Category Archives: Antistigma

Violence and Mental Illness

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). 

References

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.

Together Against Stigma Conference

Art on Display at Stigma Conference

“Stigma prevents people from seeking help and prevents many others from providing it.” – David Goldbloom

“At one point I wondered if becoming an outspoken advocate for mental health would affect my career.” – Actress Glenn Close

“My mom was told, she’s not depressed. She’s just lazy and spoiled.” – Erin Hodgson

“We are treating more people with physical disorders in poor countries than mental disorders in rich countries.” – Graham Thornicroft

I came home yesterday from the Mental Health Commission of Canada’s Together Against Stigma Conference. Wow. Those were three jam packed days, full of good content with people in attendance from around the world. There were folks from Japan, Spain, Denmark, the US, the United Kingdom and the list goes on.

I was surprised to hear speakers say that stigma is getting worse, not better – despite the reality that the public has become more educated about mental illnesses being medical brain disorders. Bernice Pescosolido, for example, noted that if you believe that mental illness is in the genes, then you are more likely to stigmatize. Why? “Because now it’s permanent.” I heard no one at the conference deny that mental illnesses were medical conditions and many of the speakers were medical professionals.  It was noted that science is useful, but the message of inclusion is really the important one. Over and over, people said that direct contact with those who live with mental illness, either live or via video helps to reduce stigma. Norman Sartorius noted that if you just provide knowledge about mental illness people just become more prejudiced. Knowledge is only useful if you also increase competence in dealing with problems and combine it with structural change, for example, laws. Anthony Jorm described mental health literacy as knowledge that you put to practical use, not just knowing about brain disorders.

Stigma amongst health care providers was discussed. Graham Thornicroft noted that if mental health workers only see people who don’t do well and are not seeing people when they are doing better, that can add to stigma. Peter Bryne noted that a major source of stigma and discrimination are the health care providers themselves. Thomas Ungar said that research has shown that patients with a history of depression receive poorer treatment for physical conditions. People with mental health diagnosis in general receiving poorer treatment for physical ailments was also discussed. Ungar recommended multiple stigma interventions for different learning groups. For health care providers, he talked about the biological information about mental illness helping to reduce stigma.

Another population discussed at the conference was youth. Heather Stuart noted that stigma impact shows an age gradient. People under twenty five years old bear the brunt and are most affected by stigma. She said that anti-stigma programs should be offered over a longer period of time in schools, not just as “one offs” and she recommended they incorporate direct and video contact with those who live with mental illnesses.

The above are just a few of the highlights that stood out to me. There was a ton of information in the conference. I took over 16 pages of notes and I was not jotting everything down! Nor could I attend everything. There were many break out sessions that overlapped. I was often torn – wanting to go to multiple sessions that occurred at the same time. Twitter came in handy on such occasions. There were a number of people sending out notes from the conference over Twitter. I was able to see those notes or “tweets” from other sessions as I sat in the one I had chosen. Pretty cool.

The most powerful part of all of it for me were the personal stories. There were lots of these – from people who have mental illness and from family members. Andrea and Michelle Zoephel, a mother and daughter team, were amongst those who spoke. Their story was touching. Michelle developed schizophrenia at a very young age and her mom, Andrea, was the main support. Andrea recalls watching her daughter be taken to hospital by police in handcuffs at the age of twelve because she was ill. It was heart wrenching to hear.

The two have started a website called  EMIS, which stands for Eliminate Mental Illness Stigma. It’s new and still under construction but sounds very promising. Give it some time to develop and check it out. They gave out fuzzy EMIS pins at the conference and invited us to take several so we can give them to others we know. They’ll be conversation pieces and, if folks ask about them (and they will), they’ll provide an opportunity to start a conversation about mental illness and stigma. We need more of those conversations. I took a handful.