Friday, May 04, 2007

Is there a connection between violence and mental illness?

Forensic psychologist Steven Erickson posts on the nexus between violence and mental illness at The Crime & Consequences blog:

A common question posed to mental health researchers is whether people with mental illnesses are more violent than those in the general population. For years, the clarion call from advocacy groups was that the answer to this question was a flat "no". However, recent research [my emphasis] is beginning to challenge that rather dogmatic view, and in so doing, has enveloped into a controversy. In particular, a recent study from the landmark National Institute of Health CATIE study suggests that for some people with mental illness the answer is yes. Of course, when examining the complex phenomena of mental illness and violent behavior a lot of caveats are in order.....


The recent research that Dr. Erickson points to above is partly found here in a 2006 study entitled: "A National Study of Violent Behavior in Persons With Schizophrenia." The study results found the following:

The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. "Positive" psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while "negative" psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization.


Every year across the United States, roughly 1,000 homicides are committed by people with severe mental illness. Can we really afford to stick our heads in the sand and deny that some mentally ill people might be violent? Instead of a controversy over whether or not the mentally ill are being stigmatized, wouldn't it make more sense to continue serious research to find out what types of illness and symptoms could lead to violence and find better (and more humane) ways to treat them?

32 Comments:

Anonymous Cousin Dave said...

There needs to be a wheat-from-chaff separation exercise here. It's equally wrong to suggest that all mentally ill people are prone to violence as it is to suggest that no mentally ill people are prone to violence. I'm not expert, but it seems obvious to me that there are some types of mental illnesses that predispose their sufferors to violence, while others do not. For some reason the mental health industry seems to be willfilly blind of that obvious fact.

4:03 PM, May 04, 2007  
Anonymous Bugs said...

I think the problem with relying on "types of mental illness" to predict behavior is that there's so much individual variation among mentally ill people and how they deal with their problems. One depressed person stops bathing and watches TV all day; another depressed person shoots himself; still another shoots himself and takes a bunch of strangers with him. So if someone's walking around with a diagnosis of "clinical depression," how does that tell us what he'll do next?

I don't know - it almost seems like we're trying to predict something that's ultimately unpredictable.

6:05 PM, May 04, 2007  
Blogger dadvocate said...

During the years I worked in mental health violent patients were common place. At the mental health center, every office had a panic button which, when pushed, alerted the front desk as the the room the button was pushed. The receptionist would then page "Dr. Armstrong" to such and such's office.

Every person who was a member of our violence intervention team, primarily large males like myself, would respond.

Two patients I worked with were murdered by other patients. Another patient had murdered his mother. We once took 5 knives off of an ex-biker paranoid schizophrenic.

In my experience, the mentally ill were at least as prone to violence as any other group I've worked with including juvenile delinquents. (I never worked with adult criminal populations, however.)

10:21 PM, May 04, 2007  
Anonymous TMink said...

That is funny, we would page Dr. Armstrong at the VA when I was there. Small inpatient world!

Trey

12:16 AM, May 05, 2007  
Anonymous Anonymous said...

"Wouldn't it make more sense to continue serious research to find out what types of illness and symptoms could lead to violence and find better (and more humane) ways to treat them?" YES!!!

Challenges:
- How to distinguish verbal harassment, such as the Alec Baldwin moment, from recognizing a person is at risk of going physical. Ms. Basinger's statements seem to indicate any physical events are in the past. Similarly for the character in the "A Beautiful Mind" movie.

How to identify successful treatment, especially in cases of self-treatment among 'white collar' people (people otherwise successful and able to learn behavior adjustments themselves -- e.g via friends, church, other social networks, reading books or reading here -- as much or more than the professional help -- the therapists, psychiatrist and medication).

10:20 AM, May 05, 2007  
Anonymous Bugs said...

My wife mentioned some "Dr." PA codes when she was working in the telecom center of our local hospital. They're used to alert staff to emergencies without panicking patients and visitors. "Dr. Red" meant a fire, and believe it or not "Dr. Brown" meant that the sewer was backing up. Instead of "Dr. Armstrong," though, they'd just page the Assistance Team.

She also mentioned that the only people who could be forcibly kept in the psych ward were court-ordered detention cases. Everyone else was free to abscond AMA if they were physically and mentally able to.

I'm wondering if a special court for psych cases might not be in order. We have family court, traffic court, etc. Maybe one that specializes in psych evaluations and dispositions would be useful in resolving cases like Cho's. Anyone in his situation might be automatically diverted to this court, where his case would be examined by judges, lawyers, and psychiatrists specializing in this sort of thing.

