Violence and Mental Illness: The Real Story and Mental Illness.pdf · • Mental illness and...

University of New Hampshire Institute on Disability/UCED

www.centerforstartservices.com

Violence and Mental Illness: The Real Story

Jill Hinton, Ph.D.Clinical Director


“I have personally known, served and supported many Americans who have had to deal with the most challenging

mental health conditions. I can’t adequately convey how deeply damaging it is when we are dragged once again into the spotlight

of blame and vilification after yet another horrific episode of mass murder.”

Harvey RosenthalPerson with lived experience


Goals for Today

• Examine historical factors• Understand that language and definitions

matter• Identify and dispel the myths around

violence and mental illness• Discuss steps we can take


• “I know stigma when I see it – and it has dangerous consequences. There is no more harmful stereotype for people with psychiatric disabilities than the assumption that they are dangerous. Our country has a long sordid history of locking up people with mental and physical disabilities in institutions in the name of preventing them from doing harm to themselves or others.”

Tony Coelho

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History of Stigma• In ancient Greece, a “stigma” was a brand to mark slaves or

criminals. People with cognitive differences were treated as slaves or criminals

• During the Middle Ages, mental illness was regarded as a punishment from God: sufferers were thought to be possessed by the devil and were burned at the stake, or thrown in penitentiaries and madhouses where they were chained to the walls or their beds.

• During the Enlightenment, the mentally ill were finally freed from their chains and institutions were established to help sufferers of mental illness.

• Stigmatization and discrimination reached an unfortunate peak during the Nazi reign in Germany

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In the US…• Late 1700’s - prevailing treatments included solitary

confinement, conditioned fear of the doctor, powerful but minimally effective drugs, bleeding, shackles, and plunge baths.

• 1840’s – Dorothea Dix - movement to improve conditions for people with mental illness. Federal government provided funding for 32 state psychiatric hospitals. Shift toward good nutrition and sleep, socialization, and recreational therapy

• Over time, they became ‘out of sight’ institutions. Government underfunding added to poor living conditions and human rights violations

• 1972 – Willowbrook State School investigation. • 1980 – Pres Reagan signed Civil Rights of Institutionalized

Persons ActAttitudes/stigma define treatment

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Stigma

• A scientific concept on the stigma of mental disorders was first developed in the middle of the 20th century, first theoretically and eventually empirically in the 1970s.

There is no country, society or culture where people with mental illness have the same societal value as people without a mental illness. (Erwin Goffman, 1963).

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Linking MI with Violence

• Association between violence and psychiatric diagnosis shift over time

• 1920s-1950s – schizophrenia described as a “mild form of insanity”. Individuals viewed as non-threatening, harmless.

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1950’s advertisement from American Journal of Psychiatry

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• It was only in the 60’s and 70’s that US society began to directly link schizophrenia with violence and guns.

• The DSM moved toward describing paranoid schizophrenia in terms of hostility and aggression.

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1960’s advertisement for Haldol – linking schizophrenia with violence

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In the news today…

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“Mentally ill monsters”

“Mental illness pulls the trigger”

“off the streets”Rebuild institutions

National registry of persons with mental illness

“delusional killers”


Public Perception

• Mental illness and violence remain inextricably intertwined• Conflation of mental illness with concept of dangerousness• Further augmented by media which sensationalizes violent

crimes – especially if mental illness is suspected. A 2016 study of 400 randomly selected news stories about mental illness, found that 38% of the new stories linked mental illness to interpersonal violence

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• 2013 Kaiser Health poll: 47% of those polled were “very” or “somewhat” uncomfortable living next door to someone with serious mental illness, and 41% felt the same way about working with someone with severe mental illness.

• “Illusory truth effect” – after repeated exposure to a piece of information, people will start assuming its true…Familiarity and repetition can override rationality and empirical evidence.

• Policy makers and public officials fall prey to the same influences

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Language and Definitions• Misunderstanding of “mental illness”, “developmental

disability”, “autism” in public and policy arena.

• Conflate ‘mental illness’ with dangerousness which is not a diagnosis.

