners, prized in courts of law and correctional settings, and key aspects of socially responsible clinical management (1,2).
Many psychiatrists, particularly those working in emergency or acute care settings, report direct experiences with violent behaviour among the mentally ill. In Canada, for example, where violence in the population is low relative to most other countries, the majority of psychiatrists are involved in the management and treatment of violent behaviour, and 50% report having been assaulted by a patient at least once (3). However, clinical experiences with violence are not representative of the behaviours of the majority of mentally ill. Social changes in the practice of psychiatry, particularly the widespread adoption of the dangerousness standard for civil commitment legislation, means that only those with the highest risk of violence receive treatment in acute care settings.
In fact, a serious limitation of clinical explanations of violent and disruptive behaviour is their focus on the attributes of the mental illness and the mentally ill to the exclusion of social and contextual factors that interact to produce violence in clinical settings. Even in treatment units with a similar clinical mix and acuity, rates of aggressive behaviours are known to differ dramatically, indicating that mental illness is not a sufficient cause for the occurrence of violence (4). Studies that have examined the antecedents of aggressive incidents in inpatient treatment units reveal that the majority of incidents have important social/structural antecedents such as ward atmosphere, lack of clinical leadership, overcrowding, ward restrictions, lack of activities, or poorly structured activity transitions (4–6).
The public are no less accustomed to ‘experiencing’ violence among the mentally ill, although these experiences are mostly vicarious, through movie depictions of crazed killers or real life dramas played out with disturbing frequency on the nightly news. Indeed, the global reach of news ensures that the viewing public will have a steady diet of real-life violence linked to mental illness. The public most fear violence that is random, senseless, and unpredictable and they associate this with mental illness. Indeed, they are more reassured to know that someone was stabbed to death in a robbery, than stabbed to death by a psychotic man (7). In a series of surveys spanning several real-life events in Germany, Angermeyer and Matschinger (8) showed that the public’s desire to maintain social distance from the mentally ill increased markedly after each publicized attack, never returning to initial values. Further, these incidents corresponded with increases in public perceptions of the mentally ill as unpredictable and dangerous.
In some countries, such as the United States, public opinion has become quite sophisticated. The public judge the risk of violence differently, depending on the diagnostic group, with rankings that broadly correspond to existing research findings. For example, Pescosolido et al (9) surveyed the American public (N=1,444) using standardized vignettes to assess their views of mental illness and treatment approaches. Respondents rated the following groups as very or somewhat likely of doing something violent to others: drug dependence (87.3%), alcohol dependence (70.9%), schizophrenia (60.9%), major depression (33.3%), and troubled (16.8%). While the probability of violence was universally overestimated, respondents correctly ranked substance abusers among the highest risk groups. Similarly, they significantly overestimated the risk of violence among schizophrenia and depression, but correctly identified these among the lower ranked groups.
Public perceptions of the link between mental illness and violence are central to stigma and discrimination as people are more likely to condone forced legal action and coerced treatment when violence is at issue (9). Further, the presumption of violence may also provide a justification for bullying and otherwise victimizing the mentally ill (10). High rates of victimization among the mentally ill have been noted, although this often goes unnoticed by clinicians and undocumented in the clinical record. In a study of current victimization among inpatients, for example, 63% of those with a dating partner reported physical victimization in the previous year. For a quarter, the violence was serious, involving hitting, punching, choking, being beaten up, or being threatened with a knife or gun. Forty-six percent of those who lived with family members reported being physically victimized in the previous year and 39% seriously so. Three quarters of those reporting violence from a dating partner retaliated, as did 59% of those reporting violence from a family member (11). In addition, many people with serious mental illnesses are poor and live in dangerous and impoverished neighbourhoods where they are at higher risk of being victimized. A recent study of criminal victimization of persons with severe mental illness showed that 8.2% were criminally victimized over a four month period, much higher than the annual rate of violent victimization of 3.1 for the general population (12). A history of victimization and bullying may predispose the mentally ill to react violently when provoked (13).
Read More Violence and mental illness: an overview.