Or that might just be another layer of bureaucracy getting in the way of treatment.

"Crazy Court." Who knows?

12:37 PM, May 05, 2007  
Blogger Helen said...

Bugs,

There are already programs known as mental health courts that specialize in helping those with mental illness. You can read more about them at:

http://www.ojp.usdoj.gov/BJA/grant/mentalhealth.html

12:41 PM, May 05, 2007  
Anonymous Bugs said...

That sounds like the very thing! Page describes it as more or less experimental at this stage - so maybe Virginia or the Blackburg area doesn't have an actual mental health court yet.

There also seemed to be an emphasis on - as you said - helping mentally ill people who have to deal with the legal system. That's admirable, but since the recent discussions here have been about detecting possible violent people, I'm wondering if these courts will end up merely "advocating" for such people rather than protecting the public from them.

Still, it seems like a step in the right direction.

2:30 PM, May 05, 2007  
Blogger jkline said...

Dr. Helen Wrote:

Forensic psychologist Steven Erickson posts on the nexus between violence and mental illness at The Crime & Consequences blog:

A common question posed to mental health researchers is whether people with mental illnesses are more violent than those in the general population. For years, the clarion call from advocacy groups was that the answer to this question was a flat "no". However, recent research [my emphasis] is beginning to challenge that rather dogmatic view,"


The problem that Dr. Erickson makes is an assumption that the quoted study compares schizophrenics with the "regular" population. It does not. The MacArthur Studies www.macarthur.virginia.edu/risk.html did a great job of examining this issue. The factors that increase the risk of violence are the ones pointed out int he study you quote, but the rate of violence for the mentally ill are the same as for the regular population.

The MacArthur studies certainly tell us which psychotic symptoms are of most concern, but the presence of mental illness in and of itself does not tell us anything.

The Study you quoted is nice in that it solidifies what symptoms to look for within a population of schizophrenics, it just does nothing to compare that population's violence with the general population.

Jeff

9:46 AM, May 06, 2007  
Blogger Helen said...

Jeff,

I am familiar with the MacArthur studies, just not sure I really believe their outcomes. Like so much of social science research, the outcomes seem to meet whatever agenda the researchers have in mind. Don't want to stigmatize the mentally ill? Then studies show that the mentally ill are no more violent than the regular population. If the research looks at kid's competency to stand trial or understand Miranda rights, somehow the research always shows that they are usually incapable. It just seems a bit suspicious, that's all. If the mentally ill are no more violent than anyone else, why have an insanity defense or diminished capacity at all? Afterall, many studies point out that the mentally ill are no more dangerous than anyone else. What about mass murderers? J. Reid Meloy found that in a study of 30 adult mass murderers, that 40% were clearly psychotic before they killed. Isn't this a little high too dismiss? I believe mental illness does tell us something about one's capacity for impulse control, control of anger and other issues--and these traits do appear to be connected to violence. I do not believe that mental illness in and of itself tells us nothing. I disagree strongly with that statement.

1:18 PM, May 06, 2007  
Anonymous Bugs said...

Another interesting bit about Cho:

http://www.wtopnews.com/?sid=1134424&nid=644

Seems like this kind of thing might a) put weird ideas in his head about himself, or b) cause him to feel further humiliation and alienated.

1:34 PM, May 07, 2007  
Anonymous Bugs said...

More happy Cho news:

http://www.washingtonpost.com/wp-dyn/content/article/2007/05/06/AR2007050601403.html?hpid=topnews

4:41 PM, May 07, 2007  
Blogger Sheila said...

Volokh Conspiracy had a really interesting post last week about a study showing inverse correlation between rates of incarceration (in both mental hospitals and prisons) and rates of violent crimes over the period of 1934-2001.

http://volokh.com/posts/1177998929.shtml

8:26 PM, May 07, 2007  
Blogger jkline said...

Helen Wrote:



I am familiar with the MacArthur studies, just not sure I really believe their outcomes. Like so much of social science research, the outcomes seem to meet whatever agenda the researchers have in mind.


The prevailing wisdom prior to the MacArthur Studies was that the mentally ill were more aggressive. Even though Rice and Quinsey and others had suggested that might not be the case. Certainly the general public (and many mental health providers) thought that and still do.

Don't want to stigmatize the mentally ill? Then studies show that the mentally ill are no more violent than the regular population. If the research looks at kid's competency to stand trial or understand Miranda rights, somehow the research always shows that they are usually incapable. It just seems a bit suspicious, that's all.