• Media often presents a binary distinction between mild mental illness and severe mental illness…. linking severe mental illness with unpredictability and lack of self control.

• At risk of “mental illness” ceasing to be a medical diagnosis and becoming a sign of violent threat

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Violence vs Violent Crime

• 10% of people with schizophrenia or other psychotic disorders act violently compared with 2% of the general population. (Prevalence is lowest in community settings and highest in acute settings and involuntarily committed settings).

• 4% of people with mental illness act violently.

• 4% of crime is committed by people with mental illness

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Violence vs Aggression

• Violence - aggression that has extreme physical harm, such as injury or death, as its goal. Subset of aggression.

• Emotional or impulsive aggression – occurs with minimal amount of forethought or intent driven by impulsive emotions. It is result of extreme negative emotions, trauma, fear, pain, etc.

*Violence is always aggression, but aggression is not always violence.

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Dispelling the Myths

• Mental illness causes gun violence• Psychiatric diagnosis can predict

gun crime• Shootings represent the deranged

acts of mentally ill loners

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Mental Illness causes gun violence

• Less than 3% - 5% of US crimes involve people with mental illness

• Percentage of crimes that involve guns are lower than the national average for persons not diagnosed with mental illness

• Most common psychiatric diagnosis (depression, anxiety, ADHD) have no correlation with violence whatsoever

• Serious mental illnesses, such as schizophrenia, actually reduce risk of violence over time as social isolation and withdrawal symptoms worsen over time

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• MacArthur Violence Risk Assessment Study – compared prevalence of violence among individuals with mental illnesses to prevalence for violence among other residents of the same neighborhoods. The two groups prevalence for violence was ‘statistically indistinguishable’

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• People with schizophrenia have victimization rates 65% to 130% higher than the general populationo Impaired reality testingo Disorganized thought processeso Impulsivity o Poor planning/problem solvingAll of these factors make people less able to detect potential risks and protect themselves; creating more vulnerability

• People with mental illness are more likely to hurt themselves than others (2/3 of gun deaths in US are suicides)

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ASD and Violence• Overall, there is not evidence that people with ASD are more

violent than those without ASD.• And people with ASD are much more likely to be victims

• Specifically related to mass shootings:o Review of 75 mass shootings in US found strong evidence of

ASD in 8%. o Small subset of ASD?o Additional risk factors presento Limitation on how ‘mass shooting’ was definedo ASD on its own does not seem to be risk factor

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What are risks for violence?• Main risk for violence:

o Youngo Maleo Singleo Lower socioeconomic level

• Relevant factors for serious violence:o Less than high school degreeo History of violenceo Juvenile detention historyo History of domestic violenceo Perception of hidden threats from otherso Recent divorce or separation

*A number of studies suggest that access to firearms during emotionally charged moments correlate with gun violence more strongly than mental illness alone.

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Psychiatric Diagnosis Can Predict Gun Crime

• Psychiatric diagnosis is largely an observational tool, not an extrapolative one

• Overall, the identified risk indicators of violent behavior have poor predictive validity, in the short-term and the long-term

• Research suggests that psychiatrists using clinical judgement are not much better than laypersons of predicting which patients will commit violent crimes and which will not

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• A recent meta-analysis found that in order to prevent one stranger homicide, 35,000 people with schizophrenia judged to be at high risk of violence would have to be detained.

• Low per capita numbers of public psychiatric hospital beds in states were not associated with higher rates of murder by firearms, and states with relatively greater numbers of beds were not associated with lower firearm murder rates.

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Shootings Represent the Deranged Acts of Mentally Ill Loners

(or what does race have to do with it?)• The image of a mentally ill, gun-obsessed, White male

loner or the individually pathologized White male brain are recent phenomena. Blame on individual with abnormal brain.

• By contrast, in 60’s and 70’s many men labeled as violent and mentally ill were also Black. (FBI diagnosed Malcolm X with “pre-psychotic paranoid schizophrenia”). Blame was often ‘Black culture” or Black activist politics – not individual, disordered brain.

