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Mental Disorders, Addictions and the Question of Violence
"Mental health status makes at best a trivial contribution to the overall level of violence in society."
— Dr. John Monahan, professor of psychology and legal medicine, University of Virginia
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Of all the misconceptions about people with mental illness — that they lack intelligence, have nothing to contribute or cannot recover — the most common misconception is that people with mental illness are violent or dangerous.
This widely-held belief is fueled by sensationalist news headlines such as "Psycho Killer" and "Madman with a Machete" and by highly-publicized cases involving violent behaviour including several police shootings of men with mental illness in the Lower Mainland.
Mental health issues rarely make headlines unless violence is involved since violence and crime drive the content of daily news. As a result, media reports tend to perpetuate misconceptions that people with mental health problems are an especially violent class of society, when current research suggests that the level of public fear of violence from people with mental illness in the community is largely unwarranted.
In 2005, a Canadian journal published a review of all relevant past research on risk assessment for violence among people with mental illness. One dominating theme of the review was that violence can be much more accurately predicted by attending to non-mental health variables compared to mental health factors. These variables include age, gender, socioeconomic status, education, and environment. Additionally, a history of violence is a much stronger predictor of future violence than any mental health-related variables.
Furthermore, current studies indicate that alcohol and substance use far outweigh mental illness in contributing to violence in society. For example, citizens are much more likely to be assaulted by someone suffering from an addiction than a major mental disorder such as schizophrenia, notes the review. The report concludes that it is unlikely that a member of the public would be at risk of violence from a person with a mental disorder who does not also have a substance use problem.
Although mental health advocates used to maintain that people with mental illness were no more violent than the general population, research during the past decade suggests that there is a modest relationship between violent behaviour and certain subgroups of people with mental illness. Risk of violence is much more elevated in individuals with concurrent substance use disorders. Certain kinds of psychotic symptoms can also increase the risk for violence. Even newer studies, however, are beginning to show that violence is more a function of personality traits also found in the general population — though these traits do appear more frequently in patient populations.
Another predictor of violence for people with mental illness is a history of violent victimization and abuse (usually starting in childhood and recurring throughout adulthood), combined with substance use problems and exposure to community violence. Therefore, it is not one variable, such as a diagnosis, but a complex interplay of environmental stresses that also combine to increase risk for violence. US researchers led by Dr. Jeffrey Swanson say that "effective interventions to reduce risk of violence among persons with serious mental illness must be comprehensive yet specifically targeted — addressing underlying major psychiatric disorder but also addiction, trauma, domestic violence, and need for housing, income, and community support."
A landmark US study from the MacArthur Research Network examines violence risk of people with mental illness in the community. According to professor John Monahon at the University of Virginia, the MacArthur Risk Assessment Study found the following:
A strong predictor of future violent behaviour in people with mental illness after hospital discharge is past violent and criminal behaviour.
Higher rates of violence are associated with patients who have been physically abused as children or grew up in homes where substance use was present.
Violent behaviour in discharged patients is partly a function of the high-crime neighbourhoods they often reside in, not of the mental illnesses themselves.
Delusional symptoms in discharged patients are not indicative of any future violent behaviour, despite their content — even in cases of violent content.
Patients with major mental disorders such as schizophrenia and bipolar disorder have lower rates of violence than patients with 'other' mental disorders, like personality and adjustment disorders.
As is prevalent in other literature, concurrent substance use disorder is a key factor in predicting violence.
But it is not as simple as just attributing all violence to addictions. Researchers point out that, more than substance use disorders alone or mental illness (particularly psychosis) alone, it is the co-occurrence of the two disorder types that seems to escalate the risk for violence. In fact, having multiple diagnoses of any kind increases violence risk factors. People with co-existing diagnoses, depending on the number of conditions they have, are up to six times more likely to commit a violent act in the past year than people with one type of disorder. The reason behind this link is not yet fully understood.
Comparing alcohol and drug use, a recent report by the Canadian Centre on Substance Abuse suggests that drinking too much alcohol was the main contributing factor to one-third of murders and assaults studied. This number jumps another 20% when drugs are combined, but illegal drugs on their own contributed to less than one in every ten violent crimes.
The mental illness/violence equation is a complex one, since there are so many aspects surrounding this at-risk population. A 2005 US study found that when stressful life events and impaired social support are factored out, the link between mental illness and violence is considerably weakened.
"It is unlikely that a large portion of community violence is attributable to persons with mental illness," Heather Stuart, professor at Queen's University in Kingston, Ontario, notes. Stuart and a colleague conducted an analysis among inmates to determine what proportion of violent crimes could be attributed to mental illness or substance use disorder. "From the perspective of public health interventions, only one in ten violent crimes in our sample could have been prevented if these disorders did not exist," she explains of the study's results. In fact, seven per cent were attributed to substance use disorders, and only three per cent were attributable to mental illnesses. "The notion that mentally ill individuals are dangerous and pose a significant risk of violence to the public reinforces social stigma and discrimination and reduces opportunities for successful community integration and improved quality of life," Stuart warns.
Public perceptions of the relationship between violence and mental illness are important, since they determine how society defines mental disorder and controls access to mental health care. For example, almost half of the mental illnesses defined in the North American standard Diagnostic and Statistical Manual for Mental Disorders are defined in part on the basis of violent behaviour.
Public perceptions also determine how people with mental illness are treated by others at home, at work and in the community.