Actually when I read the research it has generally made sense. First most of the research on adolescents shows that as a group many don't understand the miranda warning (as is true for many defendants), but no research says they all don't understand. So what is important is that you cannot take the group finding and necessarily apply to an instant case (which was the problem with Simmons v. Roper where the USSC drew a bright line on the DP with the assumption that Teens under the age of 18 should not be executed. They took a "group look," so to speak, rather than an individualistic look at the defendant). So yes there are kids who are incompetent due to lack of mental maturity, but not all.


If the mentally ill are no more violent than anyone else, why have an insanity defense or diminished capacity at all?

What? This makes no sense to me. Just because as a whole the MI population is not more dangerous, that does not say that the MI do not commit crimes, nor does it mean that some do it for crazy reasons. IF anyone has concerns, in most states the NGRI defense has been pretty much gutted and restricted to the very worse of the worse mentally ill defendants.

J. Reid Meloy found that in a study of 30 adult mass murderers, that 40% were clearly psychotic before they killed. Isn't this a little high too dismiss?

I like Meloy and have heard him speak. I would have to see the study and his definition of "psychotic." Psychosis is a fluid concept with the Freudians and Object relations folks, a much broader definition, generally than the rest of us seem to hold.

Also, even if it were true mass murders are a SMALL population both within the general pop and the SMI population. If every single Mass Murder in the 20th century were SMI it would still only equal a tiny, infinitesimal proportion of the total mentally ill population. So, being mentally ill does not help us predict who will be a mass murderer.


I believe mental illness does tell us something about one's capacity for impulse control, control of anger and other issues--and these traits do appear to be connected to violence. I do not believe that mental illness in and of itself tells us nothing. I disagree strongly with that statement.

Of course it tells us stuff about individuals, but it does not help us examine a group of individuals and cull out those more likely to be violent. It certainly can be helpful when looking at individual cases.

10:16 PM, May 07, 2007  
Anonymous Bugs said...

I'm not a pro, and I think I've lost track of where this conversation is going.

We seem to be dealing with abstrations now: what category a is person in and whether persons in this category likely to be violent. Ultimately, isn't it the individual who's violent or nonviolent?

The thing is, the mental health people had Cho - the individual psycho - in their hands and they let him go. I don't see how modified categories or revised statistics would have changed their behavior.

I guess it feels like: "Who you gonna believe, the psychotic sitting in your office or the latest statistics from the DOJ?"

Sorry if that sounds confused. I know shrinks use statistics for all kinds of things - like getting funding from the government. But ultimately it has to come down to one authority deciding what to do with one crazy guy - and making the decision stick.

1:12 PM, May 08, 2007  
Blogger Xiaoding said...

All these abstract concepts need to brought into the real world.

We need a national center for the study of the brain, with an emphaqsis on how the criminal brain difers from the normal one. A center to concentrate the advances in scanning technology into one place. With such a center, the question of how to spot violent people, and what to do with them, would become much clearer.

11:12 PM, May 08, 2007  
Blogger Helen said...

Bugs,

You may not be a "pro" but your point is well taken. All the statistics in the world will not help if the person in front of you is psychotic/and or potentially dangerous and is let go without treatment or monitoring of any kind. The idea is not to treat patients as the next mass murderer for this is indeed rare, but to get their symptoms under control so that they can both get relief from their symptoms and change the distorted thought processes that can often lead to violence. Is this always possible? No, but I have seem it happen many times in my career, enough to know that it is probable. It seems that laypeople and professionals as well think that intervention must go from one extreme, no treatment to the opposite, involuntary committment for anyone who looks a bit odd. This is not the goal. The goal is to address in some competent and humane way, the psychological issues that patients are having and monitoring those who are an imminent threat to themselves or others. This can take the form of mandated oupatient treatment but the treatment must be accounted for in some way. We cannot leave people who are obviously displaying warning signs of violence in a college class to the point where they are frightening the whole class to their own devices. Universities should not allow this type of behavior to go on without intervention and follow-up. It is not fair to the other people in the classes who have a right to learn also.

6:48 AM, May 09, 2007  
Anonymous bugs said...

H: Thanks for the detailed reply. I guess issues like this always seem more clear-cut to people (like me) who are not responsible for handling them.

It also helps me clarify my previous comment, I think. My impression is that: 1. statistics tell us that most mentally ill people aren't violent, 2. based on these statistics, we craft laws and policies that presume the non-violence of mentally ill people, so that 3. when mental health workers encounter a mentally ill person who *is* violent, the laws and policies often force them to treat the patient as non-violent. Whence, possibly, Cho.

Is that accurate?

1:53 PM, May 10, 2007  
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