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1960’s advertisement for Haldol – linking schizophrenia with violence

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• “..cultural politics underlie anxieties about whether guns and mental illness are understood to represent individual or communal etiologies. In the 1960’s and 1970’s, widespread concern about Black social and political violence fomented calls for widespread reforms in gun ownership. “

• “..in present day, the actions of lone White make shooters lead to calls to expand gun rights, focus on individual brains, and limit rights for the severely mentally ill”

• Metzl & MacLeigh, 2015

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Complexities and Limitations

• For predictive or preventive validity, public policy and public health interventions should rely on statistical modeling and predictability. Despite the perception, mass shootings are rare in light of 32,000 fatalities and 74,000 injuries caused by guns each year in US.

• There is no single diagnosis that predicts violence or gun violence.

• The connections between mental illness and gun violence are less causal and more complex than public perception

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• People with mental illness and other cognitive disorders are largely influenced by the same risk factors as anyone else.

• Guns nor people exist in isolation from historical or social influences.

• Everchanging categories of race, gender, violence, and diagnosis itself influence what some see as a straightforward question

• Proposals for remedies that hold mental health professionals accountable for identifying violent individuals create situations where legal duties misalign with predictive value of their expertise.

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What next?• Stop the false narratives – speak truth

o Mental illness does not cause gun violenceo Putting people with mental illness on a registry and/or placing them in

institutions will not reduce gun violence

• Recognize and address stigma, prejudice and discriminationo Educate otherso Call out the media (letters to editor, calls, emails)o Promote inclusion and belongingo Focus of positives/strengthso Model interaction, engagement, support

• Be clear in our language and create common understanding o aggression, violence, crime, gun violenceo Mental illness, ASD, IDD

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• Focus on what we need to learn:o Population response to multiple mass shootings in

short time spano Links between gun violence and suicideo Effects of social media exposure to gun violenceo Long term consequences for survivors, families,

communities

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• BioPsychoSocial Approacho Recognition of the multiple factors that create risk for

violence

• Trauma Informed Careo Response to gun violenceo Treatment and support for people with disabilities

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Joint Statement from Members of the Disability Community and Allies on Gun Violence Prevention Policy and Mental

Health Disabilities “It is an act of prejudice to use people with disabilities as scapegoats for the increasing incidences of mass shootings and acts of mass violence in this country. Ultimately this will do nothing to curb the epidemic of gun violence in our nation. We will not accept or support any legislation that sacrifices the civil rights of people with disabilities in exchange for the appearance of action on gun violence. Effective reform can and should be accomplished without compromising the civil rights of people with disabilities. We call upon all of our legislators to condemn this dangerous rhetoric and refute any related legislative proposals that will put the lives and freedoms of Americans with disabilities at risk. “

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ReferencesApplebaum PS. Violence and mental disorders: data and public policy. Am J Psychiatry, 2006; 168(8): 1319-1321.

Brekke JS, Prindle C, Bae SW, LongJD. Risks for individuals with schizophrenia who are living in the community, Psychiatric Serv. 2001; 52(10); 1358-1366.

Chloe JY, Teplin LA, Abram KM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health outcomes. Psychiatric Serv 2008;59:153-164.Coelho T. Guns are killing us, not mental illness. The Hill. 2019

Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2009;66:152-161.

Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry, 2006;163(8);1397-1403.

Heeramun R, Magnusson C.et al. Autism and conviction for violent crimes: Popuation-based cohort in Sweden, J Am Acad Child AdolescPsychiatry 2017.

Metzi, J, MacLeigh, K. Mental Illness, Mass Shootings and the Politics of American Firearms. American Journal of Public Health, 2015 February; 105(2); 240-249.

Monahan J, Steadman H, Silver E. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York, NY:OxfordUniversity Press; 2001.

Rosenthal H. I have mental illness. Don’t scapegoat, institutionalize people like me after shootings. USA Today. 08.21.19

Steadman H, Cocozza J. Psychiatry, dangerousness and the repetitively violent offender. J Crim Law Criminol. 1978; 69(2); 226-231.

Varshney, M, Mahapatra, A, Krishnan, V, Gupta, K, and Kousil, S. Violence and mental illness: what is the true story? Journal of Epidemiological Community Health, 2015 August.

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