There is a lot of fear mongering that sometimes happens when mental illness and violence are discussed – sometimes as part of a political agenda. Unfortunately this feeds fear and increases stigma against those of us who sometimes experience psychosis. The reality is that most people with mental illness never committ violent crimes and that there are a number of other risk factors for violence that are much more significant than psychosis. I, for one, have experienced untreated psychosis for significant periods of time and never been violent. I am not alone in that. Please find below an article on the topic of mental illness and violence by guest blogger, Simon Davis who teaches social work at a university and works in the mental health system as a manager. - Renea Mohammed
Violence and mental illness
By Simon Davis
The relationship between mental illness and violence continues to be an area of controversy. The perception that persons with mental illness are violent has strongly contributed to the stigma these individuals experience: surveys of the public have found a desire for greater social distance from persons with mental illness based on this belief. Perceptions about violence, aided by media portrayals, have also been shown to significantly influence the legal response, through the implementation of community treatment orders (an involuntary outpatient status) in a number of jurisdictions including Canada (Nielssen et al. 2011; Taylor 2008). An example of these is “Brian’s Law,” an Ontario statute named for a sportscaster killed in 1995 by an apparently mentally disordered man in a highly publicized case.
There is now enough accumulated evidence to say that mental illness is a risk factor, albeit small, for violent behaviour (Choe, Teplin and Abram 2008; Corrigan and Watson 2005; Rueve and Welton 2008; Stuart 2010). This finding obviously needs to be put into context. First, there are other risk factors that are much stronger predictors, in particular youth, maleness, and active substance misuse (Corrigan and Watson 2005; Rueve and Welton 2008; Steadman et al. 1998; Wallace, Mullen, and Burgess 2004). Second, concerning the public’s fear of “stranger violence,” violence by persons with mental disorders is most often directed at intimates, particularly family members, rather than at strangers – the same pattern seen in the general public (Arboleda-Florez 1998; Estroff et al. 1994; Lefley 1997; Wehring and Carpenter 2011). Third, persons with mental disorders are much more likely to be the victims of violent acts than the perpetrators (Choe, Teplin and Abram 2008; Wehring and Carptenter 2011). Fourth, environmental factors are significant. One study concludes that “persons with persistent psychiatric disorders may be at increased risk for committing violence because of socioeconomic factors and because of how, where and with whom they live, rather than because of their psychiatric disorders” (Estroff et al. 1994, 670). Persons with serious, persistent mental disorders are overrepresented among homeless populations and in skid-row settings, where day-to-day survival is a difficult challenge and a premium is placed on toughness.
In my own experience, which includes over 25 years of working directly with the seriously mentally ill, I have only encountered two instances of a client-on-staff (minor) assault, in both cases a situation where the assailant was experiencing psychosis, fearful, and misperceiving the presence of the staff person.
There are at least two positive corollaries here: first, that most persons with mental illness are not violent, and second, that with greater access to treatment many of these unfortunate (albeit rare) events could be prevented. Family members in particular have argued for some time that with greater access to treatment, for example the ability to get their ill relative into hospital, they would not have to wait until the situation is “too late” — an escalation requiring the intervention of police quite commonly.
Some people have argued for more widespread use of involuntary interventions and laws that support “assisted outpatient treatment,” such as “Brian’s Law,” mentioned earlier. (Inman 2011; Torrey 2011). However, these interventions have been found to be oppressive by many clients and advocates, and to potentially add to stigma and worsen the therapeutic relationship (Dreezer & Dreezer Inc. 2005; Stainsby 2000).
It may be that better early intervention approaches will help, such as EPI (Early Psychosis Intervention), but our current ability to accurately identify and predict outcomes among younger persons first experiencing a psychotic illness is poor (Brown and McGrath 2011; Kirkbride and Jones 2011).
In sum, we know that most mentally ill persons are not violent, but that the smaller number that are get disproportionate media attention (Pinfold and Thornicroft 2006). And, in working with higher-risk individuals, we need to carefully balance public safety concerns with respect for dignity and autonomy, and the potential for actually increasing stigmatization: “As health care providers and researchers we must be wary of policy directions that could result in greater restrictions on people who use mental health services, as opposed to providing them with better supports to live full and rewarding lives” (Morrow, Dagg and Pederson 2008, 1).
Arboleda-Florez, J. 1998. Mental illness and violence: an epidemiological appraisal of the evidence. Canadian Journal of Psychiatry, 43: 989-996.
Brown, A. and McGrath, J. 2011. The prevention of schizophrenia. Schizophrenia Bulletin 37: 257-261.
Choe, J., Teplin, L. and Abram, K. 2008. Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services 59: 153-164.
Corrigan, P. and Watson, A. 2005. Findings from the National Comorbidity Survey on the frequency of violent behaviour in individuals with psychiatric disorders. Psychiatry Research 136: 153-162.
Dreezer & Dreezer Inc. 2005. Report on the legislated review of community treatment orders, required under s. 33.9 of the Mental Health Act. Downloaded Aug. 2d, 2010 from the World Wide Web: http://www.health.gov.on.ca/english/public/pub/ministry_reports/dreezer/dreezer.pdf
Estroff, S., Zimmer, C., Lachiotte W. & Benoit, J. 1994. The influence of social networks and social support on violence y persons with serious mental illness. Hospital and Community Psychiatry 45: 669-679.
Inman, S. 2011. The right to be sane. Downloaded Oct. 21, 2011 from the World Wide Web: http://fullcomment.nationalpost.com/2011/07/29/susan-inman-the-right-to-be-sane/
Kirkbride, J. and Jones, P. 2011. The prevention of schizophrenia — what can we learn from eco-epidemiology? Schizophrenia Bulletin 37: 262-271.
Lefley, H. 1997. Mandatory treatment from the family’s perspective. New Directions in Mental Health Services, no. 75: 7-15.
Morrow, M., Dagg, P. and Pederson, A. 2008. Is deinstitutionalization a ‘failed experiment?’ The ethics of re-institutionalization. Journal of Ethics in Mental Health 3: 1-7.
Nielssen, O. et al. 2011. Homicide of strangers by people with a psychotic illness. Schizophrenia Bulletin 37: 572-579.
Norko, M. and Baranoski, M. 2005. The state of contemporary risk assessment research. Canadian Journal of Psychiatry 50: 18–26.
Pinfold, V. and Thornicroft, G. 2006. Influencing the public perception of mental illness. In Choosing methods in Mental Health Research, ed. M. Slade and S. Priebe, 147-156. London: Routledge.
Rueve, M. and Welton, R. 2008. Violence and mental illness. Psychiatry 5: 34-48.
Stainsby, J. 2000. Extended leave. Canadian Journal of Community Mental Health 19: 152-155.
Steadman, H. et al. 1998. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry 55: 393-401.
Stuart, H. 2010. Mental disorders and social stigma: three moments in Canadian history. In Mental Disorder in Canada: An Epidemiological Perspective, ed. J. Cairney and D., 304-330. Toronto: University of Toronto Press.
Taylor, P. 2008. Psychosis and violence: stories, fears and reality. Canadian Journal of Psychiatry 53: 647-659.
Torrey, E. 2011c. Stigma and violence: isn’t it time to connect the dots? Schizophrenia Bulletin 37: 892-896.
Wallace, C., Mullen, P. & Burgess, P. 2004. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. American Journal of Psychiatry 161: 716-727.
Wehring. H. and Carpenter, W. 2011. Violence and schizophrenia. Schizophrenia Bulletin 37: 877-878.