As psychiatric hospitals continue to downsize, the growing number of people with mental illness living in the community has raised concerns about public safety. However, when the types of crime committed by people with mental disorders are examined, violence is not at the top. A 2005 study included an inventory of the types of crimes committed by patients with schizophrenia. Of the 23% who had criminal records, two thirds had committed crimes against property, and two thirds had committed traffic law violations. Violent crimes had been committed by less than a quarter of those with criminal records — less than six per cent of the total patient population.
A 2005 BC report on street crimes, chronic offenders, and mental illness and addiction note that the majority of crime committed by this population is property crime, theft, and breaches of court orders — and many of these are related to supporting an addiction and/or to living on the streets. Street crime, not violent crime, is cited as the public's greatest concern, particularly in Vancouver.
Gender also plays a role in the types of violence committed by people with mental disorders. Men are more likely to be intoxicated and less likely to be adhering to their prescribed medications. Women, on the other hand, tend to act violent toward family members, and are more often violent in the home. Although it's true that the chances of being randomly attacked on the street are slim since family members, not the general public, are the most likely targets of violence, this fact isn't meant to sound alarm bells, rather, to remind us that any kind of violence is more common among people who are close to each other — this is true regardless of whether the violent person has a mental illness or not.
In some cases, mental disorders may even lower the potential for violence, according to Otto Wahl, author of Media Madness: Public Images of Mental Illness. The ability to carry out acts of assault requires a degree of mental coherence that may be difficult to achieve in some psychotic states, he writes.
Although many people fear violence from those who have a mental illness, research shows that people with these disorders are more often on the receiving end of violent acts than they are to commit such crimes. Not only are they more likely to be victims as opposed to instigators, they are victimized more often than the general population. People with different kinds of mental disorders are more likely to experience threatened, attempted, and completed physical assaults, as well as sexual assaults, than the general population. In fact, people with major mental disorders are at increased risk for any type of crime, not just violence.
Since many people with mental illness experience lowered socio-economic status, they are often viewed as easy targets for mugging, rape and other assaults. In fact, a landmark study of victimization found that people with severe mental illness (like schizophrenia, bipolar disorder, and psychosis) report being victims of violent crime at a rate more than 11 times higher than the general population. Victimization most often occurs in combination with factors like substance abuse, conflicted social relationships, poverty, and homelessness.
Like other people, individuals with mental illness can be victims or perpetrators of criminal acts and assault. Since violence affects everyone, it is a broader societal issue rather than specifically a mental health issue. Whatever relationship exists between violence and mental illness, research suggests that violent behaviour in people with major mental illness can be prevented, treated and better dealt with when it does occur. Access to a range of treatment supports can help reduce the impact of violence, particularly in people with both a mental disorder and substance use disorder. For example, peer-based programs can help individuals learn more constructive ways to deal with and express feelings of anger, frustration and irritability.
As for violence against people with mental illness, prevention involves changing the power dynamics in families, institutions and in treatment settings. As long as people in authority are abusing those with little authority, individuals with mental disorders have greater cause to fear violence than has the general public.
people with severe mental illness (like schizophrenia, bipolar disorder, and psychosis) have more reason to fear violence, since they report being victims of violent crime at a rate more than 11 times higher than the general population. Victimization most often occurs in combination with factors like substance abuse, conflicted social relationships, poverty, and homelessness
the strongest predictor of violence and criminality is past history of violence and criminality, whether mental illness is present or not
about three per cent of violent offenses could be attributed to mental illness and another seven per cent to probable substance use. That is to say, only one in ten crimes could be prevented if these disorders did not exist.
alcohol and other drug use far outweigh mental illness alone (as opposed to concurrent mental illness and substance abuse) in contributing to violence in society. So do gender, age and social-economic predictors. Young men, for example commit more violent crime than any other demographic group.
it is unlikely that a member of the public would be at risk of violence from a person with mental illness who does not also have a substance use problem
there is also a relationship between violent behaviour and certain kinds of psychotic symptoms — specifically, beliefs that others mean to do one harm, others can control one's thoughts, and others can put overriding thoughts into one's head
as with other types of violence, those close to a person, not random members of the general public, are the most likely targets of violence or assault
while alcohol consumption increases the risk of violence by over 13 times, early research is showing that medications such as benzodiazepines, and certain antidepressants — all commonly prescribed to patients with different types of mental illness — can actually inhibit a risk for violence
for violent behaviours among inpatient populations, predictions are fairly accurate when made based on history of violence and demographics, but no significant predictions can be made based on psychiatric symptoms
Aggressive behaviour includes increased pacing, clenching fists, yelling, pounding fists, kicking walls, shouting challenging questions and insults.
If a person is showing aggression:
take all threats seriously; if at any time you feel threatened, leave the situation to protect yourself
avoid touching the person and allow as much physical space between you as possible
do not stand between the person and an exit, but make sure you have access to an exit yourself
respond to questions with short answers so the person does not feel ignored, but do not answer questions that challenge you (e.g. "You're too dumb to help")
avoid raising your voice and don't talk too fast (people under stress don't trust people who talk fast)
stay calm and avoid nervous behaviour (e.g. crossing your arms, pointing your finger, standing with hands on hips or in pockets, shuffling your feet or fidgeting, making quick abrupt movements)
be prepared to call the police if necessary
Source: Canadian Mental Health Association, BC Division
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Links in the Sources section are up to date as of June